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FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
Adult Idiopathic scoliosis: The tethered spine Lucy Whyte Ferguson, D.C. a,b,c,* a
El Prado/Taos, NM, USA University of New Mexico School of Medicine: Pain Center, Albuquerque, NM, USA c Project ECHO Chronic Pain and Headache Management, Albuquerque, NM, USA b
Received 8 October 2012; received in revised form 14 April 2013; accepted 5 May 2013
KEYWORDS Scoliosis; Idiopathic Scoliosis; Adult Idiopathic Scoliosis; Myofascial Pain Syndrome; Chronic Pain; Fascial Pain; Benign Joint Hypermobility Syndrome
Summary This article reports on an observational and treatment study using three case histories to describe common patterns of muscle and fascial asymmetry in adults with idiopathic scoliosis (IS) who have significant scoliotic curvatures that were not surgically corrected and who have chronic pain. Rather than being located in the paraspinal muscles, the myofascial trigger points (TrPs) apparently responsible for the pain were located at some distance from the spine, yet referred pain to locations throughout the thoracolumbar spine. Asymmetries in these muscles appear to tether the spine in such a way that they contribute to scoliotic curvatures. Evaluation also showed that each of these individuals had major ligamentous laxity and this may also have contributed to development of scoliotic curvatures. Treatment focused on release of TrPs found to refer pain into the spine, release of related fascia, and correction of related joint dysfunction. Treatment resulted in substantial relief of longstanding chronic pain. Treatment thus validated the diagnostic hypothesis that myofascial and fascial asymmetries were to some extent responsible for pain in adults with significant scoliotic curvatures. Treatment of these patterns of TrPs and muscle and fascial asymmetries and related joint dysfunction was also effective in relieving pain in each of these individuals after they were injured in auto accidents. Treatment of myofascial TrPs and asymmetrical fascial tension along with treatment of accompanying joint dysfunction is proposed as an effective approach to treating both chronic and acute pain in adults with scoliosis that has not been surgically corrected. ª 2013 Elsevier Ltd. All rights reserved.
* University of New Mexico School of Medicine: Pain Center, Albuquerque, NM, USA. E-mail address: [email protected]. 1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.05.002
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
Journal of Bodywork & Movement Therapies (2014) 18, 99e111
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
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Background Adults with chronic pain related to IS who have major curvatures that have not been surgically corrected present various clinical challenges. In a review of almost 200 patients with IS that had not been surgically corrected, persistent pain was a problem in more than half, and the severity of pain increased linearly with both age and degree of curvature (Jackson et al., 1983). Adult scoliosis patients present predominantly with back pain; less commonly with leg pain and claudication symptoms and curve progression; rarely with neurological deficit; and almost never with cosmetic concerns (Aebi, 2005; Kuklo, 2006). Diagnostic procedures generally performed to evaluate these patients include static and dynamic imaging, myelo-CT, as well as discograms, facet blocks, epidural and nerve root blocks. MR studies may be misleading because the whole deformity is not in the same plane, and the MR study may mistakenly diagnose spinal stenosis (Aebi, 2005). Evaluation for Myofascial Pain Syndrome is not mentioned in the bulk of the scoliosis literature. Non-surgical treatment options that predominate in the literature consist of non-steroidal antiinflammatory medications, muscle relaxants, pain medication, muscle exercises, swimming, and occasionally gentle traction while “avoiding manipulations and physical activation that may increase pain” (Aebi, 2005). Certainly surgical correction of adults with scoliosis and significant neurological deficit can be appropriate when other more conservative measures do not sufficiently address the symptoms (Simmons and Jackson, 1979). But considering the surgical complications that can arise relating to osteoporosis and other medical conditions, nonunion, and nerve root paresis, and since neurological deficit is rare, it appears that other treatment options need to be investigated. When muscles have been considered in the bulk of the literature, the focus has been on the paraspinal muscles that are most visually abnormal. Back pain has been considered the expression of muscular fatigue or of a real mechanical instability. “Unbalanced, overloaded, and stressed, paravertebral back muscles may become very sore and in return will not contribute to balance the muscle play, consequently becoming part of a vicious circle.. The back pain can be constant and non-specific, which is a bad prognostic sign regarding treatment outcome” (Aebi, 2005). Spinal manipulation and spinal manipulation combined with various physiotherapeutic procedures to correct scoliotic curvatures has been largely unsuccessful (Morningstar et al., 2004). A few studies did treat scoliosis with some success and mention myofascial or neuromuscular treatment but none of these studies specifically identify referred pain from trigger points as a source of spinal pain. One case study combined manipulation under anesthesia with treatment of muscular trigger points using myofascial release techniques, percussion, and passive stretching, with good results (Morningstar and Strauchman, 2010). Another study of 19 subjects ranging from 15 to 65 years of age (adolescent and adult scoliosis patients) combined spinal manipulation with positional traction and neuromuscular reeducation, again with good results (Morningstar et al., 2004). Probably the most similar study to this case series study was a single case involving the use of Myofascial Release to treat an 18-
L. Whyte Ferguson year-old with painful scoliosis, with 12 treatments delivered over 6 weeks. The treatment resulted in reduction of pain and trunk rotation as well as improved posture, quality of life, and pulmonary function. The regimen included treatment of the psoas, bilateral rib release, and sustained pressure over the quadratus lumborum on the side of the concavity of the lumbar curvature (LeBauer et al., 2008). Abnormal quadratus lumborum tension having been identified as a factor in increasing stress on the concave side of the lumbar curvature, by approximating the lower rib cage with the iliac crest. This single case study does not explore the abnormal tension in the opposite quadratus lumborum, specifically the iliolumbar portion, the importance of which will be discussed below. Each of the studies discussed in this paragraph can be seen as encouragement regarding the importance of exploring the treatment of myofascial tension, myofascial trigger points and associated joint dysfunction in order to relieve back pain and other symptoms of the adult with IS, and hopefully thereby reducing the need for corrective surgery.
Purpose The purpose of this case study series is to explore and record observations regarding myofascial restrictions and imbalances and TrPs that appear to be responsible for the both acute and chronic pain in adults with uncorrected IS, describe the articular dysfunctions that accompany the myofascial dysfunction, and describe effective treatment methods and results. One of the most significant challenges clinicians face is treating the adult with significant uncorrected IS who has longstanding chronic pain. Treating acute pain from injury in such individuals is even more challenging. While the treatment approaches used in this study have been used to treat many adults with IS and chronic pain, these cases were selected to represent the most challenging examples likely to be seen by pain management clinicians, but not involving signs of neurological deficit. These cases were also selected because they had auto accidents and therefore they also represent the challenge of treating acute injury in the individual with a history of chronic pain and IS that has not been surgically corrected.
Methods Evaluation Three adults with significant IS that has not been surgically corrected and chronic spinal area pain were evaluated with standard orthopedic and neurological examination and were also examined for myofascial dysfunction including taut muscle bands and associated active and latent TrPs and fascial tension including fascial knots. Patterns of joint restriction were also identified via static and motion palpation. Myofascial TrPs and taut bands were identified while the myofascially involved muscles were placed on a partial stretch, the position in which it is easiest to identify active TrPs. The superficial fascial tissues overlying and deeper fascial tissues interpenetrating the muscles were also evaluated for abnormal tension in the same partial
stretch positions. The patients were also evaluated for Benign Joint Hypermobility Syndrome (BJHS) or ligamentous laxity. The specific positions used to evaluate and treat these patients are presented, along with figures, in Appendices 1e3. These positions and techniques have been published previously as measures for dealing with local or regional pain complaints such as whiplash injuries, shoulder pain, hip pain, back pain, etc. This is the first presentation of using these approaches to the treat scoliosis. The focus of the use of these techniques when treating scoliosis is the determination of which soft tissue restrictions increase stress on the scoliosis and decrease body balance, and then treating the soft tissue restrictions. For example, on the side of lumbar spine concavity, soft tissue restrictions tether or approximate the ribs and the pelvis. With the patient side lying with a pillow under the waist, the ipsilateral arm is raised in various directions, more anterior and more posterior. The ipsilateral leg is dropped into adduction in various directions, more anterior and more posterior. By performing these maneuvers, the clinician can identify and then treat the planes of greatest soft tissue restriction. On the side of lumbar spine convexity, the patient is placed side lying with a pillow under the pelvis in order to explore and then treat the soft tissue restrictions that tether the lumbar spine toward the pelvis. Again, by moving the ipsilateral arm and leg into various stretch positions, the planes of greatest restriction can be identified and treated. On each visit, each patient was examined and treated in each of the positions detailed in the appendix, with variations in the treatments determined by the functional changes and adaptations discussed further below.
101 afforded by the hydrocollator therapy. Again, the techniques used with each individual to treat joint dysfunction are selected according to the patient’s particular response pattern and the effectiveness of such techniques.
Functional change and adaptation during treatment The treatment positions described above and in the appendices allow the practitioner to assess and adapt treatment as the patterns of spinal distortion change during treatment. The word “unwinding” is used to describe the process, indicating following a sequence that appears effective in reducing patterns of spinal distortion and structural stress, step-by-step. For example, the tethering on the side of the high hip that elevates the hip toward the rib cage needs to be released first and anterior rotation the ilium on this side of the pelvis needs to be reduced, before the posterior pelvis on the opposite side can be derotated and restored to a position that better supports the spine. Without reducing that pelvic rotation so that the pelvis
Treatment All of these positions are used in order to evaluate specific taut bands, TrPs and fascial tension that may be associated with the body distortions involved in scoliosis. When the patterns of tension, TrPs, and joint dysfunction are identified and mapped out for a patient, then these same positions are also used to perform treatment, including joint mobilization, TrP release, and fascial release. Muscles with active TrPs are treated in conjunction with the associated functional unit, meaning the treatment includes agonists and antagonists because these muscles are also involved in the pattern of myofascial dysfunction. Techniques used in treatment include TrP compression/release, Fascial Manipulation, sustained tissue traction as in Myofascial Release, percussion, post isometric relaxation, and pin and stretch techniques. In other words, a range of techniques is employed allowing the practitioner to determine which techniques work best for the tissue imbalances that are involved in the scoliosis pattern for each individual patient. Moist heat is also applied to the body areas treated. To address joint restrictions and dysfunction, a range of techniques is used including high velocity manipulation, mobilization, post isometric relaxation (muscle energy), and the activator. The force required to restore improved joint mobility is lessened due to the degree of joint mobilization already performed during the myofascial release procedures and the relaxation
Figure 1 X-rays of M. This patient has an extreme version of the most common type of spinal curvature, with convexity to the left in the lumbar spine and to the right in the thoracic spine.
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Adult Idiopathic scoliosis
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
102 better supports the spine, it would be difficult to release the tethering of the spine that pulls it toward the low hip. Without releasing the muscle and fascial tensions that pull the spine toward the low hip, it would be difficult to reduce the rigidity of the rib hump on the opposite side of the torso, because there is a spiral of tension that crosses the midline. To clarify this point, while stretching the seated patient forward it is possible to notice that the fascial and muscular tension on the convex side of the lumbar curve needs to be released to a certain extent in order to reduce the tethering that crosses the spine and thus make it possible to reduce the rotational stress that extends into the thoracic spine and affects the rib hump. Then, only when the rigidity of the hump is reduced to a degree, is it possible to significantly retract the protracted scapula on that side. Only when the
Figure 2 X-rays of L. This patient has a lumbar curvature convex to the right.
L. Whyte Ferguson tethering of the scapula can be released and the scapula can be mobilized into better retraction can the stress on the ipsilateral neck muscles that results from the abnormally forward shoulder, be reduced. Treatment is thus directed at restoring more normal patterns of mobility in each restricted joint but also in larger patterns that affect body alignment, while releasing active trigger points and related muscle and fascial tension. All of these areas were treated in these patients on each visit.
Patient participation in care Patients are instructed in self stretches of the muscles with most persistent myofascial dysfunction. They are also
Figure 3 X-rays of K. This patient has an uncompensated curvature with significant head tilt.
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Figure 4 Pain referral pattern from the levator scapula muscle. Referred pain from trigger points in the levator scapula is a common source of upper interscapular and upper thoracic spinal area pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
taught self mobilization techniques to address areas of persistent joint restriction. Patients may be instructed in pelvic twists to stretch muscles and mobilize the pelvis. Patients may be instructed in self administering post isometric relaxation to address a persistently anterior ilium. Patients may also be instructed in mobilizing rib restriction: the patient lies supine on a firm surface (such as a rug or blanket on the floor) and places a small ball in a static position under each level of rib/spinal restriction for 1/2 to 2 min (until some release is experienced), while relaxing the shoulders and breathing deeply.
Observations and results Case 1 M. was initially treated at age 47 for chronic back pain of more than 20 years duration, more severe over the previous month. Her right hip was elevated with the spine deviating left in the lumbar spine, then deviating right starting at the thoracolumbar junction, with a marked rib hump on the right side. The right scapula was markedly protracted and was lower than the left, tethered by the muscle imbalances mentioned below. Her curvature was severe, 35 degrees,
Figure 5 Pain referral pattern from the Scalene muscle. Referred pain from Trigger points in the scalenes are a very common source of upper interscapular and upper thoracic spinal area pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
Adult Idiopathic scoliosis
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
104 and about 7 years after she came for treatment, she developed pulmonary hypertension (Fig. 1). The patient has significant ligamentous laxity: BJHS. Despite her history of chronic back pain, is was possible to treat and eliminate the pain by treating the muscular imbalance and TrPs in the quadratus lumborum (QL), the right iliopsoas, the right latissimus dorsi (LD), anterior serratus (AS) and right subscapularis. Joint dysfunctions treated included right femur/hip dysfunction, bilateral sacroiliac dysfunction, rotational stress at the thoracolumbar juncture, rib/spinal dysfunction at T1eT4 on the right, severely protracted right scapula, tethered toward the right hip, as well as cervical spine dysfunction at C1, C2 and C7. The unwinding process took about one year to complete, with pain shifting to different locations until the balance of shoulders, hips, and weight distribution around the curvature was stabilized. Thereafter, pain relief was good in general. She had been treated for several episodes of dizziness that responded to treatment of active trigger points in the right sternocleidomastoid muscle and joint dysfunction at C2. Due to her BJHS, and the fact that her severe scoliosis was uncorrectable, she had suffered occasional injuries to her hip, shoulder, neck, ankle, and recurrences of her back pain, but all of these problems were been treatable. The scapula protraction was also not fully correctable due to the large rib hump, so the problems in the right neck and shoulder were the most recurrent. Treatments of these problems were carried out in visits approximately once per month over a period of ten years. M. was recently significantly injured in an auto accident involving rear end impact while she was leaning far forward with her head turned, as she watched a bird in flight. The force of the impact threw her back against the seat, head rest and arm rest. Her initial complaints included headaches, neck pain and stiffness, jaw tension, shoulder pain, middle and lower back pain and stiffness, left leg pain, and difficulty sleeping. She also experienced significant fatigue, some memory difficulty, difficulty reading, problems with balance, plus left eye symptoms: redness, a feeling that the eyes were not “in sync”, and that the vision in the left eye was somewhat blurred. Her evaluation and treatment started the day after the accident. Initial treatment involved gently addressing all the areas of widespread muscle spasm and joint dysfunction using the techniques described above. Initially a vapocoolant spray was used during stretching to allow muscle release without having to handle the injured muscles excessively. As the patient improved, the patterns of persistent myofascial dysfunction were similar to the dysfunctions previously treated for her scoliosis and chronic pain. These dysfunctions localized primarily to her left side, including the left quadratus lumborum, abdominal obliques, and iliopsoas, and the most persistent myofascial dysfunction in the neck region switched from the pre-accident location on the right, to the left sternocleidomastoid and scalene muscles and related fascia. Nine months later, after 31 treatments as well as massage and self care activities and stretches, the patient’s injuries resolved almost entirely. The patient’s progress with care was monitored with self reports of pain level and frequency. For a period after the accident, the patient initially had pain ranging from a 6 to and 8 on a 10 point scale with pain frequency at a 10 on a 10 point scale. Her pre-accident pain was rated at a 2 at its
L. Whyte Ferguson worst, and a 1 in terms of pain frequency. The patient’s progress was also monitored with regard to the progressive localization of trigger point activity that correlated well with the patient’s descriptions of her progressively localizing pain. Trigger point examination by an experienced examiner has been found to be a reliable assessment tool (Gerwin et al., 1997) and is therefore used as an objective
Figure 6 Pain referral pattern from the latissimus dorsi muscle. Referred pain from trigger points in the latissimus dorsi is a very common source of lower interscapular pain, and middle back spinal pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
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Figure 7 Pain referral pattern from the anterior serratus muscle. Referred pain from trigger points in the anterior serratus muscle is a common source of lower interscapular and middle back spinal pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
measure of the patient’s progress. The patient returned to her pre-accident status with the exception of: recurrent stiffness and discomfort in the left waist area that she was able to relieve with stretches; neck stiffness and reduction of right rotation; and some continued difficulty with left eye coordination. There remained fascial tension in the left quadratus lumborum area and the left scalene area. The left scalene tension occurred when turning the head to the right. The active trigger points in these areas that resulted from the accident resolved.
and struck her vehicle in the left rear. She developed bilateral neck and back pain and left hip pain. Treatment started 10 days after the accident and she was released from care for the accident after 16 visits over the course
Case 2 L. age 42, had back pain of varying degrees of severity over many years. She remembered being in chronic recurrent pain from the age of 15 and cried when talking about all of the activities that she could not engage in due to her pain and how her pain increased whenever she had to stand for a long period of time. Pain was generally in the right lower back and she experienced swelling in the right paraspinal region that accompanied the pain. She may have originally injured her back as a child, when she was bucked off a horse. Two and a half years before her evaluation, she learned that she had a 40 lumbar scoliosis (Fig. 2). The patient has significant ligamentous laxity: BJHS. TrPs were active in bilateral QL, the right LD and iliopsoas muscles as well as some TrPs in the paraspinal muscles. There was tenderness and restricted mobility at multiple spinal levels between T10 and L5 and bilateral sacroiliac joints, and the right femur/hip joint. Nine treatment visits performed over 4 months resulted in the patient’s condition stabilizing. The patient no longer had increased pain when standing for lengthy periods, and she could resume normal activities. Thereafter, she was treated for occasional aggravations associated with long car drives or lifting and packing for a move. L. was injured in an auto accident when vehicle and the one behind her hit a patch of ice. Although she was able to slow and regain control, the vehicle behind her could not
Figure 8 Pain referral pattern from the quadratus lumborum muscle. Referred pain from trigger points in the quadratus lumborum muscle is a very common source of lower back, pelvis, and buttock pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 2. The lower Extremities, by Janet G. Travell and David G. Simons, Baltimore, 1983.
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Adult Idiopathic scoliosis
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106 of 5 months. The progressive localization of the patient’s descriptions of her pain correlated well with the progressive localization of trigger point activity. Upon completion of care, the patient stated that she had occasional pain in the left lateral hip that was manageable with exercises and stretching and was occasionally aggravated by long driving or longstanding. She also had some residual neck tension that was also manageable with stretches. Upon final examination, there was tenderness and slight swelling at the piriformis attachment at the left greater trochanter and there was some residual fascial tension particularly over and interpenetrating the scalene muscles. However the active trigger points in these and other injured muscles had resolved and joint dysfunction had markedly decreased. The patient’s condition was assessed as reasonably stable and manageable with the patient’s independent exercise.
Case 3 K. has IS that was not surgically corrected and was originally treated at age 38 for chronic headaches as well as recurrent back pain. He has Marfan’s Syndrome, including various manifestations of connective tissue disorder such as an aortic aneurysm that was under observation (Fig. 3). The patient also has ligamentous laxity: BJHS. The pattern of Myofascial Dysfunction was similar to that described in Cases 1 and 2, with the addition of TrPs in the left upper trapezius and sternocleidomastoid muscles. The right hip was higher than the left, the thoracolumbar scoliosis had an apex left at T11/T12 apex right at T4/T5, and involved a leftward leaning neck with right lateral flexion of the head on the neck, including C1. Restoring torso balance to the extent possible, balancing the pelvis, scapulae, and head position, and reducing overall distortion by approximately
L. Whyte Ferguson 30% in 2 visits over a 2 week period made it possible to treat his chronic headaches and recurrent back pain. Four treatments over the next 5 months resulted in reduction of the severity and frequency of his headaches, although he had some recurrent neck soreness. He required treatment approximately once every 2 to 3 months thereafter, to address recurrences of neck pain, neck and back stiffness, or any increase in headache frequency and severity. He was subsequently treated for injuries sustained in an auto accident and the same areas of muscle and joint dysfunction addressed previously had to be addressed again involving 16 visits over the year following the accident. The bulk of his accident care was conducted during the first six months following the accident, but the patient had recurrent exacerbations that were treated over the next six months until the condition stabilized. The progressive localization of his pain complaints correlated well with the progressive localization of trigger point activity. He returned essentially to his pre-injury status with this course of care.
Summary of observations and results The following original observations are based on similarities in the patterns of fascial restriction and myofascial dysfunction in these three cases. Asymmetry in length of certain muscles and related fascial layers was found critical to treatment of IS in all three patients: QL, LD, iliopsoas, AS, and subscapularis. In all three, QL and iliopsoas and related fascia were found to play a key role in affecting tilt of the lumbar spine and pelvis. These muscles have angular or off center attachments and thus can pull the spine into distortion relative to the pelvis. Different parts of the QL were shortened on both convex and concave sides. On the concave side, usually the side of hip elevation, the iliocostal portion
Figure 9 Pain referral pattern from the iliopsoas muscle. Referred pain from trigger points in the iliopsoas muscle is a very common source of lower back pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 2. The lower Extremities, by Janet G. Travell and David G. Simons, Baltimore, 1983.
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of the QL was shortened. On the convex side, generally the side on which the lumbar spine and lower rib cage are pulled down toward the hip, the iliolumbar portion of the QL was shortened. The LD, AS, and subscapularis and related fascia played a key role in rib cage mobility and tethering the scapula and appear to exert mechanical force due to their peripheral rather than central location. When the curve also involved the cervical spine, asymmetrical tension in the scalenes, levator scapulae, and sternocleidomastoid muscles and related fascia were involved in these curvatures. Referred pain patterns for TrPs in these muscles encompass the entire thoracolumbar spine (Simons et al., 1999; Travell and Simons, 1983) (Figs 4e9) Muscular forces are compounded by significant asymmetry in fascial tension, particularly along diagonal and spiral lines that accompany the force lines of the muscular asymmetries described above.
Conclusions There are common patterns of myofascial TrPs and asymmetrical muscle and fascial tension in adult patients with longstanding chronic pain and significant IS that has not been surgically corrected. BJHS is a common factor for most of these individuals. Although the paraspinal muscles appear most abnormal and different from one side of the spine to the other, other muscles, located at an angle to the spine and that have TrPs with patterns of pain referral to the spine, appear to be most responsible for spinal pain as well as possibly playing an important role in spinal distortion, scapula tethering and the dynamics of rib restriction. These conclusions are drawn from reasonably successful pain management results when the treatments methods described are applied to these challenging patients for treating both chronic and acute musculoskeletal pain. Further research is needed to compare this form of treatment with other methods, with regard to pain management, but also with regard to curve progression, pulmonary function, and quality of life issues.
Appendix 1. Seated evaluation and treatment The patient is taken through cervical passive range of motion to evaluate the length of the neck muscles and find taut bands and TrPs. Flexion is performed to evaluate semispinalis and splenius cervicis and capitis muscles. Lateral flexion with rotation is performed to stretch the levator scapulae muscles. Lateral flexion is performed to stretch the upper trapezius muscles. Extension with various degrees of rotation is performed to stretch the various portions of the scalenes and the sternocleidomastoid muscles. Planes of fascial restriction are also identified using these procedures. In these positions, the cervical facet joints are evaluated for tenderness and restriction. The upper rib/spinal joints are also evaluated for tenderness and restriction (Fig. A1). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously. Initial stretches of shoulder muscles are also performed in this position, including pectoral, biceps, subscapularis, teres minor and major, infraspinatus, and latissimus dorsi muscles. Planes of fascial restriction are identified while
Figure Appendix 1 Combining muscle stretch and joint mobilization. During passive stretch of the levator scapula muscle and associated fascia, the clinician uses the pressure of the flat of the forearm, just above the elbow, to gently depress the 1st rib and mobilize the rib-thoracic joint. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
taking the arm and shoulder through these stretch positions. Protraction of the scapulae is evaluated in this position, and the humerus position within the glenoid is evaluated to determine how centered the humerus is within the glenoid (Fig. A2). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously. The thoracolumbar paraspinals are also stretched while forward flexing the torso, with the scapulae protracted. In this position, the tenderness and restrictions at rib/spinal joints and in the lumbar spine are evaluated. Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
Appendix 2. Side lying evaluation and treatment To evaluate the length of the shoulder muscles and the tension in the anterior joint capsule, the practitioner’s thumb is placed under the pectoral muscle and anterior joint capsule to introduce stretch. The thumb or fingers are placed under the scapula to evaluate the stretch of the subscapularis and anterior serratus, and the posterior joint capsule, by mobilizing the scapula towards the spine (Fig. A3a and b). The patient’s arm is also fully abducted to evaluate the length of the latissimus dorsi and identify TrPs. A pillow under the patient’s waist assists in making it possible to take the latissimus dorsi into a full stretch position (Fig. A4). By taking the arm both up and back, the clinician can identify whether the latissimus dorsi tension is part of a restricted fascial plane that extends into the oblique abdominals and toward the groin or pubic symphysis. By taking the arm up and forward, the clinician can identify whether the latissimus dorsi tension is part of a
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Adult Idiopathic scoliosis
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Figure Appendix 2 The clinician stretches the pectoral muscles of the seated patient. The clinician hooks both hands under the lateral border of the pectoral muscles. The chair and the muscle shortness provide the resistance, and the clinician leans back and maintains a gentle but firm upward and anterior to posterior pull on the muscles and fascia as they stretch. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
restricted fascial plane that extends toward the posterior pelvis. The scapula and clavicle are mobilized inferiorly to evaluate for taut bands and TrPs and fascial restrictions in the anterior and posterior neck muscles. Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
L. Whyte Ferguson
Figure Appendix 4 Therapeutic stretch of the latissimus dorsi muscle. To stretch the right latissimus dorsi muscle, the clinician uses the left hand to hold the patient’s arm between the shoulder and the elbow. The other hand presses against the pelvic brim, so that the brim is moved away from the shoulder. A pillow is placed under the patient’s waist to provide more stretch to this long, slack muscle. The direction of stretch is downward (caudally) at the waist and upward (rostrally directed) at the arm. This stretch also stretches the subscapularis and teres major muscles and associated fascia. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
Figure Appendix 3 With the thumb under the scapula, the clinician mobilizes the scapula toward the spine. a. The humerus is elevated to insert the thumb under the lateral border of the scapula. The thumb provides sustained pressure against the trigger points and taut bands in the subscapularis and anterior serratus that are resisting the mobilization, until they release sufficiently to allow some gain in translating the scapula medially and inferiorly toward the spine. b. The other hand may simultaneously stretch the taut pectoral muscles and associated fascia. The thumb is inserted under the lateral border of the pectoral muscle pressing upward and backward to elongate taut bands. The net effect is that the humerus translates up and back and eventually down in a semicircular motion while the scapula translates inferiorly toward the spine. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
Figure Appendix 5 The side-lying position for evaluation and stretch release of the iliopsoas (and quadriceps) muscles and associated fascia. The clinician stabilizes the lumbosacral spine so that extension is focused at the hip. This is an ideal position in which to perform contract-relax-release and contract-relax-assist. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
To evaluate asymmetrical patterns of muscle and related fascial tension in the torso that affect hip imbalance, the patient is placed side-lying with the side of the high hip up, and a pillow under the waist. Often the elevated hip is also the forward hip. The hip is mobilized and dropped posterior and inferior, away from the rib cage. In this position, the length of the paraspinal muscles and the quadratus lumborum can be evaluated, and the tenderness and restriction of lumbar facet joints can also be assessed as well as tenderness and restriction of the sacroiliac joints. The thigh is stretched inferiorward, antero-inferior and postero-inferior in order to stretch the tensor fascia lata, the gluteus medius, minimus, and maximus, as well as the piriformis muscles and the fascia are stretched in these positions as well. The thigh is also stretched into extension in order to evaluate the length of the iliopsoas muscles (Figs. A5,A6). These same maneuvers are performed on the other side of the back, buttock and hip, but because this is the side of the low hip and the side that the lumbar spine tends to deviate toward, the pillow or pillows are placed under the hip rather than under the waist, and the stretching maneuvers are conducted to drop the rib cage and lumbar spine away from the hip and discern the degree of tautness in the quadratus lumborum and paraspinal muscles and related fascia. Because the pelvis is
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Figure Appendix 6 The side-lying position for the evaluation and stretch release of the quadratus lumborum and internal oblique abdominal muscles and associated fascia. A pillow is used under the waist, to enhance the separation of the rib cage and the pelvis (with the thigh posterior). The leg then should be placed forward, and different taut bands will be palpated in the quadratus lumborum, and taut bands in the external oblique abdominal muscle and associated fascia will be easier to palpate. Contract-relax-release can be performed in this position, with the clinician stabilizing at the lower rib cage and the relax-release can be performed in this position, with the clinician stabilizing at the lower rib cage and the top of the ilium. The rib cage is passively stretched away from the ilium, until tissue tension is reached, and then the patient is asked to contract (gently for a count of 4) and then release, and then the clinician stretches the ribs away from the iliac crest until a new barrier is reached, and the procedure is repeated. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
usually torqued posterior on the side of the low hip and convexity of the lumbar curvature, the sacroiliac restriction is explored in this position in order to determine what joint and soft tissue restrictions need to be addressed to “square up” the pelvis better under the lumbar spine. Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
Appendix 3. Prone evaluation and treatment In a prone position, mobility of the scapulae can be assessed. Often in the scoliosis patient, one scapula is elevated relative to the other, and one scapula is more protracted than the other. In this position, the length and relative tension of the muscles and fascia that affect scapula position can be assessed. Latissimus dorsi tension and taut bands, and that of the anterior serratus can be palpated by tractioning the scapulae cephalad and medially, toward the spine. The scapula can be lifted away from the lateral rib cage to evaluate the subscapularis tension. The pectoral muscle tension can be evaluated in
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Figure Appendix 7 Assessing shortness of the latissimus dorsi muscles and associated fascia. The clinician grasps one posterior axillary fold in each hand and feels the relative tension between each shoulder and the ipsilateral hip. In this case, the patient’s left latissimus dorsi muscle is more shortened. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
L. Whyte Ferguson scapula and humerus (Fig. A8). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously. In this position, the high ilium can be tractioned inferiorly to assess which muscles and fascia are short and contributing to hip elevation, including paraspinals, quadratus lumborum, and abdominal obliques. On the side of the low hip and the lumbar deviation toward the hip, the rib cage can be tractioned away from the hip to identify which muscles and fascia are shortened. By palpating under the torso, from the central sub-diaphragm area down toward the lesser trochanter of the femur, while internally rotating the femur, the specific locations of psoas tension and tenderness and TrPs can be evaluated along with fascial tension. By palpating from the medial border of the ilium to the lesser trochanter, the degree of iliacus tension can be
this position also, by reaching under the shoulder and palpating and stretching the underside of the pectoral muscle (Fig. A7). Fascial tension planes are also identified during these maneuvers. Joint restriction is also identified in this manner. The scapula and clavicle can be tractioned inferiorly to evaluate the scalene, levator scapula, and upper trapezius muscle and related fascial tension and the supraspinatus muscle can be stretched by tractioning caudally on the
Figure Appendix 8 Combining traction and trigger point pressure release. With the patient in a prone position, the clinician can combine gentle traction on the arm with trigger point pressure release, to accomplish muscle and fascial elongation and treat remaining trigger points in the anterior border of the upper trapezius muscle and the pressure can also be shifted to the levator scapula and the posterior scalene muscle. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
Figure Appendix 9 Prone palpation and trigger point pressure release treatment of the iliopsoas muscle and related fascia. For the clinician learning this technique, it is easiest to start with the treating hand contacting the iliacus muscle just inside the anterior iliac border (A). The lower leg is guided laterally to produce internal rotation of the thigh, until the clinician can feel the increased tension in the bands of the iliacus muscle against the fingers of the treating hand. The clinician treats tender knots in the taut bands of muscles simply by maintaining pressure with the finger tips while gently internally rotating the thigh and the treating hand gradually advances caudally, toward the insertion of the common iliopsoas tendon at the lesser trochanter (B). From this position, the clinician can follow the tension in the taut bands of the psoas muscle upward toward the origin at the lateral portion of each lumbar vertebra, near the navel and diaphragm (C). The hand that stabilizes the flexed leg can gently provide a combination of traction, abduction, and internal rotation until the desired tension is achieved. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
evaluated. The degree of adductor and medial hamstring tension can also be evaluated in this position (Fig. A9). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
References Aebi, M., 2005. The adult scoliosis. European Spine Journal 14, 925e948. Gerwin, R.D., Shannon, S., Hong, C.Z., Hubbard, D., Gevirtz, R., 1997. Interrater reliability in myofascial trigger point examination. Pain 69, 65e73. Jackson, R.P., Simmons, E.H., Stripinis, D., 1983. Incidence and severity of back pain in adult idiopathic scoliosis. Spine 8 (7), 749e756. Kuklo, T.R., 2006. Principles for selecting fusion levels in adult spinal deformity with particular attention to lumbar curves and double major curves. Spine 31 (19), S132eS138.
111 LeBauer, A., Brtalik, R., Stowe, K., 2008. The effect of myofascial release (MFR) on an adult with idiopathic scoliosis. Journal of Bodywork and Movement Therapies 12, 356e363. Morningstar, M.W., Woggon, D., Lawrence, G., 2004. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BioMed Central Musculoskeletal Disorders 5, 32. Morningstar, M.W., Strauchman, M.N., 2010. Management of a 59year-old female patient with adult degenerative scoliosis using manipulation under anesthesia. Journal of Chiropractic Medicine 9 (2), 77e83. Simmons, E.H., Jackson, R.P., 1979. The management of nerve root entrapment syndromes associated with the collapsing scoliosis of idiopathic lumbar and thoracolumbar curves. Spine 4 (6), 533e541. Simons, D.G., Travell, J.G., Simons, L.S., 1999. Myofascial Pain and Dysfunction, the Trigger Point Manual. In: Upper Half of Body, second ed., vol. 1. Lippincott Williams & Wilkins, Balti-more. Travell, J.G., Simons, D.G., 1983. Myofascial Pain and Dysfunction, the Trigger Point Manual. In: The Lower Extremities, vol. 2. Lippincott Williams & Wilkins, Baltimore.
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
Adult Idiopathic scoliosis
journal homepage: www.elsevier.com/jbmt
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
Adult Idiopathic scoliosis: The tethered spine Lucy Whyte Ferguson, D.C. a,b,c,* a
El Prado/Taos, NM, USA University of New Mexico School of Medicine: Pain Center, Albuquerque, NM, USA c Project ECHO Chronic Pain and Headache Management, Albuquerque, NM, USA b
Received 8 October 2012; received in revised form 14 April 2013; accepted 5 May 2013
KEYWORDS Scoliosis; Idiopathic Scoliosis; Adult Idiopathic Scoliosis; Myofascial Pain Syndrome; Chronic Pain; Fascial Pain; Benign Joint Hypermobility Syndrome
Summary This article reports on an observational and treatment study using three case histories to describe common patterns of muscle and fascial asymmetry in adults with idiopathic scoliosis (IS) who have significant scoliotic curvatures that were not surgically corrected and who have chronic pain. Rather than being located in the paraspinal muscles, the myofascial trigger points (TrPs) apparently responsible for the pain were located at some distance from the spine, yet referred pain to locations throughout the thoracolumbar spine. Asymmetries in these muscles appear to tether the spine in such a way that they contribute to scoliotic curvatures. Evaluation also showed that each of these individuals had major ligamentous laxity and this may also have contributed to development of scoliotic curvatures. Treatment focused on release of TrPs found to refer pain into the spine, release of related fascia, and correction of related joint dysfunction. Treatment resulted in substantial relief of longstanding chronic pain. Treatment thus validated the diagnostic hypothesis that myofascial and fascial asymmetries were to some extent responsible for pain in adults with significant scoliotic curvatures. Treatment of these patterns of TrPs and muscle and fascial asymmetries and related joint dysfunction was also effective in relieving pain in each of these individuals after they were injured in auto accidents. Treatment of myofascial TrPs and asymmetrical fascial tension along with treatment of accompanying joint dysfunction is proposed as an effective approach to treating both chronic and acute pain in adults with scoliosis that has not been surgically corrected. ª 2013 Elsevier Ltd. All rights reserved.
* University of New Mexico School of Medicine: Pain Center, Albuquerque, NM, USA. E-mail address: [email protected]. 1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.05.002
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Journal of Bodywork & Movement Therapies (2014) 18, 99e111
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Background Adults with chronic pain related to IS who have major curvatures that have not been surgically corrected present various clinical challenges. In a review of almost 200 patients with IS that had not been surgically corrected, persistent pain was a problem in more than half, and the severity of pain increased linearly with both age and degree of curvature (Jackson et al., 1983). Adult scoliosis patients present predominantly with back pain; less commonly with leg pain and claudication symptoms and curve progression; rarely with neurological deficit; and almost never with cosmetic concerns (Aebi, 2005; Kuklo, 2006). Diagnostic procedures generally performed to evaluate these patients include static and dynamic imaging, myelo-CT, as well as discograms, facet blocks, epidural and nerve root blocks. MR studies may be misleading because the whole deformity is not in the same plane, and the MR study may mistakenly diagnose spinal stenosis (Aebi, 2005). Evaluation for Myofascial Pain Syndrome is not mentioned in the bulk of the scoliosis literature. Non-surgical treatment options that predominate in the literature consist of non-steroidal antiinflammatory medications, muscle relaxants, pain medication, muscle exercises, swimming, and occasionally gentle traction while “avoiding manipulations and physical activation that may increase pain” (Aebi, 2005). Certainly surgical correction of adults with scoliosis and significant neurological deficit can be appropriate when other more conservative measures do not sufficiently address the symptoms (Simmons and Jackson, 1979). But considering the surgical complications that can arise relating to osteoporosis and other medical conditions, nonunion, and nerve root paresis, and since neurological deficit is rare, it appears that other treatment options need to be investigated. When muscles have been considered in the bulk of the literature, the focus has been on the paraspinal muscles that are most visually abnormal. Back pain has been considered the expression of muscular fatigue or of a real mechanical instability. “Unbalanced, overloaded, and stressed, paravertebral back muscles may become very sore and in return will not contribute to balance the muscle play, consequently becoming part of a vicious circle.. The back pain can be constant and non-specific, which is a bad prognostic sign regarding treatment outcome” (Aebi, 2005). Spinal manipulation and spinal manipulation combined with various physiotherapeutic procedures to correct scoliotic curvatures has been largely unsuccessful (Morningstar et al., 2004). A few studies did treat scoliosis with some success and mention myofascial or neuromuscular treatment but none of these studies specifically identify referred pain from trigger points as a source of spinal pain. One case study combined manipulation under anesthesia with treatment of muscular trigger points using myofascial release techniques, percussion, and passive stretching, with good results (Morningstar and Strauchman, 2010). Another study of 19 subjects ranging from 15 to 65 years of age (adolescent and adult scoliosis patients) combined spinal manipulation with positional traction and neuromuscular reeducation, again with good results (Morningstar et al., 2004). Probably the most similar study to this case series study was a single case involving the use of Myofascial Release to treat an 18-
L. Whyte Ferguson year-old with painful scoliosis, with 12 treatments delivered over 6 weeks. The treatment resulted in reduction of pain and trunk rotation as well as improved posture, quality of life, and pulmonary function. The regimen included treatment of the psoas, bilateral rib release, and sustained pressure over the quadratus lumborum on the side of the concavity of the lumbar curvature (LeBauer et al., 2008). Abnormal quadratus lumborum tension having been identified as a factor in increasing stress on the concave side of the lumbar curvature, by approximating the lower rib cage with the iliac crest. This single case study does not explore the abnormal tension in the opposite quadratus lumborum, specifically the iliolumbar portion, the importance of which will be discussed below. Each of the studies discussed in this paragraph can be seen as encouragement regarding the importance of exploring the treatment of myofascial tension, myofascial trigger points and associated joint dysfunction in order to relieve back pain and other symptoms of the adult with IS, and hopefully thereby reducing the need for corrective surgery.
Purpose The purpose of this case study series is to explore and record observations regarding myofascial restrictions and imbalances and TrPs that appear to be responsible for the both acute and chronic pain in adults with uncorrected IS, describe the articular dysfunctions that accompany the myofascial dysfunction, and describe effective treatment methods and results. One of the most significant challenges clinicians face is treating the adult with significant uncorrected IS who has longstanding chronic pain. Treating acute pain from injury in such individuals is even more challenging. While the treatment approaches used in this study have been used to treat many adults with IS and chronic pain, these cases were selected to represent the most challenging examples likely to be seen by pain management clinicians, but not involving signs of neurological deficit. These cases were also selected because they had auto accidents and therefore they also represent the challenge of treating acute injury in the individual with a history of chronic pain and IS that has not been surgically corrected.
Methods Evaluation Three adults with significant IS that has not been surgically corrected and chronic spinal area pain were evaluated with standard orthopedic and neurological examination and were also examined for myofascial dysfunction including taut muscle bands and associated active and latent TrPs and fascial tension including fascial knots. Patterns of joint restriction were also identified via static and motion palpation. Myofascial TrPs and taut bands were identified while the myofascially involved muscles were placed on a partial stretch, the position in which it is easiest to identify active TrPs. The superficial fascial tissues overlying and deeper fascial tissues interpenetrating the muscles were also evaluated for abnormal tension in the same partial
stretch positions. The patients were also evaluated for Benign Joint Hypermobility Syndrome (BJHS) or ligamentous laxity. The specific positions used to evaluate and treat these patients are presented, along with figures, in Appendices 1e3. These positions and techniques have been published previously as measures for dealing with local or regional pain complaints such as whiplash injuries, shoulder pain, hip pain, back pain, etc. This is the first presentation of using these approaches to the treat scoliosis. The focus of the use of these techniques when treating scoliosis is the determination of which soft tissue restrictions increase stress on the scoliosis and decrease body balance, and then treating the soft tissue restrictions. For example, on the side of lumbar spine concavity, soft tissue restrictions tether or approximate the ribs and the pelvis. With the patient side lying with a pillow under the waist, the ipsilateral arm is raised in various directions, more anterior and more posterior. The ipsilateral leg is dropped into adduction in various directions, more anterior and more posterior. By performing these maneuvers, the clinician can identify and then treat the planes of greatest soft tissue restriction. On the side of lumbar spine convexity, the patient is placed side lying with a pillow under the pelvis in order to explore and then treat the soft tissue restrictions that tether the lumbar spine toward the pelvis. Again, by moving the ipsilateral arm and leg into various stretch positions, the planes of greatest restriction can be identified and treated. On each visit, each patient was examined and treated in each of the positions detailed in the appendix, with variations in the treatments determined by the functional changes and adaptations discussed further below.
101 afforded by the hydrocollator therapy. Again, the techniques used with each individual to treat joint dysfunction are selected according to the patient’s particular response pattern and the effectiveness of such techniques.
Functional change and adaptation during treatment The treatment positions described above and in the appendices allow the practitioner to assess and adapt treatment as the patterns of spinal distortion change during treatment. The word “unwinding” is used to describe the process, indicating following a sequence that appears effective in reducing patterns of spinal distortion and structural stress, step-by-step. For example, the tethering on the side of the high hip that elevates the hip toward the rib cage needs to be released first and anterior rotation the ilium on this side of the pelvis needs to be reduced, before the posterior pelvis on the opposite side can be derotated and restored to a position that better supports the spine. Without reducing that pelvic rotation so that the pelvis
Treatment All of these positions are used in order to evaluate specific taut bands, TrPs and fascial tension that may be associated with the body distortions involved in scoliosis. When the patterns of tension, TrPs, and joint dysfunction are identified and mapped out for a patient, then these same positions are also used to perform treatment, including joint mobilization, TrP release, and fascial release. Muscles with active TrPs are treated in conjunction with the associated functional unit, meaning the treatment includes agonists and antagonists because these muscles are also involved in the pattern of myofascial dysfunction. Techniques used in treatment include TrP compression/release, Fascial Manipulation, sustained tissue traction as in Myofascial Release, percussion, post isometric relaxation, and pin and stretch techniques. In other words, a range of techniques is employed allowing the practitioner to determine which techniques work best for the tissue imbalances that are involved in the scoliosis pattern for each individual patient. Moist heat is also applied to the body areas treated. To address joint restrictions and dysfunction, a range of techniques is used including high velocity manipulation, mobilization, post isometric relaxation (muscle energy), and the activator. The force required to restore improved joint mobility is lessened due to the degree of joint mobilization already performed during the myofascial release procedures and the relaxation
Figure 1 X-rays of M. This patient has an extreme version of the most common type of spinal curvature, with convexity to the left in the lumbar spine and to the right in the thoracic spine.
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
Adult Idiopathic scoliosis
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
102 better supports the spine, it would be difficult to release the tethering of the spine that pulls it toward the low hip. Without releasing the muscle and fascial tensions that pull the spine toward the low hip, it would be difficult to reduce the rigidity of the rib hump on the opposite side of the torso, because there is a spiral of tension that crosses the midline. To clarify this point, while stretching the seated patient forward it is possible to notice that the fascial and muscular tension on the convex side of the lumbar curve needs to be released to a certain extent in order to reduce the tethering that crosses the spine and thus make it possible to reduce the rotational stress that extends into the thoracic spine and affects the rib hump. Then, only when the rigidity of the hump is reduced to a degree, is it possible to significantly retract the protracted scapula on that side. Only when the
Figure 2 X-rays of L. This patient has a lumbar curvature convex to the right.
L. Whyte Ferguson tethering of the scapula can be released and the scapula can be mobilized into better retraction can the stress on the ipsilateral neck muscles that results from the abnormally forward shoulder, be reduced. Treatment is thus directed at restoring more normal patterns of mobility in each restricted joint but also in larger patterns that affect body alignment, while releasing active trigger points and related muscle and fascial tension. All of these areas were treated in these patients on each visit.
Patient participation in care Patients are instructed in self stretches of the muscles with most persistent myofascial dysfunction. They are also
Figure 3 X-rays of K. This patient has an uncompensated curvature with significant head tilt.
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Figure 4 Pain referral pattern from the levator scapula muscle. Referred pain from trigger points in the levator scapula is a common source of upper interscapular and upper thoracic spinal area pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
taught self mobilization techniques to address areas of persistent joint restriction. Patients may be instructed in pelvic twists to stretch muscles and mobilize the pelvis. Patients may be instructed in self administering post isometric relaxation to address a persistently anterior ilium. Patients may also be instructed in mobilizing rib restriction: the patient lies supine on a firm surface (such as a rug or blanket on the floor) and places a small ball in a static position under each level of rib/spinal restriction for 1/2 to 2 min (until some release is experienced), while relaxing the shoulders and breathing deeply.
Observations and results Case 1 M. was initially treated at age 47 for chronic back pain of more than 20 years duration, more severe over the previous month. Her right hip was elevated with the spine deviating left in the lumbar spine, then deviating right starting at the thoracolumbar junction, with a marked rib hump on the right side. The right scapula was markedly protracted and was lower than the left, tethered by the muscle imbalances mentioned below. Her curvature was severe, 35 degrees,
Figure 5 Pain referral pattern from the Scalene muscle. Referred pain from Trigger points in the scalenes are a very common source of upper interscapular and upper thoracic spinal area pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
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Adult Idiopathic scoliosis
FASCIA SCIENCE AND CLINICAL APPLICATIONS: ADULT IDIOPATHIC SCOLIOSIS: OBSERVATIONAL AND TREATMENT STUDY (3 CASES)
104 and about 7 years after she came for treatment, she developed pulmonary hypertension (Fig. 1). The patient has significant ligamentous laxity: BJHS. Despite her history of chronic back pain, is was possible to treat and eliminate the pain by treating the muscular imbalance and TrPs in the quadratus lumborum (QL), the right iliopsoas, the right latissimus dorsi (LD), anterior serratus (AS) and right subscapularis. Joint dysfunctions treated included right femur/hip dysfunction, bilateral sacroiliac dysfunction, rotational stress at the thoracolumbar juncture, rib/spinal dysfunction at T1eT4 on the right, severely protracted right scapula, tethered toward the right hip, as well as cervical spine dysfunction at C1, C2 and C7. The unwinding process took about one year to complete, with pain shifting to different locations until the balance of shoulders, hips, and weight distribution around the curvature was stabilized. Thereafter, pain relief was good in general. She had been treated for several episodes of dizziness that responded to treatment of active trigger points in the right sternocleidomastoid muscle and joint dysfunction at C2. Due to her BJHS, and the fact that her severe scoliosis was uncorrectable, she had suffered occasional injuries to her hip, shoulder, neck, ankle, and recurrences of her back pain, but all of these problems were been treatable. The scapula protraction was also not fully correctable due to the large rib hump, so the problems in the right neck and shoulder were the most recurrent. Treatments of these problems were carried out in visits approximately once per month over a period of ten years. M. was recently significantly injured in an auto accident involving rear end impact while she was leaning far forward with her head turned, as she watched a bird in flight. The force of the impact threw her back against the seat, head rest and arm rest. Her initial complaints included headaches, neck pain and stiffness, jaw tension, shoulder pain, middle and lower back pain and stiffness, left leg pain, and difficulty sleeping. She also experienced significant fatigue, some memory difficulty, difficulty reading, problems with balance, plus left eye symptoms: redness, a feeling that the eyes were not “in sync”, and that the vision in the left eye was somewhat blurred. Her evaluation and treatment started the day after the accident. Initial treatment involved gently addressing all the areas of widespread muscle spasm and joint dysfunction using the techniques described above. Initially a vapocoolant spray was used during stretching to allow muscle release without having to handle the injured muscles excessively. As the patient improved, the patterns of persistent myofascial dysfunction were similar to the dysfunctions previously treated for her scoliosis and chronic pain. These dysfunctions localized primarily to her left side, including the left quadratus lumborum, abdominal obliques, and iliopsoas, and the most persistent myofascial dysfunction in the neck region switched from the pre-accident location on the right, to the left sternocleidomastoid and scalene muscles and related fascia. Nine months later, after 31 treatments as well as massage and self care activities and stretches, the patient’s injuries resolved almost entirely. The patient’s progress with care was monitored with self reports of pain level and frequency. For a period after the accident, the patient initially had pain ranging from a 6 to and 8 on a 10 point scale with pain frequency at a 10 on a 10 point scale. Her pre-accident pain was rated at a 2 at its
L. Whyte Ferguson worst, and a 1 in terms of pain frequency. The patient’s progress was also monitored with regard to the progressive localization of trigger point activity that correlated well with the patient’s descriptions of her progressively localizing pain. Trigger point examination by an experienced examiner has been found to be a reliable assessment tool (Gerwin et al., 1997) and is therefore used as an objective
Figure 6 Pain referral pattern from the latissimus dorsi muscle. Referred pain from trigger points in the latissimus dorsi is a very common source of lower interscapular pain, and middle back spinal pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
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Figure 7 Pain referral pattern from the anterior serratus muscle. Referred pain from trigger points in the anterior serratus muscle is a common source of lower interscapular and middle back spinal pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 1. Upper half of body, 2nd edition, by David G. Simons, Janet G. Travell, and Lois S. Simons, Baltimore, 1999.
measure of the patient’s progress. The patient returned to her pre-accident status with the exception of: recurrent stiffness and discomfort in the left waist area that she was able to relieve with stretches; neck stiffness and reduction of right rotation; and some continued difficulty with left eye coordination. There remained fascial tension in the left quadratus lumborum area and the left scalene area. The left scalene tension occurred when turning the head to the right. The active trigger points in these areas that resulted from the accident resolved.
and struck her vehicle in the left rear. She developed bilateral neck and back pain and left hip pain. Treatment started 10 days after the accident and she was released from care for the accident after 16 visits over the course
Case 2 L. age 42, had back pain of varying degrees of severity over many years. She remembered being in chronic recurrent pain from the age of 15 and cried when talking about all of the activities that she could not engage in due to her pain and how her pain increased whenever she had to stand for a long period of time. Pain was generally in the right lower back and she experienced swelling in the right paraspinal region that accompanied the pain. She may have originally injured her back as a child, when she was bucked off a horse. Two and a half years before her evaluation, she learned that she had a 40 lumbar scoliosis (Fig. 2). The patient has significant ligamentous laxity: BJHS. TrPs were active in bilateral QL, the right LD and iliopsoas muscles as well as some TrPs in the paraspinal muscles. There was tenderness and restricted mobility at multiple spinal levels between T10 and L5 and bilateral sacroiliac joints, and the right femur/hip joint. Nine treatment visits performed over 4 months resulted in the patient’s condition stabilizing. The patient no longer had increased pain when standing for lengthy periods, and she could resume normal activities. Thereafter, she was treated for occasional aggravations associated with long car drives or lifting and packing for a move. L. was injured in an auto accident when vehicle and the one behind her hit a patch of ice. Although she was able to slow and regain control, the vehicle behind her could not
Figure 8 Pain referral pattern from the quadratus lumborum muscle. Referred pain from trigger points in the quadratus lumborum muscle is a very common source of lower back, pelvis, and buttock pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 2. The lower Extremities, by Janet G. Travell and David G. Simons, Baltimore, 1983.
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106 of 5 months. The progressive localization of the patient’s descriptions of her pain correlated well with the progressive localization of trigger point activity. Upon completion of care, the patient stated that she had occasional pain in the left lateral hip that was manageable with exercises and stretching and was occasionally aggravated by long driving or longstanding. She also had some residual neck tension that was also manageable with stretches. Upon final examination, there was tenderness and slight swelling at the piriformis attachment at the left greater trochanter and there was some residual fascial tension particularly over and interpenetrating the scalene muscles. However the active trigger points in these and other injured muscles had resolved and joint dysfunction had markedly decreased. The patient’s condition was assessed as reasonably stable and manageable with the patient’s independent exercise.
Case 3 K. has IS that was not surgically corrected and was originally treated at age 38 for chronic headaches as well as recurrent back pain. He has Marfan’s Syndrome, including various manifestations of connective tissue disorder such as an aortic aneurysm that was under observation (Fig. 3). The patient also has ligamentous laxity: BJHS. The pattern of Myofascial Dysfunction was similar to that described in Cases 1 and 2, with the addition of TrPs in the left upper trapezius and sternocleidomastoid muscles. The right hip was higher than the left, the thoracolumbar scoliosis had an apex left at T11/T12 apex right at T4/T5, and involved a leftward leaning neck with right lateral flexion of the head on the neck, including C1. Restoring torso balance to the extent possible, balancing the pelvis, scapulae, and head position, and reducing overall distortion by approximately
L. Whyte Ferguson 30% in 2 visits over a 2 week period made it possible to treat his chronic headaches and recurrent back pain. Four treatments over the next 5 months resulted in reduction of the severity and frequency of his headaches, although he had some recurrent neck soreness. He required treatment approximately once every 2 to 3 months thereafter, to address recurrences of neck pain, neck and back stiffness, or any increase in headache frequency and severity. He was subsequently treated for injuries sustained in an auto accident and the same areas of muscle and joint dysfunction addressed previously had to be addressed again involving 16 visits over the year following the accident. The bulk of his accident care was conducted during the first six months following the accident, but the patient had recurrent exacerbations that were treated over the next six months until the condition stabilized. The progressive localization of his pain complaints correlated well with the progressive localization of trigger point activity. He returned essentially to his pre-injury status with this course of care.
Summary of observations and results The following original observations are based on similarities in the patterns of fascial restriction and myofascial dysfunction in these three cases. Asymmetry in length of certain muscles and related fascial layers was found critical to treatment of IS in all three patients: QL, LD, iliopsoas, AS, and subscapularis. In all three, QL and iliopsoas and related fascia were found to play a key role in affecting tilt of the lumbar spine and pelvis. These muscles have angular or off center attachments and thus can pull the spine into distortion relative to the pelvis. Different parts of the QL were shortened on both convex and concave sides. On the concave side, usually the side of hip elevation, the iliocostal portion
Figure 9 Pain referral pattern from the iliopsoas muscle. Referred pain from trigger points in the iliopsoas muscle is a very common source of lower back pain. Reproduced by kind permission of Lippincott Williams & Wilkins from Myofascial Pain and Dysfunction, the Trigger Point Manual, Volume 2. The lower Extremities, by Janet G. Travell and David G. Simons, Baltimore, 1983.
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of the QL was shortened. On the convex side, generally the side on which the lumbar spine and lower rib cage are pulled down toward the hip, the iliolumbar portion of the QL was shortened. The LD, AS, and subscapularis and related fascia played a key role in rib cage mobility and tethering the scapula and appear to exert mechanical force due to their peripheral rather than central location. When the curve also involved the cervical spine, asymmetrical tension in the scalenes, levator scapulae, and sternocleidomastoid muscles and related fascia were involved in these curvatures. Referred pain patterns for TrPs in these muscles encompass the entire thoracolumbar spine (Simons et al., 1999; Travell and Simons, 1983) (Figs 4e9) Muscular forces are compounded by significant asymmetry in fascial tension, particularly along diagonal and spiral lines that accompany the force lines of the muscular asymmetries described above.
Conclusions There are common patterns of myofascial TrPs and asymmetrical muscle and fascial tension in adult patients with longstanding chronic pain and significant IS that has not been surgically corrected. BJHS is a common factor for most of these individuals. Although the paraspinal muscles appear most abnormal and different from one side of the spine to the other, other muscles, located at an angle to the spine and that have TrPs with patterns of pain referral to the spine, appear to be most responsible for spinal pain as well as possibly playing an important role in spinal distortion, scapula tethering and the dynamics of rib restriction. These conclusions are drawn from reasonably successful pain management results when the treatments methods described are applied to these challenging patients for treating both chronic and acute musculoskeletal pain. Further research is needed to compare this form of treatment with other methods, with regard to pain management, but also with regard to curve progression, pulmonary function, and quality of life issues.
Appendix 1. Seated evaluation and treatment The patient is taken through cervical passive range of motion to evaluate the length of the neck muscles and find taut bands and TrPs. Flexion is performed to evaluate semispinalis and splenius cervicis and capitis muscles. Lateral flexion with rotation is performed to stretch the levator scapulae muscles. Lateral flexion is performed to stretch the upper trapezius muscles. Extension with various degrees of rotation is performed to stretch the various portions of the scalenes and the sternocleidomastoid muscles. Planes of fascial restriction are also identified using these procedures. In these positions, the cervical facet joints are evaluated for tenderness and restriction. The upper rib/spinal joints are also evaluated for tenderness and restriction (Fig. A1). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously. Initial stretches of shoulder muscles are also performed in this position, including pectoral, biceps, subscapularis, teres minor and major, infraspinatus, and latissimus dorsi muscles. Planes of fascial restriction are identified while
Figure Appendix 1 Combining muscle stretch and joint mobilization. During passive stretch of the levator scapula muscle and associated fascia, the clinician uses the pressure of the flat of the forearm, just above the elbow, to gently depress the 1st rib and mobilize the rib-thoracic joint. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
taking the arm and shoulder through these stretch positions. Protraction of the scapulae is evaluated in this position, and the humerus position within the glenoid is evaluated to determine how centered the humerus is within the glenoid (Fig. A2). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously. The thoracolumbar paraspinals are also stretched while forward flexing the torso, with the scapulae protracted. In this position, the tenderness and restrictions at rib/spinal joints and in the lumbar spine are evaluated. Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
Appendix 2. Side lying evaluation and treatment To evaluate the length of the shoulder muscles and the tension in the anterior joint capsule, the practitioner’s thumb is placed under the pectoral muscle and anterior joint capsule to introduce stretch. The thumb or fingers are placed under the scapula to evaluate the stretch of the subscapularis and anterior serratus, and the posterior joint capsule, by mobilizing the scapula towards the spine (Fig. A3a and b). The patient’s arm is also fully abducted to evaluate the length of the latissimus dorsi and identify TrPs. A pillow under the patient’s waist assists in making it possible to take the latissimus dorsi into a full stretch position (Fig. A4). By taking the arm both up and back, the clinician can identify whether the latissimus dorsi tension is part of a restricted fascial plane that extends into the oblique abdominals and toward the groin or pubic symphysis. By taking the arm up and forward, the clinician can identify whether the latissimus dorsi tension is part of a
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Figure Appendix 2 The clinician stretches the pectoral muscles of the seated patient. The clinician hooks both hands under the lateral border of the pectoral muscles. The chair and the muscle shortness provide the resistance, and the clinician leans back and maintains a gentle but firm upward and anterior to posterior pull on the muscles and fascia as they stretch. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
restricted fascial plane that extends toward the posterior pelvis. The scapula and clavicle are mobilized inferiorly to evaluate for taut bands and TrPs and fascial restrictions in the anterior and posterior neck muscles. Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
L. Whyte Ferguson
Figure Appendix 4 Therapeutic stretch of the latissimus dorsi muscle. To stretch the right latissimus dorsi muscle, the clinician uses the left hand to hold the patient’s arm between the shoulder and the elbow. The other hand presses against the pelvic brim, so that the brim is moved away from the shoulder. A pillow is placed under the patient’s waist to provide more stretch to this long, slack muscle. The direction of stretch is downward (caudally) at the waist and upward (rostrally directed) at the arm. This stretch also stretches the subscapularis and teres major muscles and associated fascia. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
Figure Appendix 3 With the thumb under the scapula, the clinician mobilizes the scapula toward the spine. a. The humerus is elevated to insert the thumb under the lateral border of the scapula. The thumb provides sustained pressure against the trigger points and taut bands in the subscapularis and anterior serratus that are resisting the mobilization, until they release sufficiently to allow some gain in translating the scapula medially and inferiorly toward the spine. b. The other hand may simultaneously stretch the taut pectoral muscles and associated fascia. The thumb is inserted under the lateral border of the pectoral muscle pressing upward and backward to elongate taut bands. The net effect is that the humerus translates up and back and eventually down in a semicircular motion while the scapula translates inferiorly toward the spine. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
Figure Appendix 5 The side-lying position for evaluation and stretch release of the iliopsoas (and quadriceps) muscles and associated fascia. The clinician stabilizes the lumbosacral spine so that extension is focused at the hip. This is an ideal position in which to perform contract-relax-release and contract-relax-assist. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
To evaluate asymmetrical patterns of muscle and related fascial tension in the torso that affect hip imbalance, the patient is placed side-lying with the side of the high hip up, and a pillow under the waist. Often the elevated hip is also the forward hip. The hip is mobilized and dropped posterior and inferior, away from the rib cage. In this position, the length of the paraspinal muscles and the quadratus lumborum can be evaluated, and the tenderness and restriction of lumbar facet joints can also be assessed as well as tenderness and restriction of the sacroiliac joints. The thigh is stretched inferiorward, antero-inferior and postero-inferior in order to stretch the tensor fascia lata, the gluteus medius, minimus, and maximus, as well as the piriformis muscles and the fascia are stretched in these positions as well. The thigh is also stretched into extension in order to evaluate the length of the iliopsoas muscles (Figs. A5,A6). These same maneuvers are performed on the other side of the back, buttock and hip, but because this is the side of the low hip and the side that the lumbar spine tends to deviate toward, the pillow or pillows are placed under the hip rather than under the waist, and the stretching maneuvers are conducted to drop the rib cage and lumbar spine away from the hip and discern the degree of tautness in the quadratus lumborum and paraspinal muscles and related fascia. Because the pelvis is
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Figure Appendix 6 The side-lying position for the evaluation and stretch release of the quadratus lumborum and internal oblique abdominal muscles and associated fascia. A pillow is used under the waist, to enhance the separation of the rib cage and the pelvis (with the thigh posterior). The leg then should be placed forward, and different taut bands will be palpated in the quadratus lumborum, and taut bands in the external oblique abdominal muscle and associated fascia will be easier to palpate. Contract-relax-release can be performed in this position, with the clinician stabilizing at the lower rib cage and the relax-release can be performed in this position, with the clinician stabilizing at the lower rib cage and the top of the ilium. The rib cage is passively stretched away from the ilium, until tissue tension is reached, and then the patient is asked to contract (gently for a count of 4) and then release, and then the clinician stretches the ribs away from the iliac crest until a new barrier is reached, and the procedure is repeated. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
usually torqued posterior on the side of the low hip and convexity of the lumbar curvature, the sacroiliac restriction is explored in this position in order to determine what joint and soft tissue restrictions need to be addressed to “square up” the pelvis better under the lumbar spine. Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
Appendix 3. Prone evaluation and treatment In a prone position, mobility of the scapulae can be assessed. Often in the scoliosis patient, one scapula is elevated relative to the other, and one scapula is more protracted than the other. In this position, the length and relative tension of the muscles and fascia that affect scapula position can be assessed. Latissimus dorsi tension and taut bands, and that of the anterior serratus can be palpated by tractioning the scapulae cephalad and medially, toward the spine. The scapula can be lifted away from the lateral rib cage to evaluate the subscapularis tension. The pectoral muscle tension can be evaluated in
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Figure Appendix 7 Assessing shortness of the latissimus dorsi muscles and associated fascia. The clinician grasps one posterior axillary fold in each hand and feels the relative tension between each shoulder and the ipsilateral hip. In this case, the patient’s left latissimus dorsi muscle is more shortened. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
L. Whyte Ferguson scapula and humerus (Fig. A8). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously. In this position, the high ilium can be tractioned inferiorly to assess which muscles and fascia are short and contributing to hip elevation, including paraspinals, quadratus lumborum, and abdominal obliques. On the side of the low hip and the lumbar deviation toward the hip, the rib cage can be tractioned away from the hip to identify which muscles and fascia are shortened. By palpating under the torso, from the central sub-diaphragm area down toward the lesser trochanter of the femur, while internally rotating the femur, the specific locations of psoas tension and tenderness and TrPs can be evaluated along with fascial tension. By palpating from the medial border of the ilium to the lesser trochanter, the degree of iliacus tension can be
this position also, by reaching under the shoulder and palpating and stretching the underside of the pectoral muscle (Fig. A7). Fascial tension planes are also identified during these maneuvers. Joint restriction is also identified in this manner. The scapula and clavicle can be tractioned inferiorly to evaluate the scalene, levator scapula, and upper trapezius muscle and related fascial tension and the supraspinatus muscle can be stretched by tractioning caudally on the
Figure Appendix 8 Combining traction and trigger point pressure release. With the patient in a prone position, the clinician can combine gentle traction on the arm with trigger point pressure release, to accomplish muscle and fascial elongation and treat remaining trigger points in the anterior border of the upper trapezius muscle and the pressure can also be shifted to the levator scapula and the posterior scalene muscle. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
Figure Appendix 9 Prone palpation and trigger point pressure release treatment of the iliopsoas muscle and related fascia. For the clinician learning this technique, it is easiest to start with the treating hand contacting the iliacus muscle just inside the anterior iliac border (A). The lower leg is guided laterally to produce internal rotation of the thigh, until the clinician can feel the increased tension in the bands of the iliacus muscle against the fingers of the treating hand. The clinician treats tender knots in the taut bands of muscles simply by maintaining pressure with the finger tips while gently internally rotating the thigh and the treating hand gradually advances caudally, toward the insertion of the common iliopsoas tendon at the lesser trochanter (B). From this position, the clinician can follow the tension in the taut bands of the psoas muscle upward toward the origin at the lateral portion of each lumbar vertebra, near the navel and diaphragm (C). The hand that stabilizes the flexed leg can gently provide a combination of traction, abduction, and internal rotation until the desired tension is achieved. Reproduced by kind permission of Lippincott Williams & Wilkins from Clinical Mastery in the Treatment of Myofascial Pain, edited by Lucy Whyte Ferguson and Robert Gerwin, Baltimore 2005.
evaluated. The degree of adductor and medial hamstring tension can also be evaluated in this position (Fig. A9). Myofascial release procedures are used to treat the muscle and fascial restrictions. Mobilization of the joint restrictions is performed simultaneously.
References Aebi, M., 2005. The adult scoliosis. European Spine Journal 14, 925e948. Gerwin, R.D., Shannon, S., Hong, C.Z., Hubbard, D., Gevirtz, R., 1997. Interrater reliability in myofascial trigger point examination. Pain 69, 65e73. Jackson, R.P., Simmons, E.H., Stripinis, D., 1983. Incidence and severity of back pain in adult idiopathic scoliosis. Spine 8 (7), 749e756. Kuklo, T.R., 2006. Principles for selecting fusion levels in adult spinal deformity with particular attention to lumbar curves and double major curves. Spine 31 (19), S132eS138.
111 LeBauer, A., Brtalik, R., Stowe, K., 2008. The effect of myofascial release (MFR) on an adult with idiopathic scoliosis. Journal of Bodywork and Movement Therapies 12, 356e363. Morningstar, M.W., Woggon, D., Lawrence, G., 2004. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BioMed Central Musculoskeletal Disorders 5, 32. Morningstar, M.W., Strauchman, M.N., 2010. Management of a 59year-old female patient with adult degenerative scoliosis using manipulation under anesthesia. Journal of Chiropractic Medicine 9 (2), 77e83. Simmons, E.H., Jackson, R.P., 1979. The management of nerve root entrapment syndromes associated with the collapsing scoliosis of idiopathic lumbar and thoracolumbar curves. Spine 4 (6), 533e541. Simons, D.G., Travell, J.G., Simons, L.S., 1999. Myofascial Pain and Dysfunction, the Trigger Point Manual. In: Upper Half of Body, second ed., vol. 1. Lippincott Williams & Wilkins, Balti-more. Travell, J.G., Simons, D.G., 1983. Myofascial Pain and Dysfunction, the Trigger Point Manual. In: The Lower Extremities, vol. 2. Lippincott Williams & Wilkins, Baltimore.
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