Introduction to Myofascial Release PDF

Introduction to Myofascial Release By: Dr. Ahmed Abd El-Moneim Lecturer of Physical Therapy Beni-Suef University Coordinator of Prosthetics & Orthotics Technology...

Introduction to Myofascial Release By: Dr. Ahmed Abd El-Moneim Lecturer of Physical Therapy Beni-Suef University Coordinator of Prosthetics & Orthotics Technology Program (BTU) Diploma of Osteopathic Medicine, IAO (Belgium) Diploma of Therapeutic Nutrition, NNI  Fascial Response to Physical Stress  Fascial tissue responds to sustained physical stress placed on it by remodeling itself to deal with and resist that specific stress. This occurs via the creation and orientation of increased collagen fibers as a result of the piezoelectric effect that is produced by the physical force.  Fascial tissue also responds to physical stress by the formation of cells called myofibroblasts.  The Piezoelectric Effect  When pressure or tension is placed on fascia, a slight electric charge results; this is known as the piezoelectric effect.  This electric field causes the collagen molecules to orient themselves relative to that field. This results in the fibers being laid down along the line of force that caused the piezoelectric effect to occur, thereby reinforcing and strengthening the fascia within that line. The Piezoelectric Effect  The Piezoelectric Effect  The fact that fascia is laid down along the line of tension within a tissue shows the adaptability of the body to model itself to accommodate the forces placed on it. This concept becomes important for patients who have had surgery.  The fascial healing process involves the formation of collagen fibers to close the wound. If movement is engaged across the site of the incision, then the collagen that is laid down to heal the incision will be appropriately oriented along the lines of tension that the tissue site encounters.  The Piezoelectric Effect  If no rehabilitation program is instituted (if the client is not given passive motion exercises and immobilizes the region), then the collagen fibers that bind the incision site will be laid down in a disorganized willy-nilly, felt-like fashion. This increases the likelihood of excessive scarring.  Myofibroblast Formation  Fascial sheets subjected to physical stress can increase their strength by the formation of special cells called myofibroblasts (have the ability to contract). This contractile ability is a result of the presence of alpha–smooth muscle actin filaments.  Myofibroblast Formation  The number of myofibroblasts within a fascial tissue varies from place to place and person to person, but their activity increases based on the degree of physical stress that the fascial tissue is experiencing.  Myofibroblasts are very active in wound healing, where the altered stress in the fascia stimulates the myofibroblasts to proliferate to pull the edges of the tissue back together. As greater and greater tensile forces are placed on the fascia, more and more myofibroblasts develop from the normal fibroblasts. These myofibroblasts can create an active pulling force that counters and opposes the pulling force that the fascial tissue is experiencing. Myofibroblast Formation  Myofibroblast Formation  The myofibroblast contraction does not occur with the speed of skeletal muscle contraction. It builds up slowly over 15-30 minutes and fades over hours. The purpose of fascial contraction is to stiffen tissues in response to long-standing tensile forces.  Fascial tissues with high concentration of myofibroblasts have been found to have sufficiently strong force to affect musculoskeletal mechanics. Although weaker in degree and slower in time than skeletal muscular contraction forces, the fascial contraction forces are significant enough to change the dynamics of force distribution.  Myofibroblast Formation  The contraction of fascial myofibroblasts, unlike skeletal muscle contraction, is not under direct neural control. They contract in response to tensile forces that are placed on the tissue and in response to certain chemical compounds such as nitric oxide, oxytocin, and growth factors that are present in the tissue.  While present in larger numbers in wound healing, uninjured fascial tissues (the thoracolumbar fascia, the plantar fascia, and the fascia latae of the thigh) have more been found to contain significant numbers of myofibroblasts. In cases where an overt physical trauma is absent, these myofibroblasts have developed in response to the accumulation of pulling tensile forces placed on these tissues.  Myofibroblast Formation  Lower myofibroblast concentrations, although not sufficiently strong to affect musculoskeletal dynamics, have been found to exert sufficient isometric contraction pulling force to maintain their tissue integrity in the face of the tensile forces they are experiencing. Myofibroblasts in the crural fascia surrounding the lower leg, for instance, get active when there is an accumulation of lymph, thus squeezing the lower leg, reducing swelling, and aiding in the return of the lymph fluid to the heart.  Properties of Fascial Connective Tissue  Stretch: The ability of a tissue to become longer without injury or damage. All soft connective tissues of the body are able to lengthen and stretch with various body movements.  Properties of Fascial Connective Tissue  Contractility: The ability to actively shorten. This property is unique to muscular tissue and that musculoskeletal connective tissue (fascia does not possess this ability). New research has shown that fascia contains a type of cell called a myofibroblast, which generates contraction that transfers through the connective tissues.  Properties of Fascial Connective Tissue  Weight bearing: The ability of a tissue of the body to bear the compressive force of the body mass that is located above it, without injury or damage. The joints of the lower extremity and the axial body are weight-bearing joints. Because of the stress involved, weight-bearing joints demonstrate greater stability so that they are not damaged and injured.  Properties of Fascial Connective Tissue  Tensile strength: The ability to withstand a distending (lengthening) force without injury or damage. Collagen fibers, the main component of connective tissues, have great tensile strength.  Properties of Fascial Connective Tissue  Elasticity: The ability of a tissue to return to its normal length after being stretched. The presence of elastin fibers adds sustained elasticity to a connective tissue.  Properties of Fascial Connective Tissue  Plasticity: The ability of a tissue to have its shape molded or altered, and the tissue then retains that new shape.  Properties of Fascial Connective Tissue  Creep: The gradual change in shape of a tissue when it is subjected to a force that is applied to the tissue in a slow and sustained manner. The creep of the tissue may be temporary or permanent. If the creep is temporary, the tissue is sufficiently elastic to return to its original form. If the creep is permanent, the elasticity of the tissue has been exceeded and the tissue is said to be plastic.  Properties of Fascial Connective Tissue The concept of creep may be negative, such as when a client changes the tissue shape and structure of the cruciate ligaments over time because of hyperextended knees, or it may be positive, such as when manual and movement therapy are done to change and correct a client’s poor tissue shape and structure.  Properties of Fascial Connective Tissue The fact that creep of a tissue tends to occur more readily when a force is applied slowly is one reason why pressure applied during manual therapy should not be sudden and forceful; rather, the increasing depth of pressure should be done in a slow manner. This is not to say that deep pressure cannot be delivered, but rather that one should slowly sink into the muscles and fascia when applying deep pressure.  Properties of Fascial Connective Tissue  Thixotropy: The ability of a soft tissue of the body to change from a softer, more hydrated (liquid) sol state to a more rigid gel state.  Properties of Fascial Connective Tissue The matrix component of most connective tissues has a substantial ability to attain more of a sol state , which is desirable because it allows for greater freedom of blood and nutrient flow and greater freedom of movement.  Properties of Fascial Connective Tissue  Hysteresis: The process wherein a tissue exhibits fluid loss and minute structural damage as a result of friction and heat buildup when it is worked excessively as in repetitive strain injury.  Myofascial Meridians and Tensegrity  A muscle and its fascial tissues are one unit that can not really be structurally or functionally separated. The term myofascial unit, describes this idea of the unity of a muscle and its fascial tissues.  Even myofascial units (muscles) are not truly separate units that act in isolation from one another. They belong to functional groups, the members of each group sharing a common joint action.  Myofascial Meridians and Tensegrity  Fascial ligaments, joint capsules, bursae, tendon sheaths, and articular and fibrous cartilage must be added, creating a myofascial-skeletal system.  Because this system cannot function without direction from the nervous system, the nervous system must be included, creating a neuro-myo-fascial-skeletal system.  The concept of myofascial meridians is a way of looking at the structural and functional interconnectedness of this neuro-myo-fascial-skeletal system.  Myofascial meridian theory puts the concept that muscles operate within continuous lines of fascia that span across the body.  Myofascial Meridians and Tensegrity  The importance of myofascial meridian theory is manyfold: 1) It places muscles into larger structural and functional patterns that help to explain patterns of strain and movement within the body.  Myofascial Meridians and Tensegrity 2) Myofascial meridian theory creates a model that explains how forces placed on the body at one site can cause somewhat far- reaching effects in distant sites of the body.  Myofascial Meridians and Tensegrity  The third importance of the myofascial meridian theory relates to the concept of tensegrity. The concept of tensegrity relates to how the structural integrity and support of the body are created.  The classic view of the body is that it is a compression structure made up of a number of parts, each one stacked on another and bearing weight down through the body parts below.  Myofascial Meridians and Tensegrity  The structural integrity of the body is dependent on compression forces (a brick wall in which the structural integrity of the brick wall is dependent on the proper position of each brick on the bricks below).  Myofascial Meridians and Tensegrity  The myofascial meridian theory, which views the musculoskeletal body as having continuous lines of pull created by muscles linked to one another in a web of fascia, offers another way to view the structural integrity of the body.  Myofascial meridian theory looks at the lines of tension created by these myofascial meridians as being responsible for the structural integrity of the body. In this view, the proper posture and balancing of the bones of the skeleton are caused by the tensile forces created by muscles within myofascial meridians that act on the skeleton.  Myofascial Meridians and Tensegrity  The advantage of a tensegrity structure compared with a compression structure is that tensegrity structures are more resilient because stresses/forces that are applied to them are more efficiently transmitted through the structure, spreading out and diminishing their effect. If a force is applied to a bone at any specific point along the skeleton, that force will be transmitted through the body along myofascial meridians, diminishing its effect at the local site of application.  Myofascial Meridians and Tensegrity  In reality, the structural integrity of the body is dependent on both tensile and compressive forces.  The bones of the skeleton are compression members that do derive some of their structural stability from being stacked on one another and bearing weight down through the skeleton below. However, much of the structural stability of the skeleton also comes from myofascial tensile forces attaching and spanning from one bone to every other bone of the body. Myofascial Meridians and Tensegrity  Introduction  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.  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 named the ‘Cinderella of orthopedic tissue’.  Elements of Fascia  Like muscles, fascia also is sensitive to mechanical loads.  The mechanoreceptors of fascia, that responds to mechanical load or distortion, are stimulated in different ways: The Golgi tendon organs, respond to active stretch and pressure. The Pacini and Ruffini corpuscles respond to rapid pressure changes and vibrational movements. The Ruffini also responds to sustained pressure and tangential stretch. The interstitial mechanoreceptors respond to both rapid and sustained pressure changes.  Elements of Fascia  Fascia is dynamic because it is constantly undergoing change. It is continually morphing in response to the demands of both the internal and external tension imposed on it.  Elements of Fascia  Fascia is a colloid, which is a continually changing substance defined by stability, attraction forces and repulsion forces of molecules in close proximity to each other. A colloid comprises particles of solid material suspended in fluid. Colloids are not rigid; they conform to the shape of their containers and respond to pressure even though they are not compressible. 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). This is why a gentle, light, sustained touch is essential to avoid resistance and viscous drag when releasing fascial restrictions.  Elastic Properties and Force Transmission  Fascia, has an innate, variable degree of elasticity that allows it to withstand deformation when forces and pressures are applied to it. It can then recover and return to its starting shape and size.  Because fascia contracts and relaxes, it responds to load, compression and force. At the beginning of loading, fascia has an elastic response in which a degree of slack is taken up. Over time, if loading persists in a slow and sustained manner, creep develops, which is a slow, delayed yet continuous deformation.  Elastic Properties and Force Transmission  An actual volume change occurs as water is forced from the tissue.  When the applied force, or loading, ceases, fascia should return to its original non deformed state.  The restoration of shape occurs through elastic recoil via hysteresis, the process of energy use and loss in which tissues are loaded and unloaded.  The time needed for tissue to return to normal via elastic recoil depends on the uptake of water by the tissue and whether its elastic potential has been exceeded.  Role of Fascia  In addition to providing support, protection and the separation of structural elements, fascia plays a vital role in the following functions: Cellular respiration Elimination Metabolism Fluid and lymph flow Repair by deposition of repair tissue Conservation of body heat Fat storage Cellular health and the immune system  Conditions That Affect Fascia  The three primary conditions that affect fascia are as follows: 1) Injury or trauma (anything physical or emotional) 2) Inflammatory processes 3) Habitual poor posture  1) Injury or Trauma  The body can become injured from an event such as a fall, blow, cut or burn.  Injury also includes surgery of any kind, the effects of medication and overuse and underuse of the tissues as in a sporting injury.  Trauma refers to any kind of injury or hurt whether physical, emotional or spiritual.  2) Inflammatory Processes  The fascial system can be compromised by an inflammatory response to injury, a medical condition or the side effects from medication.  The inflammatory response creates an imbalance in cellular fluids and possible cell death from lack of oxygen resulting in scar formation and fascial adhesions.  3) Habitually Poor Posture  Postural adaptations refer to how we place ourselves in positions to perform tasks or to cope with strain or stress that can be either physical or emotional. When performed long enough, these adaptations become unconscious and we adopt them automatically, not realizing that we may be injuring our bodies.  When fascia is consistently overloaded from supporting a position in space (standing, seated or lying), it has to bind down to support the pressure imposed on it. As it deforms, an abnormal pull is created, which in turn creates further postural imbalance, worsening the condition.  Because this imbalance occurs over a long time, the person usually doesn’t realize it until it is too late.  3) Habitually Poor Posture  Muscles are injured at a point somewhere between their origin and insertion. Fascia, however, has no end point; it is completely continuous. For this reason, the site of the original injury, physical and emotional, can be the cause of further injuries that quietly creep through the entire fascial system and become compensatory patterns that promote further injuries or conditions that seem to have no connection to the original trauma.  3) Habitually Poor Posture  Osseous structures are passive elements and are influenced by the soft tissue sup porting them. Restricted fascial strain patterns can crowd or pull the osseous structures out of proper alignment, resulting in the compression of joints and producing pain or dysfunction, or both.  Myofascial Release (MFR) Concept  MFR is a treatment approach, a therapy and a rehabilitation tool. It is a hands-on therapy, meaning that the therapist applies pressure with the hands onto, and into, the patient’s body.  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.  Myofascial Release (MFR) Concept  The MFR therapist performs a visual, movement and palpatory assessment and obtains a client consultation form. Once the evaluation has been completed, the therapist commences treatment in areas that feel tight, hot or tender. These areas will not always be where the client is experiencing pain. This is because MFR is based on the entire fascial matrix, which, when restricted, creates a tensile force, affecting pain-sensitive structures through its network.  Myofascial Release (MFR) Concept  The actual application of the hands-on technique is a slow, sustained pressure held at the barrier of tissue resistance, usually for five minutes or more without slipping over the skin.  Less pressure applied to tissue results in a greater response; firmer and quicker pressure results in tissue resistance. This emphasizes the need for slow, sustained pressure, not forgetting the response of the various mechanoreceptors.  Myofascial Release (MFR) Concept  MFR slowly squeezes out the free water from the tissue encouraging fresh, clean water to return.  MFR stimulates the four mechanoreceptors of the fascial matrix 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. Sustained MFR approach promote the healthy activation of all of the fascial mechanoreceptors ultimately promoting and maintaining health and function.  Myofascial Release (MFR) Concept  MFR 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 time needed for tissues to begin to rearrange themselves is approximately 90 to 120 seconds. 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.  Myofascial Release (MFR) Concept  As the collagen and elastin fibers reorganize themselves, cross-linkages in these fibers are broken down, fascial planes are realigned, local circulation (waste and nutrient exchange) improves and the soft tissue proprioceptive sensory mechanisms are reset. As the sensory mechanisms are reset, there is a reprogramming of the central nervous system, enabling a normal functional range of motion without eliciting the old pain pattern.  Myofascial Release (MFR) Concept  The application of quick, firm force will result in the entire matrix effectively pushing the therapist’s hands back out. Instead, the therapist must place the hands on the body and, with a gentle pressure, lean into the tissue to reach the barrier of restriction. The therapist waits, feeling for the moment the hands sink into the tissue, and takes up the slack as it is offered. The slower the pressure is applied, the greater the release of the collagen within the ground substance and the increase of bound water.  Myofascial Release (MFR) Concept  Fascia responds to touch by softening and yielding, allowing the therapist to follow that softening through barrier after barrier of restriction in any direction in a three-dimensional manner.  Because the tissue begins to release only after about 90 to 120 seconds of pressure, each technique must be performed longer than this to facilitate lasting change (MFR techniques should be performed for five minutes or more).  Myofascial Release (MFR) Concept  MFR therapists feel for tissue resistance in all techniques; this is called the end-feel, or tissue barrier. The term end-feel is used to refer to where the tissue moves and where it is stuck. Where it feels stuck (abnormal end-feel) is where a technique is applied.  In MFR, the end-feel is where the tissue (fascia) feels stuck and is resistive to subtle pressure or traction. If the therapist continues to pull or push past this tissue resistance, or end-feel, the tissue simply shuts down and the efforts to release it become useless.  Myofascial Release (MFR) Concept  Another important form of feedback during the treatment session, to help the therapist determine technique progression, is vasodilation, or red flare. This occurs where there is an increase in circulation as the tissue releases along the lines of pull.  The patient may report a sense of tissue movement or softening in sites distant to where the therapist’s hands are. This is due to the release of restrictions along a line of pull.  Myofascial Release (MFR) Concept  The MFR therapist should also note any spontaneous movement or twitching anywhere in the client’s body (myofascial unwinding).  Advantages of MFR  Works on the entire fascial matrix and not only muscles or muscle lengths and their associated fascial sheaths.  Finds the pain and looks elsewhere for the cause.  Has a time element to allow the fascia to yield to touch without force in a three dimensional manner.  Engages the patient in the entire process promoting communication to enhance the response to the treatment.  Is not protocol or session-length orientated; each session offers a unique treatment.  Benefits of MFR  General increase in health due to the increase in water volume (bound water) in the ground substance (nutrient and waste exchange).  Promotion of relaxation and a sense of well-being.  Elimination of general pain and discomfort.  Increased proprioception.  Re-established and improved joint range of motion and muscle function.  Benefits of MFR  Improved digestion, absorption and elimination.  Restored balance and promotion of correct posture.  Injury recovery and rehabilitation.  Can be used as part of an athletic or sport training routine and maintenance programme to promote mobility and performance.  Promotion of awareness of emotional issues and how they may be resolved.  Benefits of MFR  The benefits for therapists using MFR in their treatments are as follows: Is easy to learn and apply Can be easily integrated into existing practices Offers diversity in treatment approaches Increases career longevity because it is easy on the therapist’s body and hands Increases a sense of touch