Reprinted from M.D. News

The Problem

The "vicious cycle" hypothesis of pain and increased muscle tone was proposed by Travell et al in 1942, who wrote, "According to this view, limitation of motion is primarily a reaction to pain rather than the result of a structural lesion. If muscle spasm causes pain, and pain reflexively produces muscle spasm, a self-perpetuating cycle might be established"³. Although this model for chronic muscle pain is still widely held, well-controlled studies have shown no statistical significant difference in resting electromyographic (EMG) activity between painful and non-painful muscles^4,5.

Strain/Counterstrain for Elite Athletes "Strain/Counterstrain technique for my left lower quadrant allowed me to participate in the Bad Water Ultramarathon." Lisa Bliss, M.D., Physiatrist, Spokane, Washington Lisa is the winner of the 2007 Women's Division Bad Water Ultramarathon, described as the most difficult running race in the world.

In 1975, Korr proposed a neural basis for musculoskeletal pain, incriminating the muscle spindle as the non-adapting proprioceptive organ responsible for maintaining "somatic" or neuromuscular dysfunction⁶.

More recent research (1991) by Johansson and Sojka presents a more complete neuromuscular model that identifies positive neural feedback loops in the gamma-motor system which increase muscle spindle activity in the intrafusal muscle fibers, thereby maintaining increased muscular tone (hypertonicity), resulting in extrafusal muscle fiber resistance to stretch⁷. To date, the one study that was done in humans did show a linkage between muscle pain, gamma efferents, and an increase in muscle spindle sensitivity to stretch ⁸. More human studies need to be performed, but the invasive nature of the research makes the use of test animals necessary. There does exist a sizable body of animal research establishing the link between the activation of intramuscular chemo-nocioceptors (from injury), increased gamma motoneuron activity to the muscle spindle, and increased muscle spindle output, leading to chronically increased muscle tone (defined as stiffness or resistance to stretch)^9-15.

Patients experiencing this condition of chronic hypertonicity, stiffness, and pain, often present with what appears to be areas of soft tissue tightness or firmness, underlying muscle spasm, and varying degrees of limited range of motion. On palpation, the practitioner will usually find small zones of tense, unusually tender tissue, usually about one centimeter in diameter, referred to as tender points¹⁶. Sometimes the tender points may even be found in the antagonist muscle to the painful muscle¹⁷. Movement and exercise will usually decrease the feeling of stiffness, but the beneficial effect is usually not long lasting because resting allows the gamma feedback loop to further activate the muscle spindle and increase the underlying tone of the muscle. And since the muscle spindle is a non-adapting proprioceptive organ, the underlying hypertonicity will persist, causing pain, interfering with normal joint function, and because of this, possibly predisposing the patient to further injury.

The Solution

Treatment solutions for patients with chronic neuromuscular dysfunction as described above have existed for years but are only recently becoming more popular as word of their effectiveness spreads. As early as the mid 1950’s, Lawrence Jones, D.O., began developing his evaluation and treatment technique, Strain/Counterstrain. In the 1960’s,
Dr. Arthur Lincoln Pauls, a British osteopathic physician was guided toward his system of bodywork called Orthobionomy, by the work of Jones.

Leon Chaitow, N.D., D.O., has written books on the subject of passive positional release and neuromuscular treatment techniques that are used as references by Osteopaths and physical therapists, alike^16,18. More recently, P. Michael Leahy, D.C., C.C.S.P., developed an evaluation and treatment technique called Active Release Technique which he began teaching in 1991.

All of these techniques present a neuromuscular solution to soft tissue pain, and their publications and websites contain numerous testimonials from practitioners and patients relating the effectiveness of the treatment, for both chronic and acute conditions.
Also common to nearly all of the above neuromuscular approaches (with the exception of Active Release Technique), is the idea that they take advantage of the neurophysiological model of soft tissue pain as hypothesized by Johansson and Sojka, to reduce or eliminate the painful condition.

Bob LeBeau, PT, working with a patient.

One advantage of applying a neuromuscular approach to the treatment of painful soft tissue conditions is that, for the most part, the techniques are as gentle as they are effective. In addition, there are few, if any, contraindications for most of the neuromuscular approaches mentioned above. Randall Kusonose, P.T., Director of the Jones Institute (Strain/Counterstrain), reports that he receives several referrals each year to treat infants with acute torticollis, with consistently positive outcomes, including happy mothers and contented babies. The treatment techniques are just as effective with highly competitive athletes. Don Marrs, a physical therapist in Redmond, Washington,
treats professional football players and major college athletes. Don says, "Strain/Counterstrain technique has been extremely helpful in expediting the rehab process, and returning the professional and college athletes I treat to the playing field."

Where to find neuromuscular treatment practitioners

Some physical therapy private practices require their licensed professionals to become proficient at neuromuscular treatment techniques, to ensure that their patients receive the most complete care available. Advanced Rehabilitation Clinics, Inc., a provider of outpatient physical therapy services in the Chicago area, also mentors their licensed physical therapists in neuromuscular treatment techniques. This one-on-one mentoring ensures that consistent outcomes, and great results are achieved for all patients. Below are some brief, documented case histories of patients with painful soft tissue conditions, who were treated at Advanced Rehabilitation Clinics, using a neuromuscular approach.

Case Histories

Case History # 1

Patient: 17 y.o. female gymnast

Diagnosis: Status post left knee ACL reconstruction

Patient history: Patient was referred to clinic by her orthopedic surgeon, at 8 weeks post-op, after having received 8 weeks of physical therapy treatment at another provider. The surgeon reported displeasure with the lack of full knee extension.

Significant findings: The patient presented with a 13º flexion contracture of her surgical knee. Passive knee extension was painfully restricted, with the patient reporting severe anterior joint line pain at the end of range. Palpation of the popliteal space revealed a 2cm diameter zone of dense, tender soft tissue, directly adjacent and medial to the posterior border of the lateral femoral condyle.

Intervention: A neuromuscular treatment approach was applied to the painful area, one visit only.
Outcome: After one visit, patient achieved an 80% reduction of the pain at end range extension, gaining 10º of knee extension (3º short of full extension). With the surgeon’s permission, the patient was referred back to the original physical therapy clinic she had been treated at.

Case History #2

Patient: 47 y.o. male Endodontist

Diagnosis: Chronic right thoracic outlet syndrome

Patient history: Patient reported a history of an extensive medical workup, with over four (4) years of intermittent right upper extremity tingling and numbness, as well as severe, intermittent right cervical and upper trapezius pain. All symptoms worsened with working in a forward bent and right sidebent position for several hours a day. Patient expressed his reluctance to be in physical therapy at his initial visit, because he had not achieved favorable results with previous physical therapy treatment attempts. Patient admitted he agreed to attend the initial evaluation appointment only because his wife, a former patient, had requested he do so.

Significant findings: Patient presented with severely limited left cervical sidebending, with right cervical and upper trapezius pain at end range of motion. Patient also presented with palpable hypertonicity and tenderness to palpation in the right anterior cervical musculature, right scalenus anterior, right upper trapezius, right pectoralis minor, right subclavius, and right biceps. Patient reported decreased sensation throughout his entire right upper extremity. Right shoulder flexion, abduction, and external rotation range of motion were limited and painful, at end range of motion.

Intervention: Patient was treated twice weekly for 8 weeks, then gradually weaned from treatment over the next 8 weeks. Treatment consisted of an ergonomic assessment of the patient’s work environment, with recommendations for behavior modifications to avoid aggravation of his condition, therapeutic exercise, and a neuromuscular treatment approach to the hypertonic and painful soft tissue structures of the right upper quadrant.
Patient was also instructed in self-treatment techniques, incorporating neuromuscular treatment principles, for the occasional aggravation of his condition that 8-10 hours a day at work would cause.

Outcome: Patient was discharged to self management of his condition, reporting a 90% reduction in the symptoms he had originally presented with.

References

1. In Motion Institute for Orthopedic Research, Memphis, Tennessee
2. Magni G, Caldieron C, Luchini SR, Merskey H. Chronic musculoskeletal pain and depressive symptoms in the general population. An analysis of the 1st National Health and Nutrition Examination Survey Data. Pain 1990;43:299-307
3. Travell J, Rinzter S, Herman M. Pain and disability of the shoulder and arm. JAMA 1942;120:417-422
4. Matre DA, Sinkjaer T, Svensson P, Arendt-Nielsen L. Experimental muscle pain increases the human stretch reflex. Pain 1998;75(2-3):331-339
5. Mense S. Pathophysiologic basis of muscle pain syndromes. Phys Med Rehab Clin N Am 1997;8(1):23-53
6. Korr I. Proprioceptors and somatic dysfunction. J of Am Osteo Assoc 1975;74:638-650
7. Johansson H, Sojka P. Pathophysiological mechanisms involved in genesis and spread of muscular tension in occupational muscle pain and in chronic musculoskeletal pain syndromes: a hypothesis. Med Hypothesis 1991;35:196-203
8. Matre DA, Sinkjaer T, Svensson P, Arendt-Nielsen L. Experimental muscle pain increases the human stretch reflex. Pain 1998;75(2-3):331-339
9. Rybicki KJ, Waldrop TG, Kaufman MP. Increasing gracilis muscle interstitial potassium concentrations to stimulate group III and IV afferents. J Applied Physiol 1985;58:936-41
10. Kaufman MP, Rybicki KJ. Discharge properties of group III and IV muscle afferents: their responses to mechanical and metabolic stimuli. Circ Res 1987 Oct;61(4 Pt 2): 160-165
11. Hirsche H, Schumacher E, Hagemann H. Extracellular K+ concentration and K+ balance of the gastrocnemius muscle of the dog during exercise. Pflugers Arch 1980;387:231-237
12. Hnik P, Holas M, Krekule I, Kriz N, Mejsnar J, Smiesko V, Ujec E, Vyskocil F. Work-induced potassium changes in skeletal muscle and effluent venous blood assessed by liquid ion exchanger microelectrodes. Pflugers Arch 1976;362:85-94
13. Vyskocil F, Hnik P, Rehfeldt H, Vejsada R, Ujec E. The measurement of K+ concentration changes in human muscle during volitional contractions. Pflugers Arch 1983;399:235-237
14. Rybicki KJ, Kaufman MP, Keynon JL, Mitchell JH. Arterial pressure responses to increasing interstitial potassium concentrations in hind limb skeletal muscle of dogs. Am J Physiol 1984;247:R717-R721
15. Rotto DM, Kaufman MP. Effect of metabolic products of muscular contraction on discharge of group III and IV afferents. J Appl Physiol 1988;64:2306-2313
16. Chaitow L. Modern Neuromuscular Techniques, Churchill Livingstone (2003).
17. Jones L, Kusonose R, Goering E. Jones Strain-Counterstrain, Jones Strain-Counterstrain, Inc. (1995)
18. Chaitow L. Positional Release Techniques, Churchill Livingstone/Elsevier (2002).

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