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

10/22/2019 1

The Road Less Traveled: Concepts and Application

• f 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

• pportunities 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.

10/22/2019 2

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
• f 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

10/22/2019 3

• 1. Superficial Fascial Layer
• Loose knit, fibroelastic connective tissue
• Attachments
• Between dermis and sub-cutaneous layers
• Function
• Storage, insulation, pathway, afferent information

• 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

10/22/2019 4

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

10/22/2019 5

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
• utput

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 3rd law
• Equal and opposite reaction

10/22/2019 6

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
• Febrile state
• Aneurysm
• Sutures
• Healing fracture
• Advanced

degenerative changes

• Cellulitis
• Systemic/local

infection

• Osteomyelitis
• Obstructive edema
• Open wounds
• Hematoma
• Anti-coagulant therapy
• Hypersensitivity to skin
• Advanced diabetes
• Case by case basis will determine absolute vs relative, regional vs general
• Generally consider benefit vs risk when confronting regional contraindications

10/22/2019 7

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

• ut 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?

10/22/2019 8

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

10/22/2019 9

Final thought

• Rollin Becker:

“The first step in developing depth of feel and touch is re-evaluate the patient from the 3rd problem standpoint….what does the patient’s body want to tell you? Take the patient’s story/opinion and set it aside, take your opinion and dx and set it aside, and let the patient’s body give you the opinion”.

• Academy of Applied Osteopathy—1963 Yearbook

Words of Wisdom from Core PT

• “Trust your hands and your gut, don’t over think it”
• “If you think you’re light…go lighter. Use as little effort on your part and truly let

the body talk to you”

• “When palpating, make a mistake on purpose”
• “Patience, their body is trying to communicate with you IF you take the time to

listen”

• “Get really good at the basics of finding restrictions and releasing them; paired

with a solid anatomy understanding will open up doors you never expected.”

• “Tissue that is highly irritable probably is not where you should be treating,

some thing else is driving that”

• “Tightness in the myofascial system correlates with patient reported symptoms

better than any other evaluation technique or imaging study I have seen. People with tight fascial systems hurt and people with freely moving fascial systems do

• not. The dysfunctional fascial system describes why some people with arthritis
• r disc issues hurt and other people with the same arthritis or disc issue have no

pain”

Bibliography

• Ajimsha, MS, Chithra, S, and Thulasyammal, RP. Effective ness of Myofascial Release in the Management of Lateral Epicondylitis in

Computer Professionals. Arch Phys Med Rehabil. 2012; 93: 604-609, doi: 10.1016/j.apmr.2011.10.012.

• Ajimsha MS, Binsu D, ChithraS. Effectiveness of myofascial release in the management of plantar heel pain : a randomized control trial.
• Foot. 2014; June; 24(2): 66-17. doi: 10.1016/j.foot.2014.03.005.
• Ajimsha MS, Al-MudajkaNR, and Al-Madzhar JA. Effectiveness of myofascial release: a systematic review of randomized controlled trials.

J Bodyw Mov Ther. 2015 Jan;19(1):102-12. doi: 10.1016/j.jbmt.2014.06.001.

• Barnes, JF. Myofascial Release Techniques PDF. https://myofascialrelease.com/downloads/ articles/ PediatricMyofascialRelease.pdf.

Accessed 10/15/19

• Becker, R. Diagnostic Touch: Its Principles and Application. Academy of Applied Osteopathy—Yearbook 1963. Sourced from

Craniosacral osteopathy: Part 3 Workbook.

• Briner B. Craniosacral Osteopathy: Part III Course workbook, 2019.
• Bookhout, M. https://manualtherapyforum.com/2018/02/26/mark-r-bookhout-ms-pt-faaompt-cfmm/. Accessed 9/2/2019.
• Clark S, Christinasen A, Hellman DF, Meier Hurt J, Winga Hugunin K. The effects of anterior thigh oft tissue stretching on passive

unilateral straight leg raise measurements. JOSPT. 1999; 29(1): 4-12.

• Cruz-Montecinos, C, Cerda, M, Sanzana-Cuche,R, Martin-Martin, J and Cuesta-Vargas, A. Ultrasound assessment of fascial connectivity in

the lower limb during maximal cervical flexion: technical aspects and practical application of automatic tracking. BMC Sports Science, Medicine and Rehabilitation. (2016) 8:18 DOI 10.1186/s13102-016-0043-z.

• DeStefano, L. Integrated Neuromuscular Approach to Myofascial Pain Syndromes and Myofascial Release Techniques. Course syllabus,

2018.

• Greenman P. Principles of Manual Medicine, 2nd Edition. Williams and Wilkins, Baltimore, 1989.
• Hanten, WP and Chandler SD. Effects of myofascial release leg pull and sagittal plane isometric contract-relax techniques on passive

straight-leg raise angle. JOSPT. 1994: 20(3): 138-144. DOI: 10.2519/jospt.1994.20.3.138.

• Manheim C. The Myofascial Release Manual. SLACK Incorporated, Thorofare, NJ: 2008.
• McKenney K, Sinclair, A, Elder, C, and Hutchins, A. Myofascial Release as a Treatment for Orthopaedic Conditions: A Systematic Review.

Journal of Athletic Training 2013;48(4):522–527 doi: 10.4085/1062-6050-48.3.17.

• http://www.dynamicpotency.com/words-and-wisdom-osteopathic-quotes-2/ Accessed 10/5/19.
• Pratelli, E, Pintucci, M, Cultera, P, Baldini, E, Stecco, A, Petrocelli, A and Pasquetti, P. Conservative treatment of carpal tunnel syndrome :

Comparison between laser therapy and fascial manipulation. J of Bodywork and Movement Therapies. 2015; Jan; 19(1): 113-118. doi: 10.1016/j.jbmt.2014.08.002.

• Still, AT. THE PHILOSOPHY and MECHANICAL PRINCIPLES of OSTEOPATHY. ANDREW TAYLOR STILL, 1902. HUDSON-EIMBERLT PUB.

KANSAS CITY, Mo. https://fasciaresearchsociety.org/sites/default/files/docs/The%20Fascia-AT%20Still.pdf Accessed 10/5/19.

• Tozzi, P, Bongiorno D, Vitturini C. Fascial release effects on patient with non-specific cervical or lumbar pain. J Bodywork and Movement
• Therapies. 2011; Jan; 15(4): 405-416. doi: 10.1016/j.jbmt.2010.11.003.