1.     Mono and Poly Point Maneuvers

2.     Cervical, Thoracic and Lumbar Stretching Maneuvers

3.     Cervical, Thoracic and Lumbosacral Manual Traction Maneuvers

4.     Origin and Insertion Maneuvers

5.     Hand Massage

a.      Petrisage

b.     Efflurage

c.     Pincement

d.     Roulement

e.      Tapoutment

f.       Cupping

g.     Basic Pressure Techniques

     When considering monopoint and poly point maneuvers one must first understand the relationship between motor points, trigger points and areas where these points happen to coincide topographically.  Motor points are defined as that point at which a motor nerve enters a muscle.  Further, that point wherever, if galvanic stimulation is applied, it will cause a contraction of a corresponding muscle.

      A Trigger Point is defined as that point or particular spot on the body on which pressure or other stimulus will give rise to specific sensations or symptoms.

     Glogowsky and Wallraff, conducted biopsy examinations on 20 patients, with trigger point, and related that, histologically the were characterized by a waxy degeneration of the muscle fibers, destruction of fibrils, increase in number and agglomeration of nuclei of muscle fibers, and fatty infiltrations. 

     Brendstrup et al (1957) conducted 12 symmetrical biopsy examinations from chronic “fibrocystic” areas in the sacrospinales muscles of patients operated upon for herniated discs.  They found interstitial mucinous edema containing acid mucopolysaccharides and accumulation of mast cells, which are considered the origin of the mucopolysaccharide ground substance. 

    In 1959, Erwin advanced the theory that trigger points can be located in any peripheral tissue.  He classified them as into levels as follows: 

1.     Skin

2.     Subcutaneous tissue

3.     Superficial layer of deep fascia

4.     Skeletal muscle

5.     Deep layer of deep fascia

6.     Periosteum

7.     Ligament 

He believed that the most frequent locations are at levels 3,4 then 5, followed by level 7 the Ligaments.  The least frequent levels were 1 and 2. 

     In 1971 Glyn reported that during the early phase of the pain syndrome, pain may be due to “pain – producing” metabolites (see muscular splinters) released into the connective tissues, and if not immediately leached out of the area, these substances could perhaps produce the local irritation, which in turn may result in the cellular damage and the release of intracellular cathepsins, possibly from mast cells or from connective tissue itself. 

     Hackett reported that Gutstein believed that the trigger point is initiated by a localized sympathetic predominance which is associated first with changes in the H+ ion (see muscular splinters) concentration and calcium and sodium balance in the tissue fluids, and generally also with vasoconstriction and hypoxia.  These altered circulation dynamics trigger (trigger point) impulses in pain endings and proprioceptors.  The referral distribution of pain and sensory disturbance, or its anatomic pathways do not follow the normal dermatomal patters.  They generally follow a scleratomal distribution.   

    Travell studied trigger points with precision and identified the topographic location of these points.  Trigger points have been found at the level of the skin and at projections of the posterior articular bony structures by an axial pressure.  These latter points in the dorsal and lumbar vertebrae are called Trousseau’s apophyseal point in cases of neuralgia.  In any case, these apophysial trigger points coincide topographically with motor points.  Thus axial stimulation of these points aids in diagnosis (Trigger point) and result in treatment of contracted musculature (motor point). 

     Other areas have also been identified as combination motor-trigger points.  Generally, these points are bilaterally along the posterior superior border of the trapezius muscle, along the superior, medial and inferior surface of the scapula.  These points have also been found along the apophysial joints of the spine, bilaterally near the lateral border of the second to third sciatic notch, over the tissues near the Ischeal tuberosities, medially below the illiac crest, medially and just superior to the greater trocanters of the femurs, medially over the adductors of the upper thigh, bilaterally about the knee joint, just central above the tissues over the belly of the Gastrocnemius muscle and bilaterally about the ankle just inferior to the medial and lateral malleoli. 

     To locate trigger points and perhaps motor points which coincide first palpate for trigger points with physical stimulation.  Pulsating or tetanizing sine with ultrasound or galvanic stimulation can be applied to locate hot trigger points.  Note any reproduction of pain responses.        

     During the early phase of pain responses motor and sensory effects may be found in the scleratome distributions.  After several weeks, there is also involvement of the neighboring tissues. 

     Monopoint Kinopractic maneuvers are defined as the diagnosis of/and at times the treatment of the combined motor trigger point with axial pressure of usually one digit or the thumb of the physician.  Polypoint Kinopractic maneuvers are defined as the diagnosis of and treatment of multiple motor-trigger points simultaneously with multiple fingers applying the pressure.   

STRETCHING MANEUVERS

     When considering a patient, one must realize that muscular pain proper may prolong or produce the suffering in these patients.  Palpation of the muscles may reveal the presence of some contracted fasciculi, with painful induration and trigger point, which induces referred pain.  Palpation may be carried out in relaxed muscles, but it is good to complete it by palpating contracted muscles against resistance.

     The treatment of muscular spasticity lies in the realm of Kinopractic stretching techniques as illustrated with a full explanation of their procedure as follows:

      A.     Stretching Cervical Kinopractic Techniques

 1.     The patient is supine with their head rotated to the left.  The physician stands at the right side of the table with his right hand extended over the temporal bone area.  The physician paces the thenar eminence of his left hand just below the mastoid process of the left side.  A gently springing pressure exerted downward over the temporal bone by the right hand accompanies the stretching of local tissues.  Reverse the procedure for stretch of the contralateral musculature.

2.     The patient is in the supine position with his head at 0 degrees Neutral.  The physician’s right ad cups t patent’s chin gently.  The physician’s left hand cups the patient’s occipital area with their thumbs in a natural position.  The maneuver is performed as follows:  Gradually traction the head cephalad with both hands.  Next take the occipital and upper cervical vertebrae through their range of motion springing where tension appears; expect the release to be gradual.  Then raise the head superiorly and gently flex the mid and lower cervical areas in a springing motion.

3.     The patient is in the supine position with their head facing the physician.  The physician stands at the patients left side.  The physician stabilizes the right shoulder of the patient with his left hand and hooks the tips of his right fingers about the lateral mass of the neck.  The physician’s left hand stabilizes the shoulder while they pull (stretches) the muscles of the cervical area toward him then releases them by a gentle, slow, rhythmic and elastic movement.  Reverse the procedure for stretch of the contralateral musculature.

4.     The patient is either sitting on a table or stool with the physician facing the patient.  The physician places the patient’ frontal bone against his chest.  The physician now cups the posterior cervical area with his hands and fingers.  The physician then draws the patient toward them.  An exaggeration of movement is produced anteriorly and superiorly with a gentle springing motion.  Next, the patient’s head is turned to the side and lateral flexion is produced.  This is done bilaterally.  The technique is known for its excellent results with the geriatric patient.

5.     The patient is in the supine position.  The physician’s thumb and forefinger of the left hand cup the posterior cervical area, with the palm cupping the occiput.  The physician’s right hand is placed over the temporal and frontal regions and places the head into slight flexion and rotation against the thumb.  This motion is very slight.  The pressure (stretch) is relaxed slowly and reapplied gently and slowly.  This is done bilaterally.

B.      THORACIC STRETCHING TECHNIQUE:

 1.     The patient is sitting with his arms crossed in front of his chest and his thumbs hooked in each of his anti-cubital fosse.  The physician is standing facing the patient.  The physician then places his fingers under the patient’s forearms and over the transverse processes of the thoracic vertebrae.  The patient is drawn toward the physician and a superior lifting of the patient’s forearms accomplishes gentle springing and a downward pressure exerted through the fingertips.

2.     The patient I placed in the right lateral recumbent position.  The physician stands facing the patient at the side of the table.  The physician’s right forearm is slipped under the patient’s upper left arm with his fingertips on the region supero-lateral to the spinous processes.  The physician’s left hand stabilizes the shoulder, as the fingertips of the right hand are pulling toward the physician in a gentle springing maneuver to stretch the local tissues.

3.     The patient is in the prone position.  The physician stands at the side of the table facing the patient.  The physician places his right hand over the patient’s left calf; his left had is placed with is fingers forward, anterior to the contracted thoracic paraspinal musculature.  The physician affects a gentle springing motion anteriorly and superiorly with is left hand.

C:  LUMBOSACRAL STRETCHING TECHNIQUE 

1.     The patient is supine with his thighs drawn up and flexed upon his abdomen with his legs on his thighs.  The physician stands to either side grasping the patient’s knees, springing gently downward through the thighs. 

2.     The patient is supine with his legs drawn up and his feet on the table.  The physician, standing on the right side of the table, contacts the patient’s knees by his right hand and pulls toward him so that the left hand can reach across the patient and under the opposite side.  As the physician’s left hand holds its position, the patient’s knees are pushed with the right hand toward the opposite side.  This, of course, can be done to the opposite side, by reversing the procedure. 

3.     The patient is prone and the physician stands on the left and exerts a gentle deep pressure with his left hand in the right lumbar area on the right paravertebral musculature.  The physicians right hand, which is placed under the right anterior superior iliac spine is gently pulling with counter-leverage and springing with the left hand. 

4.     The patient is prone.  The physician stands at the side of the table facing the patient.  The physician places his right and on the area of the left floating rib.  The physician’s left hand crosses and contracts the crest of the ileum.  The physician separates his hands in a gentle springing (Quadrates Lumborum) motion. 

5.     The patient is prone and the right lower limb remains extended as the physician brings it across the popliteal space of the left lower limb.  The physician’s right hand holds the position of the lower extremities while the left hand produces a gentle springing motion inferiorly and laterally in the lumbar and pelvic regions.  Having the physician on the other side of the table can reverse this stretching procedure.

C.     CERVICAL TRACTION TECHNIQUE 

1.     BILATERAL FOREARM TECHNIQUE:  The patient is in the supine position.  The physician stands at the head of the table facing the patient.  The physician crosses his forearms and places them under the patient’s head with his fingers over the patient’s Clavicular area.  The physician then slowly increases pressure through flexion.

2.     SITTING TRACTION TECHNIQUE:  The patient is sitting with the physician standing behind and to the left side of the patient.  The physician places his right foot on a stool behind the patient with his right elbow resting on his right thigh.  The physician’s right hand sustains the occiput with his thumb and forefinger while the left hand sustains the forehead.  Gently elevating the right thigh and knee and then slowly releasing them produce the traction technique.

3.     SITTING LATERAL TRACTION:  The patient is sitting on a stool or bench with the physician behind, and at the side of the patient.  The physician places his right hand around the side of the patients face resting on the patient’s mandible.  The physician’s finger, one back toward the patient occiput, drawing the patient head over to the physicians chest.  The physicians opposite hand is placed on the patients far shoulder and gentle traction is applied to the head in a cephalad direction with counter-traction downward on the shoulder.  Reverse the procedure for traction of the contralateral side.

4.     SUPINE LATERAL TRACTION TECHNIQUE:  The patient is lying in the supine position.  The physician stands at the side and head of the table.  The physician places his left had on the patient’s frontal bone, and his other hand on the lateral aspect of the cervical spine along the articular facets.  The physician applies pressure on e frontal bone inferiorly, laterally and slightly caudal ward while the other hand stretches the musculature o the cervical area medially ad superiorly.  Reverse the procedure for traction of the contralateral side.

5.     SUPINE LOWER CERVICAL TECHNIQUE:  The patient is lying in the supine position.  The physician is standing at the head of the table. The patient’s head is allowed to rest on a pillow free of the palms of the palms of the physician’s hands.  The physician’s fingers are close to the cervical spine bringing anterior pressure bilaterally with slight traction through the arms of the physician.

THORACIC TRACTION

      The patient is sitting with his hands clasped behind his neck.  The physician stands behind the patient with his/her forearms under the patient’s axillae, while his/her hands are grasping the patient’s wrists reinforcing the patient’s hands.  The physician’s arms and hands simply maintain this position, while the patients, entire trunk is gently extended, rotated and laterally flexed.

LUMBAR BELT TRACTION 

     The patient is sitting astride the table near one end with his arms extended and placed forward so that his hands grasp the side of the table.  Thus, the back is held in a slight forward inclination.  The physician holds his right hand against the lumbar vertebrae and produces a gentle foreword springing motion while the physicians left hand draws gently back on the patients belt or a towel placed around the patients abdomen.

MASSAGE TECHNIQUES 

1.     PETRISAGE:  This method of tissue softening is just a simple kneading of the soft tissues. 

2.     EFFLEURAGE: a gentle stroking of the tissues utilizing the fingers and palms of the hand practices this method.  Begin effleurage at the iliac crests, working cephalad up the erector spinae to the shoulders and back down to the iliac crests using approximately 15 to 20 strokes/min.  In the beginning stages patients report a sedative effect, which after a prolonged period can become quite stimulating. 

3.     PINCEMENT:  The patient is in the prone position.  The physician stands on the side of the table at a right angle to the patient.  Use a digital and thumb contact grasping the skin and superficial fascia and lightly pinching in a circular motion.  This has a stimulating and toning effect upon the superficial muscles and breaking up any superficial fascial adhesions.  Action is 30 to 40 times/min. 

4.     ROULEMENT:  The patient is in the prone position.  The physician stands on the side of the table facing cephalad.  Grasp the skin between the thumbs and digits at the spinal base and roll the skin cephalad towards the cervicals.  Repeat procedure several times to receive a relaxing effect. 

5.     TAPOUTMENT:  The patient is in the prone position.  The physician stands on the side of the table facing cephalad.  This technique may be accomplished with the sides of the little finger and/or and.  This procedure is done extremely rapidly with the wrists held loose and the fingers bent slightly. 

6.     CUPPING:  The patient is in the prone position.  The physician stands at a right angle to the patient, facing cephalad.  This procedure always follows Tapoutment.  Your contact is digital with the hands pronated and cupped.  Begin at the base of the spine working cephalad. 

by Scott D. Neff, DC DABCO MPS-BT CFE DABFE FFABS FFAAJTS as a dedication to the medical students of our world. ©

"Why does this magnificent applied science which saves work and makes life easier, bring us little happiness? The simple answer runs, because we have not yet learned to make sensible use of it." Albert Einstein 1931