myofascial release for clbp
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Myofascial Release forcLBPDarren Grunwaldt, D.O.Statewide Campus SystemFamily Medicine PAC DidacticJune 2, 2021
REMEMBER
• The body is a unit. • Structure and Function are reciprocally interrelated.• “Everything’s connected.”
• Question for Myofascial Release:Where does fascia go?
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FASCIA
From snappygoat.com
From https://www.flickr.com/photos/nihgov/26231002464
Fibroblast cell with actin filaments in red and microtubules in green
Recent Model of Cell
Early Model of Cell
Organelles sit in a vat of cytoplasmic jelly
From Wikipedia commons
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INTRO TO MFR/INR
• Robert C. Ward, D.O., F.A.A.O.• “Bridging” technique that spans
other OMM modalities by combining principles of muscle energy, soft tissue, indirect, and inherent force cranial osteopathy
• Classified as a combined system as it influences biomechanics of musculoskeletal system and peripheral and central neural control mechanisms
COMPARING MFR AND MET
• Myofascial Release, MFR (and its close sibling, Integrated Neuromuscular Release, INR) can be done in addition to or separately from Muscle Energy Technique, MET. These are all different modalities, or styles, of Osteopathic Manipulative Treatment, OMT.
• You tend to diagnose in the same language in which you treat.• It is possible to speak OMT with multiple dialects
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COMPARING MFR AND MET
MET MFR/INR
COMPARING MFR AND MET
MET1) Patient is an active participant 2) Most often considered a direct
technique but some people dabble with indirect versions
3) Requires palpation/diagnosis of bony landmarks – focus on position preference
4) Many variations but popular versions involve reciprocal inhibition or post-isometric relaxation
MFR/INR
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COMPARING MFR AND MET
MET1) Patient is an active participant 2) Most often considered a direct
technique but some people dabble with indirect versions
3) Requires palpation/diagnosis of bony landmarks – focus on position preference
4) Many variations but popular versions involve reciprocal inhibition or post-isometric relaxation
MFR/INR1) Patient is passive with MFR, slightly
active with INR
COMPARING MFR AND MET
MET1) Patient is an active participant 2) Most often considered a direct
technique but some people dabble with indirect versions
3) Requires palpation/diagnosis of bony landmarks – focus on position preference
4) Many variations but popular versions involve reciprocal inhibition or post-isometric relaxation
MFR/INR1) Patient is passive with MFR, slightly
active with INR2) Can be direct or indirect (we will be
addressing direct technique today)
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COMPARING MFR AND MET
MET1) Patient is an active participant 2) Most often considered a direct
technique but some people dabble with indirect versions
3) Requires palpation/diagnosis of bony landmarks – focus on position preference
4) Many variations but popular versions involve reciprocal inhibition or post-isometric relaxation
MFR/INR1) Patient is passive with MFR, slightly
active with INR2) Can be direct or indirect (we will be
addressing direct technique today)3) Requires palpation/diagnosis of soft
tissue layers – focus on fascial pull preference
COMPARING MFR AND MET
MET1) Patient is an active participant 2) Most often considered a direct
technique but some people dabble with indirect versions
3) Requires palpation/diagnosis of bony landmarks – focus on position preference
4) Many variations but popular versions involve reciprocal inhibition or post-isometric relaxation
MFR/INR1) Patient is passive with MFR, slightly
active with INR2) Can be direct or indirect (we will be
addressing direct technique today)3) Requires palpation/diagnosis of soft
tissue layers – focus on fascial pull preference
4) Involves neuroreflexive change and fascial creep
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MFR’S FOUR BIG IDEAS
• 1. Tight-Loose• 2. Palpation• 3. Neuroreflexive Change• 4. Release
MFR’S FOUR BIG IDEAS
• 1. Tight-Loose• Tightness creates asymmetry, looseness allows asymmetry• Agonist and antagonist relations to muscle groups (e.g., Upper and Lower Cross
Syndrome)• Some barriers can be noted as soft tissue or bony impediment to induced
motion by operator• Other barriers can be noted as impediments to inherent tissue motion
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MFR’S FOUR BIG IDEAS
• 2. Palpation• Layer palpation - from superficial subcutaneous to deep investing fascial and
muscular layers• Also Tenderness to palpation - using palpation in myofascial pain syndromes as
part of the diagnosis and the treatment• Peripheral stimulation is used in many modalities (e.g., acupuncture, Chapman’s
reflexes, strain-counterstrain)• Common to find pain at palpably loose sites! (chronic, hypermobile, inhibited)
MFR’S FOUR BIG IDEAS
• 3. Neuroreflexive Change• Manual force into the musculoskeletal system leads to afferent stimulation which
is processed centrally (spinal cord, brainstem, cortical)• Afferent stimulation often leads to efferent inhibition but is variable and
modifiable!
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MFR’S FOUR BIG IDEAS
• 4. Release• Appropriate application of stress on tissue leads to relaxation of the fascia and
muscle• Can occur in several directions and through several levels of tissue• Similar concept noted in functional and in cranial osteopathy• “Fascial creep”
INR
• Integrated Neuromuscular Release• Addition of enhancing maneuvers to the MFR set-up
• Goal will be to find maneuvers the patient can perform that will affect the area without being overwhelming as you continue to palpate and to address the barriers• May be moving distal parts of a limb while treating fascia more proximally• May be larger than average breaths• For some, may involve something close to looning
From https://actingoutonline.com/classes/
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INR
• How is this enhancing the release?• Can help ratchet a myofascial group on and off
• Perhaps similar to mechanical effect of when people push over street signs• Repetitious, short stints of muscle energy
• Post-isometric relaxation• Antagonist-induced relaxation
• Muscle confusion, neural override (think of, e.g., Jendrassik maneuver)
From Wikipedia Commons
MFR/INR LAB 1A: LOWER BACK PRONE
• Patient (after removing belt and other potentially pokey items) prone on table with lower back exposed
• Physician at side of table facing somewhat towards patient’s head• Full hands onto lumbodorsal fascial area with focus on lumbar paraspinals• Layer palpation: appreciate skin, subcutaneous fatty layer, superficial to muscle, muscle
and deeper fascia• Diagnose the SD: Motion test the layers of fascia superiorly, inferiorly, large circle
clockwise and counterclockwise, small circle CW and CCW• Note for example “MFP CW at LS jxn”
• Engage fascial barriers with direct MFR• Add INR – ask patient to roll legs apart and together• Note tissue response: fascial change / creep• Re-check
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From Wikipedia on Thoracolumbar Fascia
MFR/INR LAB 1B: LOWER BACK PRONE LS JXN AND SACRUM
• After lab 1a, cross arms so that your hands can rest along midline with heels of hands at the LS junction and fingers pointing in opposite directions
• Layer palpate and motion test separation along midline versus shearing vectors to left or right versus small circle CW and CCW
• Diagnose SD, for example, “LS MFP compression on the right” or “MFP sacral base to the left”
• Engage barriers, feel for tissue response, add INR, re-check
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MFR/INR LAB 2A: LOWER BACK SEATED
PELVIS ROTATION• Patient sits on table facing away from physician who is also seated• Physician palpates ASIS area on one side while palpating PSIS area on
opposite side – motion test a rotation of the pelvis, then compare to other side and direction – diagnose somatic dysfunction, for example “Pelvis MFP rotation R”
• Engage rotational barriers with direct MFR• Add INR – ask patient to slowly swing feet apart and together• Note tissue response: fascial change / creep• Re-check
MFR/INR LAB 2B: LOWER BACK SEATED
QL / PSOAS AREA• After lab 2a, place hands in a butterfly position onto QL area so that thenar
side can appreciate paraspinals and fingers can span out toward edges of QL
• Layer palpate and motion test bringing thumbs superiorly while fingers drag inferiorly and vice versa both in unison and alternatingly (Caution this can be tender if you try to appreciate deeper layers.)
• Diagnose SD, for example, “QL MFP inferiorly on the right” or “MFP QL bilaterally superior”
• Engage barriers, feel for tissue response, add INR, re-check
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