Massage & Bodywork

SEPTEMBER | OCTOBER 2019

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3. The therapist passively brings the client back to the starting position (Image 11A). 4. This is repeated for a total of 8–10 repetitions, with each successive repetition beginning from the same starting position. 5. Breathing protocol can vary, but, as discussed earlier, the most important guideline is that the client breathes out when the stretch force is added in each repetition. Contract Relax Agonist Contract (CRAC) Technique. If CR and AC stretching techniques can each be performed, it stands to reason that both techniques can be performed together, thereby gaining the inhibition of both underlying neurologic reflexes. These two techniques can be combined in different ways, but following is one method of doing so—performing first CR and then AC techniques. Combining the CR and AC stretching techniques is called contract relax agonist contract (CRAC) stretching. Note: One repetition of these steps is shown for the right-side piriformis with the client supine, and the therapist pushing the thigh into horizontal adduction at the hip joint (Images 12A–12D). 1. From a neutral starting position (Image 12A), the client isometrically contracts the piriformis against the resistance of the therapist (this is the CR step that is said to engage the GTO reflex) (Image 12B). 2. The client actively moves into the position of stretch by concentrically contracting horizontal adduction musculature that is antagonistic to the piriformis (this is the AC step that engages the RI reflex) (Image 12C). 3. The client now relaxes, and the therapist further stretches the client into horizontal adduction (taking advantage of both neurologic reflexes) (Image 12D). 4. The therapist passively brings the client back to the starting position (Image 12A). Contract relax agonist contract (CRAC) stretching technique for the right-side piriformis (supine position, pushing the thigh into horizontal adduction). 5. This is repeated for a total of 3–5 repetitions, with each successive repetition beginning from the same starting position. 6. Breathing protocol can vary, but, as discussed earlier, the most important guideline is that the client breathes out when the stretch force is added in each repetition. As we can see, there are many protocols for stretching the piriformis, from purely mechanical stretches (applied broadly across the entire muscle), to pin and stretch technique (mechanical, but focuses the stretch to a specific region of the muscle), to the addition of neural inhibition techniques. Because of the tremendous importance of the piriformis, it is important for the therapist to gain expertise and be well versed in a variety of protocols. Adding stretching into a clinical orthopedic manual therapy (COMT) treatment session increases its effectiveness. And, because stretching is more effective if the tissue is first warmed up, stretching the piriformis should be done after the muscle is first warmed up with heat and/or massage. Joseph E. Muscolino, DC, has been a manual and movement therapy educator for more than 30 years. He is the author of multiple textbooks, including The Muscular System Manual: The Skeletal Muscles of the Human Body (Elsevier, 2017); The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns, and Stretching (Elsevier, 2016); and Kinesiology: The Skeletal System and Muscle Function (Elsevier, 2017). He is also the author of 12 DVDs on manual and movement therapy and teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy (COMT), and has created LearnMuscles Continuing Education (LMCE), a video streaming subscription service for manual and movement therapists, with seven new video lessons added each week. Visit www. learnmuscles.com for more information or reach him directly at joseph.e.muscolino@gmail.com. 12A 12B 12C 12D

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