Dura Mater

Working Through the Dura Mater with Deep Tissue Therapy

Introduction

Famous for their amazing ability to precisely define complex anatomical structures, the early Greeks hit the nail on its proverbial head when they labeled dura mater, the “tough mother.” Centuries later, massage therapists have come to understand the important role dura mater plays in protecting the brain and spinal cord. Interestingly enough, many therapists are surprised to learn that a variety of common neck, head and low-back complaints actually originate from distortion of this sensitive membrane.

Dural torsioning, compression and impingement often result in mysterious pain patterns that can mimic muscle spasm. If the dural tube is both overstretched and twisted from myofascial contractures, bony misalignment or spinal pathology, complex conditions such as migraines, sciatica, thoracic outlet syndrome and scoliosis can manifest. Sadly, these pain generators offer a major therapeutic challenge to today’s body worker who relies exclusively on conventional myofascial modalities to help clients who present with these conditions.

As students of an evolving, health-conscious society, massage therapists will reap fruitful rewards by incorporating specific techniques to maintain the delicate balance of tone and tension in the body’s dural system. But to learn, one must always begin by investigating the rudimentary workings of this elaborate mechanism. For example, how does the dural system operate? And more importantly, what tools are available for today’s body worker to help restore function once this sensitive membrane has been strained? Hopefully, answers to these and other questions can be gleaned from a general discussion of basic scientific information regarding this intriguing subject.

The Toughest Envelope First and foremost, one must remember that the dura is the toughest, outermost envelope enclosing the central nervous system, and the most fibrous of the three protective membranes. Two of the dural layers are complexly arranged within the skull and help form the craniosacral pumping mechanism. With several attachments to cranial structures, including the occiput, temporals and sphenoid bone, the dura loves its “free-floating” mobility within the cranial vault and is happiest when sliding freely up and down within the spinal canal (see Figure #1).

Figure #1: The dura mater. If the dural tube is both overstretched and twisted from myofascial contractures, bony misalignment or spinal pathology, complex conditions such as migraines, sciatica, thoracic outlet syndrome and scoliosis can manifest.

As a suspension bridge spans across a river or bay, the brain and spinal cord are suspended within the skull and vertebral column by tooth-like denticulate ligaments that connect the brain and cord with the dura mater. The tough dural covering is loosely bound to specified places inside the cranium. As it makes its descent downward, firm attachments bind it to only a few places along the bony vertebral column-the posterior bodies of the second and third cervicals (C2 and C3), the second sacral segment, and the most inferior vertebra of the spine, the coccyx.

The head, spine and all related myofascial structures are designed for constant movement and motion that simultaneously change the shape of the dura mater. Because the layers are plicated, or folded like a fan, the dura has the ability to slightly elongate.

For years cranial researchers, such as John Upledger, D.O., have observed and reported on the effects this changing dural tension engenders on the human nervous system and the systemic health of the individual as a whole. When the dura is stretched, compressed, torsioned or distorted by the moving of bones attached to it, the spinal cord and brain alter their shape, as well. In turn, this action overtly expresses itself by changes in intensity, frequency and the amount of nerve flow to and from the brain.

An excellent example of how misaligned bones create adverse dural tension and peculiar pain syndromes is commonly found at the second cervical vertebra: the axis.

The Axis, Suboccipitals, and Head Pain

Because of its direct attachment to the dural tube, poor alignment at C2 frequently becomes a major source of head and neck pain. In the embryo, the rod-shaped notochord develops at the axis. It is the center of development of the axial skeleton and instrumental in determining the final construction of the nervous system; therefore, therapists must appreciate this area as the body’s premiere neurological and biomechanical center.

When the axis is properly aligned, and the dural membrane is not overstretched by cranial or sacral asymmetries, all is well. But when the facet joints of C2 and C3 are jammed together and refuse to open on one side, the vertebra rotates to the side of the fixation and drags the dura with it. This condition alone can cause local pain and reduced range of motion during head flexion and rotation.

However, when a rotated axis combines forces with an already overstretched dural tube from cranial or sacral distortions, a full-blown central nervous system assault suddenly transpires. To relieve the client’s agonizing symptoms and restore healthy functioning, massage therapists must first understand how the axis becomes misaligned and which techniques work best for releasing the disgruntled dural membrane.

The axis is considered the most important cervical vertebra, partly due to its unique dural attachment and also because of the powerful myofascial structures anchoring it from above and below. Deep suboccipital muscles that bind C2 to the occiput and atlas work in harmony with other muscles to balance the head on the neck.

When a forward-head posture develops from prolonged sitting, the lower cervical vertebrae slide forward on the upper thoracics. The unrelenting force of gravity pulls the head down and one finds himself looking at the ground. Of course, the brain unconsciously revolts by immediately recruiting the suboccipitals and other head-extensor muscles to help level the eyes. Make no mistake, the brain will level the eyes against the horizon even if it means ravaging the neck.

Therapists can easily locate the C2 spinous process by palpating for the inferior bump on the occipital bone. By sliding the index finger inferiorly, a soft gap is felt. This is where the spinous process of the atlas would be if left to Mother Nature. The very next bone palpated as the finger moves inferiorly is the spinous process of the axis (flex and extend the head for easy identification). The therapist must be able to quickly locate this bony prominence to accurately assess and release three extremely important suboccipital muscles responsible for atlas/axis misalignment, forward-head posture and pain caused by “dural drag.”

Figure #2: Suboccipital muscles. Deep suboccipital muscles that bind C2 to the occiput and atlas work in harmony with other muscles to balance the head on the neck. Click on image to see larger view.

Although six of the eight suboccipitals rotate, side-bend and tilt the head back into hyperextension, the rectus capitis posterior major and minor are the primary offenders in forward-head postures and nagging headaches (see Figure #2). When hypertonic and short, the recti muscles join forces with the sternocleidomastoid and head extensors to slide the occiput forward on the atlas through the occipital condyles.

To palpate and release tight recti muscles, place the client in a left side-lying position and slide the right thumb superiorly and slightly laterally from the axis to the rectus capitis major attachment at the occiput. Place the left thumb beside the right thumb so that it contacts the client’s right rectus capitis minor (see Figure #2). Then allow the fingers of both hands to comfortably drape the client’s head. The client takes a deep breath to a count of five while gently cocking her head into hyperextension against isometric resistance from therapist’s thumbs and hands. On exhalation, the thumbs slowly bring the head into more flexion. Repeat this three times and perform the same technique on the opposite side.

Known as the most innervated of all spinal muscles, the suboccipitals revolt angrily against sustained isometric contraction from prolonged sitting, reading, computer work and general inactivity. When subjected to these stressors, the rectus capitis major and minor eventually fibrose, shorten and compress sensitive neural and vascular structures. As muscles and joint capsules accumulate toxic waste products from lack of motion, irritated chemoreceptors and nociceptors begin to fire noxious messages to the spinal cord, causing the brain to “lock down” the area with protective muscle spasm. The result: cervical stiffness, head pain, dizziness, loss of range of motion and, sometimes, vertigo-like symptoms. Furthermore, as the occiput slides forward on the atlas from hypercontracted recti muscles, blood flow from the cranium can become restricted. Pressure build-up from lack of adequate venous drainage causes trapped blood to collect and compress certain cerebral areas. Soon the client feels the first signs of painful, pounding vascular headaches that frequently hurt in one particular spot as inter-cranial pressure rises.

In many clients, fibers of the rectus capitis minor penetrate the foramen magnum attaching directly to cranial dura mater. If weak and flabby, they do not function as an adequate anchor for the dura during flexion movements. When tight and short, headaches begin as fibers of the rectus capitis minor drag on the dural membrane, interrupting cerebrospinal fluid flow.

Oddly enough, their primary function doesn’t seem to be head hyperextension. Phillip Greenman, D.O., and others have observed that these tiny suboccipitals prefer to fire at the end range of head flexion. It is believed that this reaction is a protective device for securing the dura during whiplash-type motions. Regardless, to restore proper function, these highly specialized muscles must be lengthened if fibrotic or tonified if weak and flabby.

Stomach-Sleepers

The typical “stomach-sleeper” turns his head to one side in order to breathe. Normally the head is turned to the dominant side (usually the right). Since the inferior oblique muscle is the primary head rotator (atlas on axis), prolonged stomach sleeping with the head turned right slackens this muscle over time. Meanwhile, the inferior oblique on the left becomes overstretched and weak. As the client continues sleeping with the head turned right, the muscle ends are brought closer together, increasing tonus in the right inferior oblique. Suddenly one morning the client rises and begins to straighten the head. Shooting pains cause a frantic call to his therapist-simply because the short right inferior oblique prevents the atlas from rotating back left into its normal position on the axis.

As time passes, the atlas becomes fixated in a right-rotated position in relation to the axis. Any attempt to look left forces the axis to rotate left, jamming the C2-3 facet joints together on the right. The axis can become chronically fixated in a left-rotated position, forming that familiar knot massage therapists commonly palpate in the upper left neck. With the atlas rotated right and C2 facet stuck rotated and side-bent left, the torsioned dura loudly rebels. Additionally, if the dural tube is already overstretched from a hooked coccyx, backward sacral torsion, forward-head posture or cranial deviations (particularly occiput and sphenoid), pain, nervous tension and sometimes weird scoliotic patterns appear. Dural strain from longitudinal tensional forces pulling from either end, sphenoid or coccyx, causes neurological pathways leading to and from the brain stem to become disorganized, hyper-excited and overly agitated.

Heartbeat Headaches

The typical stomach-sleeper’s headache throbs and pounds around the ear and temporal bone with each beat of the heart. Fortunately, pain from unilateral temporal headaches is usually easy to relieve using the two-step Myoskeletal Alignment Technique protocol. “Heartbeat headaches” gradually develop as the vertebral artery is stretched and compressed as it threads through the transverse processes of the misaligned atlas/axis and tucks into the foramen magnum.

	Figure #3: Inferior oblique release, step one: The therapist’s right thumb contacts the C-2 spinous process and slides superio-laterally toward the atlas transverse process while the fingers gently brace the side of the client’s face. The client is asked to inhale to the count of five while gently rotating her head right. The therapist’s right fingers isometrically resist this effort (the therapist’s thumb should feel the inferior oblique tighten). As client exhales, the therapist maintains sustained thumb pressure as the client’s head is slowly turned to the left. The post-isometric relaxation response that follows allows the fibrotic oblique muscle to soften and stretch. Repeat this three times and re-test the atlas’ ability to left-rotate on its axis.
To correct this ornery dysfunction, the client is placed in a left side-lying position, and the therapist begins by contacting the axis spinous process (see Figure #3). The therapist’s right thumb slides laterally toward the atlas transverse process while the fingers secure the right side of the client’s face. As she gently attempts to right rotate her head against the therapist’s resistance, the short, fibrotic oblique capitis inferior (inferior oblique) muscle will “pop up” into the palpating thumb. One or both thumbs may be used to lengthen this short, tight inferior oblique and begin the first step in de-rotating the atlas on the axis. It is easy to see how dural drag from a misaligned atlas/axis can cause pain by irritating this sensitive piezoelectric dural membrane and interrupting cerebrospinal fluid flow.
	Figure #4: Atlas/axis dural release, step two: With the therapist seated or standing and elbows resting comfortably on a table, extended fingers or thumbs slowly flex the client’s head and neck 45 degrees. The therapist’s right index finger braces the right transverse process of the atlas while his left index and middle fingers contact the left rotated C2-3 joint in the lamina groove. With the client’s head slightly hyperextended, the therapist’s fingers maintain constant pressure as the client slowly chin-tucks while slightly rotating her head to the right. This maneuver rotates the atlas right while releasing the fixated left C2-3 facets. Repeat this three to five times and re-check the atlas/axis alignment.
Step two for correcting heartbeat headaches is demonstrated in Figure #4. As the client slowly performs chin-tucks while right-rotating her head against resistance from the therapist’s extended fingers, adherent facets at C2-3 are released, allowing the atlas and axis to rotate into proper position. Bodyworkers will find this simple two-step procedure for restoring function to the upper cervical complex extremely useful in clients suffering unilateral, pulsating temporal headaches.  Two other remaining spinal structures responsible for head and back pain also merit special attention due to their profound effect on the dura mater: the coccyx and sacrum. The Hooked Coccyx The hooked and side-bent coccyx are two of the most devastating and often overlooked spinal dysfunctions. When this tiny group of bones “hooks” anteriorly or side-bends to one side (usually the left), the dural tube tightens (see Figure #5). There are reported cases where a hooked coccyx actually shuts down the entire central nervous system by changing the shape of the piezoelectric gel in the brain and spinal cord, thus hindering cerebrospinal fluid flow.
	Figure #5: A hooked coccyx. The hooked and side-bent coccyx are two of the most devastating and often overlooked spinal dysfunctions. There are reported cases where a hooked coccyx actually shuts down the entire central nervous system by changing the shape of the piezoelectric gel in the brain and spinal cord, thus hindering cerebrospinal fluid flow.
Strange idiopathic head and low-back pain syndromes frequently manifest when a distorted coccyx tugs on the dural tube, causing reverberating tensional forces to travel all the way up to the occiput. Recurrent, persistent headaches can also develop as a hooked or side-bent coccyx reciprocally alters the position of the sphenoid bone. Difficulty sitting for any length of time, problems with sex, urination, PMS, bed wetting, digestion and extreme sensitivity to light also raise red warning flags of possible coccyx dysfunction. Ida Rolf, Ph.D., who always referred to the coccyx as the “seat of the soul,” insisted on correcting the hooked and side-bent coccyx during her famous session six of the Rolfing series. A modified version of Rolf’s coccyx technique is demonstrated in Figure #6. An important note to therapists treating coccyx dysfunction: Always ask the client’s permission to perform this technique due to possible physical and emotional hypersensitivity in the area. Before performing any type of coccyx work, take time to clearly explain what you’re doing and the desired outcome. This ligament-release work shown in Figure #6 should always be performed through underwear or draping. Addressing a misaligned coccyx can cause the client to become very emotional, due to the vertebra’s direct attachment to the dural membrane by the filum terminale, a long, slender connective tissue strand that terminates at the end of the spinal cord. Connective tissues called the filum durae spinalis enclose the end of the spinal cord and attach it to the deep dorsal sacroccygeal ligament. Low-back, hip and head pain can manifest as the sacroccygeal ligament anteriorly flexes the coccyx, compressing the sensitive filum terminale.
	Figure #6: Sacrotuberus/ sacrospinous/ lateral sacrococcygeal ligament release. The therapist releases tight right pelvic ligaments by reaching across the client’s body and contacting the left ischial tuberosity with his dominant thumb and sliding up and under attachments at the inferior border of the sacrum. The therapist’s other thumb braces on top, maintaining sustained upward pressure to release ligaments and gently lift the coccyx from its hooked position. Two minutes of light-to-moderate, fast-paced fibroblast-frictioning helps promote collagen formation in weak, overstretched ligaments. Check the position of the coccyx. If left side-bent, repeat this procedure to short ligaments on the left to restore symmetry.
A hooked coccyx could also lead to loss of psychological integrity. In fact, some reported cases cite severe emotional disturbances in people whose coccyx has been removed or broken off, leaving no anchor for the dura mater. The coccyx has also been implicated in clients presenting with functional and structural scoliotic patterns. Through its connection with the sphenoid, excessive dural tension stresses the 11th cranial nerve, which, in turn, shortens specific neck and shoulder muscles, including splenius cervicis and levator scapulae. Protective muscle spasm from bilateral dural irritation can compress the C7-T1 area, resulting in dowager’s humps and osteoarthritic bone degeneration, while one-sided dural torsioning forces the cervicothoracic vertebrae to buckle into a scoliotic curve. Regrettably, the neck and coccyx are not the only structures affected by adverse dural tension. Bodyworkers regularly deal with clients returning week after week, complaining of generalized low-back or sciatic-type pain. Myofascial therapy offers only temporary relief for those clients whose dural tube has been distorted by sacroiliac dysfunctions. This condition is easily recognized due to chronic, sympathetic muscle spasm that stubbornly refuses to release. Standing Back Pain Clients complaining of low-back pain from prolonged standing usually suffer various forms of sacroiliac dysfunctions. Among the 10 ways the sacrum can become stuck “crooked” between the two iliac bones, the most common is called a “left unilateral flexed sacrum.” In these clients, prolonged standing forces the left sacral base to move anteriorly/inferiorly and get stuck there. This aberrant sacroiliac problem often prevents the left facet joints at L5 and S1 from closing during prolonged standing, leading to generalized hip and back pain. For some odd reason, 95 percent of all unilateral flexed sacrums are on the left. Unlike painful sciatic-like sacroiliac dysfunctions, such as backward sacral torsions, the unilateral flexed sacrum can ache deeply on both sides of the low back the longer the client stands. This is primarily due to sinuvertebral nerve innervation of the dura and joint capsule at L5-S1.  To assess this dysfunction, therapists simply palpate both sacral bases, checking for differences in depth. If the sacrum is deep on the left, it is rotated to the right. By sliding the thumbs down to the inferior lateral angles of the sacrum, the therapist can determine which side is most inferior. If the left inferior lateral angle is more inferior than the right and the left sacral base is deep, the sacrum is probably dragging on the left end of the dural membrane, causing the aching back. The myoskeletal contract/relax technique for a left unilateral flexed sacrum demonstrated in Figure #7 is successful in correcting this prevalent chronic back-and-hip complaint.
	Figure #7: Addressing the left unilateral flexed sacrum. With the client lying on her right side (knees and hips flexed), the therapist grasps the client’s left wrist with his right hand. The therapist’s left palm contacts the inferior left sacral border just above the coccyx. A slow, sustained counter-force is established between his two hands as he gently pulls on the client’s left arm while his left palm braces at the sacrum. The client is asked to inhale and hold to a count of five while gently pulling her left arm against therapist’s isometric resistance. As the client exhales, the therapist takes up the slack by lightly pulling on the client’s arm while maintaining constant pressure on the inferior sacral angle. Anterior/superior palm pressure to the inferior lateral angle of the sacrum causes the left sacral base to move posteriorly into its proper position. Additionally, the stuck facets at L5-S1 are encouraged to close as the pull from the therapist’s right hand left-rotates the client’s trunk. Repeat this three to five times and re-check for sacral base symmetry.

Therapists should remember that most sacroiliac dysfunctions are associated with muscle imbalances in the psoas, piriformis, biceps femoris and weak gluteals. Because fibers of the biceps femoris muscle often originate at the sacrum instead of the ischial tuberosity, hypercontraction of these lateral hamstrings produces a constant drag on the sacrum, dura and the entire pelvic girdle. Therefore, the first step in relieving sacroiliac dysfunction is to balance all muscle groups attaching to the pelvis from below and above.

Obviously, some of these muscles need lengthening while others require restoration of tone. Once myofascial balance is established in the muscles attaching to the pelvis, assessment and correction of any bony restrictions distorting the dural membrane can then be addressed.

Turning Challenge into Triumph

Since the nervous system directs all the body’s functioning, its immediate condition is expressed by the changing of frequency, intensity and quality from the cerebral hemisphere through the spinal cord to the rest of the body. Surprisingly, there are only a few places where the nervous system can be properly tuned, and these “adjusting knobs” are the bones that directly attach to the dura mater.

This article’s focus has primarily centered around the negative effects spinal fixations (axis, sacrum and coccyx) have on the dura mater. The omission of the enormous role cranial dysfunctions play in creating adverse dural tension is intentional. Hands-on approaches for addressing these separate yet equally disturbing conditions can best be learned by attending courses devoted exclusively to this very timely and rewarding body of work.

Faulty alignment or fixations in any bone of the cranial vault or spine will over-stretch, torsion, deform or drag on the dural membrane, disrupting its ability to send or receive reliable signals from musculoskeletal and visceral structures. Since these aberrant dural stresses frequently manifest as spasm and pain, they are often misinterpreted as muscle problems. This is but one reason why therapists will greatly benefit from the ability to quickly distinguish between common myofascial pain syndromes and true adverse dural tension signs. Long-standing pain often fades in memory as dural techniques are properly addressed through training programs devoted to this intriguing area of bodywork. Clients and therapists alike will appreciate the psycho-social-physical contribution of this holistic approach to pain management. 

Through the centuries, technological advances and exhaustive research have verified the early Greeks’ amazing understanding of the dura mater’s integral and pervasive role in optimum central nervous system functioning. All somatic therapists will be graciously rewarded by investigating, through formal hands-on training, the awesome effects of this “tough mother” and its profound significance in protecting the brain and spinal cord.

By developing a comprehensive understanding of the internal dynamics of how routine neck, head and low-back complaints originate from this sensitive membrane, today’s massage therapist can turn a therapeutic challenge into triumph by adding dural techniques to their toolbox of touch.

Pain Puzzle

Simplifying The Pain Puzzle

It was a moment of epiphany, where wisdom hung heavily in the air. The legendary, feisty, 92-year-old Detroit osteopath Clarence Harvey was about to share his unusual but profound mantra for assessing neck-and-back dysfunction with a classroom packed with students. Wearing a slight smile on his wizened face, he slowly turned to the chalkboard and boldly wrote in large letters, “Don’t chase the pain.” Although initially the intent of his statement seemed vague and somewhat cloudy, it stirred memories dating back 20 years, when the queen of fascial work, Ida Rolf, Ph.D., made a strikingly similar comment that supported Harvey ‘s advice. During an Esalen Institute presentation I attended in the early ’70s, she had bluntly stated, “Get ’em aligned and balanced. If the pain goes away, that’s their tough luck.”

Years of clinical experience had apparently brought these two manual-therapy legends to the same conclusion. Since neck/back dysfunction typically involves many pain producing structures and referral patterns, simply chasing the pain by addressing clients’ bodies where they hurt is, at best, a temporary quick-fix. Both Harvey and Rolf agreed that trying to decide exactly which structures are causing client’s neck and low back pain was basically a waste of time.

Although muscles are partly to blame, advanced diagnostic equipment confirms their theories as new research implicates other pain generating soft tissues, such as:

• Ligaments
• Discs
• Nerve dura
• Fascia
• Joint capsules

Previously thought of as only mechanical structures, clinical researchers today substantiate the presence of neural innervation in all these soft tissues.

Holistic alleviation of pain is largely dependent on restoration of proper body alignment, range of motion and proprioception. According to the great biomedical researcher Nikolai Bogduk, M.D., “Pain upon movement is not a criteria from which a biomechanical assessment can be made. To reach an accurate assessment, we need to evaluate function according to a dynamic structural model.” As massage therapists learn to integrate alignment techniques into their clinical practices, clients’ aches and pains begin to disappear without the therapist ever having to know exactly which of the soft tissues caused the pain. The trick is developing a simple and effective structural model that is easily adaptable to a typical massage therapy pain management session.

Eight Procedures

By incorporating a wide assortment of new and old manual therapy modalities, the Myoskeletal Alignment Techniques (MAT) method helps manage the neck/back pain puzzle by addressing all soft-tissue back structures in one formula.

Massage therapists trained in the MAT method of deep tissue therapy find success in assessing and correcting a wide range of chronic pain conditions by integrating the following eight procedures:

1. Observe for lower and upper crossed syndromes upon the client’s entrance.

2. Conduct a five-minute structural assessment on the therapy table with the client draped.

3. Lengthen short, hypertonic muscles with deep-tissue, myofascial release and assisted-stretching techniques.

4. Tone weak, inhibited muscles with fast-paced spindle-stimulating maneuvers.

5. Fibroblast-friction hypermobile ligaments and loosen hypomobile ligaments using finger, fist and elbow procedures.

6. Massage fibrotic transversospinalis muscles to unlock stuck facet joints or to stimulate spindles if weak and inhibited.

7. Restore joint play and capsular flexibility with co-activating receptor techniques.

8. Relieve disc compression and dural drag with gentle distraction maneuvers.

Many of today’s rapidly evolving massage schools teach students various methods for visually assessing distorted postural patterns. Special attention is usually given to obvious anterior/posterior body asymmetries, such as forward-drawn heads, swayed backs and rounded shoulders.

One medical researcher in particular, Vladimer Janda, M.D., of Czechoslovakia , has been instrumental in advancing and simplifying this visual assessment model. Unfortunately, his 40-plus years as the world’s leading authority on the effects of muscle imbalances on posture has only recently been introduced to the audience that can most dearly benefit-the massage community.

Visual assessment made easy

Having had the good fortune to observe the brilliant work of Janda in 1992, my mission was clear: to immediately integrate this practical and timely information into the MAT method of assessment. Although Janda’s research concerning muscle imbalance patterns and neuromuscular firing order falls among the most valuable gifts presented to today’s clinical massage therapist, it has been sadly underutilized in most bodywork training.

In 1988 Janda surprised the biomedical community with a remarkable discovery: All striated muscles of the body respond to stress in different but predictable ways. Simply stated, certain muscles tighten while others weaken when exposed to the same stressors. Janda’s formula for predicting tight and weak muscle groups helps explain why so many clients present with the same aberrant postures. Investigators now believe these muscle imbalance patterns develop from a bombardment of abnormal neurologic information to the spinal cord and brain, due to tension, trauma, poor posture, joint blockage, genetic influences, excessive physical demands or habitual movement patterns.

Upper and Lower Crossed Syndromes

Today’s massage therapist should enjoy working with Janda’s upper and lower, or proximal-and-distal, crossed syndrome theory when dealing with clients who suffer from neck or back pain. According to Janda, when upper crossed muscles, such as the pectorals, upper trapezius, levator scapulae, latissimus dorsi, sternocleidomastoid, anterior scalenes, suboccipitals and subscapularis are stressed, they tighten and become neurologically facilitated.

This category of muscles was labeled tonic, or postural. Inversely, electromyographic studies found that other upper crossed muscles, such as the longus capitis, longus colli, hyoids, serratus anterior, posterior rotator cuff, rhomboid major and lower trapezius, actually weaken when exposed to the same stressors. This second set of muscles was labeled phasic, or dynamic. Amazingly, this muscular response occurs in consistent and predictable patterns regardless of the pathologic condition or the dysfunction present in the tested subjects.

Typical Muscle Imbalances in the Upper Crossed Syndrome

Typical Muscle Imbalances in the Lower Crossed Syndrome

Tight, Facilitated:	Weak, Inhibited:	Tight, Facilitated:	Weak, Inhibited:
Pectorals Upper Trapezius Levator Scapulae Sternocleidomastoid Anterior Scalenes Suboccipitals Subscapularis Latissimus Dorsi	Longus Capitis & Colli Hyoids Serratus Anterior Rhomboids Lower & Middle Trapezius Posterior Rotator Cuff	Iliopsoas Rectus Femoris Hamstrings Lumbar Erectors Tensor Fascia Latae Thigh Adductors Piriformis Quadratus Lumborum	Rectus Abdominis Gluteals Vastus Medialis Vastus Lateralis Transversus Abdominis

The upper crossed syndrome. Notice how the tight line (a) passes through the levator scapulae, upper trapezius and the pectorals, causing shoulder elevation and scapular protraction. Inhibition in the deep neck flexors and lower shoulder stabilizers (b) permits this asymmetry. Since the forward head is the most common postural fault seen in our society, Janda’s upper crossed illustration is extremely helpful in visualizing exactly which muscles pull unevenly to create this distorted posture. Notice in the upper crossed illustration how the tight line (a in Figure ) passes through the levator scapulae, upper trapezius and the pectorals. Sustained hypercontraction in these typically tonic muscles elevates and protracts the shoulders. Conversely, one can clearly see how the deep neck flexors and lower shoulder stabilizers that make up the weak line (b in figure) permit this asymmetry.

The lower crossed syndrome. The tight line (a) travels through the iliopsoas and lumbar erectors, which pull and hold this aberrant swayback posture. Reciprocal inhibition weakens the abdominals and gluteals (b) allowing this dysfunctional pattern to develop. Janda employs the same concepts when analyzing the lower crossed problem. View how the tight line (a in Figure ) travels through the iliopsoas and lumbar erectors, while the weak line (b in Figure ) connects the lower abdominals and gluteals. In this crossed pattern, the short iliopsoas muscles anteriorly tilt the pelvis, creating excessive lumbar lordosis while erector spinae myofascial contractures hold this “bowing” pattern. The weak abdominals and gluteals, unable to stabilize the pelvis, allow this aberrant swayback pattern to develop. Still, a frustrating question remains: Why do so many clients present with this lower crossed pattern? The answer is, to me, painfully obvious: flexion addiction.

A Society of Flexion Addicts

The last century has witnessed a dramatic acceleration in our culture’s flexion addiction. This pervasive and insidious condition is primarily due to the population’s generational transition from an active group of movers to a sedentary bunch of sitters..

Davis’s Law emphasizes that if muscles are lax for extended periods of time, gamma gain and reciprocal inhibition will take up the slack. Thus is the case with the hip flexors. As the psoas and rectus femoris neurologically shorten from prolonged sitting, the ilia are pulled in an anterior/inferior direction, which results in excessive lumbar lordosis when standing. Compensations from this swayback condition often lead to thoracic hyperkyphosis, forward head postures and typical upper crossed asymmetries. Researchers estimate that up to 75 percent of chronic neck/back pain clients will present with one or both of these crossed patterns.

Consequently, any therapist’s practice benefits by utilizing Janda’s list of typically tight and weak muscles when addressing neck and low back pain complaints. The MAT method stresses that each pain management session begin with the intent of creating balance between the tight tonic and weak phasic muscle groups listed in Janda’s formula. The therapist begins by selecting a therapeutic technique to lengthen shortened, hypertonic muscles. Once length and flexibility have been restored to tight muscles and their fascia, specific fast-paced finger and fist techniques stimulate muscle spindles to tonify the weaker, inhibited groups. The therapist may choose a specific MAT maneuver to correct the asymmetries, or delve into his or her own toolbox for a familiar technique that has proven successful in the past. The MAT method emphasizes that specific technique selection is not as important as knowing why that particular muscle-release maneuver was chosen.

However, all hand, elbow, finger, fist and thumb techniques should correspond with the type of tissue manipulated. Tight, tonic muscles require restoration of extensibility, while weak phasics demand restoration of contractability. Incorporating Janda’s visual models of tonics and phasics makes structural work easy and fun. Of course, clients may present with occasional pattern reversals, such as military shoulders and flat backs. Prolonged slumping while sitting will eventually flatten or reverse the lumbar curve by overstretching posterior low-back ligaments. Hyperextension exercises, such as the hatha yoga cobra pose, are often helpful in reversing this painful postural pattern. Simple session modifications to Janda’s upper and lower cross formula will also restore function to clients experiencing loss of lumbar lordosis.

It should be noted that therapists frequently encounter side-to-side imbalances, such as a low shoulder, short leg or cocked head. These asymmetries are often the result of powerful unilateral myofascial forces tugging on the body’s bony framework, jamming spinal facet joints and irritating sensitive joint receptors. Facets are possibly the most innervated structures in the spine. Therefore, when the joint’s axis of rotation is disrupted due to myofascial shortening, the sensitive articular receptors provoke sympathetic spasm in neighboring muscles, causing the body to twist and torque in an effort at pain avoidance. As gravitational strain is added to the equation, unilateral distortions quickly become chronic pain-generators. So, how does the manual therapist know if these distorted postural patterns result from myofascial strains or joint dysfunction?

Tight Muscles or Joint Dysfunction?

As described in the first part of this series, Mobilizing Joints Through Muscle Manipulation (January/February), tight muscles create asymmetry and weak muscles permit asymmetry in both the myofascial and skeletal systems. Deep, intrinsic muscles and the body’s bony framework are inseparable: What affects one always affects the other. Until the therapist develops a basic understanding of how deep tissue techniques affect the bony framework, random deep tissue work is contraindicated. Massage therapists who commonly deal with chronic pain and postural problems profit by studying the laws of spinal biomechanics and learning to focus therapeutic intent on both myofascial and spine-related soft tissues.

A good example of how poor skeletal alignment promotes protective muscle spasm and aberrant postures is frequently encountered in clients suffering long-term neck, upper-shoulder and arm pain. People who habitually hold the telephone with one shoulder frequently develop chronic unilateral hypertonicity in the levator scapula and splenius cervicis muscles. Because of their common attachments at the top three or four cervical transverse processes, unilateral contraction of these muscles side-bends the neck and elevates the shoulder to help secure the phone. Problems escalate as the deep spinal rotators react to the unilateral sustained hypercontraction. When overstimulated, these fibrotic little muscles are notorious for locking facets closed on the ipsilateral side and open on the contralateral side.

Sensitive joint receptors respond to these sustained torsional forces by flooding the spinal cord with noxious afferent messages that tighten or weaken the little spinal rotator muscles, causing alterations in their firing order pattern. In scoliotic clients, therapists commonly palpate short/hypertonic rotators on the concave side and weak/inhibited muscles on the side of the convexity.

Repeated exposure to one-sided compressive forces from prolonged unilateral neck side-bending irritates the joint’s articular cartilages and promotes adhesive tissue build-up in cervicothoracic vertebrae and upper rib capsules. Because of the common attachments of the anterior scalenes with levator scapulae and splenius cervicis, unilateral sympathetic scalene spasm can join forces and pull the neck forward into an awkward flexed/side-bent/rotated position. Overstretched joint capsules soon fibrose and facet joints frequently become locked in an open position. The result: local neck ache or referred pain into the arm and interscapular area. Left unaddressed, the condition worsens.

Assume for a moment that the forward-head posture is subtly being pulled into right side-bending and right rotation due to combined hypercontraction in the levator and splenius cervicis muscles. As the client attempts to raise her head from a flexed to extended position, if the right T3 facet joint cartilage is swollen from prolonged right side-bending, it can get stuck and not be able to slide back in its proper closed position on T4. Because the left facets are operating smoothly, the superior facet on that side gladly slides closed during this maneuver. Unfortunately, because the T3 joint on the right is unable to close properly, it forces the T3-4 joint to rotate left, as illustrated below.

A swollen right facet at T3 is unable to close during extension efforts by the client, causing the vertebra to rotate left.

The dysfunctional facet joint capsule will soon fibrose, locking T-3 left rotated. To compensate, the T3 rib on the side that is not closing is usually forced into internal rotation. Now the nagging pain begins. Prolonged irritation allows this “dynamic duo” (vertebra/rib fixation) to feed off each other, creating reflexogenic inhibition in the surrounding paravertebral muscles, including the rhomboids and trapezius muscles. Retraining exercises to strengthen the lower shoulder stabilizer muscles to help resist the powerful pull of the massive pectorals are useless until both these joint fixations are addressed. Second only to backward sacral torsions, vertebra/rib dysfunction is probably the longest-lasting and most irritating joint-related problem a client will ever experience.

A Sample MAT Joint-Release Routine

To remedy this distressful situation, the splenius cervicis, levator scapula and anterior scalenes on the right must first be lengthened.

The therapist lengthens the splenius cervicis, levator scapula and scalenes by pinning the attachments with his or her left hand, while mobilizing the shoulder girdle with a right-arm lock. Since the T3-4 joint is rotated left, the therapist will feel a hard or “stringy” knot on the client’s left side in the spinal groove when palpating that area. With the client in a prone position, the therapist’s fingers or thumbs start by loosening the overlying myofascia and digging out adhesions in the deep spinal rotator muscles. Soon a bony knot will be palpated on the left at T-3, indicating the vertebra has, indeed, rotated left.

The therapist’s right thumb is placed on the protruding left transverse process while the left hand lightly rests on the back of the client’s neck. Using gentle, sustained anterior pressure on the bony knot, the client is instructed to inhale to a count of five, while carefully attempting to extend and right-rotate her head against the sustained isometric resistance from the therapist’s left hand.

As the bony knot pushes back against the therapist’s resistant thumb, a strong Golgi tendon organ release is transferred through the transverse process to the adjoining spinal rotator muscles, creating increased capsular flexibility and subsequent joint decompression.

As the client exhales and relaxes, a post-isometric relaxation response further softens the muscles and joint capsule, allowing the therapist’s thumb to slowly de-rotate and release the fixation at T3-4.

Gentle thumb pressure combined with extension and right rotation efforts by the client encourage the stuck right facet to slide down into its proper position. Fortunately, the internally rotated rib on the opposite side frequently fixes itself as the dysfunctional facet comes into alignment.

If immediate softening is palpated in the surrounding spinal muscles following this, then the therapist has done her or his job. Always check to see if the rib on the right has corrected itself by lightly scanning the rib shafts with soft fingertips, inferior to superior, feeling for a bump at about T3. If a slightly bulging rib shaft is palpated, the rib is still stuck in internal rotation. With fingers or thumbs, simply release the intercostal muscles above the dysfunctional rib in a medial to lateral direction. Then apply the same basic procedure as above to align the costotransverse rib joint.

In Summary

The therapist contacts the client’s left T3 transverse process with the therapist’s right thumb while his or her left hand gently rests on the client’s neck. With a 10-percent effort, the client inhales while extending and right rotating her head against isometric resistance from the therapist’s left hand. As T3 attempts to rotate left, the therapist’s right thumb resists this effort, causing a Golgi tendon relaxation response in the fibrotic tissues that are restricting closure of the joint

Pain Free Clients

Many years have passed since the gifts of two great and gifted visionaries-Ida Rolf, Ph.D., and Vladimer Janda, M.D.-were bestowed on me. Every day I become more convinced that managing the pain is simply an elusive journey that sidetracks us into addressing obvious problems, while missing the real cause of our clients’ dysfunction. By focusing infinitely on the body’s complex systems of interconnecting networks, one can become lost in the minutiae without appreciating our built-in, self-sustaining system that thrives when the effects of gravitational strain are reduced by proper alignment. The old adage, “You can’t see the forest for the trees,” drives home the idea of embracing the natural order of balance and simplicity within the cinemascopic context of its overall complexity.

By integrating the technological advancements of today with the wisdom passed on from our forefathers and foremothers, we can achieve the success we desire: pain-free, mobile and fully functioning clients.

Footnote

1. Bogduk, N: “Pathology of Lumbar Disc Pain,” Journal of Manual
Medicine, 1990.

Mobilizing Joints through Muscle Manipulation

Learn More About Erik Dalton Myoskeletal Alignment

from Erik Dalton, Ph.D.

The Myoskeletal Alignment Techniques program was developed as a tool to help relieve our nation’s neck/ back pain epidemic. By incorporating muscle-balancing techniques with joint-mobilization maneuvers, manual therapists learn to quickly identify and correct dysfunctional strain patterns before they become pain patterns.

This article is the first in a three-part series designed for massage therapists seeking more information about the reflexogenic relationship between muscles and joints. Combining muscle and joint modalities offers busy bodyworkers short-cuts that help shorten assessment/hands-on time, increase therapeutic efficiency; and provide clients with pain relief.

Due to the length of this article we have provided hyperlinks to it’s seven major sections:

What makes MAT special?

Well-documented theories explain how joints become fixated from myofascial stressors; yet relatively unknown in the massage therapy community is how joint dysfunction creates protective muscle spasm and dysfunctional strain patterns, such as forward head postures, slumped shoulders and scoliosis. This reflexogenic relationship between muscles and joints is the foundation of the Myoskeletal Alignment Technique and is considered not only uniquely different from traditional thinking, but possibly an important next step in addressing abnormal strain patterns caused by muscle/joint imbalances.

Massage therapists can now safely address all soft tissues, including ligaments, nerve dura, fasciae, discs and joint capsules, responsible for much of the pain previously blamed on muscles alone. Osteopathic methods, such as muscle energy, strain-counter strain and mechanical link, are also designed to relieve muscle/joint dysfunctions, but the MAT method complements today’s bodywork practices as it was specifically designed to fit a massage-therapy format.

One distinguishing goal that establishes the MAT method apart from other techniques is its dependence on identification and correction of joint fixations. This is accomplished by systematically releasing deep spinal muscles, ligaments and fibrotic joint capsules that torsion and compress spinal joints. In some cases, a bodyworker may apply direct pressure to bones to release fibrotic muscles that create joint blockages, but the intent is always soft-tissue work.

a. Following hip flexor work, the hip capsule is assessed and addressed by flexing the client’s left knee and locking her foot with the therapist’s right shoulder. b. The palm of the therapist’s left hand braces just inferior to the ischial tuberosity so a counter-force between the two hands can be established as the left leg is lifted into extension. c. The client is asked to lightly push her knee toward the table while the therapist resists this effort to a count of five.

Assessment: Anterior Hip Capsule Adhesion Note: This technique is contraindicated for clients with hip replacements or joint pathology.

d. The client relaxes and the therapist slowly pulls with his right hand while resisting with his left hand. e. The therapist should feel joint play in the capsule and iliofemoral ligament. f. Repeat the technique to loosen the joint capsule and iliofemoral ligament.

Assessment: Deep Spinal Rotator Muscles

a. The therapist secures the client’s forehead with his left hand and reaches under with a flat palm so his fingers can grip deep rotators in the cervical lamina groove. b. The client inhales to a count of five while attempting to gently turn her head left against the therapist’s resistance. c. As the left spinal rotator muscles fire, the therapist searches for and releases fibrotic knots in the lamina groove. The client relaxes. Repeat on the opposite side as necessary.

Posture’s Role

Most manual therapists today agree that no therapeutic approach to neck/back pain is complete unless body posture is generally improved. Whatever the root of the client’s condition, special attention must be dedicated to posture-especially the correct positioning of the pelvis. Many therapists complain that postural assessments are often too complex, too time-consuming, too clumsy-in a typical massage setting with the client draped.

The MAT method lessens assessment anxiety with an efficient five-minute hands-on evaluation that quickly identifies gross body asymmetries, such as pelvic tilts, short legs, sacroiliac dysfunctions, scoliosis, facet restrictions and hip-capsule adhesions. MAT also incorporates Vladimir Janda, M.D.’s upper-and-lower crossed visual assessment method for easy recognition of muscle-imbalance patterns that cause neck and low-back pain. Combining these hands-on and visual assessment techniques allows the therapist to immediately tell which muscles are tight and pulling unevenly on the body’s bony framework, and which weak muscles are permitting the asymmetry. Janda’s muscle-imbalance research has gifted bodywork practitioners with a remarkably useful model for explaining how predictable muscle imbalances cause predictable faulty postural patterns, such as slumped shoulders, forward heads, swaybacks and dowager’s hump. (Hands on procedures using Janda’s formula are detailed in Part II of this series.)

Ultimately, for long-lasting relief of chronic neck/back pain, the MAT system works to achieve these goals:

• balancing the head on the neck
• balancing the neck on the shoulders
• balancing the shoulder girdle on the rib cage
• balancing the pelvis on the femurs
• restoring pain-free movement

Recent studies have confirmed a noticeable reduction in noxious neural input entering the spinal cord and brain when the postural goals listed above are met. In 1979, biomechanical researcher J. Gordon Zink, D.O., coined the term "common compensatory patterns" to describe routinely found postural patterns in the neuromyofascial-skeletal system. His studies were the first to validate how structure and function play a dual role in posturally initiated pain syndromes. Eventually, he concluded that postural muscle stress leads to chronic, recurrent central nervous system irritation initiated by sensory receptors, such as mechanoreceptors, nociceptors and chemoreceptors.

Postural muscles are structurally designed to resist fatigue and function in the presence of prolonged gravitational exposure. If their capacity to resist stress is lost, the postural muscles become irritable, tight and shortened. Fortunately, as balance and function are re-established in distorted myofascial structures, hyperactivity in agitated joint and muscle receptors rapidly dissipates. Zink’s conclusion leads to the underpinnings of the client’s outcome: less sympathetic muscle spasm, less limbic system activation, less stress-and less pain.

How Muscles Reveal Joint Dysfunction

During a presentation to the American Back Association in the early 1990s, Phillip Greenman, D.O., unlocked the door to a brave new world of possibilities for massage therapists searching for new ways to locate and address muscle spasm when he said, "In the presence of vertebral dysfunction, palpable fourth-layer muscle fibrosis will always be found." What a simplified way for therapists to identify areas of joint dysfunction and spasm.

Professional bodyworkers’ sensitive fingers and thumbs often dig through the bulky erector spinae muscles into underlying fourth-layer spinal muscles (multifidus, rotatores, levator costalis and intertransversarii). Frequently palpated are small, hard and sometimes tender knots in these deep-tissue structures. Until now, the reason for their continued presence has remained a mystery; but, with the advent of new, more sophisticated electromyographic equipment, researchers are beginning to understand how joint misalignment promotes hypertonicity in these little spinal-rotator muscles.

The MAT system has adopted Greenman’s practical and efficient method for identifying joint dysfunction by teaching students how to palpate for fibrotic knots in the deep spinal-rotator muscles. Truly remarkable is the power these little fourth-layer transversospinalis muscles can generate. They easily pack enough punch to lock spinal joints open or closed with their strong torsional forces. Clients complaining of cricks in the neck are frequently suffering from unilateral hypertonicity and shortness in the intertransversarii muscles. Running from transverse process to transverse process, when fibrotic, these little devils like to side-bend the neck, locking the facets closed on the ipsilateral side or open on the contralateral side.

The intertransversarii are one group of muscles that should never be addressed with direct finger-pressure in the cervical region, to avoid injuring surrounding neural and vascular structures. But a therapist trained in MAT bypasses this problem by using bones as levers to release these tight little side-benders. By gently applying specific directional pressure to the neck’s bony articular pillars, the therapist waits for a Golgi tendon organ release in the intertransversarii.

Intertransversarii Muscles Facet joints stuck closed on right during flexion efforts

Because fourth-layer muscles, such as the intertransversarii, are among our phylogenetically oldest intrinsic muscles, they must be assessed and released in all neck routines to ensure proper cervical alignment. Applying Greenman’s assessment approach allows massage therapists to quickly locate areas of joint dysfunction simply by scanning the spinal groove and searching for lumpy fourth-layer tissue.

Hypertonic knots found in deep transversospinalis muscles always indicate joint dysfunction, but exactly what does this information reveal about the condition of the joint fixation? Nothing! It doesn’t tell whether the joint is locked open or closed-only that there is dysfunction at that level. Fortunately, that is all the information needed at this time using the MAT assessment system. To determine if the joint is locked open or closed, the therapist simply flexes and extends the involved area while palpating the fibrotic knot. If the bony knot pushes back when flexion is introduced, the joint is not opening on that side. If the knot pushes back during extension movements, the joint is not closing on the opposite side, forcing the vertebra to rotate back against the therapist’s palpating fingers.

Keeping It Simple

The MAT system intentionally simplifies correction of joint-related tissues by systematically releasing lumpy, fibrotic fourth-layer muscles, ligaments and joint capsules with the client in flexed and extended positions. Specific directional pressure is then applied to the bony knots until the lamina groove is smooth. Ida Rolf, Ph.D., included groove work at the end of each of her very popular 10-session Rolfing ® series. With the client seated and slowly flexing forward, she would frequently shout orders to "go for a smooth groove" as the students elbowed their way down the lamina groove. (Obviously, she was in tune with the enormous therapeutic value of proper alignment in this area.)

The advanced MAT program includes post-isometric relaxation techniques combined with specific breathing maneuvers to help clear stubborn knots that distort the groove. Simple motion tests alert the therapist to the type of fixation (i.e., whether the joint is stuck open or closed). Once the therapist determines the exact type of dysfunction present, joint play and capsular flexibility can usually be restored using the MAT method-but not always. In some cases the joint has undergone adherent cartilage degradation and facet "nipping" (microtrauma). The resultant facet degeneration causes a true adhesive joint problem. Obviously, this presents a more serious condition than tight muscles restricting joint movement. Working in close cooperation with chiropractors and manipulative osteopaths, prompt referrals should be made along with details describing the specific location of the dysfunction.

Myoskeletal therapy delves deep into body structures, but the intent is still low-force soft-tissue work and should feel exactly like a good deep-tissue session. Bones are addressed as soft-tissue structures in the MAT system, with pressure often applied directly to transverse processes. But bones are only used as levers to release hard-to-access fourth-layer muscles and fibrotic joint capsules. Joints should never be taken into a non-physiologic range of motion, as this would be outside the scope of practice of massage therapists.

Receptors: Backbone of the Myoskeletal System

Input to the central nervous system relies on receptors for detecting sensory stimuli, such as pain, touch, sound, light, heat and cold. Classified according to their actions, these receptors describe their specific duties, such as mechanoreceptors, nociceptors, chemoreceptors, thermoreceptors and electromagnetic receptors. Their primary task is to change sensory stimuli into action potential so information is continually fed to the central nervous system concerning the person’s overall body environment. Many researchers believe our bodies are receptor-driven and that these receptors are the key factor in interacting with our environment. Most massage therapists are familiar with sensory receptors, such as Golgi tendon organs and muscle spindles, but new studies substantiate the presence of other types of receptors located in frequently forgotten soft tissues of the body.

Historically, the medical and manual therapy communities have generally regarded soft tissues, such as ligaments, fasciae, joint capsules and discs, as only mechanical structures and not neurological mediators. But recent technical advances in nerve-staining techniques have revealed the presence of neural elements in all these spine-related tissues. In 1995 Hanging Jiang, Ph.D., and his associates documented the presence of mechanoreceptors and nociceptors in human supraspinal and interspinal ligaments by following 10 patients before and after spinal decompression surgery. His complex and lengthy research ultimately supported earlier scientist’ findings that ligaments, discs and fasciae are integral parts of an intricate neurological feedback loop beautifully designed to protect and stabilize the spine.

Scientists are now finding that ligaments, intervertebral discs and facet capsules are blessed with a rich supply of mechanoreceptors and free nerve endings called nociceptors that alert the brain to undue stress in joint-related tissues. Nociceptors and chemoreceptors are activated when nerve fibers are depolarized by high mechanical stresses in the joint capsule or by exposure to inflammatory chemical agents, such as histamines, prostaglandins, kinins, potassium ions and lactic acid.

When nociceptors fire in response to actual tissue damage, they quickly become major generators of both myofascial- and spinal-pain syndromes. Long-term central nervous system agitation from angry nociceptors causes the brain to twist and torque the body in an effort at pain avoidance. Regrettably, the brain has the ability to memorize these aberrant postural patterns and relearn them as normal. When the dysfunctional pattern persists long after the painful stimulus has been removed, scientists refer to the condition as neuroplasticity, reflex entrainment or spinal learning. Clients whose bodies remain distorted long after the pain has subsided present a therapeutic challenge to today’s bodyworker. Fortunately, home retraining exercises that incorporate a variety of movement patterns often help break this neurological hard-wiring problem.

Sensory Receptors and Massage Therapy

Previously found only in animal specimens, articular receptors, such as mechanoreceptors and nociceptors, have only recently been identified in human spinal tissues. The impact of these recent discoveries holds widespread significance for massage-therapy procedures. For example, it now appears that much of the spasticity and pain reported by clients might originate not only from toxic muscles and trigger points, but from irritated mechanoreceptors, nociceptors and chemoreceptors in misaligned, injured or restricted joint soft tissues. Armed with this new information, therapists can address their clients’ needs more effectively by applying special massage maneuvers to restricted joint capsules, spinal ligaments and deep transversospinalis muscles to desensitize unhappy joint receptors.

The MAT approach to improving function through structural balance always begins with conventional muscle/ fascial balancing routines. But once the therapist manages to restore optimum myofascial flexibility and symmetry, the intent changes. Focus is then directed toward calming joint receptors simply by locating and releasing restricted facet joint capsules. Robert Gillett, D.C., found that only 40 neutons of force is required to co-activate all these mechanically sensitive joint receptors.
(Footnote 1)

A Sample MAT Session

Using soft fingers or thumb pads, the therapist slowly digs through the deep fourth-layer spinal rotator muscles, searching for joint adhesions. Co-activation of hyperactive receptors at T4-5 is accomplished by applying mild, sustained thumb pressure to the misaligned vertebral transverse process of T4. The question is: Why is the therapist mobilizing T4 rather than T5?

Facet opening at T4-5

In this example, the client’s right T4-5 joint won’t open as she flexes forward, causing the T4 vertebrae to rotate right. To begin the correction, the client is positioned on the left side lying/flexed posture with the left arm behind her back. This position encourages the right rotated T4-5 joint to attempt left rotation, which is the direction it needs to go in order to open. The client is then instructed to grasp the side of the therapy table with her right hand, tuck her chin, take a deep breath to the count of five and gently pull up against the isometric resistance of the therapy table. This action fires the short spinal-rotator muscles, causing the dysfunctional T4 vertebra to push back right against the unyielding pressure of the therapist’s thumbs. As the thumbs gently resist this effort during client exhalation, slow, sustained thumb pressure begins to move the T4 transverse process in an anterior/superior direction to open the stuck facets.

Facet opening at T4-5

The process is repeated until the therapist feels a softening in the surrounding paravertebral tissues and the bony knot disappears into the contour of the lamina.

It is important to remember that although the therapist’s thumbs are pushing on bone, the intent is only to release the adhesive joint capsule and hypertonic rotator muscles that are preventing the T4-5 facet joints from opening. Application of sustained pressure to the transverse process during this technique has two very beneficial effects: As the client pulls up on the table with the therapist’s thumbs resisting her effort, a powerful Golgi tendon relaxation response is activated through the transverse process to the rotatores, multifidi, intertransversarii and levator costalis muscles; as the client exhales, a post-isometric relaxation response is automatically elicited in these tight spinal-rotator muscles, allowing deeper thumb penetration and easier release of the fibrotic soft tissues causing the joint blockage.

If the joint opens as it should, the therapist will feel an instantaneous release in the neighboring soft tissues and a palpable reduction in protective muscle guarding. However, if little change is felt, the therapist must retest to see if the fixation released completely. If the joint appears to be opening on both sides as it should but muscle spasm is still evident, then the rib adjoining the vertebral dysfunction at T4-5 has become stuck in external rotation and must be addressed using the same general procedure as above. Referred to as a dual-fixation, this vertebra/rib condition falls among the most painful, long-lasting and overlooked of all client complaints.

Why Muscles Spasm

The massage-and-bodywork community is well aware of the many ways toxic muscles progress from soreness into painful spasm, contractures and trigger points. Sustained isometric muscle contraction from trauma, tension and poor posture are obvious culprits.. Relatively less recognized, however, is the important role joint dysfunction plays in the development of muscle spasm and related myofascial pain syndromes. Muscles are the body’s primary movers and must respond quickly to all changes coming from neural structures. When tight muscles pull unevenly on spinal joints, the joint’s axis of rotation is disrupted and the center of gravity changes. Sensory nerve receptors located in spinal joint capsules, ligaments, discs and deep transversospinalis muscles become aggravated from prolonged joint misalignment.

Particularly unhappy are mechanoreceptors embedded in overstretched capsules or in the part of the joint bearing excessive weight. Range-of-motion restriction from adhesive tissue build-up in the capsule causes eventual loss of joint play.

• Sensitive joint receptors react by flooding the spinal cord and brain with noxious afferent messages that set off warning bells of spinal instability or possible tissue damage.
• To prevent further insult to the painful area, the cerebellum and gray matter react by locking up all back and neck muscles with protective muscle spasm, as described earlier.
• When over stimulated muscle, ligament, disc and joint-capsule receptors join forces and suddenly discharge on axon terminals in the neuronal pool, subthreshold stimuli quickly escalate into full-blown central nervous system attacks.
• This consolidated surge of noxious stimuli leads to jamming of neurologic pathways. In his book Palpation Skills, Leon Chaitow, D.O., refers to this insidious condition as "cross talk."
  (Footnote 2)

To complicate the situation, excessive interactive neural build-up from the effects of cross-talk layer the body with stubborn chronic spasm. The longer these powerful asymmetric myofascial forces are allowed to twist and compress the body’s bony framework, the more noxious stimuli is generated. This marks the beginning of a devastating, self-perpetuating pain/spasm/pain cycle that massage therapists battle each working day. Amazingly, researchers still do not know if impaired function of a muscle(s) is the primary cause of joint dysfunction or if the reverse is true.

Regardless of whether muscle or joint receptors initiate these painful cycles, bodyworkers usually call upon conventional muscle/ fascial techniques to deal with the painful spasm, fibrotic knots and trigger points. Myofascial techniques work extremely well in situations where spasm and myofascial shortening have not significantly altered joint alignment; however, in many cases the pain has long passed the sore muscle stage into a condition referred to as microtrauma. Basically, microtrauma is a slow-developing degenerative joint condition commonly caused by overuse, underuse or abuse. This silent villain cleverly disguises itself as a deep muscle ache. Clients who continually complain of chronic "between-the-shoulder-blade pain" often inaccurately assume this persistent irritation to be a muscle problem. But the pain and suffering usually results from inflamed rib-heads and intervertebral joints agitated by prolonged joint misalignment.

New Therapeutic Massage Tools

Muscle-related joint therapy offers today’s bodyworkers added therapeutic tools to aid clients suffering recurring, mysterious and aggravating pain or posture problems. Massage therapists who routinely see musculoskeletal pain problems will relish the synergy of both power and practicality in these new reflexogenic muscle/ joint routines. Because traditional massage techniques alone solve much of the neck/ back pain puzzle, always begin each therapy session using conventional myofascial balancing routines. Tight, hypertonic muscles are lengthened using myofascial release, assisted stretching and receptor co-activating techniques, and weak, inhibited muscles are tonified with fast-paced, spindle-stimulating maneuvers. Once myofascial balance is restored, remaining joint-related dysfunctions can be more easily assessed and corrected.

Today’s manual therapist will soon discover the added therapeutic benefits of integrating joint capsule, spinal ligament and intervertebral disc routines into their existing practices. Some massage and bodywork schools in the United States are already introducing students to the fascinating world of spinal biomechanics through complementary therapies, such as muscle energy, orthobionomy, medical massage and mechanical link.

Many teachers in the current, constantly evolving bodywork community understand how application of deep-tissue techniques to the body’s intrinsic muscles alters alignment in the skeletal system. What affects one always affects the other. Therefore, it is helpful to seek a basic understanding of joint mechanics and the laws of spinal motion before addressing clients with random deep-tissue techniques.

A safe therapist is a knowledgeable, holistic therapist. Simply put, the more the therapist knows, the safer the therapist becomes. Initially, an introduction to the concept of combining muscle-joint modalities might appear complex. But soon the therapist will recognize the marvels of muscle-joint relationships. Through hands-on training and continued studies, an exciting new world of therapeutic possibilities opens up, as the trained bodyworker wholeheartedly experiences the reflexogenic relationship between muscles and joints-a welcome addition to the therapist’s toolbox of touch.

Footnotes

1. Gillette, R.G. Journal of Manual Medicine 3:1, 1987.
2. Chaitow, L.. Palpation Skills, Churchill Livingstone, New York, 1998.