Erik Dalton’s Erik Dalton’s Freedom from Pain Institute

MyoskeletalMyoskeletalAlignmentAlignmentTechniquesTechniques®®

For Pain ManagementFor Pain Management

Sensory Receptors…Sensory Receptors…Rebels Without a Pause?Rebels Without a Pause?

Research conclusions from ongoing Research conclusions from ongoing studies:studies:

• Soft tissues (previously viewed as purely Soft tissues (previously viewed as purely mechanical structures) are innervated and mechanical structures) are innervated and participate in active balancing of the spine.participate in active balancing of the spine.

• Specialized mechanoreceptors play major Specialized mechanoreceptors play major roles in myofascial unwinding AND also roles in myofascial unwinding AND also initiate aberrant feedback loops and muscle initiate aberrant feedback loops and muscle imbalance patterns due to injured articular imbalance patterns due to injured articular structures.structures.

SENSORY RECEPTORSSENSORY RECEPTORS

• Supply CNS input on stimuli such as pain, Supply CNS input on stimuli such as pain, touch, sound, light, heat and cold.touch, sound, light, heat and cold.

• Categorized by specific physiological duties Categorized by specific physiological duties such as nociceptors, mechano, chemo, such as nociceptors, mechano, chemo, thermo and electromagnetic receptors.thermo and electromagnetic receptors.

• Transmit proprioceptive and nociceptive Transmit proprioceptive and nociceptive informationinformation

• Change sensory stimuli into action Change sensory stimuli into action potentials so the CNS continually receives potentials so the CNS continually receives data on the overall body environment. data on the overall body environment.

Muscle Joint Muscle Joint Reflexogenic Reflexogenic RelationshipsRelationships

Is impaired muscle function the primary Is impaired muscle function the primary cause of joint dysfunction, or is the cause of joint dysfunction, or is the reverse true?reverse true?

• Grieve 1988: Grieve 1988: --Postural asymmetry joint blockage enhances --Postural asymmetry joint blockage enhances

fibroblastic activity resulting in periarticular fibroblastic activity resulting in periarticular tissue fibrosis.tissue fibrosis.

• McLain 1994:McLain 1994: --Receptors monitor capsular tension.--Receptors monitor capsular tension.--Receptors may initiate protective reflexes --Receptors may initiate protective reflexes

important in preventing joint degeneration. important in preventing joint degeneration.

Catch 22 Catch 22 Pain/Spasm/Pain Cycle Pain/Spasm/Pain Cycle

• Murphy:Murphy:-- Added that changes in spinal joint soft tissue -- Added that changes in spinal joint soft tissue

fibrosis alter the normal instantaneous axis of fibrosis alter the normal instantaneous axis of rotation. rotation.

How Joints Affect How Joints Affect MusclesMuscles

• Joints influence muscle tone and Joints influence muscle tone and therefore muscle function.therefore muscle function.

• The joint’s ability to alter muscle tone The joint’s ability to alter muscle tone is mediated by articular receptors. is mediated by articular receptors.

• In the joint capsule, the greatest In the joint capsule, the greatest number of receptors is found in regions number of receptors is found in regions subject to variation of tension during subject to variation of tension during movement.movement.

• Articular receptors can inhibit or Articular receptors can inhibit or facilitate muscle tone.facilitate muscle tone.

ARTICULAR RECEPTORSARTICULAR RECEPTORS

• Freeman and WykeFreeman and Wyke categorized categorized articular receptors into four types: Type articular receptors into four types: Type I, II, III, and IV.I, II, III, and IV.

• Each is stimulated in a distinctive way and Each is stimulated in a distinctive way and responds to stimulation differently.responds to stimulation differently.

• Type I and II mechanoreceptors act as Type I and II mechanoreceptors act as physiological receptors/ active during normal physiological receptors/ active during normal movement.movement.

• Type III and IV receptors normally inactive/ Type III and IV receptors normally inactive/ only stimulated at extremes of movement…may only stimulated at extremes of movement…may function under pathological conditions. function under pathological conditions.

ARTICULAR RECEPTORSARTICULAR RECEPTORS

Ligament InnervationLigament Innervation

• Jiang et al (1995)Jiang et al (1995) documented innervation documented innervation of human supraspinal /interspinal ligaments of human supraspinal /interspinal ligaments from 10 spinal decompression surgery from 10 spinal decompression surgery patients. patients.

• Dense collagen bundles of Ruffini corpuscles Dense collagen bundles of Ruffini corpuscles suggest active monitoring of mechanical suggest active monitoring of mechanical joint loading and provide static positional joint loading and provide static positional awareness for postural control.awareness for postural control.

• Jaing’s findings support concept of ligaments Jaing’s findings support concept of ligaments as part of neurologic feedback mechanisms as part of neurologic feedback mechanisms for protection and stability of the spine.for protection and stability of the spine.

Zygapophysial Joint Zygapophysial Joint InnervationInnervation

• Belief in zygapophysial joint pain dates Belief in zygapophysial joint pain dates back to 1933 when Ghormley coined the back to 1933 when Ghormley coined the term “facet syndrome”.term “facet syndrome”.

• Facet innervation is derived from the medial Facet innervation is derived from the medial branch of the posterior primary division at the branch of the posterior primary division at the level of the joint and the levels above and level of the joint and the levels above and below. below.

• Jeffries 1988 Jeffries 1988 suggested that this multilevel suggested that this multilevel innervation is probably one reason why facet innervation is probably one reason why facet joint pain frequently has a broad referral joint pain frequently has a broad referral pattern.pattern.

McLain’s Facet StudiesMcLain’s Facet Studies

• McLainMcLain dissected human cervical facet capsules dissected human cervical facet capsules from three normal subjects to determine the type, from three normal subjects to determine the type, density, and distribution of mechanoreceptive density, and distribution of mechanoreceptive nerve endings. nerve endings.

• Mechanoreceptors were found in 17 of 21 Mechanoreceptors were found in 17 of 21 specimens. specimens.

• McLain concluded “the presence of McLain concluded “the presence of mechanoreceptive and nociceptive nerve endings mechanoreceptive and nociceptive nerve endings in cervical facet capsules proves that neural input in cervical facet capsules proves that neural input from facets is important to proprioception and from facets is important to proprioception and pain sensation in the cervical spine.”pain sensation in the cervical spine.”

Whiplash and FacetsWhiplash and Facets Barnsley et alBarnsley et al double-blind, controlled double-blind, controlled

diagnostic blocks / Investigated cervical facets diagnostic blocks / Investigated cervical facets in 50 post-whiplash patients / Found facets in 50 post-whiplash patients / Found facets were most common source of chronic neck were most common source of chronic neck pain.pain.

• Bogduk, Hirsch et al, and Yamashita et alBogduk, Hirsch et al, and Yamashita et al also reported on rich innervation of facet joints. also reported on rich innervation of facet joints.

• They concurred that altered intersegmental and They concurred that altered intersegmental and segmental joint motion and postural distortions segmental joint motion and postural distortions create aberrant traffic in neuropathways.create aberrant traffic in neuropathways.

• ““Cross-talk” perpetuates aberrant reflex Cross-talk” perpetuates aberrant reflex alterations, muscular and ligamentous alterations, muscular and ligamentous alterations, inflammatory responses and alterations, inflammatory responses and resultant pain syndromes.resultant pain syndromes.

Discogenic PainDiscogenic Pain

• Roofe (1940)Roofe (1940)-1-1stst evidence of anulus evidence of anulus fibrosus nerve fibers.fibrosus nerve fibers.

• Bogduk (1983)Bogduk (1983)-nerve fibers in outer 1/3 -nerve fibers in outer 1/3 of lumbar anulus fibrosus.of lumbar anulus fibrosus.

• Farfan (1973)Farfan (1973)-type 4 nerve receptors -type 4 nerve receptors penetrating nucleus, anulus and posterior penetrating nucleus, anulus and posterior longitudinal ligament.longitudinal ligament.

• Shinohara (1970)Shinohara (1970)-nerve fibers -nerve fibers penetrating degenerated discs nuclei.penetrating degenerated discs nuclei.

• Garfin (1995) Garfin (1995) -disc compression of normal -disc compression of normal nerve leads to paresthesias, sensory nerve leads to paresthesias, sensory deficits and motor loss…pain is absent.deficits and motor loss…pain is absent.

Wilberger and the Wilberger and the Silent Nerve Compression Silent Nerve Compression

SyndromeSyndrome• Wilberger et al Wilberger et al -lumbar myelographic -lumbar myelographic

herniated discs in 108 asymptomatic herniated discs in 108 asymptomatic patients.patients.

• Within 3 years, 64% developed Within 3 years, 64% developed lumbosacral radiculopathy.lumbosacral radiculopathy.

• Wilberger hypothesizes that time was Wilberger hypothesizes that time was required for mechanical deformation to required for mechanical deformation to cause this “silent nerve compression cause this “silent nerve compression syndrome”. syndrome”.

29 yr. old male 40 yr. old male

Radicular PainRadicular Pain

FASCIAL PLASTICITYFASCIAL PLASTICITY

• Therapist hands often palpate a myofascial Therapist hands often palpate a myofascial unwinding as sustained pressure is applied unwinding as sustained pressure is applied to superficial and deep myofascial layers. to superficial and deep myofascial layers.

• Juhan Juhan attributed alteration in connective attributed alteration in connective tissue resilience to what is commonly tissue resilience to what is commonly called thixotropy or the “gel-to-sol” called thixotropy or the “gel-to-sol” phenomenon.phenomenon.

• Currier and NelsonCurrier and Nelson -significantly more -significantly more force, time and heat must be generated in force, time and heat must be generated in order to establish permanent connective order to establish permanent connective tissue deformation. tissue deformation.

• Oshman Oshman added piezoelectricity as a added piezoelectricity as a possible explanation for fascial creep.possible explanation for fascial creep.

Robert Schleip’s Robert Schleip’s Observations on Fascial Observations on Fascial

PlasticityPlasticity• Schleip Schleip concurred: these mechanisms may be concurred: these mechanisms may be

a viable explanation for long-term tissue a viable explanation for long-term tissue changes changes but but questioned their effectiveness for questioned their effectiveness for short term tissue release experienced in short term tissue release experienced in clinic.clinic.

• Schleip studies with anesthetized patients -in Schleip studies with anesthetized patients -in the absence of neural connection, short-term the absence of neural connection, short-term fascial plasticity is lost.fascial plasticity is lost.

• Schleip, “Pacinian receptors are likely to be Schleip, “Pacinian receptors are likely to be stimulated by high-velocity thrust stimulated by high-velocity thrust manipulations as well as in vibratory manipulations as well as in vibratory techniques, whereas the Ruffini endings may techniques, whereas the Ruffini endings may be activated by slow and deep ‘melting be activated by slow and deep ‘melting quality’ soft tissue techniques.”quality’ soft tissue techniques.”

Golgi tendon organsGolgi tendon organs

• Golgi tendon organs (GTO’s) arranged in Golgi tendon organs (GTO’s) arranged in a series respond to slow stretch by a series respond to slow stretch by resetting a muscles’ length, inhibiting its resetting a muscles’ length, inhibiting its synergistic stabilizers and facilitating its synergistic stabilizers and facilitating its antagonist.antagonist.

• Jami 1992Jami 1992 -passive myofascial stretching -passive myofascial stretching does not stimulate GTO’s.does not stimulate GTO’s.

Golgi tendon organs Golgi tendon organs

• Lederman 1997Lederman 1997 - -GTO’s able to reset GTO’s able to reset their muscles’ their muscles’ length during length during dynamic forceful dynamic forceful contractions. contractions.

• GTO’s may serve a GTO’s may serve a protective function protective function by reflexively by reflexively inhibiting its agonist inhibiting its agonist at the end range of at the end range of joint motion. joint motion.

Nociceptors as Pain-Nociceptors as Pain-GeneratorsGenerators

• Nociceptor mechanical, thermal and chemical Nociceptor mechanical, thermal and chemical stimuli.stimuli.

• Nociceptor and chemoreceptor activation:Nociceptor and chemoreceptor activation:1.1. Nerve fibers depolarized by joint capsule mechanical Nerve fibers depolarized by joint capsule mechanical

stressesstresses

2.2. Thermal extremesThermal extremes

3.3. Inflammatory chemical agents such as histamines, Inflammatory chemical agents such as histamines, prostaglandins, bradykinins, potassium ions, and prostaglandins, bradykinins, potassium ions, and lactic acid.lactic acid.

• Nociceptors can quickly become major Nociceptors can quickly become major generators of both myofascial and spinal-pain generators of both myofascial and spinal-pain syndromes. syndromes.

Postural ControlPostural Control

• Soft tissues within and Soft tissues within and surrounding spinal surrounding spinal articulations are densely articulations are densely populated with sensory populated with sensory receptors. receptors.

• Macro or microtrauma may Macro or microtrauma may create joint misalignment create joint misalignment and postural distortions.and postural distortions.

• Injured articular structures Injured articular structures initiate and facilitate spinal initiate and facilitate spinal reflex pathways which reflex pathways which increase contractibility in increase contractibility in paraspinal musculature. paraspinal musculature.

Nociceptors and PostureNociceptors and Posture

• Long-term CNS agitation by irritated nociceptors Long-term CNS agitation by irritated nociceptors causes the brain to twist and torque the body in causes the brain to twist and torque the body in an effort to avoid pain. an effort to avoid pain.

• Regrettably, the brain has the ability to Regrettably, the brain has the ability to memorize these aberrant postural patterns. memorize these aberrant postural patterns.

Nociceptors and PostureNociceptors and Posture

• Dysfunctional Dysfunctional patterns that patterns that persist long after persist long after the painful stimulus the painful stimulus has been removed has been removed are referred to as are referred to as

• ““neuroplasticity” neuroplasticity” • ““reflex entrainment”reflex entrainment”• or “spinal or “spinal

learning.” learning.”

Transversospinalis Transversospinalis

• Muscles are the body's primary movers Muscles are the body's primary movers and must respond quickly to changes from and must respond quickly to changes from neural structures.neural structures.

• When tight muscles pull unevenly on the When tight muscles pull unevenly on the body’s bony framework, the joint’s axis of body’s bony framework, the joint’s axis of rotation and center of gravity changes. rotation and center of gravity changes.

• Prolonged joint misalignment (loss of joint Prolonged joint misalignment (loss of joint play) agitates sensory receptors in spinal play) agitates sensory receptors in spinal joint capsules, ligaments, discs, and joint capsules, ligaments, discs, and transversospinalis muscles. transversospinalis muscles.

Transversospinalis Transversospinalis almost almost always pulls insertion points toward origins always pulls insertion points toward origins when at work. As the TP are pulled toward when at work. As the TP are pulled toward the SP, localized rotation and sidebending the SP, localized rotation and sidebending occur.occur.

TransversospinalisTransversospinalis

• Particularly stressed are mechanoreceptors Particularly stressed are mechanoreceptors embedded in overstretched capsules and the embedded in overstretched capsules and the part of the joint bearing excessive weight.part of the joint bearing excessive weight.

GATING GATING

• Joint dysfunction results in muscle dysfunction Joint dysfunction results in muscle dysfunction by changing gamma bias of spindle cells.by changing gamma bias of spindle cells.

• Joint injury, degeneration, inflammation, or Joint injury, degeneration, inflammation, or muscle guarding causes fewer muscle guarding causes fewer mechanoreceptive fibers.mechanoreceptive fibers.

• As we age we lose mechanoreceptors = can’t As we age we lose mechanoreceptors = can’t gate. Because nociceptors are free nerve gate. Because nociceptors are free nerve endings they are not as affected.endings they are not as affected.

• This explains why a minor trauma can This explains why a minor trauma can cause much pain or a major trauma can cause much pain or a major trauma can cause only minor pain.cause only minor pain.

Co-activating Co-activating NociceptorsNociceptors

• Warmerdam 1999Warmerdam 1999 - nociceptive - nociceptive gating best achieved by stimulation gating best achieved by stimulation of low-threshold mechanoreceptors of low-threshold mechanoreceptors near nociception origination.near nociception origination.

• Nociception originating from muscle Nociception originating from muscle = passive massage, joint = dynamic = passive massage, joint = dynamic stimulation produces more sensory stimulation produces more sensory gating. gating.

Co-activating Co-activating NociceptorsNociceptors

• Lederman (1997)Lederman (1997) found that found that successful successful nociceptive gating nociceptive gating requires that the requires that the stimulus be pain stimulus be pain free or that the free or that the gating movements gating movements take place within a take place within a pain free range. pain free range.

Joint Techniques to lower Joint Techniques to lower Pain-Generating StimuliPain-Generating Stimuli

• Spinal soft tissue Spinal soft tissue manipulations manipulations that initiate that initiate passive joint passive joint movements movements result in result in mechanoreceptivmechanoreceptive stimulation. e stimulation.

Joint Techniques to Lower Joint Techniques to Lower Pain-Generating StimuliPain-Generating Stimuli

• This technique creates This technique creates presynaptic inhibition presynaptic inhibition of the nociceptive of the nociceptive afferent to diminish or afferent to diminish or abolish the perception abolish the perception of pain.of pain.

• Sandoz Sandoz –restoring –restoring normal joint structure normal joint structure /function helps /function helps normalize normalize mechanoreceptive and mechanoreceptive and nociceptive input.nociceptive input.

Cutaneous vs. Articular Cutaneous vs. Articular ReceptorsReceptors

• Massage primarily stimulates Massage primarily stimulates cutaneous receptors. Active or passive cutaneous receptors. Active or passive movements primarily stimulate movements primarily stimulate articular receptors = less joint pain.articular receptors = less joint pain.

• Active client participation better gates Active client participation better gates articular nociceptors.articular nociceptors.

• Active (rather than passive) positioning Active (rather than passive) positioning improves proprioception since muscles improves proprioception since muscles are allowed to play a larger role. are allowed to play a larger role.

Passive Cutaneous Massage Passive Cutaneous Massage Release Release

Active Articular Release Active Articular Release

MUSCLE INHIBITION OR MUSCLE INHIBITION OR ATROPHY?ATROPHY?

• Janda 1988Janda 1988 “Although muscle weakness has “Although muscle weakness has usually been considered a result of decreased usually been considered a result of decreased activity, inhibition may be an integral part of activity, inhibition may be an integral part of many, if not all, forms of weakness”.many, if not all, forms of weakness”.

• Hurley (1997)Hurley (1997)- muscle weakness- two - muscle weakness- two factors:factors:

1.1. Decreased number of extrafusal muscle fibersDecreased number of extrafusal muscle fibers2.2. A failure to activate all muscle fibersA failure to activate all muscle fibers

• A decreased number or size of extrafusal A decreased number or size of extrafusal fibers may be termed fibers may be termed atrophyatrophy, whereas failure , whereas failure to activate all muscle fibers may be termed to activate all muscle fibers may be termed inhibitioninhibition..

MUSCLE IMBALANCE MUSCLE IMBALANCE PATTERNSPATTERNS

• Janda’s Upper and Lower Crossed Janda’s Upper and Lower Crossed Syndromes -2 of most common Syndromes -2 of most common aberrant postural patterns. aberrant postural patterns.

• Exposed to same stressors certain Exposed to same stressors certain muscles become tight and facilitated/ muscles become tight and facilitated/ others weak and inhibited.others weak and inhibited.

• Abnormal afferent information:Abnormal afferent information:• poor posturepoor posture• excessive physical excessive physical

demandsdemands• joint blockagejoint blockage• habitual movement habitual movement

patternspatterns

• painful or noxious painful or noxious stimulistimuli

• CNS malregulationCNS malregulation• psychological psychological

(emotional) (emotional) stressorsstressors

Upper Crossed SyndromeUpper Crossed Syndrome

• Are the weak Are the weak lower shoulder lower shoulder stabilizers solely stabilizers solely responsible for responsible for the aberrant the aberrant forward head forward head posture seen in posture seen in the upper the upper crossed crossed syndrome?syndrome?

Upper /Lower Crossed Upper /Lower Crossed SyndromesSyndromes

• Porterfield and DeRosalPorterfield and DeRosal - forward posture - forward posture factors other than scapular retractors stretch factors other than scapular retractors stretch weakness.weakness.– Weakness and lengthening of abdominal muscles Weakness and lengthening of abdominal muscles

allows the chest to fall causing an anterior upper allows the chest to fall causing an anterior upper trunk weight shift.trunk weight shift.

– As gravitation exposure pulls upper trunk forward on As gravitation exposure pulls upper trunk forward on the rib cage, the scapulae externally rotate and the rib cage, the scapulae externally rotate and protract –forcing clavicle to drop on the first rib. protract –forcing clavicle to drop on the first rib.

• The clavicular head of pectoralis major and The clavicular head of pectoralis major and hypertonic latissimus dorsi internally rotate the hypertonic latissimus dorsi internally rotate the humerus forcing the neck and head to follow.humerus forcing the neck and head to follow.

Nociceptive Reflexes and Nociceptive Reflexes and Somatic DysfunctionSomatic Dysfunction

Somatic Dysfunction Model- restriction in mobility, Somatic Dysfunction Model- restriction in mobility, autonomic, visceral, and immunologic changes produced by autonomic, visceral, and immunologic changes produced by pain-related sensory neurons and their reflexes.pain-related sensory neurons and their reflexes.

• Nociceptor muscular guarding reactions and autonomic Nociceptor muscular guarding reactions and autonomic activation from stressed/damaged myoskeletal or visceral activation from stressed/damaged myoskeletal or visceral tissue.tissue.

• Guarding - abnormal myoskeletal position and decreased Guarding - abnormal myoskeletal position and decreased ROM.ROM.

• Local inflammatory responses and autonomic reflexes Local inflammatory responses and autonomic reflexes reinforce nociceptor activity, maintaining restriction.reinforce nociceptor activity, maintaining restriction.

• Nociceptive autonomic reflexes= visceral/immunologic Nociceptive autonomic reflexes= visceral/immunologic changes. changes.

• Abnormal guarding in muscles, joints, related tissues Abnormal guarding in muscles, joints, related tissues =changes in connective tissues, solidifying the abnormal =changes in connective tissues, solidifying the abnormal position.position.

• Stretching tissues into normal range of motion may Stretching tissues into normal range of motion may restimulate nociceptors, reinforcing the somatic dysfunction. restimulate nociceptors, reinforcing the somatic dysfunction.

CONCLUSIONCONCLUSION• Patients benefit by restoring balance/function to all soft Patients benefit by restoring balance/function to all soft

tissue structures.tissue structures.• A model for using receptor techniques to correct A model for using receptor techniques to correct

aberrant postural patterns is helpful in the clinical aberrant postural patterns is helpful in the clinical setting.setting.

• Impaired Neuromyoskeletal functions can cause stress, Impaired Neuromyoskeletal functions can cause stress, pain and altered performance of internal organs, pain and altered performance of internal organs, hormonal systems and psycho-immunological functions.hormonal systems and psycho-immunological functions.

• Working with the sensory receptor system, trained Working with the sensory receptor system, trained therapists can determine if problems are primarily therapists can determine if problems are primarily within muscles, fasciae or joint-related tissues or if the within muscles, fasciae or joint-related tissues or if the problem exists elsewhere. problem exists elsewhere.

• With assessment and treatment training, a therapist can With assessment and treatment training, a therapist can more efficiently determine dysfunction sites and improve more efficiently determine dysfunction sites and improve structure.structure.

• This leads to higher functioning in the self-regulating This leads to higher functioning in the self-regulating and self-protecting mechanisms of the body.and self-protecting mechanisms of the body.