Myofascial release ue (1)

Myofascial Release & Myofascial Release & Trigger Point TherapyTrigger Point Therapy

Modern Manual Therapy IModern Manual Therapy I

KNR 494KNR 494

FasciaFascia• 3D network of connective tissue from 3D network of connective tissue from

head to toehead to toe

• ContainsContains- Vascular structuresVascular structures- Adipose cellsAdipose cells- Sensory receptors Sensory receptors (Manheim, 2001)(Manheim, 2001)

• Myofascial tissue?Myofascial tissue?

Myofascial TissueMyofascial Tissue(Marieb, 2004)

Myofascial PainMyofascial Pain• Originates in both muscle & fasciaOriginates in both muscle & fascia

• SymptomsSymptoms- Deep, sharp, burning, dull, diffuse, Deep, sharp, burning, dull, diffuse,

heavy, squeezing heavy, squeezing

• Needs to be treated quicklyNeeds to be treated quickly- Why?Why?

What is Myofascial Release What is Myofascial Release (MFR)?(MFR)?

• Interactive stretching technique that Interactive stretching technique that uses manual pressure to facilitate uses manual pressure to facilitate maximum relaxation of tight or maximum relaxation of tight or restricted tissuesrestricted tissues- DirectionDirection- ForceForce- Duration Duration (Manheim, 2001; (Manheim, 2001; Ferguson & Ferguson &

Gerwin)Gerwin)

““Fixes/Anchors”Fixes/Anchors”• ForearmForearm• ElbowElbow• FistFist• Palm Palm • GripGrip• Reinforced thumbsReinforced thumbs• Finger(s)Finger(s)• Knuckle(s)Knuckle(s)• External devices External devices

(Manheim, 2001)

Direction of StretchDirection of Stretch

• Horizontal Horizontal • DiagonalDiagonal• Perpendicular Perpendicular • Vertical Vertical

Why not just use a gross Why not just use a gross stretch?stretch?

Benefits of MFR over GTBenefits of MFR over GT

• Less expensiveLess expensive• Patient easePatient ease• Less invasiveLess invasive• Self-treatSelf-treat• Tightness vs. restrictionsTightness vs. restrictions• Difficult to evaluate some areas with Difficult to evaluate some areas with

GTGT

General IndicationsGeneral IndicationsMyofascial restrictionsMyofascial restrictions• Pain has not been alleviated by other Pain has not been alleviated by other

treatmentstreatments• Pain is complex, global, or specific pain Pain is complex, global, or specific pain • Underlying chronic condition causing Underlying chronic condition causing

tightness and restrictionstightness and restrictions• Complex postural asymmetriesComplex postural asymmetries• Athlete needs stretching to increase Athlete needs stretching to increase

performance and prevent injury performance and prevent injury (Manheim, 2001)

Precautions/Precautions/ContraindicationsContraindications

Myofascial RestrictionsMyofascial Restrictions• Inflammation Inflammation • Patient uncomfortable with touchPatient uncomfortable with touch• DermatitisDermatitis• Contagious/infectious disease Contagious/infectious disease • Fractures/open woundsFractures/open wounds• Circulatory problemsCirculatory problems• Taking blood clotting medicine Taking blood clotting medicine • Osteoporosis Osteoporosis (Manheim,

2001)

MFR Treatment StepsMFR Treatment Steps

1.1. Gross stretch of entire body area Gross stretch of entire body area

2.2. Focused stretch of muscles in same Focused stretch of muscles in same body areabody area

3.3. Finish with gross stretch of entire Finish with gross stretch of entire musclemuscle

Focused StretchFocused Stretch• One hand, finger or body One hand, finger or body

weight acts as anchor weight acts as anchor • Use broad surface to apply Use broad surface to apply

stretch if possible for large stretch if possible for large musclesmuscles

• For smaller muscles – use For smaller muscles – use 1 or 2 fingers1 or 2 fingers

Focused StretchFocused Stretch• 1-2 fingers of each hand1-2 fingers of each hand• 1 or both hands may move1 or both hands may move• Distance between fingers may be Distance between fingers may be

several millimeters/inchesseveral millimeters/inches

Levels of MFRLevels of MFR

1.1. No stretch/pre-tension No stretch/pre-tension

2.2. Pre-tension (stripping)Pre-tension (stripping)

3.3. Moderate passive stretch Moderate passive stretch

4.4. Active MFRActive MFR(Leahy & Mock)(Leahy & Mock)

Common MistakesCommon Mistakes

• Too much pressureToo much pressure

• Too long of stretchToo long of stretch

• Too many applicationsToo many applications

Myofascial Trigger PointsMyofascial Trigger Points

Myofascial Trigger Points Myofascial Trigger Points (TP)(TP)

• A hyperirritable spot located within a A hyperirritable spot located within a taut band of skeletal muscle or its taut band of skeletal muscle or its fasciafascia- ActiveActive- Latent Latent

(Travell & Simons, (Travell & Simons, 1983)1983)

(Marieb, 2004)

Overloading Stretch/shorteni

ng Micro/macro

trauma

Destruction of sarcolema & SR

Release of Ca2+

Sustained muscle

contractionIschemia, hypoxia,

metabolic waste

Trigger point formation/activatio

n

Release of nociceptive substances

Local pain, muscle guarding & REFERRED PAIN

Loss of flexibility

(Kostopoulos & Rizopoulos, 2001)

How can TP therapy How can TP therapy alleviate this pathologic alleviate this pathologic cycle?cycle?

Considering FibromyalgiaConsidering Fibromyalgia

Trigger PointsTrigger Points• No gender biasNo gender bias

• Can be sudden & Can be sudden & related to specific related to specific movementsmovements

• Often have taut Often have taut bands and twitch bands and twitch responsesresponses

FibromyalgiaFibromyalgia

General IndicationsGeneral Indications

Myofascial Trigger PointsMyofascial Trigger Points• Frequently complaints of Frequently complaints of

referred painreferred pain• Autonomic & Autonomic &

proprioceptive proprioceptive disturbances disturbances

• Taut band Taut band • Tender and painful Tender and painful

nodules nodules • Local twitch responseLocal twitch response• Limited ROMLimited ROM• Muscle weaknessMuscle weakness

(Kostopoulos & Rizopoulos, 2001)

Precautions/Precautions/ContraindicationsContraindications

Trigger PointsTrigger Points• Inflammation Inflammation • Patient uncomfortable with touchPatient uncomfortable with touch• DermatitisDermatitis• Contagious/infectious disease Contagious/infectious disease • Fractures/open woundsFractures/open wounds• Circulatory problemsCirculatory problems• Taking blood clotting medicine Taking blood clotting medicine • Osteoporosis Osteoporosis (Manheim,

2001)

Trigger Point TherapyTrigger Point TherapyProgressive pressure Progressive pressure

technique/Ischemic Compressiontechnique/Ischemic Compression• Use pain as guideUse pain as guide

- Varying pressure (light Varying pressure (light pressure/stretching, heavy pressure)pressure/stretching, heavy pressure)

• 10 seconds to 2 minutes10 seconds to 2 minutes• Follow with myofascial stretching Follow with myofascial stretching • Positive stretch signPositive stretch sign

(Kostopoulos & Rizopoulos, 2001)

Trigger Point Therapy: Self Trigger Point Therapy: Self TreatmentTreatment

Trigger Point TherapyTrigger Point Therapy

Positional Release Therapy/Strain-Positional Release Therapy/Strain-CounterstrainCounterstrain

• Trigger points are addressed while Trigger points are addressed while body is a position of comfortbody is a position of comfort

(D’Ambrogio & Roth, 1997)(D’Ambrogio & Roth, 1997)

Physiologic basis?Physiologic basis?Reduce muscle spindle Reduce muscle spindle inputinput

Trigger Point TherapyTrigger Point TherapyIce-and-stretchIce-and-stretch• Apply ice in sweeping motion Apply ice in sweeping motion • Slow continual passive stretch is applied at same Slow continual passive stretch is applied at same

time as ice applicationtime as ice application• Can also add contraction of antagonistCan also add contraction of antagonist• Can repeat for several cyclesCan repeat for several cycles

Trigger Point TherapyTrigger Point Therapy

Stripping MassageStripping Massage• Deep-stroking massage applied with Deep-stroking massage applied with

minimal lubrication on the fingertipsminimal lubrication on the fingertips• Increase pressure with each successive Increase pressure with each successive

pass along musclepass along muscle

Both stripping and ischemic compression Both stripping and ischemic compression are believed to cause a reflexive hyperemia are believed to cause a reflexive hyperemia that returns the site to a normal conditionthat returns the site to a normal condition

Myofascial & Trigger Myofascial & Trigger Point Treatments:Point Treatments:Upper ExtremitiesUpper Extremities

Gross Stretch of Upper Gross Stretch of Upper QuarterQuarter

Arm PullArm Pull• Supine Supine • Stretch parallel to floorStretch parallel to floor• Hold for release and repeatHold for release and repeat

CautionCaution• ATC must be relaxedATC must be relaxed• Elbow flex contracture Elbow flex contracture • Hypermobile elbow Hypermobile elbow

Gross Stretch of Upper Gross Stretch of Upper QuarterQuarter

Bilateral Arm PullBilateral Arm Pull• Supine/proneSupine/prone• Stretch parallel to Stretch parallel to

floorfloor• Hold for release and Hold for release and

repeatrepeat

Posterior Cervical: TPPosterior Cervical: TP

SuboccipitalsSuboccipitals

Splenius capitusSplenius capitus

Posterior CervicalPosterior Cervical

Make sure you know pathologies associated with muscles

Posterior CervicalPosterior Cervical

Posterior CervicalPosterior Cervical

Scalenes: TPScalenes: TP

PathologyCombine with joint mobilizationIntercostals

Upper Trapezius: TPUpper Trapezius: TP

Upper TrapeziusUpper Trapezius

Upper Trapezius (Active Upper Trapezius (Active MFR)MFR)

(Johnson, 2009)

Sternocleidomastoid: TPSternocleidomastoid: TP

Subacromial Impingement: Subacromial Impingement: Forward HeadForward Head

• Causes:Causes:- Stretch of levator scapulaeStretch of levator scapulae

• Decreases scapular:Decreases scapular:- Posterior tiltPosterior tilt- Upward rotation Upward rotation

(Ludewig et al, 1996)(Ludewig et al, 1996)

Levator Scapulae: TPLevator Scapulae: TP

X

Levator Scapulae (Active Levator Scapulae (Active MFR)MFR)

(Johnson, 2009)

Acromioclavicular Ligament: Acromioclavicular Ligament: ReleaseRelease

Subacromial Impingement: Subacromial Impingement: Rounded ShouldersRounded Shoulders

• Causes:Causes:- Tight serratus anterior & Tight serratus anterior &

pectoralis minor & majorpectoralis minor & major

(Kendall, 2005)(Kendall, 2005)

• Increases scapular:Increases scapular:- ProtractionProtraction

Pectoralis Major: TPPectoralis Major: TP

Pectoralis MajorPectoralis Major

Pectoralis Major: ReleasePectoralis Major: Release

Pectoralis Major: Traction Pectoralis Major: Traction ReleaseRelease

Scapular Release:Scapular Release:ProtractionProtraction

Scapular Release:Scapular Release:ProtractionProtraction

Scapular ReleaseScapular Release

• Translate scapula toward spineTranslate scapula toward spine- SuperiorlySuperiorly- InferiorlyInferiorly

Scapular Release with Pectoral Scapular Release with Pectoral StretchStretch

Scapular ReleaseScapular Release

• Side lyingSide lying• Push scapula superiorlyPush scapula superiorly• Pull humerus inferiorlyPull humerus inferiorly

Pathology?Pathology?

Anterior Capsule ReleaseAnterior Capsule Release

Effective for adhesive capsulitisEffective for adhesive capsulitis

Pectoralis Minor: TPPectoralis Minor: TP

Pectoralis MinorPectoralis Minor

Perctoralis MinorPerctoralis Minor

SupineSupine

Pectoralis MinorPectoralis Minor

Deltoids: TPDeltoids: TP

DeltoidsDeltoids

Latissimus Dorsi: TPLatissimus Dorsi: TP

Latissimus DorsiLatissimus Dorsi

Latissimus DorsiLatissimus Dorsi

Prayer position

Middle/Lower Trapezius: TPMiddle/Lower Trapezius: TP

Lower/Middle TrapeziusLower/Middle Trapezius

Middle TrapeziusMiddle Trapezius

Lower TrapeziusLower Trapezius

Rhomboids: TPRhomboids: TP

RhomboidsRhomboids

Teres Major: TPTeres Major: TP

Teres MajorTeres Major

Serratus Anterior: TPSerratus Anterior: TP

Serratus AnteriorSerratus Anterior

Side lying with arm behind back

Subscapularis: TPSubscapularis: TP

Focused Stretch: Focused Stretch: SubscapularisSubscapularis

Subscapularis ReleaseSubscapularis Release

Subscapularis ReleaseSubscapularis Release

Supraspinatus: TPSupraspinatus: TP

SupraspinatusSupraspinatus

GIRDGIRD

Infraspinatus: TPInfraspinatus: TP

X

InfraspinatusInfraspinatus

Infraspinatus (Passive MFR)Infraspinatus (Passive MFR)

Teres Minor: TPTeres Minor: TP

Teres MinorTeres Minor

• Additional stretchAdditional stretch- Place patient’s arm in internal rotationPlace patient’s arm in internal rotation

Teres Minor (Passive MFR)Teres Minor (Passive MFR)

Posterior Capsule (Passive Posterior Capsule (Passive MFR)MFR)

Biceps Brachii: TPBiceps Brachii: TP

Biceps BrachiiBiceps Brachii

Triceps: TPTriceps: TP

Supinator: TPSupinator: TP

Supinator: TPSupinator: TP

Extensor Carpi RadialisExtensor Carpi Radialis(Longus & Brevis): TP(Longus & Brevis): TP

Pronator Teres: TPPronator Teres: TP

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Flexor Carpi Ulnaris: TPFlexor Carpi Ulnaris: TP

Flexor MassFlexor Mass