Rotator Cuff Tendonitis-Case Study
An application of the Trigenics technique
By Dr Christian Guenette, BSc, DC, RTP, FIIT(c)
Canadian Chiropractor Magazine- February 2002
Dr. Christian Guenette is a registered Trigenics practitioner with over 10 years of education in the field of human health and wellness as well as six years of experience in the fitness industry as a personal trainer. Dr. Guenette practices at the Back2Health Chiropractic Clinic in Vancouver, B.C. and sits on the Board of Governors and faculty of the International Institute of Trigenics.
Trigenics® is a manual assessment and treatment system that has sometimes been incorrectly compared to other myofascial release techniques such as Active Release Techniques (ART).(1) However, with its synergistic blend of myofascial and meridian therapies, it is quite unique in its purpose, application and effect. Incorporating aspects of western neurophysiology with eastern meridian therapy and philosophy(2), this form of manual medicine gives birth to a holistic approach which addresses the balance of both the musculoskeletal and energetic systems.
Where basic myofascial techniques(1,10,11) have focused on injuries due to repetitive strain, Trigenics® can be used to benefit any condition, both locally and holistically, which relates to nerves, muscles, tendons or related soft tissues. It is used for repair, rehabilitation, enhancement of athletic performance or for stress management and energy rebalancing. It can also be applied safely to infants and geriatrics as well as those at risk for CVA.
According to the originator, Allan Austin, D.C., Trigenics® is based upon the premise that aberrant articular kinetics can be more effectively corrected by first correcting aberrations in the connective tissues'”regulatory matrix.” This matrix was described by Terrence Bennett, D.C., as “the extracellular compartment, a single tissue that traverses the whole body from top to bottom.”(3) German naturopaths originally described this matrix as running parallel to the surface of the body through the muscles, with projections connecting to the undersurface of the body via ‘Heine cylinders.’ These ‘portals’ to the regulatory matrix have been located at specific areas on the body with many corresponding to important acupuncture meridian and trigger points. By treating these main points, corrections in this matrix can be achieved, thereby relieving interference in the structural and energetic systems simultaneously. One of the main assessment tools is strength and length muscle testing. The goal, from a musculoskeletal or meridian perspective, is to ‘balance’ the body by strengthening or lengthening the appropriate muscles. This is accomplished by neurologically resetting the gamma bias or resting ‘tone’ of the body’s musculature. Once the treatment phase has begun, application of Trigenics strengthening or lengthening procedures are directed at re-establishing musculoskeletal balance. Most weakened muscles are initially treated with the strengthening procedure, however, the more obviously hypertonic/shortened muscles are also treated with lengthening. The effectiveness of the procedure is always monitored by retesting the appropriate muscles after each application. If the muscle remains weak, then articular or nerve root involvement at the corresponding spinal level of innervation is indicated. Treatment is then provided via chiropractic adjustment at that level. Depending on the patient’s condition and treatment goals, the length of the treatment plan varies from a few sessions, to several months. Indicators for subjective patient improvement may include pain levels (intensity and duration),chronicity of the condition and restrictions in range of motion in the area of main complaint. Objective tests include range of motion testing, orthopaedic examination and muscle testing.
Rotator Cuff Tendonitis…a case study:
A 40-year-old nurse presented to my office complaining of left shoulder pain that followed several days of pushing a patient in a heavy wheelchair. It began as mild discomfort, but soon progressed to a constant ache, with restricted movement and intermittent jabbing pains at the superior aspect of the shoulder. Her family doctor had prescribed anti-inflammatories, analgesics, and rest to no avail. My initial observation of the patient’s posture revealed forward rounding of both shoulders, with moderate head forward position with respect to her centre of gravity. Asking the patient to abduct her arms revealed a painful arc of the left shoulder beginning at 20 degrees of abduction. Active and passive range of abduction were limited to about 145 degrees. Tenderness and hypertonicity werenoted with palpation of her anterior deltoid, pectorals, infraspinatus, subscapularis and supraspinatus on the left, in addition to the rhomboids, trapezius and levator scapulae bilaterally. Motion palpation revealed major subluxation patterns at T3/4 (flexion malposition). Speed’s test was negative for biceps tendonitis, but Neer’s impingement test was positive for pain in the A/C joint. Muscle testing revealed weakness in the left supraspinatus, infraspinatus and subscapularis, with pain in the area of her chief complaint with resistance. Clues of acute inflammation (redness/swelling/heat) were not noticeable in the area, but mild inflammation was suspected due to repetitive strain.
Diagnosis was that of rotator cuff tendonitis. Trigenics® treatments were suggested over the use of anti-inflammatories, as the cause of the irritation was suspected to be mainly muscular. Simply reducing the inflammation of the tendon would probably not solve her problem, however short periods of icing (5-10 minutes) were recommended for temporary relief of pain after physical activity. It was also recommended she remain off work for 5-10 days to minimize the amount of physical stress on the area.
The patient received treatment on the day of her presentation with Trigenics® Strengthening (TS) of the subscapularis. Range of motion immediately improved to 150 degrees (from 20 degrees) without pain. Next, TS was performed on the supraspinatus, which decreased the level of pain in the shoulder at the end range, however she still could not move past 150 degrees without experiencing discomfort.
Performing a TS procedure on the infraspinatus muscle improved her range of motion to 180 degrees without pain. For completeness she was also adjusted to correct for the subluxations located in her upper thoracic spine. Follow-up treatment two days later revealed 90 per cent subjective improvement, and objectively only some residual tightness in her infraspinatus and subscapularis muscles on the left.
Painful range of motion began at 120 degrees of abduction, however she could achieve full abduction with her left shoulder without feeling increased pain. TS of infraspinatus and subscapularis relieved the patient of this discomfort immediately, and Trigenics® Lengthening of the pectoralis on the left allowed her shoulder to sit in a more normal position. She followed a treatment schedule of twice a week for four weeks which resulted in complete resolution of her problem.
Optimizing the resting and dynamic length-tension relationships of the muscular system enhances proper biomechanical function of the entire neuromusculoskeletal system. Any alteration in the length/tension relationship of muscles may also lead to a change in the body’s ‘tone’, contributing significantly to the energetic imbalance of the body’s meridian system. In balancing the neuromuscular system, a positive effect in the overall tonal system of the body may be produced.
There are three main components of the Trigenics® treatment triad, namely Neuromyogenics, Acugenics and Autogenics.(2) Neuromyogenics involves the use of specific neuromuscular reflexes during the application of procedures to facilitate a dramatic automatic muscular relaxation response with consequent reduction in the target muscle’s resting tonicity.(4,5,6) Acugenics is the method of using Proprioceptive Dynamic Acupressure (PDA) at specific localized areas of the muscles called ‘myopoints’ (often corresponding to locations of the Heine cylinders mentioned earlier).(7) In the literature, these points have been scientifically proven to provide analgesic effects.(8) Taking advantage of this fact, Trigenics® achieves a level of depth in application without the usual degree of discomfort associated with other myofascial techniques. Autogenics is the application of patient-focused visualization and controlled deep breathing to create an autonomic relaxation response during the treatment.(9) This is thought to prevent of hypocapnia and muscular hypoxia which cause a negative increase in resting muscle tone. Autogenics also relates to positive energetic consequences with effects on brain-wave states and activation of beneficial viscerosomatic reflexes(3) and pain reduction, especially when applied during exhalation.(12,13) Studies have shown the analgesic effect of superficial acupuncture is significantly enhanced if it is also applied in exhalation. The same studies have shown that superficial acupuncture stimulation applied during a patient’s exhalation phase induces an overall systemic muscular relaxation response with prolonged sympathetic activation.(12,13) Synergistically combining the effects of the Trigenics® triad distinguishes this technique from all other soft-tissue therapies by creating a cascade of neurophysiological events which lead to superior results.
1. Leahy, M. Development of Active Release Techniques Soft-Tissue Treatment (Part I). Active Release Techniques, 1996.
2. Austin, A. Trigenics® Neuromuscular Meridian Medicine (Module I – Theory), International Institute of Trigenics, 2001
3. Austin, A. Trigenics. (Module III – Clinical Applications). International Institute of Trigenics, 2001.
4. Ikai T et al. Reciprocal inhibition in the forearm during voluntary contraction and thinking about movement. Electromyography & Clinical Neurophysiology; 36 (5), 1996.
5. Bertolasi L et al. Inhibitory action of forearm flexor muscle afferents on corticospinal outputs to antagonist muscles in humans. Journal of Physiology; 511 (3), 1998.
6. Knott M & Voss DE. Proprioceptive Neuromuscular Facilitation: Patterns and Techniques (2nd ed.); New York, Hoeber Medical Division; Harper & Row 1968.
7. Becker RO, Reichmanis M, Marino AA & Spadaro JA. Electrophysiological correlates of acupuncture points and meridians. Psychoenergetic System I; 105-112, 1976.
8. Chiang CY, Chang CT, Chu HC & Yang LF. Peripheral afferent pathway for acupuncture analgesia. Scientia Sinica 16: 210-217, 1973.
9. Benson H. The relaxation response: therapeutic effect. Science 278 (5344): 1694-5, 1977.
10. Leahy, PM & Mock, LE. Myofascial release technique and mechanical compromise of peripheral nerves of the upper extremity. Chiropractic Sports Medicine 6 (4), 1992.
11. Leahy, PM & Mock, LE. Altered biomechanics of the shoulder and the subscapularis. Chiropractic Sports Medicine 5(3), 1991.
12. Tanaka, T. H., Possibilities for Optimizing Acupuncture Treatment Results Through Synchronization with Somatic State: An Examination of Autonomic Response to Superficial Needling During Exhalation, American Journal of Acupuncture, Vol. 24, No. 4, 1996.
13. Nishijo, Tanaka, Leisman, The Physiological Responses Induced By Superficial Acupuncture: A Comparative Study Of Acupuncture Stimulation During Exhalation Phase And Continuous Stimulation, Intern. J. Neuroscience, Vol 90 (1-2), pp45-58, 1997