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Erik Daltons Erik Daltons


Freedom from Pain Institute
Myoskeletal Myoskeletal
Alignment Alignment
Techniques Techniques
For Pain Management For Pain Management
Sensory Receptors Sensory Receptors
Rebels Without a Pause? Rebels Without a Pause?
Research conclusions from ongoing studies: Research conclusions from ongoing studies:
Soft tissues (previously viewed as purely mechanical Soft tissues (previously viewed as purely mechanical
structures) are innervated and participate in active structures) are innervated and participate in active
balancing of the spine. balancing of the spine.
Specialized mechanoreceptors play major roles in Specialized mechanoreceptors play major roles in
myofascial unwinding AND also initiate aberrant myofascial unwinding AND also initiate aberrant
feedback loops and muscle imbalance patterns due to feedback loops and muscle imbalance patterns due to
injured injured articular articular structures. structures.
SENSORY RECEPTORS SENSORY RECEPTORS
Supply CNS input on stimuli such as pain, touch, Supply CNS input on stimuli such as pain, touch,
sound, light, heat and cold sound, light, heat and cold
Categorized by specific physiological duties such as Categorized by specific physiological duties such as
nociceptors nociceptors, mechano, chemo, thermo and , mechano, chemo, thermo and
electromagnetic receptors electromagnetic receptors
Transmit Transmit proprioceptive proprioceptive and and nociceptive nociceptive information information
Change sensory stimuli into action potentials so the Change sensory stimuli into action potentials so the
CNS continually receives data on the overall body CNS continually receives data on the overall body
environment. environment.
Muscle Joint Muscle Joint
Reflexogenic Reflexogenic Relationships Relationships
Is impaired muscle function the primary cause of Is impaired muscle function the primary cause of
joint dysfunction, or is the reverse true? joint dysfunction, or is the reverse true?
McLain 1994: McLain 1994:
-- --Receptors monitor capsular tension Receptors monitor capsular tension
-- --Receptors may initiate protective reflexes important in preventi Receptors may initiate protective reflexes important in preventing ng
joint degeneration. joint degeneration.
Grieve: Grieve:
-- --Postural asymmetry joint blockage enhances fibroblastic activity Postural asymmetry joint blockage enhances fibroblastic activity
resulting in resulting in periarticular periarticular tissue fibrosis. tissue fibrosis.
Catch 22 Pain/Spasm/Pain Cycle Catch 22 Pain/Spasm/Pain Cycle
Murphy: Murphy:
-- -- Added that changes in spinal joint soft tissue fibrosis Added that changes in spinal joint soft tissue fibrosis
alters the normal instantaneous axis of rotation alters the normal instantaneous axis of rotation
How Joints Affect Muscles How Joints Affect Muscles
Joints influence muscle tone and therefore Joints influence muscle tone and therefore
muscle function. muscle function.
The joints ability to alter muscle tone is The joints ability to alter muscle tone is
mediated by mediated by articular articular receptors. receptors.
In the joint capsule, the greatest number of In the joint capsule, the greatest number of
receptors are found in regions subject to receptors are found in regions subject to
variation of tension during movement. variation of tension during movement.
Articular Articular receptors can inhibit or facilitate receptors can inhibit or facilitate
muscle tone. muscle tone.
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ARTICULAR RECEPTORS ARTICULAR RECEPTORS
Freeman and Freeman and Wyke Wyke categorized categorized articular articular
receptors into four types: Type I, II, III, and IV. receptors into four types: Type I, II, III, and IV.
Each is stimulated in a distinctive way and responds to Each is stimulated in a distinctive way and responds to
stimulation differently. stimulation differently.
Type I and II mechanoreceptors act as physiological Type I and II mechanoreceptors act as physiological
receptors/ active during normal movement. receptors/ active during normal movement.
Type III and IV receptors normally inactive/ only Type III and IV receptors normally inactive/ only
stimulated at extremes of movementmay function stimulated at extremes of movementmay function
under pathological conditions. under pathological conditions.
ARTICULAR RECEPTORS ARTICULAR RECEPTORS
Ligament Ligament Innervation Innervation
Jiang Jiang et al (1995) et al (1995) documented documented innervation innervation of human of human
supraspinal supraspinal //interspinal interspinal ligaments from 10 spinal ligaments from 10 spinal
decompression surgery patients. decompression surgery patients.
Dense collagen bundles of Dense collagen bundles of Ruffini Ruffini corpuscles suggest corpuscles suggest
active monitoring of mechanical joint loading and active monitoring of mechanical joint loading and
provide static positional awareness for postural control. provide static positional awareness for postural control.
Jaings Jaings findings support concept of ligaments as part of findings support concept of ligaments as part of
neurologic neurologic feedback mechanisms for protection and feedback mechanisms for protection and
stability of the spine. stability of the spine.
Zygapophysial Zygapophysial Joint Joint Innervation Innervation
Belief in Belief in zygapophysial zygapophysial joint pain dates back to joint pain dates back to
1933 when 1933 when Ghormley Ghormley coined the term facet coined the term facet
syndrome. syndrome.
Facet Facet innervation innervation is derived from the medial branch of is derived from the medial branch of
the posterior primary division at the level of the joint the posterior primary division at the level of the joint
and the levels above and below. and the levels above and below.
Jeffries 1988 Jeffries 1988 suggested that this multilevel suggested that this multilevel innervation innervation
is probably one reason why facet joint pain frequently is probably one reason why facet joint pain frequently
has a broad referral pattern. has a broad referral pattern.
McLains Facet Studies McLains Facet Studies
McLain McLain dissected human cervical facet capsules from dissected human cervical facet capsules from
three normal subjects to determine the type, density, three normal subjects to determine the type, density,
and distribution of and distribution of mechanoreceptive mechanoreceptive nerve endings. nerve endings.
Mechanoreceptors were found in 17 of 21 specimens Mechanoreceptors were found in 17 of 21 specimens
McLain concluded the presence of McLain concluded the presence of mechanoreceptive mechanoreceptive
and and nociceptive nociceptive nerve endings in cervical facet capsules nerve endings in cervical facet capsules
proves that neural input from facets is important to proves that neural input from facets is important to
proprioception proprioception and pain sensation in the cervical and pain sensation in the cervical
spine. spine.
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Whiplash and Facets Whiplash and Facets
Barnsley Barnsley et al et al double double--blind, controlled diagnostic blind, controlled diagnostic
blocks / Investigated cervical facets in 50 post blocks / Investigated cervical facets in 50 post--whiplash whiplash
patients / Found facets were most common source of patients / Found facets were most common source of
chronic neck pain. chronic neck pain.
Bogduk Bogduk, Hirsch et al, and Yamashita et al , Hirsch et al, and Yamashita et al also also
reported on rich reported on rich innervation innervation of facet joints. of facet joints.
They concurred that altered They concurred that altered intersegmental intersegmental and and
segmental joint motion and postural distortions create segmental joint motion and postural distortions create
aberrant traffic in aberrant traffic in neuropathways neuropathways..
Cross Cross--talk perpetuates aberrant reflex alterations, talk perpetuates aberrant reflex alterations,
muscular and muscular and ligamentous ligamentous alterations, inflammatory alterations, inflammatory
responses and resultant pain syndromes. responses and resultant pain syndromes.
Discogenic Discogenic Pain Pain
Roofe Roofe (1940) (1940)--11
st st
evidence of evidence of anulus anulus fibrosus fibrosus nerve nerve
fibers. fibers.
Bogduk Bogduk (1983) (1983)--nerve fibers in outer 1/3 of lumbar nerve fibers in outer 1/3 of lumbar
anulus anulus fibrosus fibrosus..
Farfan Farfan (1973) (1973)--type 4 nerve receptors penetrating type 4 nerve receptors penetrating
nucleus, nucleus, anulus anulus and posterior longitudinal ligament. and posterior longitudinal ligament.
Shinohara (1970) Shinohara (1970)--nerve fibers penetrating degenerated nerve fibers penetrating degenerated
discs nuclei. discs nuclei.
Garfin Garfin (1995) (1995) --disc compression of normal nerve leads disc compression of normal nerve leads
to to paresthesias paresthesias, sensory deficits and motor losspain is , sensory deficits and motor losspain is
absent. absent.
Wilberger Wilberger and the and the
Silent Nerve Compression Syndrome Silent Nerve Compression Syndrome
Wilberger Wilberger et al 176 et al 176 --lumbar lumbar myelographic myelographic herniated herniated
discs in 108 asymptomatic patients. discs in 108 asymptomatic patients.
Within 3 years, 64% developed Within 3 years, 64% developed lumbosacral lumbosacral
radiculopathy radiculopathy..
Wilberger Wilberger hypothesizes that time was required for hypothesizes that time was required for
mechanical deformation to cause this silent nerve mechanical deformation to cause this silent nerve
compression syndrome. compression syndrome.
29 yr. old male 40 yr. old male
Radicular Radicular Pain Pain
FASCIAL PLASTICITY FASCIAL PLASTICITY
Therapist hands often palpate a myofascial unwinding Therapist hands often palpate a myofascial unwinding
as sustained pressure is applied to superficial and deep as sustained pressure is applied to superficial and deep
myofascial layers. myofascial layers.
Juhan Juhan attributed alteration in connective tissue attributed alteration in connective tissue
resilience to what is commonly called resilience to what is commonly called thixotropy thixotropy or the or the
gel gel--to to--sol phenomenon. sol phenomenon.
Currier and Nelson Currier and Nelson--significantly more force, time significantly more force, time
and heat must be generated in order to establish and heat must be generated in order to establish
permanent connective tissue deformation. permanent connective tissue deformation.
Oshman Oshman added piezoelectricity as a possible added piezoelectricity as a possible
explanation for explanation for fascial fascial creep. creep.
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Robert Robert Schleips Schleips
Observations on Observations on Fascial Fascial Plasticity Plasticity
Schleip Schleip concurred: these mechanisms may be a viable concurred: these mechanisms may be a viable
explanation for long explanation for long--term tissue changes term tissue changes but but
questioned their effectiveness for short term tissue questioned their effectiveness for short term tissue
release experienced in clinic. release experienced in clinic.
Schleip Schleip studies with anesthetized patients studies with anesthetized patients --in the in the
absence of neural connection, short absence of neural connection, short--term term fascial fascial
plasticity is lost. plasticity is lost.
Schleip Schleip, , Pacinian Pacinian receptors are likely to be stimulated receptors are likely to be stimulated
by high by high--velocity thrust manipulations as well as in velocity thrust manipulations as well as in
vibratory techniques, whereas the vibratory techniques, whereas the Ruffini Ruffini endings may endings may
be activated by slow and deep melting quality soft be activated by slow and deep melting quality soft
tissue techniques. tissue techniques.
Golgi Golgi tendon organs tendon organs
Golgi Golgi tendon organs (GTOs) arranged in a series tendon organs (GTOs) arranged in a series
respond to slow stretch by resetting a muscles length, respond to slow stretch by resetting a muscles length,
inhibiting its synergistic stabilizers and facilitating its inhibiting its synergistic stabilizers and facilitating its
antagonist. antagonist.
Jami Jami 1992 1992 --passive myofascial stretching does not passive myofascial stretching does not
stimulate GTOs. stimulate GTOs.
Golgi Golgi tendon organs tendon organs
Lederman 1997 Lederman 1997 --GTOs GTOs
able to reset their able to reset their
muscles length during muscles length during
dynamic forceful dynamic forceful
contractions. contractions.
GTOs may serve a GTOs may serve a
protective function by protective function by
reflexively inhibiting its reflexively inhibiting its
agonist at the end range agonist at the end range
of joint motion. of joint motion.
Nociceptors Nociceptors as Pain as Pain- -Generators Generators
Nociceptor Nociceptor mechanical, thermal and chemical stimuli. mechanical, thermal and chemical stimuli.
Nociceptor Nociceptor and chemoreceptor activation: and chemoreceptor activation:
1. 1. Nerve fibers depolarized by joint capsule mechanical stresses Nerve fibers depolarized by joint capsule mechanical stresses
2. 2. Thermal extremes Thermal extremes
3. 3. Inflammatory chemical agents such as histamines, Inflammatory chemical agents such as histamines,
prostaglandins, prostaglandins, bradykinins bradykinins, potassium ions, and lactic acid. , potassium ions, and lactic acid.
Nociceptors Nociceptors can quickly become major generators of can quickly become major generators of
both myofascial and spinal both myofascial and spinal--pain syndromes. pain syndromes.
Postural Control Postural Control
Soft tissues within and Soft tissues within and
surrounding spinal articulations surrounding spinal articulations
are densely populated with are densely populated with
sensory receptors. sensory receptors.
Macro or Macro or microtrauma microtrauma may create may create
joint misalignment and postural joint misalignment and postural
distortions. distortions.
Injured Injured articular articular structures initiate structures initiate
and facilitate spinal reflex and facilitate spinal reflex
pathways which increase pathways which increase
contractibility in contractibility in paraspinal paraspinal
musculature. musculature.
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Nociceptors Nociceptors and Posture and Posture
Long Long--term CNS agitation by irritated term CNS agitation by irritated nociceptors nociceptors causes the causes the
brain to twist and torque the body in an effort to avoid pain. brain to twist and torque the body in an effort to avoid pain.
Regrettably, the brain has the ability to memorize these aberran Regrettably, the brain has the ability to memorize these aberrant t
postural patterns. postural patterns.
Nociceptors Nociceptors and Posture and Posture
Dysfunctional Dysfunctional
patterns that persist patterns that persist
long after the painful long after the painful
stimulus has been stimulus has been
removed are referred removed are referred
to as to as
neuroplasticity neuroplasticity
reflex entrainment reflex entrainment
or spinal learning. or spinal learning.
Transversospinalis Transversospinalis
Muscles are the body's primary movers and must Muscles are the body's primary movers and must
respond quickly to changes from neural structures. respond quickly to changes from neural structures.
When tight muscles pull unevenly on the bodys bony When tight muscles pull unevenly on the bodys bony
framework, the joints axis of rotation and center of framework, the joints axis of rotation and center of
gravity changes. gravity changes.
Prolonged joint misalignment (loss of joint play) Prolonged joint misalignment (loss of joint play)
agitates sensory receptors in spinal joint capsules, agitates sensory receptors in spinal joint capsules,
ligaments, discs, and ligaments, discs, and transversospinalis transversospinalis muscles. muscles.
Transversospinalis Transversospinalis Almost always pulls Almost always pulls
insertion points toward origins when at work. As the TP insertion points toward origins when at work. As the TP
are pulled toward the SP, localized rotation and are pulled toward the SP, localized rotation and
sidebending sidebending occur. occur.
Transversospinalis Transversospinalis
Particularly stressed are mechanoreceptors embedded Particularly stressed are mechanoreceptors embedded
in overstretched capsules and the part of the joint in overstretched capsules and the part of the joint
bearing excessive weight. bearing excessive weight.
GATING GATING
Joint dysfunction results in muscle dysfunction by Joint dysfunction results in muscle dysfunction by
changing gamma bias of spindle cells. changing gamma bias of spindle cells.
Joint injury, degeneration, inflammation, or muscle Joint injury, degeneration, inflammation, or muscle
guarding causes fewer guarding causes fewer mechanoreceptive mechanoreceptive fibers. fibers.
As we age we lose mechanoreceptors = cant gate. As we age we lose mechanoreceptors = cant gate.
Because Because nociceptors nociceptors are free nerve endings they are not are free nerve endings they are not
as affected. as affected.
This explains why a minor trauma can cause much This explains why a minor trauma can cause much
pain or a major trauma can cause only minor pain. pain or a major trauma can cause only minor pain.
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Co Co- -activating activating Nociceptors Nociceptors
Warmerdam Warmerdam1999 1999 -- nociceptive nociceptive gating best gating best
achieved by stimulation of low achieved by stimulation of low--threshold threshold
mechanoreceptors near mechanoreceptors near nociception nociception origination. origination.
Nociception Nociception originating from muscle = passive originating from muscle = passive
massage, joint = dynamic stimulation produces massage, joint = dynamic stimulation produces
more sensory gating. more sensory gating.
Co Co- -activating activating Nociceptors Nociceptors
Lederman (1997) Lederman (1997) found found
that successful that successful
nociceptive nociceptive gating gating
requires that the stimulus requires that the stimulus
be pain free or that the be pain free or that the
gating movements take gating movements take
place within a pain free place within a pain free
range. range.
Joint Techniques to Lower Pain Joint Techniques to Lower Pain- -
Generating Stimuli Generating Stimuli
Spinal soft tissue Spinal soft tissue
manipulations that manipulations that
initiate passive joint initiate passive joint
movements result in movements result in
mechanoreceptive mechanoreceptive
stimulation. stimulation.
Joint Techniques to Lower Pain Joint Techniques to Lower Pain- -
Generating Stimuli Generating Stimuli
This technique creates This technique creates
presynaptic presynaptic inhibition of inhibition of
the the nociceptive nociceptive afferent to afferent to
diminish or abolish the diminish or abolish the
perception of pain. perception of pain.
Sandoz Sandoz restoring normal restoring normal
joint structure /function joint structure /function
helps normalize helps normalize
mechanoreceptive mechanoreceptive and and
nociceptive nociceptive input. input.
Cutaneous Cutaneous vs. vs. Articular Articular Receptors Receptors
Massage primarily stimulates Massage primarily stimulates cutaneous cutaneous
receptors. Active or passive movements receptors. Active or passive movements
primarily stimulate primarily stimulate articular articular receptors = less receptors = less
joint pain. joint pain.
Active client participation better gates Active client participation better gates articular articular
nociceptors nociceptors..
Active (rather than passive) positioning Active (rather than passive) positioning
improves improves proprioception proprioception since muscles are since muscles are
allowed to play a larger role. allowed to play a larger role.
Passive Passive Cutaneous Cutaneous Massage Release Massage Release
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Active Active Articular Articular Release Release
MUSCLE INHIBITION OR MUSCLE INHIBITION OR
ATROPHY? ATROPHY?
Janda Janda 1988 1988 Although muscle weakness has usually Although muscle weakness has usually
been considered a result of decreased activity, been considered a result of decreased activity,
inhibition may be an integral part of many, if not all, inhibition may be an integral part of many, if not all,
forms of weakness. forms of weakness.
Hurley (1997) Hurley (1997)-- muscle weakness muscle weakness-- two factors: two factors:
1. 1. Decreased number of Decreased number of extrafusal extrafusal muscle fibers muscle fibers
2. 2. A failure to activate all muscle fibers A failure to activate all muscle fibers
A decreased number or size of A decreased number or size of extrafusal extrafusal fibers may fibers may
be termed be termed atrophy atrophy, whereas failure to activate all , whereas failure to activate all
muscle fibers may be termed muscle fibers may be termed inhibition inhibition..
MUSCLE IMBALANCE MUSCLE IMBALANCE
PATTERNS PATTERNS
Jandas Jandas Upper and Lower Crossed Syndromes Upper and Lower Crossed Syndromes --2 of 2 of
most common aberrant postural patterns. most common aberrant postural patterns.
Exposed to same stressors certain muscles become tight Exposed to same stressors certain muscles become tight
and facilitated/ others weak and inhibited. and facilitated/ others weak and inhibited.
Abnormal afferent information: Abnormal afferent information:
painful or noxious stimuli painful or noxious stimuli
CNS CNS malregulation malregulation
psychological psychological
(emotional) stressors (emotional) stressors
poor posture poor posture
excessive physical excessive physical
demands demands
joint blockage joint blockage
habitual movement habitual movement
patterns patterns
Upper Crossed Syndrome Upper Crossed Syndrome
Are the weak lower Are the weak lower
shoulder stabilizers shoulder stabilizers
solely responsible solely responsible
for the aberrant for the aberrant
forward head forward head
posture seen in the posture seen in the
upper crossed upper crossed
syndrome? syndrome?
Upper /Lower Crossed Syndromes Upper /Lower Crossed Syndromes
Porterfield and Porterfield and DeRosal DeRosal -- forward posture factors forward posture factors
other than scapular retractors stretch weakness. other than scapular retractors stretch weakness.
weakness and lengthening of abdominal muscles allows the weakness and lengthening of abdominal muscles allows the
chest to fall causing an anterior upper trunk weight shift. chest to fall causing an anterior upper trunk weight shift.
As gravitation exposure pulls upper trunk forward on the rib As gravitation exposure pulls upper trunk forward on the rib
cage, the scapulae externally rotate and protract cage, the scapulae externally rotate and protract forcing forcing
clavicle to drop on the first rib. clavicle to drop on the first rib.
The The clavicular clavicular head of head of pectoralis pectoralis major and hypertonic major and hypertonic
latissimus latissimus dorsi dorsi internally rotate the internally rotate the humerus humerus forcing forcing
the neck and head to follow. the neck and head to follow.
Nociceptive Nociceptive Reflexes and Reflexes and
Somatic Dysfunction Somatic Dysfunction
Somatic Dysfunction Model Somatic Dysfunction Model-- restriction in mobility, autonomic, restriction in mobility, autonomic,
visceral, and immunologic changes produced by pain visceral, and immunologic changes produced by pain--related related
sensory neurons and their reflexes. sensory neurons and their reflexes.
Nociceptor Nociceptor muscular guarding reactions and autonomic muscular guarding reactions and autonomic
activation from stressed/damaged activation from stressed/damaged myoskeletal myoskeletal or visceral tissue. or visceral tissue.
Guarding Guarding -- abnormal abnormal myoskeletal myoskeletal position and decreased ROM. position and decreased ROM.
Local inflammatory responses and autonomic reflexes reinforce Local inflammatory responses and autonomic reflexes reinforce
nociceptor nociceptor activity, maintaining restriction. activity, maintaining restriction.
Nociceptive Nociceptive autonomic reflexes= visceral/immunologic changes. autonomic reflexes= visceral/immunologic changes.
Abnormal guarding in muscles, joints, related tissues =changes i Abnormal guarding in muscles, joints, related tissues =changes in n
connective tissues, solidifying the abnormal position. connective tissues, solidifying the abnormal position.
Stretching tissues into normal range of motion may Stretching tissues into normal range of motion may restimulate restimulate
nociceptors nociceptors, reinforcing the somatic dysfunction. , reinforcing the somatic dysfunction.
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CONCLUSION CONCLUSION
Patients benefit by restoring balance/function to all soft tissu Patients benefit by restoring balance/function to all soft tissue e
structures. structures.
A model for using receptor techniques to correct aberrant postur A model for using receptor techniques to correct aberrant postural al
patterns is helpful in the clinical setting. patterns is helpful in the clinical setting.
Impaired Neuromyoskeletal functions can cause stress, pain and Impaired Neuromyoskeletal functions can cause stress, pain and
altered performance of internal organs, hormonal systems and altered performance of internal organs, hormonal systems and
psycho psycho--immunological functions. immunological functions.
Working with the sensory receptor system, trained therapists can Working with the sensory receptor system, trained therapists can
determine if problems are primarily within muscles, fasciae or j determine if problems are primarily within muscles, fasciae or joint oint--
related tissues or if the problem exists elsewhere. related tissues or if the problem exists elsewhere.
With assessment and treatment training, a therapist can more With assessment and treatment training, a therapist can more
efficiently determine dysfunction sites and improve structure. efficiently determine dysfunction sites and improve structure.
This leads to higher functioning in the self This leads to higher functioning in the self--regulating and self regulating and self--
protecting mechanisms of the body. protecting mechanisms of the body.