Book Review  |   December 2009
Trigger Points and Muscle Chains in Osteopathy
Author Affiliations
  • Michael J. Terzella, DO
    The Stanley Schiowitz, DO, FAAO, Department of Osteopathic Manipulative Medicine, New York College of Osteopathic Medicine of New York Institute of Technology, Old Westbury
    Assistant Professor
Article Information
Book Review   |   December 2009
Trigger Points and Muscle Chains in Osteopathy
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 628-629. doi:
The Journal of the American Osteopathic Association, December 2009, Vol. 109, 628-629. doi:
Trigger Points and Muscle Chains in Osteopathy, an English translation of the second edition published in Germany in 2007, is described as a guide for “osteopaths, physiotherapists [and] chiropractors” to apply therapy techniques involving trigger points. This liberally illustrated book, combining theory with practical techniques, was written by two foreign-trained osteopaths. One author, Philipp Richter, DO (foreign), is a private practitioner and assistant director of the Institute for Applied Osteopathy in Burg Reuland, Belgium. The other author, Eric Hebgen, DO (foreign), is a private practitioner in Konigswinter, Germany. 
This book is essentially two books in one. Part A, written by Mr Richter, consists of 11 chapters. The first seven chapters review physiologic and biomechanic issues associated with what the authors call “muscle chains,” or “myofascial chains,” as modeled by various researchers. Chapters 8 through 11 define the authors' own model of muscle chains and the authors' approach to treatment. Part B, which consists of chapters 12 through 19, was written by Mr Hebgen and covers the definition, locations, and physiologic mechanisms of trigger points, as well as diagnosis and treatment related to trigger points. 
Although the authors provide no clear definition of muscle chains, Mr Richter, in part A, delineates models of muscle chains developed by Herman Kabat, MD, PhD; Godelieve Struyff-Denys (a Belgian physiotherapist); Thomas W. Meyers (a rolfer); and French osteopaths Leopold Busquet and Paul Chauffour. For example, Dr Kabat's model is described as follows: 

Kabat developed a treatment technique wherein weak muscles are integrated into a muscle chain. The muscle chain is stimulated with the aid of specific stimuli (by visual, auditive, and tactile irritants). This process takes optimal advantage of the nerve and muscle properties described by [Sir Charles] Sherrington, in order to integrate optimally the weak muscle (or muscle group) into the motion pattern.

Mr Richter next describes research findings of Irwin M. Korr, PhD; Sir Charles Sherrington, OM; and Harrison H. Fryette, DO, that are related to the subject of the book. In the two pages on Dr Korr, the author notes the significance of somatic dysfunction in the spinal column, the role of the spinal column as an information and control center, and the significance of the nerves for trophism. Mr Richter also outlines the functions and dysfunctions of connective tissue and fascia and analyzes muscle activity in walking. 
After these basic physiologic and biomechanic discussions, Mr Richter describes the craniosacral model of William G. Sutherland, DO, from a biomechanical perspective. This description includes text, as well as anatomic illustrations, on flexion, extension, torsion, sidebending rotation, and other movements of the craniosacral mechanism. Next, the musculoskeletal models of John Martin Littlejohn, DO; Vladimir Janda, MD; and J. Gordon Zink, DO, are compared. 
With the necessary groundwork laid, Mr Richter describes the muscle chain model proposed by Mr Hebgen and himself. In regard to their model, he states the following: 

Furthermore, we determined that one of the main functions of the locomotor system, namely the gait, reproduces the behavior of the spinal column and the pelvis, as described by Sutherland, Zink, and Littlejohn in their models.

For us, it is obvious that it is the muscles that form these patterns.

Mr Richter then explains that, in his and Mr Hebgen's opinion, there are only two muscle chains in each half of the body—a flexion chain and an extension chain. The muscle chains are described in detail, and anatomic diagrams help make the descriptions easily understandable. 
The last two chapters of part A cover diagnosis and therapy related to dominant muscle chain patterns. The methods of diagnosis mentioned by Mr Richter include history taking, observation, motion testing through particular traction techniques, and the use of Zink patterns. Several black-and-white photographs of human models depict the diagnostic techniques described in the text. 
The five-page chapter on therapy covers only the most basic aspects of muscle energy and myofascial release techniques. Listed, but not described, under myofascial release are the following methods: strain-counterstrain, facilitated positional release, functional release, balanced ligamentous release (ie, balanced ligamentous tension), [fascial] unwinding, and cranial osteopathy (ie, osteopathy in the cranial field). This last chapter of part A also briefly explains “neuromuscular technique” and myofascial release with ischemic compression. 
Summing up why the book presents information on the various forms of therapy, Mr Richter notes the following: 

If the therapist has found and treated (viscerally, parietally, or cranially) the dominant dysfunction, and in addition treats the trigger points in acute cases and normalizes the shortened musculature inthe affected muscle chain in chronic cases, the chances are quite good that the painful state is relieved quickly and that the danger of relapse is reduced.

In part B, Mr Hebgen first briefly discusses the classification, pathophysiologic factors, and diagnostic aspects of trigger points. He then describes, in only two pages, some therapy methods for trigger points. “Stretch-and-spray technique”; “postisometric relaxation/muscle energy technique/myofascial release”; “ischemic compression/manual inhibition”; and “deep friction massage” are succinctly put forth as such therapy. The mention of trigger point injection, however, is conspicuously absent. The author also explains how a facilitated segment resulting from visceral dysfunction may be associated with specific trigger points. 
The final chapter, comprising more than 90 pages, provides details on the location and referral patterns of commonly found trigger points. The trigger points are grouped into seven body regions—head and neck; upper thorax and shoulder; elbow-finger; upper torso; lower torso; hip, thigh, and knee; and lower leg, ankle, and foot. Mr Hebgen discusses the origins, insertions, innervations, and actions of the involved muscles and also mentions any internal organs that may be associated with each trigger point. 
Many clear photographs of human models are presented in this final chapter. Additional graphics depict the location of each trigger point and its radiation pattern on the models. The anatomic illustrations in this chapter—as in the other chapters of the book—are also clear, useful, and pleasing to the eye. However, picture credits indicate that most of the illustrations have been culled from other publications and are not original. 
It should be noted that the referencing system for part B is not as readily apparent as that in part A. While statements in part A are referenced with superscripts corresponding to numbers in the bibliography at the end of the book, references for part B are listed in the bibliography without superscripts in the text. Therefore, the reader is unable to identify the sources of particular statements. 
The concepts of muscle chains and trigger points are not for every osteopathic physician. Those who are not interested in the musculoskeletal component of medicine or trigger point treatments will not find this book useful. However, osteopathic physicians who frequently work with the musculoskeletal system and trigger point treatments might find this book to be of academic value. Part A may be of interest to osteopathic physicians who would like to learn how the authors developed their model of muscle chains based on previous research. Part B will have more widespread applicability as a quick reference for trigger points and their associated anatomic and physiologic factors. 
Overall, I recommend Trigger Points and Muscle Chains in Osteopathy to osteopathic medical students, residents, and practitioners who have a particular interest in trigger points or in learning about the concept of muscle chains. The book may stimulate thought with regard to muscle chains and osteopathic medicine, and it may provide a valuable reference for common trigger points. However, this book is not a treatment manual for osteopathic physicians. 
In conclusion, although Trigger Points and Muscle Chains in Osteopathy is not a “must have” book or a “practice changer,” it could be a useful reference for osteopathic physicians who use trigger point treatments or who are looking for another approach to address musculoskeletal problems. 
 By Philipp Richter, DO (foreign), and Eric Hebgen, DO (foreign). 230 pp, $89.95. ISBN: 978-3-13-145051-7. Stuttgart, Germany: Georg Thieme Verlag; 2009.