MYOFASCIAL
RELEASE
An
Introduction for the Patient
Gary
D. Keown, PT and Tim Juett, PT of South Umpqua Physical Therapy Services in
Winston, Oregon, have extensive experience in Physical Therapy and Myofascial
Release. The integration of the Myofascial Release approach into their Physical
Therapy practice has greatly enhanced their success. Their reputation for
excellence and resolving difficult cases has led to the growth of four very
successful Physical Therapy facilities in Oregon.
Tim
has just completed our advanced Myofascial Release III seminar and said he would
like to share some case histories with you which constitute a very valuable
patient introduction to Myofascial Release. I suggest you modify this to fit
your facility's particular requirements and print it as a handout for your
patients and referring physicians and dentists.
INTRODUCTION
Myofascial Release is a relatively new addition to the armamentarium of the physical therapist. Because it is somewhat different from traditional physical therapy, many patients ask questions such as "What is it?" and "How does it work?" Myofascial Release is generally an extremely mild and gentle form of stretching that has a profound effect upon the body tissues. Because of its gentleness, many individuals wonder how it could possibly work. To help you understand, we are providing you with this article.
FASCIA
Fascia (also called connective tissue) is a tissue system of the body to which relatively little attention has been given in the past. Fascia is composed of two types of fibres: A) Collagenous fibres that are very tough and have little stretchability; B) Elastic fibres that are stretchable. From the functional point of view, the body fascia may be regarded as a continuous laminated sheet of connective tissue that extends without interruption from the top of the head to the tip of the toes. It surrounds and invades every other tissue and organ of the body, including nerves, vessels, muscle and bone. Fascia is more dense in some areas than others. Dense fascia is easily recognizable (for example, the tough white membrane that we often find surrounding butchered meat).
WHEN
FASCIA IS INJURED
Because
fascia permeates all regions of the body and is all interconnected, when it
scars and hardens in one area (following injury, inflammation, disease, surgery,
etc.), it can put tension on adjacent pain-sensitive structures as well as on
structures in far-away areas. Some patients have bizarre pain symptoms that
appear to be unrelated to the original or primary complaint. These bizarre
symptoms can now often be understood in relationship to our understanding of the
fascial system.
ANATOMY
OF FASCIA
The
majority of the fascia of the body is oriented vertically. There are, however,
four major planes of fascia in the body that are oriented in more of a crosswise
(or transverse) plane. These four transverse planes are extremely dense. They
are called the pelvic diaphragm, respiratory diaphragm, thoracic inlet and
cranial base. Frequently, all four of these transverse planes will become
restricted when fascial adhesions occur in just about any part of the body. This
is because this fascia of the body is all interconnected, and a restriction in
one region can theoretically put a "drag" on the fascia in any other
direction.
TREATING
FASCIAL RESTRICTIONS
The
point of all the above information is to help you understand that during
myofascial release treatments, you may be treated in areas that you may not
think are related to your condition. The trained therapist has a thorough
understanding of the fascial system and will "release" the fascia in
areas that he knows have a strong "drag" on your area of injury. This
is, therefore, a whole body approach to treatment. A good example is the chronic
low back pain patient; although the low back is primarily involved, the patient
may also have significant discomfort in the neck. This is due to the gradual
tightening of the muscles and especially of the fascia, as this tightness has
crept its way up the back, eventually creating neck and head pain. Experience
shows that optimal resolution of the low back pain requires release of the
fascia of both the head and neck; if the neck tightness is not also released it
will continue to apply a "drag" in the downward direction until
fascial restriction and pain has again returned to the low back.
Muscle
provides the greatest bulk of our body's soft tissue. Because all muscle is
enveloped by and ingrained with fascia, myofascial release is the term that has
been given to the techniques that are used to relieve soft tissue from the
abnormal grip of tight fascia ("myo" means "Muscle").
The
type of myofascial release technique chosen by the therapist will depend upon
where in your body the therapist finds the fascia restricted. If it is
restricted through the neck to the arm, he/she may apply a very gentle traction
to the arm, very slowly moving the arm through range as restrictions are
released. If it is restricted in the back (more superficial than deep) he may
apply a very gentle stretch on the skin across the back, with the use of two
hands. If the thoracic inlet, deep transverse fascia is suspected of being
restricted, the therapist may place one hand on the upper back and one over the
collarbone area in front and apply extremely gentle pressure.
A
key to the success of myofascial release treatments is to keep the pressure and
stretch extremely mild. Muscle tissue responds to a relatively firm stretch, but
this is not the case with fascia. Remember the collagenous fibres of fascia are
extremely tough and resistant to stretch. In fact, it is estimated that fascia
has a tensile strength of as much as 2000 pounds per square inch. (No wonder
when it tightens, it can cause pain.)
However,
it has been shown that under a small amount of pressure (applied by a
therapist's hands) fascia will soften and begin to release when the pressure is
sustained over time. This can be likened to pulling on a piece of taffy with
only a small, sustained pressure.
Another
important aspect of myofascial release techniques is holding the technique long
enough. The therapeutic affect will begin to take place after holding a gentle
stretch and following the tissue three dimensionally with skilled, sensitive
hands.
In
general, acute cases will resolve with a few treatments. The longer the problem
has been present, generally the longer it will take to resolve the problem. Many
chronic conditions (that have developed over a period of years) may require
three to four months of treatments three times per week to obtain optimal
results. Experience indicates that fewer than two treatments per week will often
result in fascial tightness creeping back to the level prior to the last
treatment. Range of motion and stretching exercise given to you will, however,
keep this regression between treatments minimal.
Frequently
there is increased pain for several hours to a day after treatment, followed by
remarkable improvement. Often remarkable improvement is noted immediately during
or after a treatment. Sometimes new pains in new areas will be experienced.
There is sometimes a feeling of light-headedness or nausea. Sometimes a patient
experiences a temporary emotion change. All of these are normal reactions of the
body to the profound, but positive, changes that have occurred by releasing
fascial restrictions.
It
is felt that release of tight tissue is accompanied by release of trapped
metabolic waste products in the surrounding tissue and blood stream. We highly
recommend that you "flush your system" by drinking a lot of fluid
during the course of your treatments, so that reactions like nausea and
light-headedness will remain minimal or nil.
If
patients have any questions or concerns that arise concerning myofascial
release, they should be encouraged to discuss them with the therapist.
CASE
HISTORY: Chronic Low Back Pain (Post Surgery)
A
32-year old choker-setter had a lumbar laminectomy in 1983, followed by
decompression surgery at the same level in October 1985. Five months after his
second surgery he was referred to physical therapy by his surgeon for three
weeks of treatment for chronic low back pain and bilateral anterior thigh pain.
His treatment included hot wet packs with concurrent interferential electrical
stimulation, a home exercise program and myofascial release to the low back area
as well as to the surgical scar itself. After two treatments there was no
further leg pain and only mild low back pain with movement.
After
four treatments, the patient called and cancelled further appointments because
he no longer was having any pain and had returned to his job as a chokersetter.
Following up by telephone three months later, he reported having low back
discomfort at times and never any leg pain. He is very pleased with his ability
to continue his strenuous job. This is the most dramatic improvement I have
experienced with any patient having similar symptoms after two or more low back
surgeries. The only difference in treatment with this patient was the addition
of myofascial release.
CASE
HISTORY: Chronic Dislocating Patella
This
15-year-old female had a history of a chronic dislocating right patella for
three years. At age 11 she fell and hit a curb on the lateral aspect of the
right knee. Approximately one month later her patella began dislocating.
Dislocations gradually became more frequent. She stated that with "just
normal walking" the patella would dislocate and she would fall. She had
been having constant pain at the lateral aspect of the knee for the past two
years. Originally, her patella dislocated about twice per week, and this
progressed to daily for a year prior to coming to us for therapy. The only
treatment given her was quadriceps and hamstring "sets," and a trial
of two types of braces until she came to see us in June of 1987.
The
physician's referral to us requested SLR quadriceps strengthening and iliotibial
band stretching. We treated her five times with ultrasound to the lateral
retinacular area of the right patella, followed by myofascial release of the
iliotibial band and lateral retinaculum. She was also given straight-leg raises
against theraband with some external rotation of the hips, so as to emphasize
strengthening of the VMO.
After
the first treatment she had no further dislocations, even when running up and
down stairs at home. Follow-up with this patient nine months later, she reported
having no further problems at all with her right knee. This patient was a
possible candidate for surgical release of the lateral retinaculum of the right
knee. Because she had done exercises in the past without reduction of chronic
dislocation of the patella, we feel that the rapid resolution of her problem was
due primarily to the non-invasive release of the scarred and adhered lateral
retinaculum with manual myofascial release techniques.
CASE
HISTORY: Myofascial Syndrome, Status Post Open Heart Surgery
This
73-year old patient had open-heart surgery on January 15, 1988. She came for
physical therapy on March 29,1988, complaining of excruciating pain at the
sternal surgical scar region and spreading up the left sternocleidomastoid and
into the left upper extremity to the elbow. She also complained of paresthesis
of the left side of the face, episodes of dizziness, difficulty breathing when
tilting the head back, and lack of pulse in the left side of the neck.
A
total of four treatments were given in a ten-day period. They included moist
heat, myofascial release and a home program of stretching the neck and
shoulders.
Myofascial
release was performed over the surgical scar, left chest, left neck, cranial
base and left side of the face. A left "arm pull" was also performed.
At the end of the fourth and final treatment, she reported feeling "100%
improved." She had no pain. She could feel a pulse again in the left side
of her neck, breathing was unrestricted with cervical extensions, there was
normal sensation in her face and no further episodes of dizziness. Her six
standard cervical motions had improved a total of 40 degrees, including a gain
of 15 degrees of extension.
Upon
follow-up by telephone exactly four weeks following her final treatment, she
reported feeling as well as after the last treatment. She only had
"soreness" in the left neck and left axillary region when stretching
while doing her home exercises, which I had recommended that she continue daily.
CASE
HISTORY: Status Post Right Mastectomy and Radiation Burn
This
73-year old woman came for her initial physical therapy treatment on July 14,
1987. She had a right mastectomy in January, 1986. She received one year of
chemotherapy following surgery, then six weeks (30 treatments) of radiation
therapy. She had irregular shaped radiation burn with hypertrophic scarring over
the distal third of the sternum (of approximately 6-7 mm. diameter). The right
shoulder was drawn forward. The right shoulder and chest were extremely
hypersensitive to mild touch and minor movement of the right shoulder. The
radiation scar still had a small area of scab. She was referred to us as soon as
the physician felt that the burn was sufficiently healed to begin physical
therapy. Right shoulder external and internal rotation range of motions were
within normal limits. Active flexion and abduction (standing) were respectively
0-130 degrees and 0-97 degrees.
She
was given a home program of cane exercises and treated a total of 15 times
(ending August 21, 1987) with moist heat and myofascial release to the chest,
right upper extremity and neck. At the final treatment she had 160 degrees of
motion of both right shoulder flexion and abduction (equivalent to the
contralateral motions). She had no further discomfort, except for mild
tenderness when pushing her range of motion exercises to the end of range.
On
follow-up with this patient over seven months later, she had maintained her
range of motion and reported no limitations of function and no pain. She felt
fully recovered in every way other than "some tightness at the site of
radiation." She expressed how thoroughly grateful she was for the
remarkable increase of motion and reduction of pain which occurred with such
gentle and relatively painless techniques.
Tim
Juett, PT
Roseburg, Oregon
No
References
Tim
is a very caring and highly intelligent health professional who believes in a
multi-faceted approach treating the whole person. I would like to thank Tim and
request anyone else interested in sharing anything of this nature, case
histories or their experiences to feel welcome to write me. I look forward to
hearing from you.
John
F. Barnes, PT
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