Ligamentous Articular Strain Techniques Shoulder Webinar Course Manual 2020

Course Manual

Ligamentous Articular Strain Techniques Shoulder Webinar Course Manual 2020

L.A.S.T. Ligamentous Articular Strain Technique©™ 2020 No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publisher.

Note: Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice and treatment may become necessary or appropriate. Readers are advised to check the most current information concerning the frequency, intensity, duration, precautions, indications, and contraindications concerning treatment of patients and their conditions. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine frequency, intensity and duration and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, the author does not assume any liability for any injury and or damage.

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Contents

Forward Thinking ...... 4 Ligamentous Articular Strain Techniques Origins ...... 5 A New Perspective ...... 6 Ligaments and Injuries ...... 8 Ligament Pain Referral Patterns ...... 10 Referred Pain ...... 11 Changing Perspective on Treatment ...... 12 Clinical Principles - The Application of LAST ...... 13 Breathing ...... 16 Breathing Techniques ...... 17 The Biopsychosocial Approach to Pain Management ...... 17 Beyond the Biopsychosocial Approach ...... 18

Anatomy ...... 19 Neurological Innervations ...... 21 Techniques ...... 24 Costoclavicular Ligament / Upper Mediastinum ...... 25 Anterior Sternoclavicular Ligament ...... 26 Posterior Sternoclavicular Ligament ...... 27 Corocoid Ligaments with AMPs ...... 28 Pectoralis Minor / Coracobrachialis / Short Head Biceps ...... 29 Long Head Biceps/Glenohumeral Capsule ...... 30

Common Mistake’s / Do’s and Don’ts ...... 31 Ligament Pain Referral Pattern Book ...... 33 Ligament Pain Referral Pattern Posters ...... 34 Ligamentous Articular Strain Technique Courses ...... 35 About Robert ...... 36 LAST Online Educational Training Courses ...... 38

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Forward Thinking

Although the techniques described in this manual may seem separate, they are meant to be utilized as a method of continuous local and systemic assessment and treatment. The Manual Therapy clinician must encompass the original principles of Ligamentous Articular Strain Technique acknowledging that neurophysiological, biopsychosocial, cardiovasculature and somatovisceral systems can influence biotensegral function both locally and at remote sites. A patient’s primary symptom(s) may be directly or indirectly related to or influenced by impairments from various body systems regardless of proximity to the primary symptom(s).

You the clinician must look locally and see systemically.

The trend today is to treat separate tissue from other separate tissues as if they are disconnected from the whole organism. Clinicians treat carpal tunnel at the wrist without looking systemically to find that the wrist was only the last link in a chain of events and compensations for an event that happened months years, decades ago in a completely different area.

Daily we see patients who seem to have been treated by everyone, everywhere, and somehow have come to us. We are in most cases the “end of the road” before surgery or they come to us decades after surgery. Patients’ and their body are screaming out information that many clinicians do not take the time to stop, listen, hear and see.

We still utilize the ancient laying of hands to help someone in pain and discomfort. We are here to help, to serve, to listen with our hands, eyes, ears, heart, soul and intuition. We are here to connect with another organism.

Going forward, use today’s evidence-informed science to help you and your patient understand possibly what physiological process(es) are occurring; but use your common sense, intuition and, most importantly, guidance from your patients’ physiology to dictate the rate, course and direction of the treatment.

Manual therapy is an ART and a science. Treat the organism along with the segment. Treat the person not the pathology. Change your perspective to treating elasticities, densities and temperatures. Aim for an “ever-changing balance” in an asymmetrical nonlinear feedback system.

Keep Forward Thinking!

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Ligamentous Articular Strain Techniques Origins

Ligamentous articular strain (LAS) technique and balanced ligamentous tension (BLT) techniques are two techniques derived from what were once called "general osteopathic techniques." They both are primarily indirect techniques that affect connective tissues of the body: fascia, ligaments, tendons, and, indirectly, lymphatic and blood flow.

In 1915, Dr. Edythe Ashmore, a student of Dr. Still, wrote "Osteopathic Mechanics," in which she describes "There are two methods commonly employed by osteopathists in the correction of lesions, the older (ligamentous articular strain) of which is the traction method, the later the direct method or thrust (HVLA.)"

The history of the development of these techniques probably started during A. T. Still's time, but developed greatly through the work of a number of osteopathic physicians including, but not limited to W. G. Sutherland, DO; H. A. Lippincott, DO; R. Lippincott, DO; R. Becker, DO; and A. Wales, DO. Those in the central United States (i.e., Texas) eventually promoted the term LAS, and those in the northeastern United States (i.e., New Jersey and New England) promoted the term BLT.

Balanced ligamentous tension techniques have usually been associated with a very light touch, and the use of respiratory cooperation, although ligamentous articular strain techniques usually have more force applied and the use of respiratory cooperation is not always used. In general terms, the amount of force used in BLT is approximately 1 to 3lbs, whereas LAS techniques may be as high as 40lbs.

Sutherland may have been most responsible for the technique being taught in early osteopathic study groups. In 1947 Dr. Wm. G. Sutherland first instructed Ligamentous Articular Strain Techniques to his study group. Ligamentous Articular Strain Techniques were originally published in the 1949 Year Book of the Academy of Applied Osteopathy as "The Osteopathic Technique of Wm. G. Sutherland." The 1949 article discusses that Osteopathic lesions are strains of the tissues of the body and that when they involve joints, it is the ligaments that are primarily affected. "Ligamentous Articular Strain" was term preferred by Dr. Sutherland. Dr. Sutherland credited the origin of these techniques to Dr. AT Still DO.

In 1982 the Dallas Osteopathic Study Group began an extensive study of the Indirect and Direct methods of osteopathic manipulative treatment. A member of the group, Rollin Becker, D.O. had been in attendance at Dr. Sutherland’s 1947 study group presentation. Most of the indirect techniques are now called ligamentous articular strain techniques while several of them also form the basis of myofascial release techniques. In 2001 and 2009 the Dallas Osteopathic Study Group published their manual on Ligamentous Articular Strain Techniques.

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A New Perspective

"While explanations change, new information is often simply a rephrasing and a refining of descriptions of mechanisms. In the end, it may not change what we do clinically by a great deal - or at all.” – Leon Chaitow ND, DO

The information presented before you is an opportunity to advance and update the original context first put forth by A.T. Still. This is a wholly different era where evidence-informed techniques are sought after in an effort to advance the manual therapy profession to its highest potential. Presented here are the same timeless principles viewed through a modern-day lens. They are applied with the mindset of providing a simple, principle based, evidence-informed technique utilized by the clinician to improve the quality of life of their patient’s.

Some of the original perceptions, narrative and principles may seem out of touch with today’s knowledge, while others maintain the test of time. This text represents a reconceptualizing; a revitalization; an attempt to blend and update the original principles of Ligamentous Articular Strain with the research and science of today.

As Science and medicine have advanced from the days of Dr. Still, our understanding of human complexities has evolved. Advances in our understanding of anatomy, physiology, neurology, psychosocial factors, pain science, the role of fascial tissues and regenerative therapies demands that we adapt the narratives of our manual therapy applications and how we manage our patients.

Today clinicians are also transforming how they treat their patients. The consensus is to perceive oneself not acting as an “Operator” on a patient but as an “Interactor” partnering with the patient to reach a mutually desired goal. Those who treat as “Operators” see the body as a mechanical being that when injured or sick, requires fixing with a specific tool/ technique set.

The metaphor of the human body as a mechanical object has been taught in all areas of medicine from the earliest writings to today’s curriculums. Pullies, straps, nuts and bolts have been akin to muscles, ligaments, joints and bones. Today we know that the human being is much more than a mechanical object.

Machines and humans are fundamentally different in many ways. Machines are products of design; human bodies are products of natural selection. Machines have been created with clear mechanical complexities with separate parts with specific functions connected to each other in straightforward ways. Organic physiology is unimaginably complex with unclear boundaries and many functions that are often connected to each other in ways hard for us to understand. Students are taught distorted versions of biological systems; simple enough to memorize and test!

Clinicians providing therapy purely from an operator perspective, direct treatment specifically on the physiological mechanisms of an injury/condition. This strategy is insufficient in treating the patient as a whole and may lead to demoralizing contemplation from the patient, reducing treatment outcomes and potentially resulting in the patient disengaging from therapy.

The educated, engaged and interacting Clinician acknowledges and accepts that both top-down and bottom-up influences contribute to treatment outcomes.

Clinicians providing therapy from an “Interactor” perspective understand that treatment technique, experience and candour of the clinician, the life experiences of the patient, all aspects of the clinical environment, and the interaction between all these factors, contribute to the mutually desired patient outcome.

Concerning Osteopathic lesions affecting the joints, H. A. Lippincott, D.O. writes, “Since it is the ligaments that are primarily involved in the maintenance of the lesion it is they, not muscular

6 © Robert Libbey Massage Therapist Corp. All Rights Reserved 2020 Visit lastsite.ca for newsletters, videos and additional Online Training Ligamentous Articular Strain Techniques Shoulder Webinar Course Manual 2020 leverage, that are used as the main agency for reduction.” Today we know that although the ligaments are affected in joint injuries, they are not the only nor the primary tissues that may be affected.

Ligaments and joint capsules are embedded, local densifications, local specifications of the Fascial System; a body wide collagenous, fibrous mostly tension driven interconnected system. Joint injuries/conditions can cause disruptive biomechanical functions to associated structures including ligaments, muscle, bone, nerves and neurovasculature. Typically, these injuries/conditions affect the healthy functioning of tissues causing inflammation, produce nerve signaling that elicit protective neuromyofascial guarding, sensorimotor impairment and pain/discomfort, changes in joint motion and motor control.

Ligaments are highly dynamic and non-stationary organs arranged in series with muscles that along with the autonomic nervous system create a ligamentomuscular reflex joint stability system. This system allows muscles and ligaments to work together as a unit, inhibiting muscles that destabilize the joint and increasing antagonist co-activation to maintain joint stability. Ligaments communicate via mechanoreceptors’ afferent input (located in high concentrations at the ligamentoperiosteal and tenoperiosteal enthuses) and provide the central nervous system (CNS) with significant input about dynamic joint positional sense, contribute to the synergistic activation of muscles, and provide proprioceptive sensation.

Despite these structural influences and changes, ligamentous/fascial injuries are no longer seen as just simple local musculoskeletal peripheral joint injuries, but as systemic dysfunctions affecting a patients biotensegrity, influencing all aspects of their life; from the smallest properties of their physiology to their neuropsychophysiology.

Neurophysiological and neuroimaging studies provide evidence for CNS reorganization (neuroplasticity) at the cortical and spinal levels after joint injuries. Injuries to the soft tissues of joints contribute to chronic neuromuscular adaptations due in part to a loss of effective messaging from mechanoreceptors to the CNS.

Dysfunctional changes in a patients biotensegral plasticity, stability and their psychology contribute to the chronicity of injuries and extend the rehabilitation process. These injuries create the experience of pain, discomfort, impaired interoception, tissue guarding, sensory motor impairment and structural instability.

Patients may also suffer from dysfunctional psychosocial thoughts, beliefs, behaviors and emotional factors such as depression, anxiety and take part in fewer healthy social interactions. These behaviors can contribute to the production of pro-inflammatory mediators slowing the rehabilitation process.

Research from Schleip (2003) & Pelletier et. al. (2015) recommend that therapists’ change their perspective of treatment from a purely mechanical perspective to one that also is inclusive of nervous system modulation strategies.

The biomedical model should not be discarded, but instead updated to include additional considerations and concepts. Assessment and management strategies should seek to identify all tissues and aspect of a patients’ life contributing to their symptoms. Rarely is a single underlying pathoanatomical cause responsible for a patients’ complaint(s).

Manual Therapy clinicians have the opportunity to recognize autonomic protective mechanisms. It is of the utmost importance that the Manual Therapy clinician understands the physiological effects of ligamentous injuries and recognizes that instabilities and dysfunctions caused by injury must be effectively managed.

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Manual Therapy clinicians perform orthopedic and neurological testing and movement assessments to determine the dysfunctional joint(s) segments. The information gathered helps to differentially diagnose the area where instability, dysfunction and autonomic protective mechanisms are present and employ appropriate treatment strategies to improve function and improve quality of life to the patient.

Manual Therapy clinicians who are focused on the treatment and management of joint injuries/conditions should primarily be focused on improving overall function, modulating communication from the injured joint tissues to the CNS and decreasing protective nociception and pain.

Effective management of ligamentous injuries must also consist of patient education on the current understanding of pain science combined with appropriate strategies to return to activity. The Manual Therapy clinician should recognize the Biopsychosocial aspects to the patients experience with the injury, possible placebo effects, acknowledge top-down and bottom-up modulation of pain, and use motivational interviewing/verbal cueing techniques to manage their patients. Ligaments and Injuries

Ligaments and joint capsules are embedded, local densifications, local specifications of the Fascial System; a body-wide collagenous, fibrous, mostly tension driven interconnected system. They are highly dynamic and non-stationary organs, arranged in series with muscles and, along with the autonomic nervous system, create a joint stability system. They communicate with the central nervous system (CNS) via mechanoreceptor afferent input. These afferent mechanoreceptors are located in high concentrations at the ligamentoperiosteal and tenoperiosteal junction and provide the CNS with significant input about dynamic joint positional sense, contribute to the synergistic activation of muscles and provide proprioceptive sensation.

Injuries or influences to the joint’s soft tissues can happen abruptly as in the case of an ankle inversion event, or may occur slowly over a lifetime as with postural changes or diseases such as Rheumatoid Arthritis. The abrupt event can have dysfunctional ramifications that are immediate and recognizable while the long-term dysfunctional influences may be more difficult to perceive. Regardless of either state, an autonomic nervous systems response will create most likely less efficient compensatory patterns in order to maintain the joint stability system’s and function.

Within several hours after an injury, acute inflammation sets in and can last from several weeks to 12 months. If the injured tissues are not allowed to rest, recover and heal, chronic inflammation progresses. Even after 2 years, ligamentous healing does not regenerate a normal ligament, but creates scar tissue that has an inferior tissue quality, with changes in biochemical and histologic properties. Permanent disabilities occur when chronic inflammation causes degeneration of the collagen matrix, tissue atrophy and weak and non-functional ligaments.

The long-term ramifications of not effectively and immediately managing these injuries are potential damage to capsule, cartilage and tendons, nearby nerves and blood vessels, discs and further potential damage to the ligaments themselves. Full recovery has never been reported when the chronic stage of an injury is left to develop. Chronic instabilities and dysfunctions are known to drastically modify the intra-articular pressure and the muscular activity around the joint, resulting in early onset of osteoarthritis, pain, disability and eventually the need for joint replacement surgery.

Despite these structural influences and changes, ligamentous injuries/conditions are now not just seen as simple musculoskeletal injuries, but as neurophysiologic dysfunctions. 8 Neurophysiological and neuroimaging studies provide evidence for CNS reorganization (neuroplasticity) at the cortical and spinal levels after joint tissue injuries. Injuries to the soft tissues of joints contribute to chronic

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Mechanoreceptors and nociceptors in ligaments and surrounding tissues, trigger a ligamentomuscular reflex activation of associated muscles. This reflex has been shown to exist in the joints of the extremities and in the spine. Ligamentomuscular, monosynaptic and polysynaptic reflexes allow muscles and ligaments to work together as a unit, inhibiting muscles that destabilize the joint and increasing antagonist co-activation to maintain joint stability.

Joint soft tissue injuries/conditions can cause disruptive biomechanical functions to ligaments, muscle, bone, nerves and neurovasculature. Typically, these injuries/conditions can cause inflammation, muscle guarding, pain/discomfort, changes in joint motion and motor control.

Soft tissue/ligamentous joint injuries/conditions can disrupt mechanoreceptor-mediated afferent feedback, such as kinesthetic proprioceptive input, which can lead to significant joint sensorimotor impairment. These dysfunctions influence “executive functions” such as processing of somatosensory information by the prefrontal cortex, causing reorganization of the CNS, effecting neural plasticity. Injuries to the soft tissues of joints play a part in chronic neuromuscular adaptations due in part to a loss of effective messaging from mechanoreceptors to the CNS.

Neuroplastic changes may contribute to the transition from acute to chronic conditions. These changes may explain why some patients continue to experience pain when no structural cause can be determined, and why some patients fail to respond to conservative interventions.

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Ligament Pain Referral Patterns

The topic of pain is extensive, ever changing/updating and beyond the scope of this book. “Once thought to be a specific sense or input to the brain from the body, pain is now regarded as an output from the brain in response to a perceived threat.” Clinicians must understand neurophysiology, recognize placebo effects with treatment, acknowledge top-down and bottom-up modulation of pain and use motivational interviewing/verbal cueing techniques to manage their patients.

Patients may present with specific pain/discomfort referral patterns. Typically, Manual Therapists are educated on the most common trigger point and dermatomal pain referral patterns. Unfortunately, pain referral patterns from joint soft tissues such as ligaments, meniscus and capsule are excluded from their formal education.

In the 1950’s George Hackett, MD researched ligamentous injuries, their pain referral patterns, and treatment with Prolotherapy. His almost 20yrs of combined research and treatments, amounted to near 20,000 intraligamentous injections to over 1800 patients. Dr. Hackett published the book “Ligament and Tendon Relaxation Treatment by Prolotherapy” where he documented for the first- time ligament pain referral patterns.

Today we have research from Hackett, Dreyfuss, Hauser and others who have contributed to confirming that ligamentous articular structures/tissues have a rich nerve tissue supply and constant nociceptive sensory innervation. Ligaments, joint capsules and meniscus transmit information such as proprioceptive kinesthetic awareness and nociceptive messages. Patients with peripheral joint tissue injuries, causing instability and guarding of a joint or segment, may comment on feelings of give way, heaviness, loss of kinesthetic awareness, problems with balance and fatigue at the site. They may also comment on sensations of deep, dull ache, nauseating, boring, cramp like or similar to delayed muscle soreness.

Research from the Bone and Joint Journal documents that within the femoroacetabular labrum, “pain-associated free nerve ending expression was located showing characteristic distribution profiles of nociceptive and pain-related nerve fibers, which may help in understanding the origin of hip pain.” Studies have noted that the iliolumbar ligament has a rich nerve supply suggesting that the injury of this ligament might contribute to the low back pain.

An Oxford Journal Rheumatology study “demonstrated that the sternoclavicular joint is capable of referring pain to areas distant from the joint.” The paper then states “knowledge of these referral patterns will enable the SCJ to be considered in patients with pain in these areas.” It has been documented that the “PCLs have constant nociceptive sensory innervation and is the possible source of OA knee pain.”

The American Journal of Orthopedics advocate using pain maps as diagnostic tools.

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Referred Pain

When discussing how referred pain occurs in the body we refer to the Neurophysiological Model for Referred Pain. This model includes two collections of dorsal horn neurons. The first dorsal horn neuron has receptive fields in local soft tissue and the second dorsal horn neuron has receptive fields in distal deeper tissues associated with referred pain.

Injury from either a mechanical, chemical or thermal stimulus causes nociceptive activity to excite the first dorsal horn neuron(s). Latent collateral synaptic connections are then opened and either excite the neighboring neurons or facilitate the synaptic afferent input from the referred pain area, both causing the perception of referred pain. i.e.: central sensitization

The time needed for this sensitization to occur may account for the delay between perceiving the local pain and then perceiving the distal, deeper referred pain.

A possible explanation for the progressive inhibition of referred pain is that the descending inhibitory control mechanism (de-sensitization) features a relatively stronger inhibition on heterogeneous somatosensory structures than the source of pain.

7 Key Features of Referred Pain

1. Is felt distant to the initial local pain 5. Is delayed compared to local pain

2. Is semi-directional 6. Diminishes before local pain

3. Is a deep sensation 7. Stimulus at the referred pain site isn’t needed ie. Phantom Limb Pain 4. Need a higher stimulus than local pain

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Changing Perspective on Treatment

The most important thing that manual therapists can do for their patients is… restore hope.

We have the opportunity to be the "Rehabilitative Tipping Point" that restores a patients' sense of hope! Hope to return to work. Hope to play with their kids. Hope to move with less pain and dysfunction. Hope for an improved quality of life.

Manual therapy clinicians practice from an evidence-informed perspective, rationally integrating emerging research and information into their clinical reasoning and treatment.

Manual Therapy clinicians have the opportunity to recognize autonomic protective mechanisms. It is of the utmost importance that the Manual Therapy clinician understands the physiological effects of ligamentous injuries and recognizes that instabilities and dysfunctions caused by injury must be effectively managed.

Recognizing the psychosocial impact injuries have on patients, we can appropriately refer to other clinicians who utilize adjunct treatment strategies, such as counseling, Prolotherapy and active rehabilitation strategies to improve mutual cross-disciplinary therapeutic outcomes to improve the quality of life of patients.

Manual Therapy has been shown to affect connective tissue remodeling, such as modulation of fibrosis and densification of fascia, by changing its tensile status and sliding components. Research has shown that specific myofascial receptor massage techniques might improve range of motion and encourages clinicians to utilize soft tissue techniques that target areas (ligamentoperiosteal/ tenoperiosteal enthuses) of high concentration of mechanoreceptors.

Mechanoreceptor-specific techniques that target joint soft tissues affect autonomic nervous system functions result in decreased autonomic protective engagement, increased pain pressure sensitivity, normalize kinesthetic and proprioceptive awareness, and improved treatment outcomes.

Ligamentous Articular Strain Technique is a manual application utilized in the treatment of joint soft tissue injuries, conditions and dysfunctions. The technique influences the biotensegral physiology and CNS modulation.

Manual techniques, such as LAST, which target biotensegral physiology and CNS modulation have been shown to affect autonomic functions by: lowering sympathetic nervous system activity globally decreasing deep tissue pressure sensitivity increasing pressure pain threshold lowering resting pain perception increasing local proprioceptive attention decreasing muscle tonicity changing local blood supply and local tissue viscosity

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Clinical Principles - The Application of LAST

Depending on the level of skill and attentiveness of the clinician Contraindications, Precautions, and Indications may be blurred. Some clinicians feel comfortable working with acute fractures while others feel more secure working with them once consolidation has occurred. Each clinician must be aware of theirs and the patients’ limitations in treatment on the day of treatment. Acknowledging each other’s competencies and limitations ensures that minimal risk of harm is present.

Regional Interdependence Look locally. See systemically. LAST is to be utilized as a method of continuous local and systemic assessment and treatment. Clinicians must recognize that injuries or influences involve not just the function of the ligamentous articular tissues but also the neurophysiological, biopsychosocial, cardiovascular and somatovisceral systems both locally and at remote sites. A patient’s primary symptom(s) may be directly or indirectly related to or influenced by impairments from various body systems regardless of proximity to the primary symptom(s). Although a patient my present with complaints of carpal tunnel like symptoms, the clinician must determine if the fault is at the site of complaint or if the site is the end point in a series of dysfunctions.

Palpation to Sensing & Perceptive Touch We must transition from palpation to sensing. Our intellect can have preconceived biases based on the familiar process we call palpation (physical sense of touch and position). But in “sensing”, the hands are not palpating, they are not moving about the patient, they are not looking for information that is based on a convention, detecting if the patient has disproportion relative to what is considered normal. Rather, our hands are still, resting quietly, becoming almost transparent. We engage more than just the sense of touch. We bring all of the senses together to more deeply perceive and understand the information available to us.

Your hands are quiet but not frozen in place. If you wish, experiment with moving your hands to another part of the body. How is it different? How does your consciousness change when you move from palpating on the body in order to find a picture of what is happening, to resting there and letting the information come into your hands? Do not use your intention or any preconceived ideas. Wait patiently rather than picking the therapeutic end site.

Perceptive Touch Perceptive touch is a form of palpation one might call an alert, observational awareness for the functions and dysfunctions from within the patient. A perceptive touch is essential because there are subtleties of tissue functions and dysfunctions that cannot be explored by any other means than that of a skilled, sensitive, knowing sense of awareness through the use of this type of touch.

Reciprocal Tension As manual therapy clinicians, we primarily influence the nervous system. We attempt to influence it to diminish its autonomic protective mechanism. This “unprotecting” can permit improvement in function and quality of life of the patient.

Reciprocal tension represents the tensional force of a joint tissue created via the ligamentomuscular reflex. This reflex, present in all joints, refers to the normal feel of the tensile forces within the connective tissue membranes.

If you push or pull in one direction the tissue tends to want to go back equidistance in the opposite direction.

The treatment of a patient who is relatively healthy, athletic and devoid of major disease or dysfunction may require approximately 40lbs of force to match the reciprocal tension of their system and begin the disengagement process whereas treatment of a patient

13 © Robert Libbey Massage Therapist Corp. All Rights Reserved 2020 Visit lastsite.ca for newsletters, videos and additional Online Training Ligamentous Articular Strain Techniques Shoulder Webinar Course Manual 2020 presenting with Osteogenesis Imperfecta may require mere ounces. Treating with less than the appropriate amount of Reciprocal tension matching force may not be enough stimulation the intended change in the patient’s physiological environment. Yet in another, utilizing too much force will elicit an increased autonomic protective mechanism or worse, risk of harm and injury in some cases.

Fulcrums By applying a modest increase in pressure at a fulcrum to cause a slight degree of compression through the tissue, the clinician initiates the kinetic energy that will allow the structure-function of the stressed area to begin to let its pattern be reflected back to their touch.

Learn to read these changes from the fulcrum point or points established. Feel the pull and tug of the tissues deep within them; feel the patterns of mobility & motility and become conscious of the fact that there is a quiet point, a still point, within the stress pattern.

The application of the principle of the fulcrum is as varied as the list of complaints that walk into your office. Each case calls for its own application and each practitioner must develop his or her own approach.

With the development of this type of touch, feeling through the structure-function patterns manifesting their changes under our hands, we gain knowledge that increases understanding. This touch opens the door as to why this patient is experiencing the complaints they are expressing. Even when laboratory tests fail to reveal the source of the complaints the practitioner’s trained touch can bring this understanding.

Direct and Indirect Techniques Through manual manipulation, we can perceive changes in patients’ tissues. By gently, yet firmly, loading into the tissue we feel for the reciprocal tension of the tissue pressing back into our hands. Instead of forcing through the barrier of tissue, directing a release as we see fit, we come to just before the barrier and allow the tissue to release in the direction of ease (Indirect Technique).

In some circumstances, however, the tissue requires that we match the reciprocal tension in the tissue and wait for the balance to occur (Direct Technique). The amount of force required to match the reciprocal tension and begin the disengagement process may be as high as 40 Ibs.

When do we use one or the other? The tissue determines the course of treatment and in many cases both indirect and direct techniques are utilized in order to bring balance to the tissue/system.

Disengagement- Disengage (compress/decompress) the opposing articular surfaces of the joint, going in the direction of ease and continually working in the direction of ease until coming to a point of suspension.

The disengagement process takes place through all planes of motion, not on a particular axis within a joint. Working with the motion permitted and continually refining the direction of ease we come to a point of balance rather than working against a barrier.

Neutral Working in the direction of ease, we come to a point of suspension where the reciprocal tension in the tissues can almost not be felt—the tissues feel quiet, suspended, almost floating. The term ‘neutral’ comes from automotive terminology. When a vehicle’s engine is running and NOT in gear the car is not engaged—but rather, it is waiting. Neutral is a point of waiting where the mechanism is not engaged.

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There is skill in waiting. We need to empty our minds—we are perceiving health; we’re aware of life itself. Waiting can be an extremely peaceful and full experience. Just be still and quiet and let the information come to you.

Wait for the innate forces to make the correction and know that the therapeutic end point is the still point that permeates the whole patient. Don’t let your end point just be a matter of tissue releases that are secondary to the force you put in.

Treating in this unhurried, receptive way is like being in a meditative state. It is difficult to train people to do this for any length of time because many of us want to proceed to the end point, have a sense of completion, and move on. Transitioning to treating in a more receptive way can be a huge step. It can be frustrating. Part of this frustration results from the psychological tempo of practice in today’s world. People are caught up in a time frame that almost forces us to be efferent. We think we need to get to the point, remove the problem and then move on to the next patient.

Treating receptively allows you to explore something new and to find that sense of wholeness in another person.

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Breathing

Utilizing breathing as a technique when performing manual techniques is greatly underutilized by a majority of today’s therapists. Evidence supports a link between breathing difficulties and back pain. Since trunk muscles perform both postural and breathing functions, disruption in one function can negatively impact the other.

Patients with back and neck pain commonly seek manual treatment yet there are some who do not experience full recovery with the typical tool kit of manual therapy, education and exercise, suggesting the need for additional clinical approaches. Epidemiological literature linking back pain with breathing difficulties suggests one possibility. Altered motor control associated with back and neck pain appears to negatively impact breathing mechanics, which may have negative consequences on respiratory chemistry. Changes in respiratory chemistry can have profound effects on body system function. Altered breathing has been recognized for many years as a potential source of a wide variety of unexplained symptoms.

Altered breathing mechanics changes respiratory chemistry causing smooth muscle constriction, altered electrolyte balance, and decreased tissue oxygenation. These changes can profoundly impact any body system. Increased excitability in the muscular and nervous systems may be most relevant to a manual therapist.

Breathing is unquestionably a key function of the human body; it sustains life by providing oxygen needed for metabolism and removing the by-product of these reactions, carbon dioxide. Breathing, however, has other functions apart from the ventilation of air and the maintenance of oxygen and carbon dioxide. Breathing affects motor control and postural stability and plays several roles in physiological and psychological regulation. Breathing can influence homeostatic functions in other system including the autonomic nervous system, the circulatory system, chemical regulation and metabolism.

Breathing becomes dysfunctional when the person is unable to breathe efficiently or when breathing is inappropriate, unhelpful or inefficient in responding to environmental conditions and the changing needs of the individual.

Impairment of the functions of breathing affects people's lives, challenging homeostasis, creating symptoms, and compromising health. The efficiency with which breathing fulfills its various functions can be diminished because of musculo-skeletal dysfunction, disease, chronic psychological stress or other factors that affect respiratory drive and respiratory control. The neurological control of breathing shows high levels of neuroplasticity as shown by its ability to adapt to a wide range of internal and external conditions.

Breathing therapy generally aims to either correct dysfunctions of breathing or enhance its functions. Breathing, unlike most physiological functions, can be controlled voluntarily and it can serve as an entry point for physiological and psychological regulation. (International Journal of Osteopathic Medicine Volume 12, Issue 3 Pages 78-85, September 2009)

Quite simply, with diminished function of breath, our physiological systems cease to function at their maximum potential. As this process becomes chronic, the physiological environment becomes more acidic, functioning in a more sympathetic, fight/flight state slowing the recuperative processes of our immune system.

There are an abundance of instructional books, videos and classes educating us on the importance of breath and its physiological effects on all our systems.

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Breathing Techniques

There are various opinions on how, when and where to breath. As always, L.A.S.T. primarily looks to change the environment that the dysfunctional tissues are attempting to function within. There are 2 ways that we change the environment with LAST; holding of inhalation or exhalation by the patient.

Inhalation Instruction: Once you have disengaged and exaggerated the injured tissue(s) from their dysfunctional holding position, instruct the patient to breath in as deep as possible utilizing as much of their lungs and diaphragm as they can. Once they reach the top of the breath they are to hold this breath as long as comfortably possible before exhaling. This process can be repeated if necessary to create the effected change.

Exhalation Instruction: Once you have disengaged and exaggerated the injured tissue(s) from their dysfunctional holding position, instruct the patient to breath out as deep as possible. Once they have comfortably forced all the air out of their body to their fullest extent they are to hold this as long as comfortably possible before inhaling. This process can be repeated if necessary to create the effected change. The Biopsychosocial Approach to Pain Management

Pain is by nature a ‘biopsychosocial’ phenomenon. It is an amalgamated expression of three important underlying components—physical, psychological, and social. Traditionally, pain has been approached with a ‘dual’ perspective. Physicians would assume that pain was either physical (‘real’) or psychological (‘imaginary’). Today, this has changed. There is a general consensus now that both these components of pain integrate with each other as well as the patient’s social environment to produce the final notion of pain for the patient. This gives rise to the biopsychosocial model of pain.

The biopsychosocial model is particularly pertinent in chronic pain. Chronic pain requires ongoing management and often different therapeutic strategies. Patients with chronic pain are exposed to three forms of vulnerabilities:

Biological vulnerabilities

In addition to considering the primary physical insult or trauma, other biological factors that affect pain perception must be taken into account. An important factor is central sensitization meaning that the central nervous system becomes increasingly sensitive to stimuli. The patient may experience intense pain on a small stimulus (hyperalgesia) or may experience pain from a non- noxious stimulus such as touch (allodynia). Central sensitization can lead to the development of wider receptive fields and produce referred pain.7 The exact mechanisms behind the hyper- reactivity of the central nervous system are still under research.11

Psychological vulnerabilities

Anxiety and depression influence pain perception. A feeling of helplessness or loss of control can enhance the sensation of pain. On the other hand, a fear of pain can lead to avoidant behaviour. Attitude towards treatment can also play a crucial role. Patients who are positive about their therapy are more likely to experience pain relief than patients who are not.7 This is one reason why placebos can provide pain relief that is comparable to pain relieving medication. In chronic pain conditions, a factor called ‘pain memory’ exists, created from the patient’s previous experiences of painful episodes. It has a bearing on the patient’s perception of new occurrences of pain.1

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Social vulnerabilities

Cultural and socioeconomic factors can change the meaning of what is painful for individuals. Patients from lower socioeconomic groups who do not have access to proper healthcare or cannot ‘afford’ the cost of being in pain may experience lower perceptions of pain compared to their ‘well to do’ counterparts. In some cultures, ‘complaining’ about pain may be considered undignified, so patients may choose to remain ‘stoic’. Pain perception is thereby diminished in such populations.14 Beyond the Biopsychosocial Approach

Stilwell and Harman (2019) suggest that the biopsychosocial model of pain has limitations as the boundaries between the three components are artificial, and applying this model to treatment can be challenging and fragmented. This fragmentation can lead to a dualist and reductive view of pain.

As an attempt to overcome these deficiencies, Stilwell et al have proposed an “Enactive Approach” to pain. This Enactive Approach is not meant to replace, contradict or confront the biopsychosocial model; rather it supplements and builds on it. 16

The Enactive Approach conceptualizes pain as a ‘5E’ model: Pain is Embodied, Embedded, Enacted, Emotive and Extended.

Embodied—an individual’s way of perceiving sensation in their own body. This not only includes awareness of the internal body, but also the way the body reacts to the outside physical and social environment.

Embedded—the fact that the body is encased within the physical environment. This affects the way the patient experiences pain. For instance, an environment that is perceived as dangerous can increase the pain perception. It can also lead to avoidance behaviour, which may result in disability and sensitization.

Enacted—refers to the actual cognitive process. Cognition is a two-way process that is ‘enacted’ by the body’s interaction with the outside world.

Emotive—the mental feeling that the patient develops in response to the pain sensation. Emotions in turn can determine the intensity of the pain that is felt in repetitive situations.

Extended—the extension of the pain process beyond the individual’s own mind and body to the environment. The use of objects in the external environment, such as crutches or canes, can help alter the perception of pain. 16

Using the ‘5E’ model, Stilwell et al concluded that pain is essentially a ‘relational’ and ‘emergent’ process that is perceived through the lived body, but cannot be separated from the external environment.

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Anatomy

Sternoclavicular Complex

Coracoid Ligaments

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Subclavious & Costoclavicular Ligament

Pectoralis Minor

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Neurological Innervations

1.acromioclavicular joint 9 anterior branches

2 trapezoid ligament 10 humerus

3 coracoacromial ligament 11 scapula

4 conoid ligament 12 lateral pectoral nerve

5 coracoid process 13 suprascapular nerve

6 coracohumeral ligament 14 axillary nerve

7 fibrous joint capsule 15 clavicle

8 axillary nerve

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1 acromioclavicular joint 9 anterior branches

2 trapezoid ligament 10 humerus

3 coracoacromial ligament 11 scapula

4 conoid ligament 12 lateral pectoral nerve

5 coracoid process 13 suprascapular nerve

6 coracohumeral ligament 14 axillary nerve

7 fibrous joint capsule 15 clavicle

8 axillary nerve

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1 supraclavicular nerve 6 sternoclavicular ligaments

2 median branch 7 SC joint meniscus

3 intermediate branch 8 costoclavicular ligament

4 lateral branch 9 subclavious muscle

5 interclavicular ligament 10 nerve to subclavious

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Techniques

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Costoclavicular Ligament / Upper Mediastinum

Patient position: Therapist position: Supine on a table Standing at the head of the table

Technique: The costoclavicular ligament is connected to the upper mediastinum, the endothoracic fascia, sternalis-thoracicus fascia, parietal and visceral pleura. It also has connections to the mediastinum, fibrous pericardium, phrenic nerve and diaphragm. Contact this ligament at the sternal attachment of the 1st rib just posterior and inferior to the clavicle. Matching the reciprocal tension of the tissues with your flat thumbs, load your pressure posteriorly, inferiorly and laterally while your patient exhales. Repeat and gently hold this position until the tissues soften. Once a softening occurs, reassess for suppleness in the tissues.

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Anterior Sternoclavicular Ligament

Patient position: Therapist position: Supine on a table Standing beside the patient facing the patient

Technique: Treatment is for an Anteriorly/Inferiorly positioned clavicle Assess the movements of the SC joint with inhalation and exhalation. The clavicle should roll and glide superiorly/posteriorly with inhalation, inferiorly/anteriorly with exhalation. Contact the anterior/inferior aspect of the SC joint and medial 1/3 clavicle with flat thumbs. With the patients’ breath, gently match the reciprocal tension of the tissues during inhalation. Hold this position until the tissues soften and the clavicle repositions superiorly and posteriorly to a more neutral position. Once the tissues have released/softened, reassess for suppleness and movement of the tissues with inhalation and exhalation.

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Posterior Sternoclavicular Ligament

Patient position: Therapist position: Supine on a table Seated/Standing at the head of the table

Technique: Treatment is for a Posterior/Superiorly positioned clavicle Assess the movements of the SC joint with inhalation and exhalation. The clavicle should role and glide superiorly/posteriorly with inhalation, inferiorly/anteriorly with exhalation. Contact the superior/posterior aspect of the SC joint and medial 1/3 clavicle with flat thumbs. With the patients’ breath, gently match the reciprocal tension of the tissues during exhalation. Hold this position until the tissues soften and the clavicle repositions anterior and inferiorly to a more neutral position. Once the tissues have released/softened, reassess for suppleness and movement of the tissues with inhalation and exhalation.

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Corocoid Ligaments with AMPs

Patient position: Therapist position: Supine on a table Standing beside table

Technique: This technique targets the conoid and trapezoid ligaments. These ligaments have possible ligamentomuscular reflexes with the pectoralis minor, coracobrachialis and short head biceps muscles. Locate these ligaments in the small space located inferior to the lateral end of the clavicle and superior to the coracoid process. Matching the reciprocal tension of the tissues, load posteriorly, and inferiorly. Hold this position until the tissues soften. Incorporate AMP’s by having the patient gently engaging their pectoralis minor muscle 1-2%. This allows a lengthening of the tissues by increasing the space between the clavicle and coracoid process. Once a softening occurs, reassess for suppleness in the tissues.

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Pectoralis Minor / Coracobrachialis / Short Head Biceps

Patient position: Therapist position: Supine on a table Standing at the head table

Technique: Caution – If the shoulder has been previously dislocated, position the arm on the table for support

This technique is similar for all of these tissues; the only differences are in the direction of force and hand placement. Pectoralis minor muscle: Locate the attachment at the coracoid process. Matching the reciprocal tension of the tissues, maintain steady, balanced pressure in the direction of its attachments onto ribs 3-5, until you feel a release of the tension.

Coracobrachialis muscle/short head of the biceps: Place your thumbs just lateral and inferior to the coracoid process applying the same steady, balanced pressure in a lateral and posterior direction. Matching the reciprocal tension of the tissues, maintain steady, balanced pressure until you feel a release of the tension.

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Long Head Biceps/Glenohumeral Capsule

Patient position: Therapist position: Supine on a table with affected shoulder off the table Standing beside the patient facing the patient

Technique:

Please Note: If your patient has a history of anterior/inferior GH Joint dislocation and feels unsafe having their arm resting off the table unsupported, this technique may be inappropriate and recommended not to use.

This technique targets the longhead of the biceps and its synovial sheath as it travels inside the glenohumeral joint capsule attaching onto the supraglenoid tubericle of the scapula. It also targets the tissues of the glenohumeral capsule, glenoid labrum and superior glenohumeral ligamentous tissue.

The normal range of motion of the glenohumeral capsule into extension is 45-60 degrees. Depending on the severity/chronicity of injury, these ranges may not be able to attain in one treatment, therefore gaining this range should be structured over a period of treatments. Position your patient close to the edge of the table with their shoulder to be treated gently/comfortably resting off the table.

With your hand closest to the end of the table, gently rest it onto the anterior shoulder. This provides awareness and comfort for the patient. It also allows the therapist to monitor humeral movement and tissue response. With your other hand, gently contact the distal radius and ulna. Slowly and gently fully extend the elbow and fully pronate the wrist. Next slowly start to bring the whole arm into further extension. As the patients’ discomfort starts to increase, stop and hold for 3-5 seconds. Then back off the angle of treatment by 10% and start the process once again bringing the whole arm into further extension gaining an increased range of motion. Once again as the patients’ discomfort starts to increase, stop and hold for 3-5 seconds, back off the angle of treatment by 10% and start the process once again.

Advanced Technique Once you are able to gain full range of motion of the glenohumeral joint, holding the whole arm at the complete end range of motion, gently with both hands, grasp the medial and lateral condyles of the humerous. Gently compress the humerous up to the ceiling challenging the anterior tissues of the shoulder. Hold for 3-5 seconds. Next gently distract the humerous towards the floor. Hold for 3-5 second. Repeat both 3-5 times. End by slowly removing tension to all tissues and assist your patient with repositioning their arm back onto the table next to them.

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Common Mistake’s / Do’s and Don’ts

Don’t Do not think that this is a cure. We are just changing the environment of the body to increase it’s functioning.

“It's not perverted function but a wrong environment that results in the distorted appearance of function. Function is always true to its environment. Function is dependent upon its environment. Therefore, any change in any part of the environment that is not in tune or balance will apparently distort the function of the matter so involved.” - Thomas Schooley, DO

Do Remember your principles: Disengage, Exaggerate, Balance Acute, Sub-acute, Chronic Listen and follow the tissues/body

Don’t Over treat your patients with this technique tomorrow. Risk of harm Can be too much change for the patient in one session

Don’t Rush through the barrier.

Do Direct and Indirect Techniques Listen and feel for the RECIPROCAL TENSION in the tissues.

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Don’t Work quickly.

Do Slow down! “The quieter the mind The stiller the hands The less movement we make The more we are able to perceive involuntary movement” - James Jealous, DO

Don’t Treat on hardware you have never seen before get x-rays, CT/MRI reports

Don’t Think you will be proficient in this technique immediately! It takes time and Patients! LOTS of patients – 500-1000!

Do you feel Overwhelmed? 1st Thing to do! Incorporate 1-2 techniques/patient/treatment to start. Don’t over treat – It can be too much for the patient to handle!

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Ligament Pain Referral Pattern Book

This book is intended to give you information that may have been missing from your formal medical education.

Understanding the basic mechanisms of pain, how referred pain occurs, and the pain referral patterns from ligamentous and joint tissues is an integral part of understanding someone’s experience with pain or discomfort, how it affects their quality of life, and possibly on what areas to focus treatment.

KEY FEATURES • Understanding the basic physiology of pain • Understanding the basic physiology of joint tissue and ligament pain • Neurophysiological model of referred pain • Sclerotomes: fact or fiction? • Biopsychosocial approach to pain • Enactive approach to pain • Eighteen original full-colour neurological joint innervation images for axial and appendicular joints • Neurological joint innervation charts for axial and appendicular joints • Ninety-eight full-colour joint tissue and ligament pain referral pattern images with descriptions • All information contained in this book was acquired from published research and medical texts believed to be reliable sources

LIGAMENT PAIN REFERRAL PATTERNS is applicable for all levels: from the student to the most experienced therapists and clinicians.

Professionals who will find this book beneficial and significant to their practice include all manual and movement therapists: • acupuncturists • chiropractors • kinesiologists • massage therapists • medical physicians • naturopathic physicians • osteopaths • physiotherapists • structural integration practitioners • yoga teachers and therapists

To order now simply go to lastsite.ca

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Ligament Pain Referral Pattern Posters

These visually stunning, full-color posters are an invaluable diagnostic and educational tool for you and your patients.

Over the last 25yrs I’ve recognized a distinct, immediate and ongoing problem. My patients were complaining of pain referral patterns that didn’t seem to match up with the standard trigger points, dermatome or sclerotome patterns.

For years I researched scientific journals and resources all the while continually charting the referral patterns described to me by my patients.

This extensive work has culminated in my creation of this set of LIGAMENT PAIN REFERRAL PATTERN posters!

This stunning artwork is original and doesn’t exist anywhere else!

These 2 posters graphically demonstrate over 40 ligament pain referral patterns for: Spine & Upper Extremity, Spine & Lower Extremity

Multiple referral patterns are displayed for each region of the body; Spine, Shoulder, Forearm & Hand, Hip & Pelvis, Knee, Leg & Foot.

If you have patients complaining of referred pain that you just can’t figure out, if you treat joint dysfunction and want to explain more in depth the discomfort your patients are feeling, if you want to a add more value to your practice and your patients… these posters will be an asset!

These visually stunning, full-color, high glossy charts are an invaluable diagnostic and educational tool for you and your patients.

Help your patients visually see the cause of their complaints!

To order now simply go to lastsite.ca

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Ligamentous Articular Strain Technique Courses

Multi Day Courses Upper Body & Extremities Lower Body & Extremities Thorax, Abdomen & Pelvis Bowstring & Diaphragms

1 Day Courses Postural Correction Techniques Techniques for Thorax Techniques for Shoulder Techniques for Elbow & Wrist Techniques for Hip & Pelvis Techniques for Foot, Leg & Knee Techniques for Sternum

Online Courses Techniques for Shoulder Techniques for Thorax Techniques for Sternum Techniques for Elbow & Wrist Techniques for Leg & Foot Techniques for Knee Techniques for Hip & Pelvis Techniques for Postural Correction

For course schedules, visit www.lastsite.ca

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About Robert

Robert has been a (Canadian 3000hr) Registered Massage Therapist (RMT) for over 25yrs and an educator for over 20yrs.

Robert has spent his career researching, learning, developing and updating Ligamentous Articular Strain Technique. Initially studying the works of A. T. Still, DO, Robert continued to study and be influenced by W. G. Sutherland, DO; H. A. Lippincott, DO; R. Lippincott, DO; R. Becker, DO; A. Wales, DO and the Dallas Osteopathic Study Group.

As science and medicine advanced, Robert recognized that some of the original perceptions, narrative and principles may seem out of touch with today’s knowledge, while others maintain the test of time. Robert has sought to update the narrative of the technique and its outcomes by incorporating the most current research and understanding of neurophysiology psychosocial factors, pain science, fascial research and ligamentous pain referral patterns.

This text represents a reconceptualization; a revitalization of a classical Osteopathic Manual Technique.

Robert believes therapists and clinicians have a great opportunity to improve the quality of life of their patients. He has always felt that our understanding of the ligamentous articular system has been insufficient. Roberts desire is to bring greater awareness of this system’s role in neuromusculoskeletal injuries and disorders, and to provide information that will enhance the therapists and clinicians’ capacity to help their patients.

Robert maintains a full-time practice while he continues researching, developing, training and educating.

Robert can be contacted at: [email protected] or www.lastsite.ca

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Ligamentous Articular Strain Techniques Shoulder Webinar Course Manual 2020

LAST Online Educational Training Courses

Stop chasing the lateral shoulder pain. Learn how dysfunctions medially can contribute to and cause issues in the tissues elsewhere.

https://www.lastsite.ca/checkout-page- online-shoulder-course-discount/

Knee injuries can feel daunting to know how to treat them all. These specific techniques will help you be more effectively with your treatment.

https://www.lastsite.ca/checkout-page- online-knee-course-discount/

Let’s create some “Happy Feet!” Achieve a sense of lightness and let’s put some spring back into your patients’ feet and lower legs.

https://www.lastsite.ca/checkout-page- online-leg-foot-course-discount/

New strategies for treating a common area of complaints! Let’s put some wiggle in that walk!

https://www.lastsite.ca/online- courses/techniques-for-the-hip-pelvis/

This is a Compilation of my 10 most effective, simple and easy to implement, techniques for each major body area. You’re going to love this course!

https://www.lastsite.ca/checkout-page- compilation-course-cmc/

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