Monday, October 6, 2008


Dr. Ajimshaw. M.S, MPT (Neuro), PhD

The Difference is Simple Ergonomics….!!!

Epidemiology of Back Pain
Who gets it?

60-90% lifetime prevalence.
80-90% have recurrent episode.
What is the Natural history?
80-90% resolves in 1 month.
20-30% remains "chronic"
5-10% "disabling
100% Acute LBP
90% Resolved in 12 weeks
70% Resolved in 3 weeks
Work related musculoskeletal disorders (RSI) and Back Pain
With rapidly increasing industrialization in India, especially in the sectors of Information Technology and IT enabled services, work related musculoskeletal disorders (also called Repetitive Strain Injury [RSI] or Cumulative Trauma Disorder [CTD]) are spiraling upwards. Preliminary reports of one of the leading work related injury research center’s (, Bangalore) ongoing study of over 35000 Indian IT professionals (2001-2008) found that 75% reported musculoskeletal symptoms related to work and 55% got injured within a year of starting their first job, reducing the productivity or work efficiency to a significantly low level.
Making the Diagnosis

"Up to 85% of pts cannot be given a definitive diagnosis because of weak associations among symptoms, pathological changes, and imaging results."
Deyo R, et al. JAMA 1992; 268;760-765
Mechanical Low Back Pain "Many, including myself, believe the character of the vast majority (possibly as many as 97%) of low back disorders to be mechanical."
Donelson R. J Musculoskel Med 1991;8:14-29
Bed Rest vs Exercises
"…. continuing ordinary activities within the limits permitted by the pain leads to more
rapid recovery than either bed rest."
Malmivaara A. Hakiinen U, Aro T, et al. "The Treatment of Low Back Pain" N Engl J Med 1995;332:351-355
Williams Flexion Exercises
" Knee to chest and partial sit-up exercises may actually slow recovery"
Bigos S "Acute Care to Prevent Back Disability" Clin Ortho and Related Res 1987;221 (August):121-130
Muscle Layers
There are many more joints in the back than discs.
There are many more muscles than joints.
The most common cause of low back pain is when one or more muscles "forget" to relax. We call this a somatic dysfunction
Multifidus, Quadratus lumborum
Iliocostalis, longissimus, (Erector s.)
Thoracolumbar fascia
Lattisimus dorsi
Lumbar ligaments
Ligamentum flavum
Facet capsules
Interspinous ligaments
Supraspinous ligaments
Pain Generators
Annulus Fibrosis (outer 1/3 only?)
Neural Membranes (Anterior Dura)
Ligaments/ Z-joint capsules
Imaging or Not?
Low yield without RED FLAGS present.
"Abnormal" findings in Asymptomatic.
Jarvik- LAIDback study.
Anxiety, fear-avoidance- possibly help?
Depression- "there must be something wrong"
Guidelines for Imaging
Acute pain- symptomatic treatment for 4 weeks, re-evaluate. Image if pain continues.
AHCPR Guidelines for Acute LBP.
Sub acute pain- Pain for >4wks.
Failed symptomatic treatment. Image.
Chronic pain- none, unless changes in sx’s
Chronic intermittent- TX as acute patients
Who needs Surgery? Or who only needs Surgery
Unstable Spine
Acute fractures with Neurologic deficit.
Severe Stenosis
After failure of aggressive non-operative tx.
Progressive Neurologic deficit
Recently several large studies of surgical approaches such as diskectomy, fusion, and IDET have not demonstrated efficacy – even for patients with established radiculopathy and HNP
1997 1st RCT to find that Lumbar Stabilization Exercises could treat and prevent future episodes of Low Back Pain and Disability in Patients with Spondylolithesis:
O’Sullivan et al: Spine 1997
Active System - Muscles
Many layered and overlapping muscles both anterior and posterior
Core Muscles:
n Transversus Abdominis (TrAb) anteriorly
n Multifidus posteriorly
The "deep subsystem"
n External Oblique
n Internal Oblique
n Rectus Abdominis
The "superficial subsystem"
Transversus Abdominis
Flexes, forms a rigid cylinder, assists in respiration, and decreases shear and torque forces
Note the fiber alignment, which allows you to see "Nature’s Back Belt"
Trunk extensor
Postural control (segmental control)
In same fascial plane as TrAbd
Why is it important???

Interesting Back Fact: Active System
Initial onset of LBP or subsequent acute episodes create a one-sided, one level atrophy of the multifidus muscle, which does NOT spontaneously recover when pain goes away.
Currently being investigated as a possible reason for the high recurrence rate of LBP
No chronic back pain treatment should be without motor control / coordination exercise
Neural Control System
Earlier studies focused on retraining "mechanical stability" of the spine through muscular training – mixed results
Recent research focuses more on the neural control aspect
Bottom line- it’s about endurance and control not strength, and "spinal stability" is a nervous system construct, not a muscular construct
In those with LBP, the contraction of the TrAb is delayed, demonstrating poor motor control.
We need to retrain this feed-forward, or anticipatory, contraction to help patients control their LBP and maintain stability
Why Not Surgery?
Re-operation Rates over 4 years:
Decompression 17-18%
Spinal Fusion 21-28%
This isn’t the percentage who failed to be helped – it’s the percentage that failed to be helped AND needed another procedure.
ICD codes indicating fusion failure, hardware failure, or pseudoarthrosis
Remember finding is not a diagnosis..!
Spinal degenerative changes can be noted in normal individuals too
A positive MRI shouldn’t be the diagnosis! It’s just a finding……
Asymptomatic Adults- MRI Abnormalities
Disc degeneration 46- 72%
Bulging Disc 24- 81%
Disc Herniation 22- 40%
Annular tear 14- 56%
Stenosis 1- 21%
Several studies have shown that there is no correlation between MRI findings and patients’ low back symptoms.
1. Wittenberg et al., 1998
2. Smith et al., 1998
3. Savage et al., 1997
All types of Back pain is having Muscular-myofascial components Caused / Continued by cumulative traumas
The usual Mechanical Components for Chronic - Recurring Back Pain are chronic muscular spasms, which may be 1º & 2ndary (strains-sprains). 1º (muscle - motor unit - fatigue), 2ndary (nerve entrapment)
Ongoing Back Pain Symptoms are 95% Musculo – Myofascial (is it called idiopathic?).
In origin symptoms are not equal to cause…!
Make the Diagnosis, determine the specific anatomical muscular-myofascial dysfunction(s) then identify the causes for the anatomical musculo-myofascial dysfunction(s) which can be classified as Primary & Secondary, or in another way as Precipitant Cause (s) and/or All Contributing Cause (s)s
Back Pain: Etiology
Highest estimate: <10% Spinal canal: Intervertebral path: Disc ruptures, Radicular,
< (<1%) operable disc
Highest estimate: <5% Structural: stenosis, fracture, unstable. < ( <½ %) operable
Lowest estimate: >85% Idiopathic: (musculo,ligamentous, myofascial, facet, etc.)
Chronic Musculo-skeletal Strain-sprains Brought-on &/or Maintained by Cumulative Traumas developed during Daily Living – Work - - Recreation
Back pain symptoms May be relieved by:
a. Increasing central tolerance;
b. Central blocking of thalamic reception;
c. Interference with spinal neural receptors;
d. Severance of neural pathways;
e. Silencing the site or origin; or
f. Removal of the causes.
Back pain symptoms may be removed by Elimination of the causes
If back pain is an elephant our present understanding method is like
"The Blind Men and the Elephant"

Back Pain- Causation
The precipitant: may be a specific event.
Cause of pain is rarely singular usually multiple
All Back Pains are Cumulative-Trauma Phenomenon
Twelve considerations in the diagnosis and management of low back pain (Acute or Chronic – Recurring Back Pain)
We can divide it into 5-- Specific Diagnoses & 7– Contributors

• Structural injuries –disruptions, sudden or gradual: (2) -- <5%

Two Structure pathologies
1. Specific nerve-cord pressure
2. Structural instability/damage

Specific strain injuries (Jolting) – episodic, may be chronic, recurring: (3) -- 45%

Three Jolt , jarring – episodic
3. Ilio-psoas muscle strain
4. Costo-vertebral dysfunction
5. SI joint strain/ dysfunction
Axial support- muscle strain-sprains --- specific grouping (Default) --45%

Postural contributors– chronic disruptions Behavioral or Anatomical: (7) --Effect 90%
Four Behaviors / mechanics
1. Sleep position
2. Loss of arch height
3. Wallet in the back pocket
4. Stick-shift vehicle
Three Anatomical shapes
5. Short upper-arm length
6. Leg length difference
7. Short hemi-pelvis
Postural muscle strains
90% Prevalence: 45% Primary
Quatrus lumborum
Gluteus-min, mid, max
Tensor fascia lata
Gluteus min, mid, max
All these muscle involvements are rarely alone – usually in multiples

Postural muscle strains
A 1) Symptoms
Back-hip pain, +/- tingling // Diffuse back =+/- one-side // TTPs, specific

B1) Onset ; 2) Worsen ; 3) Activity
With episode or chronic // AM , sleep, drive, stand sit; // Torso move

C1) Behavior ; 2) Posture ; 3) Environment
Sleep, wallet, arch, drive // Leg-l, Hemi-p, S-A // normal-activity

D1) Physical Tests ; 2) Radiographic/ electrodiag
Cross-chest stretch, Balance, TTPs,; Pressure I-I Lgt // N/A

E1) Behavior ; 2) Posture ; 3) P.M. ; 4) Equipment
Sleep, Car, Wallet, Arch // Balance L-L, H-P, S-A support elbows // HEP, Mobility – all //

Postural muscle strains -
May have sudden trauma onset often caused by & always aggravated and maintained by
7 – factors ie 4 – behaviors & 3 –postures

Key Postural Muscles involved in CHRONIC MUSCULAR BACK SPASM are:
Quatrus lumborum
Tensor fascia lata
Gluteus minimus
Gluteus maximus
Levator scapulae
Serratus anterior
Serratus posterior
Latissimus dorsi
Levator scapulae
FACET induced

Behavior 1 mechanics (4)
1. Sleep position
2. Loss of arch height
3. Wallet in the back pocket
4. Stick-shift vehicle

Anatomical shape – posture (3)
1. Short upper-arm length
2. Leg length difference
3. Short hemi-pelvis

Structure pathology
Play a role in < 15%
1. S-1 Specific nerve-cord pressure
2. S-2 Structural instability/damage

Jolting - episodic
Play a role in 35% +
J-1 Ilio-psoas muscle strain
J-2 Facet dysfunction (Lumbar-thoracic)
J-3 SI joint strain/ dysfunction

20 +% of acute back injuries First onset is Jolting Trauma
Eg:- Jerking catch
Auto collision
Can turn chronic – 35+% chronic disabling "idiopathic" back problems
Eg:- Groin pains
Totally numb leg
Facet Dysfunction (Lumbar- Thoracic)- "Thoracic strain"
Often recurring / chronic 5+ % chronic disabling "idiopathic" mid-back problems
Low back, mid back, shoulder, neck, arm…
"Non-cardiac chest pain"
"Idiopathic" neuropathy of the upper extremity

Cervico Thoracic
Twist & reach
Jerk arm
Sleep wrong
Fall, hit chest
Overhead pull
Twist & reach
Simple bend
Several weeks to resolve
Sudden onset
Recurs at 1 – 2 year intervals
J-3. SI Joint dysfunction
Fall on hip
Blow to pelvis
Slide over bump
Behaviors / costume / mechanics
Play a role in 85%+
Start Behavior
B-1 – Sleep position
B-2 - Loss of arch height
B-3 - Wallet in the back pocket
B-4 - Stick-shift vehicle

B-1. Dysfunctional sleep position:
Pain … neck, shoulders, arms, hands, upper back, low back…
Plays a role in 80%+
Dysfunctional Sleep Positions
Stomach sleeping
Flat, flat on back
Twisted to side
Arm(s) overhead
Commonly affecting parts
Back, also mid-back,
Shoulders, neck, arms and jaw
B-2. Uncorrected loss of arch height
Prevalence ( > 85 %)
Back pain, ache with prolonged standing/ walking
Plays a role in > 70 % LBP
B-3. Wallet in the back pocket
Plays a role in > 70 % of males
"Radicular pain" from butt to the back of knee
B-4. Stick-shift vehicle
Play a role in > 85%
Chronic – Recurring
Low Back Pain
Anatomical shape
Plays a role in 70% +
Leg length difference
A 2 Short hemi-pelvis
A 3 Short upper-arm length

Functional scoliosis: The brain commands the eyes to be level and the nose to be midline
Short hemi-pelvis Back Pain + Leg-length difference: Potential for Multiple myofascial strains
A-3. Short upper-arm syndrome
"can’t sit still"
"shirt sleeves too-long"
>50% can’t reach chair arms.
Slender body is worse
If elbows are >8 ½" above the chair seat, chair arms fit only with slouching
A Quick Review
12 Considerations in Management of Back Pain
5-- Specific Diagnoses & 7– Postural Contributors
• Structural injuries –disruptions, sudden or gradual:
2 Structure pathology
• Specific nerve-cord pressure
• Structural instability/damage
• Specific strain injuries (Jolting) – episodic, may be chronic, recurring:
3 Jolt , jarring – episodic
• Ilio-psoas muscle strain
• Costo-vertebral dysfunction
• S-I joint strain / dysfunction
• Postural muscle disruptions – Axial
• Contributors to postural & structural dysfunction
4 Behaviors / mechanics
• Sleep position
• Loss of arch height
• Wallet in the back pocket
• Stick-shift vehicle
3 Anatomical shape
• Short upper-arm length
• Leg length difference
• Short hemi-pelvis
How will you manage a case of back pain?
From where you will start?
Single technique or a comprehensive approach?
Who will be the apt person for a back pain management?
How can you provide complete cure without relapses?
How will you manage a case of back pain?
Forgot the older concepts of individual approaches. Just think about the patient as a whole…………
From where you will start?
All back events are Osteomyofascial, you have to start from the reverse. That means to start from the fascia then muscle and then the Osteal part, but remember that the integration should consider the patient as a whole.

Single technique or a comprehensive approach?
Of course the approach should be always comprehensive, incorporating the above three….
Who will be the apt person for a back pain management?
The answer is a Physical Therapist…., of course he should have very deep knowledge in Back pain, mechanics, complete evaluation ( do you know one thing, a normal back pain evaluation will take a minimum of 30 minutes!), through hands on experience which is up-to-date. A Physical therapist is the only person who can implement the holistic approach. Before staring the treatment a case discussion with your Orthopaedician / Neurologist / PMR will be healthy and it will produce a positive feedback to them too.
How can you provide complete cure without relapses?
It needs an intelligent evaluation, planning & implementation. In SCeB CAPT® we are using AJIMSHAW’s Approach® for managing various Osteomyofascial dysfunctions including Back Pain.
AJIMSHAW’s approach is a unique program designed by Dr. Ajimshaw. M.S, MPT (Neuro), MTS. a specialist in Osteo Myofascial Manipulation, Neuro Physical Therapy & RSI ergonomics, which is a rare blend of recent advances in musculoskeletal disorder managements with "Hands- On" Techniques, proving to be one of the most effective method in the prevention and management of Osteomyofascial dysfunctions as per the various ongoing researches at MFTRF®, India.
AJIMSHAW’s Approach
Advanced Management for
Joint and musculofascial
Immobility, Pain and dysfunctions by
Soft Tissue Manipulations through
Hands- On physical therapy coupled with
Active exercise programs and
Work site modifications
What do you mean by Advanced Management?
Management based on resent advances and Evidence Based Practices blended in a unique way…..
What do you mean by Joint and musculofascial ?
Treating the Osteomyofascial pathologies in a comprehensive way
What do you mean by Immobility, Pain and dysfunctions?
Immobility, Pain and dysfunctions induced due to MSD, rest etc….
What do you mean by Mobilizations ?
Realignment of the Osteal system.
What do you mean by Soft Tissue Manipulations ?
Realignment of the Myofascial System
What do you mean by Hands- On physical therapy?
Using of most modern Hands-On techniques.
What do you mean by Active exercise programs?
Aerobics, basic and advanced core stabilization programs etc.
What do you mean by Work site modifications?
The Difference is Simple Ergonomics….!!!
How AJIMSHAW’s Approach can cure Back Pain?
Hhhh…..thats a secret, Visit SCeB CAPT® for details….
How much percentage of cure do you offer for your patient, what do they say after the session?
We have only one answer… SCeB CAPT® care……100% cure….

Spine: 2000; 25: 1373-81
Spine: 1997; 22: 427-34
N England J Med: 1994; 331: 69-73
Spine: 1995; 20: 2613-25
J Bone Joint Surg Am: 1990; 72: 403-8
JAMA: 2003; 279,21:2810-18 (value plain X-ray to MRI @ 6 wk.)
Martin et al. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 22(3). 2007.
Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ. 2005 May 28;330(7502):1233
Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ. 2005 May 28;330(7502):1239
Lumbar stabilization: core concepts and current literature, Part 1. Am J Phys Med Rehabil. 2005 Jun;84(6):473-80
Increasing days at work using function-centered rehabilitation in nonacute nonspecific low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2007May;86(5):857-64
Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005 May 3;142(9):776-85
United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ. 2004 Dec 11;329(7479):1377
United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ. 2006Dec 11;329(7479):1381
A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002 Dec 15;27(24):2835-43.
A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004 Dec 21;141(12):920-8.
Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC Fam Pract. 2005 Jul 14;6(1):29.
Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2007Dec 1;29(23):2593-602
Sacroiliac joint dysfunction: evidence-based diagnosis. Orthopedic Division Review May/Jun 2004.
Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-62
Martin et al. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 22(3). 2007
Caragee E et al. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005 Jan-Feb;5(1):24-35
Kleinstuck F et al. Are "structural abnormalities" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain?. Spine 31(19) 2006.
Caragee E et al. Are first-time episodes of serious LBP associated with new MRI findings? . Spine J. 2006; 6 p624-635.
Borenstein et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am. 2007Sep;83-A(9):1306-11.
Savage R et al. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6(2):106-14.
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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
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.
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
Transverse abdominis
IT band/ TFL
LD etc.
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.
Erector spinae
Glutei and piriformis
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.

Myofascial Release - An Introduction for the Patient

Reg. No. A1.M9/08, S. 289/08
Chemmanampady, Medical College, Kottayam
Ph: 9846265331, 9846474873, 9048001452 E mail:
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.
In SCeB CAPT ® our therapist are specialized in MFR and practicing most resent and proved Hands- On techniques through an approach called AJIMSHAW’s Approach ® & this is the identity and uniqueness of our clinic.
Our motto "SCeB CAPT® Care…….100% Cure……
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 fibers: A) Collagenous fibers which are very tough and have little stretch ability. B) Elastic fibers which 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 denser 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 in grained 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. 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 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. Muscle tissue responds to a relatively firm stretch, but this is not the case with fascia. Remember the collagenous fibers 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 overtime. 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 to obtain optimal results.
Frequently there is increased pain for several hours to a day after treatment, followed by remarkable improvement. After, remarkable improvement is noted immediately during or after a treatment. Sometimes new pains in new areas will be experienced. There is sometimes a very light-headedness or a feeling of 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 issue is accompanied by release of trapped metabolic waste products into the surrounding tissue arid bloodstream. 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.
Some examples of our Successes
Case History—Chronic Low Back Pain
A 32-year-old construction worker was suffering from Chronic Low Back Pain with bilateral thigh pain. Five months after his continuous pain he was referred to physical therapy by his doctor for three weeks of treatment for chronic low back pain and bilateral thigh pain. He was treated with AJIMSHAW’s Approach for his condition. After just two treatments sessions itself there was no further leg pain and only mild low back pain with movement. After the completion of the course he no longer was having any pain and had returned to his job as a construction worker. Specific exercises and activity modifications were advised. Following up by telephone three months later, he reported having no problems with his back. He is very pleased with his ability to continue his strenuous job.
Case History- Fibromyalgia
A 18-year-old BDS student was suffering from chronic low back pain, neck pain, head ache, leg pain and arm pain, she was treated with AJIMSHAW’s Approach for one month. After the course he is totally pain free and energetic and doing well in her studies.
Case History- Cervical Spondylosis
A 48-year-old businessman was referred to our centre with a diagnosis of Cervical Spondylosis. He was having symptoms of radiating pain over both the arm, neck pain and head ache. He was given a 20 days program of AJIMSHAW’s Approach. Now he is spending a normal life without any discomfort on a 4 months follow up enquiry.

Case History- Carpal tunnel syndrome
A 55-year-old retired nurse/ house wife was suffering from tingling, numbness, pain along both the wrists. All studies (EMG, NCV) confirmed the diagnosis of Carpal tunnel syndrome. She received treatment for her neck, upper back, upper arm, fore arm and wrists. There were 18 sessions after that she didn’t have any tingling episodes and reported complete recovery.
Case History- Heel pain
A 28-year-old female (House Wife) visited SCeB CAPT® for her debilitating pain on right heel. She cannot walk properly, not able to use her feet for any force producing activities. The pain was particularly worse in the morning when she is getting up from the bed. She has undergone five days treatment at our centre. According to her 90% of her pain had vanished immediately after the first session. After two months enquiry she is doing well and the pain has never returned.
Case History- Shoulder Stiffness
A 70-year-old retired businessman, known diabetic and hypertensive, was referred to our centre for his left shoulder stiffness, severe pain particularly at night which is radiating to his upper arm too. He was given a 20 day program. After 10 days itself he had a very good relief and his shoulder activities returned back to 100%. A follow up after five months reported that he is having no complaint with his left arm.
Case History- Lower leg pain.
A 45-year-old government employee, was referred to our clinic with the complaints of pain in his both lower legs. Pain intensity is worse in the right than left. He cannot walk for long, cannot squat or cannot climb steps. He was given a 15 day program of AJIMSHAW’s Approach. Now all his discomfort had disappeared and is doing well.
Case History- Tennis Elbow
A 27-year-old computer professional was referred to our centre with a history of pain and weakness on his right elbow and hand. He was given a five day program. Now he is happy because he is not having any such complaints when using the mouse of the computer.
Case History- Head Ache
A 29-year-old university employee had visited our centre with a complaint of severe head ache for which she had tried almost all treatments. Her duties include prolonged sitting and computer use. We had given a course of AJIMSHAW’s Approach with Craniosacral Therapy and given some advices regarding how to use the daily activities correctly without harming the neck. Now she back to work with no such complaints afterwords.
Other conditions for which we are having successful track records are :-
Post Chickun gunia pain
Persistent body pain after severe accidents
Stroke rehabilitation
Spinal cord injury rehabilitation
Parkinsonism rehabilitation
Cerebral Palsy
Different types of arthritis
Knee Joint Pain and so on…….