Monday, October 6, 2008

MFR and Back pain

Dr. Ajimshaw. M.S, MPT (Neuro), MTS PhD
Direct MFR is one of the most effective ways of treating back pain, be it acute or chronic. It is indeed the best choice for a well trained therapist, though the management varies in acute and chronic conditions.
We here at SCeB CAPT® utilize AJIMSHAWS Approach® for managing low back pain in its various forms.
AJIMSHAW’s Approach®:-
Advanced Management for
Joint and Musculo Fascial
Immobility, Pain and Dysfunctions by
Mobilizations
Soft Tissue Manipulation through
Hands-On" Physical Therapy coupled with
Active Exercise Program along with
Work Site Modifications.

Besides MFR we utilize techniques such as Critz Techniques, Neil Ascher Techniques, Muscle Energy Technique, Maitland manual therapy, basic as well as advanced core stabilization programmes, ergonomic retraining etc.
ACUTE LBP
A patient suffering from acute LBP requires a maximum of 2 days rest only. This is the phase we ought to utilize for assessment.
Assessment should be in detail regarding the Osteomyofascial components. It should include the osseus, muscular as well as fascial aspects of dysfunctions.
You ought to check for myofascial restrictions in
MUSCLES
Multifidus
Iliopsoas
Piriformis
Transverse abdominis
Glutei
QL
IT band/ TFL
LD etc.
Ligaments
o ALL
o PLL
o LF
o Supraspinous
o Interspinous
o Apophyseal Capsule
o Sacrotuberuous lig. etc.
Osseous level
Vertebral units
Apophyseal joints
Malalignment syndrome
Antalgic posture
Sacroiliac dysfunction
Status of lower limbs
It is very important for the therapist to understand the vicious cycle of acute pain, in order to do justice to the patient. i.e.:
Pathological Cascades
Acute pathology (osseous, muscular, fascial)

Protective muscular spasm+ Rest

Decreased ROM

Myofascial restriction + hypo mobility of involved joints + hyper mobility
of the adjacent joints + Antalgic posture

More dysfunction

Activation of Pain-Spasm-Pain

Widespread myofascial restriction + activation of Trigger points

Increased Dysfunction

Increased pain-spasm-pain cycle

Change in location of pain generators from primary area occurs due to the body’s attempt for auto resolution
Obviously in the assessment part you will go through the regular series of special tests such as SLR, Slump, SI test and of course you will be opting for either a MRI or CT or both.
As a physiotherapist trained in MFR your diagnosis does not end there. You have to use your hands, training in MFR gives utmost importance to sensitizing your hands so that you may be able to feel and understand the under lying pathology. The following areas are to be palpated (it is important to go deep) in search of pain generators, tight bands or spastic muscular components.
Multifidus
Erector spinae
Glutei and piriformis
Iliopsoas
Quadrates lumborum
ASIS, PSIS, Superior border of Iliac spine and the greater trochanter.
When a patient approaches you with positive SLR, limited ROM, severe pain (on flexion, extension or rotation), either positive or negative MRI and other diagnostic interventions you should palpate deeply the above mentioned areas and check for signs of tenderness (Jumpers Sign). The patient will probably be in the vicious cycle pain and spasm that has been explained before.
You should carefully locate the painful areas and apply a 3 minute sustained pressure thrice (this is standard MFR procedure for confirmation). Afterwards check all the special tests that you have already performed such as SLR, ROM etc:
This will definitely aid a MFR therapist in reaching the necessary conclusion and all that needs to be done is to plan the appropriate management and carry it out.
As mentioned before we here at SCeB CAPT use AJIMSHAWS approach. This in the case of acute as well as chronic LBP comprises of a well planned out set of techniques that is unique for each and every one of our patients suiting their requirements.
As per the new researches most of the cases of LBP have Osteomyofascial involvement. We treat the myofascial component of the condition using techniques such as
Indirect Technique MFR
Direct Technique MFR
Myofascial Unwinding
Myofascial Rebounding
Critz Technique
Muscle Energy Technique etc.
Further we start basic course of core stabilization followed by spinal / SI realignment programs as per the conditions requirement.
Laterally we incorporate ergonomic training as a group therapy and also Aerobics.
Most of the acute cases would require a period of 7-10 days for recovery, however in chronic cases over 20-30 days are required owing to the widespread myofascial involvement and often release of one area will reveal restrictions in other areas which also have to be cared for.
Furthermore core stabilization programs are taken from basic to advanced levels along with ergonomic training sessions, aerobics and follow up.
Why does Myofascial restriction occur?
In order to understand the reason you should bear in mind the fact that what we are talking about i.e. the myofascia is a 3D continuous web that extends without interruption throughout the body starting from cellular level. If a restriction occurs it will not only affects patient as a whole but affects cellular level metabolism too.
When a local injury occurs, there occurs acute inflammatory reaction that leads to the accumulation of exudates and a temporary muscular dysfunction. This is the starting point of myofascial restrictions. In most of the cases this types of multiple temporary dysfunctions have already happened at various levels due to faulty posture, repetitive and awkward movements, or injuries which will produce a cumulative effect and formation of myofascial restrictions. Over this when an acute injury occurs it can put tremendous pressure on already shortened Myofascial which in turn ignites a cascades of events as explained before (Please go through the article "Back Pain Management Updated: 2008" before reading this)
Physiologically speaking when there is decreased space for the muscle to contract and relax due to the restriction in the myofascial unit, the calcium ions from the sarcoplasmic reticulum which will be there in myofibrils to initiate the contraction (remember binding of calcium ion to Troponin-C is the reason for actin-Myosin Binding and after that breaking of Troponin-C calcium ion bond and exit of Calcium ion onto the SR produce the relaxation.) will stay there in excess and they remain attached to the to Troponin component as there is less space for the muscle to relax. This excess calcium causes the actin-myosin bond to remain as such and the muscle will remain in a partly contracted state.( we called it as spasm). Though this starts of at local level it starts to spread over the whole body in time because the myofascia is a single continuous web staring at the cellular level and this if untreated will definitely lead to more widespread spreading and dysfunctions ( can we call it as Fibromyalgia ?. According to my belief Myofascial Pain Syndrome (CTD) and fibromyalgia are two extremes of a continuum only!?).
Now you can think what the magic behind the MFR is, how the release of a small area itself produces wide spread effects and side effects? (Fascia not only covers the muscle but all other organs and structures of the body as a single structure such as nerves, blood vessels, visceral organs etc)
In simple words we are just releasing the fascia which is restricted (How you can find out that the fascia has released? Well there are many techniques, the simple one is there will be heat production at the site of release as fascia contracts by absorbing Heat!!). Rest is simple mechanisms, provide more space to muscle for its contraction & relaxation, all dysfunctions will automatically resolve. Fleshing out is other reason. There are various other theories which we can discuss later.

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