making life livable

Dr. Naveen, PT

Myofascial Release is a safe and very effective hands-on technique that involves applying gentle sustained pressure into the Myofascial connective tissue restrictions to eliminate pain and restore motion. This essential “time element” has to do with the viscous flow and the piezoelectric phenomenon: a low load (gentle pressure) applied slowly will allow a viscoelastic medium (fascia) to elongate.

Trauma, inflammatory responses, and/or surgical procedures create Myofascial restrictions that can produce tensile pressures of approximately 2,000 pounds per square inch on pain sensitive structures that do not show up in many of the standard tests (x-rays, myelograms, CAT scans, electromyography, etc.).

Each Myofascial Release Treatment session is performed directly on skin without oils, creams or machinery. This enables the therapist to accurately detect fascial restrictions and apply the appropriate amount of sustained pressure to facilitate release of the fascia.

Myofascial release is basically a type of massage therapy techniques, which involves stretching and releasing of the soft tissues in order to balance the body muscles. The term myofascia is derived from the Latin words for muscle (myo) and band (fascia). Fascia is the soft tissue portion that surrounds every part of the body. It plays a major role in maintaining normal metabolic process and providing the structural integrity of the body. It also protects the body cells from the invading pathogens.

The main objective of myofascial release therapy is to manipulate the fascia for combating muscle pain, healing injury, managing stress, increasing flexibility and improving body posture. It mainly focuses on treating the trigger points that are located in the muscles. Hence, myofascial therapy is also known as myofascial trigger point therapy. There are various myofascial release techniques, each of which is intended for restoring the health of the fascia.

Background and terminology

Fascia is the soft tissue component of the connective tissue that provides support and protection for most structures within the human body, including muscle. This soft tissue can become restricted due to psychogenic disease, overuse, trauma, infectious agents, or inactivity, often resulting in pain, muscle tension, and corresponding diminished blood flow. Although fascia and its corresponding muscle are the main targets of myofascial release, other tissue may be affected as well, including other connective tissue.

As in most tissue, irritation of fascia or muscle causes local inflammation. Chronic inflammation results in fibrosis, or thickening of the connective tissue, and this thickening causes pain and irritation, resulting in reflexive muscle tension that causes more inflammation. In this way, the cycle creates a positive feedback loop and can result in ischemia and somatic dysfunction even in the absence of the original offending agent. Myofascial techniques aim to break this cycle through a variety of methods acting on multiple stages of the cycle.^[1]

In medical literature, the term myofascial was historically used by Janet G. Travell, M.D. in the 1940s referring to musculoskeletal pain syndromes and trigger points. In 1976 Dr. Travell began using the term "Myofascial Trigger Point" and in 1983 published the reference "Myofascial Pain & Dysfunction: The Trigger Point Manual".^[2] There is no evidence she actually used what is now termed "myofascial release". Some practitioners use the term "Myofascial Therapy" or "Myofascial Trigger Point Therapy" referring to the treatment of trigger points, usually in medical-clinical sense. The phrase has also been loosely used for different manual therapy techniques, including soft tissue manipulation work such as connective tissue massage, soft tissue mobilization, foam rolling, structural integration, and strain-counterstrain techniques. However, in current medical terminology, myofascial release refers mainly to the soft tissue manipulation techniques described below.

Myofascial techniques generally fall under the two main categories of passive (patient stays completely relaxed) or active (patient provides resistance as necessary), with direct and indirect techniques used in each.

Direct myofascial release

The direct myofascial release (or deep tissue work) method works on the restricted fascia. Practitioners use knuckles, elbows, or other tools to slowly stretch the restricted fascia by applying a few kilograms-force or tens of newtons. Direct myofascial release seeks for changes in the myofascial structures by stretching, elongation of fascia, or mobilising adhesive tissues. The practitioner moves slowly through the layers of the fascia until the deep tissues are reached.

Robert Ward suggested that the intermolecular forces direct method came from the osteopathy school in the 1920s by William Neidner, at which point it was called "fascial twist". German physiotherapist Elizabeth Dicke developed Connective Tissue Massage (Bindegewebsmassage) in the 1920s, which involved superficial stretching of the myofascia. Dr. Ida Rolf developed Structural Integration, in the 1950s, a holistic system of soft tissue manipulation and movement education with the goal of balancing the body. She discovered that she could change the body posture and structure by manipulating the myofascial system. Rolfing is the nickname that many clients and practitioners gave this work. Since her death in 1979, various structural integration schools arose which have adapted her original ideas to their own needs and uses.

Michael Stanborough has summarized his style of direct myofascial release technique as:

Land on the surface of the body with the appropriate 'tool' (knuckles, or forearm etc).
Sink into the soft tissue.
Contact the first barrier/restricted layer.
Put in a 'line of tension'.
Engage the fascia by taking up the slack in the tissue.
Finally, move or drag the fascia across the surface while staying in touch with the underlying layers.
Exit gracefully.

As Dr. Rolf said, "Put the tissue where it should be and then ask for movement."

Indirect myofascial release

The indirect method involves a gentle stretch, with only a few grams of pressure, which allows the fascia to 'unwind' itself. The gentle traction applied to the restricted fascia will result in heat and increased blood flow in the area. This allows the body's inherent ability for self correction to return, thus eliminating pain and restoring the optimum performance of the body. This concept was suggested by Paul Svacina to be analogous to pulling apart a chicken carcass: when it is pulled apart slowly, the layers peel off intact; too fast, and it shreds.

The indirect technique originated in osteopathy schools and is also popular in physical therapy. According to Robert C. Ward, myofascial release originated from the concept by Andrew Taylor Still, the founder of osteopathic medicine in the late 19th century. The concepts and techniques were subsequently developed by his successor. Robert Ward further suggested that the term Myofascial Release as a technique was coined in 1981 when it was used as a course title at Michigan State University. It was popularized and taught to physical therapists, massage therapists, occupational therapists and physicians by John F. Barnes PT through his Myofascial release seminar series. Carol Manheim summarized the principles of Myofascial Release:

Fascia covers all organs of the body, muscle and fascia cannot be separated.
All muscle stretching is myofascial stretching.
Myofascial stretching in one area of the body can be felt in and will affect the other body areas.
Release of myofascial restrictions can affect other body organs through a release of tension in the whole fascia system.
Myofascial release techniques work even though the exact mechanism is not yet fully understood.

The indirect myofascial release technique, according to John Barnes, is as follows:

Lightly contact the fascia with relaxed hands.
Slowly stretch the fascia until reaching a barrier/restriction.
Maintain a light pressure to stretch the barrier for approximately 3–5 minutes.
Prior to release, the therapist will feel a therapeutic pulse (e.g. heat).
As the barrier releases, the hand will feel the motion and softening of the tissue.
The key is sustained pressure over time.

The main approach of every myofascial release technique is more or less similar. A physical therapist locates the restricted fascia portion and applies light stretch to the area. Pressure application is repeated for several times, until the restricted fascia can be stretched properly.

A 24 yrs old male patient came with chief complain of pain and swelling in right ankle foot. The patient had a history of Fracture of Both Bone Right Leg Distal Third three months before that was fixed through intramedullary nailing of tibia and the fibular maaleolus fixed with a screw. The patient had limited ROM at right ankle and foot. He had also difficulty in walking and prolonged standing (weight bearing activities).

Aims of Physiotherapy Treatment:

1. Reduce Pain

Reduce Oedema

2. Increase the ROM

3. Improve walking and ADL’s

Assessments:

1. Pain on VAS

At rest: 6

On Activity: 8

2. Oedema rt lt

At ankle 10.5 9

5 cm Above ankle 9.5 9.5

3. ROM

Dorsiflexion: 20⁰

Plantarflexion: 20⁰

Eversion: 10⁰

Inversion: 15⁰

4. Manual Muscle Testing

Dorsiflexion: 4+

Plantarflexion: 4+

Eversion: 4

Inversion: 4

Treatment:

1^st week:

i. Paraffin wax Bath²: 15 minutes (brushing method - 8 coats)

ii. Active Assisted ROM exercises: 10 rep each on ankle and feet exercisers

2^nd week:

i. Paraffin wax Bath: 15 minutes (brushing method - 8 coats)

ii. Resistance exercises using theraband (initial 3 days)^1,5:

Dorsiflexion: 10 rep

Plantarflexion: 10 rep

Eversion: 6 rep

Inversion: 6 rep

After three days of 2^nd week the the strengthening exercises are progressed to 3 sets of ten rep and 2 more exercises r added i.e.

iii. Calf Stretch

iv. Balancing on a pillow with open eyes

Outcome: Initial After two weeks Difference

1. Pain on VAS

At rest: 6 2 4

On Activity: 8 3.5 4.5

2. Oedema

At ankle 10 9 1

5 cm Above ankle 9.5 9.5 0

3. ROM

Dorsiflexion: 20⁰ 25⁰ 5⁰

Plantarflexion: 20⁰ 25⁰5⁰

Eversion: 10⁰ 15⁰5⁰

Inversion: 15⁰ 20⁰5⁰

Discussion:

Initially the patient had limited ROM with existence of pain and discomfort. After giving the physiotherapy treatment for 2 weeks there is significant improvement in joint ROM, pain and swelling.

After 2 weeks the patient discontinues the regular physiotherapy treatment and home advices are given to patient which include continue active assisted exercises of ankle and foot and contrast bath.