Stretches Stretches are used to lengthen muscles, thereby increasing a person’s ROM and allowing their joints to move more freely. There are several stretching methods a manual therapist is likely to use: passive (or static) stretching, and two types of proprioceptive neuromuscular facilitation (sometimes referred to as PNF stretches or facilitated stretches). Passive stretching should be a part of every therapist’s training and will not be covered here. Passive stretches also pale in comparison to the effectiveness of PNF stretches. The first type of PNF stretch is the contract–relax stretch. This stretch takes a client through several rounds of contracting a target muscle while resisting the client’s ability to move the muscle through its full ROM. The target muscle is taken to the middle of its ROM, then the client is asked to contract the muscle with 20-30% percent of their strength for 7 to 10 seconds against resistance (PNF stretches cannot always be performed, though, as they are contraindicated if a client experiences acute or substantially uncomfortable Trigger point therapy Sometimes referred to as a form of neuromuscular therapy (NMT), this technique addresses irritable muscle bundles (commonly referred to as knots) that cause not only local pain, but pain distant from the site of palpation as well. These are clinically referred to as myofascial trigger points, electrically active tight spindles of muscle in the general muscle tissue. The tightness and electrical activity found in trigger points helps them to become self-perpetuating; the tightness stimulates an electrical impulse to the muscle spindles and the electrical impulses cause the spindles to contract, causing tightness. Trigger point therapy attempts to relieve these sources of pain by holding pinpoint pressure upon the irritable muscle bundle until the trigger point begins to throb or twitch. Once this occurs, more pressure is applied until the client states their pain is approximately 7 to 8 on a scale of 10. (The client may also feel pain or pressure at a location away from the trigger point at this time.) Pressure is maintained until the twitching stops—
pain during this stretch’s execution. The client should also be asked to reduce their strength if the therapist is unable to keep the target muscle from shortening during the client’s contraction). The resulting stretch on the target muscle usually has a greater effect and lasts longer than passive stretching. The second PNF stretch reviewed here is known as an antagonist contract (AC) stretc h. This type of stretch utilizes a reflex known as reciprocal inhibition (RI) to relax a muscle. When performing this stretch, the therapist brings the client’s target muscle into its shortest length (passively simulating its contracted state). Then, keeping the muscle at its shortest length, the client actively contracts the target muscle’s antagonist against the therapist’s resistance for 3 to 4 seconds with approximately 20% of their strength. (Alternatively, this technique can be used in one-second bursts with 50-70% of the client’s strength.) This process is repeated 8 to 10 times (Behm et al., 2023). indicating that the perpetuating electrical signal has been interrupted—and the pain has subsided to at least a 2 to 3 on a scale of 10. Trigger point therapy should not be used if a client is too sensitive to their trigger points being palpated regardless of how beneficial the technique may be. And, as is the case with all deep tissue massage techniques, avoid trigger point therapy when your client has a blood disorder or is taking medication that causes hemophilia (the prevention of blood from clotting) or thrombophilia (increased blood coagulation) since the latter condition may lead to the development of a thrombosis (blood clot). Before beginning the sections on orthopedic tests, note that the specific muscle, muscle groups, or joint(s) being tested is given first, followed by how to perform the test and then what the results indicate. Finally, an ancillary note regarding the application of suitable manual techniques may be given (Domenico, 2007).
SECTION I: ORTHOPEDIC TESTS FOR THE NECK
Anterior neck flexors endurance test This procedure tests for a weakness of the
than 20 seconds. If a client fails this test, this may also be an indication that the upper trapezius, the levator scapulae, and/or the shorter posterior cervical muscles that extend the head are bilaterally hypertonic. If this is the case, applying directional massage, myofascial release, or PNF stretches to the hypertonic muscles may improve neck flexor endurance (Cleland et al 2020). Healthcare Consideration: Any orthopedic test that involves contraction of the anterior-lateral scalene muscles (anterior and middle scalene) may innervate the brachial nerve plexus that runs through the two muscles. Numbness, tingling, burning, or sharp pain down the arm would be reliable indicators that hypertonic scalenes are compressing the brachial nerve plexus. Myofascial release and PNF stretches are the most appropriate manual techniques to release these muscles as directional massage and trigger point therapy risk further compression of these muscles (Cleland et al., 2020).
sternocleidomastoid (SCM), the anterior and middle scalene muscles, and the deeper longus capitis and colli muscles. Begin by having the client in the supine (face up) position. Direct the client to tuck their chin, then lift their head off the table and hold it approximately 1 inch off the table. The anterior neck muscles are considered weak if the client cannot hold their head in flexion against gravity for less Anterior-lateral neck flexors endurance test This tests for a weakness of the sternocleidomastoid (SCM) and the scalenes group. With the client supine on the table, the client rotates their head 90 degrees (or a far as possible) away from the side being tested. The client then tries to laterally flex their head toward their chest, against gravity. The anterior-lateral neck muscles are considered weak if the client cannot keep their head in flexion against gravity for less than 20 seconds. This may also be an indication that the upper trapezius, the levator scapulae, splenius capitis, and/ or semispinalis capitis on the nontested side are hypertonic. As in the previous test, applying directional massage, myofascial release, or PNF stretches to the hypertonic muscles may improve neck flexor endurance (Cleland et al., 2020).
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