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Myofascial release PPT

This document provides information on myofascial release (MFR). It discusses the history and concept of MFR, describing it as a technique that addresses tightness and restrictions in the fascia through the application of gentle, sustained pressure. The document outlines the layers and components of fascia, and how MFR is believed to work by converting restricted fascia back to a more gel-like state, allowing collagen and elastin fibers to rearrange and adhesions to release. MFR aims to restore normal play and function to the myofascial system.

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MYOFASCIAL RELEASE DR. AKHIL SAMSON (PT) MPT(ORTHO & SPORTS), CMTP,CDNT ASSISTANT PROFESSOR DR D Y PATIL COLLEGE OF PHYSIOTHERAPY
HISTORY OF MFR • Osteopathic literature describing Myofascial models appeared in the 1950's and was preceded by the contributions of Elisabeth Dicke (connective tissue massage) and Ida Rolf (structural integration). • Myofascial therapy is not a current fad so much as a dated concept that has recently been discovered by allopathic medicine via the vehicle of physical therapy • Lawrence Jones's strain and counter-strain, soft tissue mobilization, and many other contemporary schools of thought contain similar philosophies • The term Myofascial Release as a technique was coined in 1981, when it was used as the title of the first soft tissue release courses taught at Michigan State university in the fall of that year.
FRED MITCHELL SENIOR QUOTED THE WORDS OF THE DEVELOPER OF OSTEOPATHY , ANDREW TAYLOR STILL: “THE ATTEMPT TO RESTORE JOINT INTEGRITY BEFORE SOOTHINGLY RESTORING MUSCLE AND LIGAMENTOUS NORMALITY WAS PUTTING THE CART BEFORE THE HORSE.”
MYOFASCIAL RELEASE CONCEPT • MFR has origins in soft tissue mobilization, osteopathy, physical therapy, craniosacral therapy and energy work, among others, and all have become subtly blended to form what has been known as Myofascial Release for a number of decades. • John F. Barnes has played a major role in myofascial therapy and has pioneered a sustained pressure MFR approach that is now being recognized by scientific research. • The therapist addresses the tissue barrier of resistance by feeling for tightness, restrictions and adhesions in any plane that may be causing pain or dysfunction. • MFR is a client-led therapy involving communication between the therapist and client and actively promoting feedback on the responses to the treatment and body awareness.
• The many aspects of the MFR approach depend on each other. The manual application of the techniques is one part; another is myofascial rebounding, and a third is myofascial unwinding. These three parts form an interlinked triangle. • Two others parts that are also important are setting an intention as the therapist with every part of the triangle and communicating with and requesting feedback from the client (i.e., therapeutic dialoguing). Manual Application Myofascial Unwinding Myofascial Rebounding Therapeutic Dialoguing
• The four mechanoreceptors of the fascial matrix (Golgi, Pacini, Ruffini and interstitial) respond to stimuli. • MFR, through its cultivation of touch and kinesthetic awareness, stimulates these mechanoreceptors by applying pressure-sensitive techniques followed by sustained pressure to release the restricted fascia. • As the tissue releases, it stretches, and as the client begins to spontaneously unwind, other mechanoreceptors are stimulated by this movement.
• The three aspects i.e. manual application of techniques, unwinding and rebounding, which work with and promote the healthy activation of all of the fascial mechanoreceptors ultimately promoting and maintaining health and function. • • MFR also allows the collagen and elastin fibers to rearrange themselves into a more conducive resting length by the application of biomechanical energy or pressure from the therapist’s hands (piezoelectricity).
THE MECHANORECEPTORS OF FASCIA, RECEPTORS THAT RESPONDS TO MECHANICAL LOAD OR DISTORTION, ARE STIMULATED IN DIFFERENT WAYS OFFERING FURTHER SCOPE TO THE REFINEMENT OF MFR TREATMENT AND REHABILITATION. (SCHLEIP ET AL. 2012) Mechanoreceptors Respond to Golgi Tendon Organs Active stretch and Pressure Pacinian corpuscles Rapid pressure changes and Vibration Ruffini corpuscles Rapid and Sustained Pressure changes, Vibration and Tangential Stretch Interstitial Mechanoreceptors Rapid and Sustained Pressure changes
Local circulation (waste and nutrient exchange) improves Reprogramming of the central nervous system Cross-linkages in these fibers are broken down Fascial planes are realigned Enabling of a normal functional range of motion without eliciting the old pain pattern Collagen and elastin fibers reorganize themselves The soft tissue proprioceptive sensory mechanisms are reset
• It is thought that the time needed for tissues to begin to rearrange themselves is approximately 90 to 120 seconds; the viscous ground substance determines the ease at which this occurs. • Because collagen begins to change only after 90 to 120 seconds, MFR techniques must be performed for more than five minutes to influence the entire fascial network (Barnes 1990; Covell 2009).
RECENT RESEARCH FINDINGS • Dr. Gerald Pollack’s research regarding the water content of fascia highlights the huge role of fluid dynamics in fascial bodywork. This research proposes that water has another state beside gaseous, frozen and liquid, that of a gel. He also describes water as having two main states, bound water and free water. • Water, in the presence of a hydrophilic (water-loving) tissue, organizes itself in a colloidal matrix of particles that forms a liquid crystal. Pollack describes this liquid crystal as bound water. Bound water has a high degree of viscoelasticity giving it a trampoline-like bounce and give. Free water is more chaotic in its organization and is charged differently to bound water (Pollack 2013). The protein collagen is a hydrophilic tissue.
• Water, which makes up approximately two thirds of fascial composition, in proximity to collagen forms bound water, which promotes the bounce and give that enhances nutrient, gaseous, waste product and information exchange. • In restricted fascia, however, in which the collagen and elastin fibres are drawn closer together, less bound water is present. • Elastin is a hydrophobic (water-hating) tissue that pushes the bound water (created by the hydrophilic collagen fibres) away from it leaving its free water to initiate and maintain inflammatory processes.
• Pollack goes on to describes how photonic energy (electromagnetic radiation) charges bound water increasing its viscoelasticity and promoting a healthier tissue tone. Photonic energy is present everywhere including in infrared energy (heat), which is present in and transmitted through the therapist’s hands into the client’s body during MFR. This confirms Barnes’ theory that the fascial gel, or ground substance, can be influenced by water exchange through the slow and sustained pressure of trained hands.
FASCIA • What is the myofascial system? Myo means ‘muscle’, and fascia means ‘band’. Fascia, an embryologic tissue often called connective tissue, is a web-like, three-dimensional matrix that intertwines, surrounds, protects and supports every other structure of the human body. • Fibrous collagen tissue that is part of the body’s power transmission system (definition from Fascia Research Congress 2015) • It is a single, uninterrupted sheet of tissue that extends from the inner aspects of the skull down to the soles of the feet and from the exterior to the interior of the body, ultimately making up the shape and form of the body itself. • Fascia has been described as the largest system in the human body because it touches all other structures (Pischinger 2007).
• Fascia possesses 10 times more sensory nerve receptors than its muscular counterpart (van der Wal 2009) and has been promoted as a mechanosensitive signaling system with an integrated function akin to that of the nervous system (Langevin 2006). • The fascial system is a totally integrated system and is the immediate environment of every cell in the body. This tensional network adapts its fiber arrangement and density according to the local and tensional demands placed on it (Schleip et al. 2012). The implications of this quality alone provide credibility for Myofascial Release (MFR).
Fascia is divided into 3 layers • Superficial fascia (hypodermis) lies beneath the dermis and consists of loose connective tissue and Adipose tissue. • The second layer is called the potential space. This space may enlarge due to edema suggesting that the fascia can be disrupted and stretched by any injury. • The deep fascia is a dense sheet that separates the muscles into functioning groups and lines the body, covering all organs of the body.
• The fibers in fascia run all direction ,Fascia is distensible in all directions to accommodate change in muscle bulk and to permit stretching • Contraction causes the muscle to broaden, temporarily increasing tension on the fascia. • A muscle that has hypertrophied secondary to exercise, or that is in a constant state of hypertonus due to faulty posture, will increase the constant tension on the fascia. • Fascia shrinks when inflamed and heals slowly due to its poor blood supply. • With lack of movement, sustained lengthening or shortening or sudden injury over-stressing it’s anatomy: it can retain its new found position, causing pain. Function: • Fascia links together all parts of the body • Has a significant role in balance, posture, coordination, and even positioning. • Shape • It also has a relieving effect and transfers shock and load on to bigger areas to avoid overload • Creates interstitial spaces
• Collagen is the most abundant protein in the body. Both collagen and elastin, another type of protein, are the main fibers within fascia, and together they exist within a viscous, gel-like fluid called ground substance. • Collagen provides strength and stability when mechanical stress is applied, to guard against overextension. • Elastin provides an elastic quality that allows the connective tissue to stretch to the limit of the collagen fibers' length whilst absorbing tensile force
• Fascia is a colloid. The amount of resistance colloids offer increases proportionally to the velocity of force applied to them. The more rapidly force is applied, the more rigid the tissue becomes. Therefore a gentle, light, sustained touch is essential to avoid resistance and viscous drag when releasing fascial restrictions. • Surrounding the collagen and elastin fibers is a viscous, gel-like ground substance (a polysaccharide gel complex) composed of hyaluronic acid (hyaluronan) and proteoglycans that lubricate the fibers and allow them to glide over each other (Barnes 1990; Chaitow and DeLany 2008).
• The proteoglycans form this gel-like medium, and the presence of the hyaluronan makes it hydrophilic (water loving), drawing water into the tissue. This provides a cushioning effect and aids in maintaining space between the collagen fibers. • The gel absorbs shock and disperses it throughout the body. Fascia’s ground substance provides the medium in which other elements are exchanged (gases, nutrients, hormones, cellular waste, antibodies, and white blood cells). The condition of the ground substance can affect the rate of diffusion and hence the health of the cells it surrounds (Chaitow and DeLany 2008; Juhan 2003).
FUNCTIONAL JOINT CONCEPT • For any system designed for function, it must have interfaces that allow motion: basically space built up for motion. • For skeletal structures, these interfaces are termed joints while in soft tissue, these interfaces are defined as functional joints. • These are maintained by fascial tissues and include spaces between a muscle and surrounding structures.
NORMAL PLAY • 3 dimensional mobility that exists at functional joints is termed as normal play. • Degree of normal play varies according to functional demands and mechanical interface between individual structures. • Identification of normal play is done via: 1.Palpation 2.ROM testing 3.Observation in function. • When normal extensibility, accessory mobility and biomechanical function of tissues and surrounding structures are restricted, this dysfunctional state is called as decreased or restricted play.
CAUSES OF DYSFUNCTION OF THE MYOFASCIAL UNIT • Congenital factors (short/long leg, small hemipelvis, short upper extremity, fascial, cranial and other distortions) • Overuse, misuse and abuse (and disuse) factors (such as injury or inappropriate patterns of use involved in work, sport or regular activities) • Postural stresses • Reflexive factors (trigger points, facilitated spinal regions)
• Chronic negative emotional states (anxiety, repressed anger, etc.) • Nutritional deficits • Toxic accumulations • Infection • Endocrine (hormonal) imbalances • Restrictive Scar Tissue • Adaptive Muscle shortening • Injury to musculotendinous junctions
MYOFASCIAL RESTRICTION (As the fascial system is interconnected, this stress can be transmitted through fascia to other parts of the body, causing symptoms in areas of the body unrelated to the actual restricted area.) Ground Substance of fascia is converted from gel state to solid state Fascia and underlying tissue become stuck together (Adhesion formation) Adhesions due to injury, disuse or not enough stretching Muscle fibers injured Imposition of uneven stress on fascial system
MYOFASCIAL PAIN SYNDROME • First description of the myofascial pain syndrome was published in the German literature in 1843. • Also known as Chronic Myofascial pain (CMP). • It’s a syndrome characterized by chronic pain caused by multiple trigger points and fascial constrictions. • Constitutes substantial portions of the pain spectrum, acute and chronic. • It’s a very specific type of muscular pain, which is common after injury, resulting in so called soft tissue pain.
• Should not be confused with Fibromyalgia. • It originates in both the muscle and the fascia. • The pain is often described as being deep within the target tissue. • The source of the patient's pain is often difficult to locate since the pain is often referred to seemingly unrelated and uninjured body parts or areas. • Palpation of the target tissue usually does not reproduce the pain complaint, while palpation distal to the pain does reproduce the pain complaint. • If the origin of the pain is not treated quickly and effectively, the pain may become more generalized as additional myofascial units are recruited.
DIFFERENCE BETWEEN MYOFASCIAL PAIN SYNDROME AND FIBROMYALGIA Myofascial Pain Fibromyalgia Localized Systemic Myofascial problems Neurosensory problems Characterized by Acute or chronic pain caused by trigger points and fascial constrictions Characterized by muscle pain, widespread muscle tenderness(tender points), joint stiffness and fatigue Can be acute or chronic Chronic form of myalgia of at least 3 months duration Common after injuries Commonly associated with Psychosocial components like mood and anxiety disorders. Pain referral to distant sites possible Do not have taut bands and no pain referral
MUSCULOFASCIAL RELEASE Definition- • The facilitation of mechanical, neural and psycho-physiological adaptive potential as interfaced via the musculofascial system. OR • Musculofascial release is the gentle manual application of sustained pressure to release fascial restriction.
UNDERSTANDING OF MUSCULOFASCIAL RELEASE • MFR Technique helps in correcting soft tissue dysfunction with gross and focused stretches on particular regions of the muscles. • This technique requires feedback from the patient (as well as what the therapist’s hands feel) to determine the direction, force and duration of the stretch and to facilitate maximum relaxation of tight and restricted tissue. • Since neither the tight muscle nor its antagonist is working against the stretch, activation of pain fibers is less likely, thus MFR is generally quite comfortable.
PRINCIPLES OF APPLICATION The MFR approach includes extrinsic forces applied by the operator: • 1.Point of entry (Engage the fascia by removing slack) • 2.Compression /Tension • 3.Traction • 4.Twisting (for oblique fibres)
HOW MUSCULOFASCIAL RELEASE WORKS? • The gentle sustained musculofascial release is believed to supply mechanical and thermal energy which converts the ground substance into gel state again which allows facilitation of sliding movement of collagen and elastin fibers. • Thereby freeing adhesions and softening and lengthening the fascia. • Improves circulation and nervous system transmission by freeing up fascia that may cause compression on blood vessels and nerves. • The skin/dermis is attached to the myofascia through network of collagenous fibers (retinaculum cutis) that passes from membrana basilaris to the underlying fascia, thus one should be able to move the fascia through movement of the dermis.
STEPS OF MFR 1. Evaluate the patient (DDx, History- List of medications which are currently being taken and medicines taken in the past and their side effects, positions maintained in the home/work environment, Site of pain/referred pain, tenderness) 2. Identify posture or ROM imbalances 3. Find the location of restriction 4. Treat 5. Recheck imbalance 6. Teach Self MFR techniques 7. Strengthen and educate patient to ensure imbalance doesn’t occur.
PALPATION (NOTE: KEEP FINGERNAILS SHORT AND SMOOTH) Two objectives: • Locate the affected musculofascial region • Assess the health of affected musculofascial region Protocol: • Know the attachments • Know the action • Use optimal palpation position • Use appropriate pressure • Sink slowly into the tissue and have the patient breathe • Close your eyes when you palpate • Construct a mental picture of the client’s anatomy under the skin as you palpate.
METHODS OF PALPATION • Flat palpation: With finger bellies for an initial survey of muscle tone for any spasm or superficial tenderness, local rise of temperature. • Finger tip palpation: Across muscle fibers to locate the taut bands and trigger points in small superficial muscles. • Pincer palpation: Between the thumb and fingers for accessible muscles, such as Sternocleidomastoid, upper Trapezius, Pectoralis major, Latissimus Dorsi and hip adductors. Done perpendicular to fibers. • Overlying hand palpation: One hand applies pressure while the underlying hand palpates for the deep muscles, such as Glutei muscles and Piriformis.
CARDINAL RULES OF MFR Perform all techniques without moisturizer or makeup on the skin. Skin must be clean and dry Allow your hands and fingers to sink into the tissue. Wait at the tissue barrier until it yields and melts. Do not force stretch into the tissue Make sure hands don’t slip during treatment.
An overview of treatment- • Low load gentle pressure applied along the direction of muscle fibers until resistance to further stretch is felt. • Stretch guided by the feedback the therapist feels from the patient’s body. • Stretch may be held for 1-2 minutes and sometimes up to 5 minutes. • Process is repeated until tissues are fully elongated. • Patient should feel less pain than before. • Sessions typically last 30 minutes to an hour and may be given one to three times a week depending on the patient’s condition. Progressions of MFR- • Proximal to distal • Most severe imbalance/restriction/asymmetry to less severe • Static before dynamic imbalance
THERAPEUTIC EFFECTS & BENEFITS OF MFR • Decreased pain • Improved blood flow • Improved alignment • Improved joint function • Improved sleep • Improved quality of life • Decreased anxiety • Decreased fatigue • Decreased stiffness • Decreased over activity of muscle
LONGEVITY OF EFFECTS Effects of MFR can last, • Until motion causing trauma is repeated • Research has found up to 6 months post treatment. • Research also shows that benefit can be maintained with a physical therapy visit once a week • Further lasting benefits are noted when self MFR is performed
INDICATIONS • Painful complex postural asymmetries • Patient having frequent headaches that are triggered by a variety of stimuli including trigger points. • Asymmetrical muscle tightness • Competitive athletes who need mobility and function to increase speed or accuracy
• Pregnancy- MFR is an appropriate therapy for pregnant woman after their first trimester and can be extremely beneficial in preparation for labour. MFR helps to alleviate the stressful symptoms of body change and adaptation not only as the baby grows but as a result of the hormone relaxin being secreted into the system. Relaxin softens the cartilage at the pubic symphysis and the joints at the sacroiliac in preparation for labour. Many women suffer back and pelvic discomfort in these areas during pregnancy, and MFR can be an effective therapy to maintain their integrity. As with all other forms of bodywork, abdominal work is contraindicated during the entire pregnancy.
INDICATIONS CONTINUED.. • Scar Tissue adhesions- Wait 6-8 before directly working on the scarred tissue. Prior to this, work around it. • Care and consideration are needed when working with clients with neurological, muscular spasm and spasticity conditions. E.g. Multiple Sclerosis. • Cancer- Over the years there have been conflicting opinions regarding the safety of performing massage on clients with cancer. However, it has been proven that bodywork in general promotes wellness and relaxation in these clients. MFR can be performed on clients who are in remission from cancer and those who are undergoing both chemotherapy and radiotherapy, but it is best to avoid the direct site of the radiotherapy treatment. Visit the Iris Cancer Partnership for further information on oncology massage therapy in the UK: www.iriscancerpartnership.org.uk.
CONTRAINDICATIONS Global Contraindications- • Alcohol and recreational drug use • Febrile state (high temperature) • Systemic infection • Colds and flus that are contagious • Acute circulatory conditions and acute blood disorders
• Deep vein thrombosis and aneurysm • Uncontrolled hypertension usually involving anti-coagulant therapy • Severe undiagnosed swelling • Severe undiagnosed pain • Undiagnosed lumps • Rapid weight loss or gain • Undiagnosed breathing difficulties • Undiagnosed bowel and bladder issues • Patient unable to give informed consent to treatment because of Mental status
Local Contraindications- • Open wounds • Sutures or stitches • Healing fracture • Skin hypersensitivity or inflammation • Infectious skin condition or sunburn
• Radiation therapy • Localized infection • Cortisone therapy (wait three or four days on the specific area) • Osteomyelitis (avoid the inflamed areas; do not treat if the client has other systemic symptoms) • Osteoporosis or advanced degenerative changes (avoid affected areas) • Rheumatological conditions (avoid inflamed areas) • Severe varicose veins
PRECAUTIONS • Decrease in blood pressure following the treatment. Patient should rest in horizontal position for 10-15 mins on the treatment table after the treatment. • MFR may lower the blood sugar levels; patient prone to develop hypoglycemia should have snacks prior to treatment. • Cautious in patient with impaired circulation, close monitoring should be done. • While treating a child or mentally incompetent adult, the caregiver should be present
PRE- TREATMENT PROTOCOLS
POST-TREATMENT PROTOCOLS • Extra amount of fluid should be consumed on the day of treatment and 1 to 2 days afterwards to avoid soreness • Caffeinated, artificially sweetened drink and alcoholic beverages should be avoided. • People who do not drink enough water may complain of deep aching pain, soreness, nausea and occasionally vomiting.
NOTE FOR THE THERAPISTS • MFR can cause compression of therapist’s fingers and hand muscle fatigue. • Decompress joints of each finger using low strokes from base to tip. • Stretch the palm of one hand by using the thumb of the other hand to stretch laterally and downward using the remaining fingers as fulcrum on the dorsum of your hand. • Dip in warm water
APPLICATION GROSS STRETCH FOCUSED STRETCH 1. For large muscles 2. For small muscles 1. Using one finger 2. Using 2 fingers 3. Two fingers reinforcing each other 4. Two fingers of one hand 5. Using thumb and finger of one hand VERTICAL STRETCH 1. Upward Lift 2. Downward pressure
GROSS STRETCH OF LARGE MUSCLES • Large area stretches proceed from Gross stretch to focused stretch of the large muscles in the same body area. • One hand or finger acts as a anchor from which stretch originates. • Other hand is used to provide the stretching force. • Alternatively, body weight can be used to anchor so that both hands can be used for the stretching force. • For large muscles such as erector spinae, middle trapezius and quadriceps femoris, better leverage is gained by crossed hand and pushing motion to stretch. • Broad surfaces like the entire palm, ulnar border of the arm, entire surface of the thumb or several fingers held together should be used.
• Gross stretch of any muscle- Large muscle being stretched by using crossed hands apart in line with the direction of muscle fibres. Use of broad surface of entire hand.
Use of ulnar border when more precise pressure is needed. Lateral surface of thumbs can also be used for precise pressure.
NOTE: ALTHOUGH INITIAL STRETCH IS APPLIED IN THE LINE WITH THE MUSCLE FIBERS, RESPONDING TO FEEDBACK FROM THE MUSCLE MAY CAUSE A CHANGE IN DIRECTION OF THE STRETCH. GROSS STRETCH OF SMALL MUSCLES- FOR SMALL MUSCLES LIKE MASSETER AND ANTERIOR DELTOID, ONLY ONE OR TWO FINGERS OF EACH HAND ARE NEEDED. ONE HAND PROXIMAL TO THE DISTAL ATTACHMENT OF THE MUSCLE TO BE STRETCHED. HORIZONTAL STRETCH IS APPLIED AND SLIPPING IS PREVENTED.
Gross stretch of small muscle using 2 fingers Gross stretch of small muscle using 1 hand
VERTICAL STRETCH • Any stretch applied perpendicular to the fibers of the target muscle using an upward lift or downward pressure is vertical stretch. • Biceps brachii, Brachioradialis, Gastrocnemius and Illiacus can be stretch this way. • In this stretch, muscle attachments provide stabilizing force. • Vertical stretch can also be given by:- 1. 2 fingers reinforcing each other. 2. Using 1 finger
FOCUSED STRETCH OF ANY MUSCLE- • Used to stretch a small segment of muscle to take up the available slack. • Focused stretch can also be given by- 1. Using 2 fingers 2. Using 2 fingers reinforcing each other
VARIATION- SELF MUSCULOFASCIAL RELEASE (SMRT) • Using foam roller, Lacrosse ball, etc. • Works on the principle of autogenic inhibition. Autogenic Inhibition- • When muscle tension increases to the point of high risk of injury, the GTO stimulates muscle spindles to relax the muscle. The reflex relaxation is autogenic inhibition. • The muscle contraction which precedes the passive stretch stimulates the GTO, which in turn causes relaxation that facilitates this passive stretch and allows for greater range of motion.
PRACTICAL-1. Postural Assessment 2. Skin Rolling 3. Palpation.. Check- • Tissue Drag • Tenderness • Tissue Rebound • Temperature 3. Types of Releases- • Longitudinal Release • Transverse Release • Cross Hand Release • Traction • Compression Possible- • Red Flare • Sudden outburst of emotion