Myofascial Meridian Stimulation Therapy (MMST) ??????

1
Myofascial Meridian Stimulation Therapy
(MMST)??????
Korean Integrative Medicine Institute

• Dr. Seonghyung Cho, M.D.

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MMST(??????) History

• ?? ??? ?? HOW? ??? WHY?? ??? ?? ????
  MMST(??????)? ?? ???? ??? M.D.???? ???? ????
  ?????.
• MMST(??????)? ????? ?????? ??? ?? ??? ??
  Acupuncture? ? ??????? ?????? ??????? ?? ??????
  ???? ?? ??????? ???? ?????.
• ? ??? Acupuncture? ??? ??? ??? ???? ??? ???? ??
  ???? Acupuncture? ???? ??????? ? ?? ??? ?????
  ???? ?????.
• ??? ????? ???? Acupuncture ??? ?? ??? ???? ??????
  ?? ?? ????? ?? ??? ????.

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ICMART 2004, ?? ??? Main Session?? ??

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ICMART 2005, ?? ??? ?? ? Full Time Workshop
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MMST(??????) Introduction

• Western medicine Myofascial
• Oriental medicine Meridian
  
• Integrative approach Stimulation Therapy

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Western medicine Myofascial

• Myofascia?? ??? ???????(MPS)? ???(Trigger Point)?
  ??? ??(Myofascia)? ???? ?? ??? ?? ? ??? ?? ????
  ???? ????(Myofascial lines)? ??? ??? ????.
• ??? ????? ????? ?? ??? ?????(Bio-tensegrity)? ???
  ?? ??(Segmental Nervous System)? ??? ? ?? ????.

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Oriental medicine Meridian

• Meridian??? ??? ????? ??? ??? ??? ?? ??? ????
  ??(Meridian lines)? ??? ?? ???? ???? ??? ????
  ????.
• ?????? ???? ?????? ????? ?? ??? ???? ??? ???? ??
  ??? ???? ??? ???? ?? ????? ???? ????.

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Integrative approach Stimulation Therapy

• Stimulation Therapy?? ??? ???(Myofascial line)?
  ???? ??? ??? ??(Meridian pathway)?? ?? ???? ???
  ?? ??? ?? ??? ???(Meridian point)? ??? ?? ????
  ??? ?? ????.
• Acupuncture, Dry needling, Injection, Magnetic
  therapy, Subcutaneous taped acupuncture,
  Myofascial release.
• MMST(??????)? ?? ?? ???? ????? ???? ?? ????? ???
  ? ????.

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T.P(Trigger Point or Treatment Point) on the MMST

• Segmental facilitation? ?? ??? stress? muscle
  imbalance? ?? ??? tensegrity? ????? ??.
• ??? ??? ??? ?? ??? ????? ??? kinetic chain
  (myofascial line)? ?? ??? ??? ????.
• ??? ???? referred pain?? hypertonic muscle ???
  sympathetic dysfunction ?? ?? ????? ??? ????? ??
  T.P.(Trigger Point or Treatment Point)?? ??.
• MMST(??????)??? ??? T.P.? ?? ???? concept? ??? ??
  ??? meridian point? ???? ??? ??.

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MMST(??????) Introduction

• ????? ?? MMST(??????)? ????? ????? ?? ??? ????
  ??? ???? ??? ??? ? ? ?? ??? ??? ???
  ???(Integrative approach)?? ???????.

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A prospective view of the western medicine

• Stephen M. Levin
• Bio-tensegrity(tension integrity) model
• Thomas W. Myers
• Anatomy of myofascial connections
• Autonomic nervous system and its relation to
  voluntary nervous system

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Tensegrity(Tension Integrity) model


Compression element
Continuous tension

Bicycle wheels and similar structures with
compression elements floating in a continuous
tension network have been termed
tensegritystructures by Buckminster Fuller.
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Bio-tensegrity (Tensegrity Biomechanics) proposed
by Stephen M. Levin
CT
Compression element
Myofascial tension strut
Continuous tension
LS
He asserted the bio-tensegrity model that the
human body structure is maintained by bony frame
embedded in myofascial tension strut just as a
bicycle wheel structure is maintained by
reciprocal tension of strut
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Similarity of Tensegrity model between human and
other structures
Tension Icosahedron model
Tension Icosahedron model
All human structures are similar to a tension
icosahedron model because of they are formed of
triangular truss type.
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The kinetic chain concept of biomechanics
Secondary The weakest link on remote area

• Tissue lesion or dysfunction
• in tensegrity structure

Weakest link in The same kinetic chain
Same kinetic chain or myofascial tension line
Strain or Limitation
Primary tissue lesion
As a result, Pain or Limitation on movement
Symptoms local inflammation and pain
Owing to ceaseless connection of the whole
myofascia, a disorder in one region may be
expressed in the form of pain and limitation on
certain movement in other part of body mainly in
the same kinetic chain(myofascial tension line)
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Definition of Kinetic Chain

• Three system Myofascial, Articular, Neural
  system
• Work as an integrated functional unit to provide
  structural and functional efficiency during
  integrated activities.

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Why Kinetic Chain is so important in MMST?

• Efficiency of Movement and Posture
• tensegrity and alignment of kinetic chain
• Dysfunction of tensegrity and alignment in any
  kinetic chain compensatory reaction for
  maintaining the balance of kinetic chain -gt
  serial distorsion pattern of kinetic chain
• Compensatory reaction(excess adaptive potency
  (flexibility, force, neuromuscular control) on
  tissue) tissue failure and overload -gt
  cumulative injury cycle -gt symptom and sign

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Cause of kinetic chain dysfunction

• Postural dysfunction
• Joint dysfunction
• Muscle imbalance
• Decreased neuromuscular control
• Myofascial adhesion and shortness
• Decreased core strength

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Dysfunction mechanism

• Altered length-tension relationship (Reciprocal
  Inhibition)
• Altered force couple relationship (Synergistic
  Dominance)
• Altered arthrokinematic relationship (Joint
  Dysfunction)
• Result of these relationship
• -gtAltered neuromuscular control
• -gtDecreased neuromuscular efficiency
• -gtTissue fatigue and failure
• -gtCumulative Injury Cycle
• -gtPain and other signs and symptoms

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Importance of optimum posture and alignment on
the MMST

• Help to prevent serial distorsion pattern
• Help to provide optimal shock absorption
• Help to provide weight acceptance and transfer of
  force during functional movement
• Help to prevent the initiation of the cumulative
  injury cycle

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Ideal alignment and Optimum movement

• Ideal alignment -gt facilitate optimum movement
• Malalignment due to repeated movement and
  sustained posture -gt joint or surrounding support
  system? micro-trauma ?? ???? ?? (exspinal
  segment-gt degenerative change)
• ???? wheel movement -gt wheel balance and good
  alignment for optimum rotation -gt???? ??? ??? ??
  ???? ???? ??

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Good postural alignment
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Hypothetical concepts of Connective tissue injury

• Piezo(pressure)-electric charge
• Interference field
• Electromagnetic field

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Piezo(Pressure)-Electric charge

• All the tissue of the body generate electrical
  fields when they are compressed or stretched
• Mechanical force -gt structural deformation -gt
  piezo-electric effect
• Muscles are under a constant strain. And also the
  strain creates a piezo-electric charge that runs
  through the fascia within and around the muscle
• On the body surface, the electrical resistance of
  strained point(acupuncture point) is lower than
  in its surrounding area.
• Low resistance point meridian point, strained
  point, myofascial trigger point

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Segmental superficial dry needlings
MTrP(strained point) pain-relieving mechanism
Insertion of needle into tissue immediately
overlying active pain-producing MTrP
Stimulation of A-delta sensory afferents
Direct arousal of activity in dorsal
horn-situated enkephalinergic inhibitory
interneuron
PLUS
Indirect stimulation of these as a result of
creation of activity in a serotonergic descending
inhibitory system
AND
The creation of activity in the descending
nonadrenergic system
Blockade of intra-dorsal horn passage of MTrPs
nociceptive information
Alleviation of MTrP pain
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Interference Field on tissue strain
During an injury or other imbalance, the membrane
is broken or disrupted. The electrolytes pass
freely into or out of the membrane and walls
Damage



-
-
-


-
-
-


-



-
Interference field of nerves, cells, muscles,
vessels others

• Cell,nerves,muscles,vessels,others

-
-

-

-
-



Disruption of membrane reverses normal
Bio-electrical Potential Dysfunction, Pain and
Energy loss result


Normal membrane Bio-electrical Potential
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Electromagnetic Field

• Extra-cellular matrix synthesis and repair are
  subject to regulation both by chemical
  agent(cytokines and GF) and physical
  agents,principally mechanical and electrical
  stimuli.
• In soft tissue, alternating current electrical
  fields induce redistribution of integral cell
  membrane proteins which could initiate signal
  transduction cascades and cause a reorganization
  of cytoskeletal structures.
• All physical and mental functions are controlled
  by electromagnetic fields produced by movement of
  electro-chemicals within the body.
• When an injury occurs and tissue is damaged,
  positively charged ion move to affected area,
  causing pain and swelling.

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Characteristics of Connective tissue

• As a result,
• Piezo-electric charges, Interference fields
  and Electromagntic fields in connective tissue
  resulting from constant strains can occur pain
  and dysfunction in the body.

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fascial consideration

• Surrounding, supporting, separating, wrapping of
  the body
• Be surrounded from sole to skull as one soft
  tissue structure
• Function
• innervated by many nerve ending
• elastically contraction relaxation
• muscle attachment
• support fix for balance
• all exercise
• blood lymphatic circulation
• change earlier than chronic degenerative
  disease
• chronic passive tissue congestion
• tissue congestion(formation of fibrotic
  tissue) d/t H ion increase in the joint area
• stress band in overloading area
• burning nature pain d/t stress injury
• inflammatory action
• mediatortransport of the body fluid
  inflammatory substance
• surround the CNS

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Myofascial line
Recently, a model suggested by Thomas W. Myers in
his book Anatomy Trains try to explain this
concept of the myofascial tension line
anatomically and to integrate with meridian
concept of TCM

Bio-Tensegrity

• Superficial back line
• Superficial front line
• Lateral line
• Spiral line
• Deep front arm line
• Superficial front arm line
• Deep back arm line
• Superficial back arm line
• Functional line
• Deep front line

Myofascial tension strut
network system in the body that controls
structure of posture and movement.
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Relation between myofascial connections and the
kinetic chain concept on tensegrity

• Dysfunction due to total myofascial connections-gt
  limitation of movement
• Sensitive tender point -gt pain on remote area
  (???? ? ????? ????? ??? ??? ? ???? ?? ???? ??? ?)
• ?? ??????? ??? ???? ? ?? ??? tensegrity ????? ??
  ??? ?? ?? ??? ?? ?? ?? ?? ??? ??? ??? ????? ???
  ?? ???. ?? ??? ??? ???? ?? ????? ???? ???? ???
  ????? ?? ????.
• As a result, dysfunction in excess movement -gt
  repeated stress (local inflammation and pain) -gt
  ?? ?? and biomechanical failure

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Dysfunction according to Muscle imbalance on
movement

• Nociceptive stimuli -gt postural muscles
  (tightfacilitated) phasic muscles(weakinhibite
  d)
• chain reaction -gt imbalanced pattern and movement
  dysfunction
• hypoxia -gt ischemic state -gt pain -gt continue
  feed-back cycyle -gt hyperactivty on neural
  stimulation -gt imbalance and dysfunction
• ??? ? ??? ????? ???? ????? ?? ?, ? ??? ?? ????
  overexcitable??? ?? ?? ????? hyperirritable???
  ??? ??. -gt facilitation

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Segmental facilitation by I.Korr

• Spinal segment not independently
• Principal of reciprocity
• -when the threshold of the segment is reached,
  all neurons will fire.
• The segment in lesion has a lower threshold and
  is hyper-reflexive.
• lens for afferent input collecting facilitatory
  or inhibitory afferents from segment above and
  below.
• occur at areas of focus for postural
  stress(muscle imbalance), trigger point, visceral
  problem

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In sequence of Segmental facilitation in
disturbed lesioned segment

• Facilitation of the sensory pathways -gt easier
  access to the nervous system including the higher
  centers
• Facilitation of motor pathways -gt sustained
  muscular tensions, exaggerated responses,
  postural asymmetries and limited painful
  motion.
• Since the muscles have rich sensory as well as
  motor innervation, under these condition, they
  and related tendons, ligaments, joint capsules
  may become the source of relative intense and
  unbalanced streams of impulses.

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The characteristics of the facilitated segment

• Roots are overly sensitive or hair-triggered
• hyperactive ventral motor root -gt
  intervertebral foramen -gt join the sympathetic
  nerve chain -gt in a state of chronic
  overactivity, result in damage to target organ
• Produce a palpable change in tissue texture
• local paravertebral muscle connective
  tissues develop a shoddy feel
• joints in the area are less mobile
• the tissues are tender to touch
• often painfully irritable
• Sympathetic system dysfunction
• changes in skin texture, sweat gland activity
  capillary blood supply to the skin

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Pathway of Sensory informationTransmit
information to spinal cord through dorsal horn

• via ascending fibers to higher centers
• via intrasegmental fibers to the anterior
  horn(somatic nervous system)
• via intrasegmental fibers to the lateral
  horn(autonomic nervous system)

Transmission of sensory information through
dorsal horn is modulated by descending stimuli of
high level and intersegmental reflex.

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Gray matter of Spinal cord

• Anterior(Ventral) Horn
• cell bodies of somatic efferent nerve fibers
• Posterior(Dorsal) Horn
• cell bodies of interneurons upon which
  afferent(sensory) neurons terminate
• Intermediated gray(Lateral Horn in the thoracic
  segments)
• cell bodies of autonomic(sympathetic) efferent
  nerve fibers
• Gray commissure ---- connection of left and right

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Anatomy of Autonomic nervous system

Parasympathetic nervous system is divided into
cranial outflow and sacral outflow
In sympathetic nervous system, the axon of the
sympathetic preganglionic neurons leave the
spinal cord with the ventral roots of the eighth
cervical to the second lumbar spinal nerves.
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Division of Autonomic lateral horn

• Medial column is comprised in cell bodies of
  preganglionic fibers toward internal organs
• Middle column is comprised in cell bodies of
  preganglionic fibers toward trunk
• Lateral column is comprised in cell bodies of
  preganglionic fibers toward head and extremities

Three columns are related to secondary segmental
modulations through various and numerous
interneurons.

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Secondary segmental relation
The MMST uses lateral column of lateral horn
toward head and extremities related to secondary
segmental modulation
Segmental innervation lateral horn? sympathetic nervous system? anatomy Interconnection to lateral column of lateral horn lateral horn? preganglionic cell body? efferent outflow? ?? ??? ??? ?? effector? segment
C8/T1/T2 C1/C2
T2/T3/T4 C3/C4
T5/T6 C5/C6
T7/T8/T9 C7/C8
T10/T11 L3/L4
T12/L1/L2 L5/S1/S2
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Somato-Visceral Point

• Secondary segmental relation
• For example, In C5/6 dermatome area pain,
• T5/T6 C5/C6 secondary segmental relation

We can explain that SomatoVisceral Points (SVP)
for treating abnormal somatovisceral reflex use
the anatomy of autonomic nervous system through
extremities and head and the secondary segmental
relation.
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SomatoVisceral Points (SVP) consisted of .
SomatoVisceral Points (SVP) consisted of UB
meridian points on surrounding C8-L2 dermatome
area.according to secondary segmental relation
Sympathetic nervous system C8L2
UB line
Secondary segmental relation
Segmental innervation Interconnection to lateral column of lateral horn
C8/T1/T2 C1/C2
T2/T3/T4 C3/C4
T5/T6 C5/C6
T7/T8/T9 C7/C8
T10/T11 L3/L4
T12/L1/L2 L5/S1/S2
Magnetic therapy on UB line (paraspinal dermatome
area)
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Somato-Visceral Point

vasodilation (decrease sympathetic tone )
C5/6
Secondary segmental relation
T5
T6
Magnetic therapy on UB line (paraspinal dermatome
area) onT5-6
In the selection of points for treating abnormal
somatovisceral reflex on common C5 segment area,
we used magnetic therapy on UB meridian line of
trunk related to anatomy of sympathetic nervous
system and secondary segmental relation
(C5/6-T5/6) instead of using acupuncture needle.
SomatoVisceral Points (SVP) consisted of UB
meridian points on surrounding T5-6 dermatome
area. In using acupuncture needle on T5-6 segment
of UB meridian line, the blood vessel tone was
increased on C5-6segment area. But in using
magnetic therapy, we found the blood vessel tone
was not increased in our clinical observation.
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Magnetic Therapy

• The application of magnetic field to injured area
  helps to restore the normal electromagnetic
  balance.
• The magnetic field relaxes capillary walls, as
  well as surrounding muscle and connective
  tissues, allowing for increased blood flow.
• More oxygen and nutrients are transferred to the
  injury site, while pain and inflammatory-related
  electro-chemicals are more efficiently removed.
• The overall process restores the normal
  electromagnetic balance of the area, relieving
  pain and inflammation and promoting accelerated
  healing.

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Segmental innervation
If nociceptive stimuli occur in a certain
segment, these stimuli will influence same
innervated segment (dermatome, myotome,
sclerotome and viscerotome). As a result,
referred pains, hypertonic muscles, activated
trigger points, trophic changes and autonomic
symptoms such as vasomotor symptoms can occur.

• Dermatome, myotome and sclerotome derived from
  the same somite embryologically have the same
  nervous pathway and a referral common afferent
  pathway.
• Relation with sclerotome and dermatome
• Anterior and posterior surface of plevis
  attached to iliolumbar ligament accord with L2
  sclerotome. Also, Area of referred pains in
  iliolumbar ligament accords with L2 dermatome.
• Referred pain pattern by ligament laxity follows
  the pattern of segmental dysfunction.

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Somato-Somatic Point

• Area in accordance with dermatome, myotome and
  sclerotome
• For example, In C5/6 dermatome area pain
• C5/6 segment

Treatment points in the MMST for abnormal
somatosomaic reflex use common segment area in
accordance with dermatome, myotome and
sclerotome.
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Deep dry needling
Somato-Somatic Point

In the selection of points for treating abnormal
somatosomaic reflex on left shoulder pain, we
applied SSP to common C5 segment area
(dermatome,myotome and sclerotome). These points
consisted of LU2, LI15 and TE14. Also, we
stimulated these points by deep dry needling
Stimulate meridian points (combined area of
dermatome,myotome and sclerotome on C5/6) by deep
dry needling
LU2
Combined area of dermatome,myotome and sclerotome
on C5/6

• TE14

LI15
Stimulate skin, muscle and periosteum in order
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SomatoSomatic Point (SSP)
LU2,LI15, TE14
Common Back pain
Common Shoulder pain
LI11,LU5, TE9
GB30,BL60
LR8,KI10
ST36,GB34,BL53
Common Knee pain
Deep dry needling (combined area of dermatome,
myotome, sclerotome)
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Common Back painLumbar pain with/without gluteal
pain
Primary TL junction syndrome
Compensatory reaction
1.Acute problem occur suddemly 2.Iliac crest?
???? ? ?? pain neurotrophic change of
cellulalgia 3.Typical facet locking
Secondary Pain on LS junction by ligament
laxity
1.Chronic problem TL problem??? occur 2.LS
junction??? pain -compensatory movement -gluteus
muscle? T.P. -hypersensitivity of greater
trochanter (sometimes)
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Common Knee pain
ASIS
Cellulalgic zone
Q
VMO? Medial retinaculum? ??? ?? alignment ??
Q increase external torsion of the proximal
tibia
Tenoperiosteal hypersensitivity
ROM is not limited Knee pain originated from the
spine (L3-4) 1.cellulalgic zone L3-4 dermatome
around the knee 2.T.P. Quadriceps femoris
(Vastus medialis oblique) 3.Tenoperiosteal
hypersensitivity pes anserinus area
52
Relationship between biomechanical overload and
painful joints associated with MPS and muscle
imbalance
Common Shoulder pain
Painful joint Trigger point Shortened muscle Inhibited muscle Faulty posture Faulty movement pattern
Cervico-cranial SCM Suboccipitalis DNFs Head forward Neck flexion
Gleno-humeral Upper Trapezius Levator scapulae or subscapularis Lower trapezius Rounded shoulder Scapulo-humeral rhythm
Upper ribs Scalenes Pectoralis Diaphragm Slumped posture Respiration
TMJ Lateral pterygoids Masseter Digastrics Chin poke Mouth opening
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Injection Site Facet joint ligament
UB line
Posterior primary ramus? medial branch
TL junction problem transitional zone
Knee pain originated from the spine(L3-4)
LS junction problem ligament laxity
GV line
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Spinal transitional zone
CO junction
CT junction
TL junction
LS junction
Junction? variation? ??