Dyskineticesthesia -- A New Look 2003/07/24 - Gregory T. Lawton, D.N., D.C.

Dyskineticesthesia A New Look at the Mechanopathophysiology  of the Joint Complex   Gregory T. Lawton, D.N., D.C.   Since my earlier work in the development of the concepts inherent within the homeosomatic system of medical manual therapy in 1980, I have written about and described the physiology and pathology of the joint complex systems that constitute the mechanisms by which the joints of the body and their corresponding connective tissues respond to stimuli and maintain normal function and adaptability.  In previous written materials I have related my writing and theories to Oakley Smith, D.C., D.N., the founder of Naprapathy in 1906.    Dr Smith (1900), was to my knowledge the first Chiropractor and manual therapist to relate vertebral dysfunction, and secondary symptoms, not to joint displacement (subluxation) but to abnormal joint connective tissues, such as injured ligaments.  Smith was the first to provide us with a view of joint complex neuropathophysiology, to relate this pathophysiology to the joints connective tissues, to describe the effects of this dysfunction and to prescribe a system of manual therapy, not based on adjustment and cavitation, to treat joint complex dysfunction.   The material in this article, which is written for medical manual therapists, presents a new concept in understanding joint complex mechanopathophysiology, dyskineticesthesia.   Foreword –   Somatosensory integration is the process by which the body is able to adapt to information regarding changes in its internal and external environment.  The central nervous system, composed of the brain and spinal cord, and the peripheral nervous system with its ubiquitous lattice work of nerves, serves as a data processing and transmission center whose major role is one of adaptive learning.  This adaptive learning process and its products is collectively called, neuro plasticity.    The human body, and more specifically its musculo skeletal system that facilitates the body’s locomotion, is finitely adaptable, but the limits of that adaptation have not been reached throughout millions of years of evolutionary change.  It appears that the body has been created for the constant purpose of change and growth, and that this change and growth is an inherent survival quality that ensures procreation, and creativity.    The homeosomatic system of medical manual therapy is based upon the ideas and concepts of homeostasis.  These concepts have been best described by Cannon, in the Wisdom of the Body, and Selye the modern father of the science and theories of stress.  Simply stated homeosomatic means and represents the homeostatic drive of the body to maintain it’s self in a state of balance that best promotes life and procreation.  Smith (naprapathy) incorporated this knowledge within his system of manual therapy regarding the diagnosis and treatment of joint complex dysfunction related to the neuromechopathophysiology of joints.  Smith also early recognized the relationship between soft tissue dysfunction, nerve and brain function, and general and specific somatic dysfunction.  Smith directly related joint complex dysfunction, related to injured connective tissue, to nerve function imbalances and secondary organic and somatic disorders.  Of course, Still (Osteopathy) and Palmer (Chiropractic) also had the same idea and predated Smith’s work (in the case of Still, by almost sixty years) but neither of these two physicians had related organic and somatic dysfunction to connective tissue, but had rather steadfastly stuck to lesion (Osteopathy) or subluxation (Chiropractic) theories.   It remained for Smith to pioneer a description of the actual mechanisms of dysfunction related to the joint complex, and its neuropathophysiology.   In this article I relate joint complex dysfunction to the body’s sensory integration processes, and label abnormal states of functionality as “dyskineticaesthesia”.  Dyskineticaesthesia, is the term that I have come to use to describe the negative feedback and learning processes that affect normal joint complex homeostasis.  As was previously mentioned, the body is a learning organism, that adapts to survive and procreate.  When negative feedback becomes “normal”, as in the case of chronic pain, then the body has adapted to and adopted behaviors that produce disease.  In the example of pain, this adaptation and adoption of pain causes a cascade of negative emotional, biochemical, and mechanical events that cause a progressive degenerative breakdown of the body’s cells, tissues, and organs.  More clearly stated, abnormal joint function, with its altered neurological and mechanical states, causes disease and disorders in other body systems.   Preface -   Many of the techniques and concepts presented in the material are based on the original work of Oakley Smith, D.C., D.N., the founder of  Naprapathy.  Other techniques presented in this material are techniques that I have learned from a broad variety of manual medicine practitioners over the years.  When I studied at the Chicago National College of Naprapathy in the mid 1970’s I was exposed to numerous manual therapy practitioners who either studied directly with Oakley Smith, or other manual therapy pioneers from the 1800’s.  Over the last 30 years of clinical practice I have modified much of what I have learned regarding manual therapy into the techniques presented here, and my previous manual “Medical Manual Therapy, Theories, Concepts, and Protocols”.   What is not included in this manual are the historical approaches to manual therapy founded by D. D. Palmer or later developed by his son B. J. Palmer based on subluxation theory and adjustment technique.    The manual therapy techniques presented in this material are soft tissue mobilization techniques and are not based on bone adjustment.  They are also non cavitating mobilizations designed to create positive soft tissue stress via traction, compression, torque, bending, shearing, and accommodation.    Connective tissue remodels along lines of stress, and manual therapy technique directed at increasing tissue stress along predetermined lines stimulates fibroblast activity to elaborate collagen, elastin, and glycosaminoglycans.  This is only one mechanism by which medical manual therapy assists the reparative process of the musculo skeletal system.   Manual therapy is manual medicine, and it is a science of physical rehabilitation.  Manual therapy is practiced worldwide and by almost all cultures and ethic groups.  In the United States manual therapy is practiced by nurses when they provide care to premature infants, physical, respiratory, and occupational therapists, psychologist working in biofeedback and chronic pain centers, barbers, massage therapists, chiropractors, osteopaths, and acupuncturists.   This material is written for all practitioners of manual therapy.   Introduction -   In what is now a classic sociological paper, Barber (1960) wrote about and identified several non-scientific sources of resistance to new scientific discoveries.  In his paper he cites numerous examples of non-objectivity by scientific researchers, based on preconceptions, entrenchment of attitudes and beliefs, dogmatic methodologies, or religious views that prevent an objective analysis of factual information.  There is no better example of this non objective, almost fanatical response than medical researchers attitude regarding Chiropractic, and Naprapathy.  In the specific case of Naprapathy, the research findings and pioneering work of its founder, Oakley Smith have been entirely ignored, even though his work predated medical research regarding the role of connective tissue, the nervous system, and somatic and organic pathology.  If Smith’s work had received the attention that it deserved medical treatment related to non surgical approaches to spinal disorders would have advanced by several decades.  Additionally, the relatively recent findings that chronic pain receptor (nociceptors) stimulation causes a cascade of adverse cellular, tissue, and organ system dysfunctions would have been recognized by 1906.   Modern scientific knowledge is burdened by these “sources of resistance”.  What we know, and we think is fact, is often nothing more that a side road to reality, or in some cases simply a dead end.  The objective reader must recognize the religious, social, financial and political processes that bend truth to its perspective like an optical lens bends light.  Certainly, medical research simply because it is a very profitable and political enterprise is distorted by non objective points of view and tainted research.   In the case of non medical approaches to health care the medical point of view has been hysterical.   This article invites the reader to enter the often ignored and frequently misunderstood area of soft tissue trauma and degeneration.   Even without research to back up their claims, or to point the way, manual and massage therapists have overcome medical distain and ignorance and continued the 11,000 year tradition of soft tissue therapy.   Even Hippocrates to whom the medical profession identifies its heritage and creed, practiced and recommended massage and manual therapy.    The most common reason that patients seek massage and manual therapy treatment is pain, especially chronic pain.  To my knowledge there are no studies on the demographics of who these patients are, but from thirty years of clinical experience my patients have largely been medical failures, and business has been good.  Most of the chronic pain that has shown up in my office over the years has been joint pain.  The acute conditions may involve a muscle or ligament tear, but the vast majority of chronic pain patients present with degenerative conditions of the joint complex.  Rarely are these conditions related to peripheral nerve damage, but most often result from degenerative conditions resulting either from a previous injury, surgery, wear and tear related to overuse or neglect.      This means that these patients have symptoms related to soft tissue damage that increases nociceptor signals and reduces mechanoreceptor signals.  One of the major vectors by which massage and manual therapy works is via mechanoreceptor stimulation.  Surgical medicine cannot claim this, nor can chemotherapy which either masks pain (if effective) and/or attempts to reduce localized inflammation, often at the expense of the gastrointestinal system.   It falls to the skilled hands of the massage and manual therapist to provide non invasive and effective soft tissue therapy.   Dyskineticaesthesia -   There are many mechanical, biochemical, and neurological processes that affect the joint complex.  Dyskineticaesthesia, refers to the relationship between movement, sensation, and function in a joint, and between the joint and the nervous system.  Simply stated, when a joint does not move or function normally it sends signals from its biological sensors, (mechanoreceptors and nociceptors) via the peripheral nerves, the spinal cord, and to various parts of the brain.  This communication invites the brain to respond with corrective impulses that serve survival mechanisms, but that might not duplicate normal neuromechanical function.  In other words, the joint may not function normally, and may enter a negative feedback learning curve (negative sensory integration)  that promotes further dysfunction and progressive disease and degeneration.   Hypermobility, hypomobility, and immobility of a joint all contribute to joint complex dysfunction, as does changes in muscle state and architecture like shortening, injury, and hypertoncity.  Myofascial trigger points, and other muscle hyper sensitivity conditions such as fibromyalgia also contribute to joint complex irregularities.  Irritation and inflammation of the deep joint structures like the joint capsule is frequently the cause of these previously listed conditions and contribute to dyskineticaesthesia.    Dyskineticaesthesia refers to the two way communication system that travels from the mechanoreceptors and nociceptors to the central nervous system and back to the signaling area.  This is called afferent and efferent neurological communication.  It is a circular communication system that is designed to correct problems that occur in any part of the body, but for our purposes in this article, the musculoskeletal system.  Research has demonstrated that many acute joint injuries are preceded by months or years of “sub clinical” chronic capsular inflammation.  As a condition proceeds from barely discernable to significant pain, the nociceptors send signals to the brain that communicate that there is a problem.  In many cases this “awareness” can lead to a correction in function or behavior that will move the patient beyond the pain and toward normal levels of function.  When this does not occur and the pain signals continue there is a significant input of nociceptive signals, and a resultant decrease in the volume of mechanoreceptor input.  This signifies that there is a negative feedback mechanism between nociceptors and mechanoreceptors.  When one or the other is increased the other decreases.  The author of this article has discussed this phenomenon in several other articles and medical manual therapy training manuals.   There is currently very poor standardization of terms and definitions related to describing the body’s biological sensors, mechanoreceptors and nociceptors.  For our purposes mechanoreceptors are defined as biological sensors located in the skin, muscles, joint complex and related structures, and the intervertebral disc.  Mechanoreceptors include, but are not limited to:     Golgi Tendon Organs Muscle Spindles Ruffini Endings Merkel Cell Complexes Meissner’s Corpuscles Pacinian Corpuscles     This author believes that mechanoreceptors respond best to light (pressure and movement) stimuli and communicate normal cell, tissue, and organ states to the brain.  Mechanoreceptors are our  “all clear and normal” communicators.  Mechanoreceptors like corpuscular mechanoreceptors, inhibit nociceptive signal transmissions.    Within the general massage community there is a significant misunderstanding regarding the role and function of GTO’s and muscle spindles.  Several massage authors, and systems of therapy claim that GTO’s and muscle spindles exercise direct reflexive control over muscle contraction and stretching (respectively), and they follow “tendon reflex” theories.  These outdated and inaccurate tendon reflex theories have been “debunked” by contemporary studies as bad research and protocol artifacts, that do not exist and do not function as the proponents of “tendon reflex” theories claim.  These same authors and massage systems claim to directly effect “proprioceptors”, a term which is unscientific and is incorrectly applied to mechanoreceptors.   Proprioceptors do not exist, but proprioception is a normal aspect of sensory integration.   This is not to suggest that GTO’s and muscle spindles are not important, they are.  GTO’s provide the CNS with important information regarding muscle/tendon tension, which the brain takes “under advisement” and then communicates with the joint complex on the most appropriate response based on the totality of information regarding the body’s state and condition.   GTO’s have been found to respond more aggressively to dynamic changes in muscle/tendon tension as opposed to static changes.  An example of GTO function would be during the act of picking up and lifting a heavy object. (although they respond to forces as low as 4 mg.)   Muscle spindles send information to the CNS that relates to muscle length and dynamic changes in muscle length.  An example of this would be during stretching exercises such as a forward bend or toe touch.    Some muscles take on the responsibility of gross motor function, other muscles have the responsibility for fine motor movement, and minute motor corrections.  The more sensitive and finely controlled the muscles function is the more muscle spindles (mechanoreceptors)  the muscle will contain.  For example,  the fingers and neck muscles contain the largest number of muscle spindles.  The rectus femoris contains about 50 muscle spindles per gram of muscle tissue, and the suboccipital muscles contain about 200 muscle spindles per gram of muscle tissue.  Muscles like the intertransverse contain so many muscle spindles that some authors consider this muscle group along the spine as one big mechanoreceptor.       The communication from mechanoreceptors to the CNS is partly responsible for the process within sensory integration that is called proprioception.  Proprioception refers to the body’s (and brains) ability to know where it is, and where an individual extremity is in relationship to the body (once again this communication does not occur via proprioceptors).  The sum total of all mechanoreceptor input to the CNS localizes in multiple areas of the cerebellum and cerebral cortex.  Mechanoreceptors, the process of sensory integration, and the proprioceptive response is so sensitive that simply brushing a hair can provide location and proximity information to the brain.  As mechanoreceptor information is processed through the brain centers it is translated into musculo skeletal “behavior”.  For example, signals from mechanoreceptors to the cerebellum effects coordination and “smoothness” of movements, and volitional motor control over muscles.  Other mechanoreceptors, especially those located in the neck, send signals to the cerebellum that help to maintain body position and balance.  Another example, is the mechanoreceptor information that allows the brain to process information related to keeping our eyes on an object while our heading is moving, such as looking in the sky for a high pop-up fly ball in a baseball game.   It is to the cerebral cortex the mechanoreceptors send information that assists in the process of adjusting movements, muscle and joint control, muscle tone, and maintaining posture.  It is in the cerebral cortex (and not only this area of the brain) that mechanoreceptor signals, sensory nerve input, and pain communication all combine to coordinate appropriate responses to our environment.   The cerebral cortex, of course does not perform this function alone, but receives assistance from a number of other brain centers, including the limbic system and thalamus.    It stands to reason, considering the importance of mechanoreceptor input into the CNS, that a reduction in mechanoreceptor communication, especially if that reduction becomes a chronic state that the body negatively adapts to, that the brains ability to maintain and control homeostatic neurological processes related to proprioception would be impaired.  Numerous research studies suggest that impaired or reduced mechanoreceptor communication to the CNS does indeed affect our proprioceptive and sensory integration functions, especially those related to balance, coordination, and visual adaptation.   Nociceptors are one of the two standard categories of biological sensors.  The nomenclature gets confusing because technically, a nociceptor is a mechanoreceptor, however, for ease of communication we categorize the nociceptor and mechanoreceptor as two different bio sensor categories.  It is believed that nociceptors are found in:   Fat Tissue Blood Vessels Dura Mater Fibrous Capsules Ligaments Skin Veins Vertebral Bone Vertebral Disc   Perhaps the best way to describe the nociceptor communication system is that it is like a continuously woven mesh that permeates almost all the tissues of the body.  Nociceptors are currently classified as:   Mechanical nociceptors Mechanothermal nociceptors Polymodal nociceptors   It is important not to think of the nociceptors as the bad guys of the mechanoreceptor system.  We need pain to tell us when something is wrong, and people that do not feel pain have shortened lifespans.    Nociceptors have been found to have high to very high activation thresholds.  This means that normal activities will not activate them.  Nociceptors are stimulated by acute injuries (articular nociceptors) that involve the release of chemical “irritants” like bradykinin.  Although nociceptors have high activation thresholds that normally do not respond to everyday activities chemical mediators like bradykinin and prostagradin E-2 can make them “hyper” sensitive or lower their activation threshold.  This is especially seen in chronic patients who have pain long after the initiating injury has healed.       It is believed that nociceptors become depolarized (activated) by these chemical mediators including:   Bradykinin Histamine Leukotrienes Norepinephrine Prostaglandin E-2 5-hydrotryptamine   It is important to note that nociceptors are not activated within normal tissue parameters.  Some form of trauma has to activate them.  The main form of activation is via chemical mediators, but cold and heat can activate them as well, of course extreme heat and cold do cause tissue injury that results in the release of chemical mediators.   Since nociceptors have high activation thresholds requiring potential or actual tissue damage, the mechanoreceptors normally provide the information to the CNS that is needed to monitor activity.  Nociceptors, as was previously mentioned inhibit mechanoreceptors and the converse is true as well, mechanoreceptors inhibit nociceptor activity.  This is one reason why pain hurts worse during inactive periods like sleep than when we are active and moving around.  This simple statement explains why massage, manual therapy and exercise all decrease pain.  These activities increase mechanoreceptor stimulation, and inversely dampen nociceptor activity.   Normal mechanoreceptor activation (depolarization) may involve several hundred impulses per minute, but if the target tissue is inflamed, nociceptor depolarization may discharge at a rate from 10 to 100 times that of the mechanoreceptor.  All that is needed to facilitate this shift from mechanoreceptor dominance to nociceptor dominance is some acute or chronic tissue damage.   Research has also demonstrated that once a pain pathway has been opened up, both the degree and the duration of pain may take on a self perpetuating life of their own.  This phenomenon has been observed in several studies involving differing noxious stimuli, but it was also observed by Melzack and Wall in regards to deep tissue massage technique that involved nociceptor stimulation via deep manual or trigger point therapy.   Where there is pain and inflammation it is not usual for gentle movement of pressure to facilitate pain levels beyond that expected for that kind of activity.   When manual therapy becomes pain provoking (nociceptor stimulation) it has been found to both increase patient pain and to prolong clinical recovery times.  This research data makes a bold statement against massage techniques that provoke pain.  These massage approaches actually mimic soft tissue injury and increase nociceptive signals to the CNS.  When these conditions occur a central pathway may be opened that contributes to the self perpetuating pain cycle referenced in the above paragraph.  In addition, such therapy can stimulate suprasegmental reflex responses that cause the following physiological and neurological reactions:   Increases neural sympathetic transmission. Increased secretion of catecholamines. Stimulation of the medullary center of breathing and circulatory function. Stimulation of the cortical brain centers. Stimulation of the neuroendocrine centers. Stimulation of the hypothalamus.  (Sympathetic) Stimulation of limbic structures.   These responses carried by suprasegmental sympathetic reflexes are not suggested as desirable.  The following reactions occur as a result of over stimulation of nociceptors via mechanical (or any nociceptive) activity:   Increases the workload on the heart. Increased peripheral resistance in the circulatory system. Increased blood pressure. Increased secretion of cortisol and other anabolic hormones. Increase perception of pain, lower threshold for pain. Emotional anxiety. Sweating. Nausea. Dizziness. Hypotension.   The cortisol levels (hypercortisolemia) in the blood are elevated by:   Nociceptive stimulation via any vector. Pain. Inflammation. Trauma. Hypoglycemia. Strenuous exercise. Emotional trauma.   Cortisone given for medical purposes has many documented negative side effects.  The increase in cortisone that results from the above list, is just as debilitating to the body as is medically prescribed oral or injected cortisone.  Elevated blood cortisol caused by any stressor (see list above) and including pain provoking massage or manual therapy techniques, causes a continuous debilitating and degenerative effect on the body.  This fact is not well known, and rarely taken seriously.  It is, however, very serious.  The above nociceptive stressors cause a breakdown of the body’s protein structures, a decrease in collagen synthesis, a decrease in bone tissue, and a reduction in cell mediated immunity.  Additionally, cortisol stimulates the production of fat tissue in the trunk, face, and abdomen.  Chronic hypercortisolemia causes muscle wasting and weakening of the muscle/tendon attachment points.  Elevated cortisol is a known causative factor in diabetes, heart disease, high blood pressure, obesity, depression, and some cancers.   Nociceptive signals into the CNS from distressed joints and connective tissues results in altered joint function.  This process is a form of maladaptive behavior and constitutes a form of negative sensory integration.  The normal process of sensory integration and proprioception results in mechanical and physiological reactions that facilitate normal locomotion, musculo skeletal performance, and the diverse activities of the neuromuscular system.  When repetitive nociceptive input results in negative sensory integration the plastic characteristics of the CNS and connective tissues, and these systems innate tendencies to model behaviors based on input, creates abnormal function in the joint complex and related connective tissues.   While these behaviors are adaptive, they are abnormal and will result in increased joint complex degeneration and the prolongation of the chronic pain and disability cycle.    If a simple activity like using a pair of scissors results in pain in the saddle joint of the thumb, every time that that specific activity is performed pain signals will attempt to interrupt it.   If the pain is significant enough, the nociceptive input will be successful in preventing further injury to the affected joint complex.   If the pain is tolerable and necessary, perhaps the person affected is a tailor, then the joint complex will attempt to adopt compensatory behaviors, such as altered range of motion to avoid a particularly sensitive area within the joint, or by the recruitment of other local muscles to avoid pain in primarily affected muscles, tendons or ligaments.  When the area involved in nociceptive signals is the neck or back the process of adaptation not only alters functions like range of motion, posture, and strength, but it may also affect higher level brain functions related to vision and balance.   From the perspective outline in the paragraph above, no joint pain is a trivial pain, all joint pain is symptomatic of an underlying neuropathological process that if allowed to continue without remedy, will result in altered function and progressive joint degeneration.         Dyskineticesthesia is an abnormal functional behavior in the joint complex that relates joint dysfunction to sensation (pain or discomfort) and the altered movement, strength, posture, and performance that results.   The feeling sense, related to nociceptors and joint movement are inseparable components that result from signals into the CNS, and from the CNS to the joint complex.  Although this process is complex and is composed of many stages, the result is experienced on a cognitive and emotional level, as pain and or abnormal function, or as no pain and normal function.  When the patient has maladapted to pain and abnormal function, the problem is not just physical or mechanical it is also cognitive and emotional.  When the CNS has modeled (plasticity) this maladaptive behavior as “normal”, the altered function becomes a new cause of the degenerative process.  The original cause of the pain may have been an injury to the joint, the ongoing and progressive problem has now become the new maladaptive joint function.  Often the changes in function are subtle, and the degenerative process goes undetected until more significant nociceptive signals occur.    It is the role of the medical massage and medical manual therapist to identify and to intervene with the dyskineticesthesia process.  The identification of joint complex involves the combined diagnostic procedures of:   Patient history taking. Patient observation. Patient questioning. Patient musculo skeletal assessment (ROM, strength, posture, flexibility). Patient joint complex palpation to deep structures. Dynamic assessment technique.   The above procedures provide the medical massage and medical manual therapist with detailed information regarding joint complex function, tension, and pain.  Any pain in the joint complex is considered to be an abnormal finding and requires therapy to:   Decrease pain. Decrease inflammation. Restore normal range of motion (or as near normal as possible)   The primary tools used by the medical massage and medical manual therapist in the correction of joint complex dysfunction and the restoration of normal (or near normal) function are the procedures and protocols of advance medical massage and medical manual therapy.  These procedures and protocols include:   Basic medical massage application. Medical manual therapy techniques. Facilitated Energetic Therapeutic Exercises.   Basic medical massage procedures and protocols are described in other manuals published by this author.  Medical manual therapy techniques include standard soft tissue joint mobilization (not adjustment) procedures, and techniques based on modification of the last century work of Oakley Smith, D.C., D.N.  The facilitated energetic therapeutic exercises are a system of exercises either developed by this author or “borrowed” from other exercise systems.  FETE exercises are directed at the specific muscles that contain high numbers of mechanoreceptors (muscle spindles), movements that stimulate mechanoreceptors such as repetitive motion, compression range of motion, and cyclical joint movements, and/or activities specifically designed to affect the neural plasticity of the CNS.  These activities include cross body movements, passive range of motion with repetitive motion combined with cyclical joint rotation,  and guided extremity relaxation techniques with passive or active movement of the joint.     FETE exercises are primarily designed for four classifications of patients: Chronic pain with loss of normal joint function. Chronic pain with loss of normal joint function combined with maladaptive CNS function. Patients with CNS damage or disease. Patients with muscle or skeletal abnormalities like scoliosis.   Facilitated Energetic Therapeutic Exercise -   Facilitated energetic therapeutic exercise, or FETE, is a method of cooperative therapeutic exercise and connective tissue mobilization procedures utilized in medical manual therapy for the specific purpose of isolating and exercising specific connective tissue structures such as muscle/tendon, ligaments and other joint complex components.  FETE is a system of exercises and manual therapy maneuvers developed to:   1.               Strengthen specifically isolated muscles or groups of muscles having cooperative functions. 2.               Relax muscles and ligaments. 3.               Stretch muscles, ligaments and connective tissues. 4.               Alter muscle and connective tissue architecture. 5.               Reduce muscle imbalance through mechanoreceptor stimulation and response. 6.               Coordinate higher level brain and neurological processes (CNS), somatosensory function, with lower level neurological functions. 7.               Encourage neurological plasticity in the CNS.  (CNS neurosomatic complex facilitation) 8.               Create manual therapy tissue loading (joint physics) in accordance with the mechanical principles of tissue tension, compression, torque, bending, shearing, and combinations of these physical forces.   FET exercises combine original CNS neurosomatic therapeutic exercises developed by Gregory T. Lawton, D.C. with some standard exercises commonly used in orthopedic rehabilitation.  Unique to the FETE system of therapeutic exercise are the combination of isometric exercises designed to stimulate CNS mediated neuro muscular responses on opposite sides of the body (Contra lateral agonist/antagonist isometric)  , in associated antagonist muscles, while the patient completes a single exercise activity.  An example of a FET exercise would be a single posture that stresses the thigh muscles of the right leg and the hamstring muscles of the left leg.  This type of exercise produces similar somatosensory responses to those seen in cross crawling activities used in neurological re-programming of patients with spinal cord or closed head injuries.   Another group of FET exercises combines muscle or joint compression with progressive and systematic range of motion movements, joint shaking, and joint physics (Compressive range of motion/compressive joint physics) .  This technique has a direct mechanical and physiological effect on the joint capsule complex, while also providing the joint with a mechanoreceptive stimulus.  The therapist assisted joint or muscle compression stabilizes the joint or muscle and reduces pain and discomfort via mechanoreceptor inhibition of the nociceptors.   FET exercises can be used during medical massage treatment or can be taught to patients for their use at home.  The exercises are simple, low impact, and easy for anyone in any condition to perform.  FET exercises were originally developed by Dr. Lawton for use by patient’s with scoliosis , where the different spinal and connective tissue stresses associated with the convex and concave sides of the spine required two different bilateral exercise approaches.  FET exercises now  fall into the following categories:   Contra lateral agonist/antagonist isometric Compressive mechanoreceptive Compressive stretching Compressive range of motion (ROM) Compressive joint physics Rotation with isometric resistance Resistive isotonic Resistive rotation (with or without wringing) Contra lateral resistive elevation with depression Segmental assistive/resistive vertebra extension Passive range of motion (ROM) Medial and Lateral Rotation, resistive and passive ROM Accommodation with torque Traction with Shaking/vibration Lever traction and/or shearing Cyclical Stretching and ROM Repetitive joint complex facilitation Progressive relaxation with guided facilitation Progressive incremental muscle contraction With coordinated diaphragmatic breathing   The patient who is receiving FETE therapy should first receive passive treatment (cyclical or repetitive motion) to the extremity or anatomic region being addressed.  Passive range of motion and stretching is then followed by resistive procedures with isotonic or isometric activity.  Resistive procedures are always conducted with low to moderate resistive force, no attempt is made to either fatigue or to over stress the area being treated with FETE therapy.  FETE therapy is always performed slowly and with deliberate intention by the patient and therapist.  Treatment is always performed to the tolerance and comfort of the patient.   FETE therapy works cooperatively with the body based on two important physiological principles:   Somatic connective tissue tone (muscles, tendons, and ligaments) is determined by higher level CNS nervous system functions which have the inherent property of plasticity, neurological adaptation.  The remodeling or elaboration of collagen or elastin by fibroblasts is dependent upon tissue tension along lines of tissue stress, manual therapy procedures create “intelligent” stress.   It is important to note that the FETE system is not based on popular notions of the so called tendon reflex, supposedly mediated by the golgi tendon organ.  This mechanism is most likely a fiction and if it exists cannot effectively work as claimed by its proponents.  Connective tissue tone is controlled by higher level CNS neurological functions.  The FETE system utilizes universally accepted concepts of brain/body learning and neural adaptation to therapeutic stimulus.               Definition and Descriptions of Facilitated Energetic Therapeutic Exercises:   Contra Lateral Agonist/Antagonist Isometric Exercise:   The contra lateral agonist/antagonist isometric maneuver is performed with the patient in a supine position with the arms extended above the head.  To exercise the upper extremity, the arms are crossed at the forearm with the elbows slightly flexed.  The palms face up.  The patient is instructed to “push the arms together”.  The patient then alternates this “pushing” procedure by changing the superior and inferior arm with each push.   This same procedure is used for the lower extremity.  The patient lays supine with the legs extended and crossed at the ankles.  The knees are slightly bent.  The patient then alternates pushing the ankles together in the same way as the arms were pushed together.     Compressive Mechanoreceptive:   The compressive mechanoreceptive procedures involve simple compression or grasping of the anatomical region directly over and around the joint complex and either compressing it or squeezing it.   Compressive Stretching:   The compressive stretching procedures involve simple compression or grasping of the anatomical region directly over and around the joint complex and stretching it while it is being compressed or grasped.   Compressive Range of Motion:   The compressive range of motion procedures involve simple compression or grasping of the anatomical region directly over and around the joint complex while moving the joint through a predetermined set of range of motion exercises designed to mildly or moderately stress the joint and to increase range of motion in the involved joint.    Compressive Joint Physics:   Compressive joint physics procedures involve simple compression or grasping of the anatomical region directly over and around the joint complex and creating predetermined levels of tissue tension via joint physics maneuvers; traction, accommodation, shearing, bending, torque, and combinations of these procedures.         Rotation with Isometric Resistance:   Rotation with isometric resistance involves torque of a joint complex while the therapist resists force intentionally applied by the patient.  The extremity being treated by this technique is held in extension and the patient will push the distal end of the extremity, hand, elbow, knee, or foot into the hand of the therapist while the therapist applies clockwise and counter clockwise torque to the joint capsule.   Resistive Isotonic:   Resistive isotonic procedures involve the range of motion movement of a joint with mild to moderate resistance being applied by the therapist.   Resistive Rotation (with wringing):   Resistive rotation with wringing involves the torque of a joint complex while the patient attempts to mildly or moderately resist the range of motion movement.  Compression or wringing of the joint is added to this procedure.           9.   Contra Lateral Resistive Elevation with Passive Depression:             Contra  lateral resistive  elevation  with passive  depression of a  joint      involves the resisted elevation of a  joint on  one side  of the body  while   the    opposite    joint is passively    depressed.    An example  would be the  resisted  elevation of  the  left shoulder  while  the  right shoulder  is passively  depressed.  Another example would  be  the resisted  elevation  of the  left hip while  the right  hip  is  passively depressed.       10.   Segmental Assistive/Resistive Vertebra Extension:   Segmental  assistive/resistive   vertebra  extension involves the use of a bony lever hand contact  to the  bilateral  vertebral rib  junction  that when angled  upward  to contact the inferior vertebral rib junction resists extension of that vertebra segment and  when angled  downward  to contact  the superior  aspect  of the  vertebral  rib below, assists vertebra extension.   11.   Passive Range of Motion:   Passive range of motion is a standard joint mobilization procedure used in medical manual therapy to prepare the patient and the target joint complex for treatment.  Passive range of motion is also used in cases of CNS damage or injury that result in muscle hypertonicity or spasticity.   12. Medial and Lateral Rotation, Resistive and Passive Range of Motion:   Medical and lateral rotation, resistive and passive range of motion procedures involve the rotation of a joint complex clockwise or counter clockwise, or medial or lateral rotation.  If the joint is put into a counter clockwise rotation, for example the hip joint, the rotation is then reversed with a mild or moderate isotonic resistance applied by the therapist.  These procedures are performed with the patient in the supine position and the hip and knee, or shoulder and elbow, joints flexed.   12.   Accommodation with Torque:   Static postural position with the joint in extension reduces neuro muscular responses and activity in the body in favor or ligament support of the static postural positions.  This is a postural resting state.  Accommodation with torque uses this principle to create controlled tissue stress at the joint complex.  The procedure is performed by holding the extremity in extension and accommodating the joint by applying pressure from distal to proximal and while rotating the joint at the same time.   13.   Traction with Shaking and Vibration:   Traction with shaking and vibration procedures involves the traction or distraction of a joint complex with the manual application of shaking and/or vibration of the joint.    15.  Lever Traction and/or Shearing:   Lever traction and/or shearing of the joint complex procedure involves the use of the hand, forearm, or an assistive device in order to create a lever and fulcrum force on the joint complex, resulting in both traction and shearing force at the joint.   16. Cyclical Stretching and Range of Motion:   Cyclical stretching and range of motion procedures involve the passive cyclical movement of a joint within a limited range of motion and involving mild to moderate levels of joint flexion and extension, combined with a mild to moderate level of muscle/tendon stretching.         17. Repetitive Joint Complex Facilitation:   Repetitive joint complex facilitation procedures involve the passive repetitive movement of a joint complex within a limited range of motion for the purpose of repetitively flexing and extending and/or abducting or adducting the treated joint.   18.   Progressive Relaxation with Guided Facilitation:   Progressive relaxation with guided facilitation procedures involve therapist directed relaxation   techniques practiced by the patient.  These procedures are used with patients who have a difficult time relaxing and patients with CNS damage or injury with spasticity.   19.   Progressive Incremental Muscle Contraction with Coordinated Diaphragmatic Breathing:   Progressive incremental muscle contraction with coordinated diaphragmatic breathing is  the coordination of breath with focused muscle contraction.  As the patient performs a guided reverse breath, the patient also contacts a specifically identified group of muscles.   FET Exercises for the Treatment of Abnormal CNS Disorders (Post Stroke or other CNS Injury or Disease) –   In many, if you most patient cases that involve injury to the CNS as a result of stroke, or disease or some other form of CNS injury, most often the previously normal neuromuscular function will not be restored.  New “non” normal neuromuscular behaviors and function can however be acquired by the adaptable and plastic neuromuscular systems via somatosensory integration.  Standard medical massage, or for that matter, any general massage techniques are not effective in treating conditions with CNS damage or disease.  Attempts to stretch spastic joints, or aggressively attack “contractures” will only serve to over stimulate the CNS, particularly its sympathetic component.  The trigger point therapist, deep tissue practitioner, or structural integrator cannot effectively treat these conditions and will exacerbate the patient’s symptoms and prolong recovery.   It is for these cases that the FETE system is most effective.  The repetitive passive movements combined with relaxation technique and biofeedback are the best approach to treating abnormal CNS conditions.      FET Exercises for Treatment of Scoliosis -   Facilitated energetic therapeutic exercises used in the treatment of spinal scoliosis involve the coordinated stretching and strengthening of the concave and convex curves of the scoliotic spine.  The concave side of the spine is viewed as facilitated and hypertonic and therefore needs to be stretched and relaxed.  The convex side is viewed as hyper stretched and inhibited and therefore needs to be strengthened and tonified.   Identify the concave segment of the lateral spinal curvature.  For purposes of this discussion the concave side will be placed on the right side of the spine with the apex of the curve located at T7.  Place the patient in a right side down position, right side lying.  The patient will rotate their upper body to the left to stretch the spinal rotatory muscles and then will turn back to the right while the therapist resists the right rotation by placing a hand against the patients left shoulder this will strengthen the right spinal rotators.    These procedures are reversed if the concave side of the curvature is on the left side of the spine.   In addition the patient will be taught to perform side bending exercises, against resistance, away from the concave side of the spine.  Another FET side bending exercise involving side bending on the convex side of the spinal curvature is performed with the patient in a sitting position and side bending toward the convex side of the spinal curvature while resisting the movement with a hand place on the upper thigh.  Using the example already given of a right concave, left convex curvature, the patient will side bend to the left side with the left hand placed on the upper left thigh to resist the movement.  The left hand not only resists the movement but presses into the thigh in order to engage the lateral side bending muscles and ligaments on the left, convex side of the spine.   Descriptions of Specific FET Exercises Directed at the Vertebral Joint Complex -   As was previously mentioned in this material some muscles are more richly endowed with mechanoreceptors than other muscles.  Some muscles are responsible for the coordination of finely tuned precise movements and other muscles are just the “work horses” of the body.  Specifically the muscles of the vertebral spinal column have an overwhelming number of mechanoreceptors (hundreds per gram), especially muscles such as the intertransverse.  Also as was previously mentioned mechnoreceptors respond to gentle movement and pressures, exactly like those delivered to the vertebral complex by medical manual therapy bony lever technique.  However, another way to approach and to stimulate vertebral mechanoreceptors is via FET exercises specifically designed to deliver gentle, slow, repetitive movement to vertebral segments.   The following descriptions outline FETE movements directed at the vertebral joint complexes:   Cervical Exercises:  (all FETE movements are provided in a slow, gentle, and repetitive manner)  (Cervical patients are first screened for CVAs and hyperextension of the cervical vertebra is avoided in moderate to high risk patients or patient’s experiencing problems with balance and equilibrium) (if the patient experiences dizziness the exercise session is stopped)   FETE movements are performed with twenty five to fifty repetitions.   Head and Neck Swing –  (slowly) With the neck flexed comfortably forward, the head and neck are gently swayed from side to side while tracing a slight arc with the chin.    Head and Neck Circles – (slowly) With the neck flexed comfortably forward, the head and heck are gently circled (rotation) with a minimum amount of cervical hyperextension.  This exercise is performed both clockwise for twenty five repetitions and counter clockwise for twenty five repetitions,       Head Shaking – (faster) Head shaking is performed for 10 seconds and is the same movement used to shake water out of the hair after a shower.   In addition to the two FETE exercises described above standard range of motion assistive/resistive exercises should be directed at the cervical muscles and joint complexes.   The Entire Spine Exercises:   The Snake – (slowly) The FETE snake movement involves an anterior to posterior undulation of the spinal column, like the movements of a snake.  The purpose is to facilitate anterior to posterior movement, segment by segment, throughout the entire vertebral complex.      The Side Snake – The FETE side snake movements involves a central to lateral undulation on the spinal column,  once again like the movements of a snake.  The purpose is to facilitate central to lateral movement, segment by segment, throughout the entire vertebral complex.  The easiest way to perform this exercise is by starting the movements, in each direction, by leading the movement with the shoulders.   The Lumbar Spine:   Knee circles – (slowly) This exercise is “borrowed” from Chinese yoga.  The patient is instructed to sit on the floor with the legs crossed.  The patient puts both hands on one knee, and then bends comfortably toward the opposite knee and begins to slowly and gently move their head in a small circle around that opposite knee.  This exercise is performed with twenty five repetitions clockwise and twenty five repetitions counterclockwise on each side of the body.  Reverse the hands on knee position to exercise the other side of the body.   Lumbar Circles – (slowly) The FETE movement lumbar circles are performed with a lot of assistance from the pelvic area.  This exercise has been described as pelvic undulation.  The pelvic undulations and lumbar circles are performed in an anterior to posterior motion.  This exercise was first performed on stage by Elvis.   Conclusion:   Pain is more than an annoying occurrence.  It is a form of sensation and communication that alters joint function.  Pain can either be a part of the process of correction and restoration of normal function or it can be a part of the progressive degenerative change seen with joint chronic joint stress.  Pain if allowed to continue unabated will result in abnormal CNS adaptations and modification of normal joint function.  Neither of these behaviors is desirable.  Soft tissue injury and the joint complex are poorly understand and incompetently treated by the allopathic and osteopathic medical communities.  Often surgical intervention and chemotherapies do more harm than good, either by directly contributing to the maladaptive responses in the joint complex, failed surgical approaches, or the deleterious effects of medical nostrums.  Often the medical community simply ignores soft tissue conditions or under treats them.  This may be desirable.    Only the medical massage or medical manual therapist has the diagnostic, palpation and treatment skills necessary to treat soft tissue and the joint complex comprehensively.  The chiropractor most often lacks soft tissue skills, and the physical therapist has given up manual therapy for the convenience and cost savings of machines.   This material has presented a renewed look at joint complex pathophysiology as dyskineticaesthesia, or a condition of the joint complex that involves a disruption of the body’s somatosensory integration system.   This material has not only presented a look at and reviewed of some of the current thinking related to the joint complex, but it has also presented medical massage, medical manual therapy, and therapeutic approaches to the correction and restoration of normal (or adaptive) function.