• If a spray is used, the container should be held approximately 2 feet (60 cm) away, in such a manner that the jet stream meets the body surface at an acute angle or at a tangent, not perpendicularly (Figs 8.2A,B).

• This lessens the shock of the impact. For the same reason, the stream is sometimes started in air, or on the practitioner’s hand, and is gradually brought into contact with the skin overlying the trigger point.

• The stream/ice massage/frozen canister should be applied in one direction only, not back and forth.

• Each sweep should commence in the tissues overlying the trigger point and be moved slowly and evenly outward over towards reference zone (where pain is reported as being experienced by the patient). The direction of movement of the spray/ice should follow the fibre direction of the muscle.

• It appears that it is advantageous to spray, or ice-chill, both trigger and reference areas, because secondary trigger points are likely to have developed within reference zones when pain is very strong.

• Clinical experience suggests that the optimum speed of movement of the sweep/roll over the skin, is approximately about 4 inches (10 cm) per second.

• Each sweep should be started slightly proximal to the trigger point, and be moved slowly and evenly through the reference zone, to cover it and extend slightly beyond it.

• These sweeps should be repeated in a rhythm of a few seconds on, and a few seconds off, until all the skin over trigger and reference areas has been covered once or twice.

• If aching or ‘cold pain’ develops, or if the application of the spray/ice/canister sets off a reference of new pain, the interval between applications should be lengthened.

• Care should be taken not to frost or blanch the skin.

• During the application of cold the taut fibres should be placed at light stretch, and after the chilling should be further stretched passively.

• Steady, gentle stretching is usually essential if a satisfactory result is to be achieved.

• As relaxation of the muscle occurs, continued stretch should be maintained for 20–30 seconds, and after each series of cold applications active motion should be tested.

• The patient should be asked to move in the directions that were restricted before spraying/chilling, or that were painful to activate.

• An attempt should be made to restore the full range of motion, but always within the limits of discomfort, as sudden overstretching can increase existing muscle spasm.

• The treatment is continued in this manner until the trigger points (often several are present) and their respective pain reference zones have been treated.

• The entire procedure may occupy 15–20 minutes and should not be rushed.

• Petrissage – wringing and stretching movements, across the fibre direction of muscles.

• Kneading – where the hands shape themselves to the contours of the area being treated. The tissues between the hands are lifted and pressed downwards and together.

• Inhibition – which involves application of pressure directly to the belly or origins or insertions of contracted muscles or to local soft tissue dysfunction for a variable amount of time or in a ‘make-and-break’ (pressure applied and then released) manner to reduce hypertonic contraction or for reflexive effects.

• Effleurage – this is a relaxing technique that is used, as appropriate, to initiate or terminate other manipulative methods. Pressure is usually even throughout the strokes, which are applied with the whole hand in contact.

• Vibration and friction – such contacts are used near origins and insertions and near bony attachments for relaxing effects on the muscle as a whole and to reach layers deep to the superficial tissues. It is performed by small circular or vibratory movements, with the tips of fingers or thumb. The heel of the hand may also be used.

• Roulement – this involves skin lifting and rolling, which, as with most massage methods, can be used diagnostically as well as therapeutically (see earlier in this chapter for discussion of skin rolling).

• Transverse or cross-fibre friction – this is performed along or across the belly of muscles using the heel of the hand, thumb or fingers applied slowly and rhythmically or vigorously, depending upon the objectives.

• Tapotement – involves percussive tapping, clapping, drumming and vibrating activities, involving fingertips or the ulnar borders of the hands.

• In areas that have been recently traumatized (2–3 weeks) and which are in the remodelling phase (including surgery).

• When a person is fatigued the duration and depth of the application should be reduced.

• If a patient has a fragile bone structure, the depth of pressure should be modified.

• When the patient is agitated the rhythm should be modified to create a calming effect.

• Acute infections and acute inflammation (generalized and local)

• Thrombosis

• Cardiac conditions

• Hemorrhage

• Malignant cancers

• Thyroid problems

• Acute phlebitis

• Prominent varicosities.

• Pain perception is reduced by massage, possibly due to gating of impulses (Clelland et al 1987).

• Massage mechanically modifies soft tissue status (stretching, mobilizing, etc.) depending on the variations in load application (sustained pressure, shearing load, etc.).

• The colloids in fasciae that surround, support and invest all soft tissues respond to appropriately applied pressure and vibration by changing state from a gel-type consistency to a solute, which increases internal hydration and assists in the removal of toxins from the tissue (Oschman 1997).

• Psychological effects include reduced arousal, calmer mood and modified perception of anxiety (Rich 2002).

• Neurological influences include a transient reduction in motor neuron excitability during and following massage (Goldberg 1992).

• Massage also produces a decrease in the sensitivity of the gamma efferent control of the muscle spindles and thereby reduces any shortening tendency of the muscles (Puustjarvi 1990).

1. Pressure, as applied in deep kneading or stroking along the length of a muscle, tends to displace its fluid content.

2. Venous, lymphatic and tissue drainage is thereby encouraged.

3. The replacement of this with fresh oxygenated blood aids in normalization via increased capillary filtration and venous capillary pressure.

4. This reduces oedema and the effects of pain-inducing substances that may be present (Hovind & Nielson 1974, Xujian 1990).

5. Massage also produces a decrease in the sensitivity of the g-efferent control of the muscle spindles, and thereby reduces any shortening tendency of the muscles (Puustjarvi et al 1990).

6. Pressure techniques, such as are used in NMT, and the methods employed in MET have a direct effect on the Golgi tendon organs, which detect the load applied to the tendon or muscle.

7. These have an inhibitory capability, which can cause the entire muscle to relax.

8. The Golgi tendon organs are set in series in the muscle, and are affected by both active and passive contraction of the tissues. The effect of any system that applies longitudinal pressure or stretch to the muscle will be to evoke this reflex relaxation. The degree of stretch has, however, to be great, as there is little response from a small degree of stretch.

9. The effects of MET, articulation techniques and various functional balance techniques depend to a large extent on these tendon reflexes (Sandler 1983).

• MET has been shown to improve joint range of motion, including spinal joints (Kamani & Walters 2000, Lenehan et al 2003).

• MET has been shown to improve muscle extensibility more effectively than passive, static stretching – both in the short and long term (Mehta & Hatton 2002, Feland et al 2004, Ferber et al 2002).

• In addition studies offer support for the hypoalgesic effects of MET – for example in relation to spinal pain (Brodin 1962, Cassidy et al 1992, Wilson et al 2003).

• Myofascial trigger point deactivation has been shown to be enhanced by use of MET (Chaitow 1994, Fernández-de-las-Peñas 2005, Simons et al 1992, 1999).

• Contract–relax (CR), in which the muscle being stretched (the agonist) is contracted and then relaxed, before stretching. (See Fig. 8.5A and 8.5B).

• Agonist contract–relax (ACR), in which contraction is of the antagonist, rather than the muscle to be stretched (the agonist). It is suggested that the confusing title of Agonist contract-relax (ACR) should be ignored. The approach relies, it is suggested (see below), on reciprocal inhibition.

• Contract–relax agonist–contract (CRAC), involves a combination of the two methods (CR and ACR) listed above.

• They hypothesize that the effects may result from the inhibitory Golgi tendon reflex, activated during the isometric contraction that leads to reflex relaxation of the muscle, as a result of post isometric relaxation (PIR) (see Fig. 8.6A).

• An alternative reflex effect has been suggested in which an isometric contraction of the antagonist(s) of affected muscle(s) induce relaxation via reciprocal inhibition (RI) (ACR version) (see Fig. 8.6B).

• Ballentyne et al (2003) suggest that the PIR theory is poorly supported by research. Citing EMG evidence they note that ‘various studies have shown that passive stretch does not influence the electrical activity of the hamstring muscle (Klinge et al 1997, McHugh et al 1998) demonstrating that low level muscle contraction does not limit muscle flexibility, disputing the proposal of [such] a neurological mechanism.[i.e. PIR]’

• Lederman (1995) states that the PIR model ignores the complex and dominant influence of the central nervous system.

• Fryer (2000) points to the lack of evidence supporting muscle contraction as a factor in restricted joint ROM, or in spinal dysfunction.

• Magnusson et al (1995) found that low-level EMG activity was unchanged following isometric contractions, or passive stretching.

• Magnusson et al (1996a) have demonstrated that increases in muscle length, following 90 seconds of passive stretching, occurs without any change to the low-level EMG activity of that muscle.

• Fryer (2006) has speculated that although the exact mechanism by which increased muscle extensibility occurs, remains unclear, it probably involves both neurophysiological and mechanical factors, possibly including viscoelastic and plastic changes in the connective tissue elements of the muscle. In fact Fryer maintains that although MET techniques produce greater ROM changes than static stretching, they also produce greater EMG activity in the muscle undergoing the stretch.

• Fryer & Fossum (2008) have hypothesized a neurological explanation for the analgesic effects of MET. A sequence is suggested in which activation of muscle mechanoreceptors and joint mechanoreceptors occur, during an isometric contraction. This leads to sympatho-excitation evoked by somatic efferents and localized activation of the periaqueductal grey that plays a role in descending modulation of pain. Nociceptive inhibition then occurs at the dorsal horn of the spinal cord, as simultaneous gating takes place of nociceptive impulses in the dorsal horn, due to mechano-receptor stimulation (see Fig. 8.6C).

• At its simplest this explanation observes that if, after an isometric contraction, the same degree of effort is used, as was employed to take the muscle or joint to its end of range, before the contraction, no increase in range or extensibility occurs.

• Magnusson et al (1998, 1996b) measured the degree of applied effort used during passive knee extension, before and after the hamstrings were stretched to the point of pain. They found that both ROM and passive torque were increased following the contraction – because subjects were able to tolerate a stronger stretch.

• Ballantyne et al (2003) confirmed these findings by showing that when the degree of post-test force applied to the muscle remained constant (i.e. the same as used in pre-testing), no change in length took place, suggesting that a single application of MET created a change in tolerance to stretch.

• Fryer (2006) explains: ‘The application of MET would appear to decrease an individual’s perception of muscle pain, and is greater than that which occurs with passive stretching. Stretching and isometric contraction stimulate muscle and joint mechanoreceptors and proprioceptors, and it is possible that this may attenuate the sensation of pain. … MET and stretching appear to produce lasting changes in stretch tolerance, and so the mechanism is likely to be more complex than just gating at the spinal cord, and may also involve changes in the higher centres of the CNS.’

• Hamilton et al (2007) suggest that techniques – such as MET – that stimulate joint proprioceptors, via the production of joint movement, or the stretching of a joint capsule, may be capable of reducing pain by inhibiting the smaller diameter nociceptive neuronal input at the spinal cord level.

• Degenhardt et al (2007) report that concentrations of several circulatory pain biomarkers (including endocannabinoids and endorphins) were altered following osteopathic manipulative treatment incorporating muscle energy, and other soft tissue techniques. The degree and duration of these changes were greater in subjects with chronic LBP than in control subjects.

• McPartland (2008) and others (Pertwee 2005, Agarwal & Pacher 2007) note that the endocannabinoid (eCB) system, like the better-known endorphin system, consists of cell membrane receptors, endogenous ligands and ligand metabolizing enzymes. Two cannabinoid receptors are known:

1. CB1 is principally located in the nervous system

2. CB2 is primarily associated with the immune system.

• Agarwal & Pacher (2007) suggest that cannabinoids mediate analgesia largely via peripheral type 1 cannabinoid receptors (CB1), in pain receptors.

• An isotonic eccentric stretch is one in which the practitioner overcomes the effort of the contracting muscle, stretching and simultaneously toning it (Liebenson 2006, Norris 1999, Kolar 1999).

• A rapid isotonic eccentric contraction, the origin and insertion of the muscles involved are taken further apart while the muscle is contracting, due to the greater effort of the practitioner’s counterforce overcoming the muscular effort. When such a manoeuvre is performed rapidly, it is known as an isolytic contraction. Isolytic stretches are useful in cases where a marked degree of fibrotic change is present in the soft tissues. The effect is to create microtrauma during the rapid stretch, subsequently allowing an improvement in elasticity and circulation. To achieve an isolytic contraction (eccentric isotonic), the patient should be instructed to use no more than 20% of possible strength on the first contraction, which is resisted and overcome by the practitioner, in a contraction lasting 2–3 seconds. This is then repeated, but with an increased degree of effort on the part of the patient (assuming the first effort was relatively painless). This continuing increase in the amount of force employed in the contracting musculature may be continued until, hopefully, a fairly strong but painless contraction effort is possible, again to be resisted and overcome by the practitioner. In some muscles, of course, this may require a heroic degree of effort on the part of the practitioner, and alternative methods would need to be found. NMT would seem to offer one such alternative. The isolytic manoeuvre should have as its ultimate aim a fully relaxed muscle, able to reach its normal resting length. This will seldom be possible in one treatment session.

•A slow isotonic eccentric contraction offers various important clinical benefits (Lewit 1999, Liebenson 2001, Norris 1999): To tone postural (type I) muscles that may have lost their endurance potential, a slow isotonic eccentric contraction should be performed, involving increasing degrees of effort. For example, slowly overcome flexion of the wrist forcing it into extension (i.e. the arm flexors, which are postural type I muscles, are stretched while contracting). To relax hypertonic postural (type I) muscles, a slow isotonic eccentric stretch should be performed of their inhibited antagonists (using 40–80% strength). For example, slowly overcome the extended wrist, forcing it into flexion (i.e. the arm extensors, which are phasic type II muscles, are contracting but their effort is overcome).

• A concentric isotonic contraction tones the muscle that is active.

• Ruddy (1961) suggested that the effects of what he termed rapid resisted duction (i.e. pulsed isometric contractions) include improved local oxygenation, enhanced venous and lymphatic circulation, as well as an improved static and kinetic posture, due to the effects on proprioceptive and interoceptive afferent pathways.

• These variations, along with their particular influences, appear to produce identical benefits in terms of increased ROM and extensibility of soft tissues irrespective of which form of MET methodology is employed. For example, in a study of the use of MET in treatment of piriformis dysfunction, it was found that the same results emerged whether the agonist or the antagonist was used in the contraction phase of ME usage (Wright & Drysdale 2008). (See Figs 8.7A,B.)

1. During the recovery and remodelling phase after injury (3 weeks)

2. If acutely painful before treatment

3. If pain is noted during stretching or contraction

4. If a joint is involved (‘slack’ should be taken out until new barrier(s) are engaged – defined as the ‘first sign of resistance’)

5. If tissues are inflamed.