Manual Therapy Choices for Parkinson’s Disease

In treating dysfunction, it is normal for most therapists to use a variety of modalities and methods including myofascial release, muscle-energy techniques, positional-release techniques and many more. The assumption must be that different tools achieve different effects, and the ones we choose reflect our perception as to the needs of the individual and/or of the tissues involved. Sledgehammers and walnuts are a reminder that there are appropriate and inappropriate tools for achievement of specific tasks.
A question arises as to whether there exists potential patient benefit to use a general, nonspecific, manual therapy approach, as well as specific focus on identified dysfunction (short, tight, restricted, etc). Evidence (see below) suggests that this is the case, particularly in situations of general poor health.
The variables as to why a particular method is chosen may include: how acute or chronic and how general or local the problem is; age, history and current overall health status of the person; known and/or hypothesized effects of the method in question in relation to identified dysfunctional conditions (i.e., the aimed-for objectives); and the skills, training and licensing restrictions associated with the person providing treatment.
Of course, if only a limited range of skills and modalities have been acquired, choice may be limited by that alone. In contrast, a therapist who has acquired multiple skills and a range of modalities from which to choose may be virtually spoiled for choice as to which therapeutic approach(es) to adopt.
I was reminded a few days ago of the importance that therapists acquire multiple skills when I came across a research study that evaluated a range of osteopathic methods (compared with dummy modalities) in the treatment of patients with Parkinson’s disease (PD).4 In this study, 10 patients with Parkinson’s disease and a group of eight age-matched normal control subjects were subjected to gait analysis before and after a single session of an osteopathic manipulative treatment (OMT) protocol that involved mobilization and muscle-energy procedures rather than manipulation. A separate group of 10 patients with Parkinson’s disease was given a sham-control procedure and tested in the same manner.
In the treated group of patients with Parkinson’s disease, statistically significant increases were observed in stride length, cadence, and the maximum velocities of upper and lower extremities after a single treatment.
There were no significant differences observed in the control groups. The data demonstrates that a single session of an OMT protocol has an immediate impact on Parkinsonian gait.
So, what methods were used (all of which are within the scope of practice of massage therapists, once they have acquired the skills)?

Antero-posterior and lateral mobilization of the thoracic and lumbar spine (patient seated).
Myofascial release of the thoracic spine (patient seated).
Atlanto-occiptal release (patient supine; not manipulation).
Mobilization of the cervical spine (patient supine).
Muscle-energy technique (MET) release of cervical muscles (patient supine).
General mobilization of the shoulder joints including use of MET (patient side-lying).
Mobilization of the forearms (patient supine).
Mobilization of the wrists (patient supine).
Mobilization of the SI joint (patient supine).
MET to the hip adductors (patient supine).
MET to psoas muscles (patient supine).
MET to hamstrings (patient supine).
Mobilization of the ankles (patient supine).
MET to the ankle in dorsi and plantar flexion (patient supine).
Note: This sequence was performed in this order in 30 minutes.

Obviously (and the researchers note this), these procedures would probably have been even more effective if combined with approaches that targeted restrictions and dysfunctions specific to particular individuals.
However, in the context of a research study, it was considered that it would be useful to evaluate the benefits - or lack of thereof - when a standardized set of methods were used on all patients.
The outcome was clear. There is a major general benefit to be gained from a broad, generalized, constitutional approach involving myofascial release, muscle-energy techniques and mobilization. Would the results have been even more profound if they had been combined with massage or associated approaches such as Trager therapy and/or trigger point deactivation utilizing neuromuscular techniques?1-3I would bet the farm - and more -on this!
Leon Chaitow, ND, DO

References
1. Craig L, et al. Controlled pilot study of the effects of neuromuscular therapy in patients with Parkinson’s disease. Movement Disord 2006;21(12):2127-33.
2. Duval C, et al. The effect of Trager therapy on the level of evoked stretch responses in patients with Parkinson’s disease and rigidity. JMPT 2002;25(7):455-64.
3. Hernandez-Reif M, et al. Parkinson’s disease symptoms are differentially affected by massage therapy vs. progressive muscle relaxation: a pilot study. J Bodywork Movement Ther 2002;6(3):177-82.
4. Wells M, et al. Standard osteopathic manipulative treatment acutely improves gait performance in patients with Parkinson’s disease. J Am Osteopath Assoc 1999;99(2):92-8.

Myofascial Release for Athletes

Introduction
Athletes commonly suffer from functional pain or restrictions in flexibility due to scar tissue or adhesion build-up in the muscle and fascia. This is usually caused from strains to the muscles. Myofascial Release is a massage technique that utilizes the stretching of the fascia and muscle to help increase Range of Motion or to decrease pain by breaking up these adhesions in the fascia. Fascia is the connective tissue that covers all muscle and tissue in the body. Breaking up these adhesions between the fascia and muscle allows the muscle and fascia to move smoothly over each other and helps alleviate the problem7.
The idea of Myofascial Release is to slowly stretch the fascia because fascia does not respond to quick tensile forces. Rather it will elongate with a slow moderate stretching7. This will help the muscle to glide over the fascia because it is giving the muscle more space to move, increasing flexibility. Other techniques help break down different adhesions to also increase flexibility and decrease associated pain.
In this paper I will explain Myofascial Release. I will talk about its history, the physiology and anatomy behind its use, the physiology behind static stretching, how Myofascial Release and Static Stretching increase Range of Motion, and finally different techniques used for Myofascial Release.
History of Myofascial Release
Myofascial Release, or similar theories has been around since the 19th century, however there is no documentation that suggests the exact origin of Myofascial Release. Dating back to the 1940’s the term Myofascial was used in Janet Travell’s research of different pain syndromes. In the 1950’s there were articles that were published that talked about trigger points and Myofascial pain. As we went into the 1960’s and 1970’s, the acknowledgment of Myofascial trigger points in causing pain and restrictions in Range of Motion was increasing3.
The actual term of Myofascial Release was not used until 1981. It was used in the title of a course on Myofascial Release at Michigan State University3. Myofascial Release is based on the concepts created by Andrew Taylor Still, the founder of Osteopathic Medicine, in the 19th century. The first form of Myofascial Release that was used By Still was the indirect method. This method involves the gentle stretching of the fascia, such as the cross-hand technique. The indirect method was growing at the Kansas City College of Osteopathy and Surgery. Dr. George Andrew Laughlin and Dr. Esther Smoot were very influential in the growth of this indirect method3.
The Direct Myofascial Release most likely came about in the 1920’s. This technique has developed much more slowly than the indirect technique3. Dr. William Neider developed this technique that was named “fascial twist,” which was more forceful then the gentle stretching of the indirect method3. Many of his concepts are present in today’s techniques of Myofascial Release.
To effectively use Myofascial Release, a thorough understanding of its techniques is necessary. To best utilize Myofascial Release, knowledge of the anatomy and the neurology is needed.
Physiology of Myofascial Release
Fascia is a connective tissue along with tendons, ligaments, bone, and muscle. Fascia is divided into three different layers. The first layer, which is the superficial fascia, consists of connective tissue and adipose tissue. It provides a path for nerves and blood supply3.
The second layer of fascia is called the potential space. This area can become inflamed, which shows that it can be injured or stretched with any type of injury3. The final layer of fascia is the deep layer. This layer is a very dense connective tissue that covers all the muscles and organs of the body. This layer also divides the different muscles from each other. The function of this layer is to allow movement of the muscles over each other, can provide attachments of some muscles, and it fills the spaces between some muscles and organs3.
At times the muscles that are beneath and surrounded by this fascia become large rather quickly. This can cause the fascia to be too small and tight around the muscle. This causes restrictions in Range of Motion of a particular muscle. One function of Myofascial Release is to help stretch the fascia to allow more motion of the muscle therefore increasing the Range of Motion of the body.
Restrictions in motion and the cause of pain can also occur as a result of a muscle strain. A muscle strain can lead to chronic issues and inflammation. This pain can be a result of Myofascial Pain Syndrome. Treatment of this type of pain has no real plan like the treatment of an acute injury has. This pain begins in the fascia and the muscle. This causes restrictions in Range of Motion and causes pain. If this is untreated, Myofascial Trigger Points can then develop3.
Myofascial Trigger Points are “…a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena,” quoted by J.G. Travell and D.G. Simons in The Manual of Trigger Point and Myofascial Therapy2. There are a few different theories regarding the origin of Myofascial trigger points. One of them is the thought that abnormal muscle spindles send signals that may cause a trigger point. Another theory deals with scar tissue formation, while a third one talks about nerve signals can cause a Myofascial Trigger Point2. All of these can be causes of trigger points, however researchers are not exactly sure of the origin of the trigger points.
Different techniques of Myofascial Release can help work out these trigger points and decrease pain and restore motion. Adhesions and scar tissue build-up can also be a cause of decreased motion and increased pain. Myofascial Release can be used to reduce these adhesions and restore motion and decrease the associated pain from the lack of function7.
Physiology of Stretching
Static Stretching is a technique very commonly used to help improve Range of Motion of a particular body part and help reduce the risk of injury. The principal behind static stretching is the stress-strain curve, which demonstrates the extensibility and breaking point of tissue. Muscle will stretch when a force is placed on it. When the muscle is stretched beyond its original length it will then stay at the new length if the force is great enough.
Continuous stretching over a long period of time will result the muscle to elongate and become more flexible. This will cause the Range of Motion to increase and therefore help reduce the risk of injury from a tensile force. If the muscle is more flexible, it obviously can stretch further. When a strong tensile force is placed on the muscle, it can go further than it originally could, making it harder for the muscle to tear.
Myofascial Release Techniques and Guidelines
Some contraindications to Myofascial release are its use on acute fractures, someone with osteoporosis, arthritis, on anyone with skin conditions, and over areas with heavy edema8. If the athlete does not have any of these conditions, Myofascial Release is very helpful in their treatment as will be explained later in this paper.
There are several different techniques for Myofascial Release. Some focus more on the actual stretching of the fascia, while others focus more on trying to release and work out the Myofascial Trigger Points and adhesions that can form between the fascia and the muscle. Myofascial Release can be performed anywhere there is fascia in the body and you can work out either superficial or the deep fascia.
Before you can perform this type of therapy you must find out where the restrictions are in the person. You can do this by looking for any areas of restriction or pain in the person. For example, a person may complain of chronic hamstring pain and may demonstrate hamstring tightness. This could be a candidate for the use of Myofascial Release. The athlete may also reveal previous hamstring injuries, which could be a cause of Myofascial Pain Syndrome.
One technique is the “transverse fascial-plane release” technique, which used commonly used on the diaphragm, thorax area, and the spinal column area9. Also, the cross-hand technique, in which you have your hands crossed and apply pressure in opposite directions to slightly stretch the fascia9. Another technique, which is used to help break up adhesions within the fascia, is the J-stroke method. With this technique, you hold the fascia on stretch with one hand, and move the other hand over the restricted area in a J pattern7. Another form o f release is the skin rolling technique, in which you just roll the skin between your fingers trying to work out the trigger points and adhesions that can form within the fascia to help the athlete restore his or her normal Range of Motion7. If you are looking to work the superficial fascia, you only need one hand, and just place less pressure. To release deeper fascia, a more intense pressure should be applied.
Myofascial Release and Static Stretching To Improve Function
As was stated above, Myofascial Release can help increase Range of Motion and decrease chronic muscle pain caused by either Myofascial Trigger Points or other adhesions with the Myofascia. One case report looked at a female runner who had extremely chronic hamstring pain. She was unable to run because of the pain. She also had deficits in her Flexibility in the involved leg. Also, she had tightness in many other areas such as her pectoralis major. She received Myofascial Release on her Posterior leg as well as back, and was also doing manual hamstring exercises at home 2 times per day6.
After a few treatments she had a significant reduction in pain. She also began hamstring exercises for strengthening. She was able to begin running again with no pain, and her flexibility was also increasing6. The release and stretching together helped this athlete restore her Range of Motion and reduce her pain.
The next article was a clinical study that wanted to analyze the differences between Myofascial Release and Static Stretching on increasing the Flexibility of the Hamstrings. While Static Stretching has been a known treatment of Range of Motion deficits, Myofascial Release is more commonly a secondary treatment and often coupled with other treatments. This study looks at the two different treatments alone to compare the results4. The participants of this study needed to have at least a 15-degree deficit in Hamstring flexibility to qualify to participate. Also, the participants could not have any hamstring injury or lower back pain within the last 6 months before the study4.
There were three different groups in the study: the control group, the Myofascial Release group, and the Static Stretching group. The two groups that were receiving treatment underwent four weeks of treatment, while recording the results of the active knee extension as they progressed through the study4. The stretching group did four thirty second stretches during each session. The release group did four treatments per session. The control group obviously did not do any stretching exercises during the study4.
Both the Static Stretching group and the Myofascial Release group showed significant increases in the flexibility of the athlete’s Range of Motion. However, the researches found no difference between these two groups. The study found that the two methods are both effective in increasing Range of Motion4.
Another study which is similar to the one above, focused on Myofascial Release and stretching on Range of motion and also Muscle activity. This study focused more on the hip flexors, rather than the hamstrings. This study was similar to the one above and found similar results. Both the Static Stretching and the Myofascial Release showed great increases in hip flexor flexibility. However, the two treatments had no effect on the muscle firing activity of the antagonistic muscles; in this case the gluteus maximus5.
Conclusion
Myofascial Release is a very good tool for Athletic Trainer’s to utilize in treatment of their athletes. It has been shown to greatly increase Range of Motion, the same amounts as static stretching. As well as decreasing pain and myofascial trigger points associated with chronic myofascial pain syndrome commonly from hamstring strains and the build-up of scar tissue2. Myofascial release is mostly used with another treatment, usually not as the initial treatment of injuries. I believe that coupled with static stretching, the function of the athlete can be greatly increased. One study on Static Stretching’s effect on muscle soreness found that stretching has a very small effect on the reduction of muscle soreness1. Therefore Myofascial Release and Static Stretching will greatly increase the function of an athlete.
However, to come to a definitive conclusion there needs to be more research comparing the use of Myofascial Release and Static Stretching. Also there needs to be research that compares these two treatments along with Myofascial Release and Static Stretching together.

Works Cited

1. Anderson, J.C. "Stretching Before and After Exersice: Effect on Muscle Sourness and Injury Risk." Journal of Athletic Training 40 (2005): 248-255.

2. Kostopoulos, Dimitrios, Rizopoulos K. The Manual of Trigger Point and Myofascial Therapy. (2004): SLACK Incorporated, Thorofare, NJ.

3. Manheim, Carl. The Myofascial Release Manual ed. 3 (2001)

4. McClellan EC, Padua DA, Guskiewicz KM, Prentice WE, Hirth C. " Effects of Myofascial Release and Static Stretching on Active Range of Motion and Muscle Activity." Journal of Athletic Training 39 (2004): 98.

5. Shulzt, SP, Padua DA, Petschauer MA, Hirth CJ. "Effects of Myofascial Release and Static Stretching on Hamstring Flexibility." Journal of Athletic Training 39 (2004): 90.

6. Spina, Andreo. “Treatment of Proximal Hamstring Pain using Active Release technique applied to the Myofascial Meridian: A Case Report.” Sports Performance Centres. .

7. Starkey, Chad. "Myofascial Release." Therapeutic Modalities ed. 3 (2004): 299-303

8. Sefton, JoEllen. “Myofascial Release for Athletic Trainer’s, Part 1: Theory and Session Guidelines.” Athletic Therapy Today 9 (2004): 48-49.

9. Stone, Jennifer A. “Prevention and Rehabilitation: Myofascial Release.” Athletic Therapy Today 5 (2000): 34-35

10. Zainuddin, Zainal, Mike Newton, Paul Sacco, Kazunori Nosaka. "Effects of Massage on Delayed-Onset Muscle Soreness, Swelling, and Recovery of Muscle Function." Journal of Athletic Training 40 (2005): 174-180.