Clinical Thai Bodywork

Transcription

Clinical Thai Bodywork
Fundamentals
Chuck Duff
Jennifer Rosse Berg
Thai Bodywork
School of Thai Massage
thaibodywork.com
Clinical Thai Bodywork Manual © Copyright 200613, Chuck Duff and Jennifer Wright. All rights reserved.
www.thaibodywork.com
Understanding the Scope of Symptoms We Can Treat
CTB techniques can be used to successfully address pain along with many other symptoms
that are commonly assumed to be due to injury or disease.
Pain
Pain is very widespread and poorly understood. Hundreds of billions of dollars are spent
annually on misdiagnoses and ineffective treatments for pain because our allopathic system has
a tendency toward an injury and diseasecentric worldview. Conventional treatment options
usually involve injection of cortisone at inflammation sites, painkillers and surgical repair. These
options are generally not effective and they do not deal with the origin of the problem. The vast
majority of pain is actually caused by knots in soft tissue called trigger points.
Trigger points are basically tender knots in muscle fibers that cause a perception of pain or other
symptoms elsewhere in the body. Tender points, with distal energetic effects, have been
recognized as clinically important in many Asian and Western systems. There is estimated to be
greater than a 70% overlap between the acupoints of Traditional Chinese Medicine and common
trigger point locations. The pain feels very real, can be disabling, severe and can convincingly
mimic joint problems and other serious issues. Pain due to trigger points is commonly
misdiagnosed and mistreated. The pain can only be relieved by treating the tender points, not the
area where the pain is felt. Treatment can involve compression, heat, electrical stimulation,
injection, acupuncture needling and controlled stretching.
Pain can be felt in many different ways and no matter how we are experiencing our pain,
whether it is obvious sharp pain or vague burning or numbness, it is very likely caused by trigger
points. Most pain, no matter what kind can often be resolved by treating muscles, even severe,
disabling pain. We can have enormous success treating these conditions with Clinical Thai
Bodywork. People should get a myofascial evaluation before resorting to surgery, medications,
or “pain management.” No one should have to live with myofascial pain or dysfunction.
Other Symptoms That Can Be Treated by CTB Techniques in Addition to Pain
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Postural Distortion
Hardness
Restricted ROM
Hypersensitivity
Tingling
Goosebumps
Coordination Issues
Weakness
Itching
Numbness
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Examples of Common Misdiagnoses
Diagnoses may or may not be relevant. Even in the presence of a condition like arthritis, most of
the pain may be caused by soft tissue.
In the table below, you will find commonly used diagnostic terms that only identify the region of
pain, but not the cause of the pain. Many of these diagnoses can be successfully dealt with
using CTB because the diagnosis was not an accurate analysis of the problem.
Arthritis
Tendonitis
Fibromyalgia
Headache
Inflammation
Back Pain
Sciatica
Disk Degeneration
Tennis & Golfer’s Elbow
Earache
Bursitis
Carpal Tunnel Syndrome
Toothache
Torticollis
Thoracic Outlet Syndrome
Nausea
Neuralgia
Recurring Sprain
Appendicitis
Bone Spur
Joint Dysfunction
Plantar Fasciitis
Fibromyalgia
Visual Disturbances
Dizziness
Dysmenorrhea
Radiculopathy
Migraines
Frozen Shoulder
Pelvic Inflammatory Disease
Torn Meniscus
Torn Rotator Cuff
IBS (irritable bowel syndrome)
Recognizing Muscle Dysfunction
Normal muscles should be able to move smoothly through active and passive range of motion,
should feel uniform and not ropy, and should not be overly tender to pressure or cause pain at
rest. Since Thai bodywork often involves moving the muscles, there are many opportunities to
observe dysfunctional muscle behavior.
Some of the phenomena we look for to identify muscle dysfunction include:
● taut fibers
● tenderness to pressure
● causes pain or other sensation, often felt away from the area of tenderness
● abnormal muscle length
● weakness, shaking, ratcheting, contraction when shortening
● pain can be felt at rest or while shortening/lengthening
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Trigger Point Therapy: History & Theory
Trigger Points Have Been Recognized Many Times by Many Different Systems
Focus on Tender Points Thai, Chinese, Japanese
In traditional Thai medicine and TCM (traditional Chinese
medicine), practitioners have long looked toward tenderness in
muscles as key points for treatment. It is highly likely that, long
ago, these systems independently discovered trigger point
phenomena and fit their observations into the energetic systems
they had developed.
Recognition of Energetic and Distal Effects
Other systems have identified the concept of tender points with
distal energetic effects. There is estimated to be greater than a
70% overlap between the acupoints of Traditional Chinese
Medicine and common trigger point locations. Some styles of
acupuncture place great emphasis on treatment of tender points.
While the physiology of trigger points is being increasingly clarified, Asian cultures have long
paid close attention to tender points, and there are close relationships between acupoints and
common trigger point locations. In Thai medicine, bodywork and herbs are used to remove
stagnation and restore flow. It is interesting to consider the parallels between the energetic
concept of stagnation, and the physiological concept of stagnation in trigger points.
Early Western Identification
1843: Froriep identified Muskel Schwiele or Muscle Callus as “a tender tight cord or band”
1900: Adler in America identified Muscular Rheumatism as “tender, elongated infiltrations,
radiating pain”
1904: Gowers in England identified Fibrositis as “tender fibrous beaded chains”
1920: Stockman in England identified Chronic Rheumatism as “nodules: histologically, inflamed
connective tissue”
Janet travell
Janet Travell, MD is generally recognized as the leading pioneer in
developing the diagnosis and treatment of trigger points. She served as
President Kennedy's physician she was actually the first woman to serve
as physician to the President. To alleviate Kennedy’s back pain, she
advocated use of a rocking chair, which subsequently popularized their use.
Travell was a tennis player and when she served, she would have pain in
the front of her shoulder. Her father was a cardiac surgeon so she was
familiar with cardiac referral. With the awareness of cardiac referral, she
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investigated referral of the shoulder muscles and found that when she injected her infraspinatus
muscle, it would alleviate the pain in her anterior shoulder thus starting her investigation of trigger
points and referral pain. Since she was the president’s doctor, she had access to the US army
and did extensive testing on muscle referral, documenting her findings in the trigger point
manuals and charts. She continued to practice into her 90s.
Janet Travell Timeline
19421993: authored 15+ papers and 4 books using the term “trigger point”
1952: wrote seminal paper on myofascial genesis of pain and introduced to English literature the
referred pain patterns of 32 muscles
1983: with Dr. Simons, published Myofascial Pain and Dysfunction, Vol. 1, addressing the upper
half of the body (2nd ed. published 1999)
1992: published Myofascial Pain and Dysfunction, Vol. 2, which addressed the lower half of the
body
Recognizing/Understanding Muscle Dysfunction & Trigger Points
90% of patients entering pain clinics have trigger points causing their pain
Studies have shown that the great majority of patients seeking help for pain have tender points in
soft tissue which may be causing most or all of their pain, as opposed to injury or disease.
Taut Fibers (Ropy Fibers)
In the region of the trigger point, a group of tense muscle
fibers extends from the trigger point to muscle attachments.
This group of tense muscle fibers is a taut band. The
increased tension of the taut bands is caused by regional
shortening of the sarcomeres.
The taut band will have a tender area somewhere along its
length generally near motor endplate zone. Finding the taut
band is often the first step in locating a trigger point.
Palpation & Treatment
Palpation requires sensitivity (finger pads, thumbs) and
careful movement. Palpation is not the same as treatment
but it is important to do first so that you know where to
treat. Palpation at treatment pressure is a mistake. You are
not sensitive and the client is too sensitive.
Tenderness
Myofascial Trigger Points are points of spot tenderness in a palpable taut band of muscle fiber.
Trigger points exhibit spot or local tenderness not along the entire fiber. They are called 'trigger
points' because they cause pain to be projected or 'triggered' in distant parts of the body. The
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trigger point is rarely only 2030% of the time located where pain is felt. These referral pains
follow predictable patterns that are specific to each muscle. Sometimes cause sensations
elsewhere in the body when pressed.
Referral
Referral is pain or sensation that is felt at a distant point away from the actual muscle with
dysfunctional fibers or trigger points. Trigger points cause pain to be projected or “triggered” in
distant, predictable patterns specific to each muscle. Because of this they often go
unrecognized but are the underlying cause of pain in many common "diagnoses."
Referral occurs in predictable, repeatable patterns that have been well documented. The pain is
regionspecific rather than widespread, general pain, although it can occur very distant from the
trigger point. Pain referral can confusingly mimic joint pain and organ pain, and be very disturbing
in its severity. Therapists often mistakenly try to treat the site of the pain “don’t chase the
pain”. Because most referral is to a different area than the trigger point, it is a mistake to simply
work where it hurts most of the time this is ineffective.
Referral pain often confuses medical practitioners, who then assign faulty “diagnoses” of
disease or injury.
Dysfunction
In addition to pain, trigger points can easily cause abnormal muscle behavior. Trigger points
make the muscle sensitive to increased muscle tension or shortening, which painfully limits
stretch, range of motion, and vigorous contraction of the muscle. The muscle may present as
weak, shaky, erratic, uncoordinated.
Postural Distortion
Trigger points can be either active or latent. Active trigger points are trigger points that are
causing a clinical pain complaint. Latent trigger points are points that are not causing pain at that
moment but may be causing postural changes, due to muscle shortening.
Types of Trigger Points
● Key: responsible for activating one or more satellite trigger points
● Satellite: neurologically or mechanically induced by key trigger points occurs in
referral zone
● Associated: occurs concurrently with MTrP in another muscle synergistic or contrary
assistors for particular movement
● Active: causing referral pain. Also likely causing postural effects due to shortening
● Latent: causes postural effects due to shortening point itself tender but does not cause
referral pain
● Central: motor endplate zone at or near center of muscle
● Attachment: occurs in tendinous area of muscle enthesopathy
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Causes of Trigger points
● Acute/sudden muscle overload (sometimes due to accident, poor coordination when
fatigued, or an awkward movement)
● Chronic muscle overload caused by sustained muscular contraction in a shortened
position
● Repetitive muscular activity (symptoms increase with stressfulness)
● Chronic shortening (common causes are work and sleep)
● Surgery; breaks; sprains
● Metabolic dysfunction; biochemistry
● Gait and other postural disturbances
Trigger Point Physiology
Not the Same as Muscle Spasm
A trigger point is a result of a local metabolic energy crisis, and it is often mistaken for muscle
spasm. Muscle spasm can easily be identified by motor unit activity, while taut bands show no
motor unit activity at rest. In a spasm the entire muscle contracts, while a trigger point involves
what we call a contracture. Unlike a contraction, the shortening in a contracture is limited to
specific muscle fibers.
Shortened and Stretched Sarcomeres
The sarcomeres in the contraction knot appear maximally shortened, while the remaining
sarcomeres are stretched to
compensate for the shortened
sarcomeres in the contraction
knot. Titin, the springlike
molecule that holds myosin
molecules in place, causes the
maximally contracted
sarcomeres to tend to get stuck
in this shortened state. The
central trigger point is located
near the middle of the muscle
fiber, where motor endplates are
found.
Motor Endplates
Nerve fibers travel from the spinal cord to individual muscles at motor points. The nerve cells
that initiate contraction reside in the spinal cord. Nerve cells that receive sensory input, known
as sensory nerve cells, are just outside the spinal cord in the ganglia. These ganglia, which are
small bulbous enlargements of the spinal nerves, exist between the vertebrae. Motor nerve
fibers carry impulses from the spinal cord or brain and terminate just adjacent to muscle fibers,
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usually in the central area of a group of fibers known as the endplate zone.
Causes Chemical Changes at Motor Endplates
Chemical changes can occur for various reasons in the area of the endplates, making them
dysfunctional. Triggers can be various physical, emotional and environmental stresses; chronic
or acute overload; sustained shortening of a muscle; metabolic factors such as hypothyroidism;
and many others. Once the
dysfunctional condition develops
at the endplate, a small region of
the muscle fiber goes into a
sustained microcontraction
known as a trigger point. The
contraction is maintained,
independent of any conscious
effort, and results in palpable taut
fibers in muscles that feel like
small ropes.
Local Energy Crisis
The trigger point becomes
chemically insulated, due to an
excess of calcium that
accumulates in the region of the
dysfunctional endplate. This results in a local energy crisis in which the trigger point is deprived
of proper metabolic exchange. Stasis sets in and the trigger point can remain years, until its is
disrupted by some mechanism. The trigger point is not felt until pressure is directly applied to it,
which produces considerable tenderness.
Electrical Noise causes pain and other sensations
Trigger points send a barrage of electrical noise back to the spinal cord, and result in pain and
other sensations. Often the discomfort is felt at locations that are well removed from the actual
trigger point location. This referred pain can be crippling and quite serious. It is often mistaken for
various pathologies and, therefore, is misunderstood and goes untreated. Once a trigger point is
disrupted, the muscle returns to normal and the pain disappears. Trigger points can be disrupted
through mechanical pressure, needling, electrical input or other means.
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Refining The Thai Approach for CTB Work
The Importance of Accurate Anatomy Knowledge
Trigger points are specific areas of local tenderness that are often the primary cause of pain and
dysfunction. They are not often in the area where they feel the problem. Therefore it is extremely
important that we have wide and accurate knowledge of both referral patterns and anatomy. For
example, if the infraspinatus (a posterior shoulder muscle) is contributing to a client’s anterior
shoulder pain and we only work the muscles in the area, we will not be able to help our clients.
We must know which muscles could be contributing to their pain and we must be able to
accurately locate these muscles so that we can treat them.
It is also extremely important that we know the functional anatomy. We must know what a
muscle does so that we are able to shorten and lengthen it as we are treating it. Working
muscles in a neutral position is a good start but we will have much more success if we are able
to work the muscles through their full range of motion. Often it is at the extremes of shortening
and lengthening when we are most able to identify muscle dysfunction, and when we are most
able to influence it.
Resources for Understanding Anatomy
Travell & Simons and Anatomy of Movement are excellent
resources for learning muscle anatomy and function. They are
the best resources we have found, and recommend them over
other textbooks that are strictly anatomy oriented.
It is important to fully understand how to stretch a muscle and
what its normal range of motion should be. The Spray and
Stretch illustrations in Travell & Simons are often very
educational in this regard.
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Using Isolated Contraction to Confirm Muscle Location
We can use isolated contraction to determine exactly which muscle we are on. Sometimes it
doesn’t really matter exactly which muscle we are treating, but sometimes it is crucial! For
example in figure 4 position if we are working on the upper medial part of the bent leg and notice
a ropey area and tender spot and want to use contract/relax, it is very important to know
whether we are on the quads or the adductors. If we don’t know which muscle the tenderness
resides in, we will not be able to use contract/relax effectively. To discriminate the quads from
the adductors in this case, have the client engage the quad muscle group by straightening the
leg and then have them engage the adductor group by raising the knee while we are palpating
the muscle to feel which of the actions makes the muscle in the area of the tender point contract.
Slow Down & Feel
In traditional Thai bodywork, the therapist is likely to travel the sen lines using thumbs or other
means of compression. In CTB we take this a step further, stopping and focusing on points of
tenderness that we discover during compression. As you compress, pay attention to what you
feel underneath your touch. Taut, ropey fibers are an extremely important thing to notice. If you
follow along the taut band, you will always find a trigger point. In CTB we primarily spend our
time working tender points, while areas that are not tender receive far less time.
General pressure (warming up) is used first to accustom the body area to pressure and feel for
areas of hardness. We then move into more specific work, searching for taut fibers and areas of
tenderness. We may hold tender areas for some time, working through several breath cycles.
Finally, the area is cleared with more general techniques, possibly moving the stagnant energy
out through the extremities.
Understanding What We Are Doing and How It Influences Muscular Dysfunction
Distraction
Distraction refers to techniques that temporarily defeat the neuromuscular feedback mechanism
that tends to hold taut fibers in contracture. Distraction is likely a contributing element of many
Thai massage poses. Due to their complex effects on the body, many Thai poses can
temporarily produce a confusing array of inputs
to the neuromuscular apparatus, thereby
achieving distractive effects without the use of
sprays or other devices.
One commonly used modality is Spray and
Stretch, which works by intermittent cold
distraction. Distraction with Spray & Stretch can
produce impressive gains very quickly and
allow entire groups of muscles to release
together. Cold distraction is performed by
progressively bringing muscles into stretch as
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the cold spray is slowly applied over the trigger point and referral zones. It works well on
muscles when a single therapist can gain access to the surrounding skin while maintaining the
proper mechanical advantage needed to spray and move the muscle into stretch.
Spray & Stretch is very useful for clients who are highly activated or have extensive, resistant
patterns of trigger points in related muscles that are suitable candidates for the technique. The
primary negative associated with distraction is the cost of the materials. Some muscles are
difficult to mechanically stretch while also spraying both the trigger point and referral zones with
one operator. The edge of a frozen piece of ice can be used through a thin plastic wrap instead
of the spray.
Working Actively With Clients
CTB work cannot be done with a silent or sleeping client who is uninvolved in the healing
process. First of all, the therapist needs feedback on tenderness and sensation as they work.
Secondly, a major part of the bodywork experience, in our view, is bringing awareness to issues
that might have been entirely hidden to the client. Trigger points are not generally felt unless
someone presses on them, and they refer pain to a distant location. This often confuses the
individual, who thinks their problem resides where they feel the pain.
In order to reeducate movement and neurological patterns, the client must be an active
participant in moving and feeling the affected muscles. Otherwise, we cannot provide lasting
relief, only a temporary fix. We constantly educate and inform the client and engage their
awareness during session. Something in their consciousness and life patterns must change, or
we will be addressing the same issue in the next session.
One cannot overestimate the matter of client involvement in their own healing. We can only
assist the body in healing itself. There are several ways in which we interact with clients to make
them active participants in their own healing.
Establishing an Agreed Upon Pain Scale
1=unnoticeable
24=light
5=good, penetrating pressure
67=at the high end of pressure but still able to accept without tensing body
8=client is starting to resist, not useful
910=agonizing
It's important to get client feedback as to local tenderness. Use a scale of 110, with 10 being
extreme, intolerable pain. We try to work in a range of 46. Ask the patient if they feel just local
tenderness, or if they also feel symptoms anywhere else as you press (referral). If the pain is
something they are familiar with, we would consider this a positive identification of an active
trigger point. If not, the taut band may be having primarily silent dysfunction, such as postural
asymmetry due to shortening. Notice if the reported or the typical as indicated on the pain
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chart referral covers a muscle that is also a possible suspect in the pain pattern. This could
indicate a domino effect, in which one muscle refers to another, setting up satellite trigger points
in the second muscle. If an area that you are compressing seems normal and is not tender,
move on. In CTB we don't spend valuable session time on healthy muscles. Do not be attached
to a traditional sequence of line or point work. One or two passes in an area is sufficient to
establish whether you should spend more time there or move on.
Using the Breath
Instructions for Assessing the Breath
Have the client take an uncoached full breath and notice
how they breathe naturally. Observe whether they begin
the breath with the diaphragm, and move into the thorax at
the end, and whether there seems to be unusual tension or
shallowness. Notice where the movement is easy, where
it is altered and where there is no movement. To more fully
understand your client’s breathing patterns, it can be useful
to imitate their breathing. An example of altered breathing:
we often restrict the movement of our breath in the lower
abdomen to avoid unpleasant feelings and will therefore
compensate by predominantly breathing high in the chest.
To accomplish this we will have to lift the shoulders with
muscular effort in order to get enough air which will then
set up a pattern of chronic contraction throughout the neck
and shoulders. Any attempt to address neck and shoulder
issues will be shortlived if the lower abdominals muscles
and breathing patterns are not addressed.
Breath During Compression: When you encounter a very
tender or hypersensitive area, instruct the client to the
client breathe deeply, imagining their breath coming from
their core or from their low belly as opposed to high in the
chest. It can also be helpful to ask them to imagine that
they are inhaling into the area of tightness and when they
exhale, to imagine that they are exhaling away any tension, perhaps even visualizing the tension
exiting their body through the hands, feet or navel with each exhale. We generally ask clients to
breath naturally from the core and to avoid any specific controlled breaths during treatment
(such as ujjayi breath).
Stretch: When using stretch, bring the client off the barrier slightly and have them inhale. On
exhale, feel for decreased resistance and move the muscle into the new range, being very
sensitive to the client’s comfort and acceptance of the stretch.
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Contract/Relax (PostIsometric Relaxation)
Contract/Relax or PostIsometric Relaxation (PIR), is a key part of the CTB approach. Rather
than limiting treatment to passive stretch, we have the client resist to engage (contract) a muscle
that is being treated, take a deep breath, and on exhale, bring the muscle into stretch. In
combination with the other techniques, this can quickly reduce tenderness and resistance to
stretch, and help achieve normalization of muscle activity.
PIR should be performed on both sides of the agonist/antagonist functional group. PIR should be
used after initial compression and stretch, which will establish a baseline for tenderness and
ROM. PIR should result in less tenderness and increased ROM. This should be pointed out to
the client. A key part of PIR is reeducation of muscles and joints to move through previously
painful ranges in a normal manner. PIR can be followed by active motion through ROM, which
helps fully reset the previously dysfunctional muscles to a normal state.
Using Contract/Relax
1. Bring the muscle to the end of stretch
2. Back off slightly
3. Ask the client to press against resistance (1020% effort) for 20 seconds
4. Continue pressing as you have the client inhale and hold the breath for a few seconds
5. Have the client exhale and release resistance while you guide the muscle into further
stretch
Active Range of Motion (ROM)
The client can actively move their body to bring muscles through their full ROM. This is
considered essential by Dr. Simons for full resolution and reeducation of the muscle dysfunction.
Selecting Thai Poses for Pressure, ROM & PIR
Generally, we try to use Thai poses that simultaneously allow the therapist to move the muscle
through its ROM and place the muscle under partial stretch as the tender points are being
worked. The poses we teach in CTB have been selected for this purpose. It often isn’t
appropriate or effective to work muscles under stretch, particularly in the beginning of treatment.
In some cases, placing the muscle under stretch makes it too painful to work, or the stretch
hardens the muscle to the point that tender points are very difficult to find without extreme,
injurious levels of pressure.
Thai poses that allow the muscles to be worked both short and stretched are generally available
for any area of the body. Working with mild shortening can be extremely therapeutic, particularly
if the pose allows the therapist to move the muscle through its ROM. Always remember that the
end goal is to lengthen taut fibers even if they are initially shortened to undergo work.
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Multiple Ways to Work Muscles
● Neutral
● Moving into stretch
● Moving into shortening
● Moving through ROM
● Moving crossfiber
Progressive Cumulative Release
A guiding principle of Thai massage is to move the body through several different configurations,
working an area on the short, under stretch, and in different attitudes. This allows a progressive
pattern of release and recognizes the fact that the release of held fibers may take time and may
depend upon the release of other, related areas. It is not generally realistic to try and achieve
comprehensive release by working in a specific muscle area without visiting other parts of the
body.
The holistic, fullbody orientation of traditional Thai massage should not be abandoned in CTB.
Rather, as the person achieves some relief from acute symptoms, treatment can be viewed as
an arc from specific work toward a more general approach. We continually assess during the
session. We watch for the ability of muscles to move through their range without pain,
shortening, contraction, ratcheting, or other signs of dysfunction.
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Additional Components
Taut bands must ultimately be stretched in order to regain full length and resolve their trigger
points. However, stretch alone will simply irritate the area unless it is done coincidentally with
some form of mechanical or electrical disruption of the trigger point, a distractive technique, or
both at once. Without these additions, the neuromuscular loop will keep the fiber activated and
prevent it from stretching. These additional components, combined with the compression and
distractive elements of Thai massage can help to dramatically shorten the treatment required.
Heat
Heat can be a huge asset in softening highly activated muscle groups,
allowing productive work to occur with less discomfort.
Herbal Compress (LPK or Luk Pra Kob)
The traditional Thai Luk Pra Kob is a wonderful way of combining moist
heat, compression, antinflammatory herbal effects and aromatherapy.
Fomentek
Fomentek bags can be filled with hot water and compressed through
the bag, or placed on muscles that are not currently being worked to
warm them up for later work. The bags can be filled with hot water
directly from the sink making them very convenient to use. They are
a great selfcare tool for cllients to use at home.
Electric Point Stimulator (EPS)
The electronic point stimulator, or EPS device, is an important tool for CTB. As you find tender
points, the EPS can be used on them as well as on local or distal acupoints to reduce local
tenderness. It can also reset local dysfunction at the motor endplate zone of the muscle, where
sensitizing chemicals accumulate and cause trigger point pain referral. Motor points that cause
motor activity in the area of the taut band are particularly valuable in
treatment; this approach can be compared to Matt Callison's use of
motor points in Orthopedic Acupuncture.
It is generally best to do some palpation before the EPS treatment, because it will tend to
desensitize tender points and make them harder to find. EPS on motor points can be used as
the muscle is being brought into stretch. As the EPS releases the trigger point, the muscle will
be able to achieve greater ROM. In this sense, the EPS can provide both disruption and
distraction.
Points to apply EPS
MTrPs
Motor Points
Regional Acupoints (Ex. Huatao Points)
Distal Points as appropriate (Li 4, St 38, etc.)
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Spray & Stretch
Spray and Stretch works by intermittent cold distraction. Distraction with
Spray & Stretch can produce impressive gains very quickly and allow
entire groups of muscles to release together. Cold distraction is performed
by progressively bringing
muscles into stretch as the cold
spray is slowly applied over the
trigger point and referral zones.
It works well on muscles when a single therapist can
gain access to the surrounding skin while maintaining
the proper mechanical advantage needed to spray
and move the muscle into stretch.
Spray & Stretch is very useful for clients who are highly activated or have extensive, resistant
patterns of trigger points in related muscles that are suitable candidates for the technique. The
primary negative associated with distraction is the cost of the materials. Some muscles are
difficult to mechanically stretch while also spraying both the trigger point and referral zones with
one operator. The edge of a frozen piece of ice can be used through a thin plastic wrap instead
of the spray.
Using Spray & Stretch
1. Check ROM
2. Palpate and compress
3. Spray from proximal to distal
4. Take up slack
5. Reheat (Fomentek bags)
6. Stretch
7. Move through ROM
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Structuring a Treatment
Introduction
CTB establishes a very different relationship between therapist and client than we might see in a
spa setting. In this situation, the therapist might ask the client some minimal questions about
their issues or where they have pain, and then the client relaxes or even falls asleep as the
therapist works.
CTB is based upon the premise that the client has to be an active participant in their healing and
they cannot just go to sleep while the therapist “fixes” them. We take a medical history, assess
before and during the treatment and frequently interact with the client to establish sensation and
pain levels, to have them breathe, and otherwise engage them more actively in the experience.
Intake and Assessment
It is critically important to understand a client’s history
and current conditions before undertaking the
treatment. It doesn't make sense to follow a
predetermined flow or sequence without a thorough
understanding of these issues. Using the completed
CTB Intake form, interview the client and refine the
information given on his or her pain chart to provide an
accurate location for the complaint, along with an
understanding of how long the problem has been
around, any precipitating events or health issues, if it's
worse in the morning or after work, etc.
Determine the issue that is currently the most pressing or
severe. Based on the area of the body that becomes the
focal point of of the session, you might want to do some
basic evaluation of posture and ROM before beginning
the session. Much of this can be done during the
session, as Thai poses often provide good opportunities
for assessment as well as treatment.
Use Prioritized Muscles Lists
Use Travell & Simons’ or Davies' muscle lists (at the
start of each major section) or Myo charts to determine
which muscles may be involved and establish a priority
order.
Use Trigger Point Pain Referral Charts
Once you have a sense from the prioritized muscles lists
of what muscles are likely to be most important, it can be
Clinical Thai Bodywork Manual (c) Copyright 200612, Thai Bodywork, Inc. All rights reserved. www.thaibodywork.com
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very useful to look at those muscles on the pain referral drawings
(wall or flip charts) with your client. Often this will trigger recognition
(“that’s what my pain feels like”) or perhaps a visual similarity will
point out a muscle that may not have otherwise seemed important.
Always use the Travell and Simons referral charts for your reference
if possible.
Trigger Point Books
Travell and Simons’ Trigger Point Manual
(2 volumes) are essential for serious work. Be
sure to get the second edition of Volume One, which was extensively
enhanced and published in 1994. Claire Davies’ trigger point books are also
very useful, as is Sauer and Biancalana’s Low Back Pain book.
Working With a Protocol
We rarely limit a treatment to one or two muscles instead we begin with a protocol that is
appropriate to each specific body region. We present useful protocols in the regionspecific CTB
trainings. For example, low back and hip pain are generally related, due to interlocking referral
patterns between the spinal erectors, QL (quadratus lumborum), gluteal muscles, and upper
thigh muscles. It generally makes sense to visit all of these muscle groups, altering the flow of
the session based on your findings as you treat. The protocols also approach the treatment
order based on some general working rules such as not trying to stretch muscles before both
sides of the joint have been worked, avoiding problematic shortening of muscle groups, and
beginning with general line work, assessment and gentle stretching before moving into more
intense techniques.
Start out with a general protocol appropriate to the pain region, then always be prepared to
modify it during treatment as needed. No protocol is perfect for every client on each occasion.
The protocol can be used as a guiding structure. Once muscles appear largely normal, the entire
protocol serves to integrate the progress being made, and is also useful as a comprehensive
checkup for the state of the muscles relevant to client’s initial complaint. As the muscles become
more healthy, it will be less necessary to diverge from
the protocol.
Assessing During a Session
For a patient in active pain, you have to be cautious
and sensitive as you move them into Thai asanas. You
should monitor not only muscles limiting stretch, but
muscles that might be dysfunctional in shortening.
Always try to monitor with palpation what is happening
in the muscles that cross a joint as you move patients
into Thai poses. Also have them report any pain that
they experience and where it occurs. Based on this information, you will need to prioritize the
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muscles that are in the most trouble and change the order of your treatment from either the
traditional sequence or what you may have designed at the beginning of the session, according
to these findings.
Monitoring Tenderness
Use the 110 pain scale, generally working in a 46 range. Notice and respond to any areas that
go above the 6 range. Ask clients to let you know if they experience any pain, where it occurs,
and if it is associated with any particular movements.
ROM Assessments
We don’t just move muscles into a stretch we notice their ability to achieve full ROM, and
shorten properly. We can visually assess many muscles during normal Thai treatment there is
less need to do separate ROM measurement outside of the session.
Many clients do not exhibit ROM limitation in muscles that are troubled. Some individuals have
more natural joint mobility, so don’t exclusively assess based on ROM. Check for taut fibers and
tenderness as well.
Observe Contraction on the Short
Certain poses are very likely to point out
muscular shortening issues. For example, in
knee to chest or Dak Wukao, you might find
that there is a wall of resistance as the leg
moves into flexion. If the patient complains of
pinching in the groin, monitor the state of the
psoas muscle by placing your hand on the
abdomen as you move into the flexion stretch.
If the psoas hardens (contraction on the
short), this is a clinical indicator that the psoas
is dysfunctional and needs to be treated.
Limited leg ROM could well be due more to
psoas or other hip flexor shortening than leg
extensor length.
Signs of Muscle Dysfunction During Treatment
Notice ratcheting (jumpy movement), involuntary contraction, or patient pain symptoms in
shortening muscles as you move through passive ROM. Both shortening and lengthening
muscles on either side of a joint generally need to be treated if either shows dysfunction.
Ratcheting: Erratic motion as you move the muscle through its range. It may seem as though the
client is engaging or helping, but this may be entirely out of their control.
Weakness: Muscles with trigger points cannot be strengthened. After the trigger points are
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released, the muscle will automatically test stronger without any additional strengthening. The
reason for the apparent weakness is that the muscle was not able to respond correctly to the
motor signals. Strength conditioning should not be the first course of treatment for muscles
showing weakness because trigger points are often the cause.
Client “Helping”: Clients often take conscious control when they are asked to be passive as a
means of protecting an area of the body or ROM, and avoiding expected pain.
Twitch Response: Sometimes muscles will visibly twitch when you press on a tender point or
strum across a troubled fiber bundle. This is considered a strong confirmatory finding that there
are trigger points in that particular area of the muscle.
Jump Sign: The client may reflexively pull away or startle when confronted with sudden
tenderness in an area. This can happen because trigger point tenderness is very spot specific,
and compressing a muscle at a level that was comfortable in one area may produce extreme
tenderness in the local area of the trigger point.
Spasm: A spasm is different than contraction of a particular fiber bundle. It involves involuntary
contraction of the entire muscle. Spasms can be a result of a muscle having extensive patterns
of trigger points and being asked to shorten suddenly, particularly if it is also being asked to
engage while shortened.
Summary: CTB Treatment Process
1. Establish a precise visual map of the client's pain pattern during intake, and come up
with an initial plan for treating specific regions of the body based upon Clinical Thai
Bodywork charts and reference materials.
2. Following an initial treatment plan, assessing ROM and dysfunction as you move
the client through positions.
3. Establish a treatment order based on relevant muscles and agonist/antagonist
pairings. This may differ from traditional Thai sequencing; for example, we try to
avoid shortening muscles that may be painfully activated before we’ve had a chance to
treat and resolve any trigger points.
4. Treat using traditional Thai techniques with certain modifications; for example, we
focus on tender points. Generally, muscles are treated under partial stretch, followed by
active contract/relax and ROM cycles. Herbal compress may be used for initial warming.
5. Document improvements in pain, ROM, strength and posture for internal use as
well as for referring to or collaborating with physicians, chiropractors, physical therapists
and other healthcare providers.
6. Discover lifestylebased perpetuating factors that foster continued pain and give the
client specific instructions for changes and selfcare.
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Perpetuating factors
CTB therapists are trained to get to the underlying cause of symptoms we are not interested in
just treating the symptoms! Without treating the underlying cause, even the greatest
therapeutic interventions will be thwarted. If we can figure out REASONS for our patients’
problems, we can change their lives! Their symptoms will then decrease and then ultimately
disappear.
Usage Patterns
Ergonomics
Computer work can be terrible for the body! Check that chair is at an optimal level so that feet
can touch the ground, or have foot rests to avoid having the hamstrings press into the seat of
the chair. Desk or keyboard should be at a height that allows wrist to rest comfortably. Make
sure that the chair has arm rests that are at an appropriate height and width so that arms can
rest naturally opposed to having to hold the arms up with muscular effort. Make sure there is
adequate lumbar support. Make sure the screen is at an appropriate level and distance and not
off to one side so that the neck is turned for long periods of time. It is almost impossible to work
on a laptop with good body mechanics.
Driving
Check the position of the car seat; hips should be higher than knees, head and shoulders
stacked above hips, and adequate lumbar support. Some seats are constructed so as to push
the upper body forward, increasing kyphosis and forcing the driver to use cervical extension to
keep their eyes level. Also check to make sure seat is level and not tilting to one side. You may
need to go out with your client to their car to point out any factors that may be contributing to
their pain.
Sleep Position
Sleeping with muscles either in a shortened or lengthened position can set up trigger points.
Use pillows between the knees and ankles, under the arm. Make sure pillow is properly fitted.
Avoid sleeping on stomach, there is no good way to sleep on your stomach and have healthy
muscles, sleep on back or side instead. Try to “sleep long”, fetal position can cause problems in
many muscles.
Body Mechanics & Posture
Lift objects keeping back straight with shoulders directly above the hips. Bend from the knees.
Vigorous Exercise, Especially Done Sporadically
The weekend athlete approach can be very hard on the body. Make sure the body is warmed
up and in suitable condition for any demanding sports activities.
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Other Lifestyle
Sleep
The body designed to get 8 hours of sleep per night, sometimes more or less depending on the
individual. Lack of sleep leads to many problems which can be related to perpetuating pain and
poor health. For more information, see mercola.com.
Chilling the Muscles
Keeping the room temperature on the cool side can wreak havoc on the muscles, especially
neck and shoulder muscles. Make sure to wear a scarf, hat and gloves when it is cool outside.
Janet Travell even recommends sleeping with a scarf on. Being in a draft can easily set up
trigger points avoid drafts.
Paradoxical or Inefficient Breathing
Paradoxical breathing can cause a host of problems from neck and shoulder issues to back pain
and even visceral problems which will be impossible to resolve if healthy breathing is not
relearned. In paradoxical breathing, the abdomen is held in on the inhale which defeats the
diaphragm (the primary muscle of breathing) and instead forces the muscles of the neck and
shoulders to carry out the work of breathing. These muscles are not designed for this and tire
easily.
What paradoxical breathing looks like: belly stays flat or goes in while upper chest expands.
This is the pattern that occurs in the natural fight or flight reflex when we are suddenly startled or
frightened. Over time this can actually lead to stress and anxiety, because the muscles become
chronically overused and tightened which then becomes a pattern and we find ourselves with a
constant bracing quality in the upper and even lower body. Because the muscles in the lower
body are chronically tightened, all of the organs and muscles of the lower body will suffer due to
lack of circulation.
Often we adopt this pattern because we are uncomfortable with our weight and are hoping to
appear thinner. However, the healthy functioning of the organs of digestion, assimilation, and
elimination is so seriously impaired through chest breathing that any weight loss measures won’t
even be able to work. This pattern can also be adopted as a result of a habituated stress
reaction.
Stress
The body has a limited threshold for stress after which many health problems begin appearing.
The more stress that we can eliminate the better. For stresses that cannot be eliminated, it is
important to have healthy coping strategies. If not, they will accumulate in the body creating an
environment for pain.
Anxiety & Depression
Emotional disturbance is closely associated with pain, pain can cause anxiety and anxiety can
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cause pain. Both can be caused by a lifestyle that isn’t ultimately supportive to health from
stress at work or home to lack of exercise, structural imbalances, improper diet, lack of sleep,
mercury fillings, toxic chemicals in the house, limiting thoughts and many other causes.
Body Chemistry
Travell and Simons mention more than 200 factors relating to body chemistry... in Volume 1,
Apropos of All Muscles.
Diet & Nutritional Deficiencies
For bodywork to provide lasting changes to our clients, they need to be sure that all of the
body’s needs are being provided for. Proper nutrition supports healthy muscles, bones, and
organ systems from the ground up and the inside out, rather than us trying to compensate with
bodywork for a weak system that is continuously on the edge. Nutrition is extremely important.
While, we cannot overemphasize how important a whole proper diet is to eliminating pain and
achieving overall health, there are a few nutrients that are crucial and have wellestablished links
to pain: Vitamin D, magnesium, omega 3 fatty acids, B12.
A lot of this information comes from midwestern herbalist, Jim McDonald and clinical herbalist
Paul Bergner. For more information, see Paul Bergner’s book, Healing Power of Minerals:
Special Nutrients and Trace Elements.
Vitamin D
Vitamin D is essential to the proper absorption and utilization of both calcium and magnesium.
Our bodies will produce their own Vitamin D if provided adequate sunlight to the skin, but in the
US, especially throughout the winter in the northern latitudes, our sun exposure often is not
adequate. A sign of Vitamin D deficiency is muscle pain and weakness.
Vitamin B12
Vitamin B12 is known to cause fatigue, diffuse muscle pain and neuropathy. It is only
bioavailable from animal products and supplements.
Calcium (Ca)
We’ve all been ingrained that calcium is the important nutrient to ensure “strong bones and
teeth”. While this is certainly true and adequate calcium intake is an absolute necessity, it
should also be noted that if we look at the countries in the world with the highest calcium intakes,
we find that they also have the highest rates of osteoporosis. Conversely, developing countries
where, on average, calcium intake is by our standards sub par, have much lower rates of
osteoporosis. Why is this?
There are a couple of factors at play. One of the most pertinent is that just because we’re
getting calcium doesn’t mean that it’s going to the bones. Activity levels determine where
calcium goes; when we are active, it goes to the bones, when we are inactive, it leaches out into
the serum. So inactivity, a hallmark of “developed” western cultures, causes the loss of calcium
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in the bones. It also favors the production of bone spurs and other calcifications on the exterior
of the bones, especially if there is inflammation, which essentially “cooks down” fluids and
causes the precipitation of calcium and other minerals.
The other big factor at play is that in our obsession with calcium, we neglect other important
vitamins and minerals needed to effectively absorb and utilize it. Rather, there is a tendency to
grossly overconsume calcium (many even believe the RDA of calcium is higher than it needs to
be), and are deficient in its vital adjuncts. Calcium deficiency is probably more strongly
correlated to a deficiency in the other nutrients needed to absorb and utilize it than it is to an
inadequate consumption of calcium.
Magnesium (Mg)
Magnesium plays a role in over 300 vital physiological processes, and those are only the ones
we know about. In regards to the musculoskeletal system, magnesium is of vital importance.
Magnesium deficiency, like inactivity, causes the blood to pull calcium from the bones. It also
inclines towards more brittle bones, since calcium is, by itself, a more brittle mineral. There is a
direct relationship between magnesium deficiency and muscle tension and spasm, both of
skeletal muscles, and of the heart, and severe muscle spasms and tension can be caused by or
predisposed by magnesium deficiency.
It is generally agreed among holistic nutritionists that a 2:1 ratio of calcium to magnesium is
desired. Herbalist and clinical nutritionist Paul Bergner estimates that the average ratio among
Americans is 7:1, and not uncommonly 12:1. Not only is this disparity between calcium and
magnesium bad, but it is also the case that the vast majority – even amongst health & diet
conscious folks – are magnesium deficient. Now, supposing that one knows that a 2:1 Ca/Mg
ratio is ideal, and they buy a 2:1 mineral supplement, then they actually worsen the gap, going
from (let’s say) 7:1 to 9:2. Unless someone has some reason to think they are truly calcium
deficient, it is often a better idea to take, solely, magnesium.
Travell and Simons also discuss hypomagnesemia which is associated with cramping and pain.
It is not quite the same as magnesium deficiency. Hypomagnesemia can be present without
magnesium deficiency and vice versa. Note, however, that hypomagnesemia is usually
indicative of a systemic magnesium deficit. Hypomagnesemia may result from a number of
conditions including inadequate intake of magnesium, medications such as diuretics,
malabsorption, chronic diarrhea, chronic stress, alcoholism, and other things.
Omega 3 Essential Fatty Acids (EFAs)
Omega 3 essential fatty acids are crucial and unfortunately, they are often lacking from the diet.
A diet that is deficient in Omega 3 EFAs promotes inflammation throughout the body, or one
could say Omega 3 EFAs reduce inflammation. Omega 3 EFAs also promote stronger bones,
cause greater elasticity in tissues, improve cardiovascular health, and ease depression (itself a
deficiency sign), and more.
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Omega 3 EFAs are found in some plants such as flax seed, hemp seed, evening primrose oil,
and in fish and some other meats. Animal sources must be wild, or raised in a similar manner.
Wild salmon is an excellent source of Omega 3s but farmed salmon has very little. Beef from
grass fed, free ranging cows is also an excellent source but not beef from cows that are
cornfed and raised in conventional farms. Deer, elk, bison and other game animals are all great
sources of Omega 3s. Eggs with Omega 3s can also be a good source.
According to Jim McDonald, there is “a difference between the Omega 3s contained in plant
versus animal sources, and one that will not make vegetarians all that happy. Plants sources of
Omega 3 EFAs contain alpha linolenic acid (ALA), which is referred to, structurally as a “short
chain” EFA. Animal sources contain eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA), both of which are long chain EFAs. These long chain EFAs are the ones our bodies
need. Though the body does have the ability to convert ALA to EPA and DHA, it has been
shown to only convert, at the most, 10%. So, in terms of supplements, fish oils are far more
efficiently used by the body than plant based Omega 3s. Another concern with a specific plant
based Omega 3 EFA, flax seed oil, is that it has such poor stability once press that virtually all
flax seed oil available today is some degree of rancid, and consuming rancid fats is not a good
idea. Flax seed, and the ALA it contains is still useful, but best taken freshly ground and added
liberally to foods as a condiment.”
Boron
Boron is a trace element that aids in the efficient uptake and utilization of calcium and
magnesium. It also helps to prevent it loss from the body. It may achieve this end by helping to
convert Vitamin D to its active form.
Silica
This is not usually considered an “essential nutrient” there is no recommended daily allowance
for silica – it is of vital importance in the structure of all connective tissues, offering strength,
resilience and flexibility. Silica forms the matrix of bones, cartilage, tendons, blood vessels, and
myriad other tissues, and provides the structure for proper mineralization, and aids in the
utilization of iron, calcium, magnesium, boron and potassium. It has been shown that high levels
of silica and lower levels of calcium form stronger bones that high levels of calcium and low
levels of silica. One sign of silica deficiency is brittle nails and hair with lots of split ends, both of
which are formed primarily of silica.
Medications
Many common medications have wellknown paincausing side effects. For example the statin
drugs, which are used to lower cholesterol, are known to cause extensive problems with
muscular pain. Side effects from prescription medications are often poorly understood and
conveyed. The body is a complex system and medications are given for a specific indication
without taking account systemic effects. Pain medications can cause pain because they cover
up symptoms allowing you to continue as if everything is fine while actually perpetuating and
even aggravating the problem. We could go on and on about this...
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Hydration
Adequate hydration is necessary for muscle tissues to behave normally and many other things.
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26
LegLength Inequality
It can be tricky to determine if you have a real or pseudo (muscular induced leg length inequality)
leg length difference. Either way, both real and pseudo, can be a very strong perpetuating factor
for pain. Our thigh bone (femur) sits in the hip socket of the pelvis. The length of the whole leg
can be dependent on how well the femur fits into the hip socket, how the muscles and ligaments
are working to keep the leg in place. Many functional factors come into play that can effect the
pseudo length of the leg: how the spine and sacrum interplay with the pelvis as a whole, how the
feet and ankles align upon weight bearing, the actual length of the upper and lower leg bones to
name a few. Many coexisting conditions can tilt or rotate the pelvis due to muscular, sacral or
ligament imbalance and this can create a false, or pseudo leglength inequality due to the rotation
of the pelvis causing lumbar and thoracic curves. It can also appear, on measuring, that one leg
is shorter than the other. Hyperpronation, especially if one foot measures more than 5mm
greater than the other, can also be a strong influence on pseudo leglength inequality.
We have found however that over time, even a slight difference in the pelvis/leg/torso can cause
our postural muscles to spend energy trying to counteract the imbalance. As a result, trigger
points develop and our muscles become even more dysfunctional. Local energy crisis can
occur and decreased local circulation (ischemia). This can lead to muscle weakness, loss of full
function or loss of full range of movement, pain or numbness. Then, due to the muscular
imbalance, the rest of the spine and head will try to maintain a level position leading to more
compensation and unnecessary muscular tightness above and below the hip, and in many
cases real spinal curvature (scoliosis). So as you can see, one imbalance in the hip can lead to
muscular problems all over the body. With treatment and a full selfcare protocol, this pseudo
leglength inequality can often be normalized. Following these guidelines of correcting leglength
inequalities and treating affected muscles, you may find the pelvis has leveled out and the
leglength discrepancy was really created by muscular imbalance. As little as 1/8 inch can be
enough to cause pelvic and shoulder imbalance, spinal curves and can chronically aggravate
muscles which in turn leads to myofascial dysfunction. Also, an increased spinal curvature
whether it be spinal scoliosis, lordosis or kyphosis, can develop after a lifetime of walking on
legs of different lengths.
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Ask these questions:
● Do you stand mostly on one leg?
● Do you stand on one leg with the other leg forward and to the side? (sometimes
accompanied by a hand on the hip)
● Does your back pain increase upon standing?
● Is your back pain mostly one sided?
● Do you have limited range of motion?
LegLength Inequality Evaluation
1. Have the client stand facing away from you, feet together or at most, about 3 inches
apart. (Make sure the floor in your room is level.)
2. It is best to be able to see as much of the back as possible. For draping, you can tie a
sheet around their neck and tuck the lower ends into the top of the loose fitting pants or
underwear.
3. Look at the base of the posterior skull, and the level of the ears. Are they even? Draw a
line on the assessment sheet from ear to ear showing height of ears.
4. Look at the top of the shoulders. Put your thumbs at the top of the shoulder blades (spine
of the scapula). Is one higher? Draw a line on assessment sheet.
5. Feel for the bottom tips of the shoulder blades. Place your thumbs there. Is one higher?
Note: in many cases, the shoulder will be lower on the side of the longer leg. This can be
due to the scoliotic spine curvature. If the leg inequality is 1/2inch or more the shoulder
is likely to be lower on the shorter leg side. (T&S, V1 p.930) Draw a line across
assessment sheet indicating height.
6. Does one shoulder blade area seem to bulge outward more? (this can be a sign of
torsion in the torso/ spine). Note that with arrows.
7. Press your hand into the side of the waist and feel for the top of the hip crest. Is one
higher? Is one more forward? Draw a line.
8. Press your thumbs into the dimples of the pelvis (this is the PSIS or posterior superior
iliac spine). Is one side higher than the other? Draw a line.
9. Observe and feel the way the spine lines up from the sacrum. Is the spine straight or
does it curve to the right or left? Does it have two curves? Draw a line indicating that it is
straight or showing the curves.
10. Look at any skin folds. Are they greater or deeper on one side verses the other? Make
note of all these things by drawing them on the assessment sheet.
11. Based on your assessment, if you think its needed, with your client standing facing away
from you, place approximately an 1/8inch thick magazine under the leg that seems
shorter. Did this make the hips level or close to level? Did it make the skin folds even or
close to even? Did it make the shoulders level or close to level? If it made it more level,
but they are still uneven, slip another magazine under the short leg until you see that the
hips, skin folds, and shoulders are even. Now for this to be a good correction, the person
has to like the correction. They need to feel level. They should feel strong. Now
conversely, slip the same thickness under the other leg (the "long" leg). Now they should
28
feel uneven, not stable, and uncomfortable at the hips, skin folds should be askew and
shoulders more uneven. That's enough! Take it out and put the lift under the leg that
made them feel comfortable. You can consider having the client look into a fulllength
mirror while all this is going on to reinforce and educate how these imbalances can throw
off our whole body. A single heel lift can be inserted into the shoe on a temporary basis.
12. Often we have patients whose baseline pain immediately goes down once the leg length
discrepancy is fixed. A comprehensive treatment plan and home selfcare program will
ensure that the imbalanced muscles return to their full painfree function. Selfcare up to
6 times a day may be needed at first.
Treatment Plan
1. All the muscles that harbor tightness and trigger points will need to be treated including
quadratus lumborum, paraspinals, abdominals and psoas. There are also many muscles
that can influence the pelvis including the hamstrings, quads, adductors and external
rotators.
2. If the patient has headaches, all the neck muscles and face and jaw muscles will need to
be treated, as well as all the perpetuating factors including nutritional, positional, sleep
and sitting postures.
3. Reevaluation over time will also help to determine if the heel lift is needed anymore. You
may also want to consult with a doctor of osteopathy, chiropractic doctor, or a certified
myofascial trigger point therapist to have a full evaluation.
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Small HemiPelvis
If you are sitting while reading this, reach under your buttocks and feel your "sit bones". These
bony outcroppings are found at the bottom of the pelvis and are called ischial tuberosities. It is
on these that we bear most of our weight as we sit. The sit bones are the bottom part of what is
referred to as our "pelvis". When half of the pelvis is smaller than the other half, the small half is
referred to as a "small hemipelvis".
If one half of your pelvis is smaller than the other, the effect is that you will be uneven every time
you are sitting. This will cause trigger points to develop in the head, neck, shoulder, upper, mid
and lower back, hips, buttocks and legs. Small hemipelvis is one of the biggest causes of
sciatica, low back, buttock, hip and leg pain. (In addition it is one of the biggest causes of
shoulder pain and dysfunction, hand and arm pain and dysfunction, neck pain and migraine
headache). This uneven sitting can eventually lead to curvature of the spine, i.e. scoliosis (spine
curved to the side) or kyphosis (spine curved forward).
This can happen because the chronic tilt in the seated pelvis can send proprioceptive
information into the righting centers of your brain, and in response, the head will tilt to one side to
maintain a level position. This in turn can set off a chain of events making the muscles
unbalanced. One side of the body will have muscles in a chronic state of overuse which can
eventually lead to curvature of the spine. All these extra spinal curves lead to muscular
imbalance and overload, which leads to the development of more trigger points and more
muscular dysfunction.
It may take a long time to undo all this muscular dysfunction causing the spinal curve and low
back and buttocks pain but it can be done. First step is to correct the underlying reason of the
perpetuating factor, which is the small hemipelvis.
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Questions to ask:
● Did you, when you were younger or do you currently frequently, sit with one foot tucked
under your butt?
● Do you have a hard time sitting for long? Do you have a hard time finding a comfortable
position to sit in?
● When sitting, do you always cross one leg over the other if you can?
● Do you have back pain when sitting?
● Do you have headaches?
● Have you been told you have TMJ?
● Do you have a shorter leg? (in many cases, the vertical height of the pelvis is smaller on
the same side as the short leg T&S VI 931)
● Do you prefer to have a standing job or profession?
● Do you avoid sitting?
Small HemiPelvis Evaluation
1. Have the client sit on a level, hard seat, like a wooden piano bench. Or you can place a
hard board onto a stool or softer chair. The chair should have no backrest. It is best to be
able to see the whole back, so remove as much of the clothing as possible.
2. Look at the base of the skull. Is the head tilted? If so draw it on assessment sheet.
3. Put your thumbs at the top of the shoulder blades. Is one higher? Does one shoulder
blade area seem to bulge outward more? Draw a line across the body on the
assessment sheet indicating which side is higher.
4. Feel for the bottom tips of the shoulder blades. Is one higher?
5. Press your hands into the side of the waist and feel for the top of the hip crest. Is one
higher? Is one more forward? Draw a line across body showing the height.
6. Observe the way the spine lines up from the sacrum. Is it straight? Look at any skin folds
on the sides and back of the torso. Is one skin fold greater or deeper on one side verses
the other? Draw the curve of the spine. Draw the skin folds.
7. After you have made your lines on the assessment sheet, you may begin to see a tilted
pattern. If based on these findings and yes answers to the characteristics questions
above, you may have a hunch that your client has a small hemipelvis. You can first put
the lift under the shorter side (start with enough pages of a magazine to measure about
1/8 inch). Does this correct the imbalances? If that does not seem like enough add more
pages or more magazines and keep asking how they feel with it under their butt. To
confirm that you have the lift on the correct or needed side, put the magazines on the
other side. This should accentuate the pelvic imbalance and make the client
uncomfortable. Often they will complain of feeling like they are falling over. Look to the
same landmarks as above and they should be worse or more pronounced in their
inequality. Take the magazine out and put it back under the correct side! If the one
magazine helps but the landmarks are still uneven, try raising the correction. Ask how
the client feels with this correction. If it is the needed side, they will feel better and will
report feeling like they are finally balanced! Great! You may have just changed their life!
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8. Take the magazines out and measure the thickness. This is the thickness they need for
their butt lift (ischial lift). Now that you have found one structural imbalance, you need to
include special attention in your selfcare to all the muscles on the side that have been
chronically shortened or lengthened, especially quadratus lumborum, spinal erectors,
abdominal obliques and gluteals. The person with a small hemipelvis will need to use
something to give extra height on the side of the small hemipelvis every time they are
sitting. This can be a Reader' Digest, a small note pad, a folded wash cloth. This sitting
correction must be used all the time while sitting: at work, at home, in the car, etc. On
softer surfaces, a bit more of a lift may be needed because the sits bones (ischial
tuberosities) and the buttocks as a whole will sink into a couch or lounge chair.
9. Also, since we are not using xray images to confirm the pelvic inequality, it is important
to acknowledge that feedback and monitoring needs to take place ongoing. If, after time,
treatment, extensive selfcare including compression and stretching of the affected
muscles happens to equalize the muscular component of the pelvic tilt, then the butt lift
can be decreased and or phased out and it was a muscular or pseudohemipelvis or a
muscular imbalance causing a tilt or rotation in the whole pelvis. According to Dr.'s
Travell & Simons, there are also other sacral pelvic rotation distortions that can
contribute to this uneven pelvis. A trained practitioner like a CMTPT, DC, DO, MD, could
assess for these and make manual corrections.
Short Upper Arms
Some people’s arms are anatomically shorter than the average person which means that
whenever they are using armrests designed for average length arms, their elbows will not
effortlessly rest on the arm rests. Even if their upper arms aren’t proportionately shorter, this is
still likely to be a relevant perpetuating cause. Chair arm rests are usually made at standard
unadjustable heights. Unless you happen to have a chair perfectly designed for your body, arm
rests need to be considered. If our elbows are not able to be supported, we will compensate by
leaning to the side or forward or back, stressing the QL, abdominal and back muscles, or we will
support our arms with our levator scapulae and trapezius muscles stressing these muscles.
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Hyperpronation
Hyperpronation is extremely common, occurring in about 80% of the general population and 98%
of the chronic pain population. It is known for causing much myofascial pain and is relatively
easy to address. Every client should be evaluated for hyperpronation.
Hyperpronation is caused by a slight elevation of the big toe bone. This
prevents our feet from properly supporting our bodies and that elevated
big toe bone keeps us from sensing exactly where the ground is.
Hyperpronation causes the foot to be unstable because, instead of
tracking straight forward, the foot is able to either track outward (brace)
or track inward (release). It is like walking on ice skates.
Hyperpronation causes your arches to collapse and your ankles to roll in
when you shift weight to your forefoot. It visibly causes changes in your
posture: legs rotate inward, hips rotate forward (one more than the
other)and your whole upper body and head rotate and drift forward.
Second, because this “head forward” posture creates muscle tension
and spasms, your body subconsciously tries to compensate for it, known
by medical professionals call as “Common Compensation Patterns.”
Unfortunately, over time, this typically deforms your posture further
causing even more muscle strain and pain.
Standing or walking at a relaxed pace should not require much effort, and certainly should not
cause pain. But when your body is unsure or out of balance, your muscles become tense.
Because hyperpronation causes instability and throws your body off balance, the posture
muscles from your feet to your neck remain tense all the time. They never get the “relax” signal.
In addition, the torsional stress within the knee
and hip joint as a result of the prolonged internal
rotation of the lower limbs throughout the gait
cycle increases abnormal wear and tear of these
weightbearing joints.
Hyperpronation Causes Effects Throughout
the Entire Body
Because movement, or patterns of movement in
one part of the body affect all other parts (a
closed kinetic chain) the problems continue up
through the body, affecting the back, shoulders,
neck and even the head.
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People can respond to hyperpronation in one of two ways: releasing or bracing. While everyone
who hyperpronates will compensate in both ways at various times, people often tend toward one
or the other.
Releasers:
Characteristics
● Outward turning feet
● Collapsing ankles
● Adducting knees
● Unstable gait; significant torquing or twisting in gait
● Forwardtilting/unleveled pelvis
● Shoulders rounding forward
● Forward leaning/head forward posture
Common Complaints
● Problems start early, even in teens
● Pain in ankle/knee/low back/SI joint/hip joint
● General muscular pain associated with head forward posture
● Sciatica
● TMJ
● Calluses; bunions; ball of foot pain
● Inefficient gait mechanics: poor at running or drifting when walking
Bracers:
Characteristics
● Not too many problems until late 30s
● Ankle instability/frequent ankle injuries
● Hypertonic muscles in the tibialis anterior/toe flexors
● Short gastroc/soleus
● Excessive overall muscular tension; many MtrPs; unable to relax
● Muscular contraction upon passive ROM
Common Complaints
● Shin splints
● Back pain when standing for extended periods
● Fatigue as walking increases throughout day
● Hip/knee/leg pain
● Tension throughout body
Correction:
This is really not a good term since we aren’t really ‘correcting’ the foot. By placing a thin wedge
under the ball of the big toe, we are giving the message to the body that there is stability and
stopping excessive inversion of the foot and therefore repetitive concontraction of gluteus
medius, minumus and other muscles which in turn stops activation of trigger points and the
related pain they cause. For the first metatarsal lift we use Posture Control Insoles (PCIs) but
you can also make your own.
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Other Things You Can Do To Minimize The Effects of Hyperpronation
● Lose excess body weight
● Avoid shoes with heels
● Choose shoes that are roomy in the toes. Tight shoes do not allow movement of toe
which weakens toe flexors
● Eliminate trigger points in toe flexor muscles & then strengthen
● Spend time walking barefoot
Instructions for Evaluation
1. Have the client stand casually, feet hip distance apart, and have him/her do a few knee
bends.
2. Check for hyperpronation:
● Notice if the knees traction straight ahead or drop in towards each other. (If they
work out, they may be trained in proper form for squats in which they will not let
their knees move in toward the center, may be a sign of a bracer.)
● Look at the feet.
● Do the feet collapse in?
● Is there a lot of activity in the foot and calf when they bend? Do the toes lift up?
● Do they have a long second toe or a deep first web space?
● Do they have an elevated first metatarsal or callus development outside of the big
toe?
● From the back, are the achilles tendons straight or do they collapse in?
● Look at the shoes: Do they show uneven wear patterns?
3. Feel for the subtalar joint and move it back in to neutral.
4. Place the wedges under the clients big toes at the proper height and have
clients do the knee bends again.
5. Check for hyperpronation again and note any differences.
6. Measure the amount of correction for your client and divide by three. That is
the amount you should start with. It is best to start with the smallest amount of
correction possible to allow the body time to adjust.
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Client Education & SelfCare
Selfcare teaches patients to reduce their own pain and changes their thoughts about being a
passive victim of this pain. Instead, they can come to view themselves as active participants in
getting better. When the selfcare starts to make patients better, that is when they begin to really
change. If patients do not get on board with selfcare, it is an indicator that they want to hold onto
their pain, frequently for emotional reasons.
Lifestyle changes
● Eliminate all perpetuating factors (sleep, ergonomics, etc.)
● Correct structural factors/imbalances
● Eliminate unnecessary stress
● Take work breaks every 15, 30, 45 or 60 minutes
Follow SelfCare Protocol
Step 1: WarmUp: This can be anything that you do to provide blood flow and oxygen to the
area. This step is very important because it prepares the muscle for stretching. Fomentek bags
filled with hot water, or a hot bath or shower can be used. Herbal compress balls are great for
client selfcare.
Step 2: Compression:Use an appropriate tool (lacrosse ball, fit ball, tennis balls, foam rollers,
etc.) to compress the affected area. Begin with general compression, followed by more specific
compression on any spots that are hard or tender. Then hold the tool on each tender spot,
breathing for 23 breaths while consciously relaxing the affected muscle.
Step 3: Stretch: Follow compression with gentle stretching to encourage the muscles to return
to their normal resting length and function. Straps, walls, gravity and pillows can all be used to
assist with stretching.
Step 4: Range of Motion: Take the muscles through their full stretch and full contraction. Move
the muscles in all the ways that they were intended to move, in different directions and at
different angles, with full breath.
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Clinical Thai Bodywork

Transcription

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