HEMME APPROACH TO SOFT-TISSUE THERAPY

HEMME APPROACH 

TO 

SOFT-TISSUE 

THERAPY

ii 

INSTRUCTIONS FOR THE ANSWER SHEET 

Thank you for investing in our HEMME APPROACH TO SOFT-TISSUE 

THERAPY COURSE, the first 12-hour course in the HEMME APPROACH series. 

Now that you're ready to start the course, these instructions will make it 

easier to complete the quiz on pages 162-171. First, there are no trick 

questions. The answers are clearly stated in the book. Second, the questions 

are not taken at random; they follow the same sequence as the text. Third, 

the questions cover the major points. Reading the table of contents, chapter 

headings, section headings, charts, index, and statements following numbers 

or bullets (●) will be helpful. Fourth, use the glossary. 

This course is not easy. Since 12 hours of continuing education credit 

are given for completing the course, you are not expected to read the manual 

and complete the quiz in one day. 

Feel free to use the manual as you take the quiz. It may be helpful to 

look over the questions before reading the manual. Though 70% or above 

(two points per question) is a passing grade, this should not be a problem for 

most people. If needed, retakes will be allowed. 

Above all else, please follow these three instructions: 

● COMPLETE THE TOP OF THE ANSWER SHEET. 

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● RETURN THE ANSWER SHEET IN THE ENVELOPE PROVIDED. 

When you complete the top of the answer sheet, please print legibly. 

The spelling of your name for your diploma will be taken from the answer 

sheet. Please be patient. Quizzes are normally graded the same day they 

arrive. In addition to a diploma, you will also receive a letter showing that 

12 hours of continuing education credit have been awarded to you for 

completing this course. Most state boards recommend holding certificates at 

least four years unless otherwise instructed. Good luck with the quiz, and 

thank you again for taking the course. 

HEMME Approach to Soft-Tissue Therapy

iii 

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iv 

HEMME APPROACH TO SOFT-TISSUE THERAPY 

EVALUATION FORM 

Please give us your comments about the course and return this paper with 

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v 

HEMME Approach to 

Soft-Tissue Therapy 

Copyright, David H. Leflet, 1992 

Revised 2005 

All rights reserved 

Published by HEMME APPROACH PUBLICATIONS 

3334 Spring Valley Lane 

Bonifay, FL 32425 

Office: 850-547-9320 

Toll-Free Number: 888-547-9594 

Our web site is www.hemmeapproach.com 

The author grants permission to photocopy limited portions of 

this manual for personal use. Beyond this consent, no portion 

of this manual may be copied or reproduced in any form 

without written permission from the author. 

Although the author has made every effort to ensure the accuracy of 

the information herein, science is progressive and theories change 

with time. Practitioners are advised to consult appropriate 

information sources if they have any questions concerning the 

information or principles presented in this manual. 

It is also the responsibility of the practitioner to determine the 

appropriateness of any principle or technique in terms of personal 

competency and scope of practice. Written medical opinions are the 

best way to resolve any questions concerning conditions that indicate 

or contraindicate soft-tissue therapy, and written legal opinions are the 

best way to resolve any questions concerning the law. 


vi 

PREFACE 

This manual is a "why and how-to book" that teaches the powerful and 

productive principles behind soft-tissue therapy and how to apply them. These 

principles are taken from physical medicine, osteopathy, chiropractic, and 

physical therapy, and then uniquely applied to soft-tissue therapy. No other 

book has ever compiled, organized, or summarized the principles of soft-tissue 

therapy the way they appear in this manual. 

By learning the principles behind trigger point therapy, neuromuscular 

therapy, connective tissue therapy, range-of-motion stretching, and exercise, 

practitioners will be able to provide patients with the best care possible. The 

principles in this step-by-step manual are simple to use, yet more powerful in 

some cases than either medication or surgery. Practitioners will learn how to 

help patients who have never been able to find help before and give them a 

chance to live normal, productive lives. 

This manual is organized around the acronym HEMME. This acronym 

completely summarizes the five major steps in soft-tissue therapy: 

• History: medical history. 

• Evaluation: physical evaluation. 

• Modalities: thermotherapy, cryotherapy, and vibration. 

• Manipulation: trigger point therapy, neuromuscular therapy, 

connective tissue therapy, and range-of-motion stretching. 

• Exercise: therapeutic exercise. 

The HEMME APPROACH is a problem-solving approach. History and 

Evaluation define the problem that Modalities, Manipulation, and Exercise 

solve. Understanding the HEMME APPROACH is the first major step toward 

mastering the art and science of soft-tissue therapy. 

The five main goals of soft-tissue therapy are (1) reduce pain, (2) increase 

or maintain a pain-free range of motion, (3) increase or maintain strength, (4) 

improve the quality of movement, and (5) restore normal function. The 

HEMME APPROACH was designed specifically to achieve these goals and do it 

effectively without hours of memorizing useless information or years of 

pointless study. The power behind the HEMME APPROACH is getting to the 

point and keeping it simple. 


vii 

TABLE OF CONTENTS 

Section 

Page 

INTRODUCTION ........................................................................................ 1 

PAIN CYCLES .......................................................................................... 4 

CHAPTER SUMMARY................................................................................. 13 

HEMME APPROACH............................................................................... 15 

HEMMEGON.............................................................................................. 18 


HISTORY .................................................................................................... 20 


EVALUATION ........................................................................................... 26 

MUSCLE TESTING...................................................................................... 29 

CONTRAINDICATIONS ............................................................................... 38 

PAIN ......................................................................................................... 41 


ALTERNATIVES...................................................................................... 49 



viii 

Section 

Page 

MODALITIES ............................................................................................ 53 

CONTRAST APPLICATIONS ........................................................................ 53 

THERMOTHERAPY..................................................................................... 54 

CRYOTHERAPY ........................................................................................ 56 

HEAT VS. COLD ........................................................................................ 59 

VIBRATION ............................................................................................... 60 


MANIPULATION ...................................................................................... 63 

THE PRINCIPLES OF SOFT-TISSUE THERAPY ............................................... 63 

HIGH-VELOCITY MANIPULATIONS............................................................. 65 

DYNAMICS OF SOFT-TISSUE THERAPY....................................................... 68 

METHODS OF SOFT-TISSUE THERAPY ........................................................ 74 

TRIGGER POINT THERAPY............................................................................... 75 

TRIGGER POINT VS. CROSS-FIBER FRICTION .............................................. 83 


ix 

Section 

Page 

NEUROMUSCULAR THERAPY........................................................................... 84 

INHIBITORS .......................................................................................... 90 

FACILITATORS...................................................................................... 97 

SUMMARY.......................................................................................... 100 

CONNECTIVE TISSUE THERAPY..................................................................... 101 

SUPERFICIAL TORQUE............................................................................. 106 

SKIN ROLLING ........................................................................................ 106 

CROSS-FIBER FRICTION........................................................................... 107 

PARALLEL OR PERPENDICULAR STRETCHING .......................................... 107 

LYMPHATIC DRAINAGE........................................................................... 108 

STRETCHING ................................................................................................ 109 

MODALITIES AND STRETCHING ............................................................... 114 

TRIGGER POINTS AND STRETCHING......................................................... 115 

NEUROMUSCULAR AND STRETCHING...................................................... 116 

CONNECTIVE TISSUE AND STRETCHING................................................... 116 

BALLISTIC STRETCHING.......................................................................... 117 

INDIRECT TECHNIQUES ........................................................................... 118 

PROGRESSIVE MOVEMENT ...................................................................... 118 

CHAPTER SUMMARY............................................................................... 119 


x 

Section 

Page 

EXERCISE ................................................................................................ 124 

THE OVERLOAD PRINCIPLE ..................................................................... 126 

THE INTENSITY PRINCIPLE ...................................................................... 128 

THE FREQUENCY AND DURATION PRINCIPLE........................................... 130 

THE SPECIFICITY PRINCIPLE.................................................................... 130 

THE TRAINING PRINCIPLE ....................................................................... 131 

CHAPTER SUMMARY............................................................................... 132 

OBJECTIVES SATISFIED OR NOT SATISFIED.............................. 133 

BIBLIOGRAPHY..................................................................................... 135 

GLOSSARY............................................................................................... 149 

QUIZ .......................................................................................................... 162 

INDEX....................................................................................................... 172 


1 

INTRODUCTION 

Soft-tissue therapy is the manipulation of soft or superficial tissue for 

therapeutic purposes. According to most medical dictionaries, manipulation 

refers to any skillful and dexterous treatment involving the hands. Unlike 

chiropractic adjustments that are typically high-velocity, high-impact thrusting 

movements, the manipulations in soft-tissue therapy are low-velocity pushing 

or pulling movements. 

Since chiropractic physicians theorize that skeletal malpositions are 

corrected by forcefully moving bones "into place that are out of place," 

chiropractic adjustments are directed at the osseous tissues. Skeletal 

malpositions are also called subluxations. According to chiropractic theory, 

subluxations cause pressure on nerves or nerve roots that interferes with 

sensory or motor input. Chiropractors use high-velocity, high-impact 

manipulations to correct subluxations. 

Soft-tissue therapy postulates that alignment can be corrected by 

normalizing the soft-tissue components of the body that cause distortion. 

Manipulations in soft-tissue therapy are directed at muscles, fascia, tendons, or 

ligaments to relieve pain and correct myofascial dysfunction. Instead of 

dealing with bones out of place, soft-tissue therapy treats the causes of 

malposition such as spasm, contracture, trigger points, and weakness. 

Soft-tissue therapy can be done with or without electrical or mechanical 

devices. Thermotherapy, cryotherapy, and chemical preparations are optional. 

Like manipulations, modalities produce a combination of physical, 

physiological, and psychological effects. Modalities are most effective when 

used just prior to manipulation to control edema, reduce pain, relax spasm, or 

increase tissue extensibility. Since the effects of modalities without 

manipulation are seldom long-term, modalities are used to supplement, but not 

supplant, manipulation. 

The problems treated by soft-tissue therapy are called soft-tissue 

impairments. Soft-tissue impairments are similar to what osteopathic 

physicians call lesions or somatic dysfunctions. By definition, soft-tissue 

impairments are pathologic conditions that originate or manifest in soft tissue 

and prevent normal or customary function or usage of the body. These 

impairments are characterized by (1) pain, (2) limited range of motion, and (3) 

weakness and often cause incoordination and poor-quality movement. 

Soft-tissue impairments can result from many causes: trauma, disease, 

postural defects, muscular imbalance, abnormal movements, and overuse 


injuries. Factors that contribute to soft-tissue impairments are fatigue, 

psychological stress, environmental factors, and somatic or visceral reflexes. 

Some impairments develop without apparent cause (idiopathic conditions), 

while others are caused by inappropriate treatment (iatrogenic disorders). 

Most soft-tissue impairments are caused by trauma and the most common 

sequel is tissue damage, spasm, edema, pain, and ultimately myofibrosis. 

The onset of soft-tissue impairments can be rapid or insidious. An 

example of rapid onset is trauma where the causes for impairment are easy to 

identify and sudden. Insidious onset implies the symptoms are few and the 

causes for impairment are gradual and subtle. An example of insidious onset 

is neck and shoulder pain caused by incorrect posture. 

The two most common complaints in soft-tissue therapy are pain and loss 

of movement. Characteristic signs of soft-tissue impairment are decreased 

range of movement (hypomobility), increased muscle tone (hypertonia), 

adhesions, contractures, edema, and trigger points. Signs of sympathetic 

hyperactivity such as perspiration, pilomotor responses, and changes in skin 

color or temperature are common in acute cases, and complaints of general 

weakness (asthenia), rapid fatigue, and depression are common in chronic 

cases. Symptoms reported by the patient are normally less reliable as 

indicators of a soft-tissue impairment than signs witnessed by the examiner. 

Various medical terms describe conditions with characteristics similar to 

those found in soft-tissue impairments. 

• Fibrositis: inflammation of fibrous tissue. 

• Myositis: inflammation of voluntary muscles. 

• Fibromyositis: inflammation of fibromuscular tissue. 

• Myofibrositis: inflammation of the perimysium. 

• Perimyositis: inflammation of connective tissue around a muscle. 

• Fascitis: inflammation of fascia. 

• Myofibrosis: replacement of muscle tissue by fibrous tissue. 

• Muscle rheumatism: muscular conditions characterized by pain, 

tenderness, local spasm, stiffness, myalgia, and myofibrosis. 

2 


These conditions point out three characteristics common to most softtissue 

impairments: (1) inflammation of soft tissue, (2) replacement of 

muscle tissue by fibrous tissue, and (3) pain. These three factors contribute 

to a self-perpetuating sequence called a pain cycle. 

During the initial stage of an injury (acute stage, one to three days), trauma 

is followed by inflammation, edema, impaired circulation, spasm, ischemia, 

hypoxic damage, and pain. The effects of hypoxic damage are similar to those 

precipitated by the injury that caused stage one. 

By stage two (sub-acute stage, three to seven days), the victim's range of 

motion is limited by pain, muscle guarding, and splinting. In stage three (early 

chronic stage, seven days to six weeks), if limitations on range of motion 

continue, movements become even more restricted as proliferation of 

connective tissue produces scar tissue, adhesions, or contractures. During stage 

four (late chronic stage, longer than six weeks), small movements are 

sometimes enough to irritate or rupture restricted tissues and reproduce the 

physiologic changes characteristic of stage one. Entrapment neuropathies and 

myofascial trigger points develop in stage four. 

By stage four, disuse atrophy may or may not be present, depending on the 

extent of disability. Even if present, atrophy can be difficult to identify if 

losses in muscle mass are offset by fluid accumulation. When this occurs, the 

circumference of an injured part may be smaller after treatment than before 

treatment if therapy dissipates collected fluids to other body parts. 

With the advent of modern science came two different types of medicine: 

emergency and rehabilitation medicine. Emergency medicine seeks to 

preserve life and rehabilitation medicine seeks to improve the quality of life 

after survival. The purpose of therapy is to support the parts of the wound 

healing that are beneficial and to limit the parts that cause disability. 

Whereas acute pain can be useful because it warns the body of actual or 

potential tissue damage, chronic pain can be disabling. Without therapy, acute 

pain can generate self-perpetuating pain cycles that may continue for years. 

Once pain becomes chronic, the initial causes are difficult to identify or treat. 

Painkillers, anti-inflammatories, and muscle relaxants are rarely efficacious, 

and surgery without definitive laboratory evidence is more likely to aggravate 

than correct the problem. Unlike conservative, noninvasive forms of 

treatment, surgery traumatizes the body and precipitates scar tissue. 

3 


4 

PAIN CYCLES 

Seven reasons why pain cycles are difficult to treat: 

1. The mechanisms that cause pain cycles are difficult to locate. 

2. Pain cycles are both chronic and acute at the same time. 

3. Muscular imbalance perpetuates pain cycles. 

4. Reflexogenic activity perpetuates pain cycles. 

5. Setbacks and reversals are common when treating pain cycles. 

6. The methods for treating soft-tissue injuries are often deficient. 

7. More research is needed to validate methods of therapy. 

The mechanisms that cause pain cycles are difficult to locate. 

(A) The areas where patients feel pain are rarely the origins of pain. Pain 

felt in the shoulder, elbow, or hand is often referred to these areas by injuries 

to the neck. Treating the pain without treating the causes of pain produces 

little more than symptomatic relief. The key to effective therapy is treating the 

sources of pain first and the symptoms last. 

(B) It is possible to have multiple sources of pain. A patient can 

experience local pain and referred pain in the same body part at the same time. 

Not only can untreated sources act synergistically to intensify pain, but they 

can also reactivate sources that became quiescent after treatment. If all sources 

of pain are not neutralized concurrently, the pain is likely to continue. 

(C) The areas where patients feel pain can migrate during the course of 

therapy. As muscles in one area become more functional, antagonistic or 

synergistic muscles may experience unaccustomed loading, stretching, or 

compression that causes pain. As hypersensitive areas become less sensitive 

to pain because of therapy, areas of lower sensitivity become more apparent. 

It is also possible for areas of high sensitivity to be obscured by 

widespread pain. If the tissue damage that triggered a pain cycle is confined to 

a single area, the last tissues to normalize are frequently those that suffered the 

initial insult and propagated the widespread pain. 


(D) Although pain cycles are seldom self-limiting, they may become 

quiescent for long periods of time. The mechanisms that reactivate a pain 

cycle are often difficult to identify. Possibilities include fatigue, abnormal 

movements, maximal exertions, psychological stress, disease, rapid changes in 

atmospheric conditions, or latent trigger points. 

Entrapment neuropathies can also restart a pain cycle. If nerve 

entrapments develop because of fibrosis or spasm, neurovascular compression 

can irritate nerves and reactivate pain cycles. If the pressure on nerves is 

intermittent, nerve conduction remains intact and possible symptoms are pain, 

paresthesia, or sympathetic hyperactivity. 

If pressure is more continuous than intermittent, possible symptoms are 

partial paralysis (paresis), complete paralysis, or anesthesia. Continuous 

pressure increases the risk of vascular ischemia and decreases nerve 

conduction velocities. Even if autonomic continuity is not interrupted, 

continuous pressure is more likely to cause sensory or motor loss than pain. 

(E) The body is so interconnected by muscles, fascia, and reflex patterns 

that treating a single muscle or any single tissue is normally pointless if not 

impossible. Most soft-tissue impairments involve agonistic, antagonistic, 

synergistic, and compensatory muscles simultaneously. Contralateral or 

ipsilateral muscles that share a common reflex pattern or muscles that cross the 

same joint cannot be isolated from each other. Holistic treatment is the only 

way to approach soft-tissue impairments. 

In low back pain, the primary muscles or muscle groups contributing to the 

pain cycle are gluteals, hamstrings, quadriceps, iliopsoas, and erector spinae. 

Secondary muscles are latissimus dorsi, quadratus lumborum, abdominals, 

tensor fascia latae, soleus, and gastrocnemius. Since even this list is only 

partial, it should be apparent that treating the erector spinae alone will not be 

enough to interrupt a pain cycle that is causing low back pain. 

Pain cycles are both chronic and acute at the same time. 

Although the onset may have been years ago and the patient's condition is 

classified as chronic, the traumas and microtraumas occurring on a regular 

basis because of stretching and tearing are acute. Each time contracted 

5 


tissues are stretched beyond their limit, the injuries caused by tearing 

reactivate or reinforce chronic pain cycles. As a result, pain cycles are a 

sequence of injury followed by healing, on one hand, and injury followed by 

re-injury on the other. 

Failure to understand this principle can lead to inappropriate therapy if 

acute cases are treated as chronic cases. Heat, for instance, is normally used in 

chronic cases but not acute cases. If preexisting scar tissue is torn and 

subcutaneous bleeding is present, heating modalities would only intensify the 

inflammatory reaction. This principle can also explain why proximal causes 

for pain and disability in chronic cases are sometimes mistakenly diagnosed as 

psychogenic and not physical. 

Muscular imbalance perpetuates pain cycles. 

This factor relates to muscular imbalance and the fact that most muscles or 

muscle groups work in pairs. If a muscle goes into spasm for any reason, 

opposing movements that are forceful enough to cause stretching may also 

cause tearing. The inflammation caused by tearing exacerbates the existing 

spasm, increases hypoxic damage, and irritates surrounding tissue. 

If the sarcoplasmic reticulum surrounding a muscle fiber tears, the release 

of calcium ions causes a strong attraction between actin and myosin filaments 

that results in contraction. While metabolic demands are increasing because of 

contraction, circulation is decreasing because of muscle shortening and the 

release of histamines and serotonin from injured cells. 

Muscle shortening reduces circulation by compressing blood vessels and 

causing ischemia. Sensitizing agents such as serotonin reduce circulation by 

causing vasoconstriction. Because of localized ischemia, adenosine 

triphosphate (ATP) becomes depleted, which makes it even more difficult for 

the actin and myosin filaments to separate. 

On the positive side, sustained muscle contractions caused by depletion of 

ATP may help to protect an injured body part from movement by making it 

rigid. Splinting is the fixation of a body part to avoid pain caused by 

movement, and guarding is the stiffening of a body part to avoid pain or 

further injury caused by movement. The fixation or stiffening of a body part is 

normally caused by reflex spasm. The short-term benefits of reflex spasm 

6 


and protective muscle shortening are stabilization of an injured part and 

protection against usage. In a primitive environment, protective spasm may 

help to encourage survival by minimizing hemorrhage, stabilizing potentially 

dangerous bone fragments, and forcing the victim to rest the injured part. 

On the negative side, involuntary contractions that are strong enough to 

protect a muscle from movement by making it rigid will also limit the muscle's 

range of motion. If the muscle remains shortened for extended periods of 

time, contractures may form that make the muscle highly resistant to active or 

passive stretch and cause a permanent decrease in mobility. 

If agonist muscles shorten and weaken because of spasm or contracture, 

antagonistic muscles have a tendency to weaken because of inactivity and 

lengthen because of tension. Weakness and shortness of the agonist combined 

with weakness and lengthening of the antagonist militate against movement. 

Until the agonist is lengthened and strengthened and the antagonist is 

shortened and strengthened, the balance needed for normal movement cannot 

be achieved and the pain cycle is likely to continue. 

As to which is more important, lengthening or strengthening, it appears 

clinically that lengthening a muscle by stretching should always precede 

strengthening a muscle by exercise. Besides spasm and contracture, possible 

reasons for muscle shortness include central mechanism involvement, muscle 

memory, and proprioceptive feedback from muscle spindle cells. Regardless 

of cause, exercising a shortened muscle is likely to have very little effect on 

restoring function or reducing pain. 

Except for minor and self-limiting injuries, manipulation and stretching are 

needed to normalize tissue length before exercise. Even though modalities can 

be used effectively in combination with exercise, total reliance on modalities 

and exercise to the exclusion of soft-tissue manipulation is both dangerous and 

counterproductive. 

Reflexogenic activity perpetuates pain cycles. 

Reflexogenic changes occur because of a neural pathway between a joint 

and the muscles that move the joint. It is difficult to say which comes first, 

pathologic conditions in a joint that cause muscle splinting or pathologic 

conditions in surrounding muscles that irritate the joint. Irrespective of which 

7 


comes first, inflammation of the joint and periarticular tissue is likely to 

continue until hypertonic muscles surrounding the joint relax and lengthen. 

Continued shortness in a muscle that crosses a joint (1) reduces joint space, 

(2) causes abnormal friction, (3) inflames the joint capsule, and (4) erodes 

articular cartilage. Treatments such as high-velocity manipulation that have no 

permanent effect on surrounding muscles and related tissues will do nothing 

more than provide temporary relief. If joints and related muscles are not 

treated together as a unit, the body cannot heal itself and pain cycles that cause 

weakness and limited range of motion are likely to continue. 

Setbacks and reversals are common when treating pain cycles. 

Even without secondary gain or litigation neuroses, progressive 

improvement will sometimes reverse itself for no apparent reason. The 

leading cause appears to be higher levels of activity. As patients improve, they 

feel better, become more active, and place more demands on the body. Despite 

feelings of well-being, patients should be advised to avoid strenuous activities 

until the entire body can handle the added stress. The deconditioning effects 

of inactivity are difficult to overcome. Besides pain-free range of motion, 

patients need strength, muscular endurance, aerobic endurance, and 

coordination to function normally. 

The methods for treating soft-tissue injuries are often deficient. 

In many cases, soft-tissue therapy begins too late or the methods of 

treatment are not appropriate for the problem. If an injury is not mobilized as 

soon as possible, pain, spasm, and fibrosis may limit the victim's range of 

motion and decrease activity. Extended periods of inactivity may cause 

deconditioning—weakness, atrophy, incoordination, or stiffness—and other 

pathologic changes that lay the groundwork for a long and durable pain cycle. 

Modalities or medication used without manipulation are seldom effective, and 

splints or braces worn for more than a few days retard healing, decrease range 

of motion, and may cause contractures or capsular adhesions. 

Another form of inappropriate treatment is too much focus on reports of 

pain by the patient and not enough concentration on restoring function. 

8 


Although "train, don't strain" is more popular today than "no pain, no gain," 

some forms of therapy are both necessary and painful. While any competent 

practitioner tries to minimize pain during treatment, the patient needs to 

understand that improvement without pain is not always possible. This 

includes pain that occurs during treatment and sometimes even after treatment. 

The best ways to help patients accept unavoidable pain are (1) advise the 

patient that treatments may be painful, (2) explain why the treatment is 

necessary, and (3) suggest methods for minimizing or dealing with the pain. 

The stronger the bond between patient and practitioner, the easier it is for the 

patient to accept the reality that progress may not occur without pain. 

More research is needed to validate methods of therapy. 

The seventh and final reason pain cycles are difficult to treat is a lack of 

valid research studies that support the effectiveness of soft-tissue therapy. 

Most arguments supporting soft-tissue therapy are based on anecdotal 

evidence or clinical observations. One of the major obstacles to conducting a 

valid research study is funding. Drug companies and medical equipment 

suppliers are more likely to fund research on projects involving medication or 

surgery than to support projects dealing with manual medicine. 

Another problem is terminology. The terminology describing soft-tissue 

therapy is not consistent, and many techniques are poorly described and 

documented. Good books on anatomy, physiology, and psychology are more 

common than good books on soft-tissue therapy, and many of the better books 

cover only one or two basic techniques. A truly comprehensive book on softtissue 

therapy that covers the entire range of techniques possible has yet to be 

published. Such a book would be based on principles found in physical 

medicine, osteopathy, chiropractic, and massage therapy and would cover 

applied anatomy and physiology as well as evaluation and techniques. 

Despite its many problems, a large number of people are using and 

recommending soft-tissue therapy. For most patients with soft-tissue 

impairments, soft-tissue therapy creates an environment for the body to heal 

itself. Many of these people have musculoskeletal problems that are not 

9 


esponsive to other forms of treatments. Even those who cannot be cured can 

at least find enough relief to improve the quality of their lives. 

Rather than abandon these patients to ineffective or dangerous methods of 

treatment because definitive research that validates soft-tissue therapy is not 

available, practitioners should continue treating patients to the best of their 

ability. Techniques that are beneficial, and do the patient no harm, should not 

be denied. By the same token, practitioners should support scientific research 

and look for ways to prove or disprove the effectiveness of each technique. 

Even though some of these studies may have a negative impact on profitability 

by discrediting a popular but useless technique, the positive impact on patient 

care should outweigh the loss of income. 

Despite the amazing and sometimes even miraculous results, soft-tissue 

therapy is not without limitations. First, soft-tissue therapy is not a panacea. 

The three main goals of soft-tissue therapy are less pain, a normal pain-free 

range of motion, and good quality movement. Second, if soft-tissue 

impairments are symptoms of a serious pathologic condition, treatments are at 

best palliative and symptoms are likely to recur. In some cases, surgery and 

medication are the only possible answers. 

Yet unlike surgery or medication, soft-tissue therapy is a conservative, 

non-invasive form of treatment with very few side effects. For qualified and 

conscientious practitioners, the possibilities for helping a patient are great and 

the chances of harming a patient are small. 

Another factor that limits research is the profitability of the activity itself. 

More money is normally spent validating activities that are highly profitable 

than validating activities that are less profitable. Drug companies, for instance, 

spend tremendous amounts of money validating a cure for common diseases 

because of the high profit margin but seldom spend the same amount of money 

validating a cure for rare diseases. 

As a therapeutic activity, low-velocity manipulations are normally less 

profitable than high-velocity manipulations. Where the average low-velocity 

treatment takes about 15 to 55 minutes, the average high-velocity treatment 

takes about 5 to 10 minutes. This would partially explain why in a field like 

chiropractic that uses both high-velocity and low-velocity manipulations, the 

majority of research focuses on high-velocity manipulations. 

10 


The same trend applies to allopathic medicine. Since surgery and 

medication are clearly more profitable than physical medicine, it logically 

follows that more money is being spent to validate surgical procedures or 

pharmacology than manual medicine. The same trend can also be applied to 

the field of manual medicine itself. 

Physical therapy, for instance, uses a combination of modalities, 

manipulation, and exercise. Since using manipulation because of its onetherapist-to-one-patient 

ratio is often less profitable than using modalities or 

exercise with a one-therapist-to-multiple-patients ratio, it logically follows that 

more money is being spent to validate modalities and exercise than to validate 

hands-on manipulation. 

Despite the prevailing trend in medicine to validate the activities that are 

most profitable, at least three factors seem to be operating that are changing 

this trend: Federally funded research groups, health care insurance groups, 

and groups of dissatisfied patients. Using money provided by taxpayers, the 

Federal government (1994) conducted a research project that concluded 

surgery is rarely indicated for low back pain and that conservative methods, 

including modalities and manipulation, are often beneficial. 

The health care insurance industry is starting to recognize that even though 

soft-tissue therapy is labor-intensive, it can still be cost-effective. Regardless 

of time and labor, methods that achieve success are always more cost-effective 

than methods that fail. Many insurance companies are finding that 

conservative methods such as soft-tissue therapy are less expensive than 

surgery and get patients back to work. Findings of this nature encourage 

insurance companies to research soft-tissue therapy as a way to save money. 

Dissatisfied patients are probably the largest single group responsible for 

encouraging soft-tissue therapy research. Many patients spend years of their 

life and thousands of dollars on various treatments before they discover that 

soft-tissue therapy is the only method of treatment that works for them and 

gets them back to work. For many patients, soft-tissue therapy is their last 

resort. Dissatisfaction with conventional medicine is forcing the health care 

industry to explore new options and consider the possibilities. 

Even if soft-tissue therapy is validated by research, the problem of finding 

competent practitioners to provide the service will still remain. Allopathic 

doctors, in general, have little or no interest in manual medicine. 

11 


Most medical schools do not teach manipulation and most medical doctors do 

not have the time or patience to practice manual medicine. Most chiropractors 

are more interested in spinal adjustments than soft-tissue therapy, and most 

physical therapists use modalities and exercise more than manipulation. 

Despite their long tradition of physical medicine, even some osteopaths are 

moving away from manual medicine in favor of medication and surgery. This 

trend is perhaps the greatest loss of all. More than any other group, osteopaths 

have pioneered the study of soft-tissue manipulation. Founded by Dr. A. T. 

Still (1828-1917), osteopathy is the largest single source of most knowledge 

relating to soft-tissue therapy, followed by massage therapy, chiropractic, and 

physical therapy. 

The group most likely to dominate the field of soft-tissue therapy appears 

to be massage therapy. As a rapidly growing health care profession, massage 

therapy is the only group practicing soft-tissue therapy that focuses on lowvelocity 

manipulations more than surgery, medication, modalities, exercise, or 

high-velocity manipulations. Even though chiropractors are expanding their 

use of low-velocity techniques, it appears likely that soft-tissue therapy will 

always be secondary to spinal adjustments. While it may be true that 

osteopaths are moving away from high-velocity techniques in favor of lowvelocity 

techniques, osteopathy as a profession is also moving away from 

manual medicine in favor of surgery and medication. 

If massage therapy comes to dominate the field of soft-tissue therapy, as 

appears likely, it must pick up the torch and carry on the research started by 

other health care professions. This means using a language common to other 

health care professions, following the scientific method, publishing 

information, and making its principles and techniques openly available for 

scrutiny by any member of the medical or scientific community. 

As a growing and responsible health profession, massage therapy can no 

longer be satisfied with knowing that something works without making a 

conscientious effort to understand why. In other words, massage therapy must 

try to prove what most people who practice soft-tissue therapy already know: 

soft-tissue therapy is a safe, simple, economical, and effective way to make a 

difference by correcting soft-tissue impairments and helping improve the 

quality of a patient's life. 

12 


13 

CHAPTER SUMMARY 

THREE SIGNS OR SYMPTOMS OF SOFT-TISSUE IMPAIRMENT 

• Pain 

• Limited range of motion 

• Poor-quality movement 

SIX FACTORS THAT CAUSE SOFT-TISSUE IMPAIRMENTS 

• Trauma 

• Disease 

• Postural defects 

• Muscular imbalance 

• Abnormal movements 

• Overuse injuries 


14 

THREE CHARACTERISTICS OF SOFT-TISSUE IMPAIRMENT 

• Inflammation of soft-tissue 

• Replacement of muscle tissue by connective tissue 

• Pain 

SEVEN REASONS WHY PAIN CYCLES ARE DIFFICULT TO TREAT 

• The mechanisms that cause pain cycles are difficult to locate. 

• Pain cycles are both chronic and acute at the same time. 

• Muscular imbalance perpetuates pain cycles. 

• Reflexogenic activity perpetuates pain cycles. 

• Setbacks and reversals are common when treating pain cycles. 

• The methods for treating soft-tissue injuries are often deficient. 

• More research is needed to validate methods of therapy. 


15 


Soft-tissue therapy cannot be effective without some type of systematic 

approach that progresses logically from problem to solution. The HEMME 

APPROACH was created to satisfy this need. The word HEMME (pronounced 

hem as in hem and me as in me) is an acronym that stands for 

H 

E 

M 

M 

E 

HISTORY 

EVALUATION 

MODALITIES 

MANIPULATION 

EXERCISE 

More than just a series of steps, the HEMME APPROACH is based on what 

system theory refers to as a plain language model. Language models are used 

when complex ideas cannot be formulated mathematically. The purpose of a 

language model is to simplify the process of converting knowledge into action 

and measuring the results. Language models can be used to (1) identify 

problems, (2) collect information, (3) formulate theories, and (4) test possible 

solutions by using feedback. 

The six steps that hold the model together like glue are: 

(1) ENTER PATIENT (4) OBJECTIVES SATISFIED 

(2) ALTERNATIVES (5) OBJECTIVES NOT SATISFIED 

(3) FEEDBACK (6) OUTSIDE INFORMATION 

In the HEMME APPROACH model (HEMMEGON), the five basic steps 

HISTORY, EVALUATION, MODALITIES, MANIPULATION, and EXERCISE are in 

bold letters and the other six steps are in outline letters. The starting point, the 

step titled ENTER PATIENT, is boxed. 


Lines and arrows show which directions of movement are possible within 

the model. Therapy begins when the patient enters the system. Step one is 

titled ENTER PATIENT. The first two basic steps in the model, titled HISTORY 

and EVALUATION, define the patient's problem. History refers to medical 

history and evaluation refers to physical evaluation. 

The next step in the model is ALTERNATIVES. This step is a link between 

the problem as defined by HISTORY and EVALUATION and possible solutions 

as defined by MODALITIES, MANIPULATION, and EXERCISE. 

Alternatives should be specifically defined. If modalities, manipulation, or 

exercise are needed, practitioners should know specifically which modalities, 

manipulations, and exercises are needed. Workable plans for therapy should 

include goals, timetables, and measurable results. If therapy involves more 

than one practitioner, responsibilities are assigned. 

The steps MODALITIES, MANIPULATION, and EXERCISE are situated on one 

line to emphasize that therapy can include one or more of these three steps. 

MANIPULATION was given a central position because soft-tissue therapy 

focuses on manipulation, with modalities and exercise secondary. 

The next step is FEEDBACK. Like homeostatic mechanisms that regulate 

blood pressure, the HEMME APPROACH uses positive and negative feedback to 

regulate the course of therapy. Positive feedback validates the course of 

therapy being followed and negative feedback indicates a need for change. 

Changes can be made in several ways: (1) repeat steps (2) change the sequence 

for using steps, (3) seek new information and reenter the system, or (4) exit the 

system. 

The step for entering new information, upper left-hand corner of the 

HEMMEGON, is titled OUTSIDE INFORMATION. Like any living system, the 

HEMME APPROACH is capable of receiving and processing input from the 

outside. This step can be used to enter outside information from sources such 

as consultation, research, or laboratory testing. After receiving and processing 

the new information, the practitioner can enter the model at four points: (1) 

HISTORY, (2) EVALUATION, (3) ALTERNATIVES, or (4) FEEDBACK. 

Practitioners can exit the system by using FEEDBACK to reach the steps 

titled OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED. If the objectives of 

therapy are not satisfied, the patient may exit the system or reenter at any of 

the five basic steps. HISTORY and EVALUATION can be reentered directly, 

16 


whereas MODALITIES, MANIPULATION and EXERCISE are reentered by using 

the step titled ALTERNATIVES. If the objectives of therapy are satisfied, the 

patient exits the system. 

From the step titled HISTORY you can go directly to OBJECTIVES NOT 

SATISFIED or EVALUATION. If contraindications are discovered, the step titled 

OBJECTIVES NOT SATISFIED would be used to exit the model. If soft-tissue 

therapy is indicated, the next step is EVALUATION. 

From EVALUATION you can return to HISTORY, if more history is needed, 

or go directly to the steps titled OBJECTIVES NOT SATISFIED or ALTERNATIVES. 

OBJECTIVES NOT SATISFIED would be used if therapy is contraindicated and 

ALTERNATIVES would be used if therapy is indicated. 

Even though any combination is possible, a typical sequence for soft-tissue 

therapy is (1) modalities, (2) manipulation, and (3) exercise. Another 

possibility is to use manipulation without modalities or exercise. Modalities 

and exercise, on the other hand, are seldom used without manipulation. 

Regardless of which sequence is followed, the next step is FEEDBACK. 

If the patient's problem is solved, OBJECTIVES SATISFIED can be used to exit 

the patient from the system. If the problem is not solved, OBJECTIVES NOT 

SATISFIED can be used to exit the patient from the system or continue therapy 

by repeating any or all steps connected by lines and arrows. 

There is no limit on the number of times a step can be repeated. Even after 

a case is closed, the same patient may reenter the system with a new problem 

or the recurrence of an old problem. Soft-tissue therapy is an ongoing process 

that requires enough flexibility to make changes. To apply the same routine to 

all patients ignores the fact that each patient is an individual and that no two 

people are exactly the same. 

Even though soft-tissue therapy is not easy, the HEMME APPROACH is a 

powerful way to organize the elements of therapy into a single working model. 

With nothing more than five basic steps, even the most complex therapeutic 

problems can be simplified. For the small amount of time needed to master 

the HEMME APPROACH, the results more than justify the effort. 

The HEMME APPROACH can be applied to any type of soft-tissue therapy 

regardless of what techniques are being used. While the HEMME APPROACH 

provides an outline or framework for doing soft-tissue therapy, the principles 

and techniques provide the substance. 

17 


HEMME Approach to Soft-Tissue Therapy 

18

19 


FIVE STEPS IN THE HEMME APPROACH 

• History 

• Evaluation 

• Modalities 

• Manipulation 

• Exercise 

FOUR WAYS TO USE MODELS 

• Identify problems 

• Collect information 

• Formulate theories 

• Test possible solutions by using feedback 


20 

HISTORY 

The first step in the HEMME APPROACH is HISTORY. Background 

information such as vital statistics, lifestyle, and general health should be 

entered by the patient on a standard form before the interview starts. Other 

items to include are previous injuries, operations, and past medical treatments. 

In particular, have patients advise if they are currently under medical care or 

aware of any conditions that might contraindicate soft-tissue therapy. There 

should be a blank space at the bottom of the form for the patient to add further 

information if needed. A practitioner should always read the completed 

medical history form prior to interviewing a patient. 

During the first few minutes of contact between the practitioner and 

patient, both parties form impressions that are difficult to change. Practitioners 

will evaluate the patient's honesty, intelligence, personality, and motivation. 

Patients will evaluate the practitioner's competency, attitude, demeanor, and 

communication skills. Negative opinions formed by either party can adversely 

affect the entire course of therapy. 

If practitioners decide too early that patients are motivated by litigation or 

secondary gain, legitimate signs of illness or injury may not be acknowledged. 

A premature diagnosis of hysteric conversion may cause practitioners to 

identify psychogenic symptoms but totally disregard organic signs. The initial 

interview is a time for collecting information, not making final decisions. The 

mind should remain open, objective, and focused. 

If patients, on the other hand, decide too early that practitioners are 

incompetent, uncaring, or unprofessional, subsequent attempts to regain the 

patient's confidence may be futile. Even if patients continue to use the services 

of someone they dislike or distrust, their willingness to cooperate will be less, 

especially in cases requiring self-care. 

Although difficult to say how much of any treatment is physical versus 

psychological, placebo effects cannot be overlooked. Since the effectiveness 

of any placebo depends on what the patient believes, and belief depends 

largely on the patient's attitude toward the person recommending treatment, the 

relationship between the practitioner and patient can clearly affect the final 

outcomes. Good relationships often produce good therapeutic results. 


Since little can be done to change the way patients present themselves 

during the interview, practitioners should be alert, but open-minded, when 

trying to evaluate what they see and hear. Clever patients may be skillful 

enough to deceive practitioners during the initial stages of an interview, while 

other patients may present totally honest symptoms that give the appearance of 

duplicity. Even though preliminary theories are reasonable, and even 

necessary, during the initial stages of an interview, practitioners must always 

be willing to change any belief that is later contradicted by evidence. 

Practitioners do have some control over the way they present themselves. 

The best ways to establish rapport are (1) present a professional appearance, 

(2) help the patient relax by asking non-threatening questions, (3) be 

agreeable, (4) smile and use appropriate humor, and (5) maintain eye contact 

with the patient. Since the importance of eye contact cannot be 

overemphasized, the following test of eye contact is highly recommended. 

After speaking to a patient for several minutes, look away and try to recall the 

patient's eye color. Failure to do so may suggest eye contact was faulty. 

Most patients should be allowed to sit or lie down unless other positions 

are more comfortable. If the patient is nervous and prone to movement, 

practitioners should seat the patient and remain standing themselves. This 

limits the patient's mobility and helps to establish authority. Some patients 

respond well to shaking hands or a light touch on the shoulder, while others 

prefer distance. Watching the way patients conduct themselves may suggest 

what behaviors are acceptable to the patient. 

A therapist should be able to empathize with patients but have enough ego 

strength and confidence to make difficult decisions when needed. Two 

attitudes that are strongly recommended are sincerity and caring. Other 

concerns tend to become secondary if patients believe that practitioners truly 

care about helping them. As someone once said, "Patients don't care how 

much you know until they know how much you care." 

Rapport implies trust, confidence, and cooperation. Once rapport has been 

established, review the patient's written history, ask questions about the 

questionnaire if necessary, and listen carefully to what the patient says. A 

common failing in the health care field is failure to listen. 

When conducting an interview, separate the patient from the problem and 

focus on the problem. Medical histories are taken to evaluate the patient’s 

21 


condition and not the patient. The personality or circumstances surrounding 

the patient should not be allowed to bias the investigation. 

After reviewing the patient's medical history, the examiner should ask 

questions requiring more than a "yes or no" answer. Questions concerning (1) 

the problem or chief complaint and (2) the quality of past or present treatment 

will give the examiner a good place to start. Open-ended questions about pain, 

loss of motion, and changes in lifestyle will further define the problem. Almost 

every patient can provide at least some information that is helpful enough to be 

recorded as part of the patient's permanent medical history. 

Open-ended Questions for Medical History 

• What is the nature of the problem? 

• Are you under a doctor's care? 

• Has this problem been treated before? 

• Do you have any other medical problems? 

• Are you taking any medication? 

• What type of treatments do you think might help? 

• How does the problem affect your life? 

The acronym PDQ summarizes the first three questions above: 

P-Problem 

D-Doctor's care 

Q-Quality of past treatment 

Interviews should normally proceed from general to specific. After asking 

open-ended questions about the patient's condition, the interviewer should 

continue with questions that are more specific, such as questions concerning 

the mechanism of injury. By this point, most practitioners will have formed at 

least one or two preliminary theories concerning the patient's condition. Even 

if the patient's information is not complete, any information provided will 

make it easier to reconstruct the mechanism of injury. The acronym FIRST 

can be used to assess the mechanism of injury. 

22 


23 

MECHANISM OF INJURY 

F FORCE Direction of force 

I INTENSITY Magnitude of force 

R REGIONS Body parts affected by the force 

S SEVERITY Degrees of injury or loss of function 

T TIME Frequency and duration of force 

Reconstructing an automobile accident may be helpful. If the patient's 

vehicle struck a fixed object while moving forward, the neck was probably 

flexed during the impact and then extended during the rebound. High rates of 

acceleration increase the force of impact and potential for injury. If the patient 

saw the accident coming and braced for impact, then wrist, elbow, and 

shoulder injuries can be expected. The quality of pain and changes in mobility 

and lifestyle will indicate severity, whereas time since the onset of injury may 

indicate chronicity and possibly severity. Seemingly small and insignificant 

injuries sometimes become more severe with time. 

The time elapsed since an injury occurred is also important for another 

reason: injuries of long-standing duration are normally more difficult to treat 

than injuries of short duration. As a rule, when a body part loses mobility, 

fibrotic changes and atrophy increase with time. 

Another line of questioning involves pain. 

• Where do you feel the pain? 

• When did the pain first occur? 

• When do you feel the pain? 

• How does the pain feel (sharp, dull, aching, etc.)? 

• What makes the pain feel better or worse? 

• How does the pain affect your life? 


During the final stages of the interview, practitioners need to construct 

increasingly definite preliminary theories concerning the patient's condition. 

These theories will dictate the types of physical evaluation that are appropriate 

in step number two (EVALUATION). 

Even though objectivity and open-mindedness are important, because of 

limited resources it is not practical to start a physical evaluation without 

knowing what directions to follow in terms of collecting information. These 

directions, of course, can always be changed during the course of therapy. If 

feedback or new information show preliminary theories are incorrect, new 

directions may be needed. If contradictions appear, therapy should be stopped 

immediately. Unlike standard routines that tend to be fixed and constant, the 

HEMME APPROACH is flexible enough to allow for changes. 

24 

It is no coincidence that Sir Arthur Conan Doyle, a medical doctor, and 

Sherlock Holmes, his famous fictional detective, had many traits in common. 

A good doctor or therapist is also a good detective. As far back as the 1800s, 

Sherlock Holmes was using principles of logic and reasoning that are similar 

to those used by medical investigators today. These principles can be used by 

any scientific investigator (including a soft-tissue therapist) who is seeking to 

learn the truth. The HEMME APPROACH is based on similar principles. 

1. Do not draw final conclusions before the investigation is complete. 

2. Collect facts that are relevant, trustworthy, and material. 

3. Listen carefully to all the statements, regardless of the source. 

4. Place more value on physical evidence than verbal or written statements. 

5. Little things are often the most important. 

6. Draw conclusions based on deductive logic and facts. 

7. Be able to defend your conclusions with logic and facts. 

Sherlock Holmes was famous for quoting a principle that dates back to 

Aristotle called reductio ad absurdum: After eliminating the impossible, 

whatever remains, however improbable, must be the truth. 


25 


THREE WORDS THAT FORM THE ACRONYM PDQ 

• Problem 

• Doctor's care 

• Quality of past treatment 

FIVE WORDS THAT FORM THE ACRONYM FIRST 

• Force: Direction of force. 

• Intensity: Magnitude of force. 

• Regions: Body parts affected by the force. 

• Severity: Degrees of injury or loss of function. 

• Time: Frequency and duration of force. 


26 

EVALUATION 

The second step in the HEMME APPROACH is EVALUATION. Whereas 

medical histories are based on information provided by the patient, physical 

evaluations are based on observations made by the examining practitioner. A 

similar distinction is made between symptoms and signs: symptoms are 

indications of illness as perceived by the patient and signs are evidence of 

disease or dysfunction discovered by the examiner. Even though not 

completely objective, physical evaluations and signs are considered more 

objective than medical histories and symptoms. 

The classical methods of physical evaluation are (1) percussion, (2) 

auscultation, (3) palpation, and (4) inspection. Percussion is a method of 

tapping sharply on the body and either listening or feeling for resonance. 

When resonance is detected by listening, the process is called auscultatory 

percussion. When resonance is detected by touch, the process is called 

palpation percussion. Percussion is most commonly used on the chest and 

back to examine the heart and lungs. 

Auscultation, by itself, is a method of listening for abnormal sounds such 

as crepitus or the clicking of a tendon. When aided by a stethoscope, the 

examiner can hear sounds of blood rushing through a vessel (bruits) and 

sounds of muscular contraction. 

The cracking or popping sound made when joints move is not considered 

diagnostic. Reasons for the sound include breaking a vacuum in the joint or 

releasing nitrogen gas. It normally takes about twenty minutes for the same 

joint to reset before it can pop again. 

Palpation is any form of examination done by touching or feeling with the 

hands or fingers. When done with skill, palpation can reveal spasms, contractures, 

adhesions, crepitus, and tremors or fasciculations. Palpation can also 

detect changes in the temperature, texture, tightness, and moisture of skin and 

variations in the thickness, density, symmetry, and compliance of underlying 

tissues. Changes in surface topography may suggest atrophy, swelling, or a 

pathologic growth. Palpation is frequently used in soft-tissue therapy to locate 

trigger points, tender points, indurated muscles, scars, or edema. During 

palpation patients may report pain, numbness, or itching. 


The sensitivity of the hand varies from part to part. The finger pads are 

most sensitive to touch, the dorsum of the hand is most sensitive to changes in 

temperature, and the palmar aspects of the metacarpophalangeal joints are 

most sensitive to movement. The central palm is most sensitive in terms of 

stereognosis, the ability to recognize the gross shape of an object by touch. 

Motion palpation combines palpation with active or passive movement. 

Abnormalities that are imperceptible when body parts are static and relaxed 

are sometimes more discernible when body parts are moving. Restrictions, in 

particular, become more apparent if movement causes stretching that helps the 

examiner identify tissues that are too short or too tight. The most common 

restrictions are found in muscles, fascia, ligaments, joint capsules, and skin. 

Hypertonic scalene muscles are easier to palpate when the head is rotated to 

the opposite side. The muscles may feel taut when palpated and range of 

motion may be limited. Motion can also change the position or thickness of 

overlying tissues. 

A principle of palpation that is frequently overlooked is progressive 

penetration. Tissues cover the body in layers. Examiners must first penetrate 

the superficial layers to reach the deep layers. Active or passive movements 

that stretch superficial muscles such as the trapezius will make it easier to 

palpate deeper muscles such as the rhomboids. If the iliopsoas is hypertonic, 

reducing the tension on superficial tissues will make it easier to palpate the 

muscle. Progressive penetration requires concentration and manual dexterity. 

The two most common errors during palpation are too much pressure and not 

moving the hand slowly enough. Only rarely should palpation cause pain. 

Although palpation is probably the best and sometimes the only way to 

identify soft-tissue impairments, it is also the method of evaluation medical 

doctors seem to use least. As allopathic physicians become more reliant on 

instrumentation, palpation is losing ground. This could explain why so many 

soft-tissue impairments are diagnosed as psychogenic and not organic. 

Inspection refers to examining the patient with the eyes. Observation of 

posture may show defects in symmetry or alignment, whereas observation of 

movement may identify defects in flexibility or coordination. Inspection can 

also detect atrophy, enlargements, lesions, and changes in coloration. 

Even though inspection is a valuable source of information, examiners 

should remember that bodies are not symmetric and deviations in alignment 

27 


may or may not be clinically significant. It is common for the shoulder on the 

dominant side to be lower than on the opposite side and the hip on the same 

side to be higher than the opposite side and slightly rotated posteriorly. The 

upper extremity muscles on the strong side (normally the right side) are almost 

always larger than muscles on the weak side (normally the left side). 

Functional leg length is seldom equal, and the cervical spine tends to show 

lateral flexion in one direction more than the other. Even though deviations 

from the ideal should always be noted, they are not always symptomatic. 

Of the four classic methods of physical evaluation, palpation and 

inspection are used more in soft-tissue therapy than either percussion or 

auscultation. Even though palpation is probably more important in soft-tissue 

therapy than inspection, many forms of orthopedic and neurologic testing use 

both. Inspection is normally the first method of evaluation used. 

Even though active motion testing is mainly inspection, passive motion 

testing uses both inspection and palpation. In determining the five classic 

signs of inflammation—heat, redness, swelling, pain, and loss of function— 

heat is determined by palpation; redness by inspection; swelling by either 

palpation or inspection; pain by seeing, hearing, or feeling indications of pain 

during palpation; and loss of function by inspection and palpation. 

Although pain is more of a symptom than a sign, painful areas can be 

identified by using (1) palpation to induce the pain and (2) inspection to note 

the patient's response to palpation. If trigger points are located by palpation, 

heavy pressure may cause the trigger point to become insensitive in the same 

way that ischemic pressure neutralizes a trigger point. To avoid combining 

palpation with treatment, trigger points should be located with light pressure 

and then treated with heavier pressure. 

The combination of inspection and palpation can also be used to locate 

landmarks that help to identify specific parts of the body such as muscles, 

tendons, and bones. Specific vertebrae can be located as follows. 

• The most prominent cervical vertebra is C-7. 

• The vertebra level with the inferior angles of the scapulae is T-7. 

• The vertebra level with the lower insertion of the trapezius muscle is T-12. 

• The vertebra level with the iliac crests is L-4. 

• The vertebra level with the posterior superior iliac spines is S-2. 

28 


29 

MUSCLE TESTING 

Manual muscle testing is a clinical method for measuring muscular 

strength and range of motion (ROM). Another name for muscle testing is 

resisted range-of-motion testing. Strength measures the patient's ability to 

hold steady or move against resistance. When patients hold against resistance, 

muscles contract isometrically without changing in length. When patients 

move against resistance, muscles contract isotonically and shorten. 

Muscles are composed of nerve tissue, muscle tissue, and connective 

tissue. Nerves transmit electrical impulses and muscle fibers produce force by 

contraction. Tendons and aponeuroses transmit the force to bones, and deep 

fascia separates and supports a muscle. 

Based on composition, the main factors affecting strength and weakness 

are (1) neurologic efficiency, (2) the ability of muscle fibers to contract, (3) the 

integrity of tendons and aponeuroses, and (4) the ability of deep fascia to reach 

a normal length. 

Even though joints are not part of a muscle, the integrity of joints can also 

affect strength and weakness. If a joint is irritated, locked, or unstable, a 

muscle crossing the joint may test weak even if the muscle itself is normal. 

Any condition that changes joint space above or below physiologic limits will 

adversely affect the joint's ability to produce normal movement. 

Range-of-motion testing measures joint movement by degrees of arc in a 

circle. The starting position is zero (neutral position) and degrees are added in 

the direction the joint moves from a starting position. Except for rotation, the 

starting position is normally the same as anatomical position. 

An example of range-of-motion testing is elbow flexion. Starting from 

anatomical position with the forearm vertical and the palm supinated 

(forward), elbow flexion is about 150 degrees for most people. Although the 

active ROM is normally less than passive ROM, both can be affected by pain 

tolerance or inhibition, training, and motivation. 

Joint angles can be measured with a goniometer. The accuracy of a 

goniometer depends on landmarks. Measurements are most accurate when 

landmarks are definite. Range of motion can be approximated by comparing 

opposite extremities or using a person of similar age, sex, and physique as a 

standard. Goniometers are normally used to measure a joint's passive ROM. 


If joints and the agonist are normal, the main factor limiting ROM is the 

tissue extensibility of the antagonist. If the antagonist fails to lengthen 

normally during contraction of the agonist, the joint's range of motion will be 

limited. This explains why active range-of-motion testing measures the 

strength of the agonist, the length of the antagonist, and the amount of motion 

available to a specific joint. The three main ways to increase the active ROM 

are strengthen the agonist, lengthen the antagonist, and loosen the joint. 

The following table defines active, passive, active-assisted, and resisted 

range-of-motion testing. 

Active range-of-motion testing: the force for the movement is provided by 

the patient without assistance or resistance from the examiner. 

Passive range-of-motion testing: the force for the movement is provided by 

the examiner without assistance or resistance from the patient. 

Active-assisted range-of-motion testing: the force for the movement is 

provided by the patient with some assistance from the examiner. 

Resisted range-of-motion testing: the force for the movement is provided by 

the patient and works against resistance from the examiner. 

For the safety of the patient, active, passive, and active-assisted range-ofmotion 

testing should always be done first, and resisted range-of-motion 

testing last. Active range-of-motion testing gives the examiner a chance to 

observe the patient's ROM with gravity as the only outside force. If the active 

ROM is normal, the final step is resisted range-of-motion testing. 

If the patient fails active range-of-motion testing, the next step is using 

passive range-of-motion testing to evaluate the ROM. If the patient's ROM is 

incomplete, the probable causes are joint dysfunction, spasm, or contracture. If 

the patient's range of motion is normal, active-assisted range-of-motion testing 

can be used to identify weakness. Possible causes for weakness are neurologic 

dysfunction, lack of motivation, pain, disuse atrophy, or fatigue. If a patient 

fails muscle testing at any level, it is normally better to stop and treat the 

problem than to continue with muscle testing. 

30 


31 

(1) Active Range-of-Motion Testing 

Postural muscles can be tested as a group by using active range-of- motion 

testing against gravity. A patient who completes active range-of- motion 

testing without incident can then be safely tested using resisted range-ofmotion 

testing. The following five tests evaluate the strength of muscle groups 

that are often connected with low back pain. 

• Upper abdominal muscles (without psoas): bent-leg sit-ups. 

• Upper abdominal muscles (with psoas): straight-leg sit-ups. 

• Lower abdominals: leg lifts. 

• Upper back muscles: upper body extension from prone position. 

• Lower back muscles: lower body extension from prone position. 

If the patient is unable to move a body part against gravity, the same 

movement should not be tested against manual resistance. Additional 

resistance may traumatize tissue and cause the patient needless discomfort. 

The next logical step is passive range-of-motion testing. If active range-ofmotion 

testing is normal, passive and active-assisted range-of-motion testing 

are optional. The tester can move directly from active range-of-motion testing 

to resisted range-of-motion testing. 

(2) Passive Range-of-Motion Testing 

If the examiner applies moderate force and finds the patient's range of 

motion is still restricted, the three most likely causes are joint dysfunction, 

spasm, or contracture. The way body parts feel as they reach the end of their 

range of motion will sometimes show which structure is most culpable, the 

joint or muscle. 


The end-feel for most joints is either hard like elbow extension or soft like 

elbow flexion. End-feels that are soft when they should be hard or hard when 

they should be soft indicate joint dysfunction. If the problem appears to be 

joint dysfunction, palpate the joint for signs of heat, swelling, or pain. Normal 

joints are never swollen and normal ligaments are not painful when palpated. 

The next possibility to investigate is spasm or contracture. Spasms can 

result from calcium deprivation (carpopedal spasm), sewing or writing 

(occupational spasm), spasmodic contraction of muscles (intentional spasm), 

disease (myopathic spasm), or trauma (charley horse). Contractures, on the 

other hand, are caused by tissue fibrosis (ischemic contracture), sleeping in or 

maintaining a position that allows the muscles to shorten (functional 

contracture), or the effects of heat or chemicals (physiological contracture). 

Both spasm and contracture restrict joint movement by increasing resistance to 

passive stretch. 

The initial end-feel for spasm or contracture is more like stretching a 

spring than either hard or soft: the greater the stretch, the greater the 

resistance. If properly applied, slow and steady tension will cause a decrease 

in resistance. The key points are (1) apply moderate force directly against the 

resistance and (2) use slow and steady pressure. Unlike pathologic joints that 

normally become more painful with stretching, muscles in a state of spasm or 

contracture often become less painful as tissues approach their normal length. 

(3) Active-Assisted Range-of-Motion Testing 

If the patient's passive ROM is normal, the next step is active-assisted 

range-of-motion testing. If a full range of motion is possible with assistance 

from the examiner, the implication is muscular weakness. Having the patient 

move as far as possible in one direction and then using manual assistance to 

complete the range of motion will help to identify which muscles or muscle 

groups are weak. The normal approach at this point is using facilitation 

techniques or therapeutic exercise to strengthen weak muscles. Facilitation 

techniques such as methods for activating spindle cells and repeated 

contraction are part of neuromuscular therapy. Therapeutic exercises to 

strengthen weak muscles are called progressive resistance exercises. 

32 


33 

(4) Resisted Range-of-Motion Testing 

If the patient's active range of motion is normal, the final step is resisted 

range-of-motion testing. Even if active, passive, and active-assisted range-ofmotion 

testing are normal, weakness may still exist because of injury, disuse, 

or disease. Resisted range-of-motion testing (muscle testing) is the best way to 

identify weakness. 

In resisted muscle testing, strength is measured by having a muscle hold or 

move against manual resistance. Holding against resistance is easier to apply 

than moving against resistance and less likely to involve joints than moving 

against resistance. To hold against resistance, the examiner applies an 

isometric force and the patient applies an isometric counterforce. 

Resisted muscle testing is seldom used to measure the patient's maximum 

strength unless the muscle is abnormally weak. Nor should muscle testing 

ever be used as a form of competition between the patient and the examiner. 

Since leverage should normally favor the examiner, care should be taken not to 

injure the patient by using excessive force. 

Even though some systems for measuring muscle testing apply percentages 

to each grade and use pluses and minuses to create more levels, the most 

workable grading system for muscle testing uses six levels of measurement 

that range from 5 to 0. Despite claims to the contrary, manual muscle testing 

is far more subjective than muscle testing that uses machines. 

MUSCLE TESTING BY GRADE 

NORMAL 5 Hold against gravity and full resistance 

GOOD 4 Hold against gravity and some resistance 

FAIR 3 Complete range of motion against gravity 

POOR 2 Complete ROM with gravity eliminated 

TRACE 1 Evidence of contraction only 

ZERO 0 No evidence of contraction 

Note: Normal is a higher grade than Good. 


The difficulty in using this scale is knowing whether to grade a muscle 

as normal (5) or good (4). A strong patient with serious disability may 

sometimes test higher than a weak patient with a minor disability. A strong 

patient can lose a greater percentage of strength than a weak person and still 

hold against gravity and give the appearance of normal strength. Bilateral 

comparison is one way to cross-check the results of muscle testing. 

If only one side of the body is involved, check the muscles on the 

impaired side before checking muscles on the opposite side. If the muscles 

on the impaired side are the weakest, a grade of 5 for the impaired side may 

be too high. If muscles on both sides of the body test the same, a grade of 4 

for the impaired side may be too low. 

Because of handedness, the tendency to use one hand in preference to 

the other, dominant side muscles are normally stronger than weak side 

muscles. Since most people are right-handed, the left side testing stronger 

than the right side may indicate weakness on the right. 

Muscle testing is based on the premise that no two muscles perform 

exactly the same function. According to theory, each muscle can be tested 

separately if direction of force, amount of force, and position of patient are 

correct. The direction of force is normally opposite the direction of pull for 

the muscle being tested. Deviation from this direction allows the patient to 

substitute other muscles for the muscle being tested. The amount of force 

used will vary with size and condition of the patient. Examiners will learn 

how much force to use by experience. Since leverage normally favors the 

examiner, using too much force is more likely to cause inaccuracy than 

using too little force. 

Three types of positioning are used in muscle testing: (1) positioning to 

prevent substitution, (2) positioning to reinforce fixator muscles, and (3) 

positioning to create active insufficiency. 

(1) Positioning to Avoid Substitution 

Positioning isolates the muscle being tested by using stabilization to 

prevent substitution. If the muscle being tested is weak, stabilization 

prevents other muscles from contributing to the same movement by not 

allowing the body to change position. If the initial body position favors the 

34 


pull of the muscle being tested, other muscles cannot be effective without 

repositioning the body to change their direction of pull. An example of 

stabilization is holding the elbow in place when testing the biceps brachii. If 

the elbow joint moves, upper arm flexors may substitute for elbow flexors. 

(2) Positioning to Reinforce Fixator Muscles 

Positioning combined with body weight and manual force can be used to 

reinforce fixator muscles that allow the insertion to move by locking the 

origin of a muscle in place. When a muscle contracts, tension pulls equally 

on both the origin and insertion. To produce movement, stabilizing the 

origin leaves the insertion, and the bone the insertion attaches to, free to 

move. If fixator muscles are weak, muscle testing will not be accurate. 

Fixator muscles are often antagonistic to the muscles being tested. If the 

muscles that stabilize the scapula (trapezius and serratus anterior) are weak, 

manual force should be used to fixate the scapula when testing the deltoid. 

(3) Positioning to Create Active Insufficiency 

Active insufficiency is the failure of any muscle to generate normal 

tension because the origin and insertion are too close. In certain positions, 

muscles that cross two joints cannot exert enough tension to produce a full 

range of motion in both joints simultaneously. If one- and two-joint muscles 

both perform the same function, placing the two-joint muscle at a 

mechanical disadvantage can be used to isolate the one-joint muscle. Twojoint 

muscles can be mechanically neutralized by using positioning to bring 

their origin and insertion closer together. Since muscles produce movement 

by generating tension, the slack created by approximating origin and 

insertion prevents the two-joint muscles from generating adequate tension to 

move both joints through their entire range of motion at the same time. 

As an example, both the one-joint gluteus maximus muscle and the twojoint 

hamstring muscle extend the hip. When the knee is flexed, the 

hamstring muscle cannot generate sufficient tension to extend the hip. This 

means that when the knee is flexed, the hamstring muscle is neutralized and 

the gluteus maximus can then be tested by using hip extension. 

35 


The same principle applies to the soleus and gastrocnemius. Though 

both muscles plantar flex the foot, the soleus is a one-joint muscle and the 

gastrocnemius is a two-joint muscle. When the knee is flexed: (1) slack in 

the gastrocnemius reduces plantar flexion strength by about 70 percent, and 

(2) the soleus can be partially isolated and tested by testing plantar flexion. 

● Three points are important for the safety of the patient: 

1. Apply resistance slowly (easy on). 

2. Do not break the patient's contraction. 

3. Remove resistance slowly (easy off). 

Resistance should be applied slowly to give the patient enough time to 

apply a counterforce. Force applied too quickly may break the patient's 

contraction and cause tissue damage. As a rule, the examiner should stop 

counterforce when the patient's contraction changes from isometric to 

eccentric and the muscle starts to yield. On the opposite side, force removed 

too quickly may cause a rebound effect and cause tissue damage. 

Isometric resistance is normally applied when a muscle is at or slightly 

beyond normal resting length. Because of the arrangement of myofilaments 

in the sarcomeres and the viscoelastic properties of a muscle, most muscles 

are strongest when the muscle is at or near resting length and weakest when 

the muscle is fully stretched or fully shortened. Resting length is normally 

about midway between fully contracted and fully stretched. The biceps 

brachii approaches resting length when the elbow is flexed to about ninety 

degrees. 

As a caution, testing a muscle when distal and proximal insertions are 

not far enough apart to keep tension on a muscle during contraction may 

cause cramping. Any condition that allows actin and myosin myofilaments 

to overlap seems to encourage painful spasm. This can be demonstrated by 

placing the elbow joint in full flexion (sagittal plane) and then slowly and 

carefully contracting the biceps brachii. With only mild contraction, the 

biceps will normally start to cramp. 

Although high degrees of precision are sometimes required, most 

muscles can be tested as a group. According to Beevor's axiom, the body 

36 


knows nothing of individual muscles but thinks only in terms of movement. 

Since movements depend on muscles working in combination with each 

other, muscles that perform a similar movement can often be tested as a 

group by testing a movement. The most commonly tested movements are: 

• Flexion and extension 

• Supination and pronation 

• Abduction and adduction 

• Inversion and eversion 

• Medial and lateral rotation 

Muscle testing by group is most effective when combined with feedback 

and palpation to identify the muscles that are most affected. If contraction 

causes pain, both contractile structures and closely related non-contractile 

tissues are probably involved. The most likely non-contractile tissues to be 

implicated are tendons and aponeuroses. 

Palpation can be used to identify offending tissues. Involved muscles 

are normally indurated, ropy, and painful. In severe cases, palpation of 

irritated muscles will cause fasciculations or twitching and the patient will 

show signs of a sympathetic response such as perspiration, changes in skin 

temperature, or pilomotor activity (erection of hairs and goose flesh). 

If contraction is painful, the examiner should palpate for signs of 

impairment when the muscle is relaxed. Even though most muscles are 

easier to palpate when relaxed, impairments are sometimes more 

conspicuous when muscles are contracted. When using palpation, start with 

light pressure and use moderate or heavy pressure only if needed. 

Even though observation should always be used with palpation, visible 

signs are often less reliable than kinesthetic signs. Involved muscles may be 

larger than normal because of swelling or smaller than normal because of 

atrophy. The tissues related to affected muscles may be red (flushed) and 

hot because of inflammation and vasodilation or pale (blanched) and cold 

because of anxiety and vasoconstriction. The tissues related to affected 

muscles may also appear to be normal. This makes using infrared 

thermography to identify irritated tissues extremely difficult, since the 

temperatures of the affected tissues can be hot, cold, or normal. 

37 


38 

CONTRAINDICATIONS 

Even though diagnosis is not considered part of soft-tissue therapy, 

evaluations are necessary for two reasons: (1) to decide if soft-tissue 

therapy is contraindicated for any reason and (2) to identify the best course 

of therapy for each patient. Without evaluations, patients could be exposed 

to potentially dangerous treatments because of failure to identify 

contraindications. Even if soft-tissue therapy is indicated, the quality of 

treatment is likely to suffer if the patient's condition is not properly 

evaluated. 

Soft-tissue therapy is contraindicated by the vast majority of serious 

pathological findings. The ones most frequently cited are malignancies, 

cardiac or circulatory disease, and severe respiratory disease. Even though 

soft-tissue therapy is less likely to cause bone damage than high-velocity, 

low-amplitude manipulations, the risk of fracture is always present, 

especially if bones are weak because of disease or recent trauma. 

Soft-tissue therapy is contraindicated by spinal cord lesions, nerve root 

damage, or severe neurologic dysfunction. These conditions are often 

characterized by extreme pain that remains constant regardless of position, 

paresthesia, anesthesia, or weakness that occurs with or without pain. 

Conditions involving acute inflammation, infection, or bleeding are 

normally contraindicated. The signs of inflammation are pain, swelling, 

heat, redness, and loss of function. Soft-tissue therapy is contraindicated if 

treatments cause unexplained sickness, dizziness, nausea, or disorientation. 

Some conditions, diseases, or injuries are contraindicated when acute but 

indicated when subacute. Pregnancy, age, general health, and psychological 

fitness can also be factors. If there is any doubt, refer the patient to a 

specialist and get a written prescription before treatment. 

The following conditions may contraindicate soft-tissue therapy. 

acute bursitis Active inflammation of the bursa. 

agenesis of the odontoid process Failure of the odontoid process to 

develop properly. 


39 

cardiac decompensation Failure of the heart to maintain adequate 

circulation. 

cellulitis Inflammation of cellular or connective tissue. 

communicable disease Diseases transmitted directly or indirectly 

from one person to another. 

degenerative bone disease A disease characterized by impairment 

or deterioration of the bone. 

degenerative joint disease A disease characterized by impairment or 

deterioration of the joint. 

Down's syndrome A chromosomal abnormality that may involve 

cervical deformation. 

encephalitis Inflammation of the brain. 

fever Elevation of temperature above normal. 

hernia Projection of an organ or part through the wall of a cavity that 

normally contains it. 

infections Invasion of a body by a pathogenic agent that multiplies and 

causes injury. 

infectious arthritis Arthritis because of infection. 

inflammatory edema Edema because of inflammation. 

kidney failure Reduced or complete loss of kidney function. 

laceration A jagged wound caused by tearing. 


40 

lesions An injury or pathologic change in tissue. 

nonunion fracture A fracture that has failed to knit. 

osteoarthritis Degenerative joint disease characterized by 

degeneration of articular cartilage and overgrowth of bone. 

phlebitis Inflammation of a vein. 

rash A skin eruption that is normally red in color. 

recent surgery A condition characterized by acute trauma. 

rheumatoid arthritis An extension of synovial tissue over articular 

cartilage that causes deformity and disability. 

severe burns Serious tissue injury caused by thermal, chemical, 

electrical, or radioactive agents. 

severe hypertension Blood pressure judged to be significantly higher 

than normal. 

severe hypotension Blood pressure judged to be significantly lower 

than normal. 

synovitis Inflammation of a synovial membrane. 

thrombus A blood clot obstructing a vessel or cavity of the heart. 

vertebral artery disorder A dysfunction of the vertebral artery. 

vertigo A sensation that objects are spinning or whirling around the 

person (objective vertigo) or the person is moving around in space 

(subjective vertigo). 


41 

PAIN 

Pain is often defined as the perception of an unpleasant or disquieting 

sensation. Most people seek therapy because of pain and most patients 

judge the effectiveness of therapy by how it affects their pain. Patients are 

more likely to complain about pain than loss of function. In severe cases, 

pain becomes a disease in its own right, with characteristic signs and 

symptoms. An understanding of pain is invaluable to a therapist since pain is 

often the only indicator of underlying pathology. Left untreated, pain is a 

frequent cause of physical and psychological disability. 

Pain results from stimulation of specialized nerve endings called 

nociceptors that are sensitive to noxious stimuli such as changes in 

temperature (thermosensitive), mechanical stress (mechanosensitive), or 

noxious chemicals (chemosensitive). Nociceptors transmit a signal to the 

central nervous system that alerts the organism to actual or potential tissue 

damage. Nociceptors have myelinated axons that respond to thermal or 

mechanical stimuli or unmyelinated axons (polymodal receptors) that 

respond to all three types of noxious stimulation—thermal, mechanical, and 

chemical. Though very little is completely understood about pain receptors, 

two of the most common causes for soft-tissue pain are spasm and ischemia. 

In terms of mechanical stress, tension and compression can both cause 

pain. Passive movements are more likely to cause pain by stressing inert 

tissues such as ligaments and fascia, while active movements are more likely 

to cause pain by stressing contractile structures such as muscles, tendons, or 

aponeuroses. 

When traumatized, tissues release pain-producing substances such as (1) 

histamine, (2) serotonin, (3) bradykinin, (4) proteolytic enzymes, and (5) 

potassium ions. Injured tissues also release arachidonic acid, which 

stimulates production of prostaglandins. Steroids and salicylates such as 

aspirin (acetylsalicylic acid) relieve pain by interfering with the production 

of prostaglandins. Methyl salicylate is found in oil of wintergreen. 

Pain can be beneficial when it protects the body from tissue damage by 

causing the victim to withdraw from a harmful stimulus or to remove the 

stimulus. When tissue damage becomes so severe that pain receptors are 

destroyed, the absence of pain makes it difficult for victims to avoid injury. 


Pain can be debilitating and lead to a loss of function long after the 

original injury has apparently healed. Continuation of pain in this manner is 

called a pain cycle because the pain continues to perpetuate itself for no 

apparent reason. It is common to find this condition mistakenly diagnosed 

as some form of neurosis. In a patient with no history of mental illness, pain 

is more likely to be the cause of neurosis than to be the effect. Regardless of 

origin—organic or psychogenic—pain is always subjective. 

A twelve-point sequence that explains self-perpetuating pain cycles 

involves (1) trauma, (2) inflammation, (3) edema, (4) impaired circulation, 

(5) spasm, (6) ischemia, (7) hypoxic damage, (8) proliferation of connective 

tissue, (9) adhesions, (10) contractures, (11) entrapment neuropathies, and 

(12) myofascial trigger points. This sequence is fairly consistent from one 

patient to another and each step contributes directly or indirectly to pain. 

Although pain for most people is more than just imaginary, the 

psychological component of pain cannot be ignored. Different people 

respond to pain differently because of culture, personality, experience, and 

motivation. High-intensity pain for one person may be low-intensity pain 

for another. Concentrating on pain seems to intensify the effects, whereas 

focusing attention elsewhere seems to minimize the effects. As most 

practitioners can testify, distraction does more to lessen the patient's 

perception of pain than telling a patient to relax and not worry. Focusing on 

the possibility of pain seems to intensify the pain. 

Because of differences in the way people perceive pain, a therapist 

should try to estimate the patient's pain tolerance. One way is to apply a 

mildly painful stimulus and note the results. The lowest intensity of 

stimulation that causes pain is called the pain threshold. Responses sooner 

than normal indicate hyperalgesia and responses later than normal indicate 

hypalgesia. This information will make it easier for the therapist to evaluate 

complaints of pain before, during, and after treatment. 

Purely psychogenic pain is possible, but far less common than once 

supposed. Absence of signs, exaggeration of symptoms, increased bed rest, 

denial of emotional factors, and refusal to cooperate or be touched may 

indicate a need for psychological or psychiatric counseling. 

On the opposite side, failure to identify the causes of pain should not be 

automatic grounds for claiming psychogenic origin. Historically, many 

42 


cases of soft-tissue pain and disability were diagnosed as psychogenic 

because doctors were unable to identify the organic causes for pain. Now 

that most doctors recognize the organic nature of soft-tissue pain, the quality 

of treatment is far better. When acute soft-tissue injuries are treated 

correctly, there is less chance of chronic pain. 

Although many descriptive words can be used to describe pain, the 

characteristics of superficial pain and deep pain are different. Superficial 

pain is often described as sharp prickling pain, whereas deep pain is 

described as dull aching pain. Superficial pain is normally well defined and 

corresponds more closely with points of origin than deep pain. Deep pain, 

on the other hand, is likely to be highly diffuse and produce autonomic 

responses such as pallor, hypotension, diaphoresis (perspiration), or nausea. 

Another expression used to describe pain is a prickling or tingling 

sensation that resembles "pins and needles." This feeling called paresthesia 

is normally caused by pressure on a central or peripheral nerve. Physical 

examination of the patient may reveal anesthesia or partial paralysis. 

Pain felt at some distance from the point of origin is called referred pain. 

The origin of pain seldom corresponds exactly with the patient's perception 

of where the pain is located. As a rule, the closer the offending tissue is to 

the surface of the body, the greater the correlation between the origin of pain 

and feelings of pain. At the level of the spinal cord, visceral organs and the 

skin frequently share a common synapse. For this reason, pain originating 

from visceral organs is sometimes referred to the skin and vice versa. The 

gallbladder refers pain to the tip of the right shoulder. 

According to Hilton's law, the nerve trunk that supplies a joint also 

supplies the muscles that move the joint and the skin that covers the 

insertions of the muscles that move the joint. Pain originating from one 

structure—joint, muscle, or skin—can be referred to the other structures. 

Except for elbow and knee pain that radiates in all directions and 

cervical pain that radiates upward, most pain radiates away from the midline 

and downward. As pain becomes more intense, radiation seems to increase. 

The source of pain that radiates simultaneously to both sides of the body is 

more likely to be central in origin than unilateral. 

Another source of referred pain is the irritation of either a nerve root or 

peripheral nerve. Nerve roots can be irritated by disc protrusions or bony 

43 


osteophytes. The effects will depend on which type of nerve root is 

affected: sensory or motor. Irritation of a sensory nerve root can result in 

pain or anesthesia. Irritation of a motor nerve root can facilitate motor 

activities that cause pain or spasm. Irritation of a peripheral nerve because 

of nerve entrapment or injury can also result in pain or anesthesia. 

Whether pain or anesthesia occurs depends on what part of the nerve is 

affected. End organs and nerve endings are sensitive to pain, whereas 

pressure on the axon may cause paresthesia, hypoesthesia, anesthesia, or 

paresis. In sciatica, pain results from pressure on nerve endings in the dural 

sheath (lumbar spine), and not from direct pressure on the axon itself. 

Irritation of nerves will often radiate pain in characteristic patterns of 

distribution called sclerotomes, myotomes, or dermatomes. These patterns 

are based on segments that develop during embryonic growth. Intense pain 

radiated by deep somatic structures will follow a vague pattern of surface 

distribution called sclerotomes. Musculoskeletal pain is less difficult to 

localize and radiates pain segmentally by patterns called myotomes. Pain 

arising from the skin corresponds closely to the origin or source of pain. 

Skin pain is the easiest to localize and radiates patterns called dermatomes. 

With few exceptions, segmental pain refers distally from its point of 

origin. Pain originating in a segment can be referred distally to any part of 

the segment. Irritation of a nerve root radiates pain distally and normally 

downward. The same rule applies to spinal reflexes, which spread pain 

more easily down the cord than up the cord. 

Nerve root damage in the cervical spine from C-4 down is referred to the 

neck, shoulders, and down the arms. The thoracic spine refers pain in 

circular segments that have a posterior-to-anterior downward slope. Nerve 

root damage to the lumbar spine is referred to the hips and down the legs. 

The sacral spine refers pain to the buttocks and down the legs. 

Nerve root damage above C-4 can refer pain upward to the head. 

Tension-type or muscle-contraction headaches can sometimes be treated by 

relaxing the neck and back muscles with attachments that cross C-4. 

Segmental patterns are not always well defined, and one segment will 

sometimes overlap another segment. If one segment becomes dysfunctional 

because of nerve root damage, overlap from adjacent segments may be 

enough to cover the lost segment. 

44 


The distribution of pain within a segment can vary with the intensity of 

stimulation. Strong stimulus is more likely to involve the entire segment 

and overflow to adjacent segments than weak stimulus. According to Head's 

law, painful stimulus applied to areas of low sensitivity may not be felt 

where the stimulus is applied, but may be felt in adjacent areas of high 

sensitivity. This means the areas where pain originates and the areas where 

pain is felt may not be the same. 

Treating pain but ignoring the causes will seldom produce long-term 

benefits. Understanding how pain radiates will make it easier to locate the 

origins of pain and treat the origins. Understanding which structures are 

most sensitive to pain is another way to locate the origins of pain. 

45 

STRUCTURES MOST SENSITIVE TO PAIN 

HIGH SENSITIVITY 

MODERATE SENSITIVITY 

LOW SENSITIVITY 

Periosteum and joint capsule 

Ligaments, tendons, and muscles 

Articular cartilage and fibrocartilage 

The structures most sensitive to nociceptive stimulation are the 

periosteum and joint capsule. Ligaments and tendons are moderately 

sensitive to pain and muscles are less sensitive. Articular cartilage and 

fibrocartilage are almost insensitive to noxious stimulation. 

Severe pain resulting from spasm is more likely to implicate the tendon's 

periosteal attachment than implicate the muscle. In such a case, treating the 

tendon alone will be less effective than treating both the muscle and the 

tendon. Relaxing the muscle will ease tension on the tendon. 

Times of occurrence and quality of pain can also be factors when trying 

to locate the origins of pain. Daytime pain that intensifies with activity and 

then diminishes as the activity continues indicates spasm or muscle soreness. 

Activity seems to "loosen up" the muscles. 

During periods of inactivity, muscles tend to shorten and become less 

painful. With renewed activity, muscles that become short during inactivity 

are suddenly stretched and become painful again. With continued activity, 

the muscles return to their normal length and become less painful. This 


explains why people with spasms are told to move about frequently rather 

than remain stationary for extended periods of time. Muscles that shorten 

during sleep, such as the gastrocnemius or soleus, often cause pain when a 

person gets up and starts to walk about. Because of the Achilles (calcaneal) 

tendon, pain may be felt in the heel that resembles the pain from a heel spur. 

Pain that continues both day and night, and wakes the patient during the 

night, is more likely to indicate joint damage or tissue inflammation than 

spasm. Morning stiffness involving the hands and feet is more likely to 

indicate rheumatoid arthritis than spasm. It should be noted, however, that 

muscular pain, like joint pain, may become worse during the day if spasm 

recurs or the muscle is aggravated by overuse. 

Another method for identifying the source of pain is to reproduce the 

movements that cause the pain and then determine which structures are 

involved. If pain occurs during contraction, the cause is possibly agonistic 

or synergistic muscles being contracted or antagonistic muscles being 

stretched. If the pain is not being generated directly by the muscles, it can 

also be generated indirectly by any movements that stretch or compress 

sensitive tissue. Tremors during contraction may indicate pain. 

If pressing a point refers pain to another part of the body and ice applied 

to the same point eliminates the pain, the point being tested is probably the 

origin of pain. If cervical muscles are causing headaches, pressure on the 

muscles may cause headaches and ice applied to the same muscles may 

cause relief. Deep inhibitory pressure can sometimes be used in place of ice 

if the patient reacts poorly to ice or ice is not available. Patients are often 

surprised to find that the areas where they feel pain are not the origins of 

pain and that treating the origin relieves the pain. 

If the origin of pain is correctly identified and treated, the pain as 

perceived by the patient will normally disappear. If the pain continues, treat 

the painful area. There may be two origins of pain: (1) a proximal site 

where the patient perceives pain and (2) a distal site that refers pain. 

If therapy is applied and the pain disappears, the origin of pain has 

probably been located and treated. If therapy is applied and only part of the 

pain disappears, the method of therapy may be wrong or the pain may have 

more than one origin. If therapy is applied and the pain remains the same, 

the method may be wrong or the origin of pain may not have been treated. 

46 


47 


FOUR CLASSICAL METHODS OF PHYSICAL EVALUATION 

• Percussion 

• Auscultation 

• Palpation 

• Inspection 

SIX GRADES OF MUSCLE TESTING ( 5 to 0) 

• Normal: Hold against gravity and full resistance ................................ 5 

• Good: Hold against gravity and some resistance................................. 4 

• Fair: Complete range of motion against gravity 3 

• Poor: Complete range of motion with gravity eliminated ................... 2 

• Trace: Evidence of contraction only .................................................... 1 

• Zero: No evidence of contraction......................................................... 0 


48 

THREE POINTS CONCERNING MUSCLE-TESTING SAFETY 

• Apply resistance slowly (easy on). 

• Do not break the patient's contraction. 

• Remove resistance slowly (easy off). 

TWO TYPES OF PAIN 

• Superficial pain ....................................................... sharp prickling pain. 

• Deep pain........................................................................dull aching pain. 

THREE LEVELS OF SENSITIVITY TO PAIN 

• High sensitivity ........................................ Periosteum and joint capsule. 

• Moderate sensitivity .......................... Ligaments, tendons, and muscles. 

• Low sensitivity .............................Articular cartilage and fibrocartilage. 


49 

ALTERNATIVES 

The HEMME APPROACH is a method for matching therapeutic problems 

with practical solutions. Once the first two steps, HISTORY and EVALUATION, 

define the problem, the next three steps define the solution: 

M 

M 

E 

MODALITIES 

MANIPULATION 

EXERCISE 

The word ALTERNATIVES is not written in bold letters because it represents a 

choice and not a step. Even though a therapist can use any sequence that 

seems appropriate, the normal sequence is MODALITIES first, MANIPULATION 

second, and EXERCISE third. Modalities prepare the body for manipulation 

and then manipulation prepares the body for exercise. 

The three basic modalities used in the HEMME APPROACH are 

thermotherapy, cryotherapy, and vibration. If modalities are not appropriate, 

the therapist can proceed directly to the step titled MANIPULATION. Because of 

its flexibility, there is nothing in the HEMME APPROACH that prevents a 

therapist from bypassing a step or returning to a previous step if needed. 

The step titled MANIPULATION covers the four basic methods of 

manipulation used in the HEMME APPROACH: trigger point therapy, 

neuromuscular therapy, connective tissue therapy, and range-of-motion 

stretching. 

 

 

 

 

HEMME APPROACH MANIPULATIONS 

Trigger point therapy (trigger points) 

Neuromuscular therapy (nerve and muscle tissue) 

Connective tissue therapy (connective and epithelial tissue) 

Range-of-motion stretching (trigger points and all four tissues) 


The four categories under manipulations are based on anatomy and 

physiology. Trigger points are based on physiology. They have no discernible 

structure and cannot be dissected or biopsied. Neuromuscular and connective 

tissue therapy are based on anatomy. Neuromuscular therapy focuses on nerve 

and muscle tissue, and connective tissue therapy focuses on connective and 

epithelial tissue. Range-of-motion stretching affects all four types of tissue: 

nerve, muscle, connective, and epithelial tissue. 

If feedback shows therapy is not effective, other decisions can be made by 

using the model and taking the next appropriate step. If contraindications are 

discovered, discontinue treatment and exit the patient from the model by using 

the step titled OBJECTIVES NOT SATISFIED. 

If the objectives are not satisfied and the patient wishes to continue 

therapy, the patient can reenter the model at the step titled ENTER PATIENT. 

The step titled NEW INFORMATION is used to introduce new information from 

an outside source. Possible sources include other health care professionals, 

medical reference books, professional journals, and research papers. 

Reentering at any of the five basic steps can mean (1) taking additional 

history, (2) expanding the evaluation, or (3) changing the way modalities, 

manipulation, or exercise are used. Taking additional history or expanding the 

evaluation may be needed to redefine the problem. Changing the way 

modalities, manipulation, or exercise are used may be needed to redefine the 

solution. The two main reasons for therapeutic failure are (1) failure to 

identify the problem, and (2) failure to administer appropriate therapy. 

Effective reasoning combines logic and intuition with knowledge and 

experience. In therapy, intuition and right-brain thinking are often more 

productive than logic and left-brain thinking. While nothing guarantees 

perfection, certain procedures can make it easier to deal with a complex 

situation such as solving a therapeutic problem. These procedures can be 

applied mentally or in writing. The acronym SOS defines the three steps 

needed to simplify complex situations and find acceptable solutions: 

50 

S 

O 

S 

Separate the problem into parts. 

Organize the parts. 

Simplify the problem. 


First, separate the problem into parts. Most complex problems are nothing 

more than a series of smaller problems. Computer programmers are famous 

for breaking down complex programs into smaller parts or modules. 

Second, organize the parts by creating three categories: problems, 

principles of therapy, and solutions. Problems may change, but the principles 

of therapy are fairly constant. Workable solutions are principles of therapy 

that are correctly applied to the problem. Solution: If a muscle is short and 

weak (problem), lengthen first and strengthen second (principle). 

Third, simplify the problem by eliminating useless information. Eliminate 

facts that are not related to the problem and principles that are not needed to 

solve the problem. Some people use lines to connect usable facts with usable 

principles and Xs to eliminate useless information. 

Even though logic is the backbone of scientific investigation, intuition can 

be priceless. With a good scientific background and practical experience, 

practitioners may find that solutions appear by intuition after all attempts to 

reach a logical solution have failed. Intuition seems to be strongest when hard 

work and concentration are followed by rest. Since many famous inventors 

claim that some of their greatest ideas appeared to them in a dream, the value 

of dreaming as a source of insight should not be taken lightly. 

Regardless of how solutions are formed, where they come from, or who 

does the research, all solutions must be judged by the same scientific standard. 

The best way to meet objective, scientific standards is by using the scientific 

method. The purpose of the scientific method is to make logical connections 

between facts and theories. The scientific method implies: 

1. Completely identify the problem. 

2. Formulate preliminary theories by using experience. 

3. Collect relevant facts by using careful observation. 

4. Formulate final theories by using logic or intuition. 

5. Evaluate final theories by testing the consequences. 

6. Draw conclusions and formulate a solution. 

When correctly used, the scientific method produces solutions that are (1) 

objective, (2) verifiable, (3) reproducible, and (4) highly productive. The 

HEMME APPROACH itself is built on the scientific method. 

51 


52 


TWO HEMME APPROACH STEPS THAT DEFINE THE PROBLEM 

• HISTORY 

• EVALUATION 

THREE HEMME APPROACH STEPS THAT DEFINE THE SOLUTION 

• MODALITIES 

• MANIPULATION 

• EXERCISE 

FOUR TYPES OF MANIPULATION IN HEMME APPROACH 

• Trigger point therapy 

• Neuromuscular therapy 

• Connective tissue therapy 

• Range-of-motion stretching 


53 

MODALITIES 

Modalities are used in soft-tissue therapy to improve the effectiveness of 

manipulation. Although seldom curative when used alone, modalities prepare 

patients for manipulation by reducing pain, controlling edema, reducing 

muscle spasm, and decreasing tissue viscosity. 

Manipulations are normally executed during or shortly after the 

application of modalities. When heat or cold are used, thermal effects are 

measured by calculating changes in body temperature above or below normal. 

Since large thermal effects produce more physiological changes than small 

thermal effects, time is critical. If too much time passes between the use of 

modalities and manipulation, temperatures return to normal, thermal effects 

diminish, and the benefits of using modalities are lost. 

On the negative side, thermal effects that are too large cause tissue 

damage. Tissue temperatures above 113°F may cause burning, and tissue 

temperatures below 32°F may cause frostbite. If patients are conscious and 

sentient, frostbite is potentially more dangerous than burning. Since ice 

produces analgesia, pain alerts patients to burning but not to freezing. 

CONTRAST APPLICATIONS 

Contrast applications produce large changes in body temperature. The 

cycle is normally four minutes of heat (104°F) followed by one minute of cold 

(55°F). This cycle is repeated four times, always starting with heat and ending 

with cold. At the same time contrast applications improve circulation, reduce 

edema, increase local metabolism, and hasten healing, they also act as a tonic 

and neuromuscular stimulant. Modalities that relax the neuromuscular system 

are often more conducive to soft-tissue manipulation than stimulants. 

A second problem with contrast applications relates to exposure. Four 

minutes of heat is not long enough to increase tissue extensibility and one 

minute of cold will not produce analgesic effects. Although frequently 

acclaimed as one of the most potent procedures in hydrotherapy, the ability of 

contrast applications to prepare the body for manipulation is limited. At best, 

contrast applications, such as a contrast bath, reduce muscle spasm and relieve 

pain by improving circulation and reducing edema. 


54 

THERMOTHERAPY 

Common methods for applying therapeutic heat include silicon gel packs, 

whirlpools, paraffin baths, and infrared light. Since moist air conducts heat 

more rapidly than dry air, moist heat is generally more penetrating than dry 

heat. Certain electric heating pads produce moist heat by trapping vapor that 

escapes from the body during the heating process. Although less popular than 

moist heat, infrared lamps do have certain advantages. First, they radiate 

continuous heat without producing pressure, and second, tissues can be heated 

and manipulated concurrently. 

Heat produces physiological, psychological, and reflex effects that 

influence the entire body. These include reduction of pain and spasm, 

vasodilation, increased phagocytosis, and perspiration. Most patients find that 

soaking in a hot bath (100°F-104°F) produces feelings of relaxation and wellbeing. 

These effects are mostly psychological. Temperatures above 104°F are 

very hot for most people and difficult to tolerate. Temperatures high enough 

to increase tissue extensibility are normally between 105°F and 110°F. Tissue 

damage normally starts when tissue temperatures reach 113°F and 

temperatures at this level are normally painful. 

When physical agents are being used, tissue temperature refers to the 

temperature of tissues and not the temperature of the heating or cooling 

modalities. A hot foot bath reaching temperatures as high as 115°F does not 

elevate tissue temperatures in the feet much higher than about 110°F. With 

exposure limited to the feet and soaking time 30 minutes or less, circulation of 

cooler blood from other parts of the body is adequate to cool the feet. 

Since most heating modalities in soft-tissue therapy are applied 

superficially, the effects of heat are normally topical. Three exceptions to this 

rule are (1) hydrostatic effect, (2) exposing the body to large volumes of heat, 

and (3) reflex effects. 

(1) Hydrostatic Effect 

The effects of heat can be systemic if heat causes vasodilation that 

increases blood flow from one body part to another. Hydrotherapy defines 

hydrostatic effect as fluids shifting within the body because of environmental 


changes in temperatures. This explains why using a hot foot bath or hot sitz 

bath can relieve pulmonary congestion, restore normal breathing, and relax the 

patient. When circulation shifts heated blood from lower extremities to the 

chest, heated blood dilates blood vessels in the chest and relieves congestion. 

(2) Exposing Large Portions of the Body to Moist Heat 

Superficial heating becomes systemic if large portions of the body are 

exposed to moist heat for long periods of time. Immersed in a hot bath or 

sitting in a steam cabinet, the body may not be able to dissipate excess heat 

because (1) radiation, conduction, and convection are ineffective at 

temperatures above 95°F, (2) evaporation is ineffective when surrounding air 

is fully saturated with moisture and relative humidity reaches 100 percent, and 

(3) circulation stops cooling when core temperatures reach environmental 

temperatures. 

For patients who can tolerate the heat, the benefits are general relaxation, 

reduction of spasm, and greater tissue extensibility. Therapeutic stretching 

while patients are still immersed in hot water is more effective than stretching 

after they dry off and start to cool. After the patient has cooled, general 

relaxation may decrease or remain the same, reduction of spasm may continue, 

and tissues become less extensible and more difficult to stretch. 

(3) Reflex Effects 

Local heating produces reflexogenic changes in distal parts of the body. 

These include changes in muscular activity, circulation, enzymatic activity, 

and pain levels. Temperatures higher than 104°F and exposures longer than 

five minutes are needed to produce distal heating effects. Distal heating 

effects are not as vigorous as local heating effects. 

By lowering viscosity, heat increases tissue extensibility and decreases 

resistance to active or passive stretch. This makes it easier for patients to 

attain full range of motion with less force. As a caution, people using heating 

pads or hot water for pain relief on a long-term basis are likely to experience 

continuous pain and stiffness if the tissues cool at or below resting length. 

55 


Once tissue temperatures are elevated, restricted tissues should be actively or 

passively stretched and allowed to cool while fully extended. Tissues cooled 

at or below resting length have a tendency to become abnormally short. 

The contraindications for heat are bleeding, malignancy, inflammation, 

vascular insufficiency, edema, burns, fever, tuberculosis, general weakness, 

and debilitating diseases such as heart disease. Heat is contraindicated for 

patients who are insensitive to pain or unable to communicate pain. 

• Indications for heat modalities: 

A. Muscle Spasm 

B. Pain 

C. Contracture 

D. Vascular stasis 

CRYOTHERAPY 

Ice cubes, vapocoolant sprays, and ice packs are common ways to produce 

therapeutic cold. Ice massage refers to the practice of using pieces of ice to 

massage the body. By producing thermal effects and mechanical effects 

simultaneously, ice massage combines modality with manipulation. 

Applied for less than five minutes, ice massage increases muscle tone by 

reflex action and cools the skin. Since ice often produces burning pain before 

numbing takes effect, ice can be classified as a counterirritant. By acting as a 

counterirritant, ice massage relieves pain in the same way acupuncture relieves 

pain. The effects of vapocoolant sprays are similar to the short-term effects of 

ice massage. Applied for more than twenty minutes, ice massage produces 

long-term effects such as vasoconstriction, analgesia, and loss of tonus. 

Unlike heat, cold causes vasoconstriction that reduces blood flow and 

prevents circulation from warming the exposed body parts. Because of 

vasoconstriction, cold is more likely to penetrate deeply than heat. While deep 

cooling often requires about twenty to thirty minutes, cold penetrates small 

body parts, such as digits, more rapidly than large or fleshy body parts. 

56 


The term hunting reaction implies that cold produces vasodilation when 

temperatures are low enough to cause tissue damage. Even if cold-induced 

vasodilation occurs, this principle is seldom applied to soft-tissue therapy 

because the practical uses of this concept (if true) are limited. 

The rebound effect is another way that cold produces vasoconstriction. 

When tissues are chilled by using a vapocoolant spray, blood vessels quickly 

vasodilate (rebound), as shown by capillary flare. The therapeutic value of this 

effect is difficult to assess. If the rebound effect in some way causes reflex 

inhibition, this could partially explain why less than five minutes of 

vapocoolant spray (or ice massage) seems to facilitate stretching. 

During the early stages of injury, cold reduces secondary hypoxic damage 

by decreasing tissue metabolism and neutralizing the effects of histamine and 

prostaglandin. These chemicals promote edema by increasing fluid infiltration 

from capillaries to intercellular spaces. Since prostaglandin is also a painproducing 

(algogenic) substance, cold reduces pain by slowing the conversion 

of arachidonic acid to prostaglandin. 

Cold-induced analgesia encourages exercise by controlling pain and 

reducing muscle spasm. Many patients refuse to use ice and most patients 

experience a burning or aching pain prior to analgesia. Cold reduces spasm by 

slowing nerve-conduction velocities and retarding the neural impulses from 

muscle spindles (spindle-shaped end organs in skeletal muscle that help to 

control tonus). This reduces facilitation and relaxes the muscle. Nerve 

conduction stops completely at tissue temperatures below 50°F. 

On the negative side, by increasing tissue viscosity, cold reduces tissue 

extensibility. If controlling pain and reducing spasm are more important than 

increasing tissue extensibility, cold can be used to prepare body parts for 

exercise. It will also help to control edema before, during, and after exercise. 

Cold is even more effective in controlling edema when combined with 

rest, elevation, and compression. The acronym RICE stands for (1) Rest, (2) 

Ice, (3) Compression, and (4) Elevation. These are the four main steps used in 

treating sports injuries. In sports medicine, crushed ice is normally applied to 

stabilized body parts for about twenty to thirty minutes with compression and 

elevation. Ice treatments are normally continued for about two days. 

Unlike heat, cold tends to decrease hemorrhage (bleeding) by causing 

vasoconstriction. If tissue edema and subcutaneous bleeding are present, cold 

57 


is safer to use than heat. If tissue edema and subcutaneous bleeding are not 

present, either can be used to relieve muscle ache or spasm. Unlike cold, heat 

stimulates circulation by causing vasodilation, and many people prefer heat. 

Though not in the same way as heat, cold reduces pain by relaxing muscle 

spasm. By slowing the rate of discharge from the muscle spindle and 

increasing the rate of discharge from the Golgi tendon organs, cold reduces 

facilitation and increases inhibition. While heat reduces pain by acting as a 

counterirritant, cold relieves pain by slowing nerve-conduction velocities. 

Because it penetrates deeper, cold is more likely to relieve deep pain than heat. 

By acting as counterirritants, heat and cold can mediate pain chemically by 

causing the release of endorphins that produce analgesia. 

Where time is a factor and subcutaneous bleeding is not present, heat 

reduces muscle spasm faster than cold. Heat works by reflex effect on the 

gamma system and requires only enough time for shallow penetration. Cold 

works by slowing nerve conduction velocities and requires enough time for 

deep penetration. Cold applied briefly can trigger a stretch reflex that 

aggravates spasm and makes treatment even more difficult. 

During the later stages of injury, heat promotes healing by causing 

vasodilation that increases blood flow and raises tissue temperatures enough to 

accelerate metabolism. Vasodilation aids in the resolution of inflammatory 

infiltrates and metabolic waste. Prolonged use of cold after the acute stages of 

an injury may actually retard wound healing by restricting blood flow and 

slowing metabolism. 

To simplify the question of heat or cold, acute injuries are normally treated 

by cold and subacute injuries are treated by heat. Acute injuries become 

subacute when edema stops forming, normally about 36 to 48 hours after the 

injury. An exception to this rule is low back pain. Based on clinical 

experience, heat is often used during the acute stage to relieve spasm and cold 

is often used for the subacute stage to relieve chronic inflammation. 

Another point to consider is the difference between injury and re-injury. A 

condition may be subacute in terms of when the original injury occurred, but 

acute in terms of re-injury. Even if the original injury occurred three months 

ago, any condition resulting from the re-injury of poorly healed scar tissue 

should be treated as acute, not subacute. 

58 


Contraindications specifically for therapeutic cold are people with cold 

sensitivities, heart disease, and signs of general weakness. When people with 

sensitivities are exposed to cold, release of histamine causes edema and cold 

urticaria. Another contraindication to cold is Raynaud's disease, which causes 

abnormal vasoconstriction when extremities are exposed to cold. 

• Indications for cold modalities: 

A. Muscle spasm 

B. Pain 

C. Edema 

D. Trauma 

HEAT VS. COLD 

The following table explains why cold is recommended during the acute 

stage when body parts are swollen and heat is recommended during the 

subacute stage when circulation is needed to expedite healing. 

Normal Effects of Heat and Cold 

1. Relax muscle spasm.....................................................heat and cold 

2. Reduce pain..................................................................heat and cold 

3. Vasodilation ................................................................................heat 

4. Increase local metabolism ..........................................................heat 

5. Increase local circulation............................................................heat 

6. Increase edema............................................................................heat 

7. Increase inflammation ................................................................heat 

8. Increase tissue extensibility........................................................heat 

9. Vasoconstriction .........................................................................cold 

10. Decrease local metabolism..................................................cold 

11. Decrease local circulation....................................................cold 

12. Decrease edema ...................................................................cold 

13. Decrease inflammation........................................................cold 

14. Decrease tissue extensibility................................................cold 

59 


60 

VIBRATION 

Vibration has a relaxing effect on muscles and relieves pain. When 

patients cannot tolerate compression or stretching, vibration prepares the 

patient for manipulation by desensitizing the offending tissues. Part of the 

pain-relieving effect of vibration relates to the stimulation of A-beta nerve 

fibers that block conduction of the electrical impulses that transmit deep pain. 

Another part may relate to the heat produced by friction as vibration moves 

one molecule against another. 

By improving circulation, vibration reduces edema and hastens the 

resolution of inflammation. Resolution of inflammation refers to stopping 

inflammation by absorbing and removing the products of inflammation. To 

resolve inflammation, vibration should be applied at points distal to the 

inflammation, not directly to the inflammation. 

Mechanical vibration is normally more effective and less tiring than 

manual vibration. To sedate muscles, relax spasm, relieve pain, and stimulate 

circulation, vibratory treatments should be at least three minutes long. 

Treatments that are less than three minutes long may stimulate more than 

sedate. On one hand, regardless of which method of vibration is being used— 

mechanical or manual—small amounts of force normally sedate and large 

amounts of force normally stimulate. On the other hand, though heavy 

vibration tends to stimulate, the periods of time that follow heavy vibration are 

often characterized by relaxation and a visible decrease in muscle tonus. 

While stimulation, such as heavy vibration, tends to increase functional 

activity, overstimulation can have the opposite effect and decrease functional 

activity. Even though the Arndt-Schultz law is now considered obsolete, this 

law does mention that a strong stimulus can retard physiologic activity. 

Contraindications for vibration include: inflammation, heart disease, 

open lesions, blood clots, hemorrhage, infection, malignancy, cerebellar 

dysfunction, infants, and overly sensitive or inelastic skin. Applying 

mechanical vibration with too much downward pressure can increase the 

risk of tissue damage and decrease the frequency of vibration. 


61 


FOUR INDICATIONS FOR HEAT MODALITIES (THERMOTHERAPY) 

• Muscle spasm 

• Pain 

• Contracture 

• Vascular stasis 

FOUR INDICATIONS FOR COLD MODALITIES (CRYOTHERAPY) 

• Muscle spasm 

• Pain 

• Edema 

• Trauma 


62 

SEVEN MAJOR CONTRAINDICATIONS TO HEAT 

• Bleeding 

• Malignancy 

• Inflammation 

• Vascular insufficiency 

• Edema 

• General weakness 

• Heart disease 

FOUR MAJOR CONTRAINDICATIONS TO COLD 

• Cold sensitivities 

• Heart disease 

• General weakness 

• Raynaud's disease 


63 

MANIPULATION 

Soft-tissue therapy is based on a series of scientific principles that are often 

called axioms or laws. Although principles can make it easier to simplify 

complex ideas, they do change. Pflüger's Laws of Unilaterality, Symmetry, 

Intensity, and Radiation are classical examples. 

Written in 1853 by the German physiologist Edward Pflüger, these laws 

were widely accepted for more than 50 years. When all four laws were 

shown to be invalid by Dr. Charles Sherrington in 1915, these laws became 

scientific history. This explains why the Laws of Unilaterality, Symmetry, 

Intensity, and Radiation are no longer taught in medical schools or found in 

medical textbooks or dictionaries today. 

Another law that has recently been questioned is the Arndt-Schultz law: 

Weak stimulus causes activity, moderate stimulus increases activity, strong 

stimulus retards activity, and very strong stimulus stops activity. While this 

law seems to explain the sequence that occurs when digital pressure is 

applied to trigger points—pain increases with increases in pressure until 

numbness occurs—other situations involving painful stimulation produce 

continuous pain instead of numbness. Stedman’s Medical Dictionary (26th 

ed.) shows the Arndt-Schultz law as obsolete. 

The following principles, on the other hand, are still widely accepted by 

medical science. These principles explain why forces applied to the human 

body produce certain changes that are beneficial. 

THE PRINCIPLES OF SOFT-TISSUE THERAPY 

The HEMME APPROACH is based on three fundamental laws: 

HEMME’s 1st law: Most conditions treatable by soft-tissue therapy are 

characterized by pain, limited range of motion, or weakness. 

HEMME’s 2nd law: Most conditions treatable by soft-tissue therapy can 

be identified and treated by using five basic steps: History, Evaluation, 

Modalities, Manipulation, and Exercise. 


HEMME’s 3rd law: Always be ready, willing, and able to disregard any 

law, principle, axiom, or belief that proves to be incorrect. 

Ten other principles that apply to soft-tissue therapy include: 

1. Beevor's axiom: The brain knows nothing of individual muscles, but 

thinks only in terms of movement. 

2. Creep: Deformation of viscoelastic materials when exposed to a slow, 

constant, low-level force for long periods of time. 

3. Facilitation-Inhibition: 

A. When a nerve impulse passes once through a set of neurons to 

the exclusion of other neurons, it usually takes the same path in 

the future and resistance to the impulse becomes less. 

B. As opposites, facilitation encourages a process and inhibition 

restrains a process. 

4. Head's law: If painful stimulus is applied to areas of low sensibility 

in close central connection with areas of high sensibility, pain may be 

felt where sensibility is high. 

5. Hilton's law: The nerve trunk that supplies a joint also supplies the 

muscles that move the joint and the skin that covers the insertions of 

the muscles that move the joint. 

6. Hysteresis: Energy loss in viscoelastic materials subjected to stress 

or to cycles of loading and unloading. 

7. Sherrington's laws: 

A. Every posterior spinal root nerve supplies one particular region 

on the skin, although fibers from segments above and below 

can invade this region. 

64 


65 

B. Reciprocal Inhibition: when the agonist receives an impulse to 

contract, the antagonist relaxes. 

C. Irradiation: nerve impulses spread from a common center 

and disperse beyond the normal path of conduction. 

Dispersion tends to increase as the intensity of stimulus 

becomes greater. 

8. Sherrington's reflex: A muscle contracts in response to passive 

longitudinal stretch. (also called stretch reflex or myotatic reflex) 

9. Thixotropy: Certain gels liquefy when agitated and revert to gel upon 

standing. 

10. Wolff's law: Bone and collagen fibers develop a structure most suited 

to resist the forces acting upon them. 

HIGH-VELOCITY MANIPULATIONS 

Soft-tissue therapy is broadly defined as manipulation of superficial or soft 

tissue for therapeutic purposes. Deep tissues are directly affected by 

superficial pressure and indirectly affected by reflex effects. Manipulations in 

soft-tissue therapy are normally low-velocity movements that push or pull 

tissues without high-velocity thrusting or impact. 

High-velocity manipulations are thought to relieve pain and spasm by 

stimulation of mechanoreceptors and reflex effects. By separating joints, 

breaking adhesions, and stretching ligaments, thrusting movements increase 

mobility and relieve pressure on nerves. In many cases, relief is short-term 

and patients develop long-term dependency on treatment. 

When forces strong enough to cause permanent deformation are applied 

slowly, tissues absorb the energy and deform plastically without tearing. 

When strong forces are applied rapidly, tissues have less time to absorb the 

energy and tearing becomes more likely than plastic deformation. Because of 

their rapid movements, high-velocity techniques are potentially more 

dangerous to use than low-velocity techniques. 


Tearing debilitates a skeletal muscle in three ways: (1) a loss of voluntary 

control, (2) a loss of strength, and (3) a loss of tissue extensibility. First, 

connective tissue cannot contract or relax voluntarily. Contraction of 

connective tissue during wound healing or expansion of connective tissue 

during stretching are not the same as the voluntary contraction or relaxation of 

muscle tissue in response to commands from the central nervous system. 

Second, where muscle tissue has the ability to shorten, exert force, and 

counteract or overcome external resistance, the shortening that occurs in 

connective tissue has the ability to counteract resistance, but not the ability to 

overcome resistance. Even though connective tissue has the ability to 

counteract resistance by increasing a muscle's resistance to active or passive 

stretch—as in the case of scar tissue or contractures that increase tightness and 

decrease range of motion—connective tissue does not have the ability to 

overcome resistance and produce normal movement. 

Since one measure of strength is the ability of a muscle to exert force, 

overcome resistance, and produce movement, replacing muscle tissue with 

connective tissue may cause a decrease in strength. If a large percentage of 

muscle tissue is replaced by connective tissue, the affected agonist will 

normally test weaker because of less muscle tissue and the antagonist may test 

weaker because of tightness or shortness in the agonist. 

Third, since damaged muscle tissue is often repaired or replaced by 

connective tissue that is less extensible than muscle tissue, tearing within a 

muscle often reduces extensibility. As a result of tearing, muscles become 

weaker and more resistant to active or passive stretching unless range-ofmotion 

stretching is used to restore a muscle to its normal length. 

Constant tearing can also affect ligaments. After repeated bouts of tearing 

and overstretching, ligaments remain stretched and joints become 

hypermobile. Since most joints rely on ligaments more than muscles for 

stability, the results of ligament damage are (1) the joint becomes unstable and 

(2) muscles are forced to compensate for loss of ligamentous support. 

Compensating for loss of ligamentous support can lead to overexertion and 

spasm. When muscles are locked in spasm, high-velocity manipulations are 

more likely to cause tearing than relaxation. If torn muscles intensify the 

existing spasm, the cycle may become (1) spasm, (2) high-velocity 

manipulation, (3) tearing, and (4) spasm. As a result of this cycle, patients 

66 


experience another cycle: (1) pain and stiffness, (2) high-velocity 

manipulation, (3) short-term relief, and (4) pain and stiffness. This cycle often 

continues until the high-velocity treatments are stopped or joints become 

totally unstable. 

Even if high-velocity manipulations are stopped, the scar tissue laid down 

during tearing can still be a problem. Once scar tissue forms within a muscle, 

losses of strength and extensibility increase the risk of re-injury. Re-injuries 

may cause protective spasm that limits range of motion and causes pain. 

Indications of re-injury such as joint stiffness and pain normally occur within 

24 to 48 hours after the insult. 

Original injuries and re-injuries produce almost the same sequel. First, 

trauma releases pain-producing chemicals such as histamine and bradykinin. 

Second, spasm and edema restrict blood flow and cause secondary hypoxic 

damage from ischemia. Third, secondary damage releases more painproducing 

chemicals and spreads the edema. And fourth, as inflammation 

subsides and wound healing begins, connective tissue replaces muscle tissue 

and muscles lose extensibility and strength. 

High-velocity manipulations are also more likely to cause fracture, 

paralysis, and death than low-velocity manipulations. When bone cannot 

stretch fast enough to accommodate rapid loading, fractures occur along lines 

of weakness. Bone fragments can sever nerves or blood vessels and cause 

paralysis or death. In some cases, high-velocity cervical manipulations have 

caused nerve damage or death by traumatizing vertebral or basilar arteries 

(vertebrobasilar insult). 

Although some problems may require high-velocity manipulations, lowvelocity 

manipulations are normally safer and more effective. The risk of 

tissue damage is less and many patients require fewer treatments. If highvelocity 

manipulations are needed, low-velocity techniques can be used to 

relax and stretch tissues before and after thrusting. 

Despite the potential dangers from using high-velocity manipulations, the 

risk of causing serious injury or death is very small provided the doctor 

performing the manipulation is well trained. As a general rule, chiropractors 

and osteopaths are better qualified to perform high-velocity manipulations than 

medical doctors. In the case of low back pain, any form of manipulation is 

potentially safer (and often more effective) than medication or surgery. 

67 


68 

DYNAMICS OF SOFT-TISSUE THERAPY 

All forces used in soft-tissue therapy fall into one of four basic categories: 

(1) tension, (2) compression, (3) shear, or (4) torque. Unlike older methods 

that use imprecise terms such as stripping or stroking to classify 

manipulations, the HEMME APPROACH uses physics and biomechanics to 

describe each technique with as much precision as possible. The terms 

tension, compression, shear, and torsion can be used to describe any technique 

found in trigger point therapy, neuromuscular therapy, connective tissue 

therapy, or range-of-motion stretching. The periods of time before and after 

manipulation are classified as neutral: the absence of external force. 

Four Categories of Forces Used in Soft-Tissue Therapy 

Tension: A force that pulls objects apart (stretch). 

Compression: A force that pushes objects together (press). 

Shear: A force that causes parallel but opposite movement (slide). 

Torque: A force that causes rotation about an axis (twist). 

The above four categories of force combined with magnitude of force, 

direction of force, and rate of loading define any techniques possible in softtissue 

therapy. Some techniques are basically a single force acting on tissue 

such as heavy pressure in trigger point therapy (compression) or slow 

stretching in range-of-motion stretching (tension). Heavy refers to the 

magnitude of force and slow refers to rate of loading. Other techniques are 

two or more forces acting together: skin rolling (compression and tension) or 

cross-fiber friction (compression, tension, and shear). When applied to a joint, 

distraction refers to tension and approximation refers to compression. 

The main directions in soft-tissue therapy are parallel, perpendicular, and 

diagonal. Cross-fiber friction is normally perpendicular to a tendon, and 

connective tissue stretching is normally diagonal to the surface of the body 

(compression) and parallel to fascia (tension). When applied to skeletal 

muscles in neuromuscular therapy, slow-converging parallel forces inhibit 

(compression), rapid-diverging forces facilitate (tension), slow-perpendicular 

forces inhibit (tension), and rapid-perpendicular forces facilitate (tension). 


69 

Table of Figures 

Figure 1: Belly of muscle with tendons (origin and insertion). 

Figure 2: Neutral position: no external force is acting on the muscle. 

Figure 3: Tension: used for range-of-motion stretching. 

Figure 4: Tension: quick tension that is used to facilitate muscles. 

Figure 5: Compression: slow compression that is used to inhibit muscles. 

Figure 6: Compression: pressure that is used to neutralize trigger points. 

Figure 7: Shear: parallel force that is used to stretch connective tissue. 

Figure 8: Torque: rotating force that is used to break scar-tissue adhesions. 



70


71


72


73

Lack of precision when defining classical soft-tissue techniques has made 

scientific study difficult. By defining techniques more carefully, it is possible 

to draw correlations between the forces applied, the tissues affected, and the 

effects. Principles of therapy are the link between the forces applied to the 

body (cause) and how tissues are affected (effect). For example: 

(1) Passive tension (stretch) quickly applied longitudinal (parallel) to a 

muscle facilitates contraction: Sherrington's reflex. 

(2) Compressing tissue that overlies the insertion of a muscle tends to 

inhibit the muscle: Hilton's law. 

(3) Slow, constant, low-level force (tension) applied over long periods 

of time to connective tissue reduces tissue viscosity, decreases 

resistance to stretch, and causes a permanent increase in length: creep. 

METHODS OF SOFT-TISSUE THERAPY 

There are four basic approaches to soft-tissue therapy: (1) trigger point 

therapy, (2) neuromuscular therapy, (3) connective tissue therapy, and (4) 

range-of-motion stretching. Even though these four approaches cover all four 

types of tissue found in the human body—nerve, muscle, connective, and 

epithelial tissue—and trigger points, it is highly unlikely that any type of softtissue 

impairment can ever be treated effectively by using only one approach. 

Even if a body part responds to a single type of therapy, there is always a 

chance that treating only one body part will not correct the entire problem. The 

human body is so integrated that soft-tissue impairments in one body part 

often affect other body parts. Even if problems in one body part respond 

favorably to one type of therapy, the problems created in other parts by the 

original soft-tissue impairment may not respond to the same type of therapy. 

Even so, these four basic divisions are still useful in terms of organizing 

information and separating one set of procedures from another. In general 

terms, trigger point therapy deals with trigger points, neuromuscular therapy 

deals with nerves and muscles, connective tissue therapy deals with connective 

and epithelial tissue, and stretching deals with all types of tissue. 

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75 

TRIGGER POINT THERAPY 

Trigger points are hyperirritable spots or zones that produce pain when 

stimulated by compression. When pressure is correctly applied, trigger points 

often refer pain to other areas. The patterns of pain referral produced by active 

trigger points are somewhat predictable and may overlap the pain referral 

patterns of other active trigger points. 

The onset of trigger points can be sudden or insidious, and trigger points 

are thought to be caused by fatigue, mechanical stress, changes in temperature, 

nutritional deficiencies, hormonal changes, infections, allergies, or ischemia. 

Regardless of the cause, most trigger points seem to have a lower 

concentration of oxygen than surrounding tissue. 

Trigger points can appear as nodules or palpable bands of tense, hard 

(indurated) tissue. When trigger points occur in muscles, the indurated tissue 

may be caused by trigger points interacting with muscle spindles. When 

activated by rapid stretching or noxious stimuli, muscle spindles may cause 

abnormal hardness within a muscle by facilitating the contraction of muscle 

fibers. Although not proven, trigger points within a tendon may also cause 

abnormal hardness within a muscle if trigger points interact with the Golgi 

tendon organs and stop the normal flow of negative feedback to a muscle that 

prevents contraction. Even though trigger points can occur in cutaneous, 

ligamentous, or periosteal tissue, the trigger points called myofascial trigger 

points that occur in muscles and fascia are probably the most common. 

While commonly called points, trigger points are more likely to occur as 

discrete zones than small discrete points. Sometimes a large portion of a 

muscle, or even the entire muscle, responds as a single trigger point. 

Neutralizing several points within a hypersensitive muscle will sometimes 

neutralize the trigger points that are not treated by pressure and relax the entire 

muscle. Even though trigger points are sometimes inactive for long periods of 

time, they are not considered self-limiting, and complete neutralization of a 

trigger point without treatment is rare. 

Trigger points normally produce deep aching pain as opposed to 

superficial pain. When pressure stimulates trigger points, the patient may 

recoil or experience autonomic responses such as vasoconstriction, 

perspiration, or dizziness. Activation of trigger points can also cause severe 


spasm, muscular weakness in surrounding muscles, involuntary tremors, 

twitching, fasciculations, or difficult breathing (dyspnea). Pain can radiate to 

other parts of the body and stimulate satellite trigger points. Except for trigger 

points of the sternum, where pain-referral patterns are sometimes bilateral, 

pain-referral patterns for most trigger points are unilateral. 

Trigger points can produce changes in skin temperature, as evidenced by 

palpation or shown by thermograms. Temperatures higher than normal may 

indicate active inflammation or rapid metabolism. Temperatures lower than 

normal may indicate circulatory insufficiency or sluggish metabolism. Spasm 

and edema are two of the main causes for circulatory failure in soft tissue. 

High rates of metabolism and low rates of circulation produce ischemic 

damage that corresponds with pain and weakness. When trigger points are 

properly treated, temperatures normalize, circulation improves, pain 

diminishes, and muscles become stronger. 

Some trigger points are easier to locate when muscles are stretched. If 

stretching a body part produces a dull pain, palpate the stretched muscle for 

trigger points. If trigger points cannot be found, the origin of pain is possibly 

the joint or joint capsule. Trigger points normally produce intermittent pain as 

opposed to joint or capsular pain that is normally present day and night. 

Trigger points of recent origin are often easier to treat than trigger points 

of long-standing duration. In cases of chronic pain, most patients are more 

aware of general pain than specific pain. They often express surprise when a 

practitioner discovers areas of pain that their own senses failed to identify. 

Since trigger points of recent origin are easier to locate, acute trigger points 

often take less time to eliminate than chronic trigger points. 

Locating trigger points depends on the identification of certain 

characteristic signs. The most common signs are (1) pain when pressure is 

correctly applied, (2) thickening of subcutaneous tissue, (3) a jump sign, (4) a 

twitch response, and (5) ropiness or hardness within a muscle. 

The simplest test for trigger points is the appearance of pain when pressure 

is correctly applied. Light pressure can be applied by using the fingers or 

thumb to compress suspect tissues or pinching can be used when testing 

muscles that are small enough to grasp between the thumb and fingers. 

If a patient recoils while pressure is being applied, the jump sign is 

positive. If the trigger point is in a muscle, slight pressure will sometimes 

76 


cause spontaneous contraction of the entire muscle. This contraction may or 

may not be strong enough to move the affected body part. A positive jump 

sign combined with simultaneous radiation of pain to other parts of the body is 

strong evidence of trigger point involvement. 

Cutaneous tissue responses and a positive twitch response can be used for 

additional verification. If skin that is pinched and pulled away from the body 

feels coarse, granular, and inelastic, cutaneous tissue responses are positive. If 

taut bands of indurated tissue within the muscle respond elastically by 

snapping back into place when tension from transverse stretching is released, 

the twitch response is positive. 

The amount of pressure used during palpation is critical because too much 

pressure can obscure physical signs. Responses produced by light pressure are 

sometimes canceled by heavy pressure that restricts tissue movement and 

deadens pain. Light pressure is also more sensitive to differences in tissue 

consistency than heavy pressure. In some cases, heavy pressure will change 

tissue consistency before a difference in tissue compliance can be felt. In 

trigger point therapy, it is not uncommon for evaluation and treatment to occur 

simultaneously. Even light palpation will at times neutralize trigger points. 

When locating trigger points in thick muscles or trigger points covered by 

several layers of tissue, heavy pressure can be applied by using the elbow. 

Although light pressure is normally more discriminating than heavy pressure, 

light pressure does not always penetrate far enough to locate or treat trigger 

points in deep tissue. Another method is using light pressure for longer 

periods of time to penetrate thick flesh and reach deep trigger points. It is 

often safer to start with light pressure applied for a long period of time than to 

start with heavy pressure applied for a short period of time. 

Muscle weakness and resistance to passive stretch are consistent with 

trigger point activity, but not definitive because spasm, contracture, and 

various neurologic conditions produce similar conditions. If taut bands of 

muscle tissue are compressing a nerve, the physical signs are similar to those 

caused by fibrous or osteofibrous entrapment: nerve conductivity may be 

reduced and patients may feel weakness, aching pain, or paresthesia. If the 

taut bands of muscle tissue are being caused by trigger points, trigger point 

therapy and stretching should free the nerve and relieve the symptoms. 

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78 

Three factors seem to explain why trigger point therapy reduces pain: 

Digital pressure disperses pain-producing chemicals. 

Digital pressure stimulates production of endogenous opioids. 

Trigger points activated by pressure act as a counterirritant. 

• First, when digital pressure disperses blood and pain-producing 

chemicals away from trigger points, surrounding tissues become ischemic, as 

indicated by blanching (whiteness) of the skin. A decrease in electrical 

conductivity after treatment indicates that pressure has dissipated painproducing 

electrolytes such as potassium ions. Immediately upon release of 

pressure, blood reacts to a lowered hydrostatic pressure by reentering ischemic 

areas, as indicated by flushing (redness) of the skin. The redness is caused by 

hyperemia. The net effect of ischemic pressure and reactive hyperemia is a 

lower concentration of pain-producing chemicals such as histamine, 

bradykinin, and prostaglandin, and a higher concentration of oxygen. Since 

pain-producing chemicals stimulate nociceptors and cause pain, lower 

concentrations should reduce pain. The mechanical effects produced by 

injecting trigger points are similar to those produced by using digital pressure. 

Fortunately for the patient, a single application of digital pressure produces the 

same amount of fluid exchange that it would take multiple injections to 

produce. 

• Second, trigger point therapy relieves pain by stimulating the body to 

produce endogenous opioids such as endorphins that affect the limbic system 

and brain stem, enkephalins that affect the central nervous system, and 

dynorphins that are active in the brain and pituitary. Endogenous opioids 

produce analgesia by binding to opiate receptor sites involved in pain 

perception. Not only do opioids produce a type of analgesia similar to that 

produced by opiates, but also the effects of both substances are canceled by a 

drug called naloxone that prevents or reverses the effects of morphine and 

other opioid drugs. When patients receive naloxone, the pain-relieving effects 

of trigger point therapy and acupuncture are greatly reduced. 


• Third, trigger point therapy relieves pain by acting as a counterirritant. 

According to Melzack and Wall's gate-control theory of pain, the large 

diameter A-beta nerve fibers that transmit superficial pain can inhibit the small 

diameter A-delta and C nerve fibers that transmit deep pain. Since most 

people find superficial pain more tolerable than deep aching pain, 

counterirritants such as trigger point therapy and chemical irritants are often 

useful. Some people refer to superficial pain as a "good hurt." The most 

common chemical irritants are those that feel hot or cold when applied to the 

skin. Contrary to popular advertisements, these ointments do not penetrate 

deeply into muscles. Like most counterirritants, they relieve pain by acting on 

superficial tissue. 

Although trigger points seldom follow segmental distribution patterns such 

as dermatomes, myotomes, or sclerotomes, patterns of distribution tend to be 

similar for most people, and similar trigger points seem to produce a similar 

pain-distribution pattern. If trigger points are found in one muscle, it is 

common to find other trigger points in adjacent muscles, opposing muscles, or 

synergistic muscles. It is also common to find that trigger points often 

correspond with motor points, neurovascular points, and acupuncture points. 

Satellite trigger points are trigger points activated by another trigger point 

in the same reference zone. When left untreated, satellite trigger points can 

become primary trigger points and develop their own satellite patterns of 

distribution. Untreated satellite trigger points can also reactivate primary 

trigger points that became clinically quiescent after treatment. 

Secondary trigger points develop in a synergist or antagonist because of 

overload. When active trigger points debilitate a muscle and make it more 

resistant to range-of-motion stretching, synergistic muscles try to compensate 

for the loss by substitution, while antagonistic muscles are forced to work 

harder because the agonist is more difficult to stretch. This creates an overload 

that encourages secondary trigger points to form. Since muscles normally 

work in cooperation with other muscles, when treating the agonist, always 

check antagonistic and synergistic muscles for trigger points. 

Muscles at or slightly beyond resting length produce the strongest 

contractions. Within this range, the myofilaments of the muscle are aligned in 

ways that produce optimal overlap and maximal force. Too far below resting 

length, there is too much overlap and muscles exert less force. Too far beyond 

resting length, there is too little overlap and they also exert less force. 

79 


Since strength measures a muscle's ability to contract and exert force, 

strength and resistance to active or passive stretch are not the same. Even 

though a muscle may appear taut and give the appearance of being strong, the 

muscle's ability to contract and exert force may be less than normal. 

Abnormal shortness of an antagonist because of trigger point activity may 

cause abnormal stretching of the agonist and weakness in both muscles. 

Trigger point therapy that helps a muscle achieve its optimal length for 

contraction will produce an increase in strength. In addition to helping 

muscles achieve their optimal length, trigger point therapy can increase 

strength by reducing pain and consequently reducing pain inhibition. 

Unlike active trigger points that refer pain at rest or in motion, latent 

trigger points are painful only when palpated or compressed. Latent trigger 

points can lie dormant for years until stimulated by some form of stress. After 

long periods of quiescence, painful attacks may result from stretching, 

compressing, chilling, or fatiguing the tissue afflicted by latent trigger points. 

Other causes of activation include disease or emotional stress. 

After trigger points are located by palpation, moderate to heavy digital 

pressure can often be used to neutralize a trigger point. Just as some trigger 

points cannot be located when the muscle is relaxed, some trigger points are 

difficult to treat when the muscle is relaxed. It is often easier to feel a trigger 

point change from hard to soft when the affected muscle is contracted or 

stretched during treatment. Muscles under tension may also lengthen during 

treatment if the muscles were abnormally short before treatment. 

Even though digital pressure is normally effective in treating trigger 

points, the amount of pressure needed varies from case to case. Moderate to 

heavy pressure is normally more effective than light pressure. Trigger points 

in large deep muscles or muscles that overlay soft-tissue often require more 

pressure than trigger points in small superficial muscles or muscles that 

overlay bone. 

Compared with moderate to heavy pressure, light pressure is more likely to 

cause facilitation than inhibition. When trigger points in muscles are 

stimulated by light pressure, hypertonia and spasm may increase as the muscle 

attempts to guard itself against the insult. With light pressure, pain tends to 

increase and then remain constant. This differs from moderate to heavy 

80 


pressure that normally causes pain to intensify and then diminish as the 

pressure continues and the muscle starts to relax. 

When moderate to heavy pressure is used, pressure should be applied 

slowly and released slowly. Slowly applied pressure causes less trauma 

because tissues have more time to absorb force and accommodate the changes 

caused by pressure. Slowly released pressure lessens the recoil effect that 

normally occurs after pressure is removed. Both measures will increase the 

patient's comfort and improve the probabilities that treatments will have a 

longer-lasting effect. 

Though treatment times for trigger points are sometimes given as ten to 

twenty seconds, there is no way to give a definite time that applies to all 

situations. The best method is continuing pressure until the therapist feels an 

obvious reduction in tissue consistency or turgor (fullness). At this point, 

tissue will give the appearance of "melting away" or "melting down." In a 

large, indurated muscle, changes in tissue consistency may take one or more 

minutes to occur. The gluteus maximus can take five or more minutes. 

The normal sequence is a sharp increase in pain followed by a gradual 

decrease in pain. Just before a trigger point is neutralized, many patients 

report a feeling of pressure but not pain. If the patient reports no reduction in 

pain after one minute of pressure, stop the pressure and look for signs or 

symptoms that indicate a trigger point is not causing the pain or the trigger 

point being treated is not causing the pain. If the pain is being referred from 

another trigger point, find and treat the origin of pain. If the pain is being 

caused by inflammation, edema, acute traumatic injury, or nerve entrapment 

by osseous tissue, trigger point therapy will not be effective. 

If pain continues to decrease as pressure is being applied, continue 

pressure until the affected tissues become less resistant to pressure. A 

decrease in tissue consistency normally coincides with pain relief. If trigger 

point therapy is successful, the patient will experience less pain and greater 

mobility within minutes after treatment. 

If a patient cannot tolerate digital pressure, it may be possible to pinch the 

skin directly over the trigger point and partially desensitize the area by reflex 

effect. Once the skin is desensitized, trigger points are normally less sensitive 

to pressure. It is not uncommon to find that skin pinching will sometimes 

neutralize trigger points in a muscle without further treatment. 

81 


A question periodically arises concerning the advisability of using hard 

implements such as wooden or plastic dowels (T-bars) to compress trigger 

points. These instruments can generate great pressure, but lack the sensitivity 

of hands or elbows and are more likely to cause injury than pressure applied 

by human touch. A practitioner who constantly finds a need to apply pressure 

with a T-bar may be using too much pressure. 

The final phase of trigger point therapy is stretching. If tissues are not 

stretched to a normal length, trigger points are likely to recur. Low-velocity 

stretching helps to restore normal length without causing a stretch reflex or 

tearing tissues. Another way to avoid the stretching reflex is to have the 

patient actively stretch the affected muscle at the same time passive stretching 

is being used. Even though range-of-motion stretching may eliminate some 

trigger points without trigger point therapy, it can also irritate trigger points 

and cause spasm. Stretching is normally safer and much less painful if trigger 

points are neutralized before range-of-motion stretching. 

As a rule, extensive trauma and long-standing chronicity will increase the 

number of treatments needed to neutralize all the existing trigger points. 

Another factor to consider is quality of treatment. When injured body parts are 

mobilized early, trigger points are often less numerous. Prolonged 

immobilization or bed rest seems to encourage trigger points. Lifestyle can 

also be a factor. Smoking, lack of sleep, and poor nutrition can make trigger 

point therapy more difficult. The most common nutritional deficiencies that 

affect trigger points are a lack of vitamin C, vitamin B-complex, and iron. 

It is common to treat identifiable trigger points during one session and 

have the patient return for the next session with entirely different trigger 

points. Apparently the elimination of primary points during the first session 

can make secondary trigger points more discernible during the second session. 

Treatment should always be continued until all trigger points are eliminated. 

Great improvements may occur after just one treatment. 

Trigger point therapy can be palliative or curative. If the trigger points 

being treated are only symptoms of a problem, relief can be expected but not a 

cure. If the trigger points being treated are causing the pain, neutralizing the 

trigger points should effect a cure. When trigger points are the origins of pain, 

light pressure should reproduce the signs and symptoms and heavy pressure 

should eliminate the signs and symptoms. 

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83 

TRIGGER POINT THERAPY VS. CROSS-FIBER FRICTION 

Trigger point therapy can often be used to supplement or replace crossfiber 

friction. Trigger point therapy is faster, less painful, and produces many 

effects that are similar to those produced by cross-fiber friction. When used 

together, trigger point therapy anesthetizes highly sensitive (hyperesthetic) 

tissue and cross-fiber friction stretches restricted tissue. Whether friction 

aligns connective tissue as sometimes suggested is open to debate. 

Based on Wolff's law, collagen fibers develop a structure most suited to 

resist the forces acting on them. It appears that lines of stress produce 

piezoelectric forces that align fibroblasts and reorganize collagen fibers in a 

matrix composed of intercellular material. The factors determining the 

strength of piezoelectric currents are the (1) intensity, (2) frequency, and (3) 

duration of the forces acting on the collagen fibers. 

Compared to the forces generated by daily activity, the intensity of crossfiber 

friction is high, but frequency and duration are low. In terms of intensity, 

frequency, and duration, it appears that mobilization, range-of-motion 

stretching, and exercise would have a greater effect on the alignment of 

collagen fibers than cross-fiber friction. 

What cross fiber-friction may do more effectively than trigger point 

therapy is shear the inappropriate cross-links that form between collagen fibers 

during the early stages of wound healing. Too many cross-links or poorly 

placed cross-links reduce tissue extensibility and range-of-motion. Improving 

the distribution of cross-links would allow injured tissues to lengthen properly 

as the body resumes its normal activities. Even so, the question of whether 

cross-fiber friction is the best way to improve the distribution of cross-links is 

also open to debate, since early mobilization and range-of-motion stretching 

will also improve the distribution of cross-links. 

Early mobilization is another way to reduce cross-links. Whenever 

possible, injured parts should be mobilized several times per day as collagen 

fibers proliferate and realign. Failure to do this often results in long-standing 

disability that requires extensive soft-tissue therapy to correct. 

The major problem with cross-fiber friction is probably the pain. After 

one or two sessions, many patients never return. There is also a chance that 

cross-fiber friction will traumatize tissue and cause trigger points. 


84 

NEUROMUSCULAR THERAPY 

Neuromuscular therapy is characterized by manual techniques that inhibit 

or facilitate muscle fibers. The primary tissues acted upon are nerve and 

muscle tissue. Facilitation is the enhancement or reinforcement of a reflex and 

inhibition is depression or arrest of a reflex. Inhibition encourages elongation 

and facilitation encourages shortening. 

Extensibility is the ability of muscle fibers to lengthen and contractility is 

the ability of muscle fibers to shorten. Muscles can lengthen to 50 percent 

more than resting length and shorten to about 50 percent less than resting 

length. Inhibition helps to lengthen hypertonic muscles by relaxation and 

facilitation helps to shorten hypotonic muscles by contraction. 

Neuromuscular techniques strengthen a muscle by eliminating the factors 

that cause weakness. This allows a patient to attain the greatest amount of 

strength possible without using exercise to change the upper limit of strength. 

By using inhibition and facilitation to balance opposing muscles in terms of 

length and strength, neuromuscular therapy restores function and prepares a 

patient for the next stage of therapy, which is normally exercise. 

Inhibition encourages relaxation by decreasing reflex activity and 

facilitation encourages contraction by increasing reflex activity. The two basic 

principles are (1) deactivating any facilitating mechanism tends to inhibit a 

facilitated muscle and (2) deactivating any inhibitory mechanism tends to 

facilitate an inhibited muscle. 

As the opposite of inhibition, facilitation enhances reflex activity that 

causes contraction. The least amount of stimulus needed to produce a motor 

response is called the absolute threshold. When stimulation exceeds the 

absolute threshold, muscles contract and produce force. 

If a muscle produces enough force to overcome resistance, the muscle 

contracts isotonically and shortens. If a muscle does not produce enough force 

to overcome resistance, the muscle contracts isometrically and remains the 

same length. Isotonic contractions are used for locomotion or moving objects. 

Isometric contractions are used for holding objects stationary. 

Removing any factors that cause inhibition will not always cause 

contraction. Even without inhibition, if the existing level of stimulation is not 

greater than the absolute threshold, a muscle will not contract. 


The immediate goal of neuromuscular therapy is muscular balance. This 

means balancing and normalizing opposing muscles or muscle groups in terms 

of length and strength. The effects of muscular imbalance are pain and limited 

range of motion. Pain results when muscles and joints are abnormally stressed 

by asymmetrical forces. Limited range of motion is caused by agonistic 

muscles that are too weak to initiate movement or antagonistic muscles that 

are too short to allow movement. 

Although pathologic joints can produce pain and limit range of motion, 

dislocations, loose bodies, and menisci tears are less common than muscular 

imbalance. Even when joints are implicated, muscular imbalance may have 

caused the joint to become dysfunctional. First, asymmetrical forces acting on 

the joint may cause one side of the joint to wear more rapidly than the other 

and cause irritation. Second, when both muscle pairs are too short, excessive 

tension reduces joint space and limits range of motion. If restoring muscular 

balance normalizes the joint, muscles are more likely than joints to be the 

cause of disability. 

Even if joints are the initial cause of disability, splinting often occurs 

almost immediately to protect the joint. This makes it difficult to tell which 

came first: a joint problem that causes excessive muscle tension or a muscle 

problem that reduces joint space and irritates the joint. Regardless of which 

condition occurred first, normal joints should not be hot or swollen and normal 

muscles should not be indurated or painful when relaxed. 

Meltzer's law of contrary innervation states that all living functions are 

controlled by two opposing forces. This law relates to the Chinese concept of 

yin-yang, which states that opposing and complementary forces control all of 

nature. In neuromuscular therapy, the opposing forces are inhibition and 

facilitation. Inhibition restrains an action or process and facilitation promotes 

an action or process. When neuromuscular techniques are used to balance 

muscles, inhibition and facilitation produce the following results: 

(1) Inhibition: 

• Lengthen hypertonic muscles; 

• Strengthen weak muscles. 

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86 

(2) Facilitation: 

• Shorten stretched muscles; 

• Strengthen weak muscles. 

By causing relaxation, inhibition can help to lengthen short muscles and 

strengthen weak muscles. If a muscle is abnormally short because of spasm 

(hypertonia), inhibition can make it easier to lengthen the muscle by 

decreasing the muscle's internal resistance to active or passive stretch. Even 

though inhibition may cause a transitory weakness when applied to a normal 

muscle, inhibition applied to a hypertonic muscle may cause an increase in 

strength. This runs contrary to the popular belief that inhibition always 

weakens a muscle and facilitation always strengthens a muscle. 

Inhibition strengthens a muscle by (1) allowing muscle fibers to assume 

their optimal length before contraction, and (2) by reducing pain inhibition. In 

terms of achieving maximum strength, muscles that are capable of being 

stretched to at least resting length are potentially stronger than muscles that are 

not capable of being stretched to at least resting length. 

If spasm causes a muscle to be shorter than resting length, the muscle will 

be unable to exert maximum force. If relaxation allows the muscle to reach at 

least resting length, inhibition will increase, not decrease, strength. This occurs 

because muscles cannot produce maximum force when actin and myosin 

myofilaments are excessively overlapped. Since muscles produce the greatest 

amount of force when contraction begins at a length equal to or slightly 

beyond resting length, inhibition techniques can strengthen a muscle by 

reversing the adverse effects that are caused by too much facilitation. 

Second, when treating a cramp, inhibition and relaxation may increase a 

muscle's ability to exert force more than facilitation. A cramp is a painful 

spasm caused by a prolonged tetanic contraction. When a cramp is present, 

one of the main factors limiting strength is pain inhibition. Since inhibition 

techniques are more likely to stop a cramp and relieve pain than facilitation 

techniques, inhibition will sometimes increase strength more than facilitation. 

Facilitation can shorten stretched muscles and strengthen weak muscles. 

A muscle that is stretched for extended periods of time has a tendency to 

remain stretched and become weak. This condition is called stretch weakness. 


Facilitation techniques can reverse the effects of stretch weakness in two 

ways: (1) shorten the muscle by encouraging muscle fibers to contract and 

maintain normal tonus, and (2) strengthen the muscle by reversing the effects 

of inhibition. When facilitation techniques are used to reeducate muscle 

fibers, strength tends to increase because of greater neurologic efficiency 

within the muscle. If muscles are stretched far beyond their resting length, 

facilitation will improve strength by allowing muscles to reach a length near 

resting length, which is more conducive to exerting force. 

The standard protocol for using neuromuscular therapy to lengthen 

hypertonic muscles, strengthen weak muscles, shorten stretched muscles, and 

balance muscles or muscle groups is: 

Test for active, passive, or passive-assisted range of motion. 

Use inhibition to lengthen and strengthen short tissues. 

Test for strength by using resisted range-of-motion testing. 

Use facilitation to strengthen and shorten weak muscles. 

Retest for length and strength. 

Treat again if necessary. 

The underlying principle that applies to almost any method of soft-tissue 

therapy is lengthen first and strengthen second. Rarely would it be advisable 

to strengthen a muscle with a limited range of motion. 

When dealing with two opposing muscles, the same principle can 

normally be applied. If (1) the agonist is short, (2) the antagonist is long, and 

(3) both muscles are weak, the first step would be using inhibition to lengthen 

the agonist. This will decrease tension on the antagonist and make it more 

difficult for the antagonist to remain stretched. The next step would be using 

facilitation to strengthen and shorten the antagonist. This will increase tension 

on the agonist and make it more difficult for the agonist to remain short. If this 

approach fails, use the antagonist to stretch the agonist by strengthening the 

antagonist first and then passively stretching the agonist. 

If opposing muscles test long and weak, which is not likely, strengthen 

both muscles first and monitor length to ensure that all muscles shorten at the 

same rate. Care should be taken not to overstretch either muscle. 

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88 

KEY POINT: LENGTHEN FIRST and STRENGTHEN SECOND 

Another sequence that applies to most forms of therapy is test, treat, 

retest, and treat again if necessary. Testing gives therapy direction and 

allows both practitioner and patient a chance to monitor progress. It is often 

difficult for a patient to comprehend progress unless the practitioner points 

out benchmarks and measurable objectives. 

Do not replace testing with the assumption that stretched muscles are 

always weak and contracted muscles are always strong. Strength measures 

the ability of muscle to exert force as opposed to the ability of muscle to 

resist active or passive stretch. Although "short" muscles will normally test 

stronger than "long" muscles, hypertonic muscles can be highly resistant to 

passive stretch but test weak. That one muscle is too long and the opposing 

muscle is too short does not mean that both muscles are not weak. 

Inhibition and facilitation are not substitutes for exercise. Using 

neuromuscular therapy to normalize a muscle is different from using 

exercise to strengthen a muscle. The two main factors affecting strength are 

neurologic efficiency and muscle mass. Neuromuscular techniques and 

exercise both affect neurologic efficiency, but only exercise increases mass. 

When muscles are repeatedly forced to develop maximal or near 

maximal tension, individual muscle fibers may increase in size because of 

hypertrophy. When all other factors (such as motivation and neurologic 

efficiency) are equal, hypertrophy is the only way muscles become stronger. 

Though not a replacement for exercise, inhibition and facilitation can be 

used to prepare muscles for exercise. If muscles are not properly balanced, 

exercise may prolong or exacerbate any existing imbalance. 

Muscle imbalance contributes to many disabilities. When opposing 

muscles are not symmetrical in terms of length or strength, the tension on 

joints is not symmetrical and stronger muscles may stretch or tear weaker 

muscles. Activities that favor one opposing movement over another may 

cause a muscle imbalance that results in poor posture. Activities that 

strengthen the pectoral muscles but not the rhomboid muscles may cause the 

shoulders to be drawn forward and a forward head posture. The solution is 

(1) lengthen the pectorals, and (2) strengthen and shorten the rhomboids. 


89 

 

 

 

 

FOUR WAYS TO INHIBIT A MUSCLE 

Activation of Golgi tendon organs 

Deactivation of muscle spindles 

Reciprocal inhibition (RI) 

Post-isometric relaxation (PIR) 

 

 

 

 

FOUR WAYS TO FACILITATE A MUSCLE 

Activation of stretch reflex 

Activation of muscle spindles 

Repeated contractions 

Successive induction 

Of all the different methods used to inhibit and facilitate muscles, the 

most common are those involving sensory end organs called proprioceptors 

that respond to stimulus originating within the body, such as pressure, 

equilibrium, or stretch. Proprioceptors give information concerning 

movements and positions of the body. In terms of neuromuscular therapy, 

the two most important proprioceptors are (1) Golgi tendon organs (GTOs) 

that measure the amount of tension being applied to a tendon, and (2) muscle 

spindles (MSs) that measure how rapidly and to what extent muscles are 

changing in length. 

Based on the premise that inhibition is the opposite of facilitation: (1) 

activating GTOs inhibits a muscle, (2) deactivating GTOs facilitates a 

muscle, (3) activating MSs facilitates a muscle, and (4) deactivating MSs 

inhibits a muscle. Of these four methods, deactivating GTOs is the least 

useful in clinical practice. First, other than slacking in a muscle, there is no 

practical way to deactivate GTOs. Second, if the existing level of stimulation 

is not greater than the absolute threshold, removing inhibition will not cause a 

muscle to contract. Contraction requires adequate stimulation. 


90 

INHIBITORS 

Activation of Golgi Tendon Organs (Inhibition) 

If stretching a tendon produces enough tension, the Golgi tendon organs 

generate electrical impulses that relax muscle fibers. GTOs can be activated 

by active or passive tension and appear to be a protective mechanism that 

protects muscles from being torn and tendons from being ruptured or torn 

away from the bone (avulsed). 

To activate the GTOs, tendons are commonly stretched in three ways: 

(1) direct stretching by contracting the agonist, (2) active stretching by 

contracting the antagonist, and (3) passive stretching by using external force. 

When stretched by contracting the agonist, isometric contractions generate 

more tension than isotonic contractions. When actively stretched by the 

antagonist or passively stretched by external force, the tension is greatest 

when the muscle being stretched is abnormally short because of contraction 

or contracture. 

Three cautions using tension to activate the Golgi tendon organs: 

(1) Contracting a muscle when the insertions are not far enough apart to 

apply tension on the muscle may cause cramping. This can be demonstrated 

by flexing the elbow joint until the hand touches the shoulder and then 

slowly and carefully contracting the biceps brachii. Pain and cramping are 

normally felt as muscles start to shorten. 

(2) GTO inhibition can be overridden by training or motivation. When 

GTOs are activated by tension, descending impulses from the brain can 

mediate the reflex. Athletes often injure muscles and tendons despite the 

protection provided by Golgi tendon organs. 

(3) Actively or passively stretching a normal muscle far enough to cause 

inhibition by the Golgi tendon organs may traumatize the joint. In most 

cases, pain receptors in ligaments and joint capsules react faster than GTOs 

to protect the joint and tissues surrounding the joint (periarticular tissue). If 

these warnings are ignored, the joint may be damaged. 


In situations where muscles are shortened by contraction or contracture, 

the Golgi tendon organs are normally activated before the pain receptors in 

ligaments or joints. If a muscle is hypertonic, it is also possible that active 

or passive stretching may relax the muscle by decreasing the number of 

cross-bridges between actin and myosin myofilaments. The effect would be 

similar to that produced by Golgi tendon organ inhibition. 

Theoretically, muscles can be inhibited or facilitated by increasing or 

decreasing the tension on a tendon. Since the concentration of GTOs is 

greater at the musculotendinous juncture than at the periosteal-tendinous 

juncture, pulling a tendon away from the musculotendinous juncture should 

cause inhibition and pushing a tendon toward the juncture should cause 

facilitation or stop inhibition. 

In practice, locating the musculotendinous juncture is difficult and being 

able to apply enough force to activate or deactivate the GTOs is even more 

unlikely. The amount of force needed to activate or deactivate GTOs is 

much higher than the amount of force needed to activate or deactivate 

muscle spindles. To cause inhibition, a better approach is using direct 

pressure on tendons to relax hypertonic muscles. 

For reasons not entirely understood, direct pressure on tendons may 

cause inhibition and reduce spasm. Whether the process involves the Golgi 

tendon organs or another mechanism is unknown. If pressure causes pain, 

endogenous opiates could be involved. Since many patients report local 

numbness, inhibitory pressure may cause some degree of nerve disruption 

similar to neuropraxia, a condition where nerve conduction stops because of 

trauma. Whatever the cause, direct pressure on a tendon is more practical 

than proprioceptive techniques that involve pulling or pushing a tendon. 

Deactivation of Muscle Spindles (Inhibition) 

Muscle spindles are proprioceptors located throughout a muscle and 

highly concentrated within the belly of a muscle. Where the Golgi tendon 

organs respond to changes in tension, muscle spindle cells respond to 

changes in length or velocity of movement. Extrafusal fibers are muscle 

fibers that are inside the muscle but outside the muscle spindle. Intrafusal 

fibers are muscle fibers within the muscle spindle. 

91 


When intrafusal fiber tension is less than extrafusal fiber tension, the 

muscle relaxes (inhibition). 

When intrafusal fiber tension is less than extrafusal fiber tension, muscle 

spindles cause inhibition and the muscle relaxes. Heat and gentle massage 

may cause a reflex action that encourages intrafusal fibers to relax. 

Another way to cause inhibition is compressing the belly of a muscle 

toward the center to relax intrafusal fibers. This can be done by grasping the 

muscle near the musculotendinous junctures and using convergent force to 

compress the belly until both hands meet in the center. Force is applied 

parallel and slightly perpendicular to the muscle. The rate of movement 

should be slow to very slow and tissues should be allowed to "thin out," 

"melt down," or "dissolve" as the hands move toward the center of the belly. 

The need for anything more than moderate force may indicate that 

movements are too fast. This method should relax hypertonic muscles. 

Reciprocal Inhibition (Inhibition) 

When muscles work in pairs, facilitation of the agonist causes reciprocal 

inhibition of the antagonist. As the agonist contracts, the antagonist relaxes 

to allow stretching by the agonist. If the antagonist fails to relax, the agonist 

may test weak despite normal strength. Coordinated movement is possible 

because one muscle relaxes when the opposing muscle contracts. Anything 

less than total relaxation of the antagonist restricts shortening of the agonist. 

If a flexor muscle is hypertonic, contracting the extensor muscles will 

cause the flexor muscles to relax. If a flexor muscle such as the biceps 

brachii is in spasm, contracting the opposing extensor muscle, the triceps 

brachii, should cause the biceps brachii to relax. The more completely the 

extensor muscles relax, the easier it is for the flexor muscle to generate 

movement. After relaxing a muscle using reciprocal inhibition, the final step 

is stretching the muscle to prolong the effects. 

While the methods for using reciprocal inhibition (RI) are extremely 

varied, most methods have one sequence in common: (1) contract the 

92 


antagonist, (2) relax the antagonist, and (3) stretch the agonist. Among the 

variables that may affect the way reciprocal inhibition is applied are: 

1. Starting and ending length of muscle 

2. Type and strength of resistance and counterforce 

3. Length of hold during contraction 

4. Type of stretch applied after contraction 

5. Breathing patterns 

6. Repetitions 

Based on clinical experience, the method below appears to be one of the 

most effective ways to use RI. The muscle being contracted is called the 

antagonist, and the muscle being stretched is called the agonist. 

1 The patient should start with the antagonist (1) at midrange, a length 

about halfway between fully contracted and fully stretched or (2) at a point 

just short of where the muscle starts to resist stretching (resistance barrier). 

2 The patient applies isometric resistance and the practitioner applies an 

equal amount of isometric counterforce. The strength of contraction for the 

antagonist should be about 25 percent of maximum strength. 

3 The patient should hold the isometric contraction for about 10 seconds. 

4 Shortly after the patient stops contracting the antagonist (about 3 

seconds), the practitioner should stretch the agonist. Slow stretching with 

moderate force will be more effective than rapid stretching with heavy force. 

Stretching should stop at the first sign of resistance or pain. 

5 The patient should breathe slowly out during contraction, breathe in 

during relaxation, and breathe slowly out during stretching. 

6 While up to 5 repetitions are acceptable, RI should be stopped if (1) the 

technique is too painful, (2) the patient's range of motion stops increasing, or 

(3) the patient's range of motion becomes normal. 

93 


Reciprocal inhibition is considered more gentle than inhibition 

techniques that compress or contract the agonist before stretching the 

agonist. Provided the isometric contraction of the antagonist does not 

become a contest of strength between the patient and the practitioner, 

isometric contractions are less likely to cause tissue damage than isotonic or 

isolytic contractions. During an isotonic contraction, the antagonist contracts 

and shortens because the counterforce is less than resistance. During an 

isolytic contraction, the antagonist contracts and lengthens because the 

counterforce is greater than resistance. 

Cocontraction is the opposite of reciprocal inhibition. Cocontraction 

means the simultaneous activation of two opposing muscles. Movement is 

not possible if both the agonist and the antagonist contract at the same time. 

Cocontraction increases the stability and decreases mobility. An example of 

cocontraction is holding a limb rigid. Reciprocal inhibition, on the other 

hand, increases mobility and decreases stability. 

Where limited range of motion is a problem, cocontraction is not 

beneficial. When opposing muscles such as flexors and extensors 

cocontract, the strength in both directions decreases because the extensors 

are working against flexors and flexors are working against extensors. 

Flexion would be stronger if the extensors relaxed and extension would be 

stronger if the flexors relaxed. This explains why some athletes practice 

relaxation to increase strength. Anxiety and tension weaken muscles and 

cause fatigue by encouraging cocontraction. 

Post-Isometric Relaxation (Inhibition) 

If hypertonic muscles are causing a restriction, fatigue can be used to 

inhibit contraction. Isometric contractions are the easiest way to fatigue a 

muscle without causing undue pain. If a hypertonic muscle contracts 

isometrically for about 5 to 10 seconds and then relaxes, the relaxation phase 

and latency period that follow the contraction phase decrease neurologic 

efficiency. Because of this decrease in neurologic efficiency, a muscle 

becomes more relaxed than it was before the contraction phase. During the 

relaxation phase and latency period, muscles become hypotonic and easier to 

94 


stretch. The technique of stretching an agonist after contracting the agonist 

isometrically is called post-isometric relaxation. 

While post-isometric relaxation (PIR), like reciprocal inhibition (RI), is 

subject to many variations, most methods have one sequence in common: (1) 

contract the agonist, (2) relax the agonist, and (3) stretch the agonist. Based 

on clinical experience, the method below appears to be one of the most 

effective ways to use PIR. The muscle being contracted and stretched is the 

agonist. 

1 The patient should start with the agonist (1) at midrange or (2) at a point 

just short of where the muscle starts to resist stretching (resistance barrier). 

2 The patient applies isometric resistance and the practitioner applies an 

equal amount of isometric counterforce. The strength of contraction for the 

agonist should be about 50 percent of maximum strength. 


4 Shortly after the patient stops contracting the agonist (about 3 seconds), 

the practitioner should stretch the agonist. Slow stretching with moderate 

force will be more effective than rapid stretching with heavy force. 

5 The patient should breathe slowly out during contraction, breathe in 

during relaxation, and breathe slowly out during stretching. 

6 While up to 5 repetitions are acceptable, PIR should be stopped if (1) the 

technique is too painful, (2) the patient's range of motion stops increasing, or 

(3) the patient's range of motion becomes normal. 

PIR is considered less gentle than RI because it contracts and stretches 

the same muscle. RI contracts the antagonist and stretches the agonist. If 

contracting the agonist causes extreme pain, PIR may not be safe to use. 

PIR should not be allowed to become a contest of strength, and any 

counterforces used against resistance should be slowly applied and slowly 

removed. While most therapeutic stretching is passive, having the patient 

95 


contract the antagonist while the agonist is being stretched (passive-assisted 

stretching) may help to relax the agonist by reciprocal inhibition. 

When PIR is used, breathing cycles should correspond correctly with 

periods of exertion and periods of relaxation. The best method is having the 

patient exhale during exertion, inhale during relaxation, and exhale while the 

muscle is being stretched. The following commands may help the patient 

understand the sequence: 

• Exhale slowly as you feel the muscle contract. 

• Inhale slowly as you feel the muscle relax. 

• Exhale slowly as you feel the muscle stretch. 

Exhaling during contraction reduces intrathoracic pressure and exhaling 

while muscles are being stretched makes it easier for patients to relax. Some 

patients appear to be less sensitive to pain when exhaling. 

If the elbow joint is normal and the patient is having difficulty extending 

the forearm, the two most likely problems are: (1) the extensor muscles are 

weak, and (2) the flexor muscles are restricted. To determine if these 

conditions exist, resisted range-of-motion testing can be used to evaluate the 

strength of extensor muscles and passive range-of-motion testing can be 

used to evaluate the extensibility of the flexor muscles. 

If the extensor muscles are normal and the flexor muscles are restricted, 

PIR may be a good choice for relaxing and lengthening the flexor muscles. 

Other possibilities would include activation of GTOs, deactivation of MSs, 

and RI. (In most cases, if the flexor muscles are restricted, the extensor 

muscles will be stretched and weak, and synergistic or fixator muscles will 

somehow be involved.) 

Physiological contractures are one exception to the principle that fatigue 

causes inhibition. Unlike normal fatigue, extreme fatigue depletes highenergy 

phosphate reserves (creatine phosphate) and causes muscle fibers to 

shorten. Creatine phosphate is needed to produce ATP, and muscle fibers 

cannot lengthen without energy input from ATP. Induced by heat, drugs, or 

acids, most physiological contractures, except for rigor mortis, are 

reversible. Rigor mortis is a stiffening of the body that occurs after death 

because of acids accumulating in protoplasm and coagulation of proteins. 

96 


97 

FACILITATORS 

Activation of Stretch Reflex (Facilitation) 

Muscle spindles (MSs) react to sudden stretching by reflex contraction. 

Long, rapid stretches are more detectable to a muscle than short, gradual 

stretches. A reflex contraction is called a stretch reflex or myotactic reflex. 

What is commonly called a tendon reflex is actually a stretch reflex. 

Sharply striking the patellar tendon rapidly stretches the quadriceps muscle 

and causes a "knee jerk" reaction. 

Throwing activities, such as pitching, make use of the stretch reflex by 

using a windup to put the throwing muscles on stretch before a pitch. The 

windup increases muscular power because the force from reflex contraction 

(stretch reflex) is added to the force from voluntary contraction. Because of 

viscoelastic properties of a muscle, elastic rebound from the stretch will also 

contribute to the power. 

A stretch reflex and reciprocal inhibition produce opposite effects. As 

stretching facilitates contraction, reciprocal inhibition relaxes opposing 

muscles. Once the agonist shortens, the muscle spindles reduce afferent 

discharge and the agonist relaxes. Using pitching as an example, throwing 

muscles are facilitated by the windup. As the ball is thrown, throwing 

muscles contract because of the stretch reflex and opposing muscles relax 

because of reciprocal inhibition. When the pitch is complete, the throwing 

muscles enter a resting state and relax also. 

The stretch reflex can be triggered in two ways: (1) increasing the 

distance between distal and proximal insertions or (2) physically stretching 

the muscle itself. Range-of-motion stretching increases the distance 

between insertions and cross-fiber stretching stretches a muscle at the point 

of contact. Cross-fiber stretching is applied at angles perpendicular to the 

muscle. Even a quick tap causes cross-fiber stretching. 

Since rapid stretching is more likely to trigger a stretch reflex than slow 

stretching, most forms of therapeutic stretching to lengthen a muscle are 

done slowly. The safest stretches are those that minimize force and 

maximize time. Facilitation techniques, on the other hand, are done quickly 

to encourage contraction. Rapid stretching, tapping, or shaking facilitate 

muscle contraction. 


98 

Activation of Muscle Spindles (Facilitation) 

A second method of facilitation involves relative changes in tension 

between intrafusal muscle fibers that are inside the muscle spindle cell and 

extrafusal muscle fibers that are outside the muscle spindle cell. 

When intrafusal fiber tension is greater than extrafusal fiber tension, the 

muscle contracts (facilitation). 

The two main factors affecting intrafusal and extrafusal fiber tension are 

(1) contraction or relaxation of intrafusal fibers, and (2) stretching or 

compressing extrafusal fibers. When intrafusal fiber tension is greater than 

extrafusal fiber tension, the muscle contracts (facilitation), and when 

intrafusal fiber tension is less than extrafusal fiber tension, the muscle 

relaxes (inhibition). 

The gamma system neurologically connects muscle spindles with the 

spinal cord and regulates intrafusal fiber tension. For various reasons, 

including injury or stress, intrafusal fibers contract because of innervation by 

the gamma system. This makes intrafusal fiber tension greater than 

extrafusal fiber tension and muscles contract. When a muscle is injured, 

reflex spasm and protective muscle shortening, as in splinting or guarding, 

may be caused by nerve impulses that travel from the spinal cord to muscle 

spindles. Spasm originating from the spinal cord is difficult to treat. 

When extrafusal fibers shorten by voluntary contraction, they initially 

generate more tension than intrafusal fibers. This would normally cause 

inhibition were it not for the gamma motor system stimulating intrafusal 

fibers to contract. This allows intrafusal fibers to adjust for gains in tension 

by extrafusal fibers. By adjusting to the shortening of extrafusal fibers, the 

gamma motor system acts as a positive servomechanism for the muscle. 

Without this mechanism, voluntary contractions would cause inhibition. 

Because of the gamma system, muscles can be facilitated or inhibited by 

using manual force to manipulate the belly of a muscle where the 


concentration of muscle spindle cells is greatest. If stretching the belly of a 

muscle causes intrafusal fiber tension to become greater than extrafusal fiber 

tension, the muscle contracts. This can be done by grasping the belly of a 

muscle near the center and using divergent force to stretch the muscle in 

opposite directions away from the starting point. The lines of force are 

parallel to the muscle and the rate of movement is faster than stretching to 

lengthen connective tissue but not fast enough to cause pain. Weak muscles 

will normally test stronger after facilitation. 

Facilitating a muscle by activating the MSs requires less force than 

inhibiting a muscle by activating the GTOs. Although tapping a tendon can 

stimulate muscle spindle cells enough to cause facilitation, the same amount 

of tapping will not stimulate GTOs enough to cause inhibition. 

It should also be apparent that compressing or "stripping" a muscle from 

one end to the other inhibits a muscle by compressing the belly during the 

first part of the movement and then facilitates the muscle by stretching the 

belly during the last part of the movement. Movements compressing the 

muscle toward the midpoint inhibit, while movements stretching the muscle 

beyond the midpoint facilitate. 

If the purpose of stripping a muscle is inhibition, strip the muscle from 

insertion to midpoint in one direction, and then strip the same muscle from 

insertion to midpoint in the opposite direction. A more effective way to 

inhibit a muscle is to use both hands, start from opposite insertions, and 

work toward the belly of the muscle until both hands meet in the center. If 

the purpose is facilitation, the most effective way is to use both hands, start 

at the midpoint, and stretch the muscle away from the midpoint. 

Repeated Contractions (Facilitation) 

Another facilitation technique is repeated contractions. Based on the 

treppe phenomena, muscles contract more strongly after the first contraction. 

It is possible that increases in tissue temperature after the first contraction 

are great enough to increase metabolic efficiency and reduce tissue viscosity. 

Repeated contractions may also increase gain from the gamma neurons (thus 

discouraging inhibition by the muscle spindles), and maximize both the 

number of muscle fibers activated and the rate of firing. 

99 


100 

In the absence of fatigue, muscles can be facilitated by using repeated 

contractions. If a patient's range of motion is restricted, repeated 

contractions in the direction of the barrier may facilitate muscles enough to 

overcome resistance and regain full range of motion. Once fatigue sets in, 

the strength of contraction becomes less and muscles become less efficient. 

Successive Induction (Facilitation) 

Successive induction refers to the principle that once facilitation of the 

agonist is completed, it takes less than normal stimulation to facilitate the 

antagonist. Muscles have an absolute threshold that determines how much 

stimulation is needed to cause contraction. According to the principle of 

successive induction, contracting and then relaxing the agonist lowers the 

threshold for stimulation of the antagonist and allows the antagonist to 

contract with less than normal stimulus. If shortening the agonist stretches 

the antagonist quickly enough, stretching may also facilitate the antagonist. 

Techniques that move in the direction of greatest freedom first are called 

indirect techniques. Successive induction is one factor that explains why 

range of motion can sometimes be increased by using techniques that move 

in the direction of greatest freedom first. If elbow extension is limited, but 

flexion is normal, flexing the elbow first facilitates the elbow extensors. 

Strengthening the extensors by flexion will make it easier to extend the 

elbow. A second factor relates to interstitial fluid pressure. If flexing the 

elbow reduces flexor muscle edema, elbow flexors will be less resistant to 

active or passive stretch by elbow extensors. 

SUMMARY 

Neuromuscular techniques can be used singly or in combination with 

each other to correct muscular dysfunction by facilitating or inhibiting 

specific muscles. If the patient's condition is correctly evaluated, the 

practitioner will know which muscles to facilitate and which muscles to 

inhibit. Hypertonic muscles need to be inhibited and stretched, while 

hypotonic muscles need to be facilitated and strengthened. If two opposing 

muscles are dysfunctional, synergistics or fixators are probably affected. 


101 

CONNECTIVE TISSUE THERAPY 

Of all the tissues in the human body, connective tissue is the most 

abundant. Examples of dense fibrous connective tissue include tendons, 

ligaments, aponeuroses, deep fascia, and dermis. Other forms of connective 

tissue are bone, adipose tissue, and cartilage. The four main goals of 

connective tissue therapy are: 

 

 

 

 

Increase tissue mobility 

Break adhesions 

Improve fluid exchange 

Realign torn fibers 

The main types of connective tissue affected by manipulation are deep 

fascia, ligaments, aponeuroses, and tendons. While some varieties of 

connective tissue therapy work specifically to produce reflex effects or 

improve symmetry, the HEMME APPROACH emphasizes the physical effects of 

connective tissue therapy more than the reflex effects and concentrates on 

symmetry only when a lack of symmetry causes clinical problems. 

Connective tissues have three main components: cells, fibers, and matrix 

or ground substance. The most common mechanical properties of all 

connective tissues except bone are elasticity and plasticity. Elastic materials 

yield to stress and then resume normal shape. Plastic materials yield to stress 

and remain permanently deformed. 

Of the six basic cell types in connective tissue (fibroblasts, macrophages, 

plasma cells, mast cells, fat cells, and pigment cells), two in particular relate to 

connective tissue therapy: fibroblasts that synthesize fibers and matrix and 

mast cells that release histamine and serotonin. Besides mediating pain, 

histamines cause vasodilation and edema. 

The two most important extracellular fibers imbedded in the matrix or 

ground substance of connective tissue are collagen, which is white, and elastin, 

which is yellow. Collagen fibers, which form in bundles or sheets, have high 

tensile strength but low elasticity. Elastin fibers, which form dendritically, 


102 

have low tensile strength but high elasticity. Collagen and elastin are both 

major connective tissue proteins. 

Although ligaments and tendons are both considered dense connective 

tissue, tendons have greater tensile strength because of collagen and ligaments 

exhibit higher degrees of extensibility because of elastin. Deep fascia has 

more collagen fibers than superficial fascia (loose connective tissue), but 

collagen fibers in deep fascia are less organized than collagen fibers in 

tendons, ligaments, or aponeuroses. 

Immobilization after an injury increases the density of collagen and the 

frequency of cross-bridging between fibers. The cross-bridging makes 

collagen fibers more resistant to passive stretch and less mobile. Stretching 

and exercise increase flexibility by reducing the number of cross-links. 

Proteoglycans form the intercellular matrix or ground substance that 

constitutes the bulk of connective tissue. Proteoglycans are composed of 

glycosaminoglycans (mucopolysaccharides) bound to protein chains. 

Proteoglycans form a viscous gel-like substance when combined with 

extracellular tissue fluid that contains water, metabolites, crystalloids, and 

gases. When intercellular viscosity is not too high, this gel-like substance 

reduces friction by acting as a lubricant between collagen fibers. 

The ability of ground substance to hold water allows for diffusion of 

metabolites between capillaries and cells. The presence of hyaluronic acid in 

ground substance reduces friction by increasing water retention. Hyaluronic 

acid molecules form large random chains that are filled with water. 

Proteoglycans such as hyaluronic acid give tissues elasticity and resistance to 

compression. 

Excessive water retention produces higher tissue tension and greater resistance 

to pressure. Tissue tension is a palpable sign that frequently occurs 

during inflammation or after trauma. High degrees of edema reduce mobility 

by increasing tissue tension and causing spasm. 

Reduced water retention, on the other hand, increases friction between 

fibers and causes cross-bridging. Friction and cross-bridging irritate tissues 

and reduce mobility. Without water retention, tissues lose elasticity. 

The "gel-sol" theory proposes that aqueous solutions within connective 

tissue become highly viscous and produce a sticky gelatinous or gluelike 


103 

substance that limits tissue mobility. Connective tissue manipulation is 

thought to liquefy and disperse viscous gel and restore free movement. 

Three factors explain why slow stretching produces more permanent 

changes in the length of connective tissue than rapid stretching: 

 

 

 

Thixotropy 

Hysteresis 

Creep 

Thixotropy and hysteresis explains why semisolid ground substance in 

connective tissues changes from gel to liquid when acted upon by force. Creep 

explains why connective tissues such as deep fascia are permanently 

lengthened by slow, steady, continuous tension. 

Thixotropy 

According to the concept of thixotropy, gels liquefy when agitated by any 

force that puts energy into the system. The energy input from deep stroking 

(compression and shear) is friction and heat. Changing from gel to liquid 

increases tissue mobility by decreasing tissue tension caused by edema. Tissue 

tension stimulates reflex activity that facilitates muscle contraction. When 

treating connective tissue, time is critical. To avoid trauma, wait for tissues to 

accommodate penetration by "thinning out" before advancing. Thixotropy 

also applies to trigger point therapy (compression), where slow digital pressure 

causes a "meltdown" and tissues become more compliant. 

Hysteresis 

According to the concept of hysteresis, stress and slow cyclic loading 

cause tissues to soften as energy is lost in the form of internal friction or heat. 

Cyclic loading refers to cycles of loading and unloading. Hysteresis plays a 

major role when the same tissues are treated multiple times by a sequence of 

slow steady pressure, slow release, and reapplication of slow steady pressure. 

Cyclic loading relieves tissue congestion by improving vascular flow and 

lymphatic drainage. 


104 

The white fibrous proteins found in deep fascia are collagen fibers. Unlike 

colloids such as matrix or ground substance, collagen fibers are highly 

resistant to heat and pressure. Although range-of-motion stretching is more 

efficient with heat than without heat, proprioceptive inhibition and changes in 

tissue viscosity account for this difference more than changes in collagen fiber 

extensibility. Collagen fibers do not liquefy under pressure or weaken 

measurably because of cyclic loading. 

Creep 

Creep is defined as a slow permanent deformation of viscoelastic materials 

when placed under a constant load for long periods of time. The principle of 

creep can be applied directly to myofascial release, as found in osteopathy. 

Tissues are stretched carefully until solid resistance is felt. Small amounts of 

tension are then applied slowly for long periods of time until the tissues start to 

relax and lengthen. The point at which tissues start to lengthen is sometimes 

called a meltdown or release. Constant tension is continued until the tissues 

are fully elongated or no further stretching is possible. The keys to using creep 

effectively are (1) minimize force, and (2) maximize time. 

Viscoelastic materials like deep fascia are viscous materials with some 

degree of elasticity. Deep fascia is viscous because of ground substance and 

elastic because of elastin fibers and crisscrossing collagen fibers. Although 

tendons and deep fascia are both composed chiefly of collagen fibers, in 

tendons, which are less elastic than deep fascia, most fibers are parallel. 

Viscoelastic materials are sensitive to rates of loading. When rates of 

loading are normal, deep fascia retains its original shape because of molecular 

cohesion and elasticity. When rates of loading are slow and constant, 

viscoelastic materials deform plastically with minimal force and changes in 

length are permanent. Except for spasm, deep fascia has a greater effect on the 

length of a muscle than muscle tissue. 

If tissues heated before stretching are held in extension until they cool, 

increases in length are more likely to be permanent than temporary and tissues 

are less likely to be weakened. A similar characteristic is found in 

thermosetting plastics that soften when heated and set into a permanent shape 

when they cool. 


105 

Range-of-motion stretching and topical stretching will sometimes break 

the adhesions that form during the wound-healing process. Adhesions are 

abnormal fibrous bands that connect tissues that are normally separate. 

Adhesions that form between the dermis and superficial fascia in response to 

inflammation or trauma are fairly common. Depending on how the 

attachments form, adhesions may or may not be symptomatic. Adhesions that 

irritate nerves or restrict mobility are symptomatic. 

Adhesions are common between the dermis and superficial fascia. The 

dermis has two layers: a superficial layer called the papillary layer and the 

deeper layer called the reticular layer. The papillary layer is relatively thin 

and projections from it produce fingerprints. The reticular layer is thicker and 

contains densely interwoven connective tissue and white collagenous bands. 

Forming below the dermis, superficial fascia minimizes resistance between 

the dermis and most underlying structures. Even though points of attachment 

do exist such as the soles of the feet, the palms of the hands, and skin folds, 

normal skin, for the most part, is loose. 

If abnormal attachments form that prevent the dermis from sliding freely 

over the top of underlying structures, loss of mobility and pain are likely. 

When adhesions break, relief from pain is almost immediate and the skin starts 

to move freely again. 

Like muscles, connective tissues form in layers. When attempting deep 

penetration through multiple layers of tissue, start with the uppermost layer of 

tissue first and work downward. As superficial layers "melt away" and 

become more compliant to pressure, proceed slowly to the next layer. 

Releasing superficial layers first makes it easier to work the deeper layers with 

less force. This approach is safer than using high degrees of physical force or 

hand-held devices such as wooden "T-bars" to increase pressure. 

In connective-tissue work, the direction of force can also be a factor in 

minimizing tissue damage. Connective tissue fibers that run parallel to each 

other form patterns called cleavage lines or Langer's lines. These lines follow 

about the same direction as normal skin folds. Except for cross-fiber friction 

to align tendon fibers after an injury and the use of torque or skin- rolling 

techniques to break adhesions, stretching in connective-tissue work is 


106 

normally done in the same direction as cleavage lines. This encourages 

connective tissue to lengthen as a group without causing fibers that run in the 

same direction to separate from each other. 

The angle of force can be a factor in connective-tissue work. The closer 

the angle of application approaches 90 degrees, the greater the penetrating 

force. Angles of 45 degrees divide force equally between penetration and 

forward movement. Angles less than 45 degrees reduce penetration and favor 

forward movement. For most purposes, the most effective angle in 

connective-tissue work is 45 degrees. 

Topical methods of stretching adhesions are torquing forces applied to 

superficial scars and skin rolling. Tendons are stretched by cross-fiber friction 

and fascia is normally stretched by parallel stretching. Factors that affect the 

quality of stretching are (1) intensity of force applied, (2) duration of force, (3) 

direction of force, and (4) tissue temperature. Large forces applied rapidly at 

low temperatures are more likely to cause a rupture than small forces applied 

slowly at high temperatures (105F° to 110°F). 

SUPERFICIAL TORQUE 

Superficial torquing forces are normally applied by using a force couple. 

This means that two equal, opposite, and parallel forces are applied to a body 

simultaneously. If the thumbs are placed on superficial scar tissue and 

separated about two inches, pushing one thumb forward while pulling the 

other thumb back creates a force couple. The two forces moving in opposite 

directions make an impression or wrinkle resembling the letter S on the skin. 

The combination of shear, compression, and tension produced by this 

movement is normally sufficient to rupture adhesions. When superficial 

adhesions break, it is not uncommon to hear a snap and feel a sudden release. 

The dimples or depressions caused by attachments will suddenly disappear. 

SKIN ROLLING 

Skin rolling is a particular sequence of forces (tension, compression, and 

then bending) applied to skin and subcutaneous fascia. Using both hands 

together, the balls of the thumb and forefingers of each hand are used to pull 


107 

the skin away from the patient's body using tension and compression, and then 

create a fold by bending the skin over the tips of the forefingers. Once created, 

the fold can be rolled in a wavelike motion by using the balls of the thumb to 

push the wave forward while the fingers feed new skin over the top of the fold. 

If adhesions are detected in areas of the body where the skin is normally loose, 

skin rolling, with or without additional tension, should generate enough force 

to cause rupture. 

CROSS-FIBER FRICTION 

Cross-fiber friction is another variety of connective tissue therapy. 

Tendons are composed of collagen fibers, elongated tendon cells, and ground 

substance. When lesions form on a tendon, cross-fiber friction may help to 

align the torn fibers and hasten the wound-healing process. The digital 

compression that accompanies cross-fiber friction is similar to the digital 

pressure in trigger point therapy. It serves to reduce pain and disperse fluids 

that accumulate around lesions. If cross-fiber friction is too painful and timeconsuming 

for the patient to endure, trigger point therapy with mobilization or 

range-of-motion stretching is a good substitute. 

When dealing with tendons, tendinitis may be the effect and hypertonic 

muscles the cause. The muscles controlling the tendons need to be examined 

for spasm and treated accordingly. Generally, if the agonistic muscles 

controlling a tendon are hypertonic, antagonistic muscles are stretched and 

weak. To correct this problem, use neuromuscular therapy to inhibit the 

agonist and facilitate the antagonist. Range-of-motion stretching is normally 

used after trigger point therapy or neuromuscular therapy. 

PARALLEL OR PERPENDICULAR STRETCHING 

Fascia is normally stretched in directions parallel to cleavage lines. The 

terms parallel stretching and longitudinal stretching mean the same. 

Perpendicular or lateral stretching is more common in neuromuscular therapy 

than connective tissue therapy. In neuromuscular therapy, muscles are 

stretched at right angles to inhibit or facilitate contraction. In connective tissue 

therapy, perpendicular stretching is used to separate bundles of muscle fibers 

or break adhesions. 


108 

Parallel stretching uses deep pressure to stretch fascia and restore fascial 

balance. As in most forms of connective tissue stretching, when pressure is 

slow and steady, fascia deforms plastically instead of elastically because of 

thixotropy, hysteresis, and creep. Hysteresis will have the greatest effect if the 

same tissues are stretched repeatedly. 

Although parallel stretching is often painful and may cause burning pain 

because of fascial tearing, initial treatments of an area are normally more 

painful than subsequent treatments of the same area. Most patients find 

multiple treatments of low intensity more tolerable than single treatments of 

higher intensity. Once again, increasing application time and decreasing force 

will decrease trauma. 

LYMPHATIC DRAINAGE 

Since lymphatic tissue and lymph are considered to be connective tissue, 

techniques to improve lymphatic function are considered connective tissue 

techniques. Even though the lymphatic system is normally passive, it can be 

affected by manipulation. 

The three main parts of the lymphatic system are lymphatic tissue, lymph 

fluid, and collecting ducts. The lymphatic system is sometimes known as the 

second circulatory system of the body, and the two main functions of the 

system are maintenance of fluid balance in the body and immunity. 

Lymph from the entire body, except the upper right quadrant of the body, 

drains into the thoracic duct. Lymph from the upper right quadrant drains into 

the right lymphatic duct. A decrease in drainage can result in massive edema, 

retention of toxic metabolic waste, infection, or cancer. 

Lymphatic techniques, in general, have two main goals: increase or 

maintain lymphatic flow. One basic approach is to elevate an arm or leg and 

use effleurage or petrissage to increase lymphatic flow. Lymph from the arm 

is directed toward the axilla and thorax, and lymph from the leg is directed 

toward the abdomen. The stroking to improve lymphatic flow should be slow 

and steady, and normally proceeds from distal to proximal. The pressure 

should not cause pain and the patient should breathe normally. 


109 

STRETCHING 

Unlike the stretching in connective tissue therapy that is largely topical, 

stretching as used here refers to range-of-motion (ROM) stretching. This 

means increasing the distance between muscle attachments (origin and 

insertion) to the greatest extent possible without causing tissue damage or 

jeopardizing stability. 

If an affected body part is hypomobile, ROM stretching may help to 

restore normal mobility. In some cases, range-of-motion stretching can 

minimize the effects of deep formed scar tissue, break adhesions, reduce 

spasm, decrease pain, and retard joint degeneration by increasing joint space. It 

may also improve coordination by increasing the range, velocity, and force of 

movement. ROM stretching increases velocity and force by allowing 

movements to accelerate over a longer distance with less internal resistance. 

Passive stretching covers a greater range of motion than active stretching. 

Physiologic barriers are the points to which a patient can actively move a 

joint. Anatomic barriers are the points to which a practitioner can passively 

move a joint beyond physiologic barriers. The space between the two barriers 

acts as a shock absorber for the joint. Restrictions that exist beyond 

physiologic barriers cannot be treated by active range-of-motion stretching. 

Only passive range-of-motion stretching can reach restrictions that exist 

between physiologic and anatomic barriers. Movements beyond the anatomic 

barrier disrupt tissue and may cause tissue damage or instability. 

The three main causes for restricted movement are: 

 

 

 

Pain 

Spasm 

Contracture 

These causes may occur separately or in combination with each other. The 

normal sequence for treatment is (1) control pain, (2) reduce spasm, and (3) 

lengthen connective tissue. 


110 

Even though range-of-motion stretching will have an impact on all three 

conditions, most patients are more tolerant of therapeutic stretching if pain and 

spasm are treated first. If the patient's range of motion changes radically after 

less than one minute of treatment, the probable cause of restriction is pain or 

spasm, not connective tissue shortening. 

In the absence of pain or spasm, the most significant restriction on range of 

motion is connective tissue involvement. Though many types of connective 

tissue such as ligaments, tendons, and joint capsules can restrict movement, 

the most likely is deep fascia, the fibrous membrane that covers, supports, and 

separates a muscle. The three varieties of deep fascia common to skeletal 

muscle are (1) epimysium (the outermost sheath), (2) perimysium (the 

covering that envelops each primary bundle of muscle fibers), and (3) 

endomysium (the covering that invests each striated muscle fiber and binds the 

fibers together). If shrinkage of deep fascia causes contracture, the main 

course of therapy is range-of-motion stretching. 

The correct rate for slow therapeutic stretching depends on how quickly 

the affected tissues release. During the initial stages of stretching, lengthening 

by stages may indicate that various bundles of muscle fibers are relaxing at a 

different rate. This may give the appearance that tissues are "unwinding." 

Connective tissues deforming elastically are more likely to stretch at a constant 

rate than muscle fibers. During the final stages of stretching, most muscle 

fibers are relaxed and connective tissues deform plastically at a uniform rate 

till body parts reach their limit. If these changes are not palpable, the rate of 

stretching may be too fast. 

If a sudden release occurs after tissues have reached their apparent limit, 

this may indicate that too much force was applied and tissues are starting to 

rupture. Based on Hooke's law, changes in length are proportional to force 

until tissues exceed the elastic limit. Once past the elastic limit, tissues may 

continue to lengthen and then rupture even if the amount of force being 

applied is reduced. 

As a caution, flexibility and stability are trade-offs. Too much flexibility 

causes instability and too much stability causes inflexibility. By not trying to 

go beyond a joint's normal range of motion, practitioners can use range-ofmotion 

stretching to achieve a balance between flexibility and stability in ways 

that maximize function and minimize the risk of injury. 


111 

Although measurements can be taken with a goniometer to determine if 

the patient's range of motion is normal, variations from one patient to another 

can be expected. Despite the convenience of using numeric goals, the patient's 

ability to function is more important than readings on a scale. Even if a patient 

falls short of "normal," it is safer to discontinue stretching too soon than to 

cause joint damage and hypermobility. Lengthening restricted connective 

tissue can be done with range-of-motion stretching, but repairing overly 

stretched connective tissue may require medication or surgery. 

To maximize flexibility, active range-of-motion stretching should be done 

in all directions of movement that are normal for the affected body part. To 

improve flexibility of the low back, a combination of flexion and extension 

exercises will be more effective than using just one or the other. Extension 

exercises are very effective in reducing low back stiffness when shortening of 

the gluteal or hamstring groups reduces lumbar lordosis. 

Therapeutic stretching is not always confined to normal directions and 

planes of movement. Treating the gluteals or hamstrings may require passive 

stretching in directions that combine flexion, abduction, and internal rotation 

into one movement. Stretching confined to standard directions such as flexion 

and extension or to standard planes such as sagittal, coronal, or transverse, 

may not be varied enough to reach affected tissues. 

Even though most of the standard directions and planes are based on 90- 

degree angles, a large percentage of movements made by the human body use 

other angles. Once a body part is working normally through standard 

directions and planes, movements along other planes or directions should be 

evaluated. A patient who is able to perform standard movement reasonably 

well during clinical evaluation may not function as well in the real world, 

where movements are not structured along 90-degree angles. Many of the best 

planes for therapeutic stretching are diagonal, as opposed to 90 degrees. 

The best directions for stretching are sometimes difficult. Body parts may 

try to move in directions that avoid restrictions or follow the path of least 

resistance. Patients will normally indicate directions of movement that are 

painful by showing signs of pain or trying to avoid painful movements. The 

directions of movement that patients avoid are often the same directions of 

movement that need to be improved. 


112 

If stretching is successful, some patients may report feelings of greater 

sensitivity or heat. Sensitivity will increase if stretching relieves pressure that 

traps a nerve and stops nerve conduction. Unless tearing occurs, heat is often 

caused by an increased profusion of blood within the muscle. Feeling a warm 

sensation is not the same as feeling a burning sensation. The three main 

causes for a burning sensation are fascial tearing, exercise to the point of 

fatigue, and stingers. Also called a burner syndrome, stingers are caused by 

forceful blows to the head or shoulders that irritate the brachial plexus. 

The main causes for feelings of pressure or tension are spasms, 

contractures, adhesions, or edema. Piriformis and scalenus anticus syndrome 

are caused by muscles trapping nerves that penetrate the muscle. When 

muscle tension reduces joint space, joint pressure can trap nerves that penetrate 

the joint. If a decrease in joint space is causing nerve entrapment, distracting 

the joint may relieve nerve signs and compressing the joint may intensify the 

signs. The most common nerve signs are shooting pain, numbness, or 

paresthesia (a prickling or tingling sensation). 

Until the patient can execute coordinated, full range-of-motion movements 

without pain or restriction, recovery is not complete. Range-of- motion 

stretching works to achieve the range of motion a patient can be expected to 

have if therapy is successful. Although therapeutic stretching is not always 

painless, excessive pain during or after a stretch may indicate tissue damage 

and a need for less force or a different technique. 

Despite the tendency to think all stretching should be slow, one reason for 

rapid stretching is preparing athletes for competition, where most of the 

movements require ballistic power. If range of motion is normal, ballistic 

movements can improve performance by improving the quality of movement. 

Rapid stretching is not recommended where the athlete's range of motion 

is limited. Since tissues have more time to absorb energy, slow stretching is 

safer. Boxers "roll with a punch" to give their bodies more time to absorb 

energy. Sudden force is more likely to exceed a tissue's plastic limit and cause 

rupture than slowly applied force. 

Even patients with full ROM will benefit from regular stretching. Without 

stretching, muscles and connective tissue have a tendency to shorten because 

of age or inactivity. Stretching combined with exercises for strength and 

endurance contribute to a patient's general fitness. Regular stretching helps 

patients preserve their normal range of motion and may prevent the occurrence 

or recurrence of injury. 


113 

The recommendations for regular stretching can range from 2 days a week 

to 7 days a week. In the absence of injury or spasm, stretching is fairly 

painless and sometimes even relaxing. It is always better to start a moderate 

stretching program and continue with the program than to start a strenuous 

program and stop because the program is too difficult or because of an injury. 

The long-term benefits of stretching will often depend on a patient's 

willingness to continue stretching on a regular basis without supervision. 

Patients should use overstretching (stretching a tissue beyond its present 

length) to increase range of motion until they have a normal pain-free range of 

motion. Since muscles have a tendency to shorten during sleep, one of the 

best times for stretching is shortly after rising. Stretching just before bedtime 

may help to relax the body and make it easier to sleep. 

For all the benefits, stretching alone is not the final answer. In our zeal as 

practitioners to find the best methods for treating soft-tissue impairments, there 

seems to be a tendency to champion one or more techniques to the exclusion 

of all others. In reality, no one technique is ever the best or only technique for 

all situations. Techniques are best that work best for a given situation. For all 

its versatility, stretching is normally the most effective when used in 

combination with modalities and other forms of manipulation. 

Even so, range-of-motion stretching affects more types of tissue directly 

than any other form of manipulation. The four types of tissue in the human 

body are nerve tissue, muscle tissue, connective tissue, and epithelial tissue. 

Whereas neuromuscular therapy focuses on nerve and muscle tissue and 

connective tissue therapy focuses on connective and epithelial tissue, range-ofmotion 

stretching affects all four types of tissue and duplicates many of the 

effects produced by neuromuscular and connective tissue therapy. 

Like neuromuscular therapy, stretching is capable of causing inhibition or 

facilitation. Static stretching, holding a stretch for extended periods of time, 

may cause inhibition, and rapid stretching, because of the stretch reflex, may 

cause facilitation. Where the effects of connective tissue therapy are normally 

superficial, the effects of ROM stretching can be superficial or deep. When 

treating scar tissue or contractures that form deep within a muscle, range-ofmotion 

stretching is more effective than connective tissue therapy. 


114 

Range-of-motion stretching may also duplicate many of the effects 

produced by trigger point therapy, such as neutralizing trigger points, reducing 

pain, and relieving spasm. By improving circulation, stretching may help to 

remove pain-producing chemicals, improve tissue metabolism, and increase 

the concentration of oxygen. Range-of-motion stretching should be used after 

trigger point therapy to normalize muscle tonus and make the effects of trigger 

point therapy longer-lasting or permanent. 

Range-of-motion stretching can be used alone or in combination with 

modalities or other forms of manipulation such as trigger point therapy, 

neuromuscular therapy, and connective tissue therapy. Even the effects from 

high-velocity manipulation are less likely to be short-term if high-velocity 

treatments are concluded by low-velocity range-of-motion stretching. 

MODALITIES AND STRETCHING 

While stretching can be done with or without modalities, heating and 

cooling modalities facilitate stretching by relieving pain and reducing spasm. 

In addition to these benefits, heat reduces tissue viscosity and cold produces 

analgesia. The choice of heat or cold depends on which effects are more 

important: heat-induced reduction of viscosity or cold-induced analgesia. 

Heat is preferred in the absence of swelling and serious pain, while cold is 

preferred when the patient is guarding the affected part because of pain. Cold 

can also be used after stretching or exercise to control edema and reduce pain. 

The application of ice for 15 to 20 minutes is probably the most effective way 

to control pain prior to stretching or exercise, and ice applied after stretching 

or exercise helps to control pain and reduce edema. 

A patient psychologically aroused and apprehensive of pain will be more 

resistant to passive stretching than someone relaxed and calm. The attitude of 

the practitioner and modalities such as heat or vibration can be used to induce 

relaxation. The practitioner being calm and collected seems to help the patient 

relax. If a patient prefers heat and dislikes cold, or vice versa, the patient's 

inclination should be followed whenever possible. 

Some people find various sounds, aromas, or colors relaxing. Slow 

traction and mild percussion are more likely to sedate a muscle than rapid 

traction and strong percussion. Most patients relax more during exhalation 

than inhalation and slow breathing is more relaxing than rapid breathing. 


115 

Whenever heat is used to facilitate stretching, stretching should begin 

while tissue temperatures are still elevated and the stretch should be held until 

tissue temperatures return to normal. Like thermoplastics, the shape or length 

that tissues have at the time of their cooling tends to become permanent. 

(When thermoplastics harden because of cooling, the term used is set.) 

TRIGGER POINTS AND STRETCHING 

If pain is causing a psychological or physical resistance to passive 

stretching, neutralizing trigger points may be helpful. Digital ischemic 

pressure, compressing the belly of the muscle, or pinching hypersensitive skin 

are various trigger-point methods that work well in combination with 

stretching. Chemical counterirritants, ice, or vapocoolant sprays can also be 

used to desensitize skin and reduce pain or spasm prior to stretching. 

Although vapocoolant sprays such as ethyl chloride and Fluori-Methane 

are popular (spray and stretch), ice massage can produce the same results. 

Besides cryogenic effects, ice produces ischemic pressure when used on 

trigger points. Other factors that favor ice are availability, cost, and safety. 

The risk of causing an allergic reaction or frostbite is greater with ethyl 

chloride spray than ice. Ethyl chloride is also flammable and potentially 

explosive when the vapor is mixed with air, while Fluori-Methane is a mixture 

of chlorofluorocarbons that may cause damage to the ozone layer. 

Piriformis syndrome is caused by entrapment of the sciatic nerve as it 

emerges from under the piriformis muscle. Pain is reproduced when the 

extended leg is tested with external rotation or resisted external rotation. If 

trigger points and muscle spasm are causing the entrapment, trigger point 

therapy and stretching may produce dramatic relief. With the patient prone, a 

practitioner can lean over the piriformis muscle and use the elbow to apply 

ischemic pressure. If trigger point therapy is effective, the piriformis muscle 

should be stretched by using medial rotation of the thigh with the hip straight. 

Regardless of how trigger points are treated, stretching is always the final 

step. ROM stretching can be effective without trigger point therapy, but 

trigger point therapy is seldom effective without ROM stretching. 


116 

NEUROMUSCULAR AND STRETCHING 

Neuromuscular techniques are often used in combination with active or 

passive range-of-motion stretching. In post-isometric relaxation, isometric 

contractions are used to prepare muscles for passive stretching or passiveassisted 

stretching. In reciprocal inhibition, contracting the opposing muscle 

(antagonist) is used to prepare the agonist for stretching. Any neuromuscular 

technique that inhibits contraction of the muscle being stretched or facilitates 

contraction of the opposing muscle can be used with ROM stretching. 

CONNECTIVE TISSUE AND STRETCHING 

If joints are normal and surrounding muscles are not hypertonic, 

connective tissue restrictions are more likely to prevent passive stretch than 

tissue viscosity or shrinkage of the epidermis. Connective tissues have a 

tendency to shorten when irritated or inflamed. Since muscles are more likely 

to relax progressively than all at once, lengthening may occur by stages. As 

portions of the muscle relax, slack can be taken up by stretching connective 

tissues until muscle fibers provide the next barrier. As other groups of muscle 

fibers relax, slack can be taken up again. This explains why patients are more 

likely to experience stretching as a series of small releases rather than one 

continuous release. These releases should not be confused with fibrillations 

that sometimes occur if stretching is painful. 

Following the principles of stretching and safety, stretch connective tissue 

with slow and steady pressure. Although stretching requires enough force to 

exceed the tissue's elastic limit, tissues can accommodate great stress without 

injury when forces are applied slowly. Loading applied slowly allows 

realignment of collagen molecules and redistribution of ground substance that 

encourages tissues to deform plastically without tearing. Because of creep, 

small forces applied slowly for long periods of time produce higher degrees of 

permanent deformation than larger forces applied quickly. When loading is 

rapid, molecular disorientation encourages rupture. 

Thixotropy and hysteresis are also factors. Loading is the application of 

force and cyclic loading causes fascia to lose energy. Thixotropy reduces 

friction by causing gels to liquefy when agitated by loading. Not only should 


117 

stretching be done slowly because of creep, but it should also be done in stages 

because of thixotropy and hysteresis. Small amounts of continuous force 

applied slowly and then repeated after the tissues relax may increase the 

patient's range of motion faster than single forces applied continuously. 

When multiple repetitions of stretching are used, the basic sequence is (1) 

stretch, (2) return to starting position, (3) allow the tissue enough time to relax, 

and (4) repeat the stretch. Patients should exhale during the stretching stage 

and inhale during the relaxation stage. The holding period for multiplerepetition 

stretching is normally less than 15 seconds and repetitions normally 

range from 3 to 12. A holding period of 2 seconds or less is less likely to 

trigger a stretch reflex than a holding period that is longer than 2 seconds. 

Permanent changes in tissue length occur when tissues exceed the elastic 

limit and start to deform plastically. Although stretching may at times cause 

rupture if the levels of force are too high, the stresses within a muscle are 

normally well below the rupture point and tissues deform plastically without 

tearing. High resistance to passive stretch followed by sudden release would 

indicate a rupture. A rupture is more likely to occur at the musculotendinous 

juncture than in the belly of a muscle. 

BALLISTIC STRETCHING 

Ballistic stretching is not recommended for most patients, especially when 

tissues are edematous or muscles are in spasm. Rapid stretching may trigger a 

stretch reflex that causes contraction and makes the muscle more resistant to 

active stretching. Slow stretching does not trigger a stretch reflex. In 

terms of specificity, on the other hand, athletes may need to consider ballistic 

stretching as a necessary part of their training. The principle of specificity 

states that practice activities should be as close as possible to actual 

performance. In other words, athletes should practice whatever it is they 

intend to do. If athletes participate in a sport that requires high-powered 

ballistic movements, they should practice the same movements during 

training. One form of conditioning, plyometric training, even uses ballistic 

movement to increase power. To minimize the risk of injury during training, 

warm-ups and static stretching should be done first and ballistic stretching 

with a cool-down done last. 


118 

INDIRECT TECHNIQUES 

Indirect techniques involve moving in the direction of greatest freedom 

before moving into the barrier. Since the muscles used when moving away 

from the barrier are probably the same muscles that are causing a limited 

ROM, contracting these muscles may in some way diminish their ability to 

restrict movement. The principles involved here may relate to successive 

induction and post-isometric relaxation: moving away from the barrier may 

facilitate the antagonist (successive induction) and inhibit the restricted agonist 

(post-isometric relaxation). Using the indirect approach, if elbow extension is 

limited, move in the direction of freedom (flexion) and then move into the 

barrier (extension). If successful, extension will increase. 

PROGRESSIVE MOVEMENT 

Progressive movement begins by having the patient stretch as far as 

possible into the barrier and then have the practitioner hold the body part in 

place until the pain stops and tissues relax. If possible, the patient should 

repeat the stretch. Each time the patient repeats the stretch, passive resistance 

should be used to hold the body part in place. This process should be 

continued until the patient achieves the fullest range of motion possible. 

Patients who resist passive stretching may find this method more acceptable 

because the patients control their own movements. 

Once the affected part reaches its final range of motion, the final step is 

having the patient return to starting position and repeat the entire movement 

several times without the body part being held in place at the end of the 

movement by the practitioner. The final movements by the patient should 

move into the barrier slowly to avoid a stretch reflex and back to the starting 

position slowly to avoid stressing the muscle being stretched. A typical 

movement would be (1) slowly move into the barrier, (2) hold the stretch for 2 

seconds or less without assistance, and (3) slowly return to starting position. 

The movements into the barrier and back to starting position should take about 

equal time. Since progressive movement cannot increase the patient's ROM 

beyond the physiologic ROM, passive stretching (overstretching) may be 

needed to reach the anatomic range of motion. 


119 


THREE HEMME LAWS 

• HEMME’s 1st law: Most conditions treatable by soft-tissue therapy 

are characterized by pain, limited range of motion, or weakness. 

• HEMME’s 2nd law: Most conditions treatable by soft-tissue 

therapy can be identified and treated by using five basic steps: 

History, Evaluation, Modalities, Manipulation, and Exercise. 

• HEMME’s 3rd law: Always be ready, willing, and able to disregard 

any law, principle, axiom, or belief that proves to be incorrect. 

TEN LAWS OR PRINCIPLES OF SOFT-TISSUE THERAPY 

• Beevor's axiom: The brain knows nothing of individual muscles, 

but thinks only in terms of movement. 

• Creep: Deformation of viscoelastic materials when exposed to a 

slow, constant, low-level force for long periods of time. 

• Facilitation-Inhibition: 

A. When a nerve impulse passes once through a set of neurons to the 

exclusion of other neurons, it usually takes the same path in the future 

and resistance to the impulse becomes less. 

B. As opposites, facilitation encourages a process and inhibition 

restrains a process. 


• Head's law: If painful stimulus is applied to areas of low sensibility 

in close central connection with areas of high sensibility, pain may be 

felt where sensibility is high. 

120 

• Hilton's law: The nerve trunk that supplies a joint also supplies the 

muscles that move the joint and the skin that covers the insertions of 

the muscles that move the joint. 

• Hysteresis: Energy loss in viscoelastic materials subjected to 

or to cycles of loading and unloading. 

stress 

• Sherrington's laws: 

A. Every posterior spinal root nerve supplies one particular region 

on the skin, although fibers from segments above and below 

can invade this region. 

B. Reciprocal Inhibition: when the agonist receives an impulse to 

contract, the antagonist relaxes. 

C. Irradiation: nerve impulses spread from a common center 

and disperse beyond the normal path of conduction. 

Dispersion tends to increase as the intensity of stimulus 

becomes greater. 

• Sherrington's reflex: A muscle contracts in response to passive 

longitudinal stretch. (also called stretch reflex or myotatic reflex) 

• Thixotropy: Certain gels liquefy when agitated and revert to gel 

upon standing. 

• Wolff's law: Bone and collagen fibers develop a structure most suited 

to resist the forces acting upon them. 


121 

FOUR TYPES OF FORCE USED IN SOFT TISSUE THERAPY 

• Tension: A force that pulls objects apart (stretch). 

• Compression: A force that pushes objects together (press). 

• Shear: A force that causes parallel but opposite movement (slide). 

• Torque: A force that causes rotation about an axis (twist). 

FIVE SIGNS CHARACTERISTIC OF TRIGGER POINTS 

• Pain when pressure is correctly applied 

• Thickening of subcutaneous tissue 

• A jump sign 

• A twitch response 

• Ropiness or hardness within a muscle 

THREE REASONS WHY TRIGGER POINTS REDUCE PAIN 

• Digital pressure disperses pain-producing chemicals. 

• Digital pressure stimulates production of endogenous opioids. 

• Trigger points activated by pressure act as a counterirritant. 


122 

FOUR GOALS OF NEUROMUSCULAR THERAPY 

• Inhibition: lengthen hypertonic muscles. 

• Inhibition: strengthen weak muscles. 

• Facilitation: shorten stretched muscles. 

• Facilitation: strengthen weak muscles. 

FOUR WAYS TO INHIBIT A MUSCLE 

• Activation of Golgi tendon organs 

• Deactivation of muscle spindles 

• Reciprocal inhibition (RI) 

• Post-isometric relaxation (PIR) 

FOUR WAYS TO FACILITATE A MUSCLE 

• Activation of stretch reflex 

• Activation of muscle spindles 

• Repeated contractions 

• Successive induction 


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FOUR GOALS OF CONNECTIVE TISSUE THERAPY 

• Increase tissue mobility 

• Break adhesions 

• Improve fluid exchange 

• Realign torn fibers 

THREE FACTORS THAT EXPLAIN SLOW STRETCHING 

• Thixotropy 

• Hysteresis 

• Creep 

THREE CAUSES FOR RESTRICTED RANGE OF MOTION 

• Pain 

• Spasm 

• Contracture 

ONE MANIPULATION THAT AFFECTS FOUR MAJOR TISSUES 

• Range-of-motion stretching affects the four major tissues: nerve 

tissue, muscle tissue, connective tissue, and epithelial tissue. 


124 

EXERCISE 

An exercise program is often the difference between full recovery, partial 

recovery, or no recovery at all. Although exercise programs without 

manipulations are seldom productive, the value of exercise cannot be 

overstated. The results of inactivity are deconditioning of the body as 

characterized by atrophy, fibrosis, circulatory insufficiency, loss of bone mass, 

and chronic fatigue. Patients who are unwilling to exercise on a regular basis 

can expect continuous dependency on treatment, exacerbation of symptoms, 

and progressive loss of function. Even if soft-tissue therapy is successful, 

exercises are needed to maintain fitness and decrease the risk of re-injury. If 

injuries recur, physical fitness has a positive effect on controlling the severity 

of injuries and rehabilitation time. 

After eliminating the activities that aggravate a patient's condition, the 

general goals of an exercise program are to lengthen areas of shortness and 

strengthen areas of weakness. Normal movement stops when muscles are not 

long enough to permit a full range of motion or strong enough to overcome 

internal resistance. Lengthening and strengthening also make it easier for 

muscles to overcome external resistance and move objects. 

Stretching to increase flexibility is normally the first stage of any exercise 

program. Once a full, pain-free range of motion is possible, the second stage 

is muscular strength and muscular endurance training to strengthen and 

condition muscles that need improvement. Most programs should end with 

full range-of-motion stretching exercises to help the patient maintain 

flexibility. In most clinical programs, stretching can be used before strenuous 

activity to warm up and after strenuous exercise to cool down. 

During the early stages of an exercise program, movements should not be 

extremely painful or cause fatigue. Perspiration, shortness of breath, difficulty 

talking, rapid pulse, and slow recovery times may indicate the exercises are too 

intense. Too much exercise causes overuse injuries and slows the patient's 

progress. If exercise programs are too difficult, many patients will not 

continue. 

Once pain is reduced and the patient feels stronger, some people seem to 

forget that injuries take time to heal and continue performing the same 

activities that caused the original injury. For these patients, caution cannot be 


125 

overstressed. Even though an early return to exercise is normally desirable, it 

may exacerbate the existing condition or cause new injuries. Everyone 

responsible for the patient's care, including practitioners, trainers, or physical 

fitness instructors, should carefully monitor the effects of exercise on the 

patient's condition. Any sign of reversal in the patient's condition may indicate 

the exercise program needs to be modified. 

Even after a full recovery, patients should be instructed to eliminate any 

activities that may have caused the original injury. Though some injuries such 

as traffic accidents are difficult to predict or prevent, participation in 

recreational activities should be controllable by the patient. If the activity is 

vital to the patient's self-interest, such as work-related duties, the alternatives 

are (1) conditioning the body to accept the added stress by using exercises to 

improve strength, endurance, flexibility, or coordination, and (2) using the 

body in ways that minimize the effects of stress. Patients are more prone to 

injury when tired or fatigued, weak muscles decrease joint stability, and some 

injuries could be avoided if patients used better body mechanics when lifting. 

Exercise programs should always be structured by someone with 

appropriate training in therapeutic exercise. The two groups that seem to use 

therapeutic exercise the most are athletic trainers and physical therapists. 

Because of special requirements involving space and equipment, exercise 

programs and manual therapy may not be available at the same location. 

The basic components of a physical fitness program are (1) flexibility, (2) 

muscular strength, (3) muscular endurance, (4) aerobic endurance, and (5) 

coordination. In terms of therapeutic exercise, the two main goals are 

flexibility and muscular strength. Until patients have enough flexibility to 

achieve a normal range of motion and enough strength to perform at least one 

repetition of the intended movement, muscular endurance, aerobic endurance 

(cardiorespiratory endurance), and coordination are secondary. 

Physical fitness can only be achieved by following five basic principles. 

Everyone connected with a patient's therapy, as well as anyone interested in 

their own welfare, should be familiar with these principles. All too often, 

practitioners are quick to apply these principles to a patient but slow to apply 

the same principles to themselves. These five principles are (1) the overload 

principle, (2) the intensity principle, (3) the frequency and duration principle, 

(4) the specificity principle, and (5) the training principle. 


126 

 

 

 

 

 

PRINCIPLES OF PHYSICAL FITNESS 

The Overload Principle 

The Intensity Principle 

The Frequency and Duration Principle 

The Specificity Principle 

The Training Principle 

THE OVERLOAD PRINCIPLE 

The overload principle refers to exercising at levels of stress that are 

greater than normal. When functioning at normal levels of stress, fitness 

remains about the same. The body responds to levels of stress above normal 

by making physiologic changes called adaptations or training effects that 

improve the body's ability to deal with future stress. These changes affect 

flexibility, strength, muscular endurance, and cardiorespiratory fitness. Once 

new levels of stress become standard, higher levels of stress are needed for 

improvement. 

In therapy, overload can be accomplished by using various forms of 

resistance such as gravity, weights, weight machines, opposing muscles, or 

resistance provided by the therapist. Progressive resistance exercises are based 

on the principle that resistance should be increased incrementally after the 

body adapts to each new level of stress. Adaptations to overload will continue 

until the body reaches its own limit. 

Single sessions of an exercise produce temporary changes that are called 

responses. These changes become more permanent after repeated bouts of the 

same exercise. It is not the exercise itself, but the changes because of exercise 

that improve biologic efficiency. 

The overload principle can be applied by using both isometric and isotonic 

exercises. Isometric contractions do not produce movement because internal 

forces are not great enough to overcome external resistance. Muscles 

contracting isometrically develop tension without changing length. Isotonic 

contractions, on the other hand, produce movement because internal forces are 


127 

great enough to overcome external resistance. Muscles contracting 

isotonically develop tension and become shorter. Isometric contractions 

improve static strength such as gripping or holding an object, whereas isotonic 

contractions improve dynamic strength such as pushing or pulling an object. It 

is normally easier to hold an object than to move an object. 

Although both types of contraction are used in normal living, from a 

therapeutic standpoint, isometric contractions generate less friction and are less 

likely to aggravate joints and periarticular tissues. Because there is no 

movement during contraction, isometric exercises can sometimes be used 

where isotonic exercises would cause tissue damage. 

Although not commonly considered, the overload principle can be applied 

to flexibility exercises. Flexibility refers to the mobility or range of motion of 

a given joint. The structural factors limiting flexibility are muscles, tendons, 

ligaments, fascia, body fat, skin, joint capsules, and sometimes the joint. 

Contrary to popular belief, flexibility is joint-specific. Flexibility in one joint 

does not guarantee flexibility in other joints. Flexibility patterns develop that 

are typical for a given activity. 

To use the overload principle in flexibility exercises (1) stop the stretch at 

the first sign of resistance, (2) hold the stretch until the tissues relax, (3) stretch 

slowly until the patient starts to feel pain, (3) hold the stretch until the tissues 

relax again, and (4) continue the sequence until stretching becomes too painful 

or no further increase in range of motion is needed. 

Two other approaches that use overload are (1) stop at the first sign of 

resistance, hold the stretch for less than 2 seconds, release the tension, return to 

starting position, and then repeat the sequence if needed; or (2) stop at the first 

sign of resistance, hold the stretch for 15 seconds or more, release the tension, 

return to starting position, and then repeat the sequence if needed. 

Regardless of which method is used, patients should normally exhale 

during the stretching stage and inhale during the relaxation stage. Since 

flexibility and stability are tradeoffs, increasing the patient's range of motion 

beyond normal may adversely affect joint function by decreasing stability. 

Like exercise programs in general, stretching programs should be 

constructed and supervised by someone familiar with training principles, softtissue 

therapy, and rehabilitation since too much exercise or inappropriate 

exercise can be just as damaging as no exercise or too little exercise. 


128 

THE INTENSITY PRINCIPLE 

Related to the overload principle, the intensity principle is probably the 

most important single factor in conditioning. Where overload measures the 

amount of energy expended to overcome resistance, intensity measures the 

rate of expenditure. 

Every tissue of the body has a threshold for improvement. Intensity below 

this level will not cause improvement. Strength training and, to a lesser extent, 

muscular endurance training require higher levels of intensity for improvement 

than either flexibility or cardiovascular fitness training. 

In sports training, the best measure of intensity is fatigue. Muscles are 

fatigued when they lose their ability to contract and momentarily fail. What 

causes fatigue is not always clear. Possible causes are depletion of glycogen in 

the muscle, accumulation of metabolic waste, depletion of oxygen, and failure 

of the body to regulate temperature. 

In therapy, a muscle may fatigue after one attempt to move a body part 

against gravity. Although fatigue is a good indicator that muscles are being 

used to the fullest extent possible, this level of intensity is normally too high 

for most patients. Muscle fatigue is inversely related to contractile force. 

High-intensity exercises that use near-maximum strength fatigue muscles 

rapidly and low-intensity exercises that use 30 percent or less of maximum 

strength fatigue muscles slowly. In terms of rehabilitation, low-intensity 

exercises are normally safer and more effective than high-intensity exercises. 

Even though it is not exactly clear what causes muscle soreness, intensity 

of exercise appears to be a factor. Microtrauma, spasm, and edema are several 

of the main factors that may cause muscle soreness. According to one theory, 

muscle soreness occurs when the byproducts of metabolism, such as lactic 

acid, accumulate in the tissues and cause edema. As the fluids shift back into 

blood plasma from the tissues, hydrostatic pressure decreases and pain 

subsides. Even though the accumulation of metabolites is probably a major 

factor in causing muscle soreness, the role of lactic acid is less certain for three 

reasons. One, lactic acid levels are not elevated in the muscles long enough to 

explain muscle soreness. Two, eccentric exercises produce more muscle 

soreness but less lactic acid than concentric exercises. And three, some people 

who experience muscle soreness are unable to produce lactic acid because of 

hereditary defects or disease (McArdle's disease). 


129 

The most recent theories now suggest that microtraumas are the main 

cause for muscle soreness. During intense exercise, microtraumas trigger the 

release of pain-producing chemicals such as histamines, bradykinin, serotonin, 

potassium ions, and prostaglandins. These chemicals are followed by pain, 

spasm, edema, and secondary tissue damage because of edema. The 

combination of spasm and edema may also restrict blood vessels and reduce 

circulation at a time when metabolic demands are high. Circulatory 

insufficiency may then cause metabolites to accumulate and tissues to become 

ischemic. Both metabolites and ischemia cause pain. 

In many respects, a sequence of muscle soreness resembles a pain cycle. 

The differences appear to be onset and resolution. In muscle soreness the 

onsets are sudden because of exercise; in pain cycles the onsets are insidious 

because the immediate causes are difficult to identify. Muscle soreness is 

normally self-limiting and resolves without treatment. Pain cycles are 

normally self-perpetuating and seldom resolve without treatment. 

It appears that exercise intensity has a direct effect on microtraumas. As 

the intensity of exercise increases, microtraumas increase. Though highintensity 

exercises favor rapid gain, they increase the risk of muscle soreness, 

torn muscles, ruptured tendons, fractured bones, and dislocated joints. Lowintensity 

exercises favor long-term improvements but slower progress. Since 

for many patients even small amounts of exertion may cause some degree of 

improvement, it is normally safer to exchange rapid gains for long-term 

progress. An effort of about 60 percent of maximum strength is normally 

sufficient to produce an increase in muscle size (hypertrophy). 

When muscles increase in size because of hypertrophy, part of this 

increase results from an increase in the diameter of muscle fibers and part 

results from an increase in the volume of connective tissue. Most skeletal 

muscles are about 85 percent muscle fiber and 15 percent connective tissue. If 

all other factors are equal (which is seldom the case), a muscle's maximum 

force potential is proportional to the cross-sectional area of the muscle. 

In addition to intensity, two other factors that affect progressive overload 

are frequency and duration. Frequency is the number of times an exercise is 

repeated and duration is the amount of time an exercise continues. 


130 

THE FREQUENCY AND DURATION PRINCIPLE 

Therapy sessions should be spaced far enough apart to allow sufficient 

time for rest. As tissues break down (catabolism) from exercise, rest periods 

are needed for growth and repair (anabolism) of injured tissue. High- intensity 

exercises require longer periods of rest than low-intensity exercises. Although 

flexibility training can often be done more times per week than strength 

training, the desired frequency requires a case-by-case assessment. 

While 2 or 3 treatments per week may be reasonable, some patients require 

more and others less. Since the majority of exercise training in soft-tissue 

therapy is done outside the clinic, the patient's motivation and schedule can be 

a factor in determining how many sessions are appropriate. 

The duration of exercise can also vary. Thirty minutes per patient is about 

the average, with 15 minutes the lower limit and 50 minutes the upper limit. 

High-intensity exercise requires less time than low-intensity exercise and 

strength training requires less time than aerobic training. Poorly conditioned 

patients often need shorter sessions than physically fit patients. 

THE SPECIFICITY PRINCIPLE 

Specific exercises produce specific adaptations. Each exercise has its own 

characteristics in terms of muscle groups, rates of energy expenditure, and 

patterns of movement. These patterns include velocities, accelerations, 

distances, amounts of force, and directions of movements. 

The value of training depends on what type of transfer occurs between 

practice exercises and final performance (the reason for training). The transfer 

is positive if training is beneficial and negative if training is detrimental. 

Positive transfer is greatest when the practice exercise and final performance 

are nearly identical. To increase positive transfer, a marathon runner should 

spend more time running than riding a bicycle or swimming. 

In physical fitness testing, the best way to ensure a positive transfer is to 

use the testing device for both training and testing. If a stationary bicycle is 

used to measure aerobic fitness, a stationary bicycle should be used as the 

training device. If the test involves swimming, cycling, or jogging, the 

practice should also involve swimming, cycling, or jogging. If the test 

involves push-ups, the practice should involve push-ups or possibly bench 

presses, since push-ups and bench presses use similar muscles. 


131 

Complete positive transfer is not always possible. In cases of extreme 

deficiency, strength training may be the only way to improve muscular 

endurance. Without enough strength for even a single repetition, endurance 

training would not be possible. Where strength is the limiting factor, strength 

training is needed to improve muscular endurance. 

Different exercises are needed for each factor that needs to be improved. 

A well-rounded exercise program should include exercises to improve 

flexibility, strength, muscular endurance, and cardiovascular fitness. In softtissue 

therapy, flexibility and strength are normally given more attention than 

muscular endurance and cardiovascular fitness. 

THE TRAINING PRINCIPLE 

The training principle states that patients normally make the greatest gains 

during the early stages of an exercise program. Patients in poor condition 

seem to improve faster than patients in good condition. The most common 

reasons for early improvement are better use of body mechanics and reduction 

of counterproductive movements. Neural changes that improve neurologic 

efficiency often precede morphologic changes that alter the mass or chemical 

composition of a muscle. As patients develop more self-confidence and relax, 

general performance seems to improve. 

As the program continues, progress is normally slower and some patients 

become frustrated, lose interest in the program, and quit training. Explaining 

the training principle can make it easier for patients to understand the nature of 

progress and continue with the program. 

Some people will resist exercise and refuse to participate in their own cure. 

Despite the benefits of exercise and the consequences of inactivity, some 

patients lack self-discipline. The best approach is try to find methods of 

exercise that are both enjoyable and beneficial. In most cases, a patient's 

willingness to exercise at home without direct supervision will have a greater 

long-term effect on recovery than supervised exercise. In many respects, the 

practitioner's role is making the patient capable of tolerating exercise and then 

turning responsibility for the patient's welfare back over to the patient. 


132 


FIVE PRINCIPLES OF PHYSICAL FITNESS 

• The overload principle 

• The intensity principle 

• The frequency and duration principle 

• The specificity principle 

• The training principle 


133 

OBJECTIVES SATISFIED OR NOT SATISFIED 

OBJECTIVES SATISFIED or OBJECTIVES NOT SATISFIED are the final two steps 

in the HEMME APPROACH. Objectives are satisfied when the patient regains 

normal function or achieves lesser goals if restoration of normal function is not 

possible. Lesser goals may include less pain, a greater range of motion, or 

more strength. If the same problems continue to occur despite therapy, a lesser 

goal could be fewer occurrences of the same problem or less disability when 

the same problem recurs. 

If the patient's problem is not solved, the objectives are not satisfied. 

Reasons for not solving a problem are many. Some patients will not cooperate 

and some conditions are not treatable by soft-tissue therapy. For many of 

these conditions, the only alternatives are medication, surgery, or 

psychological counseling. 

In rare cases, high-velocity manipulations are more effective than lowvelocity 

manipulations. Fragments of bone or cartilage (joint mice) that cause 

knees to lock and joint dislocations may respond better to high-velocity 

manipulations than low-velocity manipulations. High-velocity manipulations 

are normally performed by chiropractors, osteopaths, or medical doctors. 

Some problems are not solved because patients refuse to change their 

lifestyle or eliminate factors that contribute to the problem. If patients 

continue pursuing activities that cause overuse injuries, therapy will not be 

effective. Patients with low intakes of vitamin C and B complex are more 

prone to soft-tissue impairments and overuse injuries than patients with 

healthy diets. Refusal to exercise or change eating habits can adversely affect 

the outcomes of therapy. 

In any event, only two alternatives are possible, either the objectives are 

satisfied or they are not satisfied. Objectives are satisfied when soft-tissue 

impairments are corrected to a satisfactory degree. The five main goals of 

soft-tissue therapy are normally (1) reduce pain, (2) increase or maintain a 

pain-free range of motion, (3) increase or maintain strength, (4) improve the 

quality of movement, and (5) restore normal function. 

If the objectives are satisfied, verifiable evidence of improvement such as 

an increased range of motion by degrees or increased strength based on muscle 

testing should be recorded as part of the patient's medical history. Retesting to 

determine if the objectives are satisfied or not satisfied normally resembles 

step number two in the HEMME APPROACH titled EVALUATION. 


134 

Objectives are not satisfied when the patient's condition remains the same 

or becomes worse. If the original objectives are not satisfied, therapy can be 

continued or discontinued. If therapy is continued, the original goals can be 

reattempted or new goals can be set. If a realistic appraisal of the patient's 

condition shows the original goals are not feasible, new goals can be set using 

modified standards. For some patients, any improvement at all is a realistic 

goal. 

When making final evaluations, statements by the patient are not always 

reliable. If the patient and practitioner have good rapport, the patient may 

claim improvement just to please the practitioner. On the other hand, if good 

rapport is lacking, patients may deny improvement to frustrate the practitioner. 

Some patients may deny improvement to justify withholding payment or not 

making a complete payment. 

While patients concerned about losing their employment or being passed 

over for promotion may overstate the recovery, patients anticipating secondary 

gain from litigation or sympathy may overstate the disability. Insurance 

benefits and job dissatisfaction seem to encourage malingering. To avoid 

being overly influenced by the patient, rely on physical signs more than 

statements or complaints by the patient. 

Therapy is a never-ending learning process and failures are going to occur. 

You sometimes learn more from failure than success. Each learning 

experience offers new information that makes it easier to find solutions in the 

future. By learning from mistakes, a practitioner becomes more adaptable and 

patients derive the benefit. 

Above all else, always bear in mind a statement made by the Greek Father 

of Medicine, Hippocrates, 460-400 BC: "Whenever a doctor cannot do good, 

he must be kept from doing harm." In other words, whether a doctor or 

therapist, the first and highest duties to perform are: 

• PROVIDE THE BEST CARE POSSIBLE 

• DO THE PATIENT NO HARM 


135 

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148 


149 

GLOSSARY 

acute Short duration, not chronic, rapid onset, severe. 

active trigger point Hyperirritable spots or zones that actively produce pain 

and may cause autonomic responses. 

adhesion 

separated. 

A tissue structure holding parts together that are normally 

adipose Pertaining to fat. 

agonist Muscle or muscle group primarily responsible for performing some 

movement (prime mover). 

anabolism The constructive phase of metabolism. 

analgesia Loss of sensitivity to pain. 

anesthesia Partial or complete loss of feeling, with or without loss of 

consciousness. 

ankylosis Fixation of a joint. 

anoxia Without oxygen. 

antagonist Muscle or muscle group that opposes the movement of the 

agonist and produces the opposite movement. 

antalgic A posture or gait that avoids pain. 

aponeurosis A flat fibrous sheet of connective tissue that attaches muscles 

to bone. 

approximate To bring close together. 


150 

apraxia Loss of ability to perform purposeful movement in the absence of 

paralysis. 

asthenia Loss of strength or energy. 

ataxia Loss of motor coordination. 

athetosis Snakelike movements. 

atonia Lack of tension or tone, flaccid. 

atrophy Decrease in size of an organ or tissue. 

auscultation Listening for sounds made by various body structures. 

ballistics A study of motion and trajectory. 

barrier An obstruction that tends to restrict free movement. 

blanch To become pale, white, or lose color. 

capsulitis Inflammation of a capsule. 

CAT SCAN Computerized (axial) tomography scan. 

catabolism Destructive phase of metabolism. 

causalgia Burning pain. 

chronic Long duration, normally more than six months. 

claudication Lameness resulting from inadequate circulation. 

clonus Uncontrolled spasmodic muscle jerking. 


151 

cocontraction Mutual contraction of antagonistic muscles for the purpose 

of stabilizing a body part. 

collagen A fibrous protein found in connective tissue. 

compensatory Making up or compensating for a defect, deficiency, or loss. 

concentric contraction A muscle shortens during contraction. 

contractility Having the ability to contract or shorten in response to 

stimulus. 

contraction Increased tension caused by physiologic shortening of a 

muscle. 

contracture A pathologic shortening of a muscle due to spasm or fibrosis that 

increases resistance to active or passive stretch. 

convergence The moving of two or more forces toward the same point. 

conversion Changing emotions such as hysteria into physical manifestations. 

counterirritation Superficial irritation that relieves another irritation or 

deep pain. 

cramp Strong and painful spasm. 

creep A slow permanent deformation of viscoelastic materials when placed 

under a constant load for long periods of time. 

crepitus The sound of bone rubbing against bone. 

cryotherapy Therapeutic application of cold. 


152 

cyanosis Bluish or gray discoloration of skin because of reduced hemoglobin 

in blood. 

cyst A closed sac or pouch containing fluid, semisolid, or solid material. 

diaphoresis Profuse sweating. 

disease A morbid or pathologic condition that deviates from normal 

function where agent, signs, and symptoms are identifiable. 

distract To separate. 

divergence The moving of two or more forces away from a common 

center. 

dysesthesia Unpleasant sensations produced by ordinary stimulus. 

eccentric contraction A muscle lengthens during contraction. 

EMG Acronym for electromyogram, the graphic record of muscle contraction 

that results from electrical stimulation. 

encephalitis Inflammation of the brain. 

endogenous Produced or developed from within the organism. 

entrapment syndrome Entrapment of a nerve by hard or soft tissue. 

etiology Scientific study involving the causes of disease. 

exacerbation Aggravating symptoms or increasing the severity of a disease. 

exostosis Bony growth arising from the surface of bone. 

extensibility The ability to lengthen. 


153 

exteroceptor A sense organ receiving stimuli from outside the body. 

extracellular Outside the cell. 

extravasation Fluids escaping from vessels into surrounding tissue. 

fascia A fibrous connective tissue membrane covering, supporting, and 

separating a muscle. 

fasciculation Spontaneous contraction or twitch of a group of muscle 

fibers. 

fascitis Inflammation of any fascia. 

fibrinolytic Dissolution or splitting up of fibrin. 

fibroblast A cell that produces connective tissue. 

fibroma A fibrous, connective tissue tumor. 

fibroplasia Development of fibrous tissue during wound healing. 

fibrositis Inflammation of fibrous tissue. 

FIRST Acronym for mechanism of injury: 

Severity, and Time. 

Force, Intensity, Regions, 

flail joint Excessive mobility of a joint, usually because of paralysis. 

force That which changes or tends to change a body's motion or shape. 

gamma motor neuron An efferent nerve cell that innervates the ends of 

intrafusal muscle fibers. 

ganglion Benign cystic tumors developing on a tendon or aponeurosis. 


154 

GTO Acronym for Golgi tendon organs. 

guarding Involuntary muscle contractions that limit range of motion to 

avoid pain. 

HEMME Acronym for History, Evaluation, Modalities, Manipulation, and 

Exercise. 

hypalgesia Decreased sensitivity to pain, opposite of hyperalgesia. 

hyper- Prefix meaning more than, excessive, above. 

hyperalgesia Increased sensitivity to pain, opposite of hypalgesia. 

hyperemia Increased quantity of blood in a body part shown by redness of 

skin. 

hyperesthesia Increased sensitivity to pain; hyperalgesia. 

hyperirritable Increased response to stimulus. 

hypermobility Excessive mobility of any joint. 

hypertonia Excessive tone of skeletal muscles that increases resistance to 


hypertonic A state of greater than normal tension in muscles. 

hypertrophy Increase in size of organ or tissue. 

hypo- A prefix meaning less than, deficient, beneath. 

hypoesthesia Decreased sensitivity to pain; hypalgesia. 

hypokinetic Decreased motor function. 


155 

hypomobility Decreased mobility of a joint or range of motion. 

hypotonia Diminished tone in skeletal muscles and decreased resistance to 


hypotonic A state of less than normal tension in muscles. 

hypoxia Deficiency of oxygen. 

hysteresis Energy loss in viscoelastic materials subjected to stress or cycles 

of loading and unloading. 

hysteria A neurotic condition presenting somatic symptoms in the absence 

of organic disease. 

iatrogenic An adverse state or condition induced by treatment. 

idiopathic A disease of spontaneous origin with unknown cause. 

induration Hardening of soft-tissue caused by extravasation of fluids. 

insidious A disease that appears slowly and progresses with few or no 

symptoms indicating the illness. 

inspection Examination by the eye. 

ischemia Insufficient blood supply to a tissue or organ. 

isometric contraction Contraction of a muscle with no change in length. 

isotonic contraction Contraction of a muscle with a decrease in length. 

joint mice Bits of bone or cartilage that are present in joint space. 

keloid scar A raised, red, smooth scar that is often painful. 


156 

kinetics A study of forces acting on a system. 

latent trigger point Trigger points that lie dormant except when palpated. 

ligament A band of fibrous connective tissue connecting the articular ends 

of bones. 

lipoma A fatty tumor that is not metastatic. 

malingering Pretending to be ill. 

manipulation Therapeutic use of hands with or without impulse. 

matrix The intercellular substance of a tissue. 

mechanism of injury The forces that caused the injury. 

metastasis Spread of malignant cells. 

mobilization Making a joint movable. 

modality A therapeutic or physical agent such as thermotherapy (heat), 

cryotherapy (cold), hydrotherapy (water), or vibration. 

MRI Acronym for magnetic resonance imaging. 

muscle hypertrophy An increase in the size of a muscle because of activity. 

muscle atrophy A decrease in the size of a muscle. 

myalgia Muscular pain. 

myofascial release An osteopathic technique that follows the principle of 

creep. 


157 

myofascial Involving muscles and fascia. 

myofibrosis Replacement of muscle tissue by fibrous connective tissue. 

myositis Inflammation of a voluntary muscle. 

myotenositis Inflammation of a muscle and its tendon. 

necrosis Death of a tissue. 

neuralgia Pain along the course of a nerve. 

neuritis Inflammation of a nerve. 

neuropraxia A traumatized nerve that no longer conducts even though 

anatomic structure appears to be intact. 

nociceptor A nerve for receiving and transmitting injurious or painful 

stimuli. 

opioid An opiate-like synthetic narcotic not derived from opium. 

osteoarthritis Chronic disease involving degeneration of joints. 

osteoblast A cell that produces bone. 

palliative Relieving symptoms but not a cure. 

Palmer, Daniel Self-educated manipulator (1845-1913) and founder of 

chiropractics. 

palpation Examining the body by application of hands or fingers to the 

surface of the body. 

paralysis Loss or impairment of voluntary muscle function. 


158 

paresis Incomplete loss of voluntary muscle function. 

paresthesia Abnormal sensation such as "pins and needles," 

burning, tickling, or tingling. 

pathology Condition or manifestation produced by disease. 

percussion Tapping sharply on the body to determine position, size, and 

consistency of underlying structures. 

periosteum A fibrous connective tissue membrane that covers bone. 

physiatrist A doctor specializing in physical medicine. 

pilomotor Pertaining to the arrector muscles that cause hairs to move or 

stand erect (goose flesh). 

PNF Acronym for Proprioceptive Neuromuscular Facilitation. 

proprioceptor A receptor within the body that responds to pressure, 

position, or stretch. 

proteoglycans The extracellular matrix of connective tissue composed of 

glycosaminoglycans (GAG) bound to protein chains. 

psychogenic Created by the mind. 

radiculitis Inflammation at the origin of a nerve. 

range of motion The maximal span of a joint as measured by angular 

displacement between two adjacent segments. 

Raynaud's disease A peripheral vascular disorder characterized by 

abnormal vasoconstriction of the extremities when exposed to cold. 


159 

rebound tenderness Pain or discomfort when pressure is released. 

reflex An involuntary response to stimulus. 

rheumatoid arthritis A form of arthritis involving inflammation of joints, 

stiffness, and swelling. 

RICE Acronym for rest, ice, compression, and elevation. 

ROM Acronym for range of motion. 

salicylate Any salt of salicylic acid that is used in drugs such as aspirin to 

reduce pain and temperature. 

satellite trigger point A trigger point activated by another trigger point in 

the same reference zone. 

sciatica Severe pain along the sciatic nerve. 

secondary trigger points Trigger points that develop in a synergist or 

antagonist because of overload. 

self-limiting A condition that runs a definite course and then stops without 

treatment. 

sentient Capable of feeling sensation. 

servomechanism A control mechanism that operates by positive or negative 

feedback. 

sign Objective evidence of an illness. 

somatic dysfunction Altered or impaired function related to components 

of the body and treatable by manipulation. 


160 

spasm Involuntary contraction of a muscle beyond physiologic needs. 

spastic Inflicted by spasm. 

spondylolisthesis anterior displacement of lower lumbar vertebrae over the 

body of the sacrum. 

spondylosis Vertebral ankylosis that may involve osteoarthritis. 

spondylotherapy Spinal manipulation for treating disease. 

sprain Trauma to a joint causing injury to ligaments. 

stasis Stagnation of blood or other body fluids. 

statics A study of systems that do not move. 

stenosis Constriction or narrowing of a passage. 

Still, Andrew American physician (1828-1917), founder of osteopathy. 

strain Trauma to a muscle or musculotendinous unit. 

strength The ability to exert muscular force. 

stress The results produced when a structure is acted upon by force. 

subluxation A partial or incomplete dislocation. 

symptom Subjective evidence of an illness. 

syncope Loss of consciousness caused by inadequate blood flow to the 

brain, fainting. 

syndrome A group of signs and symptoms characterizing a disease. 


161 

synergist A muscle functioning in cooperation with another muscle. 

telepathy Communication between two people without physical or 

physiological explanation, a form of extrasensory perception. 

tendinitis Inflammation of a tendon. 

tendon A fibrous connective tissue attaching muscles to bones. 

TENS Acronym for Transcutaneous Nerve Stimulation. 

thermotherapy Therapeutic application of heat. 

thixotropy A property of certain gels that liquefy when agitated and become 

semisolid again when left standing. 

torque A turning caused by rotary force acting about a pivot point. 

traction Process of pulling apart. 

trigger point or zone A spot or zone of the body that produces sudden pain 

when stimulated by pressure. 

urticaria Eruption of skin characterized by severe itching. 

vasoconstriction Decrease in the caliber of blood vessels. 

vasodilation Increase in the caliber of a blood vessel. 

vertigo Sensation of whirling or rotating in space or being surrounded by 

objects that are whirling or rotating in space. 

viscoelastic A viscous material that is also elastic. 

viscosity Resistance to flow or shear caused by stickiness or cohesion. 


162 

HEMME APPROACH QUIZ 

1. Which sign or symptom does not characterize soft-tissue impairments? 

a. pain Hint: use the table of contents, 

b. limited range of motion 

index, and chapter summaries. 

c. poor quality movement 

d. subluxations 

2. Which factors cause soft-tissue impairments? 

a. trauma 

b. disease 

c. postural defects 

d. all of the above 

3. What is replacement of muscle tissue by fibrous tissue called? 

a. fibrositis 

b. myofibrosis 

c. myositis 

d. fascitis 

4. Which statement about pain cycles is false? 

a. Mechanisms that cause pain cycles are difficult to locate. 

b. Pain cycles are both chronic and acute at the same time. 

c. Muscular imbalance has no effect on pain cycles. 

d. Reflexogenic activity perpetuates pain cycles. 

5. Which sequence describes the basic steps in the HEMME APPROACH? 

a. Subjective, Objective, Appraisal, and Plan 

b. History, Evaluation, Modalities, Manipulation, and Exercise 

c. Problem, Theory, Testing, Solution 

d. None of the above 


163 

6. What does the first letter of the acronym FIRST refer to? 

a. fibrosis 

b. fascia 

c. force 

d. fibroblast 

7. Which process is not a classical method of physical evaluation? 

a. inspection 

b. palpation 

c. telepathy 

d. auscultation 

8. Which classification defines range-of-motion testing where the force 

is provided by the examiner without assistance from the patient? 

a. active range-of-motion testing 

b. passive range-of-motion testing 

c. active-assisted range-of-motion testing 

d. resisted range-of-motion testing 

9. In muscle testing, what is the ability to hold against gravity with full 

resistance graded as? 

a. normal 

b. good 

c. fair 

d. zero 

10. In muscle testing, which procedure is potentially unsafe? 

a. apply resistance quickly 

b. apply resistance slowly 

c. do not break the patient's contraction 

d. remove resistance slowly 


164 

11. Which condition is not commonly cited as a contraindication to softtissue 

therapy? 

a. malignancies 

b. hypertonic muscles 

c. cardiac or circulatory disease 

d. severe respiratory disease 

12. Which condition would normally contraindicate soft-tissue therapy? 

a. fibrosis 

b. myalgia 

c. encephalitis 

d. myofibrosis 

13. Specialized nerve endings that receive and transmit painful (nociceptive) 

stimulus are sensitive to what changes? 

a. temperature (thermosensitive) 

b. mechanical stress (mechanosensitive) 

c. noxious chemicals (chemosensitive) 


14. Which compound is not considered a pain-producing substance? 

a. salicylate 

b. histamine 

c. serotonin 

d. bradykinin 

15. Which phrase characterizes deep pain? 

a. sharp prickling pain 

b. dull aching pain 

c. well-defined pain 

d. tingling pain 


165 

16. Which structures are least sensitive to pain? 

a. periosteum and joint capsule 

b. ligaments and tendons 

c. articular cartilage and fibrocartilage 

d. muscles 

17. Which method of manipulation is not used in the HEMME APPROACH? 

a. high-velocity spondylotherapy 

b. trigger point therapy 

c. neuromuscular therapy 

d. connective tissue therapy 

18. Which condition is not indicated for heat? 

a. muscle spasm 

b. pain 

c. contracture 

d. edema 

19. Which condition(s) contraindicate the use of heat? 

a. bleeding 

b. malignancy 

c. inflammation 


20. Which condition is not indicated for cold? 

a. muscle spasm 

b. pain 

c. vascular stasis 

d. edema 


166 

21. Which condition(s) contraindicate the use of cold? 

a. Raynaud's disease 

b. cold sensitivities 

c. severe heart disease 


22. Which principle states the brain knows nothing of individual muscles 

but thinks only in terms of movement? 

a. Arndt-Schultz law 

b. Beevor's axiom 

c. Head's law 

d. Hilton's law 

23. How is soft-tissue therapy defined? 

a. manipulation of osseous tissue for therapeutic purposes 

b. manipulation of sensory tissue for therapeutic purposes 

c. manipulation of superficial or soft tissue for therapeutic purposes 

d. manipulation of visceral tissue for therapeutic purposes 

24. What is the force called that pushes objects together? 

a. creep 

b. cocontraction 

c. compression 

d. contracture 

25. Which principle states that all living functions are continually 

controlled by two opposing forces? 

a. Wolff's law 

b. Sherrington's reflex 

c. Meltzer's law 

d. Facilitation 


167 

26. What is another name for stretching? 

a. tension 

b. compression 

c. shear 

d. torque 

27. Trigger points are indicated by what signs? 

a. thickening of subcutaneous tissue 

b. a jump response 

c. ropiness within a muscle 


28. Which factor does not explain why trigger point therapy reduces pain? 

a. production of heat by friction 

b. dispersion of pain-producing chemicals 

c. production of endogenous opioids 

d. counterirritation 

29. What are trigger points called that lie dormant for years? 

a. active trigger points 

b. satellite trigger points 

c. latent trigger points 

d. secondary trigger points 

30. Which method of therapy produces many effects that are similar to those 

produced by cross-fiber friction (connective tissue therapy)? 

a. trigger point therapy 

b. neuromuscular therapy 

c. range-of-motion stretching 

d. none of the above 


168 

31. Which method of inhibition or facilitation is not used in neuromuscular 

therapy to balance muscles? 

a. lengthen hypertonic muscles 

b. strengthen weak muscles 

c. weaken strong muscles 

d. shorten stretched muscles 

32. Which neuromuscular principle is referred to as a key point? 

a. lengthen first, strengthen second 

b. strengthen first, lengthen second 

c. lengthen only 

d. strengthen only 

33. Which technique in neuromuscular therapy facilitates? 

a. activation of Golgi tendon organs 

b. activation of muscle spindles 

c. reciprocal inhibition 

d. fatigue (post-isometric inhibition) 

34. Which technique in neuromuscular therapy inhibits? 

a. activation of Golgi tendon organs 

b. activation of muscle spindle cells 

c. repeated contractions 

d. successive induction 

35. What are the aims of connective tissue therapy? 

a. break adhesions 

b. improve fluid exchange 

c. realign torn fibers 



169 

36. Which concept explains why gels liquefy when agitated? 

a. thixotropy 

b. hysteresis 

c. creep 


37. Which concept explains why viscoelastic materials placed under a 

constant load for long periods of time deform with minimal force? 

a. thixotropy 

b. hysteresis 

c. creep 


38. Superficial torque, skin rolling, cross-fiber friction, and parallel or 

perpendicular stretching are found in what type of therapy? 



c. connective tissue therapy 

d. range-of-motion stretching 

39. Which factor(s) are likely to cause limited range of motion? 

a. pain 

b. spasm 

c. contracture 


40. What fibrous membrane covers, supports, and separates a muscle? 

a. superficial fascia 

b. deep fascia 

c. keloid tissue 

d. adipose tissue 


170 

41. Which tissues are the focus of connective tissue therapy? 

a. nerve and muscle tissue 

b. connective tissue and epithelial tissue 

c. connective tissue and muscle tissue 

d. connective tissue and nerve tissue 

42. Which method of therapy targets the four major types of tissue? 



c. connective tissue therapy 

d. range-of-motion stretching 

43. Which technique moves in the direction of greatest freedom first? 

a. direct technique 

b. indirect technique 

c. linear technique 

d. circular technique 

44. Which principle of exercise refers to exercising at levels of stress that 

are greater than normal? 

a. overload principle 

b. intensity principle 

c. specificity principle 

d. training principle 

45. Which principle states that patients normally make the greatest gains 

during the early stages of an exercise program? 

a. overload principle 

b. intensity principle 

c. specificity principle 

d. training principle 


171 

46. Which word defines loss of sensitivity to pain only? 

a. analgesia Hint: use the glossary. 

b. anesthesia 

c. asthenia 

d. ataxia 

47. Which term defines mutual contraction of antagonistic muscles? 

a. concentric contraction 

b. cocontraction 

c. eccentric contraction 

d. isometric contraction 

48. Which term defines involuntary muscle contractions that limit range of 

motion to avoid pain? 

a. atonia 

b. hypotonic 

c. guarding 

d. hypotonia 

49. Which term defines a disease of spontaneous origin with unknown cause? 

a. hysteria 

b. idiopathic 

c. iatrogenic 

d. insidious 

50. Which term defines a nerve for receiving and transmitting injurious or 

painful stimuli? 

a. exteroceptor Please return only the 

b. nociceptor 

one-page answer sheet. 

c. proprioceptor 

d. synergist 


172 

INDEX 

active insufficiency 35 

active range-of-motion testing 30, 31 

active-assisted range-of-motion testing 30, 32 

auscultation 26, 28 

ballistic stretching 117 

Beevor's axiom 36, 64, 119 

connective tissue and stretching 116-117 

connective tissue therapy 49, 101-108 

contraindications to cold 59 

contraindications to heat 56 

contraindications to soft-tissue therapy 38-40 

contraindications to vibration 60 

contrast applications 53 

creep 64, 104-105 

cross-fiber friction 83, 107 

cryotherapy 56-59 

exercise 124-131 

facilitation 86, 89 

Facilitation-Inhibition 64 

fascia 1-3, 5, 27, 29, 41, 68, 101-108, 110, 112, 116, 127 

FIRST 22-23 

fixators 35 

forces 68-74 

frequency and duration principle 130 

Golgi tendon organs 90-91 

Head's law 45, 64 

heat vs. cold 59 

HEMME’s 1st law 63 

HEMME’s 2nd law 63 

HEMME’s 3rd law 64 

HEMME APPROACH 15-18 

HEMMEGON 18 

high-velocity manipulation 1, 8, 10, 12, 38, 65-67 


173 

Hilton's law 43, 64, 74 

Hooke's law 110 

hysteresis 64, 103-104 

indirect techniques 118 

inhibition 85, 89 

inspection 27-28 

intensity principle 128-129 

latent trigger points 80 

low-velocity manipulations 1, 10, 12, 74 

lymphatic drainage 108 

Meltzer's law 85 

modalities 53-60 

modalities and stretching 114-115 

muscle spindles 91-92, 98-99 

muscle testing 29-37 

muscle testing by grade 33 

muscle testing safety 36 

myofibrosis 2 

neuromuscular and stretching 116 

neuromuscular therapy 84-100 

nociceptors 41 

overload principle 126-127 

pain 41-46 

pain cycle 3-9, 42, 129 

pain-sensitive structures 45 

pain-producing substances 41 

painful stimulus 42 

palpation 26-28 

parallel or perpendicular stretching 107 

passive range-of-motion testing 30-32 

PDQ 22 

percussion 26, 28 

post-isometric relaxation 94-96 

principles of soft-tissue therapy 63-65 

reciprocal inhibition 92-94 


174 

repeated contractions 99-100 

resisted range-of-motion testing 30, 33 

restrictions 27, 109, 111, 116 

salicylate 41 

satellite trigger points 76, 79 

secondary trigger points 79 

Sherrington's laws 64, 74 

Sherrington's reflex 65 

skin rolling 106 

soft-tissue impairments 1-3, 5, 9-10, 12, 27, 74, 113, 133 

soft-tissue therapy 1-2, 8-12, 16-17, 38, 53-54, 63-65, 68, 74 

SOS 50-51 

specificity principle 130-131 

stretch reflex 97-98 

stretching 109-118 

substitution 34 

successive induction 100 

superficial torque 106 

thermotherapy 54-56 

thixotropy 65, 103 

training principle 131 

trigger point therapy 75-83 

trigger points and stretching 115 

trigger point signs 76 

vibration 60 

Wolff's law 65, 83 


I 

QUICK REFERENCE GUIDE FOR 

NEUROMUSCULAR THERAPY 

INHIBIT 

FACILITATE 

BELLY 

BELLY 

Slow compression directed toward the belly of a muscle tends to inhibit. 

Rapid tension directed away from the belly of a muscle tends to facilitate. 

The belly is normally the wide, fleshy, or central portion of a muscle. 

Copyright, David H. Leflet, 1997 

HEMME Approach Publications 

3334 Spring Valley Lane, Bonifay, FL 32425 

850-547-9320 


II 

INHIBITION AND FACILITATION 

Slow, progressive 

stretching tends 

to inhibit a 

muscle. 

slow stretch (pull) 

Rapid stretching 

tends to facilitate 

a muscle. 

rapid stretch (pull) 

tendons 

Pressure on a 

tendon tends 

to inhibit a 

muscle. 

Repeated 

contractions 

tend to facilitate 

a muscle. 


III 

RECIPROCAL INHIBITION (RI) 

Practitioner 

applies 

counterforce 

while patient 

contracts the 

antagonist. 

Practitioner 

stretches the 

agonist to 

increase ROM. 


counterforce (hold) 

1 The patient should start with the antagonist at midrange, a length about halfway between 

fully contracted and fully stretched or at a point just short of where the muscle starts to resist 

stretching (resistance barrier). 

2 The patient applies isometric resistance and the practitioner applies an equal 

amount of isometric counterforce. The strength of contraction for the antagonist 

should be about 25 percent of maximum strength. 


4 Shortly after the patient stops contracting the antagonist (about 3 seconds), the 

practitioner should stretch the agonist. Slow stretching with moderate force will be 

more effective than rapid stretching with heavy force. Stretching should stop at the 

first sign of resistance or pain. 

5 The patient should breathe slowly out during contraction, breathe in during 

relaxation, and breathe slowly out during stretching. 

6 While up to 5 repetitions are acceptable, RI should be stopped if the technique is 

too painful, the patient's range of motion stops increasing, or the patient's range of 

motion becomes normal. 


IV 

POST-ISOMETRIC RELAXATION (PIR) 

Practitioner 

applies 

counterforce 

while patient 

contracts the 

agonist. 

Practitioner 

stretches the 

agonist to 

increase ROM. 


counterforce (hold) 

1 The patient should start with the agonist at midrange or at a point just short of 

where the muscle starts to resist stretching (resistance barrier). 

2 The patient applies isometric resistance and the practitioner applies an equal 

amount of isometric counterforce. The strength of contraction for the agonist should 

be about 50 percent of maximum strength. 


4 Shortly after the patient stops contracting the agonist (about 3 seconds), the 

practitioner should stretch the agonist. Slow stretching with moderate force will be 

more effective than rapid stretching with heavy force. 

5 The patient should breathe slowly out during contraction, breathe in during 

relaxation, and breathe slowly out during stretching. 

6 While up to 5 repetitions are acceptable, PIR should be stopped if the technique is 

too painful, the patient's range of motion stops increasing, or the patient's range of 

motion becomes normal.

HEMME APPROACH TO SOFT-TISSUE THERAPY

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