Archives for posts with tag: manual therapy

Many clinicians are still focused on “stretching fascia”. Research shows that fascia requires up to 1997 N/cm2 of force (448.9 pounds of force) to stretch and deform it.(1) Not that clinicians would be able to deform it with manual techniques but the questions becomes if it should be deformed. When a structure or tissue is deformed, it loses its structural integrity. With connective tissues, muscle loses its ability to lengthen or contract due to tearing of the fibers where fascia loses its ability to dissipate electrical discharge to coordinate movement patterns.(2, 3) Our manual techniques do produce mechanical changes, it is on the abnormal collagen crosslinks that form during the inflammatory process that, hopefully, are still immature and malleable. However, there is also an effect via the nervous system provided by sensory input and muscle spindle stretch that can also be utilized to create functional changes and decreasing symptoms.

A review of myofascial grading system finds the range from I-V and encompasses both passive (grades I-III) and active (grades IV-V) techniques. With increases grades, many assume this corresponds with increasing pressure but that is an incorrect assumption; it corresponds with increased tissue tension. If there is significant pressure applied, the brain interprets it as a painful stimuli and will contract the tissues to protect the underlying structures. Even though the techniques are designed to be inhibitory, the patient may present as tighter after the techniques if the self-protection mechanisms have been activated via the nociceptor stimulation.

Here is a review of myofascial release techniques, their purpose and their mechanism of action:

Grade I

Rationale: to decrease pain after acute trauma or in instance of central sensitization (fibromyalgia, complex regional pain syndrome, reflex sympathetic disorder, thoracic outlet syndrome)

Technique: pressure is applied to tissue is passively placed in the position it assumes as it contracts

Mechanism: neurological: autogenic inhibition via decreased tension of the muscle spindle

Basis for: Jones Strain-Counterstrain (SCS), Positional Release Techniques (PRT)

Grade II

Rationale: to decrease pain after acute trauma or in instance of central sensitization (fibromyalgia, complex regional pain syndrome, reflex sympathetic disorder, thoracic outlet syndrome)

Technique: pressure is applied to tissue in a shortened positioned then moved to neutral

Mechanism: neurological: autogenic inhibition via decreased tension of the muscle spindle

Basis for: pin-and-stretch technique

Grade III

Rationale: to improve mobility in areas of myofascial adhesions and mechanical restrictions

Technique: pressure is applied to tissue in a shortened positioned then passively moved to a stretch

Mechanism: mechanical: stretching and shearing of abnormal collagen crosslinks

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

Grade IV

Rationale: to improve mobility in areas of myofascial adhesions, mechanical restrictions or trigger points

Technique: pressure is applied to tissue in a shortened positioned then actively moved to a stretch

Mechanism:   mechanical: stretching and shearing of abnormal collagen crosslinks

Neurological: relaxation of the tissue via reciprocal inhibition

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

Grade V

Rationale: to improve mobility in areas of myofascial adhesions and mechanical restrictions

Technique: pressure is applied to tissue in a lengthened positioned then concentrically contracted

Mechanism: mechanical: stretching and shearing of abnormal collagen crosslinks

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

References

  1. Chaudhry H, Schleip R, et al. Three-dimensional model for deformation of human fasciae in manual therapy. 2008. Journal of the American Osteopathic Association. 108:379-390.
  2. Langevin HM. Connective tissue: a body-wide signaling network? 2006. Medical Hypothesis. 66(6):1074-77.
  3. Ingber DE. Tensegrity and mechanotransduction. 2008. Journal of Bodywork and Movement Therapies. 12(3):198-200.

From our DVD “Combining Manual Therapy with Kinesiology Taping”:
Steve Middleton, MS, ATC, CSCS, CES, CKTP, FMT discusses the benefits of gua sha and how to incorporate it into your clinical practice:  “Introduction to Instrument Assisted Soft Tissue Mobilization”

Typically, when discussing fascial compensations, we discuss hypomobility in one area leading to compensatory hypermobility in another region that typically becomes symptomatic/painful. However, there are times when weakness in a portion of the line will lead to compensations elsewhere.

Superficial Anterior Fascial Line
A fascial line spans the human form from the feet to the cranium. While it is looking at fascia specifically, the overlay tends to encompass common postural muscles. The SAFL is comprised of :
Extensor digitorum/hallucis longus
Anterior tibialis
Rectus femoris
(connection via the inguinal ligament)
Rectus abdominis
Sternalis/sternal fascia
Sternocleidomastoid
Cranial aponeurosis

When weakness occurs in one of the sub-units/muscles, another area will increase in tone to tension the entire line for either stability or strength. This may be automatic in some individuals but a trained response in others.

SAFL Strength and Stability
Any anterior core exercise can be utilized to assess the strength and stability of the SAFL. Common examples include:

The Crunch
Due to weakness in the rectus abdominis, the individual initiates the movement in the cervical spine by moving into lower cervical flexion and upper cervical extension via contraction of the sternocleidomastoid. This will tension the sternalis/sternal fascia which then tensions the rectus abdominis to pull the thoracolumbar junction into flexion. In cases of extreme rectus abdominis weakness, the clinician can see a whipping action of the head as the individual attempts to create momentum to bring their upper torso off the floor.
Cuing should consist of keeping the scapula retracted and the cervical spine in neutral while activating the rectus abdominis. Range of motion may initially be limited to ensure proper form before progressing through a larger range or performing an isometric hold.

The Plank
Again, weakness in the rectus abdominis tends to be the limiting factor in completing this movement. The individual tensions the rectus femoris which creates slight knee hyperextension but definite hip flexion. The pull of the rectus femoris on the AIIS of the pelvis creates an anterior rotation that pulls the distal insertion of the rectus abdominis inferiorly to tension the muscle. In cases of extreme rectus abdominis weakness, you may also see cervical flexion as the sternocleidomastoid also attempts to tension the rectus abdominis via a superior pull as well.
Cuing should emphasize performing an isometric contraction of the gluteus maximus (i.e. glute set, glute squeeze) to provide lumbo-pelvic stabilization. Modifications should consist of proper initiation of the rectus abdominis by having the thighs fully supported on a Swiss ball or mat table where the patient only has to manipulate half of their body weight initially; progression would involve moving the ball distally towards the feet to increase weight bearing status while also increasing the number of anterior core muscle recruited.

REFERENCE
Myers T. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists.

CLINICIAN EDUCATION: synaptic facilitation

 

Pavel Tsatsouline is a well known Russian strength coach known for his somewhat unorthodox approaches to training and conditioning. One of his well known approaches is referred to as “greasing the groove”. With this approach, he discusses practicing certain techniques to improve the ability to perform other, more complicated movements.

This can easily be applied to rehabilitation:

1. address soft tissue restrictions by performing post-isometric relaxation techniques (agonist-contract, contract-relax, contract-relax-agonist-contract) to the antagonist of the movement

2. apply proprioceptive neuromuscular facilitation to the agonist of the muscle to activate it from the movement’s synergists

3. have the person perform a set of 10 reps of active movement

CLINICAL EXAMPLE: decrease hip extension

1. ensure no restriction of mobility due to joint or capsule adhesions

2. with the patient prone, perform PIR to the hip flexors (rectus femoris, iliopsoas, tensor fascia latea, sartorius)

3. with the patent prone, perform PNF to the gluteus maximus and hamstrings (semi membranosus/ semitendinosis)

4. with the patent prone, have him/her perform active hip extension for 10 reps

PATIENT EDUCATION:  Sitting Posture #2

The vast majority of our patients sit at desks for their 8-10 hour workday. They tend to present with neck and upper back pain due their jobs. But why is this happening?

Sitting posture can have a significant impact on the body as a whole. Often, it is a hip restriction that prevents proper sitting posture. In the image below, the postural compensations (kyphosis, forward head posturing) are a result of the hip being unable to reach 90 degrees of flexion. This is required in order to keep the spine in neutral.

However, many people develop poor sitting posture during their teen years by slumping or lounging in chairs where their hips never reach 90 degrees or above. Others develop hip hypo mobility due to poor furniture design: most chairs and couches are too deep where the back is not supported in an upright position so the person ends up leaning backwards (hip < 90 degrees flexion) in order to have their spine supported.

Physiologically, several pathologies may be contributing to this long term dysfunction. The person may develop posterior soft tissue shortening: gluteus maximus and hamstrings primarily. S/he may also develop contractors of the joint capsule that will prevent the hip from moving to 90+ degrees. Skilled therapy services are required to identify which, if not both, of the conditions are affecting overall posture and the symptoms associated with it.

PATIENT EDUCATION:  Sitting Posture #1

Rarely do we think of how we are sitting. Often, we are given a chair at work or purchase a chair for home without ever trying it out by seeing how it fits our body type.

Most people are unaware that chairs are designed for a certain height range. Do you know what it is? (see image below)

People outside of this height range have to make compensations to be able to sit somewhat comfortably. Individuals below this height, typically females, tend to tuck their feet back so they can tip-toe balance on the chair. Males above this height range also tend to tuck their feet in order to get their knees out of their chests.

As the feet tuck back, this leads to shortening of the calf muslces (gastrocnemius and soleus). The increased knee flexion also leads to shortening of the hamstrings and the popliteus. With the feet unsupported, the pelvis tilts anteriorly which leads to compensatory arching of the low back (lumbar hyperextension) which shortens the lumbar paraspinals, thoracolumbar fascia and latissimus dorsi. The majority of these are components of the Posterior Fascial Line from Anatomy Trains. This can lead to pain in the primarily in the ankles but may also affect the knees, hips, low back and even the neck and shoulders with tightness initially but progressing to pain with prolonged abnormal use.

A better option would be to make the chair compensate to you. If you are shorter than the range, use a small box or phone book under your feet to bring the floor closer to you. If you are taller than the chair range, placing a pillow or cushion in the seat to make it taller would be beneficial.

CLINICIAN EDUCATION:  Therapeutic Exercise

Does a muscle that tests weak automatically need strengthening?

The functional unit of a muscle, a myofibril, is comprised of 2 primary fibers: actin and myosin. Muscles have optimum lengths determined by the amount of actin and myosin overlap. At optimal length, the actin and myosin are able to couple and create a ratcheting force to pull the fibers closer together and create a concentric contraction (shortening) to move the corresponding joint.

It is well accepted that a muscle that is too long (>4 mm of striation spacing), the muscle well test weak during manual muscle testing (MMT) with a grade of 4/5 or less. Strengthening exercises are required to provide appropriate neural input and muscular strengthening. However, the muscle may be inhibited by a hypertonic (short/tight) antagonist that needs to be appropriately lengthened to allow the agonist to contract properly.

However, a muscle that is too short (2.0 mm or less of striation spacing) will also test weak. In this case, there exists excessive overlap where the actin and myosin are already so contracted that the fibers cannot slide further to create a concentric contraction. In this instance, strengthening the weak muscle will actually make it more hypertonic and, subsequently, weaker if the person is even able to perform the exercise. These shortenings are most likely due to a myofascial adhesion where a more appropriate treatment option would be myofascial release, instrument assisted soft tissue mobilization and/or stretching to restore appropriate muscle length which should restore strength by allowing appropriate sliding of the actin and myosin filaments.

REFERENCES
http://www.tiem.utk.edu/~gross/bioed/webmodules/muscles.html

I often joke that as we are becoming Doctors (of Physical Therapy, of Occupational Therapy, of Athletic training), we are becoming more like Doctors (of Medicine) in that many are taking a hands-off approach to patient care. Oddly, some chiropractors are taking a hands-off approach in using adjusting tools such as the Activator Methods International or computerized adjusting equipment from Sigma Instruments. (This is especially ironic since “chiro” is Latin for “of the hands”.)

While physical touch can have many positive influences from a rehabilitative stand point, it can also improve psychological and emotional well-being:

Manual therapies have been shown to decrease anxiety, tension and depression in active populations(1). The results have actually shown a greater reduction in psychological complaints than running. Improving psychological well-being may influence physical pain by decreasing central sensitivity or how the brain interprets peripheral input.

Massage may also create multi-system releases in tension. Interventions have been shown to decrease pulse rate which is under autonomic control(2). These individuals also reported decreased anxiety while demonstrating decreased output of cortisol in their urine and saliva (decreased adrenal activity).

Eating disorders such as bulimia are also psychological in nature. Manual therapy has been shown to be an effective intervention in decreasing anxiety and depression associated with disordered eating which can also help control the disorder eating itself(3).

On the opposite end of the spectrum are aggression issues. These may be hormonally or psychologically induced issues. Manual therapy has also been shown to decrease anxiety and aggression in adolescents via positive affects on mood(4).

Often, these results are thought to be associated with traditional massage therapy practice of 60 to 90-minute sessions. However, results can be seen with as little as 10-minutes(5). Elderly patients noted a psychological state of relaxation after the interventions of kneading from the occiput to the sacrum.

Even if manual therapy is not a strong suit, touch can be incorporated into treatment in several ways. Stabilizing touch during therapeutic exercises may have the same affect. Facilitating touch on the muscle that should be contracting is another approach.

REFERENCES
1. Weinberg R, Jackson A, Kolodny K, The relationship of massage and exercise to mood enhancement. Sports Psychologist 1988;2:202-211.
2. Field T, Grizzle N, Scafidi F, Schanberg S. Massage and relaxation therapies’ effects on depressed adolescent mothers. Adolescence 1996;31:903-911
3. Field T, Schanberg S, Kuhn C. Bulimic adolescents benefit from massage therapy. Adolescence 1998;33:555-563.
4. Diego MA, Field T, Hernandez-Reif M, et al. Aggressive adolescents benefit from massage therapy. Adolescence 2002;37:597-607.
5. Frazier J, Kerr J. Psychophysiological effect of back massage on elderly institutionalized patients, Journal of Advanced Nursing 1993;18:238-245

Myofascial Release

Did you know there are grades (degrees) of Myofascial release?

Grade I
Technique is applied with no tension through the tissue and it is on slack

Grade II
Technique is applied with minimal tension, typically with the tissue in neutral position

Grade III
Technique is applied with the tissue on stretch (passive)

Grade IV
Technique is applied as the tissue is stretch via a concentric contraction of the tissue’s antagonist (active)

Grade V
Technique is applied as the tissue concentrically contracts

[Image shows grade III MFR to cervico-pectoral fascia to improve left cervical rotation as well as right scapular depression/retraction]

Fascia

Fascia is like Saran-Wrap. For years, researchers thought it was merely something to help hold the body together. More research is coming out that discusses how it is an extension of the central nervous system and helps coordinate movements. Saran-wrap has a high tendency to stick to itself; once it is stuck, it becomes difficult to open back up. Similarly, through injury and overuse, fascia develops adhesions: it becomes sticky (thanks to its extracellular matrix) and adheres to itself as well as the muscles deep and the skin superficially. When this occurs, the tissues lose their ability to slide over one another. This greatly restricts movement. Any movement that does occur creates shearing of the tissues and subsequent pain.

Manual therapy techniques are not designed to ‘deform’ the fascia but merely restore the gliding properties.

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