124557524-1556432607 - Integrative - Manual - Therapy

124557524-1556432607 - Integrative - Manual - Therapy

(Parte 1 de 6)


An Integrated Systems Approach Introducing

. Muscle Energy and 'Beyond' Technique For Peripheral Joints . Synergic Pattern Release© with Strain and Counterstrain

. Myofascial Release, Fascial Fulcrum Approach

Sharon Weiselfish-Giammatteo, Ph.D. P.T. Edited by Thomas Giammatteo, D.C., P.T.

North Atlantic Books Berkeley, California

1 ntegrative Mamlal Therapy for the Upper and Lower Extremities

Copyrighr © 1998 by Sharon Weiselfish-Giammarreo and Thomas Giammarreo. All righrs reserved. No portion of this book, except for brief review, may be reproduced, stored in a retrieval system, or transmitted in any form or by any means---electronic, mechanical, photo copying, recording, or otherwise-without written permission of the publisher.

Published by

North Arlantic Books

P.O. Box 12327 Berkeley, California 947"12

Cover and book design by Andrea DuFlon Phorography by John Giammarreo

Printed in the Unired Stares of America

Integrative Manual Therapy for the Upper and Lower Extremities is sponsored by rhe Sociery for the Study of Native Arts and Sciences, a nonprofit educational corporation whose goals arc to develop an educational and crossculrural perspective linking various scientific, social, and artistic fields; to nurture a holistic view of arts, sciences, humanities, and healing; and to publish and distribute literature on the relationship of mind, body, and nature.

I would like to take this opportunity to thank all those whose instruc tion, support and encouragement contributed to this book. My husband, Tom Giammatteo, D.C., P.T., contributed his time, effort and skill to make this book possible. Lawrence jones, D.O., founder of Strain and Counter strain Technique was a significant influence. Frank Lowen contributed his perception and insight for the development of my "Listening" skills. All of my colleagues at Regional Physical Therapy in Connecticut participated in the implementation of single subject design research to help refine the tech niques in this book. Most of all, my clients were always ready to try any thing new which might help. Many thanks to john Giammatteo for his gift of photography, and to

Ayelet Weisel fish and Genevieve Pennell for their contributions of art work.

My appreciation, once again, to Margaret Loomer, whose creativity and skill made this book a reality.

My sincere appreciation is extended to my best friend, jay Kain, who has shared in my research and development of new material for many years.

Gratitude is extended to Richard Grossinger, publisher, and Andrea

DuFlon, designer. My best efforts could not have produced this text with out their intervention.

My love to my wonderful family, Tom, Nim, Ayelet, Amir, and Debbie for their personal commitment to the success of this book.

Thank you. Sharon Weiselfish-Giammatteo

J would love to describe in depth the clinical research which guided me to publish the contents of this book. Hundreds of patients have received all of the therapeutic intervention presented in this book. Thousands of patients have received some of the therapy outlined in this book, by myself, my associates, and other practitioners of manual therapy. The material in this text is almost all unique, the outcome and synthesis of my knowledge, skills, and "listening" abilities. Experience with all patient populations, orthopedic, neurologic, chronic pain, pediatric and geriatric, has granted me an exceptional opportunity for learning.

Quantitative research studies have been performed on four hundred severely impaired joints with impartial "pre and post testing," using Myofascial Release, the 3-planar Fascial Fulcrum approach. Otherwise, single subject designs are the common research approach incorporated into my clinical practice. I could have performed quantitative research studies for all of the unique techniques presented in this book, but then it would be several years before this text could be published. My preference was to publish this book, at this time; within it is important information for the health care consumer. [ sincerely hope that practitioners will use this infor mation with their clients to meet their individual needs.

Good luck and health. Sharon Weiselfish-Giammatteo, Ph.D., P.T.

I have been forrunate and honored by a close working relationship with

Sharon Weiselfish-Giammarreo for many years. The effect she has had on my personal and professional growth has been one in which the status quo is rarely satisfactory and the words "can't" and "never" have been replaced by "anything is possible" and "always."

The first lecture I heard from Sharon in 1982 was truly representative of the passion she has for sincerity, integrity, and truth in a professional field where new information is often frowned on, ridiculed, and frequently vehemently opposed. While discussing a new concept of a systems approach for evaluation and treatment, she intetjected a statement about the common overuse of ultrasound by many physical therapists. I was amazed to observe the majority of the audience either go completely silent or get extremely fidgety over the prospect that they were guilty of a com mon infraction. In other words, no one wanted to hear something that shook their reality. The paradigm shift was too great. With that statement and Sharon's thirst for continued practical knowledge, this scenario has been repeated more often than I can remember. Sharon's own learning encompasses a constant search for new and betrer ways to treat the whole person. Each bit of information she gains is immediately integrated into what she already knows, and quite often new and unique ways to treat people are created.

This Muscle Energy text is the direct result of that precise learning mode. While her first Muscle Energy text comprised remnants of her early learning from many of the field's top osteopaths, chiropractors, physical therapists and allopaths plus her own research, this new text encompasses totally new constructs taken as an application of the biomechanical princi ples she learned then and now newly applies. The product is a classic cul mination of Sharon's learning and processing style in regard to applied biomechanics and a natural complement for her other integrative work. Sharon is the consummate student, researcher, and clinician when it comes to one of her greatest passions, biomechanics of the skeletal system. Not surprisingly, this work, already four to five years in process, has been refined to make its application simple, powerfully effective, and efficient and nonaggressive to both the patient and the therapist. When mastered along with the constructs in her first text, this book creates a solid corner stone for the treatment of a majority of the body's biomechanical dysfunc tions. Her newer research regarding cranial and transitional or Type I vii viii ADVANCED ITRAIN AND COUNTERITRAIN biomechanics sheds even further insight into the study of structure and function of the skeletal framework.

Sharon's research and clinical efforts have continued to cast light into unexplained and unexplored areas of applied biomechanics and clinical kinesiology. The work is grounded in core Newtonian-Cartesian physics but at the same time embraces the concepts of quantum physics and beyond.

Sharon's abiliry to facilitate and create new learning paradigms in dif ferent realms will most likely cause friction for those individuals who resist change or fear the unknown. Their facile reaction will be to deny the mate rial, bur their challenge will be to put as much energy into understanding and growing from the new knowledge as they would in opposing it.

I look forward not only to the dispersal of this material bur the excite ment and energy Sharon will put into her next text and the enthusiasm that she'l expend taking many of us on the journey to even greater health, har mony, and professional satisfaction.

lay B. Kain, Ph.D., P.T., A.T.e.

Chapter 1 Postural Compensations of the Upper and Lower Extremity joinrs

Chapter 2 lnrroduction to Muscle Energy and 'Beyond' Technique: A Concept of Biomechanics and the Quantum Energetic Forces Within the lnrra-Articular joinr Spaces 8

Chapter 3

Muscle Energy and 'Beyond' Technique for the Lower Extremities: Treatmenr to Increase the Vertical Dimension of the lnrra-Articular joint Spaces 16

Chapter 4

Muscle Energy and 'Beyond' Technique for the Upper Extremities: Treatmenr to Increase the Vertical Dimension of the lmra-Articular joint Spaces 28

Chapter 5

Synergic Pattern Imprinrc and Synergic Pattern Releasec: A Model for Treatmenr of Protective Muscle Spasm 4

Chapter 6

A Hypothetical Model to Explain the Decrease of Hypertonicity with Manual Therapy 46

Chapter 7 The Muscle Barrier 53

Chapter 8

Trearment of Lower Quadrant Hypertonicity for Synergic Partern Releasec with Strain and Counterstrain Technique 5

Chapter 9

Treatment of Upper Quadrant Hypertonicity for Synergic Pattern Releasec with Strain and Counterstrain Technique 7

Chapter 10

Myofascial Release: A 3-Planar Fascial Fulcrum Approach to Correct Soft Tissue and joint Dysfunction with DeFacilitated Fascial Release 101

Chapter 1

Tendon Release ThetapyC for Trearment of Tendon Tissue Tension with Advanced Strain and Counterstrain Technique I ix x ADVANCED STRAIN AND CDUNTERSTRAIN

Chapter 12

Ligaments: a Tensile Force Guidance System: Treatment with Ligament Fiber TherapyO 114

Chapter 13

Procedures and Protocols to Correct Upper and Lower Extremity Dysfunction with Integrative Manual Therapy 120

Chapter 14 Pressure Sensor TherapyO of the Foot and Ankle Complex 135

Chapter 15 Reflex Ambulation TherapyO with Synchronizerso 143

Index 152


The results of a comprehensive postural evalua tion can facilitate a more effective and efficient treatment process. Posture is evaluated on a sagittal plane, a coronal plane, and a transverse plane. It is important to stand with a neutral base of support during all standing posture eval uations. The feet should be acetabular distance apart with approximately 15-20 degrees of equal external rotation of the feet. It is impor tant to note that one foot is nOt slightly in front of the other. The knees should be equally flexed/extended. If there is recurvatum of one knee, it should be maintained in sagittal plane neutral to reflect similar posture to the other knee.

Philosophy: Posture Refle(ts Movement Potential

Limitations of physiologic motion (flexion, ex tension, rotations and side bendings) should correlate with static posture evaluation. Pos tural deviations indicate the body's potential for dynamic movement. Consider: there are mild, moderate, and severe neuromusculoskeletal dysfunctions.

Mild, Moderate, or Severe Posturallndi(ations

Severe dysfunction will cause severe limita tions in ranges of motion with severe posi tional imbalance of articular surfaces. Pain and compensation patterns will be observed in inner ranges of motion. Postural devia tions will be considerable. Moderate dysfunction will cause moderate limitations in physiologic ranges of motion. Pain and compensation patterns will not be observed until mid-ranges of motion. Pos tural deviations will be moderate.

Figur. 1. The pelvis wililypi<ol� presenl a "laleral shear." There is Iypi<olIy a decrease in the (onvex curve on palpation of the greater tUKhonler secondary 10 the <ompr".on of the femoral head.


Figur. 2. The proximollibiol articular 5UrfOce will shear lateral.

Mild dysfunction will only cause mild limitations in ranges of motion. Pain and compensation parrerns will only be observed in outer ranges of motion. Postural devia tions will be slight.

Assessment of Postural Dysfunction is performed to assess the body's capacity for normal joint mobility, soft tissue flexibility, and physiologic ranges of motion.

Pelvic and lower Extremity Posture

Observe in supine, prone, and standing. Ob serve postural deviations on three planes: sagit tal, coronal and ttansverse. Observe articular balance of all joints. Document articular pos tural deviations of the knees, such as shears and rotations of proximal tibial articular surface. Observe postural deviations of the feet: supina tion, pronation. Observe specific joint devia tions of all ankle and foot joints (malleolus, navicular, cuboid, first ray, etc.)

A Compensatory Pattern

When there is joint and/or soft tissue dysfunc tion, the body will "compensate" in order ro at tain movement goals. Compensations typically occur at joint surfaces, and result in loss of "articular balance." "Articular balance" is the normal neutral relationship of two articular sur faces of a joint throughout a full physiologic movement.

lower Extremities: Typical Compensatory Postures The pelvis will shear lateral (Figure 1). The femoral head will be approximated, caudal, adducted and internally rotated

(Figure 1). The proximal tibial articular surface will shear lateral and externally rorate (Figure 2).

UPPER AND LOWER EXTREMITIES 3 The distal tibial articular surface will glide posterior (Figure 3). The talus will glide anterior (Figure 3). The distal fibula head will shift inferior and

posterior (Figure 4). The calcaneus will invert (Figure 5). The foot will be pronated or supinated.

Neck and Upper Extremity Posture

Observe in supine, prone, sitting and standing. Observe postural deviations on three planes: sagittal, coronal and transverse. Observe articu lar balance at the joint surfaces. Document ar ticu/ar postural deviations of the neck, shoulder girdle, elbow, forearm, wrist, hand, thumb and fingers. Observe at the joint surfaces.

Upper Extremities: Typical Compensatory Postures The neck is side bent away from or towards the side of shoulder girdle obliquity (elevated shoulder girdle).

The head is rotated opposite the direction

of the side bending of the neck. There is an elevated shoulder girdle (shoulder girdle obliquity) (Figure 6). There is a protracted shoulder girdle (Figure 6). There is an abducted scapula (Figure 6). The humeral head is caudal, anterior and compressed in the glenoid fossa (Figure 6). The humerus is adducted, flexed and internal rotated (Figure 6). The elbow is flexed. The ulna is abducted (Figure 7). The proximal radius head is anterior (Figure 7). The distal ulna head is anterior.

The distal radius head is posterior. The forearm is pronated. The proximal carpal row is anterior. The wrist is in anterior shear during extension.

Figure 3. The distal tibia glides pasterior, while lalus glides anleriar. The person is �anding in planlar flexion (extended ankle). Extension 10"" will be �ans"ibed up the leg during �anding and ambulatian.


Figure 4. The dolal fibula head 0 hypo mabile, sluck inferior and posterior.

The thumb is flexed, internal rotated, and adducted. The proximal head of the 1st metacarpal is in anterior shear and compressed.

Movement Corresponds with Postural Deviations

Observe deviations during movement from mid line neutral. Assess right-left symmetry, and lim itations in ranges of motion. "Fixate" to inhibit compensatory "trick" movements, which occur because of poor articular balance. Limitations of ranges of motion should correspond with compensatory patterns observed during static postural assessment. For example, a protracted shoulder, observed in a static posture assess ment, will present limitation in horizontal ab duction during dynamic movement testing.

(Parte 1 de 6)