Manual techniques

Postisometric Relaxation (PIR)

LEWIT TECHNIQUE

The concept of applying postisometric relaxation in the treatment of myofascial pain was presented for the first time in a North American journal in 1984.  Combining this technique with reflex augmentation of relaxation greatly enhances its effectiveness. Enhancements include the use of gravity to take up the slack in the muscle and the use of coordinated respiration and eye movements.

For this technique to be effective, the patient must be relaxed and the body well supported. The muscle is passively and gently lengthened to the point of taking up the slack (reaching the barrier or the point of initial resistance). If this initial positioning causes pain, either the extent of the movement has been excessive or the patient has actively resisted the movement.

The process of postisometric relaxation is to contract the tense muscle isometrically against resistance and then to encourage it to lengthen during a period of complete voluntary relaxation. Gravity is an effective force to "encourage" release of the muscle tension.

Postisometric relaxation begins by having the patient perform an isometric contraction of the tense muscle at its initial tolerated length, while the clinician stabilizes that part of the body to prevent muscle shortening. Contraction should be slight (10-25% of maximum voluntary contraction). After holding this contraction for 3-10 sec., the patient is instructed to "let go" and to relax the body completely. During this relaxation phase, the clinician gently takes up any slack that develops in the muscle, noting the increase in range of motion. Care is taken to maintain the stretched length of the muscle and not to return it to the neutral position during subsequent cycles of isometric contraction and relaxation.

Respiration

The effectiveness of postisometric relaxation is augmented by combining it with phased respiration. Since inhalation encourages contraction of most muscles and exhalation encourages their relaxation, the contraction-relaxation cycle is coordinated with these phases of respiration. The patient slowly inhales during the isometric contraction phase and then slowly exhales during the relaxation phase. These breaths should be deep. Patients who have difficulty using such a slow respiratory pattern are helped by pausing, breathing naturally several times, and relaxing between each cycle.

For the torso, inhalation facilitates moving toward the neutral erect position. Leaning forward is naturally associated with exhalation and relaxation. From the forward-flexed position, standing or sitting up straight is associated with inhalation. Similarly, when one is in a retro-flexed (bent-back) position, inhalation again facilitates straightening up toward the erect position; exhalation facilitates further backward extension.

The jaw elevator muscles have a respiratory reflex response opposite to that of most muscles. The elevators are reflexly relaxed during the inhalation associated with a yawn. Since yawning requires activation of jaw depressors, this may be an example of overriding reciprocal inhibition. For these jaw elevators, the isometric contraction phase is coordinated with exhalation, and the relaxation [stretch) phase is coordinated with inhalation (the patient is instructed to yawn or imagine yawning).

Eye Movements

In general, eye movements facilitate the movement of the head and trunk in the direction of the patient's gaze and inhibit movement in the opposite direction. This holds true for lifting the head and torso as well as for stooping and rotation. Eye movement (gaze) does not facilitate side bending, however. Looking up does facilitate straightening up from the side-bent position. These eye movements should not be exaggerated, because a maximum-effort movement may have an inhibitory effect.

Myofascial syndromes managment and PIR

Articular Dysfunction

Articular dysfunction either as joint hypomobility (including loss of joint play) that requires manual movement, mobilization, or manipulation to restore normal function, or as hypermobility that requires stabilization.

Backbone manipulations

Diagnostic and mobilization techniques in backbone pain syndromes

Massage

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