4

The variety of
reflex points
CHAPTER CONTENTS
Reflex patterns and areas
In this chapter some of the major systems that
Reflex patterns and areas 75
have identified and classified reflex areas on the
Are all tender points trigger points? 76
body surface will be discussed, because many of
Distinguishing features of myofascial trigger points 76
the ‘points’ that these identify are bound to be
Mechanotransduction, fascial pathways, and 77
accessed during the application of NMT in an
endocannabinoid influences – some recent
advances assessment or a treatment mode.
Mechanotransduction 77 Osteopathic physician Eileen DiGiovanna (1991)
Fascial communication 77 states: ‘Today many physicians believe there is a
Endocannabinoids 77 relationship among trigger points, acupuncture
Summary 78 points and Chapman’s reflexes. Precisely what
Acupuncture points 78 the relationship may be is unknown.’ She quotes
Acupuncture points and their morphology 78 from a prestigious osteopathic pioneer, George
Acupuncture and applied kinesiology 79 Northup (1941), who stated as far back as 1941:
Ah Shi points 82
One cannot escape the feelings that all of the
Alarm points, Associated points, Akabane points 82
seemingly diverse observations (regarding reflex
Bennett’s neurovascular reflex points 84
patterns) are but views of the same iceberg the
Chapman’s reflexes 86
tip of which we are beginning to see, without
Connective tissue massage/manipulation 89
understanding either its magnitude or its depth
CTM: Method and mechanism 90
of importance.
Jones’ tender points 90
Periosteal pair points 93
Awareness of the reflex potential of the body
Confusion? 93
surface widens the therapeutic potential of
NMT, although deciding which of the many pos-
sible applications of reflex activity to utilize in
diagnosis or treatment can be a daunting task.
The discussion in this text of these reflex systems
and classifications should not be taken as indicat-
ing recommendation for their use, merely recog-
nition of the fact that they are widely used, and
that NMT offers an additional means of access
and employment of their potential.
Felix Mann (1983), one of the pioneers of acu-
puncture in the West, entered the controversy as
 CHAPTER FOUR
76 The variety of reflex points

to the existence, or otherwise, of acupuncture be Chapman’s reflexes, Gutstein’s myodysneuria

meridians (and indeed acupuncture points). points, Jones’s tender points, or acupuncture
Mann, in an effort to alter the emphasis that tradi- alarm points. These, however, will not necessarily
tional acupuncture places on the specific charted refer painful symptoms to distant sites in the obvious
positions of points, stated: manner displayed by trigger points.
This is not to say that any ‘tender’ or sensitive
McBurney’s point, in appendicitis, has a defined
point cannot become a trigger point, since,
position. In reality it may be 10cms higher, lower,
clearly, before it is active, a trigger point has to
to the left or right. It may be one centimetre in
evolve, and in its earlier stages will be painful,
diameter, or occupy the whole of the abdomen, or
sensitive or tender, but may at the time of palpa-
not occur at all. Acupuncture points are often the
tion not be sufficiently sensitized and hyperreac-
same, and hence it is pointless to speak of acu-
tive to refer pain and other symptoms. If a point
puncture points in the classical traditional way.
‘belonging’ to any of the various classifications
Carefully performed electrical resistance measure-
discussed below does refer symptoms in the man-
ments do not show alterations in the skin resis-
ner of trigger points, then it can be so classified
tance to electricity, corresponding with classical
and treated.
acupuncture points. There are so many acupunc-
ture points mentioned in some modern books, that
there is no skin left which is not an acupuncture Distinguishing features of myofascial
point. In cardiac disease, pain and tenderness trigger points
may occur in the arm however this does not occur
(modified from Simons 2002)
more frequently along the course of the heart
meridian, than anywhere else in the arm. • Active myofascial trigger points produce
regional pain complaints and not bodywide
Hence, Mann concludes, meridians do not
pain and tenderness.
exist, or – more confusingly perhaps – the whole
• Not all tender points are myofascial trigger
body is an acupuncture point!
points, but all myofascial trigger points are
Leaving aside the validity of Mann’s comment,
tender.
it is true to say that if all the multitude of points
• Referred tenderness, as well as referred
described in acupuncture, traditional and mod-
pain, is characteristic of a myofascial trigger
ern, together with those points described by
point.
Travell and co-workers, Chapman, Jones and
• All myofascial trigger points are associated
Bennett (see later in this chapter), were to be
with a taut band.
placed together on one map of the body surface,
• Not all taut bands are palpable (requires
we would soon come to the conclusion that the
sufficient palpation skill and accessibility).
entire body surface is a ‘potential acupuncture
• All active myofascial trigger points cause a
point’.
clinical pain (sensory disturbance) that is
This realization is supported by Speransky’s
familiar to the patient.
findings from the 1930s, as discussed in Chapter 3.
• Only an active myofascial trigger point, when
compressed, reproduces the clinical sensory
Are all tender points trigger points? symptoms that are familiar to the patient.
• However, a latent myofascial trigger point
A number of respected researchers and clinicians
produces no clinical sensory (pain or
are frequently in error when they describe loca-
numbness) complaint that is familiar to the
lized soft tissue areas that palpate as sensitive,
patient.
but that do not refer symptoms elsewhere, as trig-
ger points. Some of the major ‘point’ classifications involv-
Certainly a trigger point will always be palpa- ing reflex activity, and with a diagnostic potential,
ble, and will always be sensitive to pressure, but are considered in this chapter, in alphabetical order
then so will most other ‘points’, whether these (not in order of apparent importance).
 Reflex patterns and areas 77

Mechanotransduction, fascial pathways, may trigger messenger systems to activate sig-

and endocannabinoid influences – some naling indirectly.
recent advances A veritable cascade of biochemical changes result
Before looking at a selection of point classifica- from mechanical deformation of tissues, involving
tions, involving reflex activity, the evidence of calcium, insulin and a variety of complex sub-
recent research relating to the process of mechano- stances that signal to other tissues ‘downstream’.
transduction requires a brief introduction, as does It seems probable that such signalling can be
introduction of endocannabinoid influences. modulated, directed, to achieve positive changes,
We have seen earlier in this chapter that there via appropriate manual methods of treatment
exist in many individuals discrete localized areas (Levin 2000).
that generate pain, and/or other symptoms (often
at a distance), as a result of local or central Fascial communication
sensitization.
It is therefore important to be able to demon- Closely linked to these ideas is an increased
strate evidence that these can: awareness of fascial connections that link distant,
1. be identified via palpation, and as well as local, areas of the body (Myers 2008,
2. be manipulated/treated manually via Huijing & Baan 2001).
stretching or compression – for example – or Langevin et al (2005) have proposed fascia/
by tool assisted means (e.g. acupuncture). connective tissue as a communication system:
Assessment/palpation will be investigated in Connective tissue may function as a previously
Chapter 5, while therapeutic approaches will be unrecognized whole body communication system.
described in Chapters 6, 7, 8, 9, 10 and 11. Since connective tissue is intimately associated
But what are the mechanisms associated with with all other tissues (e.g. lung, intestine), connec-
influencing symptoms and tissues at a distance? tive tissue signaling may coherently influence
As we have seen, neurological explanations (and be influenced by) the normal or pathological
have been at the forefront of attempts to explain function of a wide variety of organ systems . . .
reflex influences. However, there have been other connective tissue functions as a body-wide
recent developments in our understanding of mechanosensitive signaling network [involving]
how manual treatment can influence distant tis- three categories of signals: electrical, cellular and
sues, for example via the biochemical and other tissue remodeling, each potentially responsive to
processes involved in what is termed mechano- mechanical forces over different time scales.
transduction; and also via the release of
endocannabinoids. Khalsa et al (2005) report that ‘Langevin’s
research describes a common feature of manual
therapies – the application of mechanical forces to
Mechanotransduction connective tissues. Immediate (viscoelastic and
Burkholder (2006) notes: mechanotransduction) and delayed (remodeling)
connective tissue effects of these forces may con-
There are many ways by which deformation of a tribute to the mechanism of these therapies.’
myofiber might be converted to a biochemical
signal. When a deformation is imposed on a mus-
Endocannabinoids
cle, changes in cellular and molecular conforma-
tions link the mechanical forces with biochemical In the 1990s a new class of self-generated pain-
signals, and the close integration of mechanical relieving substances was identified in the body,
signals with electrical, metabolic, and hormonal the endocannabinoids. These substances mimic
signaling may disguise the aspect of the response the pain-relieving and euphoria-generating
that is specific to the mechanical forces. The effects of the use of cannabis, and help to explain
mechanically induced conformational change its illegal use by many chronically pain-ridden
may directly activate downstream signaling and individuals (Degenhardt 2007).
 CHAPTER FOUR
78 The variety of reflex points

As McPartland & Simons (2007) explain: The location of acupuncture points, with their
fixed anatomical locations, are capable of corrobo-
The endocannabinoid (eCB) system, like the better-
ration by electrical detection, each point being
known endorphin system, diminishes nociception
evidenced by a small area of lowered electrical
and pain, reduces inflammation in myofascial
resistance.
tissues, and plays a role in fascial reorganization.
When ‘active’, possibly due to reflex factors,
The overall role of the eCB system can be sum-
these points become even more detectable, as
marized as ‘resilience to allostatic load,’ a phrase
the electrical resistance lowers further. The skin
synonymous with health. Practitioners wield sev-
overlying them also alters and becomes hyper-
eral tools that upregulate eCB activity, including
algesic and not difficult to palpate as differing
myofascial manipulation, diet and lifestyle
from surrounding skin. Active acupuncture
[particularly exercise].
points also become sensitive to pressure and this
is of value to the therapist because the finding of
Summary sensitive areas during palpation or treatment is
of diagnostic importance. Sensitive and painful
NMT (and other soft tissue approaches to treat-
areas that do not have detectable tissue changes
ment of somatic dysfunction) clearly ‘deform’ tis-
as part of their make-up may well be ‘active’ acu-
sues (compression, shear, stretch, etc.), albeit
puncture points, or tsubo, which means ‘points on
briefly, and over and above the local effects on tis-
the human body’ in Japanese (Serizawe 1976).
sue, the signalling potential that follows remains
Not only are these points detectable and sensi-
an intriguing area for further research. At the same
tive, but they are also amenable to treatment by
time endocannabinoid influences are likely candi-
direct pressure techniques. They therefore dis-
dates to explain at least some of the local and
play, in almost all particulars, the same features
distant effects of manual treatment such as NMT.
as trigger points.
Empirical clinical evidence certainly indicates
that distant influences are achieved using NMT,
and these current research areas appear to Acupuncture points and their morphology
explain some of the mechanisms.
Pain researchers Wall & Melzack (1989), and others
(Travell & Simons 1992, Melzack et al 1977), main-
Acupuncture points tain that there is little, if any, difference between
acupuncture points and most trigger points.
Soft tissue changes often produce organized dis- Dorsher (2004), carefully compared the loca-
crete areas that act as generators of secondary tion of 255 trigger points, as identified by Travell
problems. A repetitive question arises as to and Simons, with 747 acupuncture points as iden-
whether traditional acupuncture points are in fact tified by the Shanghai College of Traditional
the same as trigger points (Fig. 4.1). Medicine (Chen 1995):

Figure 4.1A, B Location of

some important acupuncture Gall bladder 14
points on the head and neck. Gall bladder 1
Research indicates that over Gall bladder 3 Common trigger point sites on
75% of defined acupuncture the Bladder meridian
points are also sites of Gall bladder 20
common trigger points.
Gall bladder 21
 Acupuncture points 79

The findings were that 92% of TPs had anatomi- point, which could account for the particular
cally corresponding acupuncture points, 83% of effects noted by such points being treated. This
these points had similar regional pain indica- is of interest to those using Bennett’s neurovascu-
tions, and 87% of myofascial TPs had referred lar points. The implications for those practitioners
pain patterns that are identical or nearly identi- not employing needles, and who rely on pressure
cal to the corresponding acupuncture points’ techniques in order to provide stimulus or seda-
meridian distributions. tion to such areas, is that, if accurately applied,
the effects of pressure should be identical (to nee-
The conclusion was: TPs are essentially a
dle acupuncture), especially in relation to pain
‘rediscovery’ of the 2000-year-old acupuncture
control.
tradition (a subset of acupuncture points). As will
be noted below, not all researchers or clinicians
agree with these findings (Birch 2008). Acupuncture and applied kinesiology
The morphology of acupuncture points has An attempt to correlate the various reflex systems
been studied, notably by Bosey (1984). and methods has been made by the American chi-
Some of his major conclusions, in summary, ropractor George Goodheart. His system of
are as follows: applied kinesiology involves testing muscle
• Points are situated in palpable depressions groups for weaknesses and then, depending upon
(‘cupules’). the results of such tests, using various massage
• The skin (epiderm) over the point is a little and pressure techniques applied to specific loca-
thinner at the cupule level, under which lies a tions (points) in order to normalize function.
fibrous cone in which there is frequently found These points correspond to Chapman’s reflexes,
either a neurovascular formation, or simply a acupuncture points and other less well known
cutaneous neurovascular bundle. reflex systems. Many of Goodheart’s techniques,
• Free nerve endings are noted, and the theories and methods support and utilize meth-
presence, beneath the point, of Golgi endings ods that are in line with NMT.
and Pacini corpuscles is common.
• Connective tissues lie below at varying Acupressure and pain thresholds
depths.
It has been shown that pain thresholds can be
• Fascia and aponeurosis are noted and a
dramatically raised by pressure techniques
passage of vessels and nerves, through the
applied to specific points. Researchers at the Pek-
fascia, is very often found under the
ing Medical College conducted complex experi-
acupuncture point.
ments which demonstrated that finger pressure
The practice of manipulating the needle in acu- acupuncture produced a rise of 133% in pain
puncture imposes a degree of traction on the threshold of rabbits (using radiant heat as the
underlying (muscular) tissue, which imposes painful stimulus). When cerebrospinal fluid was
stimulation on underlying receptor organs. Fat is perfused from one rabbit to another after such
also a common factor in the morphology of experiments, the recipient rabbit was found to
points, and this, and the connective tissue, is have achieved a rise in pain threshold of up to
thought to be a key factor in the achievement of 80%. This suggested the presence of hormone-like
the ‘acupuncture sensation’ that accompanies substances produced by the brain in response to
successful treatment. The conclusion reached is the original acupressure stimulus. These sub-
that a number of tissues are simultaneously stances are now known to be enkephalins and
affected needling – a phenomenon confirmed by endorphins, and these play a role in NMT pain
Langevin (2006), supporting the mechanotrans- control. The point used in these tests was equiva-
duction mechanisms discussed earlier. lent to the acupuncture point known as Bladder
Some points, when dissected, showed that neu- 60, posterior to the ankle (externally) and just
rovascular structures lie immediately below the anterior to the Achilles tendon.
 CHAPTER FOUR
80 The variety of reflex points

Acupuncture points and trigger points: not all (CNS). They suggested that this might eventually
agree that they are the same phenomenon lead to a combining with noxious stimuli deriving
from other structures, innervated by the same
As outlined earlier, because they spatially
segments, to produce an increased awareness of
occupy the same positions in at least 75% of cases
pain and distress. They found it reasonable to
(Wall & Melzack 1989, Dorsher 2004, Dorsher &
assume that trigger points and acupuncture
Fleckenstein 2008) there are strong indications
points represented the same phenomenon, having
that trigger points are in fact no more than active
found that the location of trigger points on West-
acupuncture points. Wall & Melzack (1989) have
ern maps, and acupuncture points used com-
concluded that: ‘trigger points and acupuncture
monly in painful conditions, showed a
points when used for pain control, though dis-
remarkable 75% correlation in position.
covered independently and labelled differently,
It is interesting that the link between the source
represent the same phenomenon’.
of pain or tender points, and the referred area of
Baldry (1993) does not agree, however, claiming
pain noted in trigger points, in many instances
differences in their structural make-up. He states:
seems to travel along the routes of traditional acu-
It would seem likely that they are of two different puncture meridians, but certainly not always.
types, and their close spatial correlation is Spontaneous pain in such a point, according to
because there are A-delta afferent-innervated acupuncture tradition, indicates the need for
[fast transmitting receptors with a high threshold urgent attention. It is not the intention of this
and sensitive to sharply pointed stimuli or heat book to provide instruction in acupuncture meth-
produced stimulation] acupuncture points in odology, nor necessarily to endorse the views
the skin and subcutaneous tissues immediately expressed by traditional acupuncture in relation
above the intramuscularly placed, predominantly to meridians and their purported connection with
C afferent-innervated [slow transmitting, low organs and systems. However, it would be short-
threshold, widely distributed and sensitive to sighted to ignore the accumulated wisdom that
chemicals – such as those released by damaged has led many thousands of skilled practitioners
cells – mechanical or thermal stimulus] trigger to ascribe particular roles to these points, for
points. example Alarm, Associated and Akabane points
as described in this chapter.
Clearly, stimulation of an area that has, As far as a manual therapy is concerned, there
beneath the contacting instrument or digit, both seems to be value in having awareness of the
an acupuncture and a trigger point will influence reported roles of particular acupuncture points,
both types of neural transmission and both and of incorporating this into diagnostic and ther-
‘points’. Which route of reflex stimulation is pro- apeutic settings.
ducing a therapeutic effect, or whether other As we palpate and search through the soft tis-
mechanisms altogether are at work – endorphin sues, in basic neuromuscular technique, we are
or endocannabinoid release, as examples – is bound to come across areas of sensitivity that
therefore open to debate. This debate can be fur- relate to these points. They are also often found
ther widened if we include the vast array of other to overlap with neurolymphatic and neurovascu-
reflex influences identified by other systems and lar points, as described elsewhere in this text.
workers, as discussed later in this chapter. For example, reflex number 19 in Chapman’s
Whereas traditional oriental concepts focus on reflexes, which relates to the urethra, is identical
‘energy’ imbalances in reaction to acupuncture to the neurovascular point of the bladder, and
points, there exist also a number of Western the acupuncture alarm point of the Bladder
interpretations. meridian. Careful comparison shows many such
Melzack et al (1977) have assumed that acu- overlaps.
puncture points represent areas of abnormal General guidance as to how to treat acupunc-
physiological activity, producing a continuous ture points, which are sensitive, must relate to
low-level input into the central nervous system whether a stimulating or sedating effect is
 Acupuncture points 81

desired. The body often seems to utilize therapeu- researchers, are quoted by Stephen Botek, Assis-
tic stimulation to its best advantage. tant Professor of Clinical Psychiatry, New York
Selye has shown us (see Ch. 1) that homeostatic Medical College (Ernst 1983).
mechanisms are at work, so that any stimulus, if Botek (1985) believes that ‘myofascial needling’
appropriate and not excessive, can result in a ben- is the term of choice to define the type of acupunc-
eficial response. In accord with the methods used ture that dispenses with traditional explanations
in treating neurolymphatic and neurovascular as to the effects of acupuncture. The points utilized
points (described elsewhere in this chapter) it is in one study were Large Intestine 4 (Hoku) in the
suggested that, to some extent, the ‘feel’ of the tis- web between thumb and the first finger, and Stom-
sues be allowed to guide the practitioner. A ach 36 (Tsu san li) below the knee. The study
change (in the sense of a release of tension, or a recorded skin temperature of the face, hands and
softening, or a sensing of a gentle pulsation in feet. It was found that, compared with a resting
the tissues) is often an indication of an adequate period, both manual and electrical stimulation of
degree of therapy. In order to sedate what is an both points induced a general warming effect. This
overactive point, up to 5 minutes of sustained or was immediate in the face (Lewith & Kenyon 1984)
intermittent pressure, or rotary contact, may be and appeared after 10–15 minutes in hands and
required. feet. The temperature increase was notably more
For stimulation, the timing could involve marked after manual acupressure than after elec-
between 20 seconds and 2 minutes. By this time, trical stimulation. Manual stimulation of these
some degree of change should be palpable. As points was shown to be more effective than other
must be clear, if pressure is sustained beyond a forms of stimulation.
certain point quite the opposite effect will be Lewith & Kenyon (1984) point to a variety of
achieved. This is a common natural phenomenon suggestions having been made as to the mechan-
which occurs in response to all factors in life that isms via which acupuncture, or acupressure,
are initially stimulating. If prolonged, they achieves pain-relieving results. These include neu-
become enervating or exhausting, and in terms rological explanations such as the ‘gate control
of therapy this is undesirable unless anaesthesia theory’. This, and variations on this theme, look
is required. at the various structures of the CNS and the
A short cold (water) application, for example, brain in order to define the precise mechanisms
will stimulate, whereas a long one will sedate, involved in acupuncture’s pain-relieving action.
and too much can kill. The words of Speransky This, in itself, is seen to be an incomplete expla-
and Selye should be recalled and the minimum nation, and humoral (endorphin, endocannabi-
effort used, consistent with achieving a response. noid release, etc.) and psychological factors, are
We have noted previously that many of the dif- also shown to be involved in modifying the
ferent reflex systems have points that seem to be patient’s perception of pain.
interchangeable, and that many of these are tradi- A combination of reflex and direct neurological
tional acupuncture points. In terms of local pain, elements, as well as the involvement of a variety
the view of Chifuyu Takeshige (Takeshige 1985), of secretions, such as enkephalins and endor-
Professor of Physiology at Showa University, is phins, is thought to be the modus operandi of
that: ‘The acupuncture point of treatment of mus- acupressure, and probably of all of the various
cle pain is the pain-producing muscle itself.’ systems of reflex activity discussed in this section
Respected acupuncture clinicians, such as (neurolymphatics, etc.).
George Ulett, suggest that ‘acupuncture points Many of the points of referred pain and tender-
are nothing more than time honoured muscle ness used in Western medical diagnosis are also
motor points’. Professor C. Chan Gunn, however, acupuncture points, for example:
finds this too simple an explanation, and states:
‘Calling acupuncture points “motor points” or • Head’s zones could be shown to include most
“myofascial trigger points” is too simple. They acupuncture points, especially the Alarm and
are Golgi tendon organs.’ These, and other Associated points (given below).
 CHAPTER FOUR
82 The variety of reflex points

• The points noted as being ‘tender’ in midline, the others are bilateral. Tenderness
appendicitis, such as McBurney’s, Clado’s, elicited by palpation of an Alarm point may
Cope’s, Kummel’s, Lavitas’s, are on the indicate dysfunction of the organ related to the
Stomach, Spleen and Kidney meridians of point. In traditional acupuncture, if sensitivity
traditional acupuncture, and these are used by is noted on light pressure, there is an
acupuncturists in treating appendicitis. associated energy deficiency. If heavy pressure
• Patients with a gastric ulcer produce is required, the condition relates to an energy
tenderness at a site known as Boas’ point, and excess.
this is sited precisely on Bladder point 21, • Associated points lie on the back of the body,
which is the Associated point of the Stomach and these are all on the Bladder meridian,
meridian. which runs parallel to the spine, bilaterally.
• Brewer’s point, in Western medicine, is noted Each Associated point is related to one of the
in kidney infection, and this is Bladder point meridians and its function. The same assumed
20, the Associated point for the Spleen relationship with energy deficit or excess
(in traditional acupuncture this has a exists, as in Alarm points (sensitivity on light
controlling role over water, the element of pressure ¼ deficiency, and on heavy pressure
the kidneys). ¼ excess). There are also a few extra Associated
points, as illustrated (see Fig. 4.3). Spontaneous
The degree of overlap between these well-
pain at any of these listed points indicates a
known points can also be noted when comparing
disorder in that meridian, and in its associated
other classification systems of points.
organ or function.
• Akabane points are found on the fingers and
Ah Shi points
toes, being the terminal points of the
Acupuncture methodology also includes the meridians. Sensitivity of any of these is said to
treatment of points that are not listed on the relate to dysfunction and imbalance of energy
meridian maps, and that are known as Ah Shi in that meridian. Electronic measurement of
points. These include all painful points that arise these points (Melzack et al 1977) is performed
spontaneously, usually in relation to particular in a number of modern electroacupuncture
joint problems or disease. For the duration of systems such as electroacupuncture according
their sensitivity they are regarded as being suit- to Voll (EAV). Manual testing is common, and
able for needle or pressure treatment. These was obviously the method used before
points may therefore be thought of as identical electrical methods arrived on the scene. These
to the ‘tender’ points described by Lawrence points are all bilateral.
Jones in his strain/counterstrain method, dis-
cussed later in this chapter.
Location of Alarm points
Alarm points, Associated points, Akabane Alarm points (Table 4.1, Fig. 4.2) are on the ante-
points rior surface of the body. Spontaneous pain at any
point is considered to indicate a disorder of the
There are, in traditional acupuncture, a number of
affiliated meridian. If tenderness is elicited on
key points that are most likely to become painful
light pressure, a deficiency of energy in the
in relation to particular visceral dysfunction.
meridian is assumed, whereas tenderness elicited
These have been classified as Alarm points. They
on heavy pressure indicates an excess of energy
are presented below, and the following general
in the meridian.
information may make their employment easier:
These are reflex points for meridian function,
• The Alarm points are found only on the ventral and awareness of the roles apparently played by
surface of the body, each point being the various meridians in body energy economics
associated with one of the 12 meridians and is necessary to evaluate the significance of reac-
its functions. Six of the points are on the tions that produce tenderness in Alarm points.
 Acupuncture points 83

Table 4.1 Alarm points Location of Associated points

Acupuncture Associated points are on the dorsum of the body
point (Fig. 4.3). Spontaneous pain is thought to indicate
a disorder in the meridian associated with it. Ten-
Point 1 Lung LU1
derness elicited on light pressure indicates a defi-
Point 2 Liver LV14
Point 3 Gall bladder Bilateral GB24
ciency in energy in that meridian, and tenderness
Point 4 Kidney GB25 elicited on heavy pressure indicates an excess of
Point 5 Spleen LV13 energy in the associated meridian. These points
Point 6 Large intestine ST25 are all on the Bladder meridian and their associa-
Point 7 Heart constrictor VC17 tions are given in Table 4.2. The points are
Point 8 Heart VC14 slightly lateral to the median line bilaterally and
Point 9 Stomach VC12 are also reflex points for the meridians with
Point 10 Triple heater VC5 which they are associated.
Point 11 Small intestine VC4
Point 12 Bladder VC3 Location of Akabane points
Akabane points (Table 4.3, Fig. 4.4) represent the
terminal points of the meridians. Sensitivity of
these is thought to relate to imbalance in the

Acupuncture point

Lung LU1
Acupuncture point

Liver LV14 VC17 Heart constrictor

Gall bladder GB24
VC14 Heart
Bilateral
Kidney GB25 VC12 Stomach

Spleen LV13
VC5 Triple heater
VC4 Small intestine
VC3 Bladder
Large intestine ST25

Figure 4.2 Location of Alarm points, which lie on the anterior surface of the body. If spontaneous pain develops in any alarm
point, the associated meridian is thought to be involved. If light pressure produces tenderness, an ‘energy deficiency’ is
considered to exist; if heavy pressure produces tenderness, an ‘energy excess’ is assumed. An understanding of the organs and
functions associated with particular meridians is necessary in order to utilize these points therapeutically or diagnostically.
 CHAPTER FOUR
84 The variety of reflex points

Figure 4.3 Location of Associated points, which lie

on the dorsal surface of the body slightly lateral to
the median line bilaterally. If spontaneous pain
develops in any associated point, the allied meridian
is thought to be involved. If light pressure produces Meridian Bladder
meridian
tenderness, an ‘energy deficiency’ is considered to point
exist; if heavy pressure produces tenderness, an
Lung 13
‘energy excess’ is assumed. An understanding of the
organs and functions associated with particular
Heart constrictor 14
meridians is necessary in order to utilize these points
therapeutically or diagnostically. Heart 15
Governor vessel 16

Liver 18
Gall bladder 19
Spleen 20
Stomach 21
Triple heater 22
Kidney 23
, ,
Sea of Energy 24
(extra associated point)
Large intestine 25
Small intestine 27

Bladder 28

Table 4.3 Akabane points

Points on feet Points on hands
Table 4.2 Associated points
1. Spleen 7. Large intestine
Meridian Bladder meridian point 2. Liver 8. Heart constrictor
3. Stomach 9. Triple heater
Point 1 Lung B13 4. Gall bladder 10. Heart
Point 2 Heart constrictor B14 5. Kidney 11. Small intestine
Point 3 Heart B15 6. Bladder 12. Lung
Point 4 Governor vessel B16
Point 5 Liver B18
Point 6 Gall bladder B19 energy of the meridian. Comparative sensitivity
Point 7 Spleen B20 shows relative imbalance in organ (energy) sys-
Point 8 Stomach B21 tems. Manual or electronic testing is possible.
Point 9 Triple heater B22
Point 10 Kidney B23
Point 11 ‘Sea of Energy’ B24 (extra associated Bennett’s neurovascular reflex points
point) (Martin 1977)
Point 12 Large intestine B25
Point 13 Small intestine B27 A wide degree of clinical experience resulted
Point 14 Bladder B28 in an American chiropractor, Terrence Bennett,
reaching the conclusion that there was a group
 Acupuncture points 85

Small intestine Figure 4.4A,B Location of Akabane points, which

Heart represent the terminal points of the 12 meridians.
Triple heater Sensitivity of the points is thought to relate to
imbalance in related organs (energy) systems. Both
Heart constrictor manual and electronic testing of these points is
possible.
Large intestine

A Lung

Bladder
Kidney
Gall bladder

Stomach

Liver
B Spleen

of previously unknown reflexes available for tissue dysfunction, a lack of anticipated elasticity
diagnostic and therapeutic use, which he termed will be noted in the skin as this distraction takes
neurovascular reflexes. He described his work in place. By maintaining the slight stretch on the tis-
a series of lecture notes, which were compiled sues (in effect a ‘mini’ myofascial release), a yield-
and published by Ralph Martin, after Bennett’s ing occurs, and it is after this that a pulsation
death, as Dynamics of Correction of Abnormal sensation should normally be felt. John Thie
Function (Martin 1977). The major points are listed (1973) describes this pulsation sensation thus:
in Chapter 5, which deals with diagnostic
A few seconds after contact is made, a slight
procedures.
pulse can be felt, at a steady rate of 70 to 74 beats
Bennett describes the tissues that are palpated
per minute. This pulse is not related to the heart-
as altered in texture, being contracted or indurated,
beat, but is believed to be the primitive pulsation
in much the same way as Chapman’s reflexes
of the microscopic capillary bed, in the skin.
(described below). His method of treatment calls
for a slight degree of pressure, which he describes Bennett insisted that the contact be maintained
as ‘only minimal, enough to render the tissues until a response was noted in the form of the tissue
semi-anaemic, which is adequate stimulus’. altering, relaxing and, most importantly, until the
Experience indicates that the light operator became aware of the presence of pulsa-
pressure should be accompanied by slight stretch- tion. This could arrive within a few seconds or take
ing of the skin. In accordance with the views of some minutes to emerge, depending on the patient
Karel Lewit (1992), gentle stretching of the skin and his or her condition. Bennett termed the pulsa-
induces reflex activity when hyperalgesic (sensi- tion felt as the ‘arteriole pulse’ because, he stated:
tized) skin zones are used therapeutically (see
It is the beginning of the system, at the junction of
Ch. 5). When hyperalgesia occurs, skin becomes less
the artery and the arteriole, that controls the
elastic, with greater adherence to the underlying
metabolism. The sensation of pulsation is essential
fascia and with lowered resistance to electricity.
. . . It has to be there, or else we are not accomplish-
In Bennett’s system the skin is stretched with
ing anything.
the minimum of force, so as to take up the slack,
by the fingertips being drawn lightly apart. In Together with this, the change in tissue feel is
most cases, if the area involves any degree of soft important:
 CHAPTER FOUR
86 The variety of reflex points

The tissues under your fingers begin to relax as In the 1930s, Chapman and Owens described a
you work for a few moments; you sense the ‘neurolymphatic’ reflex pattern, now widely used
degree of tension releasing. When it releases that in osteopathic and chiropractic methodology.
is all you can do. Chaitow (1965) discussed these reflexes as follows:
Some points are purely diagnostic, others are The reflexes of Chapman that I intend to discuss
used for treatment, and some are both. are not the whole picture – being only a part of
For example, the coronary reflex in the 2nd tho- the visible portion of the iceberg – but of immense
racic interspace on the left, which is a palpable area value nonetheless. Drs Chapman and Owens first
of tissue change and which is sensitive to the patient, reported on Chapman’s original findings in the
is only diagnostic (not illustrated). Awareness of late 1930s. A revised edition of their work has
Bennett’s reflex areas may be found to be a useful been published by the Academy of Applied Oste-
addition to the range of available therapeutic and opathy. The surface changes of a Chapman’s
diagnostic knowledge. In using NMT in its diagnos- reflex are palpable. They may best be described
tic mode, the tissues being evaluated will yield a as contractions located in specific anatomical
multitude of sensitive points. Some of these may cor- areas and always associated with the same viscera.
relate with Bennett’s findings, and they may then be In describing each organ reflex Chapman nor-
used as part of an overall assessment of the nature of mally indicated tissue reflex areas, occurring
the dysfunction affecting the patient. They may, of anteriorly and posteriorly. These reflexes found
course, also be used, as Bennett intended, as a sys- in the deep fascia are described as ‘gangliform’
tem in their own right, for assessing and treating vis- contractions. These contractions vary in size from
ceral and functional physiological changes and a pellet to a large bean and are located anteriorly
pathology. A number of Bennett’s points have been in the intercostal spaces near the sternum. Similar
incorporated into the methods of applied kinesiol- tissue changes are found in those reflexes occur-
ogy, notably the points on the cranium, which are ring on the pelvis. The tissue changes found in
used for treating emotional disturbances. reflexes located on the lower extremities are
Among the cautions issued by Bennett are: described as ‘stringy masses’ or ‘amorphous
shotty plaques’. Those reflexes occurring posteri-
• Do not overtreat the points on the cranium (2–3
orly along the spine, midway between the spinal
minutes is a maximum).
processes and the tips of the transverse processes
• In hyperthyroid patients, do not treat the
are of a more oedematous nature.
thyroid and pituitary reflexes at the same visit
(one should be treated, and alternated with the
other at a subsequent visit). Characteristics
• If the heart is enlarged then the 3rd rib, at the
Patriquin (1997) describes the characteristics of
mid-clavicular line, should not be treated.
Chapman’s reflexes as:
• Aortic sinus reflex should be treated before any
of the brain reflexes are contacted. • small
• If the ovary is being treated, the thyroid should • smooth
receive prior attention. • firm
• discretely palpable
A list of Bennett’s reflex points can be found in
• approximately 2–3 mm in diameter.
Chapter 5, which considers diagnostic applica-
tions of NMT. Sometimes they are described as feeling like
small pearls of tapioca, lying, partially fixed, on
the deep aponeurosis or fascia.
Chapman’s reflexes
Clinical value of the reflexes
(Kuchera 1997, Mannino 1979, Owens 1980, Because the location of these palpable tissue
Patriquin 1997, Walther 1988) changes is relatively constant in relation to
 Chapman’s reflexes 87

specific viscera, it is possible to establish the loca- Explaining results of neuromuscular technique
tion of pathology without knowing its nature. The
These reflexes seem to offer explanations for the
value of these reflexes is threefold:
sometimes startling results obtained through neu-
1. As diagnostic aids – Patriquin (1997)
romuscular technique. Stanley Lief placed great
points out that some of the reflexes, such as
emphasis on normalizing the tissues of the inter-
that for appendix (tip of 12th rib on the
costal spaces and the paravertebral areas – sites
right; see point 38 on Fig. 5.8B) are
of many major neurolymphatic reflexes. He also
invaluable in helping with differential
stressed the importance of not overtreating, a con-
diagnosis when faced with right lower
sideration that cannot be repeated too often.
abdominal pain: ‘Today, Chapman’s
reflexes are more likely to be used as an
Research evidence supports Chapman’s reflex
integral part of osteopathic physical
usefulness
examination than as a specific therapeutic
intervention.’ • Caso (2004) reported a case study involving
2. They can be utilized to influence the motion of chronic constipation and low back pain. Use of
fluids, mostly lymph. Chapman’s NL reflexes was seen to be useful
3. Visceral function can be influenced through diagnostically as well as therapeutically. ‘The
the nervous system. ‘[The] reflexes can be rather remarkable outcome from the
clinically manipulated to specifically reduce application of this relatively simple, yet
adverse sympathetic influence on a particular valuable, diagnostic and therapeutic procedure
organ or visceral system . . . patients with represents a thought-provoking impetus for
frequent bowel movements from the effects of future study and clinical application.’
IBS report they have normal or near normal • Lines et al (1990) treated 30 asymptomatic
function for days to months after soft tissue individuals, on four separate occasions,
treatment over the iliotibial bands and/or the employing stimulation of the neurolymphatic
lumbosacral paraspinal tissues and associated reflexes theorized to relate to the diaphragm.
Chapman’s reflexes’ (Patriquin 1997). (See Spirometric assessment of respiratory function
point 24, anterior and posterior, in Figs 5.8A before and after each treatment was
and 5.8C.) performed. Measurements of forced vital
capacity (FVC) and forced expiratory volume
in 1 second (FEV1) over the whole sample
Mechanism of the reflexes
showed no significant improvement following
Regarding the mechanism whereby these reflexes the treatment regimen. However eight of the 30
act, it would appear that, in so far as the intercos- subjects had lower than predicted initial FVC
tal reflexes are concerned, stimulation of the and FEV1 values. When the results for the group
receptor organs that lie between the anterior of eight subjects were analysed separately, it was
and posterior layers of anterior intercostal fascia found that a significant improvement was attained
acts through the intercostal nerve, which ener- from the first pretreatment FVC to last
vates the external and internal intercostal mus- posttreatment.
cles and thus, through the sympathetic fibres, • In a trial conducted to assess the effects of
affects the intercostal arteries, veins, lymph forms of manipulation on blood pressure, one
nodes, etc. Stimulation thus causes afferent and of the methods used was stimulation of a
efferent vessels draining these tissues to increase Chapman’s reflex (Mannino 1979). A specific
or decrease, permitting lymph flow to be effect attributable to this treatment was noted.
increased or decreased, thus affecting the drain- The point chosen for treatment was the one
age of the entire lymph system in the area. related to adrenal function. The trial involved
Through the sympathetic fibres associated with treatment of this point, or a sham point, in
these tissues, the lymph nodes of the vital organs which pressure was applied to either the real
are also affected. or a false point, for a total of 2 minutes, in a
 CHAPTER FOUR
88 The variety of reflex points

make-or-break circular motion. The point is Vanneron & Nimmo’s first point is in contra-
located in the intertransverse space, on both diction to Gray’s Anatomy (Gray 1973), which tells
sides of the 11th and 12th thoracic vertebrae, us that lymph moves in a number of ways. Filtra-
midway between the spinous processes and tion occurs, generated by filtration of fluid from
the tips of the transverse processes (see point the capillaries. There is also a degree of move-
37 on Fig. 5.8F). The sham treatment involved ment engendered by contraction of surrounding
the area between the 8th and 9th thoracic muscles, which compress lymph vessels, the
vertebrae, which relates to small intestine movement of which is determined by the pres-
problems, and would have no effect on the sort ence of valves. This muscular contraction is
of condition being assessed in these trials. The dependent upon normal activity, and muscular
results showed no immediate effect on blood contraction–relaxation sequences. Lymph is fur-
pressure, but did indicate fascinating alteration ther capable of being moved, in such regions,
in aldosterone levels and subsequent blood according to Gray, by massage movements.
pressure drop. Abnormalities in aldosterone Pulsating arterial vessels, in close proximity, also
levels have been shown in populations with assist lymph movement, as does respiratory
essential hypertension. Following treatment of movement. Also in contradiction of Vanneron &
the reflexes there was a demonstrable and Nimmo, Gray states: ‘The smooth muscle in the
consistent fall in aldosterone levels within 36 walls of the lymphatic trunks is most marked just
hours of stimulation of the Chapman reflex for proximal to the valves; stimulation of sympathetic
the adrenals, but no change at all in the levels nerves accompanying the trunks, results in con-
when the sham points were stimulated. A drop traction of the vessels; the intrinsic muscle of the
of 15 mmHg systolic and 8 mmHg diastolic vessels thus probably aids the flow of the lymph.’
was noted some 36 hours after treatment of the In 1979, rhythmic pulse waves were recorded
adrenal points. The delay in response from the lymphatic vessels of five healthy, upright,
suggested that the treatment had a tendency to motionless males at a rate of 8–10 per minute,
interrupt, or damp down, a feedback to the asynchronous with respiration or leg movement
adrenal medulla by the sympathetic nervous (Oszeweski & Engeset 1979). Degenhardt &
system (Patriquin 1997). Kuchera (1996) describe the process as follows:
‘The regulation of the intrinsic contractility of the
lymphatic system is based on transmural disten-
Nimmo’s dismissal of the Chapman reflexes
sion of the vessel walls and neural and humoral
An element of disinformation has emerged mediators.’
regarding Chapman’s neurolymphatic reflexes. They comment:
Vannerson & Nimmo (1971) writing in The
The physiology of the lymphatic system is quite
Receptor – the journal of the organization that
complex. Research has only begun to demon-
used (in the 1960s) to teach Nimmo’s receptor-
strate the many factors that influence lymphatic
tonus technique (see Ch. 2) – stated:
flow. The extrinsic compression of the myofascia
Research has not borne out the presumption [by on the lymphatics has been the focus of many
Chapman] of a neurolymphatic reflex. Muscle manipulative techniques . . . Studies now consis-
fibres, which alone have the specific function of tently demonstrate contractility in the lymphatic
constricting vessels, do not exist in the walls of vessels. This intrinsic pumping has been shown
lymph vessels, except for a few fibres in the tho- to be under autonomic control, modulated locally
racic duct, and a few large trunks. These are by soft tissue chemicals and systemically pro-
sparsely located, and have little effect in lymph duced hormones. Currently it appears that
fluid propulsion. intrinsic contractions have more influence on
lymph flow than extrinsic forces.
These two authors then deride Chapman’s
assertion that the reflexes could exist at specific This evidence, therefore, suggests that the
sites, an idea that they call ‘fantastic’. term ‘neurolymphatic reflex’, as described by
 Connective tissue massage/manipulation 89

Chapman, may indeed be an accurate description be asked about, for example, stomach or digestive
of the phenomenon. symptoms.
Vanneron & Nimmo’s second observation Treatment of the lymphatic aspects of these
(relating to the specificity of the reflex sites) may dysfunctional organs or functions (should their
be more valid, especially if anatomical individu- existence be corroborated by other clinical evi-
ality is taken into account. Points of the body dence) might usefully include gentle applications
surface are never likely to be precisely identifiable of rotary pressure to the posterior points, in the
by description of anatomical position. However, sequence described in Chapter 5.
a general identification as to site is possible. Arbuckle (1977) writes of Chapman’s reflexes:
McBurney’s point, for example, if present in
The diagnostic value of these reflexes is amazing.
appendicitis, is usually located within a few
For instance, a female having severe pain in the
degrees of its commonly described location. There
right lower quadrant of the abdomen, presents sev-
are exceptions, of course, and in the inscrutable
eral possibilities, but the offending organ may well
manner of the Orient, the Chinese have taken this
be located by means of the reflexes, the positive one
well into account, in describing the locations of
showing whether the disturbance is due to appen-
acupuncture points. The invention of the ‘human
dix, cecum, tube or ovary. With a degree of under-
inch’, which takes account of the individual anato-
standing of the interrelation of the endocrine
mical proportions of each person, allows for such
glands, and of the importance of the lymphatics
individualization. In terms of the charts and maps
and the autonomic distribution, the therapeutic
to be found in this text, the same factor should be
value of these considerations can be shown clini-
borne in mind. The positions are approximate,
cally. There is a definite sequence, which must be fol-
because variations exist from person to person.
lowed, in the management of these reflexes, to
Dysfunction in soft tissues is, however, palpa-
produce desired results, and, if not so applied, just
ble, and not dependent upon maps. Thus, the
as surely as the misapplication of any other therapy,
general guidelines provided by charts are useful,
further confusion of the body mechanism will result.
but cannot take the place of palpatory skills.
A complete illustrated list of Chapman’s
reflexes is found in Chapter 5, which deals with
Connective tissue massage/
diagnosis and treatment using NMT.
manipulation

Palpating for, and treating, the neurolymphatic Another system that uses reflex effects diagnosti-
points cally as well as therapeutically is connective tis-
sue massage (CTM). CTM involves ‘rolling’ (or
Kuchera (1997) suggests: ‘If Chapman’s [neuro-
stretching using shear forces, or lifting) the tissues
lymphatic] myofascial tender points are to be
in order to achieve reflex and local effects.
tested, palpate them early in the examination
Citak-Karakaya (2006) evaluated the use of
because motion of the myofascial tissues in their
CTM on 20 female patients with fibromyalgia
area decreases their sensitivity. In this case their
(FMS). The results showed that:
diagnostic clue, tenderness with palpation, may
not be evident.’ Statistical analyses revealed that pain intensity,
If, during NMT assessment mode application impact of FMS on functional activities, and com-
to the anterior thorax and abdominal region (see plaints of non-restorative sleep improved after
Ch. 7) unusual tenderness is noted in the region the treatment program.
of the umbilicus, this may relate to bladder, kid-
Additional studies using CTM have demon-
ney or adrenal dysfunction (see points 15, 16
strated benefit in cases of:
and 37 on Figs 5.8A & 5.8B); similarly, tenderness
in the area if an anterior point is noted in the • Migraine (Akbayrak et al 2001)
left fifth or sixth intercostal interspace (see points • Tension-type headache (Akbayrak et al 2002,
13 and 14 on Fig. 5.8A), the patient may usefully Demiturk et al 2001)
 CHAPTER FOUR
90 The variety of reflex points

• Fibromyalgia (Citak et al 2001) neighbouring segment and finally to the diseased

• Raynaud’s disease (Demiturk et al 2000) organ. The origin of the connective tissue reflex
• Autonomic imbalance (Reed 1988) zones and the influence of the CTM depend on
• Anxiety (McKechnie A et al 1983). the relationship between the function of the inter-
nal organs, vessels, and nerves as well as the tis-
sues of the locomotor apparatus, which descend
CTM: Method and mechanism
from the same metamere.
According to Ebner (1962), the palpable reflex tis-
Some of the reactions to CTM are normal auto-
sue changes that are identified in diagnosis and
nomic responses such as pleasant fatigue, bowel
treatment involving CTM, can take any of the
movements and diuresis. Oedema is markedly
following forms:
reduced and hormonal distribution is seen to
• drawn-in bands of tissue achieve a degree of balance. Aspects of CTM are
• flattened areas of tissue similar to those of NMT, and the ‘skin rolling’
• elevated areas, giving the impression of methods used in some body areas are virtually
localized swelling identical in application. The effects are therefore
• muscle atrophy or hypertrophy interesting from a comparative point of view.
• osseous deformity of the spinal column.
The common ‘zones’ of influence involving Jones’ tender points (Fig. 4.5)
such changes are illustrated and discussed fur-
(Jones 1980)
ther in Chapter 5 (see Fig. 5.3). The digital strokes
used in CTM pull and stretch the tissues, and it is In his evolution of the ‘strain and counterstrain’
suggested that the method’s effectiveness is based (SCS) functional manipulative approach to the
on a viscerocutaneous reflex. normalization of hypertonicity, Lawrence Jones
Bischof & Elmiger (1960) explain: described a series of ‘points’ that he had identi-
fied. These sensitive areas were, Jones discovered,
The specific mechanical stimulation of the pull
related to specific strains and stresses in the
on connective tissue seems to be the adequate
musculoskeletal system, and were used by the
stimulus to elicit the nervous reflex. Connective
therapist as monitors while the areas were being
tissue massage/manipulation acts first on the
guided into a position of ease, during which pro-
sympathetic terminal reticulum in the skin. The
cess there was both a reduction in sensitivity in
smallest branches of the autonomic nervous sys-
the palpated tender point as well as a relaxation
tem contact the impulses activated by the pulling
(increased ease) of the stressed tissues associated
strokes to the sympathetic trunk and the spinal
with it. The tender points as described by Jones
cord. The impulses travel from the skin either
and the methods of treating them fall within the
through a somatosensory spinal nerve via a poste-
umbrella term ‘positional release techniques’
rior root ganglion to the grey matter or over the vas-
(Chaitow 2001, D’Ambrogio & Roth 1997, Deig
cular plexus to the same segmental sympathetic
2001). The methodology of SCS is summarized
ganglion or to the ganglion of the neighbouring
in Chapter 8, and is incorporated into the
segment, through the ramus communicans albus
integrated (INIT) sequence for trigger point deac-
to the posterior root and grey matter of the spinal
tivation, as described in Chapter 9.
cord. They terminate either directly or by means
In many ways these ‘tender’ points, while sen-
of the internuncial neurons at the efferent auto-
sitive to palpation, are not usually areas in which
nomic root cells.
the patient was previously aware of pain. They
In the efferent pathway the impulses travel from are therefore similar to Ah Shi – spontaneously
the autonomic lateral horn, or the intermedio- tender – points in traditional Chinese medicine
lateral column, over the anterior root, ramus (Chaitow 1991).
communicans albus, to the segmental sympa- Significantly perhaps, as the area being treated
thetic ganglion or to the ganglion of the is positioned in ‘ease’ so that tenderness vanishes
 Connective tissue massage/manipulation 91

Squamosal Supra-orbital nerve

Nasal
Masseter-temporo-mandibular Infra-orbital nerve

Anterior 1st thoracic

Anterior 7th cervical
Anterior acromio-clavicular
Latissimus dorsi Anterior 8th cervical

Depressed upper ribs

Anterior 7th thoracic

Anterior 8th thoracic

Medial and lateral coronoid
Anterior 9th thoracic

Anterior 10th thoracic Radial head

Anterior 12th thoracic

Anterior 11th thoracic
Anterior 1st lumbar
Anterior 2nd lumbar IIiacus
Anterior lateral trochanter
Anterior 5th lumbar Low ilium

Low ilium, flare out Thumb and fingers

Medial and lateral meniscus Media and lateral patella

Media and lateral extension strain Media and lateral hamstrings

of meniscus

Tibialis anticus, medial ankle

Flexion strain of ankle

Figure 4.5A Jones’ points on the anterior body surface, commonly relating to flexion strains.

Figure 4.5 Location of Jones’ tender points, which are bilateral in response to specific strain (acute or chronic) but are shown
on only one side of the body in these illustrations. The point locations are approximate and will vary within the indicated area,
depending upon the specific mechanics and tissues associated with the particular trauma or strain.
 CHAPTER FOUR
92 The variety of reflex points

Right lambdoid
Sphenobasilar
Left occipito-mastoid
Posterior 1st cervical
Inter-vertebral extension dysfunction

Elevated 1st rib

Supraspinatus
Elevated upper ribs Posterior acromio-clavicular
(tender points on angles of ribs) Medial 2nd thoracic; shoulder
Lateral second thoracic; shoulder
strain or pain
3rd thoracic and shoulder
strain or pain

Upper lumbars

Medial and lateral olecranon

Upper pole 5th lumbar 4th lumbar

Lower pole 5th lumbar
3rd lumbar
High flare out sacro-iliac Posterior lateral trochanter

Posterior medial trochanter

Posterior medial trochanter

Anterior cruciate ligament strain

Extension strain of ankle
(tender point on gastrocnemius)
Posterior cruciate ligament strain

Lateral ankle strain

Figure 4.5B Jones’ points on the posterior body surface, commonly relating to extension strains.
 Confusion? 93

Periosteal pain points

Squamosal (Adapted from Lewit 1992)
Postero-auricular These painful areas (Table 4.4) usually relate to
acute or chronic contraction of associated muscles
and tendons.
Felix Mann, pioneer acupuncture researcher
and author, describes periosteal acupuncture as
Subscapularis being more effective than ordinary acupuncture
in a number of conditions (Mann 1963). He lists
the sites given in Table 4.5 amongst the common
sites usefully employed in this approach. Clinical
experience indicates that NMT ischaemic com-
pression techniques and muscle energy methods
are as likely as traditional needling to produce
benefit when treating these points.

Lateral trochanter
Confusion?
The soft tissues are of major importance to the
body’s economy, structural integrity and well-
being. They are also a major source of pain and
dysfunction and, as must now be obvious, of
reflex disturbances.
The various theories, methods and descriptive
terminologies relating to the many point systems
and classifications of ‘points’ are significant inas-
much as NMT offers the opportunity to access
Lateral ankle strain
and use their potential. If we accept that there
C
are many ways of looking at and interpreting
Lateral calcaneus
the same phenomenon, then it will be an easy
Figure 4.5C Jones’ points on the lateral body surface, step to acknowledging that an acupuncture point
commonly relating to strains involving side-bending or and a trigger point and a Chapman’s reflex point,
rotation. for example, can all be the self-same point, but
with different aspects of its reflex potential being
from the tender point, a degree of ischaemic com- considered in each classification.
pression/inhibitory pressure/acupressure would NMT can (with other modalities) be used as
be taking place. It is worth considering that the an effective measure to detect and eliminate nox-
benefits noted, in terms of pain relief and reduc- ious trigger points and areas that generate or
tion in contraction or spasm, could relate in some help to maintain dysfunction, or that influence
part to the resulting inhibitory/endorphin release reflexive activity. Such dysfunction can take the
action as well as to the subsequent improvement form of muscular weakness, muscular contrac-
in circulation and possible neural influences, tion, pain, vasodilatation, vasoconstriction, tis-
through the tissues and neurological modulation sue degeneration, gastrointestinal disturbances,
produced by the placing of the tissues into a situ- sympathetic nervous system abreactions, respi-
ation of ‘ease’. ratory and a myriad other disorders including
 CHAPTER FOUR
94 The variety of reflex points

Table 4.4 Periosteal pain points (adapted from Lewit 1992)

Site Muscular/joint implication

Pain on head of metatarsals Dropped arch, flat foot

Spur on calcaneum (pain on pressure) Tight plantar aponeurosis
Pain on tubercle of tibia Tight long adductor/possible hip dysfunction
Pain on head of fibula Biceps femoris tightness
Posterior superior iliac spine tenderness Various possible implications, involving low back, gluteal and sacroiliac region
Lateral aspects of symphysis pubis Adductors tight. Hip or sacroiliac dysfunction
Pain on coccyx Gluteus maximus tightness, possibly piriformis or levator ani involvement
Crest of ilium – pain Tight quadratus lumborum/gluteus medius and/or lumbodorsal dysfunction
Pain on greater trochanter Tight abductors/hip dysfunction
Pain on lumbar spinous processes Tight paraspinal muscles
(especially L5)
Pain mid-dorsal spinous processes Lower cervical dysfunction
Pain spinous process of C2 Levator scapulae tight: C1–2, 2–3, dysfunction
Pain on xyphoid process Rectus abdominus tight. 6–8 rib dysfunction
Pain on ribs, on mammary or axillary line Pectoralis tightness. Visceral dysfunction referred to here
Pain at sternocostal junction upper ribs Scalenus tightness
Pain on clavicle, medial aspect Tight sternocleidomastoid
Pain transverse process of atlas Tight sternocleidomastoid and/or recti capitis lateral. Atlanto-occipital
dysfunction
Pain on occiput Upper cervical or atlas dysfunction
Pain on styloid process of radius Elbow dysfunction
Pain on epicondyles Local muscular or elbow dysfunction
Pain at deltoid attachment Scapulohumeral dysfunction
Mandibular condyles painful Temporomandibular joint dysfunction. Tight masticators

Table 4.5 Periosteal acupuncture points and

emotional and ‘psychological’ disorders such as associations
anxiety.
Noxious (pain producing) points that are the Site Associated with
end result of various forms of stress imposed on
1. Appropriate Headache, migraine, interscapular
the tissues housing them may reside in either
transverse pain and cervical spondylosis
hypertonic or hypotonic muscle, or in ligamen- cervical process
tous or fascial tissues, or in apparently normal tis- 2. Area of sacroiliac Low back pain, sciatica without
sues. When active, such points will always be joint neurological deficit, testicular pain
sensitive to correctly applied pressure and can 3. Coracoid process Painful shoulder joint
often be neutralized by manual pressure or a 4. Medial condyle Knee pain, without advanced
combination of chilling and manual pressure tibia pathology
and stretching. 5. Neck of femur Hip pain, without major changes
In the treatment sections there will be discus- evident on radiography
sion of methods for locating and treating such 6. Lateral aspect of If sacroiliac joint (2 above) does
points; however, what effects each therapist posterior spine of not yield benefit, these areas may
attempts to achieve by manipulating reflexively lower lumbar be used
active points depends on the individual’s profes- vertebrae
sional training and beliefs.
 References 95

References
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