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J A O A Vol 103 No 12 December 2003 5 8 3Danto Original Contribution

Integrated neuromusculoskeletal release (INR) using asegmental anterior/posterior approach is an osteopathicmanipulative treatment technique that is easily learnedand applied. The segmental anterior/posterior approach toINR was developed as a practical osteopathic manipulative

treatment procedure for the inpatient setting, but also hasequal efficacy in the outpatient setting. It builds on theprinciples of INR and myofascial release techniques, aswell as other techniques. This approach focuses on both theanterior and posterior connectivity of the body through theneuromusculoskeletal system and uses this connectivity toe ffectively treat somatic dysfunctions. The principles ofINR are discussed, as well as the role of INR in the diag-nosis and treatment of somatic dysfunctions in the thoracic,l u m b a r, and sacral regions.

Integrated neuromusculoskeletal release (INR) is an osteo-pathic manipulative treatment (OMT) technique that has been formalized by Robert C. Ward, DO. According to Ward,

Integrated neuromusculoskeletal release and myofascialrelease ideas have been a part of American osteopathicthinking from early in the professions history. Until recently,they were commonly referred to as isometric-isotonic, fascialrelease, and functional techniques. 1(p843) Ward goes on todefine INR and myofascial release as combined proce-dures designed to stretch and reflexly release patterned softtissue and joint-related restrictions. Both direct and indirectmethods are used interactively. 1(p843)

The segmental anterior/posterior (SAP) approach toINR is a time-efficient OMT technique that can be used any-where at any time. The SAP approach to INR does not requirea treatment table, and it is the authors experience on hun-dreds of inpatient and thousands of outpatient encounters thatthe technique is nontraumatic and well tolerated. This articlediscusses the application of the SAP approach to INR in the

diagnosis and treatment of the thoracic, lumbar, and sacralregions. A full review of INR techniques is beyond the scopeof this article, but it, as well as a variety of OMT techniques(eg, ligamentous articular strain technique, muscle energytechnique, facilitated positional release, strain/counterstrain,

Stills technique, myofascial release) that similarly focus on the balancing of muscles, fascia, and the nervous system, can beused to address the entire body. It has been the authorsexperience that a SAP approach to INR can be taught in bothclinical and classroom settings. In addition, students have been receptive and recognize its practicality immediately.

FasciaThe whole of OMT has been concerned, purposefully or not,with manipulation of the fascia. However, historically, therewere a number of years in the osteopathic profession duringwhich OMT techniques emphasized the joints role in somaticdysfunction. Yet today, few would argue that even high-velocity low-amplitude OMT techniques do not have a sig-

nificant myofascial release component.For the purpose of this article, the starting point for a dis-cussion of fascia will be on its gross anatomy. Jacobs and Fallsuse the following to describe the gross anatomy and physicalcharacteristics of fascia ( Figure 1) :

Fascia is a derivative of mesoderm. Throughout the bodythere is a subcutaneous layer of loose connective tissue calledthe superficial fascia. It contains collagen fibers as well as vari-able amounts of fat. Superficial fascia increases skin mobility,acts as a thermal insulator, and stores energy for metabolic use.The dense connective tissue envelope that invests and separatesindividual muscles of the limbs and trunk is deep fascia. It isalso composed primarily of collagen fibers.

Between individual muscles there is a fascial plane that rep-resents the separation of the connective tissue investment

(wrapper) of the individual muscles. In the limbs and neckdeep fascia pass over and between muscle groups and connectto bone periosteum. The deep fascia passing between musclegroups are called intermuscular septa. Together with the deepfascia passing over muscle groups, they serve to compart-mentalize muscle groups of similar functions and innerva-tions. Deep fascia between individual muscles that moveextensively are loose connective tissue, which facilitate move-

Review of Integrated Neuromusculoskeletal Releaseand the Novel Application of a Segmental Anterior/PosteriorApproach in the Thoracic, Lumbar, and Sacral Regions

Jay B. Danto, DO

Dr Danto is attending physician at Botsford General Hospital in FarmingtonHills, Michigan.

Address correspondence to Jay Danto, DO, 6450 Farmington Rd, #121,West Bloomfield, MI 48322.

E-mail: [email protected]

ORIGINAL CONTRIBUTION

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ment. As connective tissue, fascia provide formobility and stability of the musculoskeletal system.There is a myofascial continuity throughout the b o d y .

Peripheral nerves, blood, and lymph vessels liein the loose connective tissue fascia between muscles.This fascia binds together these nerves and vessels,and collectively these components form the neu-rovascular bundle. 1(p35)

Jacobs and Falls also describe the myofascial conti-nuity of the body through the example of the tendi-nous attachment of muscle to bone:

The dense fibrous connective tissue is anchored to thecompact cortical substance of bone by microscopicconnective tissue penetrating fibers, Sharpeys fibers.The connective tissue that then forms the mass of thetendon becomes feathered to interdigitate with the

skeletal muscle fibers that will form the substance of the muscle.... The connection of tendon to bone pro-vides functional integrity of each part of the bodyacross each synovial joint by way of the muscletendon complex. 1(pp41-42)

Moving on to a more functional description of the fascia, Chila eloquently and succinctly defined itsrole in structural support, motion, and maintenanceof balance:

Fascia of the human body can be described as asheet of fibrous tissue that envelops the body beneaththe skin; it also encloses muscles and groups of mus-cles, separating their several layers or groups.... Inaddition to extensive attachment for muscles, thefascia of the human body is provided with sensorynerve endings and is thought to be elastic as well ascontractile. Fascia supports and stabilizes, helping tomaintain balance. It assists in the production andcontrol of motion and the interrelation of motion of related parts. Many of the bodys fascial specializa-tions have postural functions in which stress bandscan be demonstrated. 1(p819)

To fully understand the diverse role of fascia, itis necessary to explore the neuroanatomy of thisstructure. According to Beyers and Bonica:

It is clinically important that approximately 20% of cutaneous high-threshold mechanoreceptors sup-plying the skin also have receptive fields in the sub-cutaneous tissue, usually the fascia.... The stretchreceptors of muscle comprise only approximately25% of the sensory innervation, and the other 75%consists of free endings in fascia of the muscles, betweenmuscle fibers, and in the walls of blood vessels and tendons.These endings are supplied by thin A-delta myelinated axons(group III) and unmyelinated C fibers (group IV).... A majorityof them respond to inflammatory mediators and also toinnocuous to noxious pressure and thermal stimuli and are

therefore clearly polymodal receptors. They also can be acti-vated by muscle stretch or contraction. Approximately 80% of the C fibers are polymodal, but their threshold to mechanicalstimuli is higher than that of the A fibers, their receptive fieldsare small areas within muscle or tendon, adaptation is slow,and few respond to stretch and none to contraction. 2

Danto Original Contribution

Figure 1. Transverse section through an extremity illustrating the organiza -tion of superficial and deep fascia.

Figure 2. Myofascial layers. The different colors represent muscle layers at dif -ferent depths (blue, superficial; yellow, intermediate; red, deep). (FromG r a n t sAtlas ImagesComplete Collection. Baltimore, Md: Williams & Wilkins; 1998.)

S u p e rf i c i a l

F a s c i a

S k i n

B o n e

D e e pF a s c i a

I n t e rm u s c u l a rFascial Septum


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J A O A Vol 103 No 12 December 2003 5 8 5

that need to be considered. First, it is important functionally toconsider the tight-loose concept of INR, which is well elab-orated upon by the observations and research of Janda:

Muscle shortness or tightness, which develops without any evi-dent structural neurological lesion and is apparently associatedwith overuse of the particular muscle, has never been properlydefined. It indicates a condition in which the muscle is shorterthan normal at rest and cannot be stretched either passively oractively to its normal length. Such a shortened muscle maymove the joint from the normal rest position when inactive. Itdoes not allow full range of motion. The important point is thata tight muscleevidently in keeping with Sherringtons lawof reciprocal innervationinhibits its antagonist counterpart....(Sherringtons law: When a muscle receives a nerve impulseto contract, its antagonists receive, simultaneously, an impulseto relax.)

The result of decreased muscle flexibility is not only alower excitability threshold, but also a changed elasticity, evi-dently due to hypertrophy and retraction of the retractile con-nective tissue in the muscle. The hypertrophy and retractionunfavorably influences the contractile ability of the musclefibers. In addition, it may lead to impaired circulation pro-ducing ischemia and thus accelerating degeneration. Ulti-mately, the whole process results in a functional disability. 3

It must be remembered that the connective tissue towhich Janda refers is fascia, and it is therefore the fascia thatis hypertrophied and retracted with resulting unfavorable

As we have established the myofascial continuity of the body, it is important to add that the periosteum, joint capsule,ligaments, joint fat pads, and even blood vessels are inner-

vated with the same polymodal nerve fibers previouslyd e s c r i b e d . 2 Furthermore, the joints are also innervated bylarge (group I) and medium (group II) A fibers that termi-nate in mechanoreceptive endings that detect the torque thatdevelops as a joint is extended, flexed, or rotated to theextreme of its range. 2

For the purpose of this discussion, it is necessary toexamine the trunk from a more macroscopic view of thefascia. One observes the tubular nature of the fascia coveringan inner core of the spine and organs, and then a progressionof layers. For instructional purposes, these muscle group-ings have been traditionally divided into the superficial,intermediate, and deep muscles of the body ( Figure 2). On theanterior surface of the body, there is a central tendon ontowhich the fascia anchors, and this goes from the symphysispubis, along the linea alba, and then onto the sternum. Pos-teriorly, the fascia is anchored from the tailbone to the spinousprocesses of the vertebrae, and from the nuchal ridge of thecervical spine to the skull ( Figure 3) .

MusclesWhile a discussion of the entire muscular system is beyond thescope of this article, there are properties of these structures



Figure 3. Anterior and posterior fascial attachments. A , Myofascial attachments in the thoracic region;B, Myofascial attachments in the abdom -inal region; C , Myofascial attachments of the back.( F r o m Grants Atlas ImagesComplete Collection. Baltimore, Md: Williams & Wilkins; 1998.)

A

B C

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Figure 4. Tight-loose relationship of the thoracic inlet. A , Anterior tight-loose relationship ; B,Posterior tight-loose relationship. Note that the example has an alternating pattern with respect to the right-left relationship and anterior-posterior relationship. tight; l o o s e .

A

B

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Digging deeper, it must be understood that the rota-tional component of this part of the common compensatorypattern is maintained by a tight-loose relationship of themusculature of this region governed by Sherringtons law.There is an anterior-to-posterior and side-to-side relation-ship to the tight-loose phenomenon. For example, if there istightness at T4 on the posterior right aspect of the body, thenthere will be looseness on the contralateral posterior side atthat level and at the ipsilateral anterior part of the body( Figure 4). There is also a corresponding tightness at the ante-rior contralateral side of the body. The tight-loose relationshipis one of the key concepts used in diagnosis and treatment inINR and will be developed further in the treatment sectionof this article.

Another characteristic of tight muscles is that theytend to develop trigger points. Travell and Simons define amyofascial trigger point as a hyperirritable spot, usually

within a taut band of skeletal muscle or in the muscles fascia,that is painful on compression and that can give rise to char-acteristic referred pain, tenderness, and autonomic phe-n o m e n a . 5(p3) According to the integrated hypothesis, thelatest and most feasible theory that explains the nature of trigger points,

It is now becoming clear that the region we are accustomed tocalling a trigger point or a tender nodule is a cluster of numerous microscopic loci of intense abnormality that arescattered throughout the nodule. The trigger point is like anest of hornets that contains multiple minute sources of intensetrouble. The critical trigger point abnormality now appearsto be a neuromuscular dysfunction at the motor endplate of anextrafusal skeletal muscle fiber, in which case the myofascialpain caused by trigger points would be a neuromuscular dis-e a s e .5(p57)

Treatment of trigger points is by trigger point injection,the application of a coolant followed by stretch or the use of postisometric relaxation (also known as muscle energy tech-n i q u e ) .4,5(pp150-173)As a result of its role as a mixed technique,when used in a direct manner, integrated neuromuscu-loskeletal release can also be thought of as a muscle energytechnique applied directly to the myofascial system. In otherwords, the myofasciae is put into a position of stretch to the barrier, the patient is instructed to perform a muscular con-traction, and on completing the contraction a new barriercan be established. Consequently, INR can be used to treattrigger points and to decrease the myofascial conditions thatresult in trigger point formation. Furthermore, INR, by virtueof its release of myofascial restrictions, can have a direct rolein addressing the compensatory patterns of Zink discussede a r l i e r .

Treatment ConsiderationsViscoelasticity is a characteristic of the fascia that means it willdeform in relation to the amount of force that is placed on it 6through twisting, compression, or stretching. The viscoelasticity

influences upon the muscle fibers. Ward has similarly andsuccinctly written: For every tightness, there is a three-dimensionally related looseness. Commonly, the looseness isin exactly the opposite direction from the tightness. 1(p848)

To continue to develop this concept in more distinctlyosteopathic terms, a muscle that is facilitated as the result of a somatic dysfunction (due to direct injury, somatosomatic orviscerosomatic reflexes) will inhibit its antagonist(s). On a broader scale, this tight-loose concept can be extrapolatedto explain osteopathic observations like Zinks common com-pensatory pattern. Zink and Lawson described the commoncompensatory pattern based on palpatory and observationalfindings, like those described in the following excerpt relatingto the cervicothoracic junction:

The cervicothoracic curvature rotates the first thoracic vertebraand side-bends it to the right, causing the first rib on the leftto be moved anteriorly so that the infraclavicular-parasternalarea on the left appears to be full, or convex; the first rib onthe right is forced posteriorly. Therefore, the infraclavicular-parasternal area on the right seems hollowed out, or con-c a v e.4


Figure 5. Screeningposterior hand placement in the thoracic r e g i o n .

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Figure 6. Segmental definition in the thoracic region. A , A n t e r i o r hand placement; B, Posterior hand placement; C , Hand placement as seen from above.

C

B

A

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of treatment so that the patient has grown comfortable with thephysicians hand placements by the time the treatment pro-gresses to the thoracic area.

By placing the pads of the fingers medial to the trans-verse processes of the vertebral column or the sacroiliac regionand using an anterolateral pressure and fascial drag, it is pos-sible to identify almost every attribute of the somatic dys-function. This includes tissue texture abnormality, asymmetry,restricted range of motion, and tenderness. A somatic dys-function that is not tender on the posterior aspect at a levelwhere tissue texture abnormality and restricted motion arepresent will be tender on the anterior aspect at that level.

Screening for myofascial tension can be done with the

patient in virtually any position, but we will discuss the supine, bed-ridden, hospitalized patient for our intended purpose.The first step is to slide the hand(s) between the bed and thepatient so that the pads of the physicians fingers are restingin the recess lateral to the spinous processes and medial tothe muscle mass of the erectorspinae muscles ( Figure 5) onthe same side at which the physician is sitting or standing.This is followed by a lateral pull on the tissues and a partialflexing of the outstretched fingers so that the pads move ante-riorly. Tissues that are not tight, tethered, or restricted willmove freely, and the transverse processes will rotate awayfrom the finger pads as a result of the gentle anterior pres-sure. Somatic dysfunctions that are rotated to the side of thephysicians fingers will resist rotation and will be stiff.

Segmental Definition in the Thoracolumbar and Sacral Regions Tissue Tension To further segmentally define the somaticdysfunction, the physician places one hand anteriorly at thesame level as the posterior hand that is on the somatic dys-function. Passive motion testing is done when the physicianperceives that the pads of his fingers have sunk into the appro-priate tissue layer that encompasses the whole of the restric-

of fascia is one of the characteristics that make it treatable.Wolffs law essentially states that fascia will deform as a resultof the lines of force to which it has been subjected. 6 An exampleof Wolffs law is found among certain cadavers who, previousto passing, had chronically held tension in their shoulders. Ithas been observed in these specimens on dissection that thickerfascia is found in the region of the muscles that elevate theshoulders. Hence, the fascia had developed and deformedalong the lines of stress in that area, and consequently rein-forced a maladaptive pattern. By applying direct myofascialrelease maneuvers (eg, the SAP approach to INR) to theseareas of tightness, these maladaptive patterns are released. 1(p848)

Segmental Anterior/Posterior Approachto Integrated Neuromusculoskeletal ReleaseTechniqueGeneral Considerations and the Screening Examination There are many osteopathic musculoskeletal screening exam-inations that are useful in a variety of situations. The one pre-sented in this article is chosen because of its ease of applicationand its foundation in skills taught at all colleges of osteopathicmedicine. However, physicians are encouraged to screen forsomatic dysfunction in whichever way they find most com-f o r t a b l e .

It is important to note that although segmental definitionand treatment are presented in this article in separate sections,they are usually performed simultaneously at each level, ie,after segmental definition has been achieved, that segment istreated without moving on to define another segment.

Because there is an anterior and posterior hand place-ment, care is taken with the anterior hand not to place it inany position that could be misconstrued as having sexualovertones, for obvious reasons. This is usually not a problemif the examination starts in the sacral area and progressescephalad. Enough lumbosacral restrictions are usually in need



Figure 7. Segmental definition hand placement in the lumbosacral region. A , Posterior hand placement; B , Anterior hand placement.

BA

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Figure 8. Segmental definitionrota -tion to the left. A , Anterior hand takesthe tissue laterally ; B , Posterior hand takes the tissue medially.

A

B



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Figure 9. Segmental defini -tionflexion. A , P o s t e r i o r hand takes the tissuec e p h a l a d ; B , Anterior hand takes the tissue caudad.

A

B



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Figure 10. Segmental defini -tioninhalation. A , P o s t e r i o r hand takes the tissue clockwise;B, Anterior hand takes the tissuec o u n t e r c l o c k w i s e .

A

B



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Figure 11. T r e a t m e n t t h o r a c i c region with the hula maneuver.The physician applies a constant force in the cumulative directionof all the resistances examined while the patients moves his or her arms to the right (A) and to theleft (B), as if dancing the hula.

A

B

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Figure 12. Treatmentthoracic region with the touchdownmaneuver. The physician applies a constant force in the cumulativedirection of all the resistances examined while the patient raises hisor her arms as if signaling a touchdown in a football game. Thismay be accompanied by a deep inhalation on raising the arms and exhalation on lowering them.

tion. The pads of the physicians fingers remain in place pos-teriorly between the patients transverse and spinous pro-cesses. The pads of the physicians anterior and posterior fin-gers are placed at corresponding areas, as if a perpendicularrod existed between the finger pads of the physicians twohands ( Figure 6). In the sacroiliac region, the physicians pos-terior hand placement will be slightly medial to the sacroiliac joint, and the physicians anterior hand placement will bemedial to the anterior border of the iliac bone ( Figure 7) .

Rotation, Flexion, and Extension Once the desired level of the tissue is reached, the physician places the posterior portionunder a medial stretch and the anterior portion under a lateralstretch. This, in effect, causes myofascial rotation toward thephysician ( Figure 8). The stretch is then applied in the oppo-site directions (anterior hand going medially and the posteriorhand going laterally, causing rotation away from the physi-cian). Rotation will be myofascially restricted in one direc-tion or the other.

To define f l e x i o nusing the SAP approach to INR, the

physician introduces a cephalad stretch posteriorly and acaudad stretch anteriorly. Moving the posterior hand caudadand the anterior hand cephalad causes extension at thatlevel. Relatively freer motion in flexion versus extension indi-cates that the segment is myofascially flexed ( Figure 9). Rela-tively freer motion in extension versus flexion indicates thatthe segment is myofascially extended.

Clockwise and Counterclockwise Testing At the level of the involved thoracic vertebra, a clockwise and counter-clockwise rotation can be used to identify rib involvement thatis restricted in inhalation, exhalation, or torsion. Keeping thephysicians hands at the same level, the posterior hand ismoved clockwise as the anterior hand is moved counter-clockwise to test exhalation on the right and inhalation on theleft ( Figure 10). Rotating the anterior hand in a clockwisedirection and the posterior hand in a clockwise directionintroduces torsion. This is compared with counterclockwiserotation of the anterior hand and counterclockwise rotationof the posterior hand (torsion in the opposite direction).

In the lumbar region, the clockwise and counterclockwisetesting has more to do with sidebending. Keeping the physi-cians hands at the same level, the posterior hand is movedclockwise as the anterior hand is moved counterclockwiseto test sidebending toward one direction. Reversing the direc-tion of the rotation of the hands tests sidebending in theopposite direction.

Specifics of Treatment Using the SAP Approach to INR Treatment of the thoracolumbar and sacral regions using theSAP approach to INR can be done in a direct or indirect

manner. When first learning INR, it is easiest to start with adirect technique. The reason for this is that the direct barrieris often easiest to feel and monitor for myofascial release.

For example, in the thoracic region, if a tissue textureabnormality is identified at the level of T4 on the left andrange of motion is restricted when the posterior hand stretchesthe fascia cephalad, medial, and with a counterclockwiserotation while the anterior hand senses restriction when thefascia is stretched caudad, lateral, and in a clockwise rota-tion, then T4 may be said to be ERS (extended, rotated, andside-bent) right. Furthermore, the fourth rib will probablyresist inhalation. Once the myofascial barrier has been engagedin all of these directions, the physician can have the patient dorelease-enhancing maneuvers to encourage the myofascialrelease. In the thoracic and upper lumbar regions, this is doneusing the hula maneuver. To do this, patients move theirarms to the right and then the left, much the way a huladancer would ( Figure 11). Raising the arms over the headwith a touchdown maneuver can encourage the extensionrelease ( Figure 12), and the return of the arms to anatomicneutral enhances the flexion release. The patients respira-tion can also be used to encourage a release. Combination of the touchdown maneuver with a deep inhalation as the arms


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be identified for them in advance. The phenomenon seemssimilar to postexercise muscle soreness, though no research has been done on it. Usually the experience occurs only once, butpatients with immunologic disorders such as lupus erythe-matosus and fibromyalgia can experience repeated flare-ups,so one must be cautious. However, posttreatment discomfortis the exception and not the rule with the SAP approach to INR.There are two theories that the author proposes for this dif-ference in posttreatment discomfort: (1) It may be that the spe-cific segmental approach or the anterior/posterior aspect of theapproach may result in the patient being closer to a balancedfascial state than the traditional INR treatment and thus requireless adaptation and neuromuscular rebalancing. (2) The SAPapproach to INR does not result in as powerful of a myofas-cial release as the traditional INR treatment and can therefore be thought of as a lower-dose application of INR. Either way,there is not much posttreatment discomfort.

References1 . Ward RC, ed. Foundations for Osteopathic Medicine . Baltimore, Md:Williams & Wilkins; 1997.

2 . Byers MR, Bonica JJ. Peripheral pain mechanisms and nociceptor plasticity.In Loeser JD, Butler SH, Chapman CR, Turk TC, eds. Bonicas Management of P a i n. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001.

3 . Janda V. Muscle strength in relation to muscle length, pain and muscleimbalance. In Harms-Ringdahl K, ed. Muscle Strength (International Per - spectives in Physical Therapy 8). London: Churchill Livingstone; 1993.

4 . Gordon Z, Lawson WB. An osteopathic structural examination and func-tional interpretation of the soma. Osteopathic Annals . 1979;7:12-19, 433-4 4 0 .

5 . Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. The Upper Half of Body. Baltimore, Md: Williams & Wilkins;1 9 8 3 .

6 . Sutherland WG. Lets be up and touching. Contributions of Thought . 2nded. Portland, Ore: Rudra Press; 1988.



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