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Trigger Points and Muscle Chains Kabat’s model is described as follows: reproduces the behavior of the in Osteopathy spinal column and the pelvis, as Kabat developed a treatment tech- described by Sutherland, Zink, and By Philipp Richter, DO (foreign), and Eric nique wherein weak muscles are Littlejohn in their models. Hebgen, DO (foreign). 230 pp, $89.95. integrated into a muscle chain. The For us, it is obvious that it is the muscles that form these patterns. ISBN: 978-3-13-145051-7. Stuttgart, Germany: muscle chain is stimulated with the Georg Thieme Verlag; 2009. aid of specific stimuli (by visual, auditive, and tactile irritants). This Mr Richter then explains that, in his rigger Points and Muscle Chains in process takes optimal advantage of and Mr Hebgen’s opinion, there are Osteopathy, an English translation of the nerve and muscle properties only two muscle chains in each half of T described by [Sir Charles] Sher- the second edition published in Ger- the body—a flexion chain and an exten- rington, in order to integrate opti- sion chain. The muscle chains are many in 2007, is described as a guide for mally the weak muscle (or muscle “osteopaths, physiotherapists [and] chi- group) into the motion pattern. described in detail, and anatomic dia- ropractors” to apply therapy techniques grams help make the descriptions easily involving trigger points. This liberally understandable. illustrated book, combining theory with Mr Richter next describes research The last two chapters of part A practical techniques, was written by findings of Irwin M. Korr, PhD; cover diagnosis and therapy related to two foreign-trained osteopaths. One Sir Charles Sherrington, OM; and Har- dominant muscle chain patterns. The author, Philipp Richter, DO (foreign), rison H. Fryette, DO, that are related to methods of diagnosis mentioned by is a private practitioner and assistant the subject of the book. In the two pages Mr Richter include history taking, director of the Institute for Applied on Dr Korr, the author notes the signif- observation, motion testing through Osteopathy in Burg Reuland, Belgium. icance of somatic dysfunction in the particular traction techniques, and the The other author, Eric Hebgen, DO spinal column, the role of the spinal use of Zink patterns. Several black-and- (foreign), is a private practitioner in column as an information and control white photographs of human models Konigswinter, Germany. center, and the significance of the nerves depict the diagnostic techniques This book is essentially two books in for trophism. Mr Richter also outlines described in the text. one. Part A, written by Mr Richter, con- the functions and dysfunctions of con- The five-page chapter on therapy sists of 11 chapters. The first seven chap- nective tissue and fascia and analyzes covers only the most basic aspects of ters review physiologic and biome- muscle activity in walking. muscle energy and myofascial release chanic issues associated with what the After these basic physiologic and techniques. Listed, but not described, authors call “muscle chains,” or biomechanic discussions, Mr Richter under myofascial release are the fol- “myofascial chains,” as modeled by var- describes the craniosacral model of lowing methods: strain-counterstrain, ious researchers. Chapters 8 through William G. Sutherland, DO, from a facilitated positional release, functional 11 define the authors’ own model of biomechanical perspective. This descrip- release, balanced ligamentous release muscle chains and the authors’ tion includes text, as well as anatomic (ie, balanced ligamentous tension), [fas- approach to treatment. Part B, which illustrations, on flexion, extension, tor- cial] unwinding, and cranial osteopathy consists of chapters 12 through 19, was sion, sidebending rotation, and other (ie, osteopathy in the cranial field). This written by Mr Hebgen and covers the movements of the craniosacral mecha- last chapter of part A also briefly explains definition, locations, and physiologic nism. Next, the musculoskeletal models “neuromuscular technique” and myofas- mechanisms of trigger points, as well as of John Martin Littlejohn, DO; Vladimir cial release with ischemic compression. diagnosis and treatment related to Janda, MD; and J. Gordon Zink, DO, Summing up why the book pre- trigger points. are compared. sents information on the various forms Although the authors provide no With the necessary groundwork of therapy, Mr Richter notes the fol- clear definition of muscle chains, laid, Mr Richter describes the muscle lowing: Mr Richter, in part A, delineates models chain model proposed by Mr Hebgen of muscle chains developed by Herman and himself. In regard to their model, he states the following: If the therapist has found and Kabat, MD, PhD; Godelieve Struyff- treated (viscerally, parietally, or cra- Denys (a Belgian physiotherapist); nially) the dominant dysfunction, Thomas W. Meyers (a rolfer); and Furthermore, we determined that and in addition treats the trigger French osteopaths Leopold Busquet and one of the main functions of the points in acute cases and normal- Paul Chauffour. For example, Dr locomotor system, namely the gait, izes the shortened musculature in

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the affected muscle chain in chronic ments in part A are referenced with First Aid for the COMLEX: cases, the chances are quite good superscripts corresponding to numbers An Osteopathic Manipulative that the painful state is relieved in the bibliography at the end of the Medicine Review: Second Edition quickly and that the danger of book, references for part B are listed in relapse is reduced. the bibliography without superscripts in By Zachary Nye, DO; John M. Lavelle, DO; the text. Therefore, the reader is unable Stockton M. Mayer, DO; and Rachel In part B, Mr Hebgen first briefly to identify the sources of particular Laven, DO; edited by Elise B. Halajian. discusses the classification, pathophys- statements. 260 pp, $44.95. ISBN: 978-0-07-160025-5. iologic factors, and diagnostic aspects of The concepts of muscle chains and New York, NY: The McGraw-Hill Compa- trigger points. He then describes, in trigger points are not for every osteo- nies; 2009. only two pages, some therapy methods pathic physician. Those who are not for trigger points. “Stretch-and-spray interested in the musculoskeletal com- irst Aid for the COMLEX: An Osteo- technique”; “postisometric relaxation/ ponent of medicine or trigger point treat- Fpathic Manipulative Medicine Review: muscle energy technique/myofascial ments will not find this book useful. Second Edition—written by Zachary release”; “ischemic compression/ However, osteopathic physicians who Nye, DO; John M. Lavelle, DO; manual inhibition”; and “deep friction frequently work with the muscu- Stockton M. Mayer, DO; and Rachel massage” are succinctly put forth as loskeletal system and trigger point treat- Laven, DO, and edited by Elise B. Hala- such therapy. The mention of trigger ments might find this book to be of aca- jian—is an excellent “just meat, no point injection, however, is conspicu- demic value. Part A may be of interest to bone” review of osteopathic manipu- ously absent. The author also explains osteopathic physicians who would like lative medicine (OMM) for the Com- how a facilitated segment resulting to learn how the authors developed their prehensive Osteopathic Medical from visceral dysfunction may be asso- model of muscle chains based on pre- Licensing Examination-USA (COMLEX ciated with specific trigger points. vious research. Part B will have more -USA) Levels 1, 2, and 3. The authors The final chapter, comprising more widespread applicability as a quick ref- are former teaching fellows at Mid- than 90 pages, provides details on the erence for trigger points and their asso- western University/Chicago College location and referral patterns of com- ciated anatomic and physiologic factors. of Osteopathic Medicine in Downers monly found trigger points. The trigger Overall, I recommend Trigger Points Grove, Illinois, and current residents at points are grouped into seven body and Muscle Chains in Osteopathy to osteo- various institutions. The editor is an regions—head and neck; upper thorax pathic medical students, residents, and OMM fellow at Midwestern. This team and shoulder; elbow-finger; upper practitioners who have a particular has produced a highly useful resource torso; lower torso; hip, thigh, and knee; interest in trigger points or in learning for osteopathic medical students who and lower leg, ankle, and foot. about the concept of muscle chains. The are preparing to take COMLEX-USA. Mr Hebgen discusses the origins, inser- book may stimulate thought with The book is organized into five sec- tions, innervations, and actions of the regard to muscle chains and osteopathic tions, consisting of 13 chapters, that involved muscles and also mentions medicine, and it may provide a valuable cover the following topics: (I) “Guide any internal organs that may be asso- reference for common trigger points. to Efficient Examination Preparation,” ciated with each trigger point. However, this book is not a treatment (II) “OMT Fundamentals,” (III) Many clear photographs of human manual for osteopathic physicians. “Regional and Systems-Based Assess- models are presented in this final In conclusion, although Trigger ment,” (IV) “Historical Highlights, Key chapter. Additional graphics depict the Points and Muscle Chains in Osteopathy is Points, and Musculoskeletal Tests,” and location of each trigger point and its not a “must have” book or a “practice (V) “Osteopathic Treatments and Tech- radiation pattern on the models. The changer,” it could be a useful reference niques.” This organization—along with anatomic illustrations in this chapter— for osteopathic physicians who use the easy-to-follow bullet-point format of as in the other chapters of the book—are trigger point treatments or who are information presentation, concise tables, also clear, useful, and pleasing to the looking for another approach to address and useful figures (including black-and- eye. However, picture credits indicate musculoskeletal problems. white illustrations and photographs)— that most of the illustrations have been make this book essential for time-con- culled from other publications and are Michael J. Terzella, DO scious osteopathic medical students and not original. Assistant Professor, The Stanley osteopathic physicians who are sitting Schiowitz, DO, FAAO, Department of for the OMM component of a state It should be noted that the refer- Osteopathic Manipulative Medicine, New York encing system for part B is not as readily College of Osteopathic Medicine of New York licensing examination. Also useful are apparent as that in part A. While state- Institute of Technology, Old Westbury the end-of-chapter review questions

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(with answers), many of which Section III is the “meat” of the book. of high-yield topics and key points for resemble board-style questions in The first chapter of this section presents COMLEX-USA. I recommend that format and complexity. regional diagnosis concepts, from osteopathic medical students read this Section I starts with a discussion of occiput to sacrum, in a logical and intu- section the day before taking the exam- the structure of COMLEX-USA for each itive manner. For each body region, the ination. The text briefly reviews the vis- of the four steps (Levels 1, 2-Cognitive text discusses relevant anatomic infor- cerosomatic reflex, Chapman reflex, and Evaluation, 2-Performance Evaluation, mation followed by material on range of Jones counterstrain tender points, then and 3). In Table 1-1, a list of the per- motion and steps for segmental diag- discusses the most common orthopedic centages of examination content nosis and treatment. A good example of tests that appear on COMLEX-USA. devoted to various topics provides for how the authors convey this informa- The tables and figures in chapter 6 are a quick review. A discussion of exam- tion is their discussion on sacral especially useful. Table 6-1 and Table 6- ination grading and mean scores is fol- mechanics, diagnosis, and treatment— 2 are chock-full of information that stu- lowed by a review of how osteopathic a topic that is traditionally represented dents need for the examination, such manipulative treatment (OMT) is inte- heavily on COMLEX-USA. The authors as locations of reflexes and tender grated into COMLEX-USA. This sec- use a step-by-step diagnostic approach points. In addition, several figures show tion ends with a “Walk Through of Test for both the sacral torsion model and locations of tender points. Day,” which summarizes what to the anterior-posterior sacrum model, What I find most brilliant about the expect on the day of examination, such including providing examples for each material in section IV is the list of ortho- as a 50-minute orientation consisting of model with bullet points and figures. I pedic tests with descriptions and cor- video and oral presentations and the have not seen another text, let alone responding illustrations. These features timings of lunch and other breaks. After another review book, that presents will enable osteopathic medical stu- reading section I, osteopathic medical information on these two models of dents to achieve higher examination students should not have any surprises sacral mechanics so effectively. scores because orthopedics and OMM on test day. The second chapter of section III are integrated on COMLEX-USA. Section II provides a lightning-fast covers systems-based assessment in Section V wraps up the book by cov- but thorough review of the basics of clinical medicine. For each system, the ering various OMT techniques OMT. Explanations of somatic dys- discussion begins with relevant according to body regions—cranial; cer- function and tissue texture changes, anatomic information, then addresses vical; thoracic, rib, and diaphragm; including acute and chronic palpatory visceral somatic reflexes. The section lumbar; sacrum and pelvis; extremity; findings, are addressed in bullet and finishes with osteopathic medical con- and systemic. Techniques are well table format. As in the rest of the book, siderations and treatment guidelines. described and illustrated. This section several illustrations in this section stress The material on obstetrics is a prime is most useful for students who are important concepts. For example, example of how the authors’ presenta- preparing for the COMLEX-USA Figure 2-2 summarizes the barrier con- tion of a topic works well. Table 5-1, Level 2-Performance Evaluation and for cept by using simple traffic signs, such “Contraindications of OMT in the Preg- osteopathic physicians who are sitting as a stop sign to represent an anatomic nant Patient Divided by Trimester,” is for the OMM component of the state barrier and a railroad-crossing gate to a perfect reference for studying for licensing examination. represent loss of range of motion. boards as well as for rounds on an The only caution I have for students Throughout the book, the authors obstetrics floor service. The discussion about section V is that it is not meant to present material in a variety of formats, of trimester-specific chief complaints be an all-inclusive atlas of OMT tech- including bullet points, tables, and illus- and related somatic dysfunctions is niques. Thus, confusion may occur if trations. These different formats enable especially straightforward and easy to comparison is made between the tech- readers to acquire knowledge in the understand. niques presented in this section and the form they understand best. The authors The systems-based information pro- techniques presented in individual col- also convey information using note vides osteopathic medical students with leges of osteopathic medicine. (On a points, located in the side margin of a high-yield review of clinical consid- sidenote, contrary to the photograph in each page. For example, in section II, erations of OMT for COMLEX-USA. Figure 13-2, gloves should be worn note points, bullet-point lists, and an However, this chapter at times reads a when performing all intraoral tech- illustration all address Fryette princi- bit like a “cookbook” in that the suc- niques with patients.) ples. Students can easily review these cinct lists of diagnosis and treatment In summary, First Aid for the note points without stopping to look steps seem to be taken out of the context COMLEX: An Osteopathic Manipulative the topic up elsewhere, making the of osteopathic medicine. Medicine Review: Second Edition is a well- learning process extremely efficient. Section IV is a concise presentation written, well-illustrated, and concise

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review book for COMLEX-USA that I recommend to any osteopathic med- Correction ical student who is preparing to take The JAOA regrets an error that appeared in the following contribution: any level of the examination. I also rec- ommend this book to any osteopathic Dyachenko A, Melius K, Fujima L, Wen M, Lin S, Bergeron N, et al. physician who desires a quick review of The effect of acute fructose infusion on hepatic glucose metabolism OMM or who is preparing to take the in humans [abstract]. J Am Osteopath Assoc. 2009;109:433-434. C9. osteopathic practical component of a state licensing examination. The for- Ms Lin’s name incorrectly appeared as Steve Lin, OMS IV. However, Ms Lin’s mula of integrating bullet-point descrip- first name is Shintau, and she is not an osteopathic medical student. Her name tions, tables, and figures with the rein- should have appeared as Shintau Lin. forcement of point notes gives this book This change was made to the full text (http://www.jaoa.org/cgi/content an advantage over other available /full/109/8/425) and PDF (http://www.jaoa.org/cgi/reprint/109/8/425) COMLEX-USA review books. versions of this contribution online.

Francisco Laboy III, DO Department of Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine, Philadelphia College of Osteopathic Medicine, Pennsylvania

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