연부조직의 촉진 palpation technique - 반드시 다시 정리해야

[문형철]

systemic palpatation 

- 이 용어에 대한 깊은 통찰에 도달하고 있다. 

- 문제가 있는 모든 근육을 어떻게 빠짐없이 시스템적으로 촉진할 것인가? 어떤 순서에 기반할 것인가? 

- 이 용어를 어떤 말로 번역을 할까? 시스템 촉진, 전신 촉진, 전체적 촉진 ... 쏙 마음에 드는 말이 없네? 

완벽하게 촉진할때까지 촉진하고 또 촉진하라

panic bird..

Skin and muscles represent independent sensory input organs for treatment methods based on reflexes (connective-

tissue massage) and energy flow (acupuncture) as well as locally applied treatment methods (e.g .. Swedish massage).

- 피부와 근육은 반사반응(결합조직마사지)과 에너지 흐름(경락), 국소적으로 적용되는 치료법(스웨덴식 마사지)를 위한 독립적인 감각기관임. 

Systematic palpation of these tissues has long been a topic of discussion. In connective-tissue massage, changes

in skin consistency, for example  are attributed to specific disorders of the inner organs or the vertebral column. Classical massage treatment targets pathological muscle tension in particular. In these treatment methods. palpation is used for the purpose of assessment and also for monitoring progress. Massage is rarely used without previously palpating local or general hardening in the muscles.

- 피부와 근육의 전체적인 촉진은 탐구의 주제가 됨. 결합조직마사지에서 피부의 점조도 변화는 척주나 내부장기의 특이질환 치료를 위한 방법.  전통적인 마사지 치료는 병리적 근육긴장 치료를 위한 타겟임. 이러한 치료방법에서 촉진은 질병의 변화와 진단을 목적으로 사용함. 

Therapists must manually palpate through skin and muscles if they wish to reach deeper-lying structures. As an example, certain segmental tests and treatment procedures cannot be successfully conducted without moderate pressure being applied to deeper tissues. It would be easy to incorrectly interpret the patient's pain solely as a result of the applied pressure if you were unable to assess the sensitivity of the different layers of tissue. 

- 치료사는 만약 깊이 위치하는 구조를 촉진하고 싶다면 손으로 피부와 근육을 통해 촉진해야 함. 예를들어 분절적인 테스트와 치료과정은 깊이 있는 조직에 적절한 압력을 적용하지 못하면 성공적으로 촉진할 수 없음.  만약 당신이 각기 다른 층의 연부조직의 민감성에 접근할 수 없다면 적용한 압력에 따른 환자의 통증을 잘못 해석할 수 있음. 

Therapists should not only gain information about superficial tissue if, for example, they wish/intend to treat these tissues later (Swedish massage. connective-tissue massage); the sensitivity of superficial tissue should also be assessed in cases where the therapy involves applying sufficient pressure to penetrate deeper layers of tissue (manual therapy). 

- 치료사는 표층 조직에 대한 정보를 얻어야 할 뿐아니라 치료를 해야 함. 표층의 민감도는 깊은 조직층을 뚫고 들어갈 충분한 압력을 적용한 치료의 경우에 반드시 측정되어야

In particular. patients with chronic back symptoms are the least able to provide exact information about their symptoms. These patients are frequently affected by hyperalgesia or hyperesthesia as a result of central sensitization. They have difficulty describing the exact location of their symptoms, and the corresponding interpretation of tests that use direct pressure is unsuccessful. When therapists are unable to recognize such changes, they tend to attribute the symptoms to the skin, the muscles, or bony parts, depending on which area their work mainly focuses on.

- 특히 만성 요통은 정확한 증상에 대한 정보가 제공되어야 함. 만성요통은 통각과민이나 감각과민의 영향을 받음. 만성통증은 그들의 정확한 증상의 위치를 결정하기 어려움. 치료사가 이러한 변화를 인지하지 못할때, 환자는 그들의 증상을 피부, 근육, 뼈의 탓으로 돌림. 

Common Applications for Treatment 

Skin and muscle are frequently the tissue targeted in:

• Reflex-based treatment forms: connective-tissue massage. reflex zone therapy based on the work of Glaser/Dalichow. etc.

• Regional or locally applied techniques: Swedish massage. heat therapy. soft-tissue techniques in manual therapy (Fig. 8.1). and more. 

Required Basic Anatomical and Biomechanical Knowledge

Even beginners only need a short amount of time to gain the relevant prerequisite knowledge. Being able to initially orient yourself using general bony and muscular structures in the neck, back, and pelvis is sufficient. The techniques used to locate these structures will be described in the coming sections. Two prerequisites should be created:

• To conduct an orienting and systematic palpation.

• To be able to describe the location of palpated structures well and to document these findings. (See also Table 8.1.)

Criteria for Palpation 

What will be assessed:

• The surface of the skin.

• The consistency of tissue.

• Sensation.

• Pressure pain sensitivity.

피부의 표면(The surface of the skin)

The following characteristics are assessed: smooth/rough, dry/moist, warm/cold, hair growth, protrusions. Check as

well whether the changes are general or only found locally (compare with the other side of the body! ).

촉진하는 피부가 부드러운지, 거친지, 건조한지 촉촉한지, 열감이 있는지 냉한지, 털이 있는지, 돌출된 부분이 있는지를 검사해야. 

Tip: As an exercise, try to write a list of adjectives describing the characteristics of the skin surface, for example, soft,

coarse, elastic, tensed, thickened, parchmentlike(양피지같은), cracked.

조직의 점조도(consistency of tissue)

The term consistency has many different meanings. It is used here as a standard to measure the compliancy of tissues

when displaced or when pressure is placed on the tissues. It is along these lines that the viscoelastic properties

of tissue are assessed.

Skin and muscles have their own terminology for consistency. The term turgor is used for the skin and tension for the muscles. Both of these terms are used in palpation to define the amount of tension that the displacing or pressurizing finger feels as resistance.

- 피부와 근육은 각기 자신만의 점조도를 가짐. 피부에 사용되는 용어는 팽창(tugor), 근육에 사용되는 용어는 긴장(tension)

감각(sensation)

Skin sensation is checked in passing when the surface of the skin and its consistency are being examined. It does not need to be assessed separately in clinical practice. The therapist will be made aware that the sensation needs to be assessed during the subjective assessment or when the patient informs them of sensory changes during palpation.

What should the therapist pay attention to?

Sensory deficits are rare in the trunk. Sensory deficits are more likely to occur in the joints of the limbs as a result of nerve-root compression or peripheral-nerve lesion. A hypoesthesia or an anesthesia in the region of the back is to be classified as dangerous! If one of these symptoms is encountered, it is necessary to clarify whether this is a familiar symptom or whether it should be investigated further. 

몸통에 감각저하가 발생하면 일단 심각한 질환으로 간주하여 반드시 추적검사를 실시해야 함. 

Do not treat the back if the cause of sensory deficits has not been clarified.

Sensory deficits interfere with massages or other interventions (e.g., electrotherapy) as the patient cannot provide the therapist with important feedback regarding the appropriate dosage. Such treatment must be performed with appropriate caution.

When considering whether, and in what dosage, treatment should be administered, it is also important to identify possible hypersensitivity to touch (hyperesthesia) or pain stimuli (hyperalgesia). It is normal for tissue to be hypersensitive to pressure during wound healing in the acute, exudative stage. This is the result of peripheral sensitization. 

Pathological hyperesthesias or hyperalgesias develop secondary to chronic pain. This is the result of central sensitization in the dorsal horn of the spinal cord. Hypersensitive parts of the body transmit pain signals when touched roughly and can only be treated using techniques where minimal pressure is applied or large surface contact is made (e.g., stroking as part of classical

massage). At times it may be appropriate not to treat manually at all (refer to Gifford, 2006 or Butler and Moseley, 2003 to gain further knowledge of the physiology of chronic pain). 

Sensitivity to Pressure that Causes Pain

The size of the area being treated and the selection, speed, and intensity of treatment techniques are chosen according to the pain sensitivity of the tissue, amongst other factors. It is also possible to estimate the expected results of muscle treatment by assessing whether the muscles are the source of pain. Ideally, the techniques described later in the book provoke pain in the patient's muscle tissue. If the techniques do not provoke pain in the muscles or if the skin or skeleton are the source of symptoms, the treatment of soft tissue will not result in any kind of pain relief. 

Method and Techniques of the Palpatory Process

A specific methodology is available that enables palpation to be conducted comprehensively in a short period. This succession of techniques places increased stress on the tissue:

• Skin:

- Stroking the skin to assess its qualities.

- Stroking the skin to assess its temperature.

- Assessing the skin's consistency using displacement tests.

- Assessing the skin's consistency using the lifting test.

- Assessing the skin's consistency using skin rolling.

피부의 촉진을 통해 피부의 질, 온도를 검사함

displacement test, skin lifting, skin rolling을 이용하여 피부의 점조도를 검사함. 

• Muscles:

- Assessing the muscles' consistency using transverse frictions with the fingers.

근육의 점조도 판단은 손가락을 이용한 수평마찰법을 이용함. 

Figure 8.4 illustrates the procedure used to assess the consistency of the skin (left-hand side) and the muscles (right-hand side). The techniques are conducted using different areas of the hand. These areas are suitable for the palpation of certain sensations due to their differing degrees of special receptor dispersion. For example, the most successful method for the palpation of skin temperature is to use the back of the hand or the posterior surface of the fingers. A large number of thermoreceptors are found here. The finger pads are used to detect fine differences in contour and consistency in tissue. The high density of mechanoreceptors makes the finger pads ideal for this purpose.

촉진의 시작자세 starting position

1) 엎드린 자세

2) 앉은 자세

3) 옆으로 누운 자세

촉진 테크닉의 실제

피부 질의 촉진

피부 온도의 촉진

피부의 displacement test 테크닉

This is the simplest and least provocative test. The outstretched hand is placed on the surface of the skin. Minimal pressure is applied and the skin is pushed in a superior direction until the increasing tension in the skin restricts further movement (Fig. 8.10). The therapist conducts this test in a rhythmic manner, paying special attention to the tissue's resistance to movement and the path that both hands follow over the body's surface. 

피부 변위테스트 테크닉은 가장 간단하고 최소의  자극테스트임. 

쭉 편손으로 피부표면에 대고, 최소의 압력을 피부에 가하면서 움직임제한이 있는 피부범위까지 장력을 증가시킴. 

치료사는 리드믹한 방법으로 이 검사를 시행하여 인체 표면에서 조직의 움직임 제한이 있는지 주의깊게 살핌. 

The area to be assessed encompasses the sacral region, passes over the iliac crests in a lateral direction, runs paravertebral up to the cervicothoracic junction, and includes both scapulas (see also Fig. 8.4). This is the only test that can be used to gain information about the skin's consistency if the skin is extremely sensitive. Both of the following tests are more aggressive.

피부변위 테스트 부위는 천골부위를 아울러 장골릉을 지나 척추 양측으로 경흉추 관절까지 올라가는데, 양측 견갑골을 포함함. 

이 방법은 만약 피부가 극단적으로 예민한 경우에 피부의 점조도에 대한  유일한 검사임. 

피부 lifting, rolling  검사는 좀더 자극적임. 

피부 lifting test 테크닉

The test on the next level of intensity deforms the skin perpendicular to the skin's surface. This test can also be performed bilaterally and simultaneously. The thumb and a few finger pads grasp a section of the skin and form a skin fold, which is then lifted away from the surface of the skin (Fig. 8.11 ).

The same assessment criteria apply here: tissue resistance and the degree of motion. It is almost impossible to assess these criteria when patients are obese or have a high level of turgor. Also, it is frequently observed that it is impossible to lift up the skin in the lumbar region. This is purely a variation of the norm. The skin is usually lifted up several times  paravertebrally from approximately S3 to T1.

피부긴장의 정도를 검사할 수 있음. 

S3에서 T1까지 양측척추를 따라 검사할 수 있음. 

피부 Rolling 테크닉

This technique combines skin lifting perpendicular to the body's surface and displacement parallel to the body's surface. It is very informative but is a fairly aggressive, more challenging technique, and can only be conducted on one side at a time. Both hands are used to form a skin fold on one side of the body, similar to the skin-lifting test. Starting with the

lumbosacral region, this skin fold is then quickly rolled paravertebrally in a superior direction (Fig. 8.12). The therapist tries to keep the skin lifted as much as possible and to not lose the skin fold during the movement. The finger pads always pull new skin into the fold, and the thumbs push the fold upward in a superior direction.

피부 Rolling 검사는 피부 lifting검사와 함께 시행하면 매우 유익하고, 꽤 자극적인 검사법임. 

근육의 점조도 촉진(근육 긴장성 평가)

Most soft-tissue techniques on the trunk influence the pathologically altered muscle consistency (muscle tension).

Only a positive result in the assessment of muscle  tension justifies the use of soft-tissue treatment techniques (e.g., massage). Therefore, the state of the muscle must be systemically examined at the start of a treatment series and also be included at the start of each treatment session. It is not enough to depend on information from the patient to accurately observe treatment progress.

The palpation of tissue resistance in muscles requires a certain intensity, appropriate technique, and a reliable procedure (see also Fig. 8.4). Muscle tension is palpated after the skin has been pushed against the body's fasciae. This prevents the skin from providing the therapist with further information. Furthermore, the amount of pressure applied depends on the size or the thickness of the muscle to be palpated.

The technique applied is, therefore, transverse friction using the fingers. This should be performed in the gluteal

and the lumbar regions with the hand pushing down (with the aid of the other hand when necessary) so that deeper-lying muscles such as the piriformis can be reached. Palpation is performed in the thoracic, cervical, and scapula regions with both hands separate from one another to save time.

손가락을 이용한 transverse friction은 근육 긴장성 평가에 사용됨. 

둔부, 요부는 손을 겹쳐서 깊이 위치하는 근육인 이상근 등을 검사해야함. 흉추, 경추, 견갑골 부위는 시간을 절약하기 위해서 한손으로 검사가능함. 

The palpating hands now "scan" the muscle tissue using large movements. An attempt is made to gain a general idea of the consistency. The tissue is only palpated at a local level if abnormalities have been identified during the general "scan." Local palpation of muscle is then conducted using small movements, assessing the muscle's precise condition and the extent of change. This way of proceeding saves time and is effective. If the palpation provokes pain, extra attention must be paid toward the hardened tissue (see the section "Interpreting the Muscle Consistency [Tension] Palpation Findings" below). 

Principally, global and local hardening of muscles can easily be found using intensive transverse palpation. During the physical therapy training, palpation is introduced as a separate entity. Later on it is usually conducted in connection with the objective assessment. It is nevertheless recommended that beginners separate the results of observation and palpation to train the respective senses.

Techniques

1 . The therapist begins by pushing the fingers of one hand down onto the gluteal area at the edge of the sacrum and applies frictions.

2. The hand moves transversely over the gluteus maximus and the underlying piriformis.

3. The hand then moves laterally onto the small gluteal muscles (Fig. 8.13a) in the space between the iliac crest and the greater trochanter.

4. The lumbar erector spinae are palpated paravertebrally (Fig. 8.13b). If the back extensors are very well developed, the palpation will have to be separated into more medial and more lateral segments.

5. The thoracic erector spinae are palpated paravertebrally until approximately the level of T1 is reached. The therapist will be able to use both hands simultaneously for the palpation from here onward most of the time. It is no longer necessary to place extra weight on the palpating hand to apply enough pressure to reach the deep tissues.

6. The therapist moves along the medial border of the scapula in the area of the rhomboids and the transverse and ascending parts of the trapezius (Fig. 8.13c).

7. The infraspinatus and supraspinatus are assessed, moving laterally from a medial position over the scapula.

8. The belly of the descending part of the trapezius is then palpated, returning in a medial direction.

9. The paravertebral and suboccipital neck muscles are assessed next (Fig. 8.13d).

1 0. Tense adductors are expected to be found in patients with overloaded or painful shoulder joints. The palpation continues laterally along the scapula and the consistency of latissimus dorsi, teres major, and trees minor is felt. It is useful to also palpate the deltoids since a loss of muscle tone may be found here as a result of inactivity.

The palpating finger must not only overcome the skin to reach the muscles; it must also overcome the body's fasciae. These fasciae are not always of the same thickness in each section of the back (see Chapter 1). When the therapist is aware of how the fasciae are constructed, expectations regarding the consistency of the muscle tissue to be palpated will be correct.

촉진하는 손가락은 반드시 피부를 넘어 근육까지 도달해야 함. 반드시 인체의 근막을 극복해야함. 

근막은 등부위에서 모두 같은 두깨가 아님. 

치료사가 근막의 구성이 어떻게 되어있는지를 정확히 알때, 근육의 점조도와 연관된  촉진에 대한 기대는 올바를 수 있음. 

촉진의 치료와 평가에 대한 지식

The palpation of the posterior soft tissue is analyzed first. When the patient indicates pain, the therapist should consider how they can proceed systematically to clearly identify the tissue in which pain originates. Following this, the results of the individual palpatory findings are discussed. This section ends with examples of treatment, the main focus being on the treatment of muscles.

환자가 통증이 있다고 할때, 치료사는 문제있는 조직을 시스템적으로 어떻게 촉진하여 통증 오리진을 찾을  것인가를 고려해야 함. 

Differentiating between Tissues

How can you find out which tissue is affected?

당신은 어떻게 문제있는 조직을 찾아낼 것인가? 

The pressure applied during palpation is uncomfortable when the skin is hyperesthetic or hyperalgesic. It is also known that a certain amount of palpatory pressure, for example, onto the back extensors, is transferred as a slight movement onto the vertebral segment. How is it then possible to reliably find the affected tissue when pressure causes pain?

- 압박으로 통증이 유발될때, 어떻게 영향받은 조직을 찾아낼 것인가? 

We will discuss this by using the example of paravertebral palpation along the middle thoracic spine. Visualize the situation with a patient. The therapist systematically palpates the back extensors from inferior to superior using transverse frictions. 

At the level of the scapula the patient reports the pressure to be very uncomfortable. The question is: does muscle hardening definitely cause the reported pain? The therapist must now differentiate between tissues to answer this question.

- 근육의 단단함이 분명 통증을 유발하는가? 치료사는 반드시 이 질문에 응답할 수 있어야!!

Is the skin sensitive to pressure? 

The therapist should have already gained information about this when assessing skin consistency. It can happen that something is overlooked, in which case the skin consistency test is repeated using the technique that stresses the skin the most: skin rolling.

치료사는 피부점조도를 미리 평가해 정보를 얻어야 촉진압력에 피부감각과민이 있는지 알수 있음. 흔히 간과될 수 있으므로 주의해야 함. 

 The therapist broadly rolls the skin over the affected area now and compares it to the other side. When the patient indicates the same symptoms as those that appeared during localized pressure, the skin is the source of pressure pain. More precise information about the condition of deeper-lying structures is not possible using palpation. lf the muscles are treated (e.g., soft-tissue technique or massage) despite the skin sensitivity, treatment must be conducted with caution and with a large area of surface contact.

Is the vertebral column causing the symptoms? 

The therapist places the flat hand directly over the vertebral column and pushes anteriorly, alternating between more  pressure and less pressure while gradually increasing the overall pressure (Fig. 8.14). If this is not precise enough, the therapist can use the ulnar side of the hand and the same technique on the spinous and transverse processes in the area of pain. The vertebral column is at least partially the source of symptoms if the patient indicates the same symptoms felt during the previous palpation.

- 척주에서 통증을 유발하는가?

- 극돌기와 횡돌기를 압박하여 통증이 유발되는지를 치료사는 잘 알아야...

Are the costovertebral joints sensitive to pressure? 

It can be difficult to differentiate a myogelosis (local muscle hardening) from a sensitive costovertebral joint in thin

patients. Both are found very locally and are very firm. A myogelosis can mostly be pushed somewhat to the side. This cannot be expected with a rib. To make sure, the therapist places the ulnar side of their hand or thumb on the rib and pushes down onto the rib using a slow rocking motion and gradually increasing the pressure (Fig. 8.15) (see also the section "Posterior Palpation Techniques," Chapter 1 1 , p. 284). 

- 마른 환자에서 costovertebral joint 민감성으로부터 근육의 단단담을 구별하는 것은 어려울 수 있음. 

If this is the most painful test, the source of symptoms can be found in an irritated or blocked costovertebral joint. Treating the muscle alone will most likely not result in permanent relief. The therapist can be sure that the muscles are sensitive and are the cause the patient's symptoms when the provocation of skin, vertebral column, and the costovertebral joints do not provide clear answers. Remember these differentiating tests, especially when soft-tissue treatment has not yet produced the desired result. 

- 근육통과 costovertebral joint의 통증을 잘 구분해야..

Interpreting the Findings of Skin Surface Palpation

The most important questions following this are:

• Does the skin give you a reason not to test or treat deeper-lying structures? Possible reasons include diseases or injuries to the skin, but can also include rough, cracked, parched skin where strong deformations of the skin, as is the case during massages, are contraindicated. Acne, scarring, and lipomata also restrict the area that can be treated. The chronification of pain and disorders of the peripheral nervous system can cause hyperalgesia or hyperesthesia. The pressure from the therapist's hand may then be perceived as unpleasant. The treatment is questionable in this case.

• How much pressure can probably be applied when the use of a manual technique is possible?

• When classic massage treatment is used, how much of the massage product should be used?

Interpreting the Skin Consistency (Turgor) Palpation Findings

All three tests presented here should result in the same findings. Elasticity and sensitivity noted should be equal. The techniques should be reassessed or the patient questioned again if this is not the case. These tests stress the skin with different degrees of stretch (see also Chapter 1).

The sympathetic nervous system regulates the balance of fluids. Reflex changes to fluid accumulation are a sign of nociceptive afferents that are above or below threshold and arise from sections of a neurological segment (viscerotome, sclerotome, myotome). These changes may be seen during observation in the form of retracted skin or swelling. For further explanations, please read the relevant on reflexology. Certain changes in consistency, especially the retraction or adhesion of skin, can be positively affected by manual techniques (skin rolling, soft-tissue techniques to the thorax, etc.). Such findings are seen during the skin palpation of patients suffering from pulmonary and bronchial disorders (bronchial asthma, post-pneumonia).

Interpreting the Muscle Consistency (Tension) Palpation Findings

The assumption regarding "normally tensed" tissues and the corresponding palpable resistance is critical when interpreting the muscle consistency results. It can be assumed that muscle tissue yields quite a lot to pressure applied perpendicular to the muscle tissue and that the tissue has a soft and very elastic feel. Palpation on patients frequently results in completely different findings.

Muscle-tissue consistency can change due to physiological and pathological reasons. It can be either softer or harder

than expected. Softer consistencies are seen in atrophies following immobilization or injury as well as in disorders of the nervous system that are accompanied by hypotonic paralysis.

Harder consistencies are interpreted as hardened muscles when the entire muscle or large parts of the muscle are affected. Smaller areas of hardening are identified as myogeloses or trigger points (see also Chapter 1 ). Besides these harder consistencies, classified as pathological, there are also completely normal deviations from the expected consistency norm.

What Does it Mean When a Hardened Muscle Is Found?

Not every hardened muscle has to be treated. Painful, hardened areas that correspond to the patient's reported area of pain are of interest. Naturally, hardened muscles that hinder the access to deeper-lying structures (e.g., facet joints) are also of interest.

If the therapist finds an abnormally hardened area in a muscle during palpation, it is recommended that the therapist ask the patient the following questions to determine the pathological degree of the hardened area and its importance to the patient:

• Question 1: Can you feel the hardened area?

- The therapist does not attach any meaning to the findings if the patient's answer is "no."

- The therapist proceeds with the questioning if the patient's answer is "yes." 

• Question 2: Is the pressure that I apply to the hardened area uncomfortable?

- The therapist does not attach any meaning to the findings if the patient's answer is "no."

- The therapist proceeds with the questioning if the patient's answer is "yes."

• Question 3: Does the hardened area correspond to the area where your symptoms are?

- The therapist attaches little meaning to the findings if the patient's answer is "no."

- The therapist makes a mental note of the findings if the patient's answer is "yes," classifying the findings as particularly important, and documents this on a body chart.

This list of questions enables the therapist to individually structure their treatment using soft-tissue techniques or massage to target the symptoms. It also prevents the therapist spending too much time on less important areas of muscle. The therapist should pay particular attention to the following areas of hardening when planning treatment:

• Hardening that was conspicuous during the third question.

• Hardening that prevents access to deeper-lying structures.

• Hardening that is important for the familiarization with and the treatment before the application of manual-therapy techniques.

촉진치료의 사례

lumbar functional massage in the prone position

Functional massages are used to supplement the treatment of lumbar back extensors and quadratus lumborum, making massage even more effective. The first of the two phases used in this technique can also be used for extremely painful conditions in the lumbar spine. It is also suitable to prepare the patient for manual therapy techniques, especially when these involve lateral flexion. The technique can be conducted rhythmically or as a static stretch. Both variations decrease the tension in the muscle.

There are two variations available when applying this technique. The first variation does not involve targeted vertebral movement during treatment. The vertebral column may move as it follows the movement of other structures or be placed in lateral flexion before starting treatment to optimize the mobilizing effect.

Starting Position-Variation 1

The patient lies prone in a neutral position or with padding underneath the abdomen. The therapist places both hands over the back extensors on the other side of the patient. The thumbs are placed flat over the hollow between the bulk of the muscle and the spinous processes. They exert significant pressure into this hollow. The fingers point laterally and grasp around the muscle belly between the costal arch and the iliac crest (Fig. 8.16). 

Technique

While continuing to hold onto the muscle, the therapist stretches the muscle laterally by pushing with the thumbs and slightly spreading the fingers. This movement is quite small. It can be conducted in either a rhythmical manner or as a static stretch (Fig. 8.17).

Starting Position-Variation 2

The starting position can be altered with the help of the patient to make treatment more effective. This is achieved by:

• either shifting the pelvis toward the therapist;

• or shifting the pelvis away from the therapist.

The back extensors are approximated when the pelvis shifts toward the therapist (Fig. 8.18), relaxing the back extensors -+ use this method when muscles are extremely tense. The muscles are lengthened when the pelvis is shifted away from the therapist (opposite side, Fig. 8.19). This results in the muscles being placed under preliminary tension in a longitudinal direction. Accordingly, transverse stretching is even more effective in terms of decreasing muscle tension -+ use this method when muscles are moderately tense. You should abstain from using this second variation in cases of extreme pain unless positioning in lateral flexion to a particular side relieves pain in lying.

Lumbar Functional Massage in Side-lying

This functional massage involves significantly more movement than the previous massage. It should therefore only be used after lateral flexion has been assessed and the contraindications have been checked. However, the decrease in muscle tension and the mobilization is particularly effective. 

Starting Position

The patient is found in neutral lateral flexion. The side to be treated is uppermost. The therapist places both hands paravertebrally, grasping the upper-lying back extensors. The superior end of the therapist's forearm rests against the patient's thorax. The inferior end of the forearm rests on the pelvis between the greater trochanter and the iliac crest (Fig. 8.20).

Technique

Phase 1: The back extensors being treated are displaced laterally (in spatial terms toward the roof). The therapist achieves this by pulling the finger pads upward and slightly separating the thumbs.

Phase 2: To intensify this technique, the therapist pushes the elbows against the areas of support. The more inferiorly

positioned arm slides up to 80% during this movement. The role of the more superiorly positioned forearm is to prevent the thorax from moving with the rest of the body. Its job is not to force lateral flexion! The result should be lateral flexion of the lumbar spine (toward the right in this example). This combines the transverse stretch from phase 1 with a longitudinal stretching of the back extensors (Fig. 8.21).

Phase 3: The lower legs can be used as a lever to increase the range of lateral flexion in younger patients where lateral

flexion is pain free. The patient's lower legs hang over the edge of the treatment table (phase 3a, Fig. 8.22). 

The therapist pushes on the pelvis with the forearm and the patient lowers their lower legs (phase 3b, Fig. 8.23) ..... lateral

flexion is increased immensely. Not every patient can be expected to undergo this enormous stress on the lumbar spine. There are, therefore, a few contraindications that should be observed with this technique:

• Any acute, painful symptoms in the lumbar spine.

• Pronounced instability in the lumbar spine.

• Arthritis and severe restrictions in mobility in one hip.

• Total hip replacement.

• All other contraindications for physical therapy. 

Tip: The muscles in the area of the lumbosacral junction can be reached by changing the hand placement in each variation of this technique (Fig. 8.24). Only the therapist's more superiorly positioned hand hooks medially around the back extensors. The more inferiorly positioned hand rests on the pelvis and facilitates lateral flexion only. It is no longer in contact with the back muscles. 

The treatment effect can be intensified by using neurophysiological aids to increase the range of pelvic and leg motion (in phase 3), which increases the movement in the lumbar spine:

• Reciprocal inhibition for phase 2.

• Contract relax for phase 3.

Reciprocal Inhibition for Phase 2

The aim is to inhibit the upper-lying back extensors through activity in the lower-lying muscles. Therefore, the therapist instructs the patient to move the upper-lying side of the pelvis inferiorly. The patient can only achieve this by activating the lower-lying lumbar muscles (and therefore inhibiting the upper-lying lumbar muscles). The patient begins to move at exactly the same moment when the therapist uses both arms to force lateral flexion. 

Contract Relax for Phase 3

The relaxing effect following isometric muscular activity has been discussed in the literature. Neurophysiological evidence cannot be described at present. This principle functions though in clinical situations. It is therefore impOl·tant that the patient becomes increasingly involved in the procedure by focusing their attention on the muscle tension and relaxation, and that the patient is given enough time to relax. During the phase 3 procedure, the patient lifts both lower legs to the level of the treatment table, then holds this for a few seconds, perceives the tension in the lumbar spine and the pelvis, lets the lower legs drop, and then feels the relaxation. It is only now that the therapist manually forces lateral flexion and changes the erector spinae's form. 

Functional Massage of the Trapezius in Side-lying

The functional massage in side-lying is one of the most effective options to decrease tension in the frequently painful and tense descending fibers of the trapezius. The technique combines longitudinal stretching (movement of the shoulder girdle) with a manual transverse stretch. As patients are often unable to relax their shoulder girdle muscles, it is recommended to first passively protract, retract, elevate, and depress the scapula and move the scapula diagonally.

At the same time the therapist can assess whether the necessary movements can be performed without causing pain in the shoulder girdle joints. The technique itself starts with the trapezius in a slightly approximated position, followed by a diagonal movement of the shoulder. The hand molded over the trapezius applies an impulse or pressure onto the muscle belly in the opposite direction.

Starting Position

The patient lies in a neutral side-lying position and slides as close as possible to the edge of the treatment table next  to the therapist, who stabilizes the patient with their body from a standing position. One hand is resting on the shoulder joint and facilitates the shoulder girdle, while the other hand holds onto the descending fibers of the trapezius using the palmar grip

(Fig. 8.25).

Variation 1 of the Technique-Depression and Retraction with an Anterior Stretch from the Hand

The muscle is approximated by slightly elevating and protracting the shoulder girdle (scapula moves forward and upward).

The thenar eminence pushes the muscle in an anterior direction without the hand slipping over the skin ..... transverse

stretch. The shoulder girdle is facilitated into an extremely depressed and retracted position (scapula moves backward

and downward, Fig. 8.26) ..... longitudinal stretch. The stretch is stopped if the muscle belly slips out from underneath the therapist's hand.

Tip: If the heel of the therapist's hand continuously rubs up against the superior angle of the scapula during the previously

described technique, the scapula can be moved out of the way. This is achieved by passively elevating the arm to a sufficient extent (at least 90° of glenohumeral joint flexion) and maintaining this position. The scapula is placed in extensive external rotation, and the superior angle of the scapula moves inferiorly. There is now more space on the trapezius for the therapist's molding hand (variation according to Matthias Griitzinger, Fig. 8.27).

Variation 2 of the Technique-Depression and Protraction with a Posteriorly Directed Stretch

The muscle is approximated to some extent by slightly elevating and retracting the shoulder girdle (scapula moves backward and upward). The fingers are slightly flexed and move the muscle in a posterior direction without sliding over the skin.

The shoulder girdle is eased into extensive depression and protraction (scapula moves forward and downward, Fig. 8.28).

The stretch is stopped if the muscle belly slips out from underneath the hand. As sensitive neural and vascular structures are found here, the therapist must exercise a great deal of caution when grasping with the fingertips. 

Tip: The effectiveness of this technique can be further improved by prestretching the muscle farther using lateral flexion away from the side to be treated (the head section of the treatment table is lowered or the pillow is removed). The stretch is significantly more effective due to this (Fig. 8.29). 

Caution: lateral flexion must be pain-free for the patient and must be assessed before commencing the technique. 

Functional Massage o f the Trapezius in the Supine Position

A technique in the supine position provides the therapist with another option to lower the tension in the descending part of the trapezius and the paravertebral neck muscles. It essentially differs from the technique in side-lying through its use of cervical rotation and simple shoulder girdle depression. The range of pain-free cervical rotation must therefore be assessed before applying the technique.

Starting Position

The patient lies toward the head-end of the treatment table in a neutral supine position. The back of the head should actually extend somewhat over the edge of the bed. It is supported with some padding, for example, with a folded towel. Caution: do not place padding underneath the cervical spine!

The patient's forearm on the side to be treated is placed on the abdomen and held onto by the other hand (variation according to Oliver Oswald). This facilitates the necessary movement of the scapula (Fig. 8.30). The therapist's body is in contact with the side of the patient's head. One hand facilitates the shoulder girdle while the other hand grasps the trapezius and molds the muscle. The therapist's forearm rests against the side of the patient's head.

Technique

The hand nearest the head molds the muscles (trapezius and neck muscles) by stretching the trapezius transversely

in an anterior direction and stretching the paravertebral muscles more to the side. The therapist's forearm facilitates the head into cervical rotation while the therapist slightly moves their body out of the way. The second hand leads the shoulder girdle into depression. The deformation of muscles and the depression are eased again as the therapist's body brings the patient's head back into a neutrally rotated position:

• Variation 1 (Fig. 8.30): more emphasis is placed on the trapezius, forced shoulder girdle depression, and less cervical rotation. The grip is more to the side.

• Variation 2 (Fig. 8.31): more emphasis is placed on the paravertebral neck muscles using less depression and significant rotation. The grip is therefore more medial. 

[heoss]

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