The Road Less Traveled: Concepts and Application of Myofascial - PDF document

10/22/2019 The Road Less Traveled: Concepts and Application of Myofascial Release Justin Scherff, PT, DPT Goal/Objectives • Goal: This course is designed to give participants a greater understanding of the myofascial system and how it is related to patient management in physical therapy. This course has many opportunities for hands-on experiences. • Objectives: Upon completing this course, the participant will be able to: • 1-Describe the anatomy and physiology of the myofascial system • 2- Develop confidence in performing specific myofascial release techniques • 3-Discuss the role of myofascial release techniques in patient management. • 4- Perform a whole-body myofascial resiliency assessment. • 5- Apply the principles of myofascial release to musculoskeletal impairments. Introduction • Core Physical Therapy • Outpatient clinics: Adel, West Des Moines • Core WHY: To partner with each person on their journey so that, together, we can help them achieve their best life. 1

10/22/2019 Initial Thoughts • Application of the myofascial skill/technique is only limited by the knowledge and skill of the practitioner • Carol Manheim • You begin with anatomy, and you end with anatomy, a knowledge of anatomy is all you want or need • A.T. Still, DO What is myofascial release • Osteopathic origin • Robert Ward, 1980s • Graded, hands-on manual technique, guided by the patient’s body • Resiliency testing (eval), MFR treatment are easily interchanged, often hard to tell difference throughout a session Make-up of Fascia • 3-D network of collagen/elastin fibers • Highly innervated, avascular • High density of mechanoreceptors, proprioceptors for CNS connection • Contains ground substance • Generally 3 main layers of fascia in the body based on the anatomy and location https://www.myofascialrelease.com/images/about/deep_tissue_1.jpg 2

10/22/2019 1. Superficial Fascial Layer • Loose knit, fibroelastic connective tissue • Attachments • Between dermis and sub-cutaneous layers • Function • Storage, insulation, pathway, afferent information https://www.memorangapp.com/flashcards/58577/Anatomy%3A+Skin+%26+Subcutaneous+Tissue+I/ 2. Deep Fascia • Varies in density depending on location and function throughout the body • Compartmentalizes body (septum, pericarium, etc) • Epimysium, perimysium, endomysium • Epineurium, perineurium, endoneurium • Function • Assist w/ development of muscle tension • Connection of MSK system https://www.slideshare.net/AabyAbraham1/muscles-of-head-and-neck https://quizlet.com/134102671/histology-cross-section-of-a-peripheral-nerve-flash-cards/ Subserous Fascia • Subserous fascia • Location • Deepest layer • Function • Surrounds viscera • Provides lubrication, structure and mobility 3

10/22/2019 https://www.sciencedirect.com/topics/medicine-and-dentistry/fascia https://www.sciencedirect.com/topics/medicine-and-dentistry/fascia What does fascia do for me? • Most pervasive tissue in the body • Web-like collagenous matrix • Contributes to body contour • Helps balance/resist gravity • Enable frictionless motion, creates stability • A knowledge of the universal extent of the fascia is imperative, and is one of the greatest aids to the person who seeks the causes of disease. –A.T. Still https://www.euniquemassageandfitness.ca/index.php?page_id=Myofascial_Release 4

10/22/2019 How do Restrictions Develop • Physical Trauma • Injury, surgery, injections, asymmetrical loading • Chronic Microtrauma • Anatomical short leg, postural imbalances, lack of movement • Psycological Trauma Concepts of MFR-Greenman • Tight-loose • “tightness creates and weakness permits asymmetry” • Use of palpation • Assess, treat, reassess almost simultaneously • Neuroreflexive changes • Highly individualistic and dependent on bio-psycho-social aspects • Release phenomenon • Appropriate input into fascial system can create appropriate output Theories about why it works • Law of Facilitation • Repetitious neuronal network activation decreases threshold of activation • Law of Diffusion • SNS/PNS activation carries out through entire body • Motor Learning theory: • New mvmt pattern learned faster when patient’s body solves a problem • Arndt-Shulz law • Direct relationship between different types of touch and CNS activation • Wolff’s Law • Bones and soft-tissues deform along lines of force place on them • Hooke’s Law • Amount of strain on elastic tissue is in proportion to activating stress • Newton’s 3 rd law • Equal and opposite reaction 5

10/22/2019 General Treatment Guidelines • Find the restriction • General and isolated • Isolate body area of greatest restriction • Not necessarily the area of greatest pain • Direct or indirect? • Goal is to restore asymmetry and give exercises to solidify proper movement patterns and myofascial stress/strain patterns to improve ease of motion. MFR Treatment Concepts • POET( 3 ) • Point of Entry • T1-Tension: T2-Traction: T3-Twist • Enhancers • Anything that helps to increase tension • Isometrics, joint motion, respiration, eye movement, etc. • Exercises: • Stretch the short/tight and then strengthen the weak • Goal is balance of entire MSK system, will never be perfect • Other: • Discuss general health issues Contraindications of MFR-Barnes • Malignancy • Osteomyelitis • Febrile state • Obstructive edema • Aneurysm • Open wounds • Sutures • Hematoma • Healing fracture • Anti-coagulant therapy • Advanced • Hypersensitivity to skin degenerative changes • Advanced diabetes • Cellulitis • Systemic/local infection • Case by case basis will determine absolute vs relative, regional vs general • Generally consider benefit vs risk when confronting regional contraindications 6

10/22/2019 Proof is in the… • Research • Not a high amount of RCT/level 1 evidence • Outcomes • Care Connections outcomes • Practitioner Experience • Mark Bookhout I would challenge others in our profession to open their minds to new ideas and techniques that may not have evidence to support it, but experienced therapists and patients know they are effective. I personally have found that I’m 15-20 years ahead of the research that is coming out today to support what I’ve been teaching for years.” -Mark Bookhout- Is MFR evidence Based? • Clark et al. 1999-MFR and SLR • Hanten et al. 1994- LE pull technique and SLR • Tozzi et al 2011.-US documentation of fascial changes • Pratelli et al. 2015.-MFR and carpal tunnel • Ajimsha et al 2012.-MFR and lateral epicondylitis • Cruz-Montecinos et al 2016. –US documentation of fascial motion • Ajimsha et al 2014-MFR and plantar heel pain. Where is the pain? 7

10/22/2019 Case Study • Male, 65 y/o • Chronic B shoulder pain, L>R, referring dx: impingement • + empty can, speeds, L shoulder flex/abd limited vs R, PROM ER 72 deg and R 90. 25% lack of ext/rot in thorax • Recently on reflux meds • 4 visits working thoracic/GH mobility had full AROM/PROM pain-free, decreased daily pain, persistent riding pain • More focused MFR around diaphragm/hepatoduodenal ligament • Post tx thoracic rotation improved 25 deg • Next follow-up. More stability on the horse, riding without pain, reflux gone Case study • 38 y/o female referred for headaches, back pain • Lumbar flex 50%, ext <25% pain, SB 50% R pain, L 75% • Hip IR< 25% B w/o pain, ER 50%, SLR 50%, FRS R L5, L on R sacral torsion. • Additionally, she suffers from asthma and restricted exhalation capacities • Sig restriction around the anterior thorax/diaphragm • After treatment through abdominal/thoracic fascia, pt returned the next visit to report her back pain was totally gone. • Also reported a change from 400 to 550 L/min n her peak expiratory volume flow and no “catch” she reported prior. Summary • Fascia is everywhere • Contributes to musculoskeletal, neurological, endocrine, circulatory, and immunological functions • Eval/treatment/reassessment happen continually • Find the asymmetry, restore asymmetry • Exercises are used to provide re-education of new “tension pattern” • Once a new balance is reached and maintained, pain resolves https://reikigreet.com/collections/happy/products/club 8