Case Studies
Abstract
Patient was a 44-year-old female presenting with adhesive capsulitis ofher right upper extremity. Previous treatments of physical therapy 1-2 times per week for two months followed by chiropractic and cold laser therapy 2-3 times per week for two months had proved ineffective. Treatment using Manual Ligament Therapy was chosen due to the patient’s extreme sensitivity to ligament palpation and muscle guarding patterns. The patient was treated over the course of ten days, and results were documented photographically and clinically by the attending massage therapist, based on objective assessment and the patient’s subjective statements.
After three treatments the patient regained approximately forty percent of active shoulder range of motion and experienced a decrease in pain of sixty percent. The findings of this study show manual ligament therapy to have been an effective treatment for this patient’s adhesive capsulitis. Key words: Ligament, Mechanoreceptors, Innervation, Proprioception
Introduction
In the early 1900’s a chiropractor by the name of Hugh B. Logan, while searching for more effective ways to treat scoliosis patients, discovered that directional pressure to the sacrotuberous ligament reduced muscle tone in surrounding muscle tissue that was not necessarily connected to the ligament (Homola, 1963). Despite success with the treatment, Logan never appeared to have pursued the question of why pressure on this ligament reduced muscle tone or if it would work on other ligaments. This is the question that inspired creation of the technique called Manual Ligament Therapy (MLT) in an attempt to correct chronic muscle guarding patterns.
For the past several hundred years, medical science has regarded ligaments having in their primary role, the offering of being attachments between bones and little else (Thompson, 2004). The description of ligaments to date consistently follows that path of thought established centuries ago.
Over the last 25 years, studies and the resulting literature had revealed agreement with the concept that ligaments were innervated to a certain extent and contained mechanoreceptors. Published articles pertaining to ligamentous innervation and proprioceptive qualities concluded ligaments playing a role as sensory organs. An article stated, “Ligaments are also major sensory organs, capable of monitoring relevant kinesthetic and proprioceptive data.” (Solomonow, 2006)
Another group of authors asserted that, “Ligament afferents may contribute to joint stability, muscle coordination and proprioception through direct polysynaptic reflex effects onto ascending pathways and skeletomotoneurons, and/or indirectly via reflex actions on the gamma-muscle spindle system.1 Theoretical and experimental evidence indicate that ligament afferents, together with afferents from other joint structures, muscles and the skin, provide the CNS with information on movements and posture through ensemble coding mechanisms, rather than via modality specific private pathways.” (Sjolander, 2002)
It was further hypothesized that when a major ligament is damaged, the muscles surrounding the compromised area became hypertonic in a guarding pattern. This hypothesis was confirmed in a study designed to measure the effects of ligament creep and its influence on the tone of muscles associated with it.
1.Gamma-muscle spindle system- Interactive loop between efferent upper-motor neurons, aka gamma moto neurons, and intrafusal fibers within muscle spindles where gamma motoneurons supply the intrafusal fibers with information in regards to degree of stretch thereby regulation muscle tone.
Using electromyography to measure tonicity, “(i)t was found that in extension, quadriceps electromyography activity increased significantly after anterior cruciate ligament creep.”(Chu, 2003)
This response is also shown on a clinical level in cases such as anterior cruciate ligament tears (ACL) and ankle sprains where even minimal sprain to ligament structures can result in moderate to severe inflammation and splinting of surrounding tissue. Another study investigated the hypothesis of mechanoreceptors and proprioceptive mechanisms existing in the cruciate ligaments and with afferents to muscles in the upper-leg. Again utilizing load bearing and shearing force to the ACL and posterior cruciate ligament along with changes in flexion at the knee, electromyogram readings revealed muscle recruitment in response to the level of load and shear applied to the ligaments (Raunest, 1996).
Based upon hypothesis and reflected in the results of the afore mentioned studies, it was theorized that if a muscle was influenced by a ligament into a chronic state of guarding or spasm, direct pressure to the involved ligament could reduce the tone of the muscle through a neurological feedback similar to golgi tendon release, or trigger point therapy. The following chain of events describes a possible cause of ligament influenced musculotendonous hypertonicity and a course of treatment:
1.) Occurrence of injury, either acute or repetitive stress induced.
2.) Ligament creep caused by hysteresis1 follows.
3.) Mechanoreceptors (Rufini Corpuscles) within ligaments send afferent signals to the CNS instigating muscle splinting. This is done by direct and indirect ligamentous influence on intrafusal fibers via the gamma muscle spindle system (gamma motor neurons as vector), the intrafusal fibers are then signaled to increase gain (level of hypertonicity) thereby causing a shortening of skeletal muscle.
4.) Due to the lack of general nutritional circulation in ligaments, both active and latent trigger-points form, the latter causing joint dysfunction. Once the injury has abated and or resolved, the latent trigger-points thrive in the nutrient-scarce tissues of the ligaments. These latent trigger-points continue to cause ligament mechanoreceptors to send incorrect information to the CNS falsely signaling present injury, in turn maintaining a high gain signal within intrafusal fibers instigating ongoing tonicity in otherwise healthy muscle tissue.
5.) Without ligament treatment, in turn canceling incorrect afferent information to the thalamus and gamma muscle spindle system, re-establishment of tonicity and holding patterns within muscle fibers persist even after heavy manipulation to osseous and musculotendonous structures.
1.Hysteresis- Micro tearing within ligaments due to inability of ligamentous tissue to efficiently adjust to cyclic loading and unloading of weight stress.
6.) Trigger-point therapy applied to ligamentous tissue resolves latent trigger-point activity, finally correcting afferent information to the CNS, thereby turning down intrafusal gain and relaxing muscle fibers.
Dr. Logan demonstrated with his Logan Basic Technique, that application of mild to moderate, static digital pressure to different aspects of the sacrotuberous ligament, followed by changing the angle of pressure, resulted in significant reduction in hypertonicity of para-spinal muscle groups. (Homola, 1963)
Over the course of 7000 hours in research and development, clinical application of MLT resulted in the formulation of specific referral patterns connecting the position of a ligament to an associated muscle or muscles. Manual Ligament Therapy is a principle very similar to the Logan Basic Technique. MLT is applied to the ligament influencing the symptomatic muscle, with its effect being reduction in hypertonicity. This is accomplished by moving the associated limb or anatomy into pre-determined positions, whereby only the symptomatic muscle is affected by the release. It was revealed early on in clinical research that ligamentous tissue in dysfunction exhibited to the clinician an almost-bone like texture, but with digital pressure applied for a longer duration (20-30 seconds), would begin to creep and soften. This softening would then be accompanied by an immediate reduction in hypertonicity of surrounding musculotendonous tissue. The recipient of MLT would report a burning sensation at the site of the ligament being different from the sensations felt during muscle palpation and treatment. As the ligament softened, the recipients would report a “breathing” sensation in surrounding tissues as the muscles released their tension. This cycle has been duplicated on numerous occasions over the past 5 years of application and has also been reproduced by other doctors and manual therapists of varying specialties upon instruction of method.
The following patient had pathology of chronic muscle guarding and general increased muscle tone, which had not responded as expected to traditional treatments. Pre- and post-treatment, objective assessments of range of motion, muscle tone, and inflammation were recorded along with the patient’s subjective pain level and functional status.
Methods
The patient was a 44-year-old female who presented with an insidious onset of adhesive capsulitis. At the time the patient was unemployed but had, for the majority of her life, been a competitive swimmer until a diagnosed lung condition restricted her activities. On first presentation, range of motion was significantly limited to ninety degrees of abduction (Fig. 1a), and ninety-five degrees of forward flexion (Fig. 2a). Scapulo-humeral and clavicular articulation was in deficit causing the patient to recruit torso involvement in the form of lateral flexion when performing range of motion tests. Pain levels were rated at 8/10 with active motion and limitations with reaching into dishwasher and lifting any weight away from the body.
The patient had undergone a traditional approach to recovery involving the following modalities:
1. Physical therapy including electrical stimulation, trigger-point therapy, stretching, and exercise.
2. Chiropractic care including adjustments, stretching, trigger point therapy, and therapeutic laser applications.
3. The patient also received Massage therapy on multiple occasions.
The afore-mentioned therapies had been administered for several months with little to no results.
Attending massage therapist noted increased muscle tone and trigger points of 8/10 through the infraspinatus, subscapularus, supraspinatus, levator scapulae, anterior/medial deltoids, pectoralis minor/major, biceps, and triceps. Significant tenderness of acromioclavicular, coracoacromial, coracoclavicular, supraspinous, and sternoclavicular ligaments was also noted. MLT was chosen due to the patient presenting with ligament tenderness, predictable guarding patterns, and previous successful patient outcomes documented by the attending massage therapist using MLT.
Also, based on previous experience with this technique, the provider decided on a treatment frequency of two times per week with an expected duration of four weeks. Treatment area was limited to affected rotator cuff and surrounding structures; treatment times were limited to forty-five minutes and also included limited use of trigger point therapy and muscle energy technique. Photographic evidence of active range of motion along with SOAP notes and subjective written data was used to record resulting changes after treatment.
Results
After three consecutive treatments the patient was shown to have increased active range of motion from ninety degrees to one hundred twenty degrees abduction (Fig. 3 and 5), and from ninety degrees to one hundred sixty degrees of forward flexion (Fig. 4 and 6). Scapulo-humeral and clavicular articulation also displayed improvement allowing the patient to perform movement without recruiting upper-torso lateral flexion as noted previously.
Subjectively, the patient reported a decreased pain level of 2/10, increased ease with general rotator cuff movement, and that it was no longer difficult to reach into the dishwasher or support weight away from the body. Objectively, trigger points and muscle tone had decreased to 2/10.
Discussion
When the body detects a compromising injury to any given joint it will put surrounding muscles into spasm to support and protect that joint. This can be observed in the clinical setting and has been documented in much of the literature listed in the bibliography.
As stated by Dr. Moshe Solomonow and other referenced researchers, is the concept that a torn or damaged ligament may result in muscle guarding patterns (Solomonow, 2004). This supports the concept that ligaments are innervated and provide sensory input to the brain, a conclusion that is discussed in some research-related descriptions of the ligament healing process.
Following this approach, it could be theorized that an undamaged or minimally damaged ligament that is inflamed, contains trigger-points, or restricted by scar tissue could be considered in dysfunction and could influence surrounding muscle tone. In a study prepared by Dr. Solomonow, it was revealed that ligaments were sensitive to frequency of loading and stretching in a repetitious fashion, and without proper rest they will recruit surrounding musculature in attempt to stabilize the joint or region. It was also found that once the ligaments become weak and strained, this could lead to immobilization followed by more weakness and dysfunction, causing increased muscle recruitment (Solomonow, 2004).
With a ligament being in the afore-mentioned state, and in a response similar to what is seen with a golgi tendon release and trigger point therapy, pressure to a ligament in dysfunction could, in theory, be responsible for reducing tone in affected muscles. This being the case, MLT would be limited to chronic or subacute conditions of increased muscle tone in which the ligament was the propagating factor. However, multiple cases of patients suffering acute grade-1 and grade-2 muscle strain, after receiving MLT, have reported marked improvement in the speed of recovery and pain reduction in comparison with experiences utilizing applications of rest, ice, and elevation alone. MLT would also be a useful tool for any clinician who has a patient presenting unresolved muscle tone.
With regards to teaching the MLT modality to new practitioners, it is acknowledged that some manual therapists may have difficulty differentiating between bone tissue and ligamentous tissue due to the texture, density, and depth of ligaments. In the early stages of instructing MLT, an emphasis on ligament location, anatomy, patient feedback, and tissue response is necessary in order for the clinician unfamiliar with ligaments to find, assess, and treat them with competency.
There are emerging beneficial rehabilitation aspects in regards to the MLT technique resolving injury to ligamentous tissue. Apart from Dr. Logan’s research into the benefits of sacrotuberous release (Homola, 1963), reference to techniques similar to MLT is sparse. Therefore, the following areas of research are suggested:
1. More prolific research into the neuro-ligamentous link to muscle tone and function could support the theory of MLT and benefit the field of ligamentous tissue injury.
2. Research into ligament hydration and circulation could expand on the effects of Manual Ligament Therapy and potential contra-indications.
3. Manual therapists using techniques to discover the effects of ligament trigger points will help in developing advanced protocols for MLT.
It is also important for the attending clinician to adhere to guidelines regarding acute and sub-acute treatment of sprains. In the event of a grade-1 or grade-2 sprain, MLT would not be advisable for at least 4 weeks based on healing qualities of ligaments. If there is a grade-3 sprain involving tearing of the ligament, MLT would obviously not be a wise modality to utilize until the patient has clearance from his/her physician.
With literature and research strongly supporting the existence of afferents between ligaments, the brain, and muscle with ligaments monitoring and influencing muscle tone, the same scenario might be applied to the role ligament tissue plays in influencing internal organs. This could lead to a break through in the field of preventing and correcting organ failure as well as in the field of visceral manipulation modalities.
The results of research into the realm of ligamentous properties and the conclusions of this case study provide insight into the potential for favorable outcomes in regards to Manual Ligament Therapy application, and warrant the further scientific investigation of its effectiveness as a valid treatment protocol.
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