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A Question of Ethics
Recently, after I had finished teaching a class on ethics, I  read a blog post on the AAAOM
website regarding "gainful employment." The published information made me reflect on what I had just discussed with the students — the acupuncturists' ethical responsibility to the patient, the profession and the public.

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Integrated Bodywork

By Leon Chaitow, ND, DO

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Is it A or B, a Soft Tissue or Joint Restriction Problem?

In my experience it is common for therapists to label musculoskeletal symptoms as being either a soft tissue or a joint related problem before deciding on an appropriate course of manual or movement therapeutic intervention.

The reality is that most joint restrictions are primarily (or totally) due to soft-tissue changes. Exceptions are those joint conditions where pathological changes have taken place — such as osteoarthritis (OA). But even when OA exists, much of the reduced mobility will involve local, and sometimes distant, soft-tissue adaptations to whatever joint changes have occurred.

In 2003 osteopathic physicians Kappler and Jones described a basic truth relating to all restrictions, that I suggest all manual therapists might usefully reflect on, when confronted by joint problems.

"As the [restriction] barrier is engaged, increasing amounts of force are necessary and the distance decreases. The term barrier may be misleading if it is interpreted as a wall or rigid obstacle to be overcome with a push. As the joint reaches the barrier, restraints in the form of tight muscles and fascia, serve to inhibit further motion. We are pulling against restraints rather than pushing against some anatomic structure."1

Kaltenborn's test

There are a number of methods for testing whether the primary feature of a restriction is intra-articular (inside the joint) or extra-articular (i.e. soft-tissue primarily). For example Kaltenborn (1980) described ways of screening for an answer to the question. He pointed out that if perceived discomfort increases when a painful area is stretched, the primary features probably involve soft tissues. However, if compression of the painful area increases pain, intra-articular tissues are most probably mainly involved.

Kaltenborn has also pointed out that if active movement — initiated by the patient — in one direction, produces pain (and/or is restricted), and movement — controlled by the therapist — in the opposite direction, also produces pain (and/or is restricted), then contractile tissues such as muscles and ligament are almost certainly the main culprits.2 To confirm this probability — if the patient's controlled movement, and the therapist's controlled movement in the same direction produce pain (and/or restriction), then joint dysfunction is the most likely source of pain.

Finding the Results

If joint restrictions are usually due to tense, tight, shortened and dense muscle/fascial changes — remedial therapeutic action requires that methods and modalities should be used that can safely modify these soft-tissue barriers, in order to improve motion. Janda (1988) acknowledges that it is not always easy to know whether dysfunction of muscles causes joint dysfunction, or the other way around, but he suggests because there is a lot of clinical evidence that joint mobilization influences the muscles and fascia that are directly related to a joint, it is probable that normalization of the excessive tone in those tissues, is what is providing benefit.3 Since reduction in muscle hypertonicity commonly results in a reduction in joint pain, the answer to many such problems would seem to lie in appropriate soft tissue attention.

Soft Tissue Treatment

Fortunately there is a great deal of evidence offering evidence that soft tissue methods of treatment — many of which are employed as part of therapeutic massage — can offer safe and effective solutions to musculoskeletal pain and dysfunction.

Examples of such successful use of soft tissue treatment options include Muscle Energy Techniques (MET) in care of "mechanical neck pain,"4 Positional Release Techniques such as strain/counterstrain (SCS) and/or MET in treatment, of low back conditions:

"The current results proved that both MET and SCS techniques are effective in reducing pain and functional disability in patients with chronic low back pain."5 The value of Myofascial Release techniques for conditions such as low back pain have also been validated.6

Hopefully these thoughts will serve to remind us that remediable joint restrictions and dysfunction are usually the result of soft tissue changes — and that even when the articulation itself has altered (due to trauma or pathology) soft tissue approaches are likely to offer the possibility of functional relief.

References

  1. Kappler RE, Jones JM. "Thrust (high-velocity/low- amplitude) techniques, in Ward RC (ed) Foundations for osteopathic medicine, 2nd edn." Philadelphia: Lippincott, Williams and Wilkins, pp 852–880, 2003.
  2. Kaltenborn F. "Mobilization of the extremity joints." Oslo: Olaf Novlis Bokhandel, 1980.
  3. Janda V. "Muscles and cervicogenic pain syndromes, in Grant R (ed) Physical therapy of the cervical and thoracic spine." New York: Churchill Livingstone, pp 153–166, 1988.
  4. Phadke A, et al. "Effect of muscle energy technique and static stretching on pain and functional disability in patients with mechanical neck pain: A randomized controlled trial.". Hong Kong Physiotherapy Journal, 35:5-11, 2016.
  5. Ellythy m. "Efficacy of muscle energy technique versus strain counter strain on low back dysfunction." Bulletin of the Faculty of Physical Therapy, 17(2):29-35, 2012.
  6. Ajimsha M, et al. "Effectiveness of Myofascial release in the management of chronic low back pain in nursing professionals." Journal of Bodywork & Movement Therapies, 18, 273-281, 2014.
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