Myofascial Release and MET Presentation Slides

@Physiocouk #manchesterphysio facebook.com/physio

03/01/16 2
Welcome
An introduction to Myofascial Release (MFR) and
Muscle Energy Techniques (MET)
With Katie Emmett & Daniel Smith
@Physiocouk #manchesterphysio facebook.com/physiocouk

3
Who are we?
Katie’s LinkedIn: www.linkedin.com/katieemmett
Twitter: @KatiePhysiocouk
Dan's LinkedIn: www.linkedin.com/danielsmith
Twitter: @DanPhysiocouk

4
Let’s connect
Website: www.physio.co.uk
Twitter: @physiocouk
Facebook: www.facebook.com/physiocouk

Aims of today
 Learn and understand fascia structures and it's anatomy
 Learn the different Myofascial release techniques and how to
perform them
 Learn the different types of Muscle Energy Techniques
 Learn the handling of METs and when to use them

Itinerary
10.00 - 10.30 - Induction / Arrival
10.30 - 11.15 - Theory: MFR
11.15 -12.00 - Practical: MFR
12.00 - 12.30 - Lunch
12.30 - 13.00 - Theory: MET
13.30 - 14.00 - Practical MET
14.00 - 15.00 - Evidence and Case Studies

Theory:
Myofascial
Release

Definition
Myo = muscle
Fascia = a band or sheet of connective tissue
Release = the relaxation and/or stretching of tight structures

Definition
•Safe and effective hands-on technique that works on the fascia
to release restrictions
•Based on both massage work and gentle stretching
Works gently through the skin into the fascia surrounding the
muscles
•Applied with a static, prolonged pressure to restricted tissue
•Aims to release tension and stretch out restricted parts of the
fascia. Deeper layers can be reached as fascia releases

Definition
“Myofascial Release is a specialised physical and manual therapy used for the effective treatment and
rehabilitation of soft tissue and fascial tension and restrictions”
Myofasical Release UK
“Myofascial release is a manipulative treatment that attempts to release tension in the fascia due to
trauma, posture, or inflammation. Connective tissues called fascia surround the muscles, bones, nerves,
and organs of the body. Points of restriction in the fascia can place a great deal of pressure on nerves
and muscles causing chronic pain.
Practitioners of myofascial release employ long stretching strokes meant to balance tissue and muscle
mechanics and improve joint range of motion in order to relieve pain”
Spine-health

What is fascia?
• Fascia is a layer of fibrous tissue that surrounds groups of
muscle, bone, blood vessels and nerves
• It binds some structures together, while permitting other
structures to glide smoothly over each other
• Fascia is classified depending on it’s distinct layers, functions
and anatomical position – superficial, deep or visceral
• Fascia are dense regular connective tissues, containing
closely packed bundles of collagen fibres orientated in a
wavy pattern parallel to the direction of pull

Anatomy - Fascia
• Consists of cells and extra- cellular matrix (ECM) mainly fibroblasts and macrophages.
• The ECM is made up of fibres, predominantly collagen and elastin and ground
substance

Anatomy - Fascia
Collagen is the fibre that makes fascia tough and durable. It is inelastic and provides
tensile strength and integrity. It is stronger than steel!
Elastin - allows the fascia to stretch and absorb shock
Ground substance is a viscous gel which provides the immediate environment of every
cell in the body
•It is similar to egg whites in it's consistency.
•it is able to distribute forces whilst maintaining its shape
•contains sensory receptors, mechano, chemo, noci and thermo receptors and
therefore is a proprioceptive material
•contains myofibroblasts which are able to contract in smooth muscle type manner
and these are responsive to stimulation and involved with wound healingautonomic
nervous system (ANS)

Anatomy – Muscle
tissue
• Muscle is composed of fibres, nerves and connective tissues and
account for over 40% of the body weight.
• The fibres contract to produce tension on the associated tissues
or tendons.
• Muscle tissue is enclosed in fascia, which in turn is attached to
other structures including ligament.
There are three types of muscle tissues
• Skeletal
• Cardiac
• Smooth muscles.

Macro structure
. Muscle fibres are made up of bundles of
fascicles
Several fascicles bound by epimysium to
form whole muscle
Connective tissue fascial sheaths
perimysium and endomysium join at end
to form tendons
Muscles are as much fascia as muscle
fibres hence term myofascial
Tendon inserts into periosteum

Anatomy – Muscle
tissue
• All muscle tissues have a superficial covering of vary thickness of
fascia, made of connective tissue and laced with adipose tissue.
• Inside the fascia, the muscle tissue is surrounded
by epimysium and individual muscle bundles or fascicles are
surrounded by perimysium.
• Endomysium is the connective tissue that separates muscle
fibers within a fascicles.
• The unit of fascicles is a muscle fibre (or cell) called myofibril

Anatomy – Muscle
tissue

Anatomy – Muscle
tissue
Types of muscular tissue
Important when applying Myofascial release and MET’s as the orientation
and direction of the muscle fibre dictate the direction/angle force is applied

Anatomy – Muscle
tissue
Muscle Spindle Fibres
Sensory receptors within the muscle belly that detect changes to the length of
a muscle. This information is relayed to the central nervous system and is
processed by the brain to determine the positions of body parts
Golgi Tendon Organs
Are located in the tendon of skeletal musculature. They detect changes to the
tension of the muscle providing proprioceptive feedback to the brain. They
prevent damage by inhibiting contracting muscles if the force is great enough
that there's a risk of tissue damage.

Function of fascia
Physical
•To reduce friction
•Provide a sliding environment for muscles
•Suspend organs in their “proper” place
•Transmit movement from muscles to bones
•Provide a supportive and protective environment for nerves and
blood vessels as they pass through and between muscles.
•Facilitates circulation – lymph and blood
•Provides support and connection
•Physiological adaptable - plastic

Function of fascia
Communication
•Mechanical pull and vibration – through the concept of
“tensegrity”
•Fascia has piezoelectric force. i.e changing mechanical force in
to electric energy
•A sensory proprioceptive organ receiving and responding to
mechanical and chemical information via receptors. These
sensory nerves also communicate with the ANS influencing blood
flow and muscle tone.

Function of fascia
Movement facilitator
•Reduced friction at macro and micro level
•Distributor of forces/shock absorber
•Enhances force generated by muscle contraction – rebound
•Provides a pre-tensioned background tone making muscle
contraction more effective and efficient ( feel like being shrink
wrapped)
•Pre tensioned tone allows for maximum response during fight
or flight

Fascia – why does it go
wrong
• Age and injury can cause an increase of laying down of
collagen, increased cross linkages and restrictions
(adhesions)
• Fascia increases its density and looses its ability to slide
freely when:
• Trauma and injury
• Infections or disease
• Over and under use
• Ischaemia
• Local and systemic inflammation
• Tissue dehydration
• Emotional stress and centralised pain

Fascia – when does it go
wrong
For example: injury – micro tearing and fibrosis formation will
affect
• Electrical conductivity in fascia
• Cell to cell communication
• Interfere with freedom of movement of fascial planes and
communication properties
• Sensitisation of nerve endings
• Influence plastic adaptation
SO – the local pathology will affect local fascial communication
and cause a cascade of more remote symptoms.

Indications for Rx
•Loss of mobility and range of motion
•Increased amounts of scar tissue and adhesions
•Increased tone of over active muscles
•Poor quality of movement

Contraindications to Rx
Local Systemic
Broken skin/Open cuts Cancer (Malignancy)
Skin conditions Acute Circulatory disorders
Haematoma Blood Thinning Medications (e.g.
Warfarin)
Healing Fracture Bleeding disorders (e.g.
Haemophilia)
Active infections Systemic Infection
Obstructive Oedema
Acute RA
Advanced Diabetes

Precautions to Rx
• Pregnancy
• Hypersensitivity
• Hyper or Hypo- tension
• Patient Anxiety
• Acute/ Inflammatory stage of healing

Aims and Benefits
Myofascial Release can decreases Pain: it is claimed that this technique can release
the body’s natural painkillers, endorphins, by allowing the blood, lymph and nerve
receptors to work efficiently so pain is relieved.
It helps to strengthen the immune system. When fascia is restricted, the lymphatic
flow is slowed down, which affects the immune system (the body’s first line of defence
against infection and primary aid to healing).
Myofascial Release increases the circulatory flow of lymph and therefore hastens
healing of injuries or infections.
Myofascial Release Technique can work to relieve pressure which may be caused by
fascial adhesions pressing on the nerves. Keeping a healthy circulatory system reduces
stress on the heart and can prevent painful cramps, brings nutrients to the cells and
takes away the waste; Myofascial Release Technique increases circulation and assists
this process.

Release guidelines
• Gentle and sustained, pressure should be applied for a specific period of time
– a minimum of 90 – 120 seconds
• This amount of time permits fascia to naturally elongate and return to normal
resting length which will restore the healthy status quo, giving greater
flexibility, mobility and eliminating pain.
• Techniques applied for less than 2 minutes will temporarily lengthen the
elastic fibres in the muscles and fascia and the tissues will feel looser for a
while but gradually tighten up again.
• It is like stretching a rubber band – if stretched for a short time it will quickly
spring back to its original shape but if left stretched around an object for
some time it will remain permanently lengthened.

Anatomy Trains – Tom Myers
Theory
•Certain fascial lines become identified as we commonly see
restricted movement patterns
•If structures can be grouped together in recognised fascial lines
then it is possible to release the tone in one structure and see it
presented further along the line
•The point of restriction may be away from the point of pain
(victim and cause)

Anatomy Trains
• Function is to support the body in full upright extension
• During child development it is this line we see mature to enable the child
to lift its head, crawl and then walk
• With the knees extended the line is continuous
• It has a higher degree of slow twitch endurance muscle fibres and extra
heavy sheets of fascia to overcome the postural demands (postural
adaptations!)
• There is no deep back line although some aspects of the SBL are deeper
than others. There is no consistent and connected layer deeper than the
SBL
Superficial Back Line

SBL – myofascial tracts and bony stations

Anatomy Trains
Superficial Front Line
• Function is to balance the SBL and provide tensile support
from the top to lift those parts of the skeleton which extend
forward of the gravity line (pubis, ribcage and face)
• Viewing the patient from the side reveals the state of
imbalance between the SFL & SBL

SFL – myofascial tracts and bony stations

Anatomy Trains
Deep Front Line
• Infused with slow twitch endurance muscle fibres, the DFL provides
stability and subtle positioning changes to core structure.
• Restriction within this line is seen in every patient who is dominated by
sitting
• Restriction within this line affects the ability of gaining extension at the
hips and improving the postural alignment of the trunk and pelvis
• Working alongside the SBL it’s co function is to control our ability to work
with gravity allowing our posture to selectively extend against or move
with gravity
• Failure of the DFL does not cause an acute change but more functional
restriction over a period of time which may appear in another line.
• Its role in surrounding the heart and lungs has a significant affect upon
respiration and also the potential for CV function

DFL – myofascial tracts and bony stations

Anatomy Trains…
Demonstration of theory

Practical:
Myofascial
Release

Manual Handling and
Body Position
• Posture
– Bed height
– Stance
– Patient position
• Use different parts of your hands/ arms to apply pressure
• Keep arms straight to utilise body weight when applying
pressure/resistance.
• Move from the hips and knees as much as possible
• Oil (or cream)- only needs to be a little bit.
Look after yourself before you look after the patient!

Post Treatment Irritation
Very common for people to experience irritation for up to 72
hours after treatment.
Side effects can include:
• Bruising
• Redness
• Tenderness/Increased Sensitivity
• Increased symptoms
• Aching similar to DOMS

Post Treatment Irritation
Causes
• The release of toxins/waste products from muscular tissue
• Neurological sensitisation
• Increased blood flow and micro trauma can lead to bruising and
redness
Advice
•Reassure the patient it's a normal response to be sore
after soft tissue treatment
•Advise them to use ice (safely)
•Recommend they drink water to keep hydrated

Palpation
Finding fascia…
1.Rest hand lightly on forearm – do not press into the arm. This
is the superficial fascia
2. Allow your hand to sink into the forearm, this is the deep
fascia - the fascia of the forearm extensors
3.Withdraw out of the fascial layers…..

Back
1. Gliding
2. Erector Spinae frictions
3. QL release

Shoulder
1. Upper fibre traps in side : Stripping Technique (1)
2. Upper fibre traps : Technique (2)
3. Pectorals

Glutes
1. Fix an stretch
2. Fix and stretch in side lying

Hamstrings
1. Gliding
2. Skin rolling/ Friction
3. Tack and stretch

Calf
1. Stripping
2. Gliding
3. Tack and Stretch
4. Gastroc on stretch - elbow stripping

Lunch

Theory:
Muscle Energy
Techniques
(METs)

• "A manual medicine treatment procedure that involves the voluntary
contraction of muscles in a controlled direction, at varying levels of
intensity, against a counterforce applied by the operator.’’
(Greenman 1996)
• “Muscle Energy Techniques are a manipulative treatment in which
patients muscles are actively used on request from a precisely
controlled position, in a specific direction and against a distinctly
executed counterforce.” (Ward 2003)
MET’s Definition

• Isometric Contraction
• Reciprocal Inhibition
• Post Isometric Relaxation
• Isotonic Eccentric Contraction
• Isotonic Concentric Contraction
• Isokinetic
MET’s Types

METs: Protocol
• With Isometric METs- the muscle/limb is moved until a barrier of
resistance is reached.
• The isometric contraction is performed and held for 3-5 seconds.
• The muscle is then allowed to fully relax (this can also take a few
seconds)
• Passive mobilisation is then used to stretch the muscle/limb until a new
barrier of resistance is reached.
• The contraction/relaxation cycle is then repeated until normal
movement is restored or no further benefit is gained (usually 3-5
repetitions at most).

METs: Isometric
Contraction
Reciprocal Inhibition
Method
 Resistance is applied by the therapist
 The patient produces an isometric
contraction of the muscle group that
opposes the affected muscle
 The contraction is held
 The patient then relaxes and a stretch
can be applied to the affected muscle.

Reciprocal Inhibition
Theory
•Agonist muscle contracts
•Muscle spindles are activated to send
feedback on muscle length
•This causes the release of an
inhibitory mediator at the spinal cord
•The motor neurone of the Antagonist
muscle is inhibited by this, causing
relaxation
METs: Isometric
Contraction

Reciprocal Inhibition: Example
E.G. Hip Adductor Injury.
•Hip abduction is resisted by the therapist
•Agonist group (hip abductors) contract
•Antagonists (hip adductors) are inhibited as a
result
•Relaxation/Lengthening occurs in the adductors
(affected) muscle group
METs: Isometric
Contraction

Post Isometric Relaxation
Method
• Resistance is applied by the
therapist
• The patient produces an isometric
contraction of the affected muscle
• They then relax and a stretch can
be applied
METs: Isometric
Contraction

METs: Isometric
Contraction
Post Isometric Relaxation
Theory
• Strong muscle contraction excites
Golgi tendon organs
• This causes inhibition of the motor
neurone to the muscle
• When the muscle contraction stops
the muscle relaxes and lengthens as
a result of this

METs: Isometric
Contraction
Post Isometric Relaxation: Example
E.G. Hip Adductor Injury
•Resistance is applied against Adduction of the
hip
•Isometric contraction occurs
•When the muscle relaxes it will lengthen
•And the hip can be passively stretched further
in to abduction

METs: Isotonic Eccentric
Contraction
Method
•The patient contracts the affected muscle while the therapist applies a
force stronger than the force of contraction.
•This results in the muscle being lengthened whilst contracting.
Theory
•Golgi tendon organs are excited by the contraction of the muscle. The
muscle is also being stretched/lengthened during the contraction
• So when the muscles relaxes, these effects combine and this results in
a lengthening/relaxation of the muscle.

METs: Isotonic Concentric
Contraction
Method
•Therapist applies a resistance, the patient concentrically contracts the
affected muscle and moves through range of movement against the
resistance.
•This movement is then performed repeatedly
Theory
•This causes increased motor activity to a muscle which increases tone
•Over time alongside strengthening exercise hypertrophy would occur.

METs: Isokinetic
Method
• Varying amounts of force are applied by the therapist as the muscle is
contracted through its full range of movement
• Force is altered to ensure the muscle moves at a constant speed through
its full range
• (It’s considered a combination of isotonic and isometric contractions)
Theory
•Aims to increase strength and tone similar to isotonic concentric
contractions.

METs:
Contraindications
and Precautions

METs: Practical

Remember:
•Your body position and handling
skills
•Post Rx advice where appropriate

Neck and Shoulder
1. Supine Neck side flexion
2. Pec- abduction

Glutes
• Internal/external rotation
• Side lying

Hips
1. Abduction
2. Adduction

Hamstrings
1. Contract and Relax in Supine

Calf
1. Resisted Plantarflexion

Case studies

Case Study: Neck
Pain
PC/HPC: 25 year old female with an onset of neck pain and stiffness 1/12 following a
RTC. Feels worse in the mornings and aggravated by sitting for long periods. Scores
her pain 7/10 on the VAS scale.
SH: Work- Solicitor 85% desk based. Spends large amounts of time commuting in the
car and traveling on trains.
Hobbies- attends the gym 2-3 times a week. Not able to go since the accident
PMH: None
DH: Analgesics
Objective signs- increased uft tone R>L, Limited in all ROM of CX SP, TOP posterior
neck muscles, uft and rhomboids, active TP in R uft, no neurological symptoms to
note.

Case Study: Neck
Pain
Objective signs
•Increased uft tone R > L
•Limited in all ROM of CX SP
•TOP posterior neck muscles, uft and rhomboids
• Active TP in R uft,
•No neurological symptoms to note

Case Study: Neck
Pain
•Diagnosis?
•What MFR techniques could you use?
•Would you use METs? If so, why?

Case Study:
Hamstring
PC/HPC: 30 year old male, 4/10 pain into R hamstring when running. Felt “pull”
2/52 ago towards the end of a 5k run. Instant pain and unable to continue run.
No instant swelling of bruising. Pain eased 3/7 after – tried running but still feels
pain. Also reports an increase of constant tightness.
SH: Work- Shop assistant. On feet all day. Training for Manchester 10k
PMH: L Shoulder surgery from cycling accident
DH: Nil to note

Case Study:
Hamstring
Objective signs-
• Sway back posture
• Reduced range in R hamstring in 90/90 test
•-ve neuro symptoms on SLR
• Palpation : area of adhesion located mid hamstring-
tender on deep palpation.

Case Study:
Hamstring
•Diagnosis?

Case Study:
Shoulder Pain
PC/HPC: 45 year old Male with and 8/12 History of Right shoulder pain
that onset insidiously, coincided with being busier at work and doing
longer hours.
SH: Work- Desk based- pain gets worse through the day
Hobbies- Golf- unable to play due to pain
PMH: Hypertension
DH: Ramipril, Occasional Ibuprofen

Case Study:
Shoulder
Objective signs
•Protracted shoulder posture with increased Tx Kyphosis
•Limited ROM of the right shoulder and the neck
•Positive outcome on impingement tests
• Patient indicates pain refers to the elbow
•Tenderness on palpation of the right shoulder joint, pectorals rotator cuff,
traps and thoracic spine musculature
•Increased muscle tone and trigger points in the pecs and traps
•Muscle weakness- on all shoulder movements
•Joint stiffness in the right shoulder

Case
Study:Shoulder
•Diagnosis?

Case Study:
Sciatica
PC/HPC: 32 year old female with a 5-6 week history of back pain and pins
and needles radiating down the left leg. Initially noticed it after lifting a
heavy object at work
SH: Work- Cleaner- pain is aggravated by lifting and bent postures
Hobbies- Gym- Spinning class and Zumba- unable due to pain
PMH: Nil
DH: Naproxen

Case Study:
Sciatica
Objective signs:
•Tenderness on palpation of the lumbar, gluteal and piriformis
musculature
•Muscular trigger points throughout the glutes and piriformis (which
trigger lower limb symptoms)
•Piriformis tightness on testing
•Hip flexor weakness
•Positive findings for neural tension/irritation on Straight leg raise
•Pain limited lumbar flexion and hip flexion and internal rotation
•Indicates pins and needles down the leg laterally to the foot
•Neurological symptoms aggravated by putting pressure on the buttock
(e.g. sitting)

Case Study: Sciatica
•Diagnosis?

Evidence: METs
The Immediate Effects of Muscle Energy Technique on Posterior
Shoulder Tightness: A Randomized Controlled Trial (Moore et al.
2011)
• Investigated the immediate effects of METs on shoulder horizontal
adduction and internal rotation ROM
• Used Asymptomatic baseball players as their study sample
• Compared 3 groups: MET for horizontal abductors, MET for external
rotators and a control group
• Found significant improvements in ROM using horizontal abductor
METs
• Suggests benefits for injury prevention and rehabilitation.

Evidence: METs
The effect of isolytic contraction and passive manual stretching on
pain and knee range of motion after hip surgery: A prospective,
double-blinded, randomized study (Parmar et al. 2011)
• Compared Isolytic (Eccentric) MET to passive manual stretching for knee
ROM.
• Used individuals post hip surgery following a fracture.
• Assessed knee ROM and pain (VAS)
• Found significant improvements in ROM using both treatment
techniques
• MET group had significantly better reductions in pain
• Suggests METs are a better technique as they impact on ROM and pain.

Evidence: METs
Muscle Energy Technique Versus Corticosteroid Injection for
Management of Chronic Lateral Epicondylitis: Randomized Controlled
Trial With 1-Year Follow-up (Küçükşen et al. 2013)
• Compared an isometric MET (resisted pronation) to Corticosteroid injections
• Used patients with symptomatic Lateral Epicondylitis (Tennis Elbow)
• Followed up at 6, 26 and 52 weeks to assess short and long term impact
• Cortisone injections showed better improvements in pain, grip strength and
function initially but longer term follow-up found more benefit from METs
• METs are a better long term treatment for Lateral epicondylitis than
Cortisone.

Evidence: MFR
Benefits of Massage-Myofascial Release Therapy on Pain, Anxiety,
Quality of Sleep, Depression, and Quality of Life in Patients with
Fibromyalgia (Castro- Sanchez et al. 2010)
• A randomised controlled trial, used an experimental and placebo
group
• Recruited patients diagnosed with FMS aged 18 – 65 years
• Experimental group underwent a protocol of massage-
myofascial release therapy during a weekly 90-minute session
for 20 weeks
• Pain was assessed with the Visual Analog Scale (VAS), which
assesses the pain intensity and degree of relief experienced by
the patient (score of 0=no pain; 10=unbearable pain)

Evidence: MFR
Benefits of Massage-Myofascial Release Therapy on Pain, Anxiety,
Quality of Sleep, Depression, and Quality of Life in Patients with
Fibromyalgia (Castro- Sanchez et al. 2010)
Results:
•The experimental group significantly improved pain, anxiety, quality of
sleep, and quality of life
• The treatment reduced the sensitivity to pain at sensitive points, mainly
at the lower cervicals, gluteal muscles, and right greater trochanter.
•Release of fascial restrictions in these patients also reduces anxiety levels
and improves sleep quality, physical function, and physical role
•Massage-myofascial program can be considered as an alternative and
complementary therapy that can achieve transient improvements in the
symptoms of these patients.

Evidence: MFR
Effectiveness of Myofascial release in the management of chronic
low back pain in nursing professionals (S.Ajimsha et al, 2013)
Results:
•MFR group performed better than the control group in 8 weeks and 12
week
•McGill Pain questionnaire and Ouebec Back Pain Disability Scale was used
to assess
•MFR reported 53.3% reduction in pain compared to control groups 26.1%
at 8 weeks
•MFR group reported 29.7% reduction in functional disability compared to
9.8% by control group at 8 weeks
•This study provides good evidence that MFR when used along side specific
back exercises

References
The Immediate Effects of Muscle Energy Technique on Posterior Shoulder Tightness: A Randomized
Controlled Trial. Stephanie D. Moore, Kevin G. Laudner, Todd A. Mcloda, Michael A. Shaffer, Journal of
Orthopaedic & Sports Physical Therapy, 2011 Volume:41 Issue:6 Pages:400–407.
The effect of isolytic contraction and passive manual stretching on pain and knee range of motion after
hip surgery: A prospective, double-blinded, randomized study. Shraddha Parmar, Ashok Shyam, Shaila
Sabnis, Parag Sancheti, Hong Kong Physiotherapy Journal, Volume 29, Issue 1, June 2011, Pages 25–30
Muscle Energy Technique Versus Corticosteroid Injection for Management of Chronic Lateral
Epicondylitis: Randomized Controlled Trial With 1-Year Follow-up. Sami Küçükşen, Halim Yilmaz, Ali Sallı,
Hatice Uğurlu, Archives of Physical Medicine and Rehabilitation, November 2013, Volume 94, Issue 11,
Pages 2068–2074
Ward R.C. et al. Foundations of Osteopathic Medicine. 2nd Edition. Baltimore, MD: Williams and Wilkins,
2003. (page 881)
Greenman P. Principles of Manual Therapy. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996.

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