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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 studies:Research conclusions from ongoing studies:•• Soft tissues (previously viewed as purely mechanical Soft tissues (previously viewed as purely mechanical

structures) are innervated and participate in active structures) are innervated and participate in active balancing of the spine.balancing of the spine.

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

SENSORY RECEPTORSSENSORY RECEPTORS

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

•• Categorized by specific physiological duties such as Categorized by specific physiological duties such as nociceptorsnociceptors, mechano, chemo, thermo and , mechano, chemo, thermo and electromagnetic receptorselectromagnetic receptors

•• Transmit Transmit proprioceptiveproprioceptive and and nociceptivenociceptive informationinformation•• Change sensory stimuli into action potentials so the Change sensory stimuli into action potentials so the

CNS continually receives data on the overall body CNS continually receives data on the overall body environment. environment.

Muscle Joint Muscle Joint ReflexogenicReflexogenic RelationshipsRelationships

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

•• McLain 1994:McLain 1994:----Receptors monitor capsular tensionReceptors monitor capsular tension----Receptors may initiate protective reflexes important in preventiReceptors may initiate protective reflexes important in preventing ng

joint degeneration. joint degeneration.

•• Grieve: Grieve: ----Postural asymmetry joint blockage enhances fibroblastic activityPostural asymmetry joint blockage enhances fibroblastic activity

resulting in resulting in periarticularperiarticular tissue fibrosis.tissue fibrosis.

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

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

alters the normal instantaneous axis of rotation alters the normal instantaneous axis of rotation

How Joints Affect MusclesHow Joints Affect Muscles

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

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

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

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

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ARTICULAR RECEPTORSARTICULAR RECEPTORS

•• Freeman and Freeman and WykeWyke categorized categorized articulararticularreceptors into four types: Type I, II, III, and IV.receptors into four types: Type I, II, III, and IV.

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

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

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

ARTICULAR RECEPTORSARTICULAR RECEPTORS

Ligament Ligament InnervationInnervation

•• JiangJiang et al (1995)et al (1995) documented documented innervationinnervation of human of human supraspinalsupraspinal //interspinalinterspinal ligaments from 10 spinal ligaments from 10 spinal decompression surgery patients. decompression surgery patients.

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

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

ZygapophysialZygapophysial Joint Joint InnervationInnervation

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

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

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

McLain’s Facet StudiesMcLain’s Facet Studies

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

•• Mechanoreceptors were found in 17 of 21 specimens Mechanoreceptors were found in 17 of 21 specimens •• McLain concluded “the presence of McLain concluded “the presence of mechanoreceptivemechanoreceptive

and and nociceptivenociceptive nerve endings in cervical facet capsules nerve endings in cervical facet capsules proves that neural input from facets is important to proves that neural input from facets is important to proprioceptionproprioception and pain sensation in the cervical and pain sensation in the cervical spine.”spine.”

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Whiplash and FacetsWhiplash and Facets

•• BarnsleyBarnsley et alet al doubledouble--blind, controlled diagnostic blind, controlled diagnostic blocks / Investigated cervical facets in 50 postblocks / Investigated cervical facets in 50 post--whiplash whiplash patients / Found facets were most common source of patients / Found facets were most common source of chronic neck pain.chronic neck pain.

•• BogdukBogduk, Hirsch et al, and Yamashita et al, Hirsch et al, and Yamashita et al also also reported on rich reported on rich innervationinnervation of facet joints. of facet joints.

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

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

DiscogenicDiscogenic PainPain

•• RoofeRoofe (1940)(1940)--11stst evidence of evidence of anulusanulus fibrosusfibrosus nerve nerve fibers.fibers.

•• BogdukBogduk (1983)(1983)--nerve fibers in outer 1/3 of lumbar nerve fibers in outer 1/3 of lumbar anulusanulus fibrosusfibrosus..

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

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

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

WilbergerWilberger and the and the Silent Nerve Compression SyndromeSilent Nerve Compression Syndrome

•• WilbergerWilberger et al 176et al 176 --lumbar lumbar myelographicmyelographic herniated herniated discs in 108 asymptomatic patients.discs in 108 asymptomatic patients.

•• Within 3 years, 64% developed Within 3 years, 64% developed lumbosacrallumbosacralradiculopathyradiculopathy..

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

29 yr. old male 40 yr. old male

RadicularRadicular PainPainFASCIAL PLASTICITYFASCIAL PLASTICITY

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

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

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

•• OshmanOshman added piezoelectricity as a possible added piezoelectricity as a possible explanation for explanation for fascialfascial creep.creep.

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Robert Robert Schleip’s Schleip’s Observations on Observations on FascialFascial PlasticityPlasticity

•• SchleipSchleip concurred: these mechanisms may be a viable concurred: these mechanisms may be a viable explanation for longexplanation for long--term tissue changes term tissue changes but but questioned their effectiveness for short term tissue questioned their effectiveness for short term tissue release experienced in clinic.release experienced in clinic.

•• SchleipSchleip studies with anesthetized patients studies with anesthetized patients --in the in the absence of neural connection, shortabsence of neural connection, short--term term fascialfascialplasticity is lost.plasticity is lost.

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

GolgiGolgi tendon organstendon organs

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

•• JamiJami 19921992 --passive myofascial stretching does not passive myofascial stretching does not stimulate GTO’s.stimulate GTO’s.

GolgiGolgi tendon organs tendon organs

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

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

NociceptorsNociceptors as Painas Pain--GeneratorsGenerators

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

•• NociceptorNociceptor and chemoreceptor activation:and chemoreceptor activation:1.1. Nerve fibers depolarized by joint capsule mechanical stressesNerve fibers depolarized by joint capsule mechanical stresses2.2. Thermal extremesThermal extremes3.3. Inflammatory chemical agents such as histamines, Inflammatory chemical agents such as histamines,

prostaglandins, prostaglandins, bradykininsbradykinins, potassium ions, and lactic acid., potassium ions, and lactic acid.

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

Postural ControlPostural Control

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

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

•• Injured Injured articulararticular structures initiate structures initiate and facilitate spinal reflex and facilitate spinal reflex pathways which increase pathways which increase contractibility in contractibility in paraspinalparaspinalmusculature. musculature.

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NociceptorsNociceptors and Postureand Posture

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

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

NociceptorsNociceptors and Postureand Posture

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

•• ““neuroplasticityneuroplasticity” ” •• “reflex entrainment”“reflex entrainment”•• or “spinal learning.” or “spinal learning.”

Transversospinalis Transversospinalis

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

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

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

TransversospinalisTransversospinalis Almost always pulls Almost always pulls insertion points toward origins when at work. As the TP insertion points toward origins when at work. As the TP are pulled toward the SP, localized rotation and are pulled toward the SP, localized rotation and sidebendingsidebending occur.occur.

TransversospinalisTransversospinalis

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

GATING GATING

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

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

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

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

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CoCo--activating activating NociceptorsNociceptors

•• WarmerdamWarmerdam 19991999 -- nociceptivenociceptive gating best gating best achieved by stimulation of lowachieved by stimulation of low--threshold threshold mechanoreceptors near mechanoreceptors near nociceptionnociception origination.origination.

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

CoCo--activating activating NociceptorsNociceptors

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

Joint Techniques to Lower PainJoint Techniques to Lower Pain--Generating StimuliGenerating Stimuli

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

Joint Techniques to Lower PainJoint Techniques to Lower Pain--Generating StimuliGenerating Stimuli

•• This technique creates This technique creates presynapticpresynaptic inhibition of inhibition of the the nociceptivenociceptive afferent to afferent to diminish or abolish the diminish or abolish the perception of pain.perception of pain.

•• SandozSandoz ––restoring normal restoring normal joint structure /function joint structure /function helps normalize helps normalize mechanoreceptivemechanoreceptive and and nociceptivenociceptive input.input.

CutaneousCutaneous vs. vs. ArticularArticular ReceptorsReceptors

•• Massage primarily stimulates Massage primarily stimulates cutaneouscutaneousreceptors. Active or passive movements receptors. Active or passive movements primarily stimulate primarily stimulate articulararticular receptors = less receptors = less joint pain.joint pain.

•• Active client participation better gates Active client participation better gates articulararticularnociceptorsnociceptors..

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

Passive Passive CutaneousCutaneous Massage Release Massage Release

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Active Active ArticularArticular Release Release MUSCLE INHIBITION OR MUSCLE INHIBITION OR ATROPHY?ATROPHY?

•• JandaJanda 19881988 “Although muscle weakness has usually “Although muscle weakness has usually been considered a result of decreased activity, been considered a result of decreased activity, inhibition may be an integral part of many, if not all, inhibition may be an integral part of many, if not all, forms of weakness”.forms of weakness”.

•• Hurley (1997)Hurley (1997)-- muscle weaknessmuscle weakness-- two factors:two factors:1.1. Decreased number of Decreased number of extrafusalextrafusal muscle fibersmuscle fibers2.2. A failure to activate all muscle fibersA failure to activate all muscle fibers

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

MUSCLE IMBALANCE MUSCLE IMBALANCE PATTERNSPATTERNS

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

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

•• Abnormal afferent information:Abnormal afferent information:

•• painful or noxious stimulipainful or noxious stimuli•• CNS CNS malregulationmalregulation•• psychological psychological

(emotional) stressors(emotional) stressors

•• poor posturepoor posture•• excessive physical excessive physical

demandsdemands•• joint blockagejoint blockage•• habitual movement habitual movement

patternspatterns

Upper Crossed SyndromeUpper Crossed Syndrome

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

Upper /Lower Crossed SyndromesUpper /Lower Crossed Syndromes

•• Porterfield and Porterfield and DeRosalDeRosal -- forward posture factors forward posture factors other than scapular retractors stretch weakness.other than scapular retractors stretch weakness.–– weakness and lengthening of abdominal muscles allows the weakness and lengthening of abdominal muscles allows the

chest to fall causing an anterior upper trunk weight shift.chest to fall causing an anterior upper trunk weight shift.–– As gravitation exposure pulls upper trunk forward on the rib As gravitation exposure pulls upper trunk forward on the rib

cage, the scapulae externally rotate and protract cage, the scapulae externally rotate and protract ––forcing forcing clavicle to drop on the first rib. clavicle to drop on the first rib.

•• The The clavicularclavicular head of head of pectoralispectoralis major and hypertonic major and hypertonic latissimuslatissimus dorsidorsi internally rotate the internally rotate the humerushumerus forcing forcing the neck and head to follow.the neck and head to follow.

NociceptiveNociceptive Reflexes and Reflexes and Somatic DysfunctionSomatic Dysfunction

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

•• NociceptorNociceptor muscular guarding reactions and autonomic muscular guarding reactions and autonomic activation from stressed/damaged activation from stressed/damaged myoskeletalmyoskeletal or visceral tissue.or visceral tissue.

•• Guarding Guarding -- abnormal abnormal myoskeletalmyoskeletal position and decreased ROM.position and decreased ROM.•• Local inflammatory responses and autonomic reflexes reinforce Local inflammatory responses and autonomic reflexes reinforce

nociceptornociceptor activity, maintaining restriction.activity, maintaining restriction.•• NociceptiveNociceptive autonomic reflexes= visceral/immunologic changes. autonomic reflexes= visceral/immunologic changes. •• Abnormal guarding in muscles, joints, related tissues =changes iAbnormal guarding in muscles, joints, related tissues =changes in n

connective tissues, solidifying the abnormal position.connective tissues, solidifying the abnormal position.•• Stretching tissues into normal range of motion may Stretching tissues into normal range of motion may restimulaterestimulate

nociceptorsnociceptors, reinforcing the somatic dysfunction. , reinforcing the somatic dysfunction.

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

structures.structures.•• A model for using receptor techniques to correct aberrant posturA model for using receptor techniques to correct aberrant postural al

patterns is helpful in the clinical setting.patterns is helpful in the clinical setting.•• Impaired Neuromyoskeletal functions can cause stress, pain and Impaired Neuromyoskeletal functions can cause stress, pain and

altered performance of internal organs, hormonal systems and altered performance of internal organs, hormonal systems and psychopsycho--immunological functions.immunological functions.

•• Working with the sensory receptor system, trained therapists canWorking with the sensory receptor system, trained therapists candetermine if problems are primarily within muscles, fasciae or jdetermine if problems are primarily within muscles, fasciae or jointoint--related tissues or if the problem exists elsewhere. related tissues or if the problem exists elsewhere.

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

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