MyoFascial Therapy and Research Foundation®

Core Stabilization Program for Low Back Rehabilitation

2011-08-02T22:54:00.000-07:00

Dr. Ajimsha. M S, MPT (Neuro), ADMFT, PhD (Neuro), School of Physiotherapy, Faculty of Allied Health Professions, AIMST University

Introduction

A strong foundation of muscular balance and core stability is essential for normal movements and lumbo pelvic integrity. Weakness or lack of sufficient co-ordination in core musculature can lead to less efficient movements, compensatory movement patterns, strain and overuse and injury. The program starts with restoration of normal muscle length and mobility to correct any muscle imbalances. Next, fundamental lumbopelvic stability exercises are introduced, teaching the patient to activate the deeper core musculature. When this has been mastered, advanced lumbo-pelvic stability exercises using the Physioball are added for greater challenge. As the patient makes the transition to the standing position, sensory-motor training is used to stimulate the sub-cortex and provide a basis for more advanced functional movement exercises, which promote balance, co-ordination, precision, and skill acquisition.

Concept of Core Stability
The core musculature is composed of 29 pairs of muscles that support the lumbopelvic-hip complex. These muscles help to stabilize the spine, pelvis, and kinetic chain during functional movements. When the system works efficiently, the result is appropriate distribution of forces; optimal control and efficiency of movement; adequate absorption of ground-impact forces; and an absence of excessive compressive, translation, or shearing forces on the joints of the kinetic chain.
The term core has been used to refer to the trunk or more specifically the lumbopelvic region of the body (Bergmark, A, . Mcgill, S.M, Mggill, S.M et al, Panjabi, M.M,). The stability ofthe lumbopelvic region is crucial to provide a foundation for movement of the upper and lower extremities, to support loads, and to protect the spinal cord and nerve roots (Panjabi, M.M). Panjabi defined core stability as "the capacity of the stabilizing system to maintain the intervertebral neutral zones within physiological limits". The stabilizing system has been divided into 3 distinct subsystems: the passive subsystem, the active muscle subsystem, and the neural subsystem (Panjabi, M.M).

The passive subsystem consists of the spinal ligaments and facet articulations between adjacent vertebrae. The passive subsystem allows the lumbar spine to support a limited load (approximately 10 kg) that is far less than body mass. Therefore, the active muscle subsystem is necessary to allow support of body mass plus additional loads associated with resistance exercises and dynamic activities (Mcgill, S.M, Mggill, S.M et al, Panjabi, M.M).

Bergmark divided the active muscle subsystem into "global" and "local" groups, based on their primary roles in stabilizing the core. The global group consists of the large, superficial muscles that transfer force between the thoracic cage and pelvis and act to increase intraabdominal pressure (e.g., rectus abdominis, internal and external oblique abdominis, transversis abdominis, erector spinae, lateral portion quadratus lumborum). Conversely, the local group consists of the small, deep muscles that control intersegmental motion between adjacent vertebrae (e.g., multifidus, rotatores, interspinal, intertransverse). The core muscles can be likened to guy wires, with tension being controlled by the neural subsystem.

As tension increases within these muscles, compressive forces increase between the lumbar vertebrae; this stiffens the lumbar spine to enhance stability (Mcgill, S.M, Panjabi, M.M). The neural subsystem has the complex task of continuously monitoring and adjusting muscle forces based on feedback provided by muscles spindles, Golgi tendon organs, and spinal ligaments. The requirements for stability can change instantaneously, based on postural adjustments or external loads accepted by the body. The neural subsystem must work concomitantly to ensure sufficient stability but also allow for desired joint movements to occur (. Mcgill, S.M, Mggill, S.M et al, Panjabi, M.M).
A key muscle that works with the neural subsystem to ensure sufficient stability is the transversis abdominis. Cresswell and Thorstensson (Cresswell & Thorstensson) demonstrated that this muscle functioned primarily to increase intra-abdominal pressure, which reduced the compressive load on the lumbar spine. Other studies have demonstrated that the transversis abdominis was the first muscle activated during unexpected and self-loading ofthe trunk (Cresswell, Oddsson et al) and during upper and lower extremity movements, regardless of the direction of movement. Hodges and Richardson proposed a feed-forward mechanism associated with function ofthe transversis abdominis.

The neural subsystem utilizes feedback from previous movement patterns to coordinate and preactivate this muscle in preparation for postural adjustments or the acceptance of external loads. In another study, Hodges and Richardson demonstrated delayed activation of the transversis abdominis in subjects with low back pain, suggestive of neural control deficits.

Some practitioners mistakenly believe that the smaller local muscles are involved primarily with core stability, whereas the larger global muscles are involved primarily with force production (Johnson, P, Verstegen, M., & P. Williams). This mistaken belief has prompted ineffective training strategies designed to train the local and global muscle groups separately in nonfunctional positions. For example, the abdominal draw-in maneuver, typically performed in the quadruped or supine body position, has been widely promoted to train the stabilizing function of the transverses abdominis (Johnson, P, Verstegen, M., & P. Williams). Although this muscle is a key stabilizer of the lumber spine, several other core muscles, both local and global, work together to achieve spinal stability during movement tasks (Cresswell & Thorstensson,). For example, local muscles, such as the multifidus and rotators, contain high densities of muscle spindles. Therefore, these muscles function as kinesiological monitors that provide the neural subsystem with proprioceptive feedback to facilitate coactivation of the global muscles to meet stability requirements (Nitz, A.J., & D. Peck).
McGill stated, "The relative contributions of each muscle continually changes throughout a task, such that discussion of the most important stabilizing muscle is restricted to a transient instant in time". Core stability is a dynamic concept that continually changes to meet postural adjustments or external loads accepted by the body. This suggests that to increase core stability, exercises must be performed that simulate the movement patterns of a given activity. The co-contraction of the deeper-layer transverse abdominus and multifidi muscle groups occurs prior to any movement of the limbs, and believe that this neuromuscular pre-activation is critical in stabilising the spine prior to any movement.

The core program
Stability work should be started only after the patient has achieved good mobility, as adequate muscle length and extensibility are crucial to proper joint function and efficiency. Although beyond the scope of this article, a thorough evaluation of the muscular system should include an assessment of the muscles for over-activity, shortening, weakness, inhibition, and quality of motion. This is best accomplished by a skilled physician or therapist using muscle-length tests, strength tests, and tests for the efficiency of basic movement patterns and neuromuscular control. A thorough postural observation and video taping of the patient's gait will help in assessing and identifying any movement imbalances.

Preliminary stretches for shortened muscles should include proprioceptive neuromuscular facilitation (PNF) type or contract-relax stretches that strive for isometric contraction, followed by end-range stretching. These are effective techniques for maintaining muscle length and joint mobility. Myofascial Release Techniques when used in conjunction with stretching techniques, have shown great promise in restoring muscle length and soft-tissue extensibility. Patients can be taught to do their own self-mobilization with use of a foam roll.
Specific exercises for the patient should progress from mobility to stability, to reflexive motor patterning, to acquiring the skills of fundamental movement patterns, and finally, to progressive strengthening. These sequences may not be applicable to all patients; therefore, the key is to analyze the individual in each exercise category and then to tailor an exercise regimen that will best suit that patient's needs. For example, patients with iliotibial band syndrome often have weakness in their hip abductors that predisposes them to increased stress on the iliotibial bands. Thus, a preventative training program for patients with this syndrome must target the hip abductors, particularly the posterior aspect of the gluteus medius that assists external rotation or in decelerating internal rotation of the hip. Other muscles that prove weak or inhibited on evaluation should also be strengthened on a case-by-case basis.

Fundamental lumbo-pelvic stability

The purpose of basic core stabilization exercises is not only to increase stability, but more importantly it is to gain co-ordination and timing of the deep abdominal-wall musculature. It is extremely important to do these basic exercises correctly, as they are the foundation of all other core exercises and movement patterns. These basic exercises emphasize maintaining the lumbar spine in a neutral position.
This first stage of core stability training begins with the patient learning to stabilize the abdominal wall. Proper activation of these muscles is considered crucial in the first stages of a core stability program, before progressing to more dynamic and multi-planar activities.The exercise program should progress sequentially through the fundamental movements as detailed below. The following exercises are to be performed regularly to maximize results, you have to continue the basic pattern even you have mastered the advanced patterns. The patient begins with one to two sets of 15 repetitions and progresses to three sets of 15-20 repetitions. These exercises are taught initially in either a supine, hook-lying position. The patient can progress to the more functional standing exercises, as control is developed. Important concepts taught at this stage include not tilting the pelvis or flattening the spine. We also emphasize normal rhythmic breathing

Abdominal Hollowing

The Abdominal Hollowing method to stabilize the spine is based on the Richardson philosophy of trunk stabilization. Often rehabilitation and exercise specialists will use this method of stability as they feel that trunk stabilization retraining should start with reestablishing local lumbar stability first.
To instruct your client to perform the Abdominal Hollowing technique follow the following directions:
1. Let your client lay down on the floor or on a treatment table in a supine hook-lying position.
2. Stand next to the client.
3. Ask the client to put both of their hand on their lower abdominal region at he level of their belly button.
4. With permission from the client put your hand on top of their hand as if covering their belly button.
5. Instructions: “Breath in and out normally for a few breaths until relaxed. To accomplish Abdominal Hollowing, take a deep breath then breath out completely, draw your belly button towards your spine at about 30% intensity – hold this position for 10 seconds. breath in, relax and repeat this maneuver.
6. Cues: “Try to suck in your belly button as if you walk on the beach in a bathing suit ”.
7. The pattern will be ‘breath in, breath out, abdominal hollowing (press down your belly button), relax and breath in’.

Supine Bent-Knee Raises
This is a fundamental exercise for recruiting the deep abdominal muscles and for lumbopelvic control. The patient lies on her back, with knees bent and feet flat on the floor. She then braces the abdominal wall, holding the lumbar spine in a neutral position as described above, and slowly raises one foot 15-30cm off the ground with alternate legs. Common errors when performing this exercise include rocking the pelvis, abdominal protrusion, or an inability to maintain the neutral lumbar curve. If this happens, discontinue the exercise for a rest period. Quality more than quantity is stressed.
Progression: The exercise can progress to alternately extending the legs and lowering to the ground. Once the patient can maintain stability with alternate leg lifts. She can add alternate, overhead arm raises for greater challenge. The arm raises should be performed slowly, while maintaining lower abdominal bracing.

Figure 1: Supine Bent-Knee Raises

Quadruped with Alternate Arm/Leg Raises
This exercise prepares the patient for the proprioceptively more challenging, more dynamic exercises of the trunk. It specifically engages the multifidi-the deep transverse spine stabilizer and extensor of the lumbar spine.
The patient should position herself on all fours. She then braces the abdominal wall as described above. While maintaining a midrange/neutral curve of the lumbar spine, the patient should raise the right arm and the left leg (opposite upper and lower limbs) into a line with the trunk, while preventing any rocking of the pelvis or spine (excessive transverse or coronal-plane motion). If it helps to maintain alignment, the patient may use an object, such as a foam roller or wooden dowel, placed along the spine, for added tactile feedback. The leg should be raised only to the height at which patient can control any excessive motion of the jumbo-pelvic region. She then performs the exercise raising the left arm with the right leg.
Progression: A Physioball underneath the trunk can provide significantly more proprioceptive challenge owing to its unstable surface. The goal once again is for the patient to maintain lumbar stability while the opposite arm and leg are raised slowly.

Figure 2: Quadruped with Alternate Arm/Leg Raises

Bridging

Bridging is a fundamental core-stability and gluteal-strengthening exercise.
The patient begins the exercise on her back, in a hook-lying position, with arms resting at her sides. She activates the abdominals and squeezes the gluteal cheeks prior to initiating the movement. The patient lifts the pelvis and hips off the ground while maintaining neutral lumbar alignment. There should be no rotation of the pelvis. The hips should be aligned with the knees and shoulders in a straight line. The patient should hold the position for 10sec and then slowly lower the pelvis to the floor.
Progression: In the lifted-bridge position, while maintaining neutral lumbar and pelvic alignment. the patient can lift one foot off the ground and extend the leg. By placing her arms across her chest, she can increase the challenge of stabilising the lumbo-pelvic region. To progress further, the patient can raise both arms up to the ceiling and then move one arm out to the side. She should bring the arm back to the centre and repeat with the other side.

Figure 3: Bridging

Prone Plank

This is a fundamental, static core-stability exercise.
The patient supports herself with her forearms resting on the mat, elbows bent at 90 degree, and the toes resting on the mat. The patient maintains the spine in a neutral position, recruits the gluteal muscles, and keeps the head level with the floor. She is instructed to breath normally throughout the exercise, while maintaining the abdominal brace. We suggest holding the position for 20sec, working up to one minute for two to three repetitions. No compensatory motion, such as increased lumbar lordosis or sag, should be seen.
Progression: In this position, the patient can add leg lifts for more difficulty: one leg can be lifted off the mat, held for five seconds, and then repeated on the opposite side.

Figure 4: Prone Plank

Side Plank

This is a fundamental, static core-stability exercise designed to challenge the patient's body against gravity in the coronal/frontal plane and is an ideal exercise to train the quadratus lumborum.
The patient is lying on her right side with the right arm extended in a straight line up from the shoulder, with the forearm resting on the mat. She then raises the pelvis from the floor and holds it in a straight-line "plank" position. The hips should not be allowed to sag toward the floor. We suggest holding the position for 20sec, working up to one minute holds for two to three repetitions.
Progression: The top foot can be raised to increasingly challenge the core and gluteal musculature.

Figure 5: Side Plank

Advanced lumbo-pelvic stability
Once the patient demonstrates good stability with all static core exercises, they can be replaced with more advanced exercises on the Physioball detailed below. These exercises should be performed at least two times per week to maximize results. The patient progresses to two sets of 10-15 repetitions. Quality is more important than quantity; the patient must maintain lumbar neutral and keep the spine in perfect alignment throughout the exercises.

Seated Marching on a Physioball
This exercise is more difficult because the patient positions her body against gravity in a seated position on an unstable surface.
The patient begins by sitting upright on a Physioball, with the lumbar spine in a neutral position. She places her feet hip-width apart While bracing the abdominal muscles, she lifts one leg and foot off the ground. (The limb does not need to be lifted very high, just enough to be off the ground approximately 5cm to start) The patient should focus on controlling the weight shifting to the weight-bearing limb while maintaining lumbo-pelvic stability.
Progression: Once lumbo-pelvic stability can be maintained with alternate leg lifts, the patient can add opposite arm lifts.

Figure 6: Seated Marching on a Physioball

Spinal Flexion on Physioball (Advanced versions)
If the patient’s progression is very good and she is mastering all the techniques perfectly; you can transform the program into the next level. The patient pre-activates her abdominal brace in the starting position and maintains this as she rolls back into spinal extension. She then slowly raises the body, focusing the rotation in the thoracic spine. Picture the head and neck as a rigid block on the thoracic spine to prevent flexing the cervical spine. The patient concentrates on attempting to touch the bottom of her ribs to her pelvis (ASIS). The hands can be placed over the ears to eliminate pulling on the neck.
Progression: The patient holds a 2.0 to 4.0kg medicine ball in front of the chest with the arms extended (see Figure 7b).

Figure 7a

Figure 7b

Alternate Leg Bridge with Shoulders on Ball
The patient starts this exercise sitting on the Physioball and walking forward with his feet on the ground, slowly leaning back until his back rests on the ball. This is called the bridge position. The head, neck and shoulder blades should be supported on the ball. Knees should be bent at a 90° angle, with feet on the ground. While bracing the abdominal muscles, the patient raises the foot and extends the leg off the ground. The weight will be shifted to one side, and the patient should focus on maintaining stability of the lumbo-pelvic region. The patient should strive for stability and balance, while holding this position for 10sec and alternating lower limbs.
Progression: The patient lifts the arms up in the air or out to the sides.

Figure 8: Alternate Leg Bridge with Shoulders on Ball

Abdominal Rollout
The patient kneels behind the ball, with both hands on the ball. Keeping the abdominal muscles braced and lower back in a neutral position, she then rolls the ball away from her body a short distance until there is a straight line from the shoulder to hips. While maintaining alignment, she pulls the ball back a short distance, then pushes it away again. The movement should occur only at the shoulders, not the back
Progression: The patient can gradually straighten the body until she is up on her toes. There should be a straight line from the back of the head to the knees. Now she can again move the ball away and back toward the body a short distance with the arms.

Figure 9: Abdominal Rollout

Squat Ball Thrust
Keeping the abdominal muscles braced and lower back and shoulder blades in a neutral position, he patient uses her abdominal contraction to move the ball forward and back. Keep the spine in neutral alignment throughout the movement. If the exercise shown is too challenging, start with the shins instead of the toes on the ball.

Progression: The patient can perform the exercise with only one foot on the ball (see Figure 10b).

Figure 10a

Figure 10b

Development of balance and motor control
The following movements require reflexive control. The patient can establish this control using an unstable surface and taking advantage of the numerous proprioceptors in the soles of the feet, and by activating the neck muscles, which contribute greatly to postural regulation. This sensory-motor training is an attempt to provide the sub-cortex with a basis for movement that is progressively more challenging. It involves exercises that stimulate balance, coordination, precision and skill acquisition.
Various devices are useful to progressively challenge balance, including a balance board with a whole sphere underneath the board (which creates multi-planar instability) or a rocker-board with a curved surface underneath the board (which allows single-plane motion). Dynamic foam rollers are an inexpensive alternative to the boards that also can be used to challenge balance, proprioception, and stability. These include half-rollers and full-sized rollers. Two other items that are invaluable to challenge balance and core stability and aid proprioceptive training in the standing position are the Bosu Balance Trainer and the Dyna Disk (these can be used interchangeably.) The Bosu has two functional surfaces that integrate dynamic balance with sports-specific or functional training: the domed surface is convex, the other side is flat and can be used for less challenge. The Dyna Disk is an air-filled plastic disc that can be firmly inflated. It has a smaller diameter than the Bosu and can be used like the Bosu Trainer, as it creates an increased proprioceptive challenge to the patient while standing on it. The Dyna Disk is unstable and does not have a base like the Bosu trainer.

Forward/Backward Rocking
In this exercise, a rocker-board is used to challenge balance in the frontal plane of motion. Standing on the rocker-board with both feet in perfect postural alignment, the patient gently rocks forward and backward. (To maintain ideal posture, the patient can create an imaginary line through the joints of the ankle, knee, hip, and shoulder. The ear should align in a straight line with these joints, with no excessive extension [swayback] of the lumbar spine or anterior pelvic rotation.) While rocking, there should be no excess body movement in the coronal or transverse planes. This exercise should be performed for several minutes. The goal is to optimally align the spinal curves and lower extremities.

Progression: The patient can progress to a slight flexed-knee position, with fast and slow movements to stimulate the righting reflexes and balance reactions. She also can progress the stepping motion to the three axes of motion.

Figure 11: Forward/Backward Rocking

Single-Leg Balance-3 Planes
This next exercise progresses the patient to a single-leg stance. The rocker-board is used in the three planes of motion. This exercise also can be performed with a balance board, which is more demanding as it incorporates all planes of motion simultaneously. The patient takes one step forward while maintaining alignment and balance, controlling aberrant motion, mimicking a forward running motion. The goal is to maintain lumbo-pelvic alignment. The patient controls movement in the three planes of motions by placing her feet in various positions on the board. The patient then alternately steps forward and backward onto the rocker-board.
Progression: Once the patient achieves static stability and can remain stable while standing on the rocker board, she can add an accessory motion. The patient can swing the arm and the non-weight-bearing opposite leg (as though mimicking running). No excessive motion in the pelvis or lumbar spine should occur during the swing phase.

Figure 12: Single-leg Balance-3 Planes

Weight Transfers with Proper Alignment
The preceding exercise progresses to "falling" onto an unstable surface. Figure 13 shows a rocker-board and "falling" onto a circular balance board. Again, the emphasis is on spinal alignment from the head to the sacrum. The patient steps forward quickly and catches herself from falling over with a quick forward movement of the leg onto the board.

Figure 13: Weight Transfers with Proper Alignment

Functional Movement Training
Functional movements require acceleration, deceleration, and dynamic stabilization. A functional exercise regimen includes single-leg drills, three-dimensional lunges, resistive diagonal patterns of the upper and lower extremities, and tri-planar movement sequences. Patients can progress through the three planes of motion by performing similar exercises on balance boards, the Dyna Disk or Bosu type trainers, as static trunk and core stability have been mastered. Once these exercises are performed at a high level, the therapist can be assured the patient has the necessary core stability to start plyometric drills.

Single-Leg Balance with Hip Flexion
This exercise provides a functional movement pattern that is similar to running. The exercise seeks to increase stability of the lower abdominal muscles while using a forward motion at the hip. The exercise is designed to develop sagittal-plane control. While balancing on one leg, the patient imitates a running motion. As the upper thigh is lifted forward in a running motion, she concentrates on maintaining the abdominal brace and lumbo-pelvic stability while avoiding excessive anterior or posterior pelvic rotation. The patient raises the opposite arm simultaneously into flexion, while maintaining postural alignment with an erect spine, allowing only the extremities to move.
Progression: Once the patient can maintain lumbar spine stability without effort, she can attach a pulley or resistive cord to the ankle to increase the challenge to the hip flexors.

Figure 14: Single-leg Balance with Hip Flexion

Multi-Directional Lunges
The patient begins this exercise with a forward lunge. Again, the emphasis is on maintaining a neutral spine position and abdominal brace throughout the entire movement. As the patient steps forward, knee flexion of the forward leg is limited to 90°. The knee joint should be over the ankle joint and the patella aligned with the second toe. The lower part of the leg should be perpendicular to the ground, as shown in Figure 15.
Progression: Once strength and stability in the forward (sagittal) plane have been achieved, the patient can begin stepping out at oblique angles, creating a narrower lunge or a wider lunge in the coronal or transverse planes. The patient can also step out onto an unstable surface such as a Bosu Trainer or Dyna Disk, which vastly increase the proprioceptive and dynamic core-stability challenge.

Figure 15: Multi-directional Lunges

Resisted Alternate Arm/Leg Step-Ups
This exercise is a continued progression of multi-directional lunges and must not be started until strength and stability in that exercise has been achieved.
This exercise utilises a sports cord to resist shoulder and hip flexion while doing Step-ups. The movement pattern is similar to the running gait. The patient's opposite arm and leg are resisted simultaneously to increase the strength and co-ordination of this movement pattern.

Figure 16: Resisted Alternate Arm/Leg Step-ups

Multi-Directional Resisted Alternate Arm/Leg Step-Ups
This is a continued progression of the previous exercise. Once strength and stability is achieved in the frontal plane of motion, the patient can begin stepping up at a 45°.

Figure 17: Multi-directional Resisted Alternate Arm/Leg Step-ups

Standing Pulley or Medicine Ball Rotation
This resistive, dynamic trunk pattern challenges the core with a rotational movement pattern while the patient maintains stability in the hips and pelvis. It requires strict bracing of the abdominal muscles and locking the rib cage and pelvis together to avoid unnecessary stress from torsion on the spine.
The patient stands with feet about shoulder-width apart and knees slightly bent. She activates the abdominal brace prior to the movement. It is important to emphasize postural alignment, with the scapulae retracted and depressed. The patient should maintain neutral spinal angles throughout the movement. Holding a straight-arm position (elbows extended) while grasping the pulley handle or medicine ball with both hands, the patient rotates the trunk by activating the abdominal obliques and spinal rotators. She concentrates on keeping the arms extended in front of the chest. It is important that the pelvis remains stable in the movement. Resistance is perpendicular to the body.

This exercise can be done in the same manner using a 2.0 to 4.0kg medicine ball. Progression: The patient can add diagonal motions with the pulley or medicine ball.

Figure 18: Standing Pulley of Medicine Ball Rotation

Forward Lunge with a Medicine Ball with Trunk Rotation
The purpose of this exercise is to challenge the trunk muscles with appropriate weight shift, balance, and control on one leg. It uses a resistive movement of the trunk with a lunge that demands a high level of lumbo- pelvic and lower extremity stability as the patient moves the ball in a diagonal pattern across the body.
The patient will need approximately 30m to complete this exercise. She stands upright, holding onto a 2.0 to 4.0kg medicine ball, with arms outstretched, perpendicular to the body. She steps forward with the medicine ball in front of her chest with the arms extended. Once the lunge portion is completed, she rotates the trunk by bringing the ball across her body towards the same side as the front leg and then returns the ball to midline as the next step is made. It is important that the knee joint on the step- ping limb does not come forward past the vertical angle relative to the ankle joint. The second toe is aligned perpendicular with the patella.

Figure 19: Forward Lunge with a Medicine Ball with Trunk Rotation

Standing Reverse Wood-Chop with a Medicine Ball
This exercise is a resistive diagonal pat- tern of the trunk that demands a high level of lumbo-pelvic stability and combines upper- and lower-chain integration as the ball is moved in a diagonal pattern across the body.
The patient stands, holding onto a 2.0 to 4.0kg medicine ball with both hands, with the feet approximately shoulder-width apart. While holding the arms in front of the body with elbows extended, the patient moves the ball from a lower position at the hip, raising it across the body to the opposite shoulder, simulating a wood-chopping motion. The motion is then reversed by starting at the lower knee position and bringing the ball diagonally across the body, ending overhead at the opposite shoulder. This exercise also can be performed with resistive cords or a pulley system simulating the same motions.
Progression: The patient can progress to standing on one leg, using the opposite arm to complete the motion.

Conclusion

This article is intended to provide an understanding of the importance of core musculature to low back pain patients and to offer exercises that will help them achieve desired stability, balance, and neuro- muscular control. It is highly recommended, however, that patients consult a skilled physiotherapist to address individual needs and maximize results from a program of this nature.

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Dr. Ajimsha’s new research gives hope to headache sufferers

2011-03-27T18:00:00.000-07:00

A new drug-free, non-surgical therapy called Myofascial Release has been clinically proven to cure tension type headaches. This is good news for the millions of people who suffer from acute and chronic tension type headaches. The new therapeutic approach may bring hope and much needed relief. Tension-type headache (TTH) is a bilateral headache of a pressing or tightening quality without a known medical cause. Tension-type headache is classified as episodic if it occurs on less than 15 days a month and as chronic if it occurs more often. A survey from the United States by Schwartz et al in 1998 found a one-year prevalence of 38% for episodic tension-type headache and 2% for chronic tension-type headache.

With so many people suffering with headaches, there has been an enormous amount of research into finding a cure. Much of the effort has been directed to pharmaceutical interventions (including numbing agents, muscle relaxants, anti-depressants, non-steroidal anti-inflammatories and others). However, myofascial release has proven as powerful and effective breakthroughs in headache treatment, which is practiced by physiotherapists and osteopaths across the world for common musculoskeletal conditions.

According to Dr. Ajimsha. M.S; researcher and lecturer of School of Physiotherapy, AIMST University, Kedah – “this approach seemingly goes after the cause of the problem instead of merely masking symptoms (as is the case with so many drug approaches)”. He has done a study on 63 individuals with tension type headache by applying two different types of myofascial release techniques to different groups and compares it with a control group which received soft stroking around the head and neck.

In the clinical study published by the ‘journal of body work and movement therapies’ by Elsevier Ltd; Dr. Ajimsha. M.S proved that after the application of myofascial release the proportion of responders who had at least 50% reduction in headache days per month were 81.8% and 86.4% in the two myofascial release groups where as it was 0% in the control group. After the treatment patients in the myofascial release group reported 59.2% and 54% reductions in their headache frequencies compared to the 13.3% reduction in the headache frequency of the control group. Both the myofascial release techniques studied here were equally effective in reducing the headache frequencies. This study provides evidence that myofascial release is highly effective for tension type headaches and a significant proportion of patients with tension type headache might benefit from the use of myofascial release.

Reference:

Ajimsha, M.S., Effectiveness of direct vs indirect technique myofascial release in the management of tension-type headache, Journal of Bodywork & Movement Therapies (2011), doi:10.1016/j.jbmt.2011.01.021.

Fascia is able to contract in a smooth muscle-like manner and thereby influence musculoskeletal mechanics

2010-10-15T01:35:00.000-07:00

R Schleip,W Klingler, F Lehmann-Horn

Summary
With immunohistological analysis we demonstrate the presence of myofibroblasts in normal human fasciae, particularly the fascia lata, plantar fascia, and the lumbar fascia. Density was found to be highest in the lumbar fascia and seems to be positively related to physical activity. For in vitro contraction tests we suspended strips of lumbar fascia from rats in an organ bath and measured for responsiveness to potential contractile agonists. With the H1 antagonist mepyramine there were clear contractile responses; whereas the nitric oxide donator glyceryltrinitrate induced relaxation. The measured contraction forces are strong enough to impact upon musculoskeletal mechanics when assuming a similar contractility in vivo.

Introduction
Fascia is usually considered to be a passive force transmitter in musculoskeletal dynamics. Nevertheless the literature mentions indications for an active contractility of fascia due to the presence of contractile intrafascial cells. This study for the first time shows clear evidence, that human fascia is able to actively contract and thereby may influence biomechanical behavior.

Methodology
Rodent, porcine and human tissue samples from different fasciae were collected and used for the experiments according to the guidelines of the ethics committee of Ulm University, Germany. Fascia samples from 32 human bodies (ages 17-91, 25 male, 7 female) were analyzed for the presence of myofibroblast, by immunostaining for α- smooth muscle actin, which was digitally quantified. Samples of lumbar fascia from rats and mice were used for comparison. Additionally fresh samples of fascia were exposed to mechanographic force registration under isometric strain in vitro. These were conducted in an immersion bath and in a specifically modified superfusion bath. Tissues were challenged mechanically, electrically and pharmacologically, and changes in tissue tension were registered electronically. Unviable fascia tissues were investigated to elucidate the cellular contribution.

Results

The histological examination revealed that myofibroblasts are present in normal fasciae. The human lumbar fascia with its lattice-like fiber orientation exhibits a higher myofibroblast density, compared with other examined fasciae of both humans and rats. There is generally a large variance in myofibroblast density between different persons. The data indicate a positive correlation between myofibroblast density and physical activity. It was shown that the increase in initial stiffness in response to repeated in vitro stretching (as reported in the literature) was due to changes in matrix hydration. No responses could be detected with electrical stimulation. However, smooth muscle-like contractions could be induced pharmacologically. High dosages of the antihistaminic
substance mepyramine had most reliable and sustaining effects (n=29, p<0.05); while histamine and oxytocin induced shorter contractile responses in selected fasciae only; and addition of an NO donator triggered brief relaxation responses in several samples.No response could be elicited with epinephrine, acetylcholine, and adenosine. The mepyramine induced tissue contractions demonstrated very slow and enduring response curves, lasting up to 2 h. Since the histological examination had revealed an increased myofibroblast density in endo- and perimysial intramuscular fasciae, mepyramine was additionally applied to whole muscular tissue pieces including their fasciae, which showed similar contractile response curves as pure fascia, apparently not due to myogenic contraction. The maximal in vivo contraction forces were hypothetically calculated and applied to the human lumbar area. The resulting forces are strong enough to alter normal musculoskeletal behavior, such as mechanical joint stabilization or ¡-motor regulation.

Conclusions
These results suggest, that fascia is a contractile organ, due to the presence of myofibroblasts. This ability is expressed on the one hand in chronic tissue contractures which include tissue remodeling; and on the other hand in smooth muscle-like cellular contractions over a time frame of minutes to hours, which can be strong enough to influence low back stability and other aspects of human biomechanics. This offers future implications for the understanding and clinical management of pathologies which go along with increased or decreased myofascial stiffness (such as low back pain, tension headache, spinal instability, or fibromyalgia). It also offers new insights for treatments directed at fascia, such as osteopathy, the Rolfing method of myofascial release, or acupuncture. Further research on fascial contractility is indicated and promising.
(For details please read the original articles)

Manual Therapy Choices for Parkinson’s Disease

2010-05-26T17:50:00.000-07:00

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

2010-05-26T17:31:00.000-07:00

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.

Home based MFR managements for pelvic floor dysfunctions

2010-01-02T00:43:00.000-08:00

Home based MFR managements for pelvic floor dysfunctions (5 Series)

Part I to V

Myofascial Release for Women’s Health Problems

(Read one by one from Part I)

Home based MFR managements for pelvic floor dysfunctions: Part I

2010-01-02T00:36:00.000-08:00

Myofascial Release for Women’s Health Problems

Pelvic Floor Dysfunctions and Treatments

There are thousands of women and men who believe that incontinence (loss of bowel or bladder control) and pelvic floor dysfunctions are normal part of aging. It is NOT a normal part of aging. We do not have to endure pads and medication - there are non-surgical options for retraining the bladder and pelvic floor that are proven through research as effective and efficient.

For Women, normal pelvic function also means that there is not supposed to be pain in the pelvic floor. Insertion of tampons, sexual intercourse, gynecological examinations and clothing should never cause pain. The muscles and tissues of the pelvic floor can be aggravated by many conditions including vulvodynia, vestibulitis, prolapse or cystocele/rectoceles or pudental Neuralgia. Myofascial release is a new tool to ‘down train’ the muscles of the pelvic floor, and to help restore normal flexibility and tolerance to the soft tissues both externally and internally.

Myofascial practitioners specialized in perineal, external and internal pelvic floor releases can help those sufferers retrain the muscles of the pelvic floor and assist with bladder and bowel training to return women and men to normal function.

Normal function means you can:

Allow the bladder to expand (fill) and contract (empty) normally and without pain.
Have the sensation and awareness of when the bladder is full – and be right.
Have the ability to get to the bathroom.
Have the ability to remove your clothing.
Participate in sexual intercourse without pelvic pain
Sit comfortably
Tolerate gynecological examinations

Myofascial Release Eases the Pain of Women's Health Problems

Myofascial Release has been on the forefront of health care for the past two decades particularly in the resolution of complex chronic pain problems. In that time, there has been an increasing number of women reporting problems such as urinary incontinence, pelvic pain, menstrual problems, fibromyalgia, chronic fatigue syndrome, and/or headaches. It is unclear whether this rise in these complaints is due to an increased prevalence or that women are just communicating more about their problems.

Whatever the case may be, it remains clear that the numbers are staggering in terms of the women who are affected by these problems. For instance, in 1996 the US Department of Health and Human Services reported that 13 million Americans are incontinent; 11 million of them are women. One in four women ages 30 to 59 have experienced an episode of urinary incontinence. 16.4 billion dollars are spent each year on incontinence-related care and 1.1 billion dollars is spent yearly on disposable products for incontinent adults.

How the Myofascial Release can help:

Incontinence: Some women undergo pelvic or abdominal surgery to help resolve incontinence, menstrual, or pelvic pain problems often associated with pelvic floor muscle weakness following multiple child births. This solution, however, often puts these same women at risk for developing other pelvic pain problems or reproductive dysfunction and infertility problems because of the scar tissue that forms following surgery.

Myofascial Release has been a tremendous help to women suffering with incontinence and pelvic pain. Myofascial Release techniques specific to the pelvis are helpful in decreasing the restrictions in that area that lead to incontinence and pelvic pain. This technique has also been adopted in areas such as the urology department at Stanford University, as noted in “A Headache in the Pelvis: A new understanding and treatment for prostatitis and chronic pelvic pain syndromes” by Dr. Anderson, MD.

Infertility: It is common to hear about the infertility problems that many women suffer with through the media or through family and friends. Many women go through expensive hormonal therapies and attempts at in vitro fertilization that offer no guarantees and are generally not covered by insurance. Expenses can run into the tens of thousands of dollars for the best technological advances that modern medicine have to offer in order to merely bypass what often is a structural imbalance in the body caused by myofascial restrictions.

Many women who have gone through all types of fertility treatments and had given up on ever becoming pregnant have been pleasantly surprised of the effects that Myofascial Release have had on their infertility...they became pregnant when all else failed! While they may have originally been receiving Myofascial Release for other pain problems, the effects of Myofascial Release particularly in freeing the pelvic region of adhesion has allowed for more normal reproductive function in these women.

The Myofascial system and chronic symptoms:

The myofascial system surrounds and interpenetrates every organ, nerve, blood vessel, and duct within the pelvic floor. Trauma, inflammation, surgical scars, and child birth very commonly tighten the myofascial system around these delicate and pain sensitive structures. Tightness and restriction within the myofascial system can cause or contribute to many women's health issues including pelvic floor pain and dysfunction, infertility, incontinence, vulvodynia, coccydynia, pelvic adhesion from endometriosis and surgical scars, painful episiotomy scars, interstitial cystitis, fibromyalgia and pregnancy related back pain and sciatica.

It is estimated that a large number of women experience infertility as a result of fascial restrictions from scar tissue, endometriosis or inflammatory processes. These fascial restrictions may physically interfere with fertility by compressing the reproductive structures such as the fallopian tubes or ovaries and can be helped with Myofascial Release. In addition, because the fascial system surrounds every system of the body, including the endocrine system, fertility problems related to hormonal imbalance may be helped using Myofascial Release. For example, the pituitary gland, the master gland of the body is housed within the sphenoid bone of the skull. Fascial restrictions throughout the neck, dural tube and particularly the suboccipital region often create compression of the sphenoid bone, which houses this delicate gland. Releasing fascial restrictions helps to free these structures and restore more normal function of the endocrine system thus helping to resolve fertility problems related to hormonal imbalance.

Painful or tight episiotomy scars are another common cause of pelvic floor pain and dysfunction and can be effectively treated by the therapists using this highly specialized form of Myofascial Release.

In addition to the various general and specialized myofascial release techniques for women with pelvic pain and incontinence, the therapists at the Myofascial Release Treatment Centers also address problems with back pain, neck pain, headaches and pelvic imbalance and instability that are frequently associated with these problems. Special techniques are utilized to eliminate pelvic torsions and upslips. Patients also learn valuable home self-treatment techniques to ease their pain.

Understanding the relationship between pain, anxiety, and structural changes allows trained therapists to restore the normal length and tension of the structures and connective tissues supporting the pelvic organs. Along with this, specific exercises and home care techniques are taught to correct faulty postural and movement patterns and restore function.

Don’t settle for less than health

You can contact Dr. Ajimsha through his official mail scebcaptmfr@gmail.com to discuss these treatment techniques and the possibility for you regaining control and use of your pelvic floor. Pain, loss of function for sex, inability to exercise and bladder problems are not a normal part of aging.

Home based MFR managements for pelvic floor dysfunctions: Part II

2010-01-02T00:32:00.000-08:00

Myofascial Release for Pelvic Pain and Infertility

Myofascial Release has been on the forefront of health care for the past two decades particularly in the resolution of complex chronic pain problems. In that time, there have been an increasing number of women reporting problems such as urinary incontinence, pelvic pain, menstrual problems, fibromyalgia, chronic fatigue syndrome, and/or headaches. It is unclear whether this rise in these complaints is due to an increased prevalence or that women are just communicating more about their problems.

Whatever the case may be, it remains clear that the numbers are staggering in terms of the women who are affected by these problems. For instance, in 1996 the US Department of Health and Human Services reported that 13 million Americans are incontinent; 11 million of them are women. One in four women ages 30 to 59 have experienced an episode of urinary incontinence. 16.4 billion dollars are spent each year on incontinence-related care and 1.1 billion dollars is spent yearly on disposable products for incontinent adults.

One of the missions of this article series is to turn these numbers around if they can receive this. It is pathetic that the best our healthcare system has to offer incontinent women is disposable pads and adult diapers. Some women undergo pelvic or abdominal surgery to help resolve incontinence, menstrual, or pelvic pain problems often associated with pelvic floor muscle weakness following multiple child births. This solution, however, often puts these same women at risk for developing other pelvic pain problems or reproductive dysfunction and infertility problems because of the scar tissue that forms following surgery.

Myofascial Release has been a tremendous help to women suffering with incontinence and pelvic pain. Myofascial Release techniques specific to the pelvis are helpful in decreasing the restrictions in that area that lead to incontinence and pelvic pain.

Nowadays, it is common to hear about the infertility problems that many women suffer with through the media or through family and friends. Many women go through expensive homonal therapies and attempts at invitro fertilization that offer no guarantees and are generally not covered by insurance. Expenses can run into the tens of thousands of dollars for the best technological advances that modern medicine have to offer in order to merely bypass what often is a structural imbalance in the body caused by myofascial restrictions.

Many women who have gone through all types of fertility treatments and had given up on ever becoming pregnant have been pleasantly surprised of the effects that Myofascial Release have had on their infertility...they became pregnant when all else failed! While they may have originally been receiving Myofascial Release for other pain problems, the effects of Myofascial Release particularly in freeing the pelvic region of adhesion has allowed for more normal reproductive function in these women.

The myofascial system surrounds and interpenetrates every organ, nerve, blood vessel, and duct within the pelvic floor. Trauma, inflammation, surgical scars, and child birth very commonly tighten the myofascial system around these delicate and pain sensitive structures. Tightness and restriction within the myofascial system can cause or contribute to many women's health issues including but not limited to pelvic floor pain and dysfunction, infertility, incontinence, vulvodynia, coccydynia, pelvic adhesion from endometriosis and surgical scars, painful episiotomy scars, interstitial cystitis, fibromyalgia and pregnancy related back pain and sciatica.
It is estimated that a large number of women experience infertility as a result of fascial restrictions from scar tissue, endometriosis or inflammatory processes. These fascial restrictions may physically interfere with fertility by compressing the reproductive structures such as the fallopian tubes or ovaries and can be helped with Myofascial Release. In addition, because the fascial system surrounds every system of the body, including the endocrine system, fertility problems related to homonal imbalance may be helped using Myofascial Release. For example, the pituitary gland, the master gland of the body is housed within the sphenoid bone of the skull. Fascial restrictions throughout the neck, dural tube and particularly the suboccipital region often create compression of the sphenoid bone, which houses this delicate gland. Releasing fascial restrictions helps to free these structures and restore more normal function of the endocrine system thus helping to resolve fertility problems related to hormonal imbalance.

The therapists at the Myofascial Release Treatment Centers are highly trained in performing techniques specifically geared at releasing restrictions in the pelvic region. Painful or tight episiotomy scars are a common cause of pelvic floor pain and dysfunction and can be effectively treated by the therapists using this highly specialized form of Myofascial Release.

In addition to the various general and specialized myofascial release techniques for women with pelvic pain and incontinence, the Myofascial Release Therapists also address problems with back pain, neck pain, headaches and pelvic imbalance and instability that are frequently associated with these problems. Special techniques are utilized to eliminate pelvic torsions and upslips. Patients can learn valuable home self-treatment techniques to ease their pain.

NORMAL PELVIC FLOOR DYSFUNCTIONS

Myofascial Pelvic Pain
Vulvodynia
Dyspareunia
Endometriosis
Adenomyosis
Pelvic Inflammatory Disease (PID)
Abdominal Pain
Coccygodynia
Vaginismus
Vulvar Vestibulitis
Interstitial Cystitis
Anismus
Levator Ani Syndrome

Women with pelvic pain, urinary incontinence, urinary frequency, fertility problems and menstrual problems are encouraged to do these guidelines or else contact Dr. Ajimsha through his official e-mail scebcaptmfr@gmail.com with any questions. Our goal is to return you to a pain free, active lifestyle.

Home based MFR managements for pelvic floor dysfunctions: Part III

2010-01-02T00:10:00.000-08:00

Self Myofascial release for chronic pelvic floor pains

AJIMSHAW’s Approach part I

Self Myofascial release (SMFR) for chronic pelvic floor pains for the easiness of description can be divided into ‘External Pelvic Release’ and ‘Internal Pelvic Release’. ‘External Pelvic Release’ focuses on pelvic release by manipulating fascia externally and ‘Internal Pelvic Release’ is via either vagina or rectum. This techniques can be practiced either yourself or by the help of your counterpart. Some of these techniques are of moderate difficulty if you will practice alone. Anyway it will take at least a month to get your result. Be patient and do it regularly. Some times there will be an exaggeration of symptoms initially because body will attempt some self healing when fascia starts releasing. Don’t worry this will be for a short time. Please don’t stop the release apply some ice over the pain full area after the release. Application of some heating pads on the painful area ‘before’ the release is also found useful. If pain is unbearable you can use some over the counter type pain medications. But please don’t stop the release.

To get the maximum effect try to combine some of the below components to your SMFR program. Descriptions for these are out of this article’s scope. Refer other citations for its details.

‘Adjunctive of SMFR’

Perineal and Pelvic Hygiene (24 Hrs)
Breathing control or Diaphragmatic breathing program.
Relaxation programs(Yoga, T.M, Tai Chi etc)
Daily aerobics (walking, jogging, cycling, swimming etc)
Twice in a week sauna bath or steam bath if possible.

If you can add these four components to your SMFR program, I can assure you will praise us later.

I. External Pelvic Release

In EPR we have to use some sort of semi foam rolls or some balls of different sizes. You can buy these from any shops or can order specific items (Eg:- foam rolls, myoballs etc) from e-markets.

General guidelines

Start with the ‘Adjunctive of SMFR’
Before starting the SMFR have a hot shower, or hot pad application.
Slowly palpate superficially and then deeply in areas specified by us during our successive descriptions.
Concentrate and exactly locate the pain spot and mark it. Try for some other related areas for pain spots and mark it too. (More latent pain points will be activated so that you will find out more points as treatment progresses.)
Position your ‘release device’ around the area of pain and position your self over so that gravity can release your fascial restrictions.
Roll the device or roll over the device slowly and two and fro. Stop moving when and where you feel the pain. Apply firm and tolerable pressure over the pain spot for ’90 seconds’. Start moving again and reach the pain full area (new or previous) stop again for 90 seconds.
Repeat it three times for an area then move to the next area.
Apply ice on the treated area for 7 minutes.
Practice some more aerobics or stretching programs.

CONTRAINDICATIONS

The following are several reasons you may not want to include SMFR, or areas to avoid:
Recently injured areas
Circulatory problems
Bony prominences/joints (if it is inflamed)

MODALITIES
GENERAL THOUGHTS
Like all things training related, we need to have a rationalized progression if we want to see continued progress. SMFR techniques are no different—there are multiple ways we can change pressure, density, and other factors to progress the training.

DENSITY AND PRESSURE
Before we discuss the specific modalities you can use, let’s briefly review the concepts of density and pressure from a physics sense.
The formula for density is:
Density = Mass/Volume

Regarding density and SMFR techniques, we have three options if we want to increase the density:

Increase the mass
Decrease the volume
Increase mass and decrease volume

Typically, the easiest option is to increase the mass. This is seen when we progress someone from a tennis ball to a lacrosse ball, or from a lighter foam roller to a heavier foam roller. We don’t necessarily increase the volume (size) of the object, but we most definitely increase the mass.
The formula for pressure is:
Pressure = Force/Area

Much like density, if you want to increase pressure, you either need to
Increase the force
Decrease the area
Increase force and decrease area

As is the case with SMFR techniques, force doesn’t necessarily change all that much. If you want to increase the force, here are a few options:
If you have both legs on the roller, take one off.
If possible, stack one leg on top of the other.
If you have a hand/foot on the ground for stability purposes, take it off (this will put more of the body’s weight on the area being rolled).

Rather than trying to increase force, it’s generally easier to decrease the area. This is accomplished by using progressively smaller (or more focal) implements. We’ll discuss the different modalities below, starting with the largest surface area and working down to the smallest surface areas.

FOAM ROLLER

A foam roller is the largest implement we would use from a pressure perspective. The foam roller is very versatile, as you can work almost every muscle group using a foam roller alone. Rollers also come in varying densities, which allows for progression as well.

Foam rollers are best used for the big muscle/fascial areas like the gluteals, quadriceps, and IT band.

MEDICINE BALL

While not as popular as the foam roller, the medicine ball may actually be a more versatile tool for SMFR purposes. Not only is it more focal when compared to the roller (the surface area being worked is smaller, which increases pressure), but it also allows you to work in a more three-dimensional fashion.

Virtually any muscle group that can be addressed with a foam roller can also be addressed with a medicine ball. Once the foam roller becomes comfortable, I generally progress my trainees to a medicine ball. The medicine ball can be progressed as well; simply moving to a smaller ball (and further decreasing surface area being rolled) will increase the pressure and intensity of the exercise.

TENNIS BALL/LACROSSE BALL

A tennis ball is generally the smallest implement we would use for SMR purposes. It’s very convenient for muscle/fascial groups with smaller surface areas (such as the plantar fascia, calves, and peroneals) as well as upper body muscles where the ball must be placed against a wall (such as the pecs and posterior shoulder capsule). Once the tennis ball becomes easy, move on to a lacrosse ball.

THE STICK

The Stick is yet another convenient tool when it comes to soft-tissue work. While it’s not necessarily better or worse than the other modalities discussed, it’s narrow diameter allows you to work on some tendons (e.g., quadriceps, hamstrings) better than a medicine ball or foam roller would. As well, the Stick is a good option for the hamstrings, which generally don’t respond that well to foam rolling since your hands/arms are supporting the majority of your body weight to hold yourself up.

MORE POINTED OBJECTS

More pointed objects are needed for perineal releases. Different trigger point release tools can be available. You can modify some house hold utensils for this too provided that all are hygienic.
Eg:-

Indexnobber

Jacknobber

nobbers

Thera cane

Whatever the tools the techniques of application is always the same.

Women with pelvic pain, urinary incontinence, urinary frequency, fertility problems and menstrual problems are encouraged to do these guidelines or else contact Dr. Ajimsha through his official e-mail scebcaptmfr@gmail.com with any questions. Our goal is to return you to a pain free, active lifestyle.

Home based MFR managements for pelvic floor dysfunctions: Part IV

2010-01-01T21:28:00.000-08:00

Self Myofascial release for chronic pelvic floor pains
AJIMSHAW’s Approach part II

SPECIFIC SESSIONS

I. External Pelvic Release

This session explains how to do External Pelvic Release by using SMFR. Follow the same guidelines for all releases.
(‘X’ mark in pictures indicates the pain spot or trigger points. When you are applying sustained pressure or release you will feel tenderness (pain on palpation) on these sites and pressure on this area will cause radiating or dull aching pain in particular areas shown in shades)

GRAPHIC OF PELVIC FLOOR AND REFERRED PAIN
The muscles of the pelvic floor support and raise the pelvic organs. The trigger points in the pelvic floor are in the sphincter ani, levator ani and coccygeus muscles. The sphincter ani surrounds the margin of the anus. The levator ani's contraction increases intraabdominal and pelvic pressure for defecating and straining in general. The coccygeus muscle is attached to the coccyx (the tail bone). It relates to the levator ani and the piriformis muscle (see the illustration of the piriformis).
Release of the pelvic floor. You will learn in the next part.

The Tender Muscles in Pelvic Dysfunction

THE PIRIFORMIS

Piriformis is one of the important muscles involved in chronic pelvic pain of any reason. Release of Piriformis is having its own importance in pelvic pain.
The muscles of the pelvis are made of two groups, the pelvic floor muscles and the hip-joint muscles. The piriformis muscle, which is located partly in the pelvis and partly at the back of the hip joint, is a hip rotator muscle as well as a support muscle of the pelvic floor. The piriformis is under the gluteus (buttock), and attaches the lower part of the sacrum (the triangular composite bone in the back of the pelvis) to the great trochanter (the top of the thigh). The graphic below of the piriformis illustrates the location, trigger points, and areas of referred pain. (Stars or X's represent the trigger points. The shaded areas represent the referred pain caused by the trigger points.)

Alternate Position

THE OBTURATOR INTERNUS

The piriformis often blends with the tendon of the oburator internus muscle. The oburator internus, like the piriformis muscle is a hip rotator located partly in the pelvis and partly at the back of the hip joint. It is attached to the ramus (see the illustration of the pelvic floor for location of the ramus). The anatomical graphic below illustrates the inside of the pelvic girdle at a three quarter front view. Locate the thigh bones and spine to understand the illustration. Refer to the trigger points and affected areas.

Release of the obturator Internus will be explained under the session Internal Pelvic Release.

THE GLUTEUS MEDIUS

The muscles of the buttocks work the hip joint. The gluteus medius is an important hip stabilizer, as well as a postural muscle. This muscle keeps the hips stable while walking and running. The gluteus medius is partly covered by the large buttock's muscle, the gluteus maximus. Refer to the following illustration to understand this muscle's role in pain.

THE GLUTEUS MAXIMUS

The gluteus maximus is a large buttocks muscle that relates to many of the joints and muscles of the pelvis, including the ilium, sacrum, coccyx, ischial tuberosity (sitz bone), great trochanter (top of the thigh bone), the hip rotators mentioned above, as well as some of the muscles of the thigh. The gluteus maximus assists the trunk in an erect posture. It's function helps mostly with running and climbing.

THE TENSOR FASCIA LATAE, ANTERIOR GLUTEUS MEDIUS, AND GLUTEUS MINIMUS

THE ILIOSPOAS MUSCLE

The psoas muscle runs from the 12th rib (the last rib) down along the lumbar spine to the sacroiliac joint (sometimes including the sacrum and buttock). It then follows the border of the pelvic brim and attaches to the front of the hip joint. The psoas tendon attaches to the pubic bone. The psoas muscle is a powerful hip flexor and postural muscle that assists the body when rising to a sitting position from a lying position.

ADDUCTOR COMPARTMENT

Adductor brevis and longus: Pain from the adductor longus and brevis goes deep into the groin above and below the crease of the thigh.

Adductor magnus Trigger Points are deep in the groin and inner thigh, but go farther into the pelvis. These deeper pains are described as internal pelvic pain, but sometimes referrals are felt in the pubic bone, vagina and rectum. Occasionally patients even describe bladder pain.

Pectineus pain is similar to the short adductors but referring pain mostly below the inguinal ligament as well as deep into the groin. Pain can feel as if it were in the hip joint itself.

Alternate technique.

Via palpation find out the painful points in your adductor area (Inner thigh area) apply 90 sec pressure to such points, repeat it for three times. Progress more deeply and incorporating more areas.

You have to concentrate more on this area as this area will be under tremendous spasm in patients with pelvic pain.

THE QUADRICEPS - I

THE QUADRICEPS - II

RECTUS FEMORIS (2 POSITIONS)

THE QUADRICEPS - III
VASTUS LATERALIS

THE IT BAND

THE HAMSTRINGS

THE QUADRATUS LUMBORUM

GENERAL MUST DO RELEASES

Follow the next session named ‘Internal Pelvic Release’ for the complete series.

Women with pelvic pain, urinary incontinence, urinary frequency, fertility problems and menstrual problems are encouraged to do these guidelines or else contact Dr. Ajimsha through his official e-mail scebcaptmfr@gmail.com with any questions. Our goal is to return you to a pain free, active lifestyle.

Home based MFR managements for pelvic floor dysfunctions: Part V

2009-12-31T21:12:00.000-08:00

Self Myofascial release for chronic pelvic floor pains
AJIMSHAW’s Approach part III
SPECIFIC SESSIONS
II. Internal Pelvic Release

Fascial tightness of the perineum and its structures have major role in pelvic floor dysfunction and pain. Inorder to balance the pelvic floor it should be managed both externally and internally. This session explains the techniques of ‘Internal Pelvic Release’.
To understand the importance of ‘Internal Pelvic Release, have a look at the below picture. The “X” marked are trigger points in pelvic floor muscles and the reddish areas are the referred pain due to the trigger points. ‘Internal Pelvic Release’ is the most advanced way to release these triggerpoints.

60-80% DID NOT RECEIVE AN ACCURATE DIAGNOSIS (GPWPP 2007)

Causes of Pelvic Myofascial Trigger Points
Excessive tension on muscle fibers
Straining
Habitual tightening
Trauma as in pregnancy, injury
Inflammation

Types of Pelvic Floor Muscle Trauma
Severe trauma from accidents of falls (coccygeal injury)
Urological or gynecological surgery
Repetitive minor trauma from bicycle seats, uncomfortable chairs
Childbirth

Inflammation of the Pelvic Organs
Infections eg:- prostate, bladder, vaginal
Endometriosis
Inflammatory bowel disease/IBS

Feet position and Pelvic Dysfunction

Inward or outward rotated feet can lead to muscle imbalance and tension in the hip rotators causing abnormal tension in the pelvic nerves (Pudental Nerve)

Correct your Foot deformity and improve your pelvic floor function!
THE PERINEUM

The perineum and perineal body lies between the vagina and the anus on a female and between the bulb of the penis and the anus on a male. The Perineal body is essential for the integrity of the pelvic floor, particularly in females. Its rupture during delivery leads to widening of the gap between the anterior free borders of Levator Ani muscle (pelvic floor muscles) of both sides, thus predisposing the woman to prolapse of the uterus, rectum, or even the urinary bladder.

The following muscles converge and are attached to the perineum:
External anal sphincter
Bulbospongiosus
Superficial transverse perineal muscle
Anterior fibers of the levator ani
fibers from external urinary sphincter
Deep transverse perineal muscle

Because of different reasons myofascial dysfunctions and trigger point developments are very common and most of the time these trigger points will be unidentified and its importance is being ignored. Result; increasing pelvic floor dysfunctions and pain.

As we have discussed in the previous sessions the success of ‘Self Myofascial Release’ lies in the ability of finding the exact sites of myofascial restrictions and trigger points. Palpation with your finger tips and application of firm pressure over 90 seconds is the basics of SMFR.

The picture illustrates the techniques of palpation of myofascial restrictions and trigger points. When you reach the restricted area you can find or feel nodules, bands or thickness. Pressure on this area will produce pain over there and you will feel pain radiating to adjacent or distant areas which is called radiating pain.

Trigger points in the perineum and vulva.
The picture below is a true representation of myofascial restrictions and trigger points in the perineal area and the vulva(female external genitalia) the ‘blue’ shades represents triggerpoints which can be approached externally and ‘yellow’ shades represents triggerpoints which only be approached internally. Every person’s myofascial restriction patterns and dysfunctions vary. You have to examine each of this area using the below picture as reference. On palpation if you feel pain marks that area with a non irritant marker.
Vulva with triggerpoints
(Save this picture or take a print out for reference during SMFR)

Common Sites of Connective Tissue Restrictions in pelvis

Steps to follow for Perineal SMFR

Perineal SMFR is a technique which slowly and gently releases the myofascial trigger points and restrictions around the vagina, perineum and rectum.
CAUTIONS:
Avoid the urinary opening (see diagram) to prevent urinary tract infections.
Do NOT do Perineal SMFR if you have active herpes lesions or any other infections, as you could spread the infection to other areas.
General Hints:
The first few times it’s helpful to use a mirror to find the vagina and perineum and see what they look like.
If you feel tense, take a warm bath or use warm compresses on your perineum for 5 to 10 minutes.
If you have had an episiotomy with a previous birth, concentrate part of your SMFR on that area, Scar tissue isn’t as stretchy as the rest of your skin and needs extra attention.
After Perineal SMFR, tone up the muscles in the vagina by practicing the pelvic floor (Kegel) exercises regularly.
Directions:
1. Wash your hands.

2. Find a private, comfortable place and sit or lean back in a comfortable position.

3. Put a lubricant such as KY Jelly, vitamin E oil, or pure vegetable oil on your thumbs and around the perineum if the skin is very dry/ scaly. Care should be taken for extra hygiene and use lubricant in a lesser quantity. For Perineal SMFR you can use the tools which we have discussed earlier (nobbers, myoballs etc)

The techniques
4. a. Pelvic diaphragm Release
Use the below description if your partner or care giver can help you other ways apply pressure over the prescribed area by using appropriate tools.

• Lie on your back in a comfortable position
• Let your partner to sit at side of pelvis to be treated, facing your head
• Bend your knee and hip and introduce index & middle fingers medial to ischial tuberosity (the ischiorectal fossa)[when you are palpating the area as shown in the picture above you can feel a bony prominence over there]
• Take a deep inspiration and during exhalation, press fingertips superiorly as shown I the picture in a slow and sinking way.
• Maintain this position, during next exhalation, continue to follow and press fingers more superiorly (and deeply)
• Repeat several cycles
• RE-TEST
• Alternately you can use myo balls, nobbers etc for this release.

4.b. Perineal SMFR

Trigger points (which cause referred pain in persons with chronic pelvic pain/ic) in the perineum can refer pain and sensation to the rectum, vagina, and site of palpation. It is very important that you have to release this area by SMFR.
Apply pressure to the perineal body ----the technique is far gentler, for the tissue and muscles here can be very sensitive. Take it easy when applying pressure to perineal body; find out the restrictions and trigger points, apply pressure and gradually sink into the area, hold there for 90 second time, concentrate on your breathing, try to sink down during deep exhalation. Treat multiple areas as necessary. Remember you are trying to soothe pain, feed the area blood and oxygen, not beat it into submission.
You will need either of a comfortable tool as we mentioned earlier. If you don't have one apply pressure using finger tips or a dilator until you can purchase one. It is important that you find a comfortable place to lay down where you will be ensured privacy.(Note: perineal SMFR is especially helpful before and after sexual activity.)If you use gloves they should be non-latex and lubricants should be paraben-free and have no propylene glycol which can irritate the tissue. Check labels.

4. c. Vulvar SMFR

The SMFR procedure for the vulva is same as for other SMFR. But in vulva you have to check for restrictions in a systematic manner. There can be inactive or multiple fascial restrictions. So palpate areas by dividing it into multiple sections (refer the trigger point diagram above and compare)

4. d. Vaginal SMFR
For vaginal SMFR a clean hand with or without a sterile glove is enough. Our goal is stretching the pelvic floor muscles through either vagina or rectum. Use your finger (index finger, some finds comfort by using both the thumbs together for the opposite sides, select as per your convenience)

Stretch the vaginal wall with an aim to go deep and find out the restrictions at the internal pelvic floor muscle. We used to call his as “Palpation through stretching” move around the vagina while maintaining the stretch, apply firm pressure to the restrictions or trigger points for 90 seconds and repeat the treatment.

This treatment is especially useful for all type of female genital discomforts and pain especially after the menopause.
Follow the pictures

Home program for painful intercourse

SELF TREATMENT: URGENCY/ FREQUENCY

Use the picture “Vulva with trigger” point as reference

4. e. Rectal SMFR

Rectal SMFR is indicated for those females who are having chronic pelvic/sacral/coccygeal pains and for males. The techniques of application is same like the ‘vaginal SMFR” provided that a sterile glove should be used always. Most of the clients finds it difficult , but the difficulty depends on your physique. A partner can help you in this regards.

SUMMERY

Success in the management of all painful pelvic, gynecological conditions needs multidisciplinary approach. You need to remain active. Performing some back exercises and pelvic floor exercises immediately after the release is found to hasten the improvement. So be active and be cool. Don’t forget that there will be an increase in discomfort when you are starting the SMFR, don’t give up it’s a short period after that you will praise me.

My advice is be cool, be active and be a master of pelvic SMFR. If you are having any queries please contact me via scebcaptmfr@gmail.com.

Joining/ making pelvic pain interest groups are always good. So plan for that too. Discuss these topics among you. Please inform other pelvic floor dysfunction patients about this.

Self Myofascial Release

2009-12-05T02:38:00.000-08:00

What is Self Myofascial Release

Definition of Self Myofascial Release (SMR)
Neurologically release adhesions, tender spots or “knots”

1. Contractile fibers can be inhibited from releasing to normal resting length
2. This can be due to injury, muscle imbalances, muscles being overworked
3. Tension helps golgi tendon organ stimulate muscle spindles to relax

Protocol for SMR
Using Styrofoam roller, stick, or tennis balls; find knots and hold position as close to tension area as possible

1. Breathe; hold position for 30-45 seconds or until tension dissipates
2. Repetition of SMR makes it easier to bear and reduces tender spots in general
3. Potential contraindications
a. Large bruises, phlebitis, varicose veins, open wounds, undiagnosed lumps, and skin infections, circulation issues

Benefits of SMR
Perfect for clients who feel tension but whose muscles do not need stretching/lengthening
Releasing knots can facilitate blood flow and circulation
Releasing knots can facilitate proper firing patterns

SMR for Cycling
Potential tender spots/adhesions

1. Lower extremity
a. Lateral chain: calf; peroneals; bicep femoris; IT band; piriformis
b. TFL; anterior hip/quads

2. Upper extremity
a. Lats; teres major; upper middle back; pecs/anterior delts

Program Design

Sequencing release/stretching/strengthening

1. Lower extremity
a. SMR lateral chain
b. Stretch lateral muscles/external rotators
c. Strengthen medial muscles/core
- lateral lunges
- core with adductors
d. Check gluteus medius integrity

2. Upper extremity

a. SMR upper middle back
b. Stretch anterior muscles
c. Mobility/strengthening exercises for upper middle back

Suggested Reading
1. Alter, Michael J. Science of Flexibility. Human Kinetics, 1996.
2. Biel, Andrew. Trail Guide to the Body. Harcourt Brace & Co., 1943.
3. Forem, Jack. Healing with Pressure Point Therapy. Penguin Putnam Inc., 1999.
4. Myers, Thomas, W. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. Churchill Livingstone, 2001.

How to do self Myofascial Release

2009-12-05T02:14:00.001-08:00

SELF-Myofascial Release Techniques Using Foam Rollers

Self myofascial release techniques (SMRT), although not new, have become more and more prominent amongst athletes and fitness enthusiasts alike.
Both allopathic and alternative Therapists have embraced the use of myofascial release massage to reduce chronic pain and rehabilitate a range of injuries. Some therapists claim a long list of benefits, from curing tennis elbow to IBS relief. While some claims may be contentious, it seems likely that many sports men and women can benefit from this regenerative therapy.
It’s important to understanding two key terms in order to appreciate how self myofascial release technique acts favourably on the body. They are ’fascia’ and ’trigger points’. Both are explored below before moving on to some sample self myofascial release exercises.

Fascia & Trigger Points
Fascia is a specialized connective tissue layer surrounding muscles, bones and joints and gives support and protection to the body. It consists of three layers - the superficial fascia, the deep fascia and the subserous fascia. Fascia is one of the 3 types of dense connective tissue (the others being ligaments and tendons) and it extends without interruption from the top of the head to the tip of the toes (1).
Fascia is usually seen as having a passive role in the body, transmitting mechanical tension, which is generated by muscle activity or external forces. Recently, however some evidence suggests that fascia may be able to actively contract in a smooth muscle-like manner and consequently influence musculoskeletal dynamics (2).

Obviously, if this is verified by future research, any changes in the tone or structure of the fascia could have significant implications for athletic movements and performance. This research notwithstanding, the occurrence of trigger points within dense connective tissue sheets is thought to be correlated with subsequent injury.
Trigger points have been defined as areas of muscle that are painful to palpation and are characterized by the presence of taut bands. Tissue can become thick, tough and knoted. They can occur in muscle, the muscle-tendon junctions, bursa, or fat pad (3). Sometimes, trigger points can be accompanied by inflammation and if they remain long enough, what was once healthy fascia is replaced with inelastic scar tissue.
It has been speculated that trigger points may lead to a variety of sports injuries - from camps to more serious muscle and tendon tears. The theory, which seems plausible, is that trigger points compromise the tissue structure in which they are located, placing a greater strain on other tissues that must compensate for its weakness. These in turn can break down and so the spiral continues.
According to many therapists, trigger points in the fascia can restrict or alter the motion about a joint resulting in a change of normal neural feedback to the central nervous system. Eventually, the neuromuscular system becomes less efficient, leading to premature fatigue, chronic pain and injury and less efficient motor skill performance. An athlete's worst nightmare!

What causes a trigger point to form?

The list of proposed causes includes acute physical trauma, poor posture or movement mechanics, over training, inadequate rest between training sessions and possibly even nutritional factors (4,5).
Self myofascial release is a relatively simple technique that athletes can use to alleviate trigger points. Studies have shown myofascial release to be an effective treatment modality for myofascial pain syndrome (6,7,8), although most studies have focused on therapist-based rather than self-based treatment.

Self Myofascial Release Exercises

For these exercises you will need a foam roll You can also get them from anywhere that sells sports medicine or physical therapy supplies.

Adductor Self Myofascial Release

1. Extend the thigh and place foam roll in the groin region with body prone (face down) on the floor. 2. Be cautious when rolling near the adductor complex origins at the pelvis. 3. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Hamstring Self Myofascial Release

1. Place hamstrings on the roll with hips unsupported. 2. Feet can be crossed so that only leg at a time is one the foam roll. 3. Roll from knee toward posterior hip. 4. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Quadriceps Slef Myofascial Release

1. Body is positioned prone (face down) with quadriceps on foam roll 2. It is very important to maintain proper core control (abdominal drawn-in position & tight gluteus) to prevent low back compensations 3. Roll from pelvic bone to knee, emphasizing the lateral (outside) thigh 4. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Iliotibial Band Self Myofascial Release

1. Position yourself on your side lying on foam roll. 2. Bottom leg is raised slightly off floor. 3. Maintain head in “neutral” position with ears aligned with shoulders. 4. This may be PAINFUL for many, and should be done in moderation. 5. Roll just below hip joint down the outside thigh to the knee. 6. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Upper Back Self Myofascial Release

1. Place hands behind head or wrap arms around chest to clear the shoulder blades across the thoracic wall. 2. Raise hips until unsupported. 4. Stabilize the head in a “neutral” position. 5. Roll mid-back area on the foam roll. 6. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

General Guidelines
• Spend 1-2 minutes per self myofascial release technique and on each each side (when applicable).
• When a trigger point is found (painful area) hold for 30-45 seconds.
• Keep the abdominal muscles tight which provides stability to the lumbo-pelvic-hip complex during rolling.
• Remember to breathe slowly as this will help to reduce any tense reflexes caused by discomfort.
• Complete the self myofascial release exercises 1-2 x daily.

• CONTRAIDICATIONS: Please discontinue exercises and consult your phycisian if you are experiencing sharp pains during foam rolling. Also consult your doctor if you are pregnant, healing from fractures or surgery, have been diagnosed with osteoperosis, rhumatoid arthritis, varicose veins or other chronic conditions.

References

1) Scanlon, V.C., and Sanders, T. Essentials of anatomy and physiology, 3rd edition. Canada: F.A. Davis Company. 2002
2) Schleip R, Klingler W, Lehmann-Horn F. Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Med Hypotheses. 65(2):273-7. 2005
3) Borg, S. et al. Trigger points and tender points. One and the same? Does injection treatment help? Rheum. Dis. Clinics of North America. 22(2). 1996
4) Vecchiet, L., Giamberardino, M.A., Saggini, R. Myofascial pain syndromes: clinical and pathophysiological aspects. Clin J Pain. 7 Suppl 1:S16-22. 1991
5) Saggini, R., Giamberardino, M.A., Gatteschi, L., Vecchiet, L. Myofascial pain syndrome of the peroneus longus: biomechanical approach. Clin J Pain. Mar;12(1):30-7. 1996
6) Hanten, W.P., Olson, S.L., Butts, N.L., Nowicki, A.L. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Phys Ther. Oct;80(10):997-1003. 2000
7) Hanten, W.P. et al. Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points. Physiotherapy Theory and Practice. 13(4). 1997
8) Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. Oct;83(10):1406-14. 2002

How to do Self Myofascial Release

2009-12-05T01:56:00.000-08:00

Self Myofascial Release

Erector Spinae Stretch
Exercise Description: Erector Spinae Stretch
Classification: Self Myofascial Release
Instructions: 1. Position the client on the foam roller at the level of approx. T-2.
2. Instruct client to perform a drawing in and pelvic floor contraction to aid in spinal stabilization. 3. Once the client is positioned correctly, instruct them to roll slightly to one side (so that they are on the muscle that runs parallel to the spine and not the spine itself) and HOLD. 4. SLOWLY, the client should roll the foam roller down the side of the spine toward to pelvis, feeling for an area of increased tension.
5. Once found, the client should HOLD on this area for 30 sec - 1 min or until the muscle has relaxed about 50% (AVOID rolling over this trigger point area).
6. Once released, roll to another spot and HOLD

Gastroc Soleus Stretch
Exercise Description: Gastroc Soleus Stretch
Classification: Self Myofascial Release
Instructions: 1. Place foam roll under mid belly of lower leg.
2. Cross left leg over right leg to increase pressure (optional).
3. Slowly roll calve area to find the most tender area.
4. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Lattisimus Dorsi SMR1 stretch
Exercise Description: Lattisimus Dorsi SMR1 stretch
Classification: Self Myofascial Release
Instructions: 1. Position yourself on your side with arm outstretched and foam roll placed in axillary area.
2. Thumb is pointed up to pre-stretch the latissimus dorsi muscle.
3. Movement during this technique is minimal
4. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Lattisimus Dorsi SMR Stretch

Exercise Description: Lattisimus Dorsi SMR Stretch
Classification: Self Myofascial Release
Instructions: 1. Start in a side lying position with arm outstretched and thumb facing upward.
2. Place the foam roll in the axillary area.
3. Slowly move back and forth to find the most tender area.
4. Once identified, hold tender spot until the discomfort is reduced by at least 75%.
5. Progress to the next tender spot.
6. Repeat directions on opposite side.

Pereonal SMR Stretch
Exercise Description: Pereonal SMR Stretch
Classification: Self Myofascial Release
Instructions: 1. Position yourself on your side with elbow under the shoulder, opposing hand placed in front of the body and opposite leg bent forward to help stabilize.
2. Position the roller on the peroneals (lateral gastroc/soleus region).
3. Leave hip on the floor.
4. Activate the core/glutes by bracing and squeezing.
5. Raise the hips upwards increasing the pressure on the lower calf.
6. Roll in either direction until a “tender point” is found, hold on that point until you feel the tenderness release by approx 75%.
7. Muscles are 3 dimensional, so don’t just roll in the same plane-up & down. You are allowed to move across the peroneal also.
8. Don’t continually roll back and forth quickly, this will antagonize the muscle and have the opposite effect we are looking for.
9. Stop on the tender point until tenderness eases.

Rhomboid SMR Stretch
Exercise Description: Rhomboid SMR Stretch
Classification: Self Myofascial Release
Instructions: 1. This serves as a GREAT THORACIC MOBILITY TECHNIQUE AS WELL. Preparation
2. Cross arms to the opposite shoulder to clear the shoulder blades across the thoracic wall.
3. While maintaining abdominal Draw-In position, raise hips until unsupported.
4. Stabilize the head in “neutral”.
5. Roll mid-back area on the foam roll. 6. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Sternocleidomastoid SMR Stretch

Exercise Description: Sternocleidomastoid SMR Stretch
Classification: Self Myofascial Release
Instructions: 1. Standing beside a wall place roller against the wall and gently position the side of your neck against it.
2. Tilt the roller on a slight angle with the front being lower than the back. navel and squeezing your glutes. Also keep the scapulae retracted.
3. Apply a small amount of pressure to the roller in the sternocleidomastoid area, gently move it around/up & down that area until a tender point is located.
4. Stop on the tender point, once it has eased by approx. 75% move on.

Tensor Fascia Latae SMR Stretch
Exercise Description: Tensor Fascia Latae SMR Stretch
Classification: Self Myofascial Release
Instructions: 1. Body is positioned prone with quadriceps on foam roll.
2. It is very important to maintain proper Core control (abdominal Drawn-In position & tight gluteus) to prevent low back compensations.
3. Foam roll is placed just lateral to the anterior pelvic bone (ASIS).
4. If a “tender point” is located, stop rolling, and rest on the tender point until pain decreases by 75%.

Dr. Ajimsha

2009-09-18T01:26:00.000-07:00

Dr. Ajimsha. M.S

2009-09-18T01:13:00.001-07:00

The art of MFR

2009-07-28T00:40:00.000-07:00

The art of MFR

2009-07-28T00:38:00.001-07:00

our physicians are accecepting its existance now...!!!!

2009-07-28T00:23:00.000-07:00

The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee
Arthritis Rheum. 1990 Feb;33(2):160-72.

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al.

To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.

Fibromyalgia syndrome: Canadian clinical working case definition, diagnostic and treatment protocols- A consensus document
J Musculoskeletal Pain, 2004; 11(4): 3-107
Jain AK, Carruthers BM, van de Sande MI, Barron SR, Donaldson CCS, Dunne JV, Gingrich E, Heffez DS, Leung FYK, Malone DG, Romano TJ, Russell IJ, Saul D, Seibel DG.

Background: There has been a growing recognition of the need for information about objective abnormalities in people with the fibromyalgia syndrome [FMS] and for an integrated approach to its diagnosis and management by primary care physicians.

Objectives: To establish an expert consensus toward a working case definition of FMS and a working guide to its management for physicians in Canada.

Methods: An Expert Subcommittee of Health Canada established the Terms of Reference and selected an Expert Medical Consensus Panel representing treating physicians, teaching faculty, and researchers. The editors prepared a draft document which was reviewed by the Panel members in preparation for the Consensus Workshop, which was held on March 30 to April 1, 2001. Subsequent writing assignments produced subdocuments on key topics relevant to the objectives. The subdocuments were then integrated into a submission document which was approved by each of the panel members.

Results: The completed document is provided. It contains sections on a new approach to case definition, on proposed research to validate the new case definition, on a practical approach to assessment of severity, on empathetic management; and on what is known about pathogenesis.

Conclusions: A consensus document was developed to assist clinicians in distinguishing FMS from other syndromes/illnesses that may present with body pain. It is intended that this document serve as a guide: to a better understanding of FMS; to a more reasoned approach to its management; and to further research on the clinical care of people with FMS.

Fibromyalgia: more than just a musculoskeletal disease
Am Fam Physician. 1995 Sep 1;52(3):843-51, 853-4.
Clauw DJ.

Fibromyalgia is a common condition characterized by diffuse musculoskeletal pain and fatigue. The syndrome is defined by the presence of musculoskeletal tender points on physical examination. Additionally, persons with this syndrome have a high incidence of headaches, ocular and vestibular complaints, paresthesias, esophageal dysmotility, "allergic" symptoms, irritable bowl syndrome, genitourinary symptoms and affective disorders. Recent research has revealed a number of objective biochemical, hormonal and neurotransmitter abnormalities associated with fibromyalgia, making it a clearly identifiable condition. These abnormalities may clarify our understanding of the pathogenesis and treatment of fibromyalgia.

Fibromyalgia syndrome
J. Rheumatol. 2005 Nov;32(11):2270-7.
Mease PJ, Clauw DJ, Arnold LM, Goldenberg DL, Witter J, Williams DA, Simon LS, Strand CV, Bramson C, Martin S, Wright TM, Littman B, Wernicke JF, Gendreau RM, Crofford LJ.

The objectives of the first OMERACT Fibromyalgia Syndrome (FM) Workshop were to identify and prioritize symptom domains that should be consistently evaluated in FM clinical trials, and to identify aspects of domains and outcome measures that should be part of a concerted research agenda of FM researchers. Such an effort will help standardize and improve the quality of outcomes research in FM. A principal assumption in this workshop has been that there exists a clinical syndrome, generally known as FM, characterized by chronic widespread pain typically associated with fatigue, sleep disturbance, mood disturbance, and other symptoms and signs, and considered to be related to central neuromodulatory dysregulation. FM can be diagnosed using 1990 American College of Rheumatology criteria. In preparation for the workshop a Delphi exercise involving 23 FM researchers was conducted to establish a preliminary prioritization of domains of inquiry. At the OMERACT meeting, the workshop included presentation of the Delphi results; a review of placebo-controlled trials of FM treatment, with a focus on the outcome measures used and their performance; a panel discussion of the key issues in FM trials, from both an investigator and regulatory agency perspective; and a voting process by the workshop attendees. The results of the workshop were presented in the plenary session on the final day of the meeting. A prioritized list of domains of FM to be investigated was thus developed, key issues and controversies in the field were debated, and consensus on a research agenda on outcome measure development was reached.

Fibromyalgia subgroups: profiling distinct subgroups using the Fibromyalgia Impact Questionnaire. A preliminary study
Rheumatol Int. 2008 Sep 27.

de Souza JB, Goffaux P, Julien N, Potvin S, Charest J, Marchand S.

The main goal of this project was to identify the presence of fibromyalgia (FM) subgroups using a simple and frequently used clinical tool, the Fibromyalgia Impact Questionnaire (FIQ). A total of 61 women diagnosed with FM participated in this study. FM subgroups were created by applying a hierarchical cluster analysis on selected items of the FIQ (pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms). We also tested for group differences on experimental pain, psychosocial functioning and demographic characteristics. Two cluster profiles best fit our data. FM-Type I was characterized by the lowest levels of anxiety, depressive and morning tiredness symptoms, while FM-Type II was characterized by elevated levels of pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms. Both FM subgroups showed hyperalgesic responses to experimental pain. These results suggest that pain and stiffness are universal symptoms of the disorder but that psychological distress is a feature present only in some patients.

Chronic widespread pain and fibromyalgia: what we know, and what we need to know
Best Pract Res Clin Rheumatol. 2003 Aug;17(4):685-701.
Clauw DJ, Crofford LJ.

Fibromyalgia (FM) is currently defined as the presence of both chronic widespread pain (CWP) and the finding of 11/18 tender points on examination. Only about 20% of individuals in the population with CWP also have 11/18 tender points; these individuals are considerably more likely to be female, and have higher levels of psychological distress. There is no clear clinical diagnosis for the other 80% of individuals with less than 11/18 tender points, but it is likely that these persons, like FM patients, also have pain that is 'central' (i.e. not due to inflammation or damage of structures) rather than peripheral in nature. Research into FM has taught us a great deal about the confluence of neurobiological, psychological and behavioural factors that can cause chronic central pain. These conditions respond best to a combination of symptom-based pharmacological therapies, and non-pharmacological therapies such as exercise and cognitive behavioural therapy. In contrast to drugs that work for peripheral pain due to damage or inflammation (e.g. NSAIDs, corticosteroids), neuroactive compounds [especially those that raise central levels of noradrenaline (norepinephrine) or serotonin] are most effective for treating central pain.

Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment
J Rheumatol Suppl. 2005 Aug;75:6-21.
Mease P.

Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population in the USA and other regions in the world where FM is studied. Prevalence rates in some regions have not been ascertained and may be influenced by differences in cultural norms regarding the definition and attribution of chronic pain states. Chronic, widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headache, and mood disorders. Although the etiology of FM is not completely understood, the syndrome is thought to arise from influencing factors such as stress, medical illness, and a variety of pain conditions in some, but not all patients, in conjunction with a variety of neurotransmitter and neuroendocrine disturbances. These include reduced levels of biogenic amines, increased concentrations of excitatory neurotransmitters, including substance P, and dysregulation of the hypothalamic-pituitary-adrenal axis. A unifying hypothesis is that FM results from sensitization of the central nervous system. Establishing diagnosis and evaluating effects of therapy in patients with FM may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. Diagnostic criteria, originally developed for research purposes, have aided our understanding of this patient population in both research and clinical settings, but need further refinement as our knowledge about chronic widespread pain evolves. Outcome measures, borrowed from clinical research in pain, rheumatology, neurology, and psychiatry, are able to distinguish treatment response in specific symptom domains. Further work is necessary to validate these measures in FM. In addition, work is under way to develop composite response criteria, intended to address the multidimensional nature of this syndrome. A range of medical treatments, including antidepressants, opioids, nonsteroidal antiinflammatory drugs, sedatives, muscle relaxants, and antiepileptics, have been used to treat FM. Nonpharmaceutical treatment modalities, including exercise, physical therapy, massage, acupuncture, and cognitive behavioral therapy, can be helpful. Few of these approaches have been demonstrated to have clear-cut benefits in randomized controlled trials. However, there is now increased interest as more effective treatments are developed and our ability to accurately measure effect of treatment has improved. The multifaceted nature of FM suggests that multimodal individualized treatment programs may be necessary to achieve optimal outcomes in patients with this syndrome.

We can cure your Fibromyalgia

2009-07-27T19:56:00.000-07:00

About Fibromyalgia

Fibromyalgia (pronounced fy-bro-my-AL-ja) is a common and complex chronic pain disorder that affects people physically, mentally and socially. Fibromyalgia is a syndrome rather than a disease. Unlike a disease, which is a medical condition with a specific cause or causes and recognizable signs and symptoms, a syndrome is a collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause.

Fibromyalgia, which has also been referred to as fibromyalgia syndrome, fibromyositis and fibrositis, is characterized by chronic widespread pain, multiple tender points, abnormal pain processing, sleep disturbances, fatigue and often psychological distress. For those with severe symptoms, fibromyalgia can be extremely debilitating and interfere with basic daily activities.

Whether you have been diagnosed with fibromyalgia or suffer from its symptoms, or have a family member or friend with the disorder, this section is designed to provide you with a better understanding of this chronic pain disorder that affects millions of people worldwide.

Prevalence

Fibromyalgia is one of the most common chronic pain conditions. The disorder affects an estimated 10 million people in the U.S. and an estimated 3-6% of the world population. While it is most prevalent in women —75-90 percent of the people who have FM are women —it also occurs in men and children of all ethnic groups. The disorder is often seen in families, among siblings or mothers and their children. The diagnosis is usually made between the ages of 20 to 50 years, but the incidence rises with age so that by age 80, approximately 8% of adults meet the American College of Rheumatology classification of fibromyalgia.

Symptoms

Chronic widespread body pain is the primary symptom of fibromyalgia. Most people with fibromyalgia also experience moderate to extreme fatigue, sleep disturbances, sensitivity to touch, light, and sound, and cognitive difficulties. Many individuals also experience a number of other symptoms and overlapping conditions, such as irritable bowel syndrome, lupus and arthritis.
• Pain
The pain of fibromyalgia is profound, chronic and widespread. It can migrate to all parts of the body and vary in intensity. FM pain has been described as stabbing and shooting pain and deep muscular aching, throbbing, and twitching. Neurological complaints such as numbness, tingling, and burning are often present and add to the discomfort of the patient. The severity of the pain and stiffness is often worse in the morning. Aggravating factors that affect pain include cold/humid weather, non-restorative sleep, physical and mental fatigue, excessive physical activity, physical inactivity, anxiety and stress.
• Fatigue
In today's world many people complain of fatigue; however, the fatigue of FM is much more than being tired after a particularly busy day or after a sleepless night. The fatigue of FM is an all-encompassing exhaustion that can interfere with occupational, personal, social or educational activities. Symptoms include profound exhaustion and poor stamina
• Sleep problems
Many fibromyalgia patients have an associated sleep disorder that prevents them from getting deep, restful, restorative sleep. Medical researchers have documented specific and distinctive abnormalities in the Stage 4 deep sleep of FM patients. During sleep, individuals with FM are constantly interrupted by bursts of awake-like brain activity, limiting the amount of time they spend in deep sleep.
• Other symptoms/overlapping conditions
Additional symptoms may include: irritable bowel and bladder, headaches and migraines, restless legs syndrome (periodic limb movement disorder), impaired memory and concentration, skin sensitivities and rashes, dry eyes and mouth, anxiety, depression, ringing in the ears, dizziness, vision problems, Raynaud's Syndrome, neurological symptoms, and impaired coordination.
Causes

While the underlying cause or causes of FM still remain a mystery, new research findings continue to bring us closer to understanding the basic mechanisms of fibromyalgia. Most researchers agree that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation. The FM patient experiences pain amplification due to abnormal sensory processing in the central nervous system. An increasing number of scientific studies now show multiple physiological abnormalities in the FM patient, including: increased levels of substance P in the spinal cord, low levels of blood flow to the thalamus region of the brain, HPA axis hypofunction, low levels of serotonin and tryptophan and abnormalities in cytokine function.

Recent studies show that genetic factors may predispose individuals to a genetic susceptibility to FM. For some, the onset of FM is slow; however, in a large percentage of patients the onset is triggered by an illness or injury that causes trauma to the body. These events may act to incite an undetected physiological problem already present.

Exciting new research has also begun in the areas of brain imaging and neurosurgery. Ongoing research will test the hypothesis that FM is caused by an interpretative defect in the central nervous system that brings about abnormal pain perception. Medical researchers have just begun to untangle the truths about this life-altering disease.

Prognosis

While there is currently no cure for fibromyalgia, better ways to diagnose and treat the chronic pain disorder continue to be developed. Since June 2007, the U.S. Food and Drug Administration has approved three medications for the treatment of fibromyalgia and other FM medications are currently in development. Research efforts have expanded as well. In 1990 there were approximately 200 published research papers on fibromyalgia studies. Today there are more than 4,000 published reports.

While many strides have been made in the last decade, fibromyalgia remains a challenging condition. However, clinical studies have demonstrated that fibromyalgia patients can reduce their symptoms through a variety of treatment options. Working in conjunction with knowledgeable healthcare professions, motivated and informed patients can experience significant improvement in their symptoms and quality of life. Developing an individualize self-management plan, from identifying effective treatments approaches to making necessary lifestyle changes, will further improve one’s health

Treatment

One of the most important factors in improving the symptoms of FM is for the patient to recognize the need for lifestyle adaptation. Most people are resistant to change because it implies adjustment, discomfort and effort. However, in the case of FM, change can bring about recognizable improvement in function and quality of life. Becoming educated about FM gives the patient more potential for improvement.

An empathetic physician who is knowledgeable about the diagnosis and treatment of FM and who will listen to and work with the patient is an important component of treatment. It may be a family practitioner, an internist, or a specialist (rheumatologist or neurologist, for example). Conventional medical intervention may be only part of a potential treatment program. Alternative treatments, nutrition, relaxation techniques, and exercise play an important role in FM treatment as well. Each patient should, with the input of a healthcare practitioner, establish a multifaceted and individualized approach that works for them.
• Pain management
A number of pharmacological treatments for fibromyalgia are available for prescription. The first to be approved by the U.S. Food and Drug Administration to treat fibromyalgia was pregabalin (Lyrica®); the second was duloxetine (Cymbalta®); and the third was milnacipran (Savella®). Other FM medications are currently in development, and may soon receive FDA approval to treat fibromyalgia. Additionally, healthcare providers may treat patients' FM symptoms with non-narcotic pain relievers (e.g. tramadol) or low doses of antidepressants (e.g. tricyclic antidepressants, serotonin reuptake inhibitors) or benzodiazepines. Patients must remember that antidepressants are "serotonin builders" and can be prescribed at low levels to help improve sleep and relieve pain. If the patient is experiencing depression, higher levels of these or other medications may need to be prescribed. Lidocaine injections into the patient's tender points also work well on localized areas of pain. An important aspect of pain management is a regular program of gentle exercise and stretching, which helps maintain muscle tone and reduces pain and stiffness.
• Sleep management
Improved sleep can be obtained by implementing a healthy sleep regimen. This includes going to bed and getting up at the same time every day; making sure that the sleeping environment is conducive to sleep (i.e. quiet, free from distractions, a comfortable room temperature, a supportive bed); avoiding caffeine, sugar, and alcohol before bed; doing some type of light exercise during the day; avoiding eating immediately before bedtime; and practicing relaxation exercises as you fall to sleep. When necessary, there are new sleep medications that can be prescribed, some of which can be especially helpful if the patient's sleep is disturbed by restless legs or periodic limb movement disorder.
• Psychological support
Learning to live with a chronic illness often challenges an individual emotionally. The FM patient needs to develop a program that provides emotional support and increases communication with family and friends. Many communities throughout the United States and abroad have organized fibromyalgia support groups. These groups often provide important information and have guest speakers who discuss subjects of particular interest to the FM patient. Counseling sessions with a trained professional may help improve communication and understanding about the illness and help to build healthier relationships within the patient's family.
• Other treatments
Complementary therapies can be very beneficial. These include: physical therapy, therapeutic massage, myofascial release therapy, water therapy, light aerobics, acupressure, application of heat or cold, acupuncture, yoga, relaxation exercises, breathing techniques, aromatherapy, cognitive therapy, biofeedback, herbs, nutritional supplements, and osteopathic or chiropractic manipulation.

Pain tracker

What’s the benefit to keeping track of your pain? You can monitor it over a period of time and start to identify patterns, which can ultimately help you manage your pain. For example, one kind of activity may exacerbate pain while another may soothe it.

Calendar

Tracking your pain is simple: Use a calendar like format. Just write your pain details on it on a day in the calendar or add more details to a previous one. Forgot when your last entry was? The indicates existing entries.
Create a Report
View and print your pain history to discuss with your doctor.

2009-07-27T19:48:00.000-07:00

In 1990 the American College of Rheumatology developed the tender point exam, which maps 18 specific points on the body that are extremely sensitive in people with fibromyalgia. In order for your doctor to diagnose you with fibromyalgia, you need to experience pain in at least 11 of these points and have constant, widespread pain for at least three months.
When mild pressure is applied to any of these soft-tissue tender point areas around the neck, shoulder, chest, hip, knee and elbow regions, a patient with fibromyalgia often experiences it as pain. Another symptom: applying pressure to these points may trigger pain in a larger region, such as down your leg.
If you have widespread, frequent pain, above and below the waist, on both sides of your body, and in the neck, chest, or back, ask your doctor to administer the tender point test for a definitive fibromyalgia diagnosis. Once you’ve gotten a diagnosis you can begin to create a treatment plan to help you manage your symptoms
Our approach

• Myofascial Unwinding for balancing the body
• Diet and Exercise Can Calm Fibromyalgia Symptoms
• Alternatives Abound in Fibromyalgia Treatment
• Manage Stress, Manage Fibromyalgia
• Proper Sleep Is Crucial to Managing Fibromyalgia

Put Together Your Fibromyalgia Treatment Plan

If you have the flu, spend a few days in bed, and you’ll likely feel better. Fibromyalgia is different. Symptoms are eased, never cured, and there is no one “remedy” that works for everyone. For these reasons, fibromyalgia patients should develop a personalized treatment plan to minimize flare-ups and the severity of symptoms.
Identify your symptoms
Widespread, chronic pain is a hallmark of fibromyalgia. It’s diagnosed by the presence of tenderness in 18 specific points of the body, with at least 11 of those 18 spots being abnormally tender, even when mildly touched. Fatigue, sleep, and memory and concentration problems (often called “fibro fog”) also are common symptoms of fibromyalgia. You might also experience restless legs syndrome, irritable bowel syndrome, painful menstruation, depression, dry eyes, anxiety or headaches. Make sure you work with your doctor to treat all of your ailments.
Find the right medications
To date, pregabalin (Lyrica), duloxetine (Cymbalta) and milnacipran (Savella) are the only medications approved by the U.S. Food and Drug Administration (FDA) to treat fibromyalgia pain. Tricyclic antidepressants often have been found to be the most efficacious medications for fibromyalgia, especially since sleep and fatigue problems respond well to some antidepressants. But other painkillers, from over-the-counter ibuprofen to prescription-only narcotics, also are prescribed.
Talk to your doctor about what will give you the greatest relief with the fewest side effects. Because there are so many medications to choose from, you may need to use trial and error to help determine which is best for you. If antidepressants don’t work, you may need to incorporate sleep aids or muscle relaxants into your treatment plan.
Explore alternative treatments
For many people, massage and acupuncture, as well as Pilates, tai chi, chiropractic treatment, and various dietary supplements, can provide relief. You also may find it helpful to work with a physician who incorporates complementary medicine into his or her practice.
Make healthy changes
Stress reduction, a healthy diet and regular exercise can reduce fibromyalgia flare-ups, so lifestyle changes should be a part of your treatment plan. Sleep also is crucial for managing symptoms. Devising a treatment plan will require coordinating with your primary care doctor and/or a rheumatologist, physical therapist, naturopathic physician (if you use one) and other health professionals. Make sure everyone on your health care team is aware of your plan, and consult your doctor before making adjustments.

Myofascial Unwinding for balancing the body
Myofascial Unwinding is an advanced form of Myofascial Release technique, which is intended to reduce the increased body pressure or tension aroused due to myofascial dysfunction; which is the cause of the debilitating pain suffered by fibromyalgic patients.
Here a myofascial practitioner applies well controlled forces and stretches to the body by using extremities as lever. It’s a slow procedure and need 2-3 months of treatment for its complete cure. In my experience MFU is the only effective technique in its management. If MFU can be combined with the below described procedures; the effects will be four fold.
Diet and Exercise Can Calm Fibromyalgia Symptoms

A healthy diet and regular exercise are essential to anyone who wants to feel well. For someone with fibromyalgia, those two things play a critical role in helping to reduce pain, increase energy and improve quality of life.
Studies have shown that walking, strength training, stretching exercises and swimming in a heated pool can alleviate fibromyalgia symptoms. Regular exercise appears to enhance the body’s response to stress, which often triggers symptoms. It also improves endocrine function to help the body better process pain and regulate sleep patterns.
Here are the keys to an effective exercise program:
• Start slowly. Begin with gentle stretching, walking, bicycling or swimming.
Create a routine. Exercise should be a regular part of your life. Schedule time for it on your weekly calendar and take advantage of small opportunities to exercise throughout your day, such as using the stairs instead of the elevator.

• Have fun with it. Yoga, Pilates, strength training, tai chi, bicycling, walking, jogging, low-impact aerobics or swimming all are recommended. Mix it up so you won’t get bored.
While exercise is one of the most proven ways to battle fibromyalgia, the jury is still out on the issue of nutrition. A balanced diet can help increase your energy level and reduce your risk of other health problems, but more research is needed before experts can identify if specific foods affect the risk of flare-ups. Many people with fibromyalgia, however, have reported a reduction in symptoms by avoiding certain things, such as caffeine and alcohol. Experiment by cutting foods from your diet that seem to intensify your symptoms. To maintain your health, though, make sure your diet remains well-balanced.
Improving your diet can make you healthier and may even reduce your pain and fatigue. Add that to a regular exercise regimen and you may be on the road to more pain-free days.

Proper Sleep Is Crucial to Managing Fibromyalgia

It’s a vicious cycle: A poor night’s sleep makes your fibromyalgia symptoms worse, and then the pain makes it hard to fall asleep at night. Restless legs syndrome, a problem for many people with fibromyalgia, also can keep you from getting the rest you need.
Sleep is a crucial piece of the fibromyalgia puzzle. In fact, some research shows that disruptions during the deepest levels of sleep can cause the onset of fibromyalgia symptoms.
Try these suggestions to get better sleep:
Adopt a daily routine
Try to go to bed and wake up at the same time each day. Avoid daytime napping and create a nighttime relaxation ritual. This could include a warm bath, reading or listening to music as a way to wind down.
Watch your diet
Avoid caffeine and alcohol in the late afternoon and evening. Caffeine can make it harder to fall asleep and alcohol can disrupt sleep. Also, avoid spicy or fried foods if they cause heartburn or indigestion. And so your bladder won’t wake you, try not to consume any liquids right before bed.
Time your workouts
Exercise can help you sleep better at night. Some experts advise finishing at least three hours before bedtime because the stimulation may make it difficult to fall asleep right away. Others, however, point out that exercise can relax you and help you fall asleep shortly after participating in it.
Medication can help
If lifestyle changes are not enough, medication is an option. Tricyclic antidepressants can help you achieve restorative sleep, but they may leave you drowsy during the day. If you have restless legs syndrome, your doctor may prescribe sedatives such as diazepam (Valium). On the downside, the extended use of benzodiazepines can lower your pain threshold and ultimately exacerbate pain. Plus, they can be extremely addictive. Sleep medications and muscle relaxants can also help, so talk to your doctor about your options.

Manage Stress, Manage Fibromyalgia

When you have fibromyalgia, stress has a powerful grip on your life. It can cause the disease to flare-up, resulting in shooting pains, extreme fatigue, and cognitive problems like confusion and memory loss—often called “fibro fog.” In fact, many people report that a traumatic event brought on their first symptoms of fibromyalgia, leading some researchers to speculate that stress can actually trigger the disease. The National Institute of Arthritis and Musculoskeletal and Skin Diseases currently is funding research into whether fibromyalgia is caused by a breakdown in the way the body responds to stress.
Stress is known to trigger flare-ups in people with fibromyalgia, so restoring calm to your everyday life can help reduce your symptoms. Here are some coping techniques that can help you have more pain-free days.
Identify Your Stressors
Analyze your day and look for potential stress hot spots. For example, some people don’t mind sitting in traffic, but others fume as they creep along during rush hour. If you feel hurried to get out the door on time every morning, consider waking up earlier (and going to bed earlier to compensate). If talking on the phone to a certain family member is stressful, consider changing to an email-only relationship. Figure out which situations you can control and make the necessary adjustments to make your days easier.
Develop Coping Techniques
Much of life’s stress is unavoidable, but you can learn to react to it while keeping your calm:
• Schedule time to relax or meditate every day. The more you do it, the better you’ll get at relaxing. Then, when you experience a sudden stressful situation, such as a heated discussion with your boss, you’ll know how to take a few minutes afterward for deep breathing exercises or a short walk.
•
• Don’t dwell on the past. One component of stress involves regret over things we could have done differently. Live in the moment and focus on what you need to do now to control your illness.
•
• Request accommodations at work. If your fibromyalgia makes mornings difficult, ask to work from 10 a.m. to 6 p.m., for example, instead of from 9 a.m. to 5 p.m. If sitting at your desk all day leaves your body aching, ask for a better chair or for regular breaks so you can walk and stretch.
•
• Find support. Talk to others who have fibromyalgia to share coping strategies and encouragement during your bad days.
Managing stress will not cure your fibromyalgia, but it can help you gain some control over your symptoms. Allow yourself to relax and your body will thank you
Alternatives Abound in Fibromyalgia Treatment

Odds are if you have fibromyalgia, you have heard about alternative treatments that may help you feel better. In fact, 90 percent of fibromyalgia patients have reported trying such alternative therapies as massage, acupuncture, dietary supplements or chiropractic treatment to ease their symptoms.
While research has yet to prove that all alternative therapies work in treating fibromyalgia, there is a lot of evidence that supports acupuncture as a successful treatment. Using super-thin needles, acupuncturists stimulate various pressure points to provide pain relief. Some studies show that electroacupuncture, in which an electric current is pulsed through a needle, is more effective than the traditional method.
Many people with fibromyalgia find different alternative methods effective. And like mainstream fibromyalgia treatments, what works for one person might have no effect on another. Bottom line: You have to shop around to see what is best for you.
Here are some other options:
Massage: Massage therapists work on the muscles and soft tissue of the body to alleviate pain, muscle spasms and stress. However, the National Center for Complementary and Alternative Medicine reviewed research about the effectiveness of treating fibromyalgia with massage and found that the benefits are only short-term.
Cognitive behavioral therapy: Often called CBT, cognitive behavioral therapy has been shown to be among the most effective non-medication treatments for fibromyalgia. CBT helps change the way you think about pain with the goal of changing the way your body responds to pain, thus making the pain less severe. It may also help improve sleep.
Though studies on the following methods have been deemed insufficient by some medical experts, they are still widely used by people with fibromyalgia, with varying degrees of success.
Dietary supplements magnesium and SAM-e are often used to treat fibromyalgia. SAM-e is a naturally occurring compound in our bodies that helps in the production of dopamine and serotonin, which regulate mood and control the pain response. Preliminary research has shown evidence that SAM-e supplements may work to keep symptoms in check, but further study is needed. Magnesium is helpful in hundreds of ways, like converting food into energy, strengthening the immune system, and maintaining normal nerve and muscle function. Some researchers believe that a deficiency of this mineral contributes to fibromyalgia symptoms, though research into its efficacy has been inconclusive.
Finding the alternative treatment that works for you will require some experimentation. Ask your doctor for recommendations and be sure to tell him or her which treatments you already are using. This is especially important with dietary and herbal supplements since they can interact with other medications and possibly cause side effects.

For more details please contact Dr. Ajimshaw @ dr.ajimshaw@rediffmail.com or ajimsha@aimst.edu.my

Fibromyalgia and its Sufferings

2009-07-27T19:38:00.000-07:00

Understanding Chronic Pain and Fibromyalgia: A Review of Recent Discoveries

Fibromyalgia tends to be treated rather dismissively, sometimes with cynical overtones. When I trained in BPT some 10 years ago, this diagnosis was never mentioned. In the United States fibromyalgia has become a semi-respectable diagnosis within the last 10 years, but even so it has some critics. The problem for doctors is that fibromyalgia is not a problem that can be understood according to the classic medical model. This is the model that is used in all medical training. It is based on the correlation of specific tissue pathology with distinctive symptoms (e.g. tuberculosis of the lung causing a chronic cough). Elimination of the causative agent (e.g. the tubercule bacillus) cures the disease. This model has led to the most major advances in medicine that we benefit from today.

I have seen over 150 fibromyalgia patients over the past 5 years; most want to be reassured that their symptoms are the product of a "real disease" rather than figments of a fertile imagination--commonly ascribed to the psychological diagnosis such as somatization, hypochondriasis, or depression. The good news is that contemporary research is hot on the track of unraveling the changes that occur within the nervous system of fibromyalgia patients. The basic message is that fibromyalgia cannot be considered a primarily psychological disorder, but as in many chronic conditions, psychological factors may play a role in who becomes disabled and may even up-regulate the central nervous system changes that are the root cause of the problem.

What is the problem?
The problem is: disordered sensory processing.
I will try to convey to you what we mean by "disordered sensory processing." Even a superficial understanding of this topic will change the way you think about the fibromyalgia problem. Furthermore, recent advances that have been made at the molecular level hold out the promise of more effective treatment for fibromyalgia pain.

What is Fibromyalgia?
Fibromyalgia is a chronic pain state in which the nerve stimuli causing pain originates mainly in the muscle. Hence the increased pain on movement and the aggravation of fibromyalgia by strenuous exertion.

Pain is a universal experience that serves the vital function of triggering avoidance. A few unfortunate individuals have a congenital absence of pain sensation; they do not fare well due to repeated bodily insults that go unnoticed. As a physician I see patients with an acquired deficiency in the pain sensation (e.g. diabetic neuropathy or neurosyphilis) who develop a severe destructive arthritis--a result of repeated minor joint injuries that are overlooked. Thus pain sensation is a necessary part of being human. Pain sensation is a fact of life. Even the primitive amoeba takes avoiding action in the face of adverse events. In such primitive life forms, pain avoidance is purely reflex action, as they do not have the complexity of a highly developed brain to feel pain in the sense that humans do: (1)The unconscious reflex avoidance reaction that is so rapid that it occurs before the actual awareness of the pain sensation (as in all life forms), (2) the actual experience of the pain sensation (that can only occur in highly complex organisms). This is an important point, as it implies that different parts of the brain are involved in these two consequences of the pain reaction.

Over the last few years a number of important research discoveries have started to clarify the enigma of chronic pain. Many of these new findings have a special relevance to the chronic pain of fibromyalgia. The cardinal symptom of FM is widespread body pain. The cardinal finding is the presence of focal areas of hyperalgesia, the tender points. Tender points imply that the patient has a local area of reduced pain threshold, suggesting a peripheral pathology. In general, tender points occur at muscle tendon junctions, a site where mechanical forces are most likely to cause micro-injuries. Many--but not all--FM patients have tender skin and an overall reduction in pain threshold. These latter observations suggest that some FM patients have a generalized pain amplification state. There has been a recent plethora of experimental studies apposite to the pathophysiological basis of both the peripheral and central aspects of pain.

The Pathophysiological Basis for Chronic Pain
The International Association For the Study of Pain (ASP) defines pain as follows: "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." This definition explicitly affirms that pain has both a sensory and an affective-evaluative component, and furthermore acknowledges that it may occur in the absence of obvious visceral or peripheral pathology. To fully understand chronic pain, one must integrate the sensory and affective/evaluative elements of the pain experience. It is equally misguided to focus on the psychological aspects of pain, as it is to address only the sensory component and ignore the affective dimensions. However, for the sake of clarity, each of these two constitutive elements will be considered separately.

The Sensory Component
Pain is generally envisaged as a cascade of impulses that originates from nocioceptors in somatic or visceral tissues. The impulses travel in peripheral nerves with a first synapse in the dorsal horn and a second synapse in the thalamus, and end up in the cerebral cortex and other supraspinal structures.

This results in an experience of pain and the activation of reflex and later reflective behaviors. These reflex and reflective behaviors are aimed at eliminating further pain. The expectation is that this nocioceptor driven pain will be successfully abolished, allowing healing and a return to a pain-free state. The problem with chronic pain is that the linear relationship between nocioception and pain experience is inappropriate or even absent, and the expected recovery does not occur.

It is a common misconception to view the nervous system as being "hard-wired"; that is, stimulation of a nerve ending (say a needle prick) always produces the same behavioral and affective response. This concept implies that the same intensity of pain stimulus will always elicit the same degree of nerve stimulation and hence the same subjective experience of pain. It is now understood that the concept is wrong. Some 30 years ago, Melzeck and Wall proposed that pain is a complex integration of noxious stimuli, affective traits, and cognitive factors. In other words, the emotional aspects of having a chronic pain state and one's rationalization of the problem may both influence the final experience of pain. Mendell and Wall provided the first experimental evidence that the nervous system was not hard-wired in 1965. They noted that a repetitive stimulation of a peripheral nerve, at sufficient intensity to activate C-fibers, resulted a progressive build-up of the amplitude of the electrical response recorded in the second order dorsal horn neurons. If the system had been hard-wired, each stimulus would have elicited the same response in the second order neuron. They termed this phenomenon "wind-up." It is now appreciated that the phenomenon of wind-up is crucial to understanding the problem of chronic pain via the mechanism of "central sensitization."

Central sensitization refers to an increased activation of second order neurons in the spinal cord, resulting from injury or inflammation-induced activation of peripheral nocioceptors. Sensory input from muscle, as opposed to skin, is a much more potent effector of central sensitization. This may be the clue to the role of muscle pain in the total spectrum of fibromyalgia. A common example of central sensitization is post-herpetic neuralgia. Previous injury to a peripheral nerve leads to an amplification of both nocioceptive and non-nocioceptive impulses. The mechanism responsible for the abnormal perception of non-nocioceptive impulses in post-herpetic neuralgia is an increased excitation of second order nocioceptive neurons in the dorsal horn of the spinal cord. A special example of central pain occurs when there is pathology within the central nervous system. This occurs in a thalamic stroke--severe unilateral pain, often accompanied by strong emotions, that occurs in the absence of any nocioceptive input.

There are two forms of second order spinal neurons involved in central sensitization. (1) Nocioceptive--specific neurons--respond only to nocioceptive stimuli, and (2) Wide dynamic range neurons--respond to both nocioceptive and non-nocioceptive afferent stimuli. Both may be sensitized by nocioceptive stimuli leading to central senitization but wide-dynamic range neurons are generally more intensely sensitized than nocioceptive-specific neurons. Nocioceptive and non-nocioceptive peripheral nerves often converge onto the same wide dynamic range neuron (see figure). Once sensitized by ongoing nocioceptive impulses from peripheral nerves, wide-dynamic range neurons will respond to non-nocioceptive stimuli just as intensely as they did prior to sensitization. This results in sensitizations like a light touch to be experienced as pain (i.e. allodynia). Sensitization of wide-dynamic range neurons by prior pain stimuli provides the pathophysiological foundation for nonnocioceptive pain.

There is emerging evidence that afferent activity from Golgi tendon organs and muscle spindles can be converted into pain signals under the influence of central sensitization. For instance, some patients with strokes and spinal cord injuries develop severe pain on movement. Benc has proposed the term "proprioceptive allodynia" to describe this phenomenon. He describes such individuals as "while not experiencing pain at rest, they develop excruciating burning and tingling, often difficult to describe, that appear only when trying to hold an object, move a limb, stand or walk." Thus everyday muscle activity may cause pain and impair function in some individuals with central sensitization. At a physiological level, pain on movement implies that proprioceptive afferents are projecting onto second order wide-dynamic-range spinal neurons that have been sensitized by previous nocioceptive activity. Thus the central nervous system of subjects who have ongoing pain (e.g. arthritis) or have had previous pain experiences (e.g. post injury pain) may be permanently altered due to changes that can now be understood at the physiological molecular and structural levels. At a clinical level this is seen as persistent pain in survivors of serious illness who experienced high levels of pain during hospitalization, persistent pain after breast surgery, or the occurrence of fibromyalgia after automobile accidents. The reason why the phenomenon of central sensitization only occurs in a minority of individuals is not currently known. At a molecular level, there are many studies demonstrating the important role of excitatory amino acids such as glutamate and neuropeptides such as substance P in the generation of central sensitization. Substance P and CRGP are important neurotransmitters in lowering the threshold of synaptic excitability, which permits the unmasking of normally silent interspinal synapses and the sensitization of second order spinal neurons. Substance P, unlike the excitatory amino acids, can diffuse long distances in the spinal cord and sensitize dorsal horn neurons in spinal segments both above and below the input segment--with resulting pain signal generation from non-nocioceptive afferent activity. Clinically this will lead to an expansion of receptive fields; e.g. the spread of pain from to uninjured areas after an automobile accident.

The Psychological Component
It was seen in the preceding section that chronic pain could occur in the absence of ongoing tissue damage--this is an example of the sensory component of pain. It was also noted that one component of pain is a reflex avoidance behavior that can occur before the conscious appreciation of pain. In terms of brain physiology this implies that more primitive parts of the brain contain several discrete nuclei (e.g. the thalamus, cingulate gyrus, hippocampus, amygdyala, and locus ceruleus) that interact to form a functional unit called the limbic system. This is the part of the brain that subserves many reflex phenomena, including the association of sensory input with specific mood states (e.g. pleasure, fear, aversion etc.). These facts form the physiological basis for considering the emotional aspect of pain. Interestingly, the electrical stimulation of the brain during neurosurgical procedure does not induce pain sensations in pain-free subjects. However, in past pain patients it often reawakens previous pain experiences. It is surmised that such stimulation re-activates cortical and subcortical pain circuits that were previously dormant. It is not known whether there is a single cortical structure that subserves pain memory. Currently it appears that different cortical and subcortical structures are involved in the pain experience. For instance, removal of the somatosensory cortex does not abolish chronic pain, but excision of lesions of the anterior cingulated cortex reduces the unpleasantness of pain. The anterior cingulated cortex is involved in the integration of affect cognition and motor response aspects of pain and exhibit increased activity on PET studies of pain patients. Other structures involved in cortical pain processing include the prefrontal cortex (activation of avoidance strategies, diversion of attention and motor inhibition); the amygdala (emotional significance and activation of hypervigilance); and the locus ceruleus (activation of the "fight or flight" response).

All these structures are linked to the medial thalamus, whereas the lateral thalamus is linked to the somatosensory cortex (pain localization). One example of limbic system activation is the hypervigilance that accompanies many chronic pain states, including fibromyalgia.

The emotional component of pain is multifactorial and includes past experiences, genetic factors, generals state of health, the presence of depression and other psychological diagnosis, coping mechanisms, and beliefs and fears surrounding the pain diagnosis. Importantly, thoughts as well as other sensations can influence the sensory pain input to consciousness as well as the emotional coloring of the pain sensation. The term given for this modulation of pain impulses is the "gate control theory of pain." Thus thoughts (beliefs, fears, depression, anxiety, anger, helplessness, etc.), as well as peripherally generated sensations, can both dampen or amplify pain. Indeed, in many chronic pain conditions (that lack any effective therapy for the sensory/pain component), a reduction of pain and the resulting suffering can only be affected by modulating the psychological aspects of pain. As the psychological contribution to pain varies enormously from patient to patient, this approach has to be individualized. However, there are some general principles that are worth noting. There are important consequences of having pain that will not go away (as is the expected experience for most pain in most people). The unsettling realization that the problem may well be life-long generates a varied mix of emotions and behaviors that are often counterproductive to coping with a chronic problem. Many of these changes (which are partly reflex in origin) would be appropriate for dealing with acute self-healing pain events, but become a liability when dealing with chronic pain. The end result of chronic pain is often depressive illness, marital discord, vocational difficulties, chemical dependency, social withdrawal, sleep disorders, increasing fatigue, inappropriate beliefs, and a radical alteration in their previous personality. Varying degrees of functional disability are a common accompaniment of chronic pain states. The reasons for dysfunction are multiple and vary from individual to individual. Pain often monopolizes attention (causing lack of focus on the task at hand). It is usually associated with poor sleep (causing emotional fatigue). Movements may aggravate pain (causing a reluctance to engage in activity). Fear of activity often leads to deconditioning (which predisposes to muscle and tendon injuries and reduced stamina). Pain causes stress, which may result in anxiety, depression, and inappropriate behavior (causing disability due to secondary psychological distress). The modern era of psychological imaging is providing an important new framework for understanding these "emotional" responses

Newly Diagnosed Patient

Fibromyalgia (fi-bro-my-AL-ja) is a very common condition of widespread muscular pain and fatigue. Seven to ten million Americans suffer from fibromyalgia (FM). It affects women much more than men in an approximate ratio of 20:1. It is seen in all age groups from young children through old age, although in most patients the problem begins in their 20s or 30s. Recent studies have shown that fibromyalgia occurs worldwide and has no specific ethnic predisposition.

The Symptoms of Fibromyalgia

Fibromyalgia patients have widespread body pain which often seems to arise in the muscles. Some FM patients feel their pain originates in their joints. Pain that emanates from the joints is called arthritis; extensive studies have shown FM patients do not have arthritis. Although many fibromyalgia patients are aware of pain when they are resting, it is most noticeable when they use their muscles, particularly during repetitive activities. Their discomfort can be so severe it may significantly limit their ability to lead a full life. Patients can find themselves unable to work in their chosen professions and may have difficulty performing everyday tasks. As a consequence of muscle pain, many FM patients severely limit their activities including exercise routines. This results in their becoming physically unfit, which eventually makes their fibromyalgia symptoms worse.

In addition to widespread pain, other common symptoms include a decreased sense of energy, disturbances of sleep, and varying degrees of anxiety and depression related to patients' changed physical status. Furthermore, certain other medical conditions are commonly associated with fibromyalgia, such as: tension headaches, migraine, irritable bowel syndrome, irritable bladder syndrome, premenstrual tension syndrome, cold intolerance, and restless leg syndrome. Patients with estalished rheumatoid arthritis, lupus (SLE), and Sjogren's syndrome often develop FM during the course of their disease. The combination of pain and multiple other symptoms often leads doctors to pursue an extensive course of investigations, which are nearly always normal.

Diagnosing Fibromyalgia

There are no blood tests or X-rays that show abnormalities diagnostic of FM. This initially led many doctors to believe that the problems suffered by FM patients were "all in their heads," or that fibromyalgia patients had a form of masked depression or hypochondriasis. Extensive psychological tests have shown these impressions were unfounded. A physician's diagnosis of FM is based on taking a careful history and the finding of tender areas in specific areas of muscle. These locations are called "tender points." They are tender to palpation and often feel somewhat hardened if the muscle is stroked.

The Long-Term Outcome for Fibromyalgia

The musculoskeletal pain and fatigue experienced by fibromyalgia patients are chronic problems that tend to have a waxing and waning intensity. There is currently no generally accepted cure for this condition. According to recent research, most patients can expect to have this problem lifelong. However, worthwhile improvement may be obtained with appropriate treatment. There is often concern on the part of patients, and sometimes physicians, that FM is the early phase of some more severe disease, such as multiple sclerosis, lupus , etc. Long-term follow-up of fibromyalgia patients has shown that it is very unusual for them to develop another rheumatic disease or neurological condition.

However, it is quite common for patients with "well-established" rheumatic diseases, such as rheumatoid arthritis, systemic lupus, and Sjogren's syndrome, to have fibromyalgia also. It is important for these patients' doctors to realize they have such a combination of problems, as specific therapy for rheumatoid arthritis and lupus, etc. does not have any effect on FM symptoms. Patients with fibromyalgia do not become crippled with the condition, nor is there any evidence it affects their lifespan. Nevertheless, due to varying levels of pain and fatigue, there is an inevitable contraction of social, vocational, and avocational activities that leads to a reduced quality of life. As with many chronic diseases, the extent to which patients succumb to the various effects of pain and fatigue are dependent upon numerous factors, in particular their psycho-social support, financial status, childhood experiences, sense of humor, and determination to push on.

The Treatment of Fibromyalgia

The treatment of FM is frustrating for both patients and their physicians. In general, drugs used to treat musculoskeletal pain, such as aspirin, non-steroidals (e.g. ibuprofen), and cortisone, are not particularly helpful in this situation. As in any chronic pain condition, education is an essential component that helps patients understand what can or can't be done as well as teaching them to help themselves.

It is important for a patient's physician to discover whether there is a cause for sleep disturbances. Such sleep problems include sleep apnea, restless legs syndrome, and teeth grinding. If the cause for a patient's sleep disturbance cannot be determined, low doses of an anti-depressive group of drugs, called tricyclic anti-depressants or short acting sleeping medications such as zolpidem (Ambien) may be beneficial. Patients need to understand these medications are not addictive when used in low dosages (eg., amitriptyline 10 mg at night) and have very few side effects. In general, routine use of sleeping pills such as Halcion, Restoril, Valium, etc., should be avoided as they impair the quality of deep sleep. It is claimed that Ambien (zolpidem) avoids this problem.

There is increasing evidence that a regular exercise routine is essential for all fibromyalgia patients. The increased pain and fatigue caused by repetitive exertion makes regular exercise quite difficult. However, those patients who do develop an exercise regimen experience worthwhile improvement and are reluctant to give up. In general, FM patients must avoid impact loading exertion such as jogging, basketball, aerobics, etc. Regular walking, the use of a stationary bicycle, and pool therapy utilizing an Aqua Jogger (a floatation device that allows the user to walk or run in the swimming pool while remaining upright) seem to be the most suitable activities for FM patients. Supervision by a physical therapist or exercise physiologist is of benefit wherever possible. In general, 20 minutes of physical activity three times a week at 70% of maximum heart rate (220 minus your age) is sufficient to maintain a reasonable level of aerobic fitness.

Drugs such as aspirin and Advil are not particularly effective and seldom do more than take the edge off FM pain. Opioid analgesics (propoxyphene, codeine, morphine, oxycodone, methadone) may provide a worthwhile pain relief in a subgroup of severely afflicted patients, but fibromyalgia patients seem especially sensitive to opioid side effects (nausea, constipation, itching, and mental blurring) and often decide against the long-term use of these drugs. The use of opioid analgesics (narcotics) in the management of non-malignant pain has been a controversial issue for many doctors, with the usual reasons for concern: addiction, oversight by state medical boards, and criminal diversion of drugs. However, recent research has shown that addiction seldom occurs when these medications are use in chronic pain states. It is important to understand the difference between addiction and dependence (which occurs with all these drugs in the majority of patients (see Addiction/Dependence). Two particularly useful weak opioids in the management of FM pain are tramadol (Ultram) and the combination of tramadol with acetaminophen (Ultracet). Neither of these two medications is a FDA scheduled drug (i.e. they have minimal addiction potential).

Particularly painful areas often may be helped for a short time (2-3 months) by trigger point injections. This involves injecting a trigger point with a local anesthetic (usually 1% Procaine) and then stretching the involved muscle with a technique called spray and stretch. It should be noted the injection of a tender point is quite painful (indeed, if it is not painful the injection is seldom successful). After the injection, there is typically a lag of two to four days before any beneficial effects are noted. Other techniques that directly help the tender areas on a transient basis are heat, massage, gentle stretching, and acupuncture.

About 20 percent of FM patients have a co-existing depression or anxiety state that needs to be appropriately treated with therapeutic doses of anti-depressants or anti-anxiety drugs often in conjunction with the help of a clinical psychologist or psychiatrist. Basically, patients who have a concomitant psychiatric problem have a double burden to bear. They will find it easier to cope with their FM if the psychiatric condition is appropriately treated. It is important to understand that fibromyalgia itself is not a psychogenic pain problem, and that treatment of any underlying psychological problems does not cure FM.

Most FM patients quickly learn there are certain things they do on a daily basis that seem to make their pain problem worse. These actions usually involve the repetitive use of muscles or prolonged tensing of a muscle, such as the muscles of the upper back while looking at a computer screen. Careful detective work is required by the patient to note these associations and, where possible, to modify or eliminate them. Pacing of activities is important; we have recommended that patients use a stopwatch that beeps every 20 minutes. Whatever they are doing at that time should be stopped and a minute should be taken to do something else. For instance, if they are sitting down, they should get up and walk around--or vice versa.

Patients who are involved in fairly vigorous manual occupations often need to have their work environment modified and may need to be retrained in a completely different job. Certain people are so severely affected that consideration must be given to some form of monetary disability assistance. This decision requires careful consideration, as disability usually causes adverse financial consequences as well as a loss of self esteem. In general, doctors are reluctant to declare fibromyalgia patients disabled and most FM applicants are initially turned down by the Social Security Administration at the first review. However, each patient needs to be evaluated on an individual basis before any recommendations for or against disability are made.

For more details please contact Dr. Ajimshaw @ dr.ajimshaw@rediffmail.com or ajimsha@aimst.edu.my

I am still here........

2009-07-26T19:31:00.000-07:00

Hi all,
Now I am in Malaysia. ie in AIMST university of Kedah State. just joined today. it doesnt mean that i have dropped all my interest in MFR and Hands-On techs. still now i am under the work of my book on MFR; a complete version of Practical and theoretical part of MFR with demonstration pictures. I am making it as a very discriptive one with details of all the myofascial trigger points and its signs and symptoms.(I thing there are only a few materials over this). so please give me some time to complete this. during your studies if you have any queries please feel free to contact me.

Aji

Text book on MFR

2009-07-22T10:27:00.000-07:00

Hi to everyone. I am Dr. Ajimshaw. M.S, PhD, I would like to let you know that my hard work to write a comprehensive text book of MFR is going to an end, within a month you will get a comprehensive text book MFR with all its tequenique, details of MF trigger points and its reffered pain pattern, efficacy of our approaches etc in detail. so please wait for the same. you can book sighned books by Dr. Ajimshaw. M.S, as a bonus.interested students and delegates can contact directly thru the mail ajimshaw.ms@gmail.com.
Dr. Ajimshaw.M.S, PhD

Congragulations to new Myofascial Practitioners

2009-07-22T03:16:00.000-07:00

I am congragulating all students who have successfully complted the Certificate in Myofasial Release Technique 'CMFRT' course held @ months of May and June 2008. Those new MFR practioners are requested to collect their Course certificate, Pass Certificate and Transcript from MFTRF, India's office @ kottayam

Thank You
Dr. Ajimsha. PhD(PT)
Director

Cervical Myofascial Pain

2009-04-09T22:53:00.000-07:00

BackgroundDescriptions of myofascial pain date back to the mid 1800s when Froriep described muskelschwiele, or muscle calluses. He described these calluses as tender areas in muscle that felt like a cord or band associated with rheumatic complaints. In the early 1900s, Gowers first used the term fibrositis to describe muscular rheumatism associated with local tenderness and regions of palpable hardness. In 1938, Kellgren described areas of referred pain associated with tender points in muscle. In the 1940s, Janet Travell, MD, began writing about myofascial trigger points. Her text, written in conjunction with David Simons, MD, continues to be viewed as the foundational literature on the subject of myofascial pain.
Pathophysiology
Pain attributed to muscle and its surrounding fascia has been termed myofascial pain. The diagnosis of this syndrome in clinical, with no confirmatory laboratory tests available. Thus, myofascial pain in any location is characterized on examination by the presence of trigger points located in skeletal muscle. In the cervical spine, the muscles most often implicated in myofascial pain are the trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus. A trigger point is defined as a hyperirritable area located in a palpable taut band of muscle fibers. According to Hong and Simon's review on the pathophysiology and electrophysiologic mechanisms of trigger points, the following observations help to define them further
Trigger points are known to elicit local pain and/or referred pain in a specific recognizable distribution.
Palpation in a rapid fashion (ie, snapping palpation) may elicit a local twitch response (LTR), a brisk contraction of the muscle fibers in or around the taut band. The LTR also can be elicited by rapid insertion of a needle into the trigger point. range of motion (ROM) and increased sensitivity to stretch of muscle fibers in a taut band are noted frequently.
The muscle with a trigger point may be weak because of pain. Usually, no atrophic change is observed.
Patients with trigger points may have associated localized autonomic phenomena (eg, vasoconstriction, pilomotor response, ptosis, hypersecretion).
An active myofascial trigger point is a site marked by generation of spontaneous pain or pain in response to movement. This phenomenon is in contrast to the case of latent trigger points, which may not produce pain until they are compressed.
Cross-sectional drawing shows flat palpation of a taut band and its trigger point. Left: A. Skin is pushed to one side to begin palpation. B. The fingertip slides across muscle fibers to feel the cord-line texture of the taut band rolling beneath it. C. The skin is pushed to other side at completion of movement. This same movement performed vigorously is snapping palpation. Right: A. Muscle fibers are surrounded by the thumb and fingers in a pincer grip. B. The hardness of the taut band is felt clearly as it is rolled between the digits. C. The palpable edge of the taut band is sharply defined as it escapes from between the fingertips, often with a local twitch response.
Longitudinal schematic drawing of taut bands, myofascial trigger points, and a local twitch response. A: Palpation of a taut band (straight lines) among normally slack, relaxed muscle fibers (wavy lines). B: Rolling the band quickly under the fingertip (snapping palpation) at the trigger point often produces a local twitch response that usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.
Longitudinal schematic drawing of taut bands, myofascial trigger points, and a local twitch response. A: Palpation of a taut band (straight lines) among normally slack, relaxed muscle fibers (wavy lines). B: Rolling the band quickly under the fingertip (snapping palpation) at the trigger point often produces a local twitch response that usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.

Frequency
United States
Myofascial pain is thought to occur commonly in the general population. As many as 21% of patients seen in general orthopedic clinics have myofascial pain. Of patients seen at specialty pain management centers, 85-93% have a myofascial pain component.
Mortality/Morbidity
Increased mortality is not associated with cervical myofascial pain.
Race
No studies clarify whether racial differences exist in frequency of cervical myofascial pain.
Sex
While fibromyalgia occurs more commonly in women than in men, cervical myofascial pain occurs in both sexes, also with a predominance among women.
Age
Myofascial pain seems to occur more frequently with increasing age until midlife. Incidence declines gradually after middle age.
Clinical
History
Typical findings reported by the patient with myofascial pain may include the following:
The patient may present with a history of acute trauma associated with persistent muscular pain. In contrast, myofascial pain also manifests insidiously, without a clear antecedent accident or injury. It may be associated with repetitive tasks, poor posture, stress, or cold weather.
Cervical spine ROM is often limited and painful.
The patient may describe a lumpiness or painful bump in the trapezius or cervical paraspinal muscles.
Massage is often helpful, as is superficial heat.
The patient's sleep may be interrupted because of pain. The cervical rotation required for driving is difficult to achieve.
The patient may describe pain radiating into the upper extremities, accompanied by numbness and tingling and making discrimination from radiculopathy or peripheral nerve impingement difficult.
Dizziness or nausea may be a part of the symptomatology.
The patient experiences typical patterns of radiating pain referred from trigger points.
Physical
Common findings noted upon physical examination may include the following:
Patients with cervical myofascial pain often present with poor posture. They exhibit rounded shoulders and protracted scapulae.
Trigger points frequently are noted in the trapezius, supraspinatus, infraspinatus, rhomboids, and levator scapulae muscles.
The palpable taut band is noted in the skeletal muscle or surrounding fascia. An LTR often can be reproduced with palpation of the area.
Cervical spine ROM is limited, with pain reproduced in positions that stretch the affected muscle.
While the patient may complain of weakness, normal strength in the upper extremities is noted on physical examination.
Sensation typically is normal when tested formally. No long tract signs are observed on examination.
Causes
Cervical myofascial pain is thought to occur following either overuse or trauma to the muscles that support the shoulders and neck. Common scenarios are that the patient recently was involved in a motor vehicle accident or that he or she performed repetitive upper extremity activities. Trapezial myofascial pain commonly occurs when a person with a desk job does not have appropriate armrests or must type on a keyboard that is too high. Other issues that may play a role in the clinical picture include endocrine dysfunction, chronic infections, nutritional deficiencies, poor posture, and psychological stress.

Myofascial Release for Headaches

2009-02-15T22:17:00.000-08:00

Dr. Ajimshaw. M.S, MPT(Neuro), PhD
Headaches are often caused by disorders of the neck or physical and emotional tension. Physiotherapists can successfully treat headaches originating from the neck or soft tissues and show you how to prevent the pain recurring. At one time or another, everyone experiences the dull constricting pressure and pain of a tension headache. For some people, tension headaches occur almost every day.

Is your headache really a neck ache?

For many people, headaches start as pain or tension at the top of the neck. As the pain worsens, it may spread to the back of the head, the temples, forehead or behind the eyes. Moving the neck or bending forward for a long time tends to make it worse. This happens because the nerves in the upper part of your neck are connected to the nerves in your head and face. A disorder of the upper neck joints or muscles can cause referred pain to your head. Any of the following points could suggest that your neck may be causing the headache:

Headache associated with neck pain. Does the pain radiate from the back to the front of your head?
Headache with dizziness or light-headedness or giddiness, Nausea
Headache brought on or worsened by neck movement or staying in the same position for a long time.
Headache which always feels worse on the same side of your head.
Headache eased by pressure to the base of the skull.
Headache which persists after your doctor has checked for other causes.
Pain sweeping up the neck and up behind and over the ear - the 'question mark'
Stabbing pain behind the eye
Pain across the front of the forehead
'Vicelike' pain around the head
Pain under the bony ridge at the back of the skull
Accompanying nerve pain 'neuralgia' into the face, jaw and eye areas
Extreme sensitivity to light and sound
What is Myofascial Release?
The fascia is thin, strong connective tissue that covers muscles and bones and surrounds internal organs such as the heart, lungs, and intestines. Normal, healthy fascia is flexible. It provides a seamless, interconnected web that supports and shapes body structures. When the body becomes injured or inflammation occurs, fascia becomes stiff and range of motion is limited. Myofascial release is a type of bodywork that specifically treats the fascia in the body using sustained dynamic pressure. This pressure helps release the stress in the fascia, restore symmetry in the fascia, and restore balanced muscle tension and body alignment. It increases the elasticity of the fascia so range of motion is improved. Myofascial release is used in the treatment of a range of motion problems and chronic pain.

The neuromuscular and soft tissue causes of Headaches and Migraines
Headaches and Migraines can be due to a tightening and restricting of muscles and fascia in the neck and shoulders, sometimes involving trigger points - areas of muscle fibers which are permanently contracted - which referred pain to other areas of the body. Myofascial release can help with Headaches and Migraines by releasing all the fascia, connective tissue and trigger points in the neck and shoulder area, and rebalancing all the muscles involved.
Headaches from other causes

If cause of migraine is something else, as evident in a careful physical examination; your physiotherapist will recommend that you see a medical practitioner.

Prevention is better than cure!!

Here is some useful advice to help you control and prevent headaches:

POSTURE
Think tall: chest lifted, shoulders relaxed, chin tucked in and head level. Your neck should feel strong, straight and relaxed.

WORK
Avoid working with your head down or to one side for long periods. Frequently stretch and change position. Your physiotherapist will show you how.

SLEEPING
Awkward sleeping positions will add load and strain to the neck. A down pillow or polyurethane moulded pillow is best for most people. Your physiotherapist will advise you.

EXERCISE
Keep your neck joints and muscles flexible and strong with the correct neck exercises. Your physiotherapist will assess for tight or weak muscles and show you specific exercises to restore normal function.

RELAXATION
Recognize when you are tense. You may be hunching your shoulders or clenching your teeth without realizing it.

How Physiotherapy Can Help?

Physiotherapists are experts in posture and human movement. They will be able to determine if your neck is causing or contributing to the headaches and plan a treatment program accordingly.
How Myofascial Release can Help Headaches
When the body experiences physical insults such as sprains, strains, scarring from surgery or injury, inflammation, disease, trauma from falls, repetitive stress, and poor posture, it responds by assuming unnatural positions. This unnatural positioning puts abnormal stress on the various areas of the fascia. The fascia then shortens and loses elasticity. This in turn creates tension in the muscles so that they pull the body out of alignment. Poor posture, a non-ergonomic office environment, stress, and injury to the arm, shoulder, neck, or jaw are common causes of muscle tension that cause headaches. These causes can be modified by myofascial release to relieve headaches.
In order to restore flexibility to the fascia and to release muscle tension, the myofascial release practitioner performs movements that alternately stretch and compress the fascia. The goal of this is to restore the natural alignment of the body. Fascia is connected through the entire body, so myofascial release performed on parts of the fascia will release tension in the entire body. As abnormal stresses on the head and neck disappear, so do the headaches. Although myofascial release therapy works best on tension headaches, it can also help prevent or reduce the frequency of migraine and cluster headaches as well.
Headaches also can have a psychological or emotional component. People who experience emotional trauma may assume protective body positions that strain the muscles of the head, neck, and shoulders. This stress deforms the fascia and can cause tension headaches. Myofascial release is not intended to directly address the emotional causes of headache pain. However, some clients discover that during their myofascial release sessions emotions are liberated in a way that has a positive effect on both physical and emotional healing.
What Happens During a Myofascial Release Session?
Treatment of headaches can take several myofascial release sessions. On the first visit, the practitioner will discuss the nature of the patient’s headaches—what brings them on, how long they last, what activities the patient is engaged in at the onset, what kind of pain is experienced—as well as the patient’s lifestyle, stressors, and the goal of the treatment. The practitioner will explain how a myofascial release treatment plan can achieve the patient’s treatment goals and reduce frequency and severity of headaches.
During this initial visit, the practitioner will also evaluate the patient’s posture and movement to determine whether this could be a cause of tension that leads to headaches. The practitioner will develop a plan of treatment based on the individual patient’s needs, the type of headaches they experience, and the feedback the practitioner gets while working with the patient’s body.
Each myofascial release session generally lasts about an hour. Depending on the plan of treatment and the patient’s goals, sessions can occur from three to six times per week. The patient will wear minimal, non-baggy clothing to allow the practitioner access to the body. The practitioner uses light pressure, compression and traction to stretch the fascia that is tense and rigid. The patient may feel pain during this therapy; pressure is applied slowly, increasing blood flow to the site of the pressure and allowing the fascia to relax and regain its natural, correct structure.
Many times, only one or two parts of the body are worked in one myofascial release session. Trigger points on the patient’s body will tell the practitioner where work needs to be done. Trigger points are areas on the body where pain or tension resides. The practitioner will use gentle pressure to find these points based on the feedback he or she gets from touch. Even though only one or two areas may be worked, the entire body will benefit because fascia is interconnected like a web.
Temporary soreness might occasionally result after a myofascial release session, but most people do not feel any discomfort after a session. When soreness is felt, it is usually because deeper, more intense pressure was used to unwind very tense fascia. This soreness is normally quite brief.
Relief can be felt after a single myofascial release session, but three or more sessions will yield more lasting relief from headache symptoms.Usually between 2 to 6, 45 minute treatments at the Myofascial Release Clinic bring about substantial decrease in headaches and migraines.
Physiotherapists may use other techniques in combination with MFR such as :-

Craniosacral therapy
Mobilisation.
Manipulation.
Functional and rehabilitative exercises.
Encouraging normal activity.
Postural assessment, correction and advice.
Relaxation therapy.
Laser, ultrasound, electrotherapy and heat treatment.

Your physiotherapist can also offer you self-help advice on ways to correct the cause of headaches, such as practical ergonomic tips for work and in the home; adjusting furniture, relaxation and exercise. Manipulation can be an effective treatment for headache caused by neck problems, but may not be the best option in every situation. After a thorough examination your physiotherapist will discuss treatment options with you to ensure that your headaches are managed safely and effectively.
Finding a Myofascial Release Practitioner
In India, numbers of therapists who are practicing Myofascial release techniques are very few since there is scarcity in the number of authorized institutions. Myofascial Therapy and Research Foundation, India® is the one and only center in India which conducts diploma courses on Myofascial Release. The course ADMFT© (Advanced Diploma in Myofascial Therapy) is a three months duration course conducted at its main centre in Kottayam, Kerala. All type of MFR and other “Hands-On” treatments for various osteomyofascial dysfunction can be available at MFTRF®’s clinical Wing “SCeB CAPT®” (Specialized Centre for Back Care And Advanced Physical Therapy), Kottayam, Kerala(www.scebcapt.blospot.com). Here practitioners of myofascial release also have training in bodywork techniques such as Rolfing, Cranio Sacral Therapy, Critz Technique, Neil Ascher Technique, Muscle energy Technique, Maitland manipulation and Mobilization and Ergonomics .

Syllabus for MFR Modules

2009-01-11T01:44:00.000-08:00

Syllabus for MFR Modules

Introduction to Myofascial Release, the reasoning and physiology of MFR.
Structural MFR and ‘unwinding’
The MFR Evaluation, Importance of Hand Sensitivity
Concept and detection of craniosacral rhythm
Concept and practice of indirect release and direct methods
Gross cross hand stretches
Focused stretches
3-dimensional releases
J-stroking
Leg and arm pulls
Transverse fascial plane releases
Energy direction
Cranial base release
Focused rebounding
Scar tissue release
Myofascial trigger points
Specific direct technique release of all Osteomyofascial Compartments.
Cervical release
Combining techniques, e.g. skin rolling with indirect release and a focused stretch, or arm pulls with rocking and rebounding, indirect release and unwinding.
Unwinding
Combining unwinding with structural work
Myofascial Release Advanced
Advanced palpatory skills
Advanced unwinding and integration with structural techniques
Specific applications for the SI joint and pelvis
Specific applications for the thoracic spine and rib cage
Specific applications for the cervical spine
Clinical integration
Subtle energy techniques
Continuation of MFR dialoguing skills

Postgraduate practitioner training in Myofascial Release ;The ADMFT©

This is a more comprehensive course, intended to give thorough Hands-On training for true Hands-On lovers in advanced palpation skills and the whole myofascial release techniques. After training you will get a full Hands-On training on patients under Dr. Ajimshaw’s guidance at our clinical wing, SCeB CAPT®, Medical College, Kottayam
Course Duration 3 months
Initially only 5 seats are available. Candidates shall be selected based on their qualifications and the minimum qualification is bachelor of physiotherapy. So we request you to register your names free of cost by sending your resume to our email i.e.: scebcaptmfr@gmail.com.

For course details and class arrangements; please contact

The Myofascial Therapy & Research Foundation®,

India

Reg. No. A1.M9/08, S. 289/08
Chemmanampady, Medical College, Kottayam
Ph: 09495300913, 09048001450, 9048001452

Myofascial Release Training In India

2009-01-11T01:11:00.000-08:00

A New Year Bonanza from MFTRF®
Myofascial Release the magic of pain relief!
The Myofascial Therapy & Research Foundation®, India
Learn MFR from The Masters………..
MFR the fast emerging new technique in physiotherapy and is soon to become a mainstay.
Myofascial Therapy and Research Foundation® is proud to announce it new venture, for the first time in India, a golden chance to learn this miraculous technique.
By mastering this technique, you will be able to do magic with your hands and you shall raise your efficiency as a physiotherapist two fold.
The MFTRF® gives you an opportunity to learn MFR, whole body, both direct and indirect techniques. The classes are taken by Dr. Ajimsha. M.S, MPT(Neuro), Ph.D(P.T), MFR resource person of MFTRF®
We are providing you a crash course on MFR and the course will consist of three modules. By completing these 3 modules you will be in the miraculous realm of MFR and then all you would need to do is practice
Module 1(16 credit hours)
Day1-
Introduction to MFR,
Hand sensitization program
Day2-
IDRMFT,
DRMFT (upper limb)
Module 2 (16 credit hours)
Day1-
The lower extremities,
The Cervical region
Day2-
The trunk,
The pelvis
Module 3 (16 credit hours)
Day1-
Intra oral treatment,
The head and face
Day2-
The management of headache,
The pediatric supplement
MFR in neurology

This is an introductory package and the fees are applicable only for the first three batches, after which the fees shall be raised.
For colleges lecturers can avail free registration, one tutor for every ten students attending the seminar.
All certificates shall be provided by the MFTRF®, India.

Syllabus for Modules
Introduction to Myofascial Release, the reasoning and physiology of MFR.
Structural MFR and ‘unwinding’
The MFR Evaluation, Importance of Hand Sensitivity
Concept and detection of craniosacral rhythm
Concept and practice of indirect release and direct methods
Gross cross hand stretches
Focused stretches
3-dimensional releases
J-stroking
Leg and arm pulls
Transverse fascial plane releases
Energy direction
Cranial base release
Focused rebounding
Scar tissue release
Myofascial trigger points
Specific direct technique release of all Osteomyofascial Compartments.
Cervical release
Combining techniques, e.g. skin rolling with indirect release and a focused stretch, or arm pulls with rocking and rebounding, indirect release and unwinding.
Unwinding
Combining unwinding with structural work
Myofascial Release Advanced
Advanced palpatory skills
Advanced unwinding and integration with structural techniques
Specific applications for the SI joint and pelvis
Specific applications for the thoracic spine and rib cage
Specific applications for the cervical spine
Clinical integration
Subtle energy techniques
Continuation of MFR dialoguing skills
Postgraduate practitioner training in Myofascial Release ;The ADMFT©

This is a more comprehensive course, intended to give thorough Hands-On training for true Hands-On lovers in advanced palpation skills and the whole myofascial release techniques. After training you will get a full Hands-On training on patients under Dr. Ajimshaw’s guidance at our clinical wing, SCeB CAPT®, Medical College, Kottayam
Course Duration 3 months
Initially only 5 seats are available. Candidates shall be selected based on their qualifications and the minimum qualification is bachelor of physiotherapy. So we request you to register your names free of cost by sending your resume to our email i.e.: scebcaptmfr@gmail.com.
For course details and class arrangements; please contact
Please email or telephone for more details:
Dr. Ajimshaw. M.S, MPT(Neuro), MTS 09048001450, 09495300913Mailing address: The Myofascial Therapy and Research Foundation®, SCeB CAPT®, Chemmanampady, Medical College, Gandhinagar, Kottayam, Kerala.
Email: scebcaptmfr@gmail.com, dr.ajimshaw@rediffmail.com
Visit http://www.scebcapt.blogspot.com/ for more details
The Myofascial Therapy & Research Foundation®,

India

Reg. No. A1.M9/08, S. 289/08, Chemmanampady, Medical College, Kottayam
Ph: 09495300913, 09048001450, 9048001452

Understanding Myofascial Pain

2008-10-20T23:21:00.000-07:00

It has been estimated that some 44 million Americans have myofascial pain problems (1). A study from an internal medicine group practice found that 30% of patients with pain complaints had active myofascial trigger points (2). A report from a clinic specializing in head and neck pain reported a myofascial etiology in 55% of cases (3). Patients evaluated in one pain management center were found to have a myofascial component to their pain in 95% of cases (4). There is increasing awareness that active myofascial trigger points often play a role in the symptoms of patients with tension headaches (5), low back pain, neck pain (6), temporomandibular pain (7), forearm and hand pain (8), postural pain (9), pelvic/urogenital pain syndromes.
In interpreting the results of prevalence studies, it is important to distinguish between active myofascial trigger points and latent myofascial trigger points. Latent myofascial trigger points are defined as tender areas in muscle, in association with the other clinical features of the trigger point (see table 1), in the absence of associated pain syndrome. Active myofascial trigger points are associated with a pain syndrome that is reproduced by firm palpation of the trigger area.
For instance, Sola found latent trigger points in the shoulder girdle muscles of 54% of female and 45% of male subjects who were completely asymptomatic (10).
There have been no prevalence studies of myofascial pain syndromes in the context of rheumatology practice, but it is the author's experience that myofascial pain problems are often undiagnosed / untreated components of pain in osteoarthritis, rheumatoid arthritis, systemic lupus and other common rheumatic disorders.
Diagnosis
The clinical diagnosis of myofascial pain is critically dependent on your doctor being aware of this diagnosis as a possible cause for some of your pain (11). Myofascial pain syndromes may mimic a large number of other disorders, thus there is a necessity to perform a thorough physical examination, with appropriate investigations. Myofascial pain characteristically presents as a dull deep aching sensation which is aggravated by use of the involved muscles as well as psychological stressors that cause increased muscle tension (12). The defining clinical characteristic of myofascial pain is the finding of a trigger point. This is a well-defined point of focal tenderness within a muscle. Sometimes firm palpation of this focus elicits pain in a referred distribution that reproduces the patient’s symptoms. Importantly, referred pain from a trigger point does not follow a nerve root distribution (i.e. it is not dermatomal). Palpation usually reveals a ropelike induration of the associated muscle fibers, often referred to as the “taut band”. Sometimes, snapping this band or needling the trigger point produces a localized twitch response of the involved muscle. This twitch response can only be reproducibly elicited in fairly superficial muscles.
Myofascial pain often results from muscle injury or repetitive strain. In the current medical climate, especially in United States, a whole array of often expensive investigations have usually been undertaken before the possibility of a myofascial pain diagnosis is considered. Some patients, who already have a well-defined cause for their musculoskeletal pain (e.g. rheumatoid arthritis), may develop a myofascial pain syndrome that goes unrecognized, as it is assumed that all their pain emanates from their primary diagnosis. Myofascial pain has certain clinical characteristics that aid in considering this diagnosis. The pain is typically described as a deep aching sensation, often with a feeling of stiffness in the involved area; this is sometimes described in terms of joint stiffness. Myofascial pain is aggravated by use of the involved muscle(s), psychological stressors, anxiety, cold and postural imbalance. Radiation from a trigger point may be described in terms of paresthesiae and thus mimic the symptoms of a cervical or lumbar radiculopathy. Muscle weakness secondary to disuse may present with symptoms weakness, poor coordination, reduced work tolerance, fatigue and sleep disturbance. Patients with myofascial pain involving the neck and face muscles may experience symptoms of dizziness, tinnitus and poor balance.
The characteristic features of a myofascial trigger point:
1. Focal point of tenderness to palpation of the involved muscle
2. Reproduction of pain complaint by trigger point palpation (about 3 kg pressure)
3. Palpation reveals an induration of the adjacent muscle (the “taught band”)
4. Restricted range of movement in the involved muscle
5. Often pseudo-weakness of the involved muscle (no atrophy)
6. Often referred pain on continued (~5 secs) pressure over trigger point.

Common Symptoms of Myofascial Pain
A myofascial pain syndrome may be due to just one trigger point, but more commonly there are several trigger points responsible for any given regional pain problem. It is not uncommon for the problem to be initiated with a single trigger point with the subsequent development of satellite trigger points that evolve over time due to the mechanical imbalance resulting from reduced range of movement and pseudo-weakness. The persistence of a trigger point may lead to neuroplastic changes at the level of the dorsal horn which results in amplification of the pain sensation (i.e. central sensitization) with a tendency to spread beyond its original boundaries (i.e. expansion of receptive fields) (13). In some instances segmental central sensitization leads to the phenomena of mirror image pain (i.e. pain on the opposite side of the body in the same segmental distribution) and in other instances a progressive spread of segmental central sensitization gives rise to the widespread pain that characterizes fibromyalgia (14).
Low back pain
Acute low back pain has many causes. Some are potentially serious, such as cancer metastases, osteomyelitis, massive disk herniations (e.g. cauda equina syndrome), vertebral fractures, pancreatic cancer and aortic aneurysms. However the commonest cause of acute back pain is so-called lumbosacral strain. In 95% of cases this resolves within three months. In those cases that do not resolve the development of a chronic low back pain syndrome is usually accompanied by the finding of active myofascial trigger points. Simons of describes 15 torso and pelvic muscles which may be involved in low back pain (10). The most commonly involve muscle group is the quadratus lumborum; pain emanating from trigger points in these muscles is felt fin the low back with occasional radiation in a sciatic distribution or into the testicles. Trigger points involving the iliopsoas are also a common cause of chronic low back pain. The typical distribution of iliopsoas pain is a vertical band in the low back region and the upper portion of the anterior thigh. Trigger points at the origin of the gluteus medius from the iliac crest are common cause for low back pain in the sacral and buttock with a referral pattern to the outer hip region.
Neck and shoulder pain
Latent trigger points are universal finding in many of the muscles of the posterior neck and upper back. Active trigger points commonly involve the upper portion of the trapezius and levator scapula. Upper trapezius trigger points referred pain to the back of the neck and not uncommonly to the angle of jaw. Levator scapula trigger points cause pain at the angle of the neck and shoulder; this pain is often described as lancinating, especially on active use of this muscle. As many of the muscles in this area have an important postural function they are commonly activated in office workers and developmental problems causing spinal malalignment (e.g. short leg syndrome, hemipelvis and scoliosis). As the upper trapezius and levator scapulae act synergistically with several other muscles in elevation and fixation of the scapula it is common for a single trigger point in this region to initiating a spread of satellite trigger points through adjacent muscles which are part of the same functional unit.
Hip pain
Pain arising from disorders of the hip joint is felt in the groin and the lower medial aspect of the anterior thigh. This distribution is uncommon in myofascial pain syndromes except for iliopsoas pain. The great majority of patients complain of hip pain in fact localize their pain to the outer aspect of the hip. In some patients this is due to a trochanteric bursitis, but in the majority of cases it is related to myofascial trigger points in the adjacent muscles. By far the commonest trigger points giving rise to outer hip pain are those in the attachments of the gluteus medius and minimus muscles into the greater trochanter.
Pelvic pain
The pelvic floor musculature is a common sight for myofascial trigger points. There is increasing recognition by gynecologists and urologists that pain syndromes described in terms of prostatitis, coccydnia, vulvodynia and endometriosis are often accompanied by active myofascial trigger points. One of the most commonly involved intrapelvic muscles is the levator ani; its pain distribution is central low buttock.
Headaches
Active myofascial trigger points in the muscles of the shoulder neck and face are a common source of headaches (15). In many instances the headache has the features of so-called tension headache, but there is increasing acceptance that myofascial trigger points may initiate classical migraine headaches or be part of a mixed tension/migraine headache complex. For instance sterno-cleido mastoid trigger points refer pain to the anterior face and supraorbital area. Upper trapezius trigger points refer pain to the vertex forehead and temple. Trigger points in the deep cervical muscles of the neck may cause post occipital and retro-orbital pain.
Jaw pain
There is a complex interrelationship between temporomandibular joint dysfunction and myofascial trigger points (3) Common trigger points involved in jaw pain syndromes are the massetters, pterygoids, upper trapezius and upper sterno-cleido mastoid.
Upper Limb pain
The muscles attached to the scapula are common sites for trigger points that can cause upper limb pain (16). These included the subscapularis, infraspinatus, teres major and serratus anterior. It is not uncommon for trigger points in these locations to refer pain two the wrist hand and fingers. Extension flexion injuries to the neck often activate a trigger point in the pectoralis minor with a radiating pain or down the ulnar side of the arm and into the little finger. Myofascial pain syndromes of the upper limb are often misdiagnosed as frozen shoulder, cervical radiculopathy or thoracic outlet syndrome (10).
Lower limb pain
Trigger points in the tensor fascia lata and ilio tibial band may be responsible for lateral thigh pain and lateral knee pain respectively. Anterior knee pain may result from trigger points in various components of the quadriceps musculature. Posterior knee pain can result from trigger points in the hamstring muscles and popliteus. Trigger points in the anterior tibialis and the peroneus longus muscles may cause pain in the anterior leg and lateral ankle respectively. Myofascial pain syndromes involving these muscles are often associated with ankle injuries or an excessively pronated foot. Sciatica pain may be mimicked by a trigger point in the posterior portion of the gluteus minimus muscle.
Chest and abdominal pain
Disorders affecting intrathoracic and intra-abdominal organs are some of the commonest problems encountered in internal medicine. For instance, anterior chest pain is a frequent cause for the emergency room admissions, but in the majority of patients a myocardial infarction is not found. In some cases the chest pain is caused by trigger points in the anterior chest wall muscles (17). Pectoralis major trigger points cause ipsilateral anterior chest pain with radiation down the ulnar side of the arm – thus mimicking cardiac ischemic pain. A trigger point in the sternalis muscle typically causes a deep substernal aching sensation. Trigger points at the upper and lower insertions of the rectus abdominus muscles may mimic the discomfort of gall bladder and bladder infections respectively. It is important to note that myofascial trigger points may accompany disorders of intrathoracic and intra-abdominal viscera, and thus a diagnosis of an isolated myofascial cause for symptoms should never be made without an appropriate workup.
Causation
The precise basis for the trigger point phenomena is still not fully understood. There is a general agreement that electromyographic recordings from trigger points show low voltage spontaneous activity resembling endplate spike potentials (18). Simons envisions a myofascial trigger point to be “a cluster of numerous microscopic loci if intense abnormality that are scattered throughout the tender nodule” (10). It is thought that these loci result from a focal energy crisis (from injury or repetitive use) that results in contraction of focal sarcomeric units due to calcium release from the sarcoplasmic reticulum. Factors commonly cited as predisposing to trigger point formation include deconditioning, poor posture, repetitive mechanical stress, mechanical imbalance (e.g. leg length inequality), joint disorders, non-restorative sleep and vitamin deficiencies.
Here is a cartoon of a trigger point complex seen in a longitudinal section of muscle. The top component represents a muscle with a taut band. The middle component represents a magnified view of the taut band containing an active trigger point focus. The lower component represents further magnification of the taut band and trigger point focus showing contraction knots (contracted sarcomere units). It is envisaged that these contraction knots are responsible for the nodularity of the taut band.

Prognosis
Uncomplicated myofascial pain syndromes usually resolve with appropriate correction of predisposing factors and myofascial treatment (12). If the symptoms are persistent, due to ineffective management, the development of segmental central sensitization may lead to a stubbornly recalcitrant pain disorder. In some such cases, the spread of central sensitization leads to the widespread pain syndrome of fibromyalgia

References
(1) Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs 2004; 64(1):45-62.
(2) Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West J Med 1989; 151(2):157-60.
(3) Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol 1985; 60(6):615-23.
(4) Gerwin RD. A study of 96 subjects examined for both fibromyalgia and myofascial pain. J Musculoskeletal Pain 1995; 3 (suppl. 1):121-5.
(5) Fernandez-de-Las-Penas C, onso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Headache 2006; 46(8):1264-72.
(6) Fernandez-de-Las-Penas C, onso-Blanco C, Miangolarra JC. Myofascial trigger points in subjects presenting with mechanical neck pain: A blinded, controlled study. Man Ther 2006; .
(7) Ardic F, Gokharman D, Atsu S, Guner S, Yilmaz M, Yorgancioglu R. The comprehensive evaluation of temporomandibular disorders seen in rheumatoid arthritis. Aust Dent J 2006; 51(1):23-8.
(8) Hwang M, Kang YK, Kim DH. Referred pain pattern of the pronator quadratus muscle. Pain 2005; 116(3):238-42.
(9) Treaster D, Marras WS, Burr D, Sheedy JE, Hart D. Myofascial trigger point development from visual and postural stressors during computer work. J Electromyogr Kinesiol 2005; .
(10) Simons DG. Myofascial pain caused by trigger points. In: Mense S, Simons DG, Russel IJ, editors. Muscle Pain: Understanding its Nature, Diagnosis, and Treatment. First ed. Philadelphia: Lippincott Williams & Wilkins; 2001. 205-88.
(11) Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams & Wilkins; 1983.
(12) Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician 2002; 65(4):653-60.
(13) Graven-Nielsen T, Arendt-Nielsen L. Peripheral and central sensitization in musculoskeletal pain disorders: an experimental approach. Curr Rheumatol Rep 2002; 4(4):313-21.
(14) Arendt-Nielsen L, Graven-Nielsen T. Central sensitization in fibromyalgia and other musculoskeletal disorders. Curr Pain Headache Rep 2003; 7(5):355-61.
(15) Borg-Stein J. Cervical myofascial pain and headache. Curr Pain Headache Rep 2002; 6(4):324-30.
(16) Gerwin RD. Myofascial pain syndromes in the upper extremity. J Hand Ther 1997; 10(2):130-6.
(17) Travell J, Simons D. Myofascial Pain and Dysfunction: The trigger point manual, Volume 2. Baltimore: Williams & Wilkins; 1992.
(18) Rivner MH. The neurophysiology of myofascial pain syndrome. Curr Pain Headache Rep 2001; 5(5):432-40.
(19) Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil 2002; 83(3 Suppl 1):S40-S49.
(20) Rudin NJ. Evaluation of treatments for myofascial pain syndrome and fibromyalgia. Curr Pain Headache Rep 2003; 7(6):433-42.
(21) Hong C-Z. Considerations and Recommendations Regarding Myofascial Trigger Point Injection. J Musculoskeletal Pain 1994; 2(1):29-59.
(22) Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994; 73(4):256-63

BACK PAIN MANAGEMENT UPDATE: 2008

2008-10-06T22:51:00.000-07:00

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 (Recoup.org, 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
Deep
Multifidus, Quadratus lumborum
Iliocostalis, longissimus, (Erector s.)
Superficial
Thoracolumbar fascia
Lattisimus dorsi
Lumbar ligaments
ALL, PLL
Ligamentum flavum
Facet capsules
Interspinous ligaments
Supraspinous ligaments
Pain Generators
Annulus Fibrosis (outer 1/3 only?)
Periosteum
Neural Membranes (Anterior Dura)
Ligaments/ Z-joint capsules
Muscles.
Imaging or Not?
Low yield without RED FLAGS present.
"Abnormal" findings in Asymptomatic.
Jarvik- LAIDback study.
Psychological.
Anxiety, fear-avoidance- possibly help?
Depression- "there must be something wrong"
Guidelines for Imaging
NO RED FLAGS!
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.
Tumor?
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"
Multifidus
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%
N=24,882!
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
Make the DIAGNOSIS!
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
LOW BACK
Quatrus lumborum
Ilio-costalis
Piriformis
(Ilio-psoas)
Gluteus-min, mid, max
Multifidus
HIP, LEG, GROIN
Piriformis
Tensor fascia lata
Gluteus min, mid, max
(Ilio-psoas)
All these muscle involvements are rarely alone – usually in multiples

Postural muscle strains
Symptoms:
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 //
Activity

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:
LOW BACK
Multifidi
Quatrus lumborum
Ilio-costalis
Piriformis
Ilio-psoas
Gluts-min-mid-max
HIP, LEG, GROIN
Piriformis
Tensor fascia lata
Gluteus minimus
Gluteus-medius
Gluteus maximus
Ilio-psoas
UP-BACK
Trapezius
Levator scapulae
Serratus anterior
Rhomboids
Serratus posterior
Latissimus dorsi
Multifidi
NECK
Trapezius
Levator scapulae
Scalenes
Occipital
Para-cervicals
FACET induced
(Thoracic)
(Lumbar)
(Cervical)
FACTORS -7

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
Fall
Bike
Digging
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…
"Costochondritis"
"Non-cardiac chest pain"
"Idiopathic" neuropathy of the upper extremity

Causes
Cervico Thoracic
Twist & reach
Fall
Jerk arm
Sleep wrong
Fall, hit chest
Overhead pull
Lumbar
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
"long-waisted"
"long-necked"
"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
Managements
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
Mobilizations
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….

REFERENCES
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. www.orthodiv.org
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.
Jarvik J et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003 Jun 4;289(21):2810-8.

MFR and Back pain

2008-10-06T22:15:00.000-07:00

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.

Myofascial Release - An Introduction for the Patient

2008-10-06T22:09:00.000-07:00

SCeB CAPT® & MFTRF®
Reg. No. A1.M9/08, S. 289/08
Chemmanampady, Medical College, Kottayam
Ph: 9846265331, 9846474873, 9048001452
www.scebcapt.blogspot.com. E mail: scebcaptmfr@gmail.com
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.
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
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…….

Back Pain

2008-08-31T20:59:00.000-07:00

Myofascial Release Training In INDIA

2008-08-31T04:03:00.000-07:00

'Health is not only about feeling better but getting better at feeling'
-John F Barnes-

Myofascial Release (MFR) is a whole body, hands-on approach to healthcare. It is a mild and gentle form of stretching that has a profound effect upon the body. A slow gentle pressure allows the body's tissue to reorganize without force, release physical restrictions and release the body's unconscious holding and bracing patterns.
Myo means muscle and fascia means band, or connective tissue, is a 3D continuous web that extends without interruption throughout the body. It is composed of two main types of fibers, collagen and elastin, that promote strength and flexibility. It is dynamic in nature and changes and conforms to pressures applied to it. It meets resistance in order to protect and support the human frame. Fascia is prominently vertical in orientation and Surrounds, infuses and protects every other tissue and organ of the body. When healthy, the fascial system is relaxed, providing a supportive cushioning mechanism allowing us to move safely without restriction or pain.
Following all physical and emotional injury, and through poor posture, fascia scars and hardens in the affected site and along the tension lines imposed on it. As the fascial system is completely continuous then any injury will compromise the whole structure. Once injured, fascia twists and pulls, like the pull in a jumper, creating a spider web effect of tension throughout the system. This tension can exert a pressure of up to 2,000 pounds per square inch crushing and impinging important structures like the dural tube, organs, and the circulatory, nerve and lymphatic systems. The "fascial tension can also affect the alignment of the skeletal and muscular system all of which create on-going physical and emotional tension and pain.

Over time these twists and pulls create a devastating effect on the body. It is not uncommon for patients to complain of a symptom in one area of the body that may have originated elsewhere. As the body tries to compensate for the restrictions, further imbalance and tension occurs. This is one of the main reasons we experience on-going
physical and emotional discomfort when the whole body remains un-treated. Many people don't recognize that their body is being compromised by fascial pulls as these pulls happen so gradually. However there is usually 'the last straw that breaks the camel's back' and the body is no longer able to support the structure without pain'. It is therefore important for the Myofascial Practitioner to treat not just the injury but to treat the body as a whole and the whole fascial history.
Fascial restrictions do not show up on any X- Ray, MRl or CAT scan and patients may complain of bizarre pain and discomfort that can remain undiagnosed and subsequently, and unfortunately, may remain untreated within traditional healthcare systems.
The body remembers
The body and mind are one and the same and have the subconscious ability to associate postural positions, actions and emotions to a memory. It also subconsciously constructs and memorizes habit and bracing patterns in order to protect itself from physical and emotional pain and discomfort. This creates further fascial restrictions inhibiting the free flow of the subconscious mind throughout the body. Therefore the experiences we are compensating for become locked within the fascial system, without our awareness, maintaining body/mind dysfunction and increasing pain and discomfort. Without awareness there is no choice.
With the help of MFR, the physical and emotional content of any injury, literal or
symbolic, can be addressed in a safe and gentle way. MFR releases the restrictions within the fascial network, allowing valuable subconscious information to be released into awareness where it can be resolved in order to restore health.
A sense of art
MFR is an art form. The MFR Practitioner not only takes into consideration what they see in the patient's postural assessment but works directly with what they feel and sense from palpating and treating the body. They feel for the fascial restrictions and follow them to source, treating the cause and not merely the symptom. One of the important jobs of the fascial system is to meet resistance. When a force is applied to the system the fascial network meets that resistance in order to protect. The fascial network responds and releases to the Piezoelectric effect, a low load pressure over a sustained length of time. Therefore MFR should never force the fascial network but instead work slowly through the layers of restriction. It takes approximately 90 seconds for the fascial network to respond to the slow gentle pressure applied to it and a fascial release can take anywhere between 3 to 5 minutes, sometimes longer.
The fascial system is 3D, therefore we treat in a 3D manner. No patient ever injured themselves lying flat, motionless, on a massage table. Every patient's fascial restrictions are unique; therefore we treat each patient in a unique, 3D, way. MFR is not bound by protocols or structured techniques. It is rather an exploratory journey feeling, sensing, palpating and ultimately facilitating the release of restricted tissues that may have been tight and which have possibly been creating pain and dysfunction for years.
MFR is so gentle it allows the body/mind to reorganize itself and unwind its own tractions or twists. Some patients feel their body becoming lighter, twitch or feel their body move during treatment. This is a natural process and is our body's own inherent self-correcting mechanism which unravels the tension and restriction in a natural way.
Patients are encouraged to allow this to happen and to become more aware of what they are feeling during treatment to assist the process and ultimately take control of their health.

How to access the Fascial Network using the arms and legs as levers
If the fascial system is completely connected then we can work the whole system using the body as a lever.
Treating the body with an arm or leg pull is an effective tool for assessing the body's fascial pulls and restrictions. It is also a way to introduce MFR to a patient, particularly those who are in pain or who are anxious about treatment.
As the therapist it is important at all times to maintain a high level of softness and flow in your own body as resistance will diminish sensitivity in picking up the subtlety of the patient's fascial voice.
Completing arm and leg pull techniques may take anywhere from 5 to 10 minutes and sometimes longer depend on the fascial restrictions. Always treat within painless range of motion and treat each patient in a unique fascial way.

Arm pull technique

An arm pull can assist in the treatment of not only the arm, finger, wrist and shoulder but also the fascial restrictions and fascial pull throughout the entire body.
Hold the wrist /lower arm or elbow gently and slowly externally rotate the arm until you feel the smoothness of the movement change to a more sluggish movement. This is the first level of restriction. Hold at this barrier.
Next slowly abduct the arm until you feel the smooth movement change. Hold at this barrier.
Next, gently and slowly traction the arm until you meet restriction and also hold at this barrier. We are now treating the body 3D. Feel into the body and maintain your gentle 3D traction. We must always meet the resistance and never force the barrier. Gradually you will feel the arm soften and you will be able to take up a little more slack, in any or all of the 3D tractions.
This may take anywhere between 3-5 minutes. Follow the releases, slowly and gently into full circumduction, or within painless range of motion.
With the arm above the patient's head you can access into the chest area, back and pelvis and further on down into the legs. By placing the arm down next to the body you can release up into the neck, shoulder, face and TMJ.
As you traction the arm over the patient's head move into adduction and flexion with trunk rotation and grasp the medial border of the scapula and apply a lateral pull while continuing the arm traction. This position allows a release through the upper back, shoulder and neck area. Always return the arm back through its entire range slowly.
Leg pull technique
Patient lies supine with the therapist at the foot of the table. The leg pull uses the same concepts as the arm pull techniques
Gentle pick up the leg at the foot/ankle or lower leg and slowly externally rotate to the first barrier whilst dorsiflexing the foot. Gently abduct the leg to the barrier and hold. Next, gently give traction the leg to meet resistance.
Slowly and gently feel for the fascia! releases and follow them through abduction then adding in leg flexion while maintaining dorsiflexion, all of which must be within a painless range of motion. Return the leg back through its full range maintaining traction and dorsiflexion.
Next internally rotate the leg and gently adduct to the first fascial barrier. This position will pull into the hip and the patient will move into trunk rotation. This position will gently release the low back, sacroiliac joint areas and hip. Slowly return the leg back through its range to neutral whilst maintaining traction and dorsiflexion.
Contraindications
Contraindications such as malignancy, aneurysm and acute Rheumatoid arthritis may be considered absolute, while others such as Haematoma,. open wounds, healing fractures, etc. may be regional.
Malignancy
Open wounds
Cellulitis
Sutures
Febrile State
Haematoma
Systemic or localised infection
Healing fracture
Acute citculatory condition
Osteomyelitis
Degenerative Changes
Aneursym
Anticoagulant Therapy
Obstructive Oedema
Advanced Diabetes
Acute Rheumatoid arthritis
Skin hypersensitivity
Always perform a thorough patient history and always refer the patient back to their GP/Doctor if you are in any doubt as to contraindications for MFR treatment and also if their condition persists. Please refer to your own code of practice.

Myofascial Release Training In INDIA
Advanced Diploma In Myofascial Therapy© (ADMFT)

There is only one foundation which ic conducting course on MFR which is Myofscial Therapy and Research Foundation, India. with its main centre at Kottayam, Kerala (SCeB CAPT). Advanced Diploma In myofascial Thewrapy© (ADMFT) is available as 3 months course, with Certificate, Transcript and life time membership in MFTRF for those who are joining early. The ADMFT provides advanced fascial release techniques that can be easily and immediately integrated into your existing practice. ADMFT is presented by Dr. Ajimshaw. M.S, an Osteomyofascial Manipulator, Advanced MFR Practitioner and Neuro Physical Therapist at MFTRF, SCeB CAPT, Medical College, Kottayam, Kerala.

At SCeB CAPT you can learn “AJIMSHAWs approach” which is a unique method of Hands-On release invented by Dr. AJIMSHAW. M.S, by combining recent advances in Physical Therapy with Hands-On techniques. AJIMSHAWs approach is very different from traditional MFR or soft tissue mobilization. By adding these valuable fascial release techniques to your treatments you will change the way you view, feel and assess your patients and you will create structural change that is both measurable and functional.
For further information and to contact your local MFT therapist visit http//:scebcapt.blogspot.com, or e-mail at scebcapt@gmail.com or call 09495300913.

2008-08-31T04:00:00.000-07:00

There is only one foundation which ic conducting course on MFR which is Myofscial Therapy and Research Foundation, India. with its main centre at Kottayam, Kerala (SCeB CAPT). Advanced Diploma In myofascial Thewrapy© (ADMFT) is available as 3 months course, with Certificate, Transcript and life time membership in MFTRF for those who are joining early. The ADMFT provides advanced fascial release techniques that can be easily and immediately integrated into your existing practice. ADMFT is presented by Dr. Ajimshaw. M.S, an Osteomyofascial Manipulator, Advanced MFR Practitioner and Neuro Physical Therapist at MFTRF, SCeB CAPT, Medical College, Kottayam, Kerala.

At SCeB CAPT you can learn “AJIMSHAWs approach” which is a unique method of Hands-On release invented by Dr. AJIMSHAW. M.S, by combining recent advances in Physical Therapy with Hands-On techniques. AJIMSHAWs approach is very different from traditional MFR or soft tissue mobilization. By adding these valuable fascial release techniques to your treatments you will change the way you view, feel and assess your patients and you will create structural change that is both measurable and functional.
For further information and to contact your local MFT therapist visit http//:scebcapt.blogspot.com, or e-mail at scebcapt@gmail.com or call 09495300913.

Golden Rules of Back Pain..

2008-08-09T04:32:00.000-07:00

1. Back pain is as mystifying today as it was decades ago.

Despite excellent tests and procedures, modern back specialists admit that up to eighty percent of all cases have no clear physiological cause. In fact, many pain-free people show bulging or herniated discs in x-rays.

2. Also, despite everything we know about back pain, ninety percent of us are going to have a disabling episode at some point in our lives.

3. It is difficult to predict which individual person will develop back pain.

Strength, fitness, and back x-rays are not good predictors. One major study concluded that the only predictors were 1) whether the person has had back pain before, and 2) whether the person smokes cigarettes.

4. On the other hand, job characteristics are predictors of back pain.

Jobs with heavy or frequent lifting are high risk, as are jobs involving prolonged standing or sitting.

5. There is little agreement on how to do lifting with little risk.

Lifting with the legs is easy on the back, but hard on the legs and muscles. Lifting with the back puts strain on the disks but is less fatiguing.

6. So-called 'back belts' have not been proven to strengthen backs or prevent back problems.

On one hand, they may help remind wearers to lift carefully. On the other hand, they may give wearers a false sense of greater strength, encouraging them to lift more than they should.

7. People who sit for long periods are at risk for back disorders.

The two greatest problems seem to be 1) sitting upright or forward, and 2) not changing position.

8. An upright posture with a ninety-degree hip position is actually unhealthy, from the perspective of the intervertebral discs.

For a number of reasons, the discs experience more pressure --- and the pressure is more lopsided --- than while standing. So it's a good idea to sit with the hip joints somewhat straightened. Yes, this resembles a slouch, with your rear end scootched (a technical term!) forward in the seat. A supported slouch may be healthy in the long run. Forward-tilt chairs support this posture, but so do chairs with level seats and reclined backrests.

9. Even if the hip joints aren't somewhat straightened, sitting in a reclined posture is more healthy than sitting upright.

This is because reclined sitting puts more of your weight onto the chair's backrest. If the chair backrest holds up more weight, the discs in the lower back hold up less weight. (Well-designed armrests also take some of the upper body weight from the discs.)And reclined sitting lets the back muscles relax.

10. All sitters should move around.

In addition to helping the muscles relax and recover, this alternately squeezes and unsqueezes the intervertebral discs, which results in better filtration of fluids into and out of the cores of the discs. Discs stay plumper and, in the long run, healthier.
One implication: chairs should follow the sitter as he/she changes posture.

11. The most important chair adjustments are
seat height from the floor --- the feet should be able to rest flat on the floor. (However, this doesn't mean the feet should always be flat on the floor. Legs should be free to stay in different positions).
depth from the front of the seat to the backrest --- sitters should be able to use the backrest without any pressure behind the knees.
lumbar support height --- every person is shaped differently.

12. The 'proper' chair adjustments and chair posture are greatly influenced by the rest of the work area.

In particular, the eyes can affect posture, especially if the work material is too far, low, or high. Hand positions (especially working far from the body) can also affect body position, particularly the posture of the upper back and neck.

13. Upper back and neck discomfort is often related to upward viewing angles.

For example, monitors above eye height or leaning, twisting, or reaching (for example, looking down and sideways at a document on the desk, or reaching for a mouse).

14. For people with existing, chronic, difficult back pain: all the above rules are optional, because each back pain case is different.

Rules for prevention of back pain or treatment of medium- level cases may be completely inappropriate for individual cases of severe back pain. Before accepting any advice, trust the "advice" of your own body's discomfort reactions
15. If you are a back or naeck pain sufferer, there is only one centre in kerala which can give you a comprehensive care for your problems and a complete cure for your pains. It is the one and only SCeB CAPT…………….So visit SCeB CAPT today itself as tomorrow is too late………….

How to Prevent Repetitive Strain Injuries

2008-08-09T04:15:00.000-07:00

There are many kinds of RSI (Repetitive Strain Injuries) medical conditions that have ergonomic causes among office workers, including carpal tunnel syndrome and various kinds of tendon inflammation.Some other disorders, such as myofascial pain syndrome, fibromyalgia, thoracic outlet syndrome, and reflexive sympathetic dystrophy are believed to be the results of Repetitive Strain Injuries in some cases.
1. Because of the complexity and subtle differences between disorders, physicians don't always diagnose RSI 's correctly or easily. The most knowledgeable medical specialists for RSI 's are generally considered to be physical Therapy specialists.
2. RSI s can happen when there is very little repetitious work. Besides repetition, other possible causes include:
Holding one position. Muscles that hold a body part in position for long periods are more prone to fatigue than muscles that move a body part around.
Non-neutral postures. In this context, "posture" is the position of an individual joint, not overall body posture. Any posture significantly different from "neutral" is considered to be at risk for musculoskeletal distress. "Neutral" is considered to be the position about halfway through the available range of motion for the joint.
Localized pressure. Direct pressure on nerves or tendons can cause damage in the long run. The wrist is one location of concern. The elbow (the funny-bone or crazy-bone nerve) is another.
Use of force. Even small exertions can cause stress if small muscles are involved. Sudden, fast motions involving a jerk or snap.
Cold temperatures.
Vibration, as with hand-held power tools or whole-body vibration as caused by driving heavy equipment.
3. Keeping these causes in mind, some of the rules of thumb for preventing RSI 's are:
Break up repetitious work.
Relax. Don't use your muscles to hold your hands or shoulders in a particular position. Keep your limbs and shoulders limp as much as possible, even during short pauses.
Use moderate postures for individual joints. Stay away from positions near the extremes of your joints' range of motion --- the most neutral joint position is about halfway.
Minimize contact with hard or sharp surfaces. This is especially important at the wrists and elbows.
Don't use too much force. Notice any exertions you have to make and see if they can be eliminated. "Exertions" don't have to involve breaking into a sweat. They can be subtle, such as pulling a hard-to-reach drawer or lifting a heavy file.
Move with an even motion. Avoid snapping the wrist or jerking against outside forces.
Keep your hands and fingers warm. Consider gloves or even fingerless gloves.
Break up exposures to vibration.
4. "Fitting the physical workspace to the worker" is often touted as the best way to prevent RSI. This is an incomplete view. Although physical workstation design, physical tool design, and adjustability are important, there are many other work-related factors. Three less tangible but extremely important factors are job design, stress control, and individual workstyle.
Examples of job design are infrequent or inflexible breaks, low activity variety, and fast pace. Examples of stressors are deadlines, monitoring, and bad management. Examples of harmful workstyles (in the context of computer work, for instance) are how hard the individuals hits keys, how the individual holds his/her wrists, and where the individual places the mouse.
5. Most RSI 's are preventable and curable if caught early. The key is to notice trouble when it starts --- and do something about it. Early signs may include persistent pain, tingling, numbness, burning, or aching. The signs may be constant or may occur mostly after certain activities. The drastic cures --- such as surgery --- are not reliable and should be a last resort. Nevertheless, a health professional should be consulted when you are concerned about possible early signs.
6. Some people get RSI 's because their bodies are vulnerable to them. For example, carpal tunnel syndrome seems to be related to diabetes, overweight, thyroid conditions, hormone conditions such as those caused by hysterectomy or removal of both ovaries, rheumatoid arthritis, previous injuries, and other conditions. Smoking may also increase the risk. Anyone with any of these conditions --- particularly obesity --- should be especially careful about prevention.
7. RSI 's can happen because of non-work activities. Hobbies, sports, driving, and even sleeping positions can contribute to them. Any attempts at treatment or prevention should include a look at off-the-job factors.
8. One of the most important preventive measures is 'variety.' In other words, change posture and activities often. If possible, take breaks before getting tired. Extremely short breaks can be very helpful of frequent enough. A "break" doesn't have to be a rest break --- it can simply involve doing something else for awhile.
9. Don't follow RSI prevention rules without looking for consequences. Every fix has a drawback. Every ergonomic rule or gizmo has a downside which can possibly make matters worse rather than better. The best way to evaluate ergonomic fixes is by considering all the ergonomic risk factors described above in #2. Example: a wrist rest may force a straighter wrist (vertically) but may put too much pressure on the underside of the wrist or make the individual bend the wrist sideways to reach side keys.
10. Total RSI prevention involves ergonomics (changing the environment), ergonomics education (changing work styles or habits), medical management (optimizing treatments and return-to-work procedures), and management (monitoring statistics to find the most hazardous jobs and working proactively). RSI 's usually cannot be adequately dealt with without all four approaches happening together. Many obstacles to good ergonomics are not scientific, medical, or engineering reasons ... they are political in nature.

Aching Back or Neck @ Office…! Read This…….!

2008-08-09T03:56:00.000-07:00

There are many employers who hear the word "ergonomics," and feel that they must spend thousands of dollars and completely renovate their office to make the necessary improvements. Actually, it takes very little time and effort to make changes that can substantially improve workplace safety and comfort of your dispatchers.
The ultimate goal of ergonomics is to prevent repetitive injuries and maximize work efficiency. But its benefits can extend to lower sick leave, fewer disability cases, and the increased morale of your dispatching staff.
Repetitive injuries can occur when a body part-most commonly a shoulder, elbow, wrist or finger-performs the same motion over and over during the workday. While the human body is quite resilient, if these movements is outside the body's normal movement range, just a few year's work can permanently damage joints, tendons and nerves.
But it's not enough to simply purchase ergonomic furniture. You also have to position the furniture and assemble the other elements into a workspace that fits your work flow, preserves the employee's health, and makes the employee feel at home.
Your first step in improving a dispatcher's workspace is simple-ask your dispatchers how their workspace might be improved. They may have some very simple suggestions that could be inexpensively implemented.
You should also consult with your medical insurance carrier for more specific ideas on how you can improve the ergonomics of your operation. They may also be able to familiarize you with state and federal regulations or laws that apply to your employees.
You should know that the federal Occupational and Safety Administration (OSHA) has released a draft of ergonomic regulations for public comment. They apply to the manufacturing and material handling industries, but also to other companies where a hazard has been identified or after an injury has been reported. The regulations could become law in early 2000, and are posted on-line now at www.osha.gov.
To get started, we'll assemble the individual pieces that make up a dispatcher's workstation, focus on arranging them for maximum efficiency, and then adjust the entire set-up according to advice of experts.
Chairs
Ideally, all the furniture should be adjustable, so it works together to put your body in the proper position to type, write, or answer the telephone. However, if your budget can't accommodate a full set of adjustable furniture, your first choice in adjustable furniture should be an ergonomic chair.
Your comfort-and continued health-is very dependent upon the position of your body as you're seated. Your neck, back, hips, legs, arms and hands are all positioned according to the size, angle and position of the chair you use.
Any chair you purchase should be sturdy enough to take the abuse of a round-the-clock operation. Office chairs are simply not designed to be used more than 40 hours a week, although some premium models might qualify.
Chairs, like human beings, come in differing sizes. Larger size chairs are not only wider, but are adjustable within a range of higher elevations. You should consider purchasing more than one size of chair to accommodate the differing heights and weights of your dispatchers.
Lastly, each part of the chair should be adjustable for height and/or angle: the arms, the back and the seat. When you're evaluating chairs, examine how the adjustments work, what you have to loosen and tighten, if the adjustments are in steps or are continuous. Also check on the warranty supplied with the chair and if spare parts are available.
There are as many chair designs as there are designers. Some have high backs, some low. Other chairs have seat springs, while others use material stretched over a frame to provide comfort. All these design elements contribute to comfort, but the colors, fabrics and general design of the chair should be secondary to its adjustability.
Proper Desk
The next most important element of ergonomics is a work surface that can be properly adjusted and arranged. Workstations are a popular item of furniture now, and many manufacturers offer suites that integrate desks, keyboard shelves, partitions and storage compartments. But you can also assemble these items yourself to create a very efficient space.
The most sophisticated desks can be adjusted up and down to accommodate sitting or standing work positions. Some of these desks are motor-driven to make quick adjustments, while others require a hand crank and take a bit longer to move. You'll have to consider price, the number of persons working per day, and your ergonomic needs to determine which style you need.
The work surface should be smooth and durable, and should wrap slightly around to allow easy access to items on the desk. Workstations that are U-shaped, or that have a slight cut-out, put desktop items within easy reach, which reduces the chance of a sprain or strain while over-reaching.
If your dispatcher uses a keyboard for data entry, check if the desk has an integrated or add-on keyboard shelf. An adjustable shelf, while not as ergonomic as a fully adjustable desk, will help put the dispatcher's hands and arms in a safer position to prevent repetitive injuries.
Computer Screen
If you have an automated dispatching operation, you have other considerations besides the placement of the keyboard-the video display.
Your employees' vision will help determine the set-up for the terminal. First, you should try to obtain the largest display for the area-17 and 19-inch computer displays are becoming the minimum standard size.
Next, position the display at least 16 inches away from the dispatcher's face, to minimize potential health hazards from static electricity, attracted dust and possible eletromagnetic hazards. The display should be positioned just slightly below eye level for the most comfortable neck position.
Others Items
Before you move in the desk and chair, do some evaluation: how does your dispatching operation fit in with your day-to-day work?
Examine the flow of people and paperwork around the office. Does your dispatcher also perform public counter duties? Do drivers and office personnel frequently need face-to-face contact to conduct business?
You don't want to hide your dispatcher in a back room, but you also don't want to place the operation in an area full of distractions and noise, where they can't hear the radio or telephone. The location must be a balance between the necessity to interact with other employees, to receive and pass along the necessary paperwork, to use copiers and fax machines, and your need to provide the dispatcher with a workspace where they can concentrate and perform their best.
Items that are frequently used should be placed at desktop height. Less-used files and office equipment should be placed to discourage a dispatcher from twisting, turning or bending to reach it.
While you're considering the location, look up and check the lighting. Is it bright enough for desk work? Does it create glare on computer screen? Is it adjustable to accommodate different dispatchers' preferences? And does it allow the nightshift dispatcher to "tone down" the lighting?
Most modern offices use fluorescent overhead lights that provide adequate brightness over a wide area. But this type of lighting is usually not connected to dimmers to adjust the amount of light, and can be very irritating to some people's eyes. The broad coverage of fluorescent reflectors often makes glare a major issue for computer users.
On the other hand, incandescent lighting can be focused and aimed much more precisely, and many workers find it has more pleasant color that doesn't flicker.
Also look over your shoulder, to see if lighting beyond and behind the workstation creates a glare for the dispatcher. Public counters are notorious glare sources, as the dispatcher sits in office lighting and gazes out into the sunlight. In the long term, direct or reflected glare off a computer screen could cause health problems for your employees.
Likewise, you should check the airflow around the workstation to see if it's near air conditioning outlets or inlets. Employees who work in the midst of a draft will not only be uncomfortable, but could be subject to increased illness or allergic reactions because of the airborne materials swirling around them.
One of the most important pieces of workplace equipment is the telephone, and it can be a significant source of repetitive injuries. Scientific studies-and common sense-say that cradling a telephone handset between your head and shoulder can lead to neck, shoulder and back problems.
The obvious solution is a telephone headset. In the old days, headsets were worn only by telephone operators and cost $200 or more. Today, the headset is a corporate mainstay, and there are several models designed for small businesses that cost less than $100. They plug into existing telephone equipment, are lightweight and make writing, typing and retrieving paperwork very easy while talking on the telephone.
Adjustments
Now that you've assembled the furniture and equipment, it's time to sit down and begin adjusting your workstation for optimum comfort and safety. The adjustments you make will depend very much on how much your equipment can be moved up, down and sideways.
Upon first sitting down, raise or lower the chair so that your feet are flat on the ground, and your thighs are horizontal to the floor. The chair back should be sufficiently upright so that your spine is virtually straight up and down. Any armrests should gently support your forearms at their optimum position, but not bear their full weight.
Now, slide your chair in to the desk top. If your desktop is not adjustable, you might have to raise or lower your chair to obtain a good hand-to-desk position. If the desktop is adjustable, or you have an adjustable keyboard shelf, adjust those components and leave the chair as is.
With non-adjustable desktops, you may have to raise your chair so that your feet are off the ground. You'll have to compensate for this with a footrest that provides support for both feet. Never let your legs dangle off the chair, or you'll cut off leg circulation and may promote nerve damage.
The optimum position for your hands is slightly below your elbows. Your hands should never be positioned so they're higher than your elbows, because that will put tension on your wrists when you write or type.
The angle of your wrists is most important-when writing or typing your hands should be a straight extension of your forearms. They should never be angled up or down, or pointed in or out in relation to your forearm, or you could very easily inflame the nerves running through the carpal tunnel of the wrist.
The easiest way to give your desktop a final check is to put your elbows at your side, and then raise both hands as if someone said, "Stick'em up!" Now close your eyes and simply lower your hands slowly until they rest on the desktop or keyboard. That is the most comfortable and healthy position for your hands. Now, open your eyes and see how close your desk or keyboard comes to this optimum position.
Once you've accomplished these steps, your dispatcher can step in a begin working. But be sure to follow up on the set-up of the workstation, to insure it's meeting your goals of providing dispatchers a safe and comfortable place to work

Myofascial Therapy – A Reliable Treatment for Carpal Tunnel Syndrome

2008-08-03T01:34:00.000-07:00

When you are suffering from what physicians called as Carpel tunnel syndrome, they often prescribe heavy medications for your discomforts, which has gone terribly wrong in the case of treating soft tissue, bone and joint pain. The recent findings on the cardiovascular side effects resulting from long-term use of Cox-2 Inhibitors, such as Viox, have shocked the FDA, prescribing physicians and the major pharmaceutical companies. Also stomach complications associated with long-term use of most oral systemic pain medication make them not a viable alternative for long-term treatment of pain. These finding make it especially urgent to find alternatives therapies that work.
A remarkable new kind of therapy is allowing people to obtain relief from pain and suffering associated with repetitive stress and soft tissue injuries without the complications of oral medication, or risks of steroid therapy and invasive surgery. Because, the methods for diagnosing, monitoring and tracking soft tissue injury and healing have not been well developed, the conventional medical world has been slow to recognize and endorse Myofascial Therapy. However, conventional medicine have also been slow to develop treatment regimens that are effective for soft tissue, bone and joint pain that are acceptable to well informed healthcare consumers.
Today, there is an undeniable body of evidence that specifically designed Myofascial Therapy directed at well known sources of pain or injury can have remarkable results for patients suffering from these type of disorders.
A common example of well known soft tissue impairment is repetitive stress induced Carpal Tunnel Syndrome. CTS affects over 75 million people globally. It is growing most rapidly in industrialized countries where repetitive stress in assembly line manufacturing is common. However, as the information age accelerates across the globe, it has been found that long hours of keyboard use have become a leading contributor to repetitive stress and CTS. In countries like the US where information technology has taken hold, chronic CTS diagnosis is growing at a rate of 10% per year. CTS is the leading cause of lost time at work.
Repetitive hand and wrist action often results in subcutaneous tissues becoming injured and swollen. These tissues include fascia, muscle, ligament, tendon, sheaths, retinaculum and peripheral nerve and blood vessels. In restricted passages of the body, swollen soft tissue can become compressed together creating intense pressure. Adjacent soft tissue can adhere together when compressed under these conditions over a prolonged period.
The Median Nerve passes through a narrow tunnel created by bones and the carpal ligament at the base of the hand where it meets the wrist. This passage is known as the Carpal Tunnel. When the Median Nerve is compressed and impinged against inelastic body parts by the surrounding soft tissue in this restricted space, Carpal Tunnel Syndrome results. CTS sufferers deal with intense pain, numbness and lack of feeling in the hand, fingers and thumb, sleep loss and hand dysfunction—all of which inhibits hand activity at work, home and during recreation.
While Carpal Tunnel Syndrome is a big problem, the conventional medical treatments have left most CTS sufferers less than content with the outcomes. Carpal Ligament Release Surgery is a great case in point, it has a less than 60% success rate. It begs the question: Who is going to take on the risks of surgery with such a low probability of success? Only somebody that is desperate. Indeed there are over 300,000 Carpal Release Surgeries performed every year in North America. Many CTS sufferers are not armed with the facts regarding the odds of a good surgical outcome. Often if repetitive stress hand activity is continued the surgery has to be repeated within two or three years. For most healthcare consumers this is not an acceptable methodology! Now there are reliable alternative for most soft tissue hand injuries and CTS sufferers.
Myofascial Therapy decompress the injured soft tissue by exerting gentle release consistently applied over several sessions. “This gentle stretching action consistently applied decompresses the soft tissue in and around the carpal tunnel and relieves the pressure on the Median Nerve.” It is the ideal way to treat your hands with a proven and non-invasive Carpal Tunnel Therapy that is natural and has no downtime, risks or complications associated with conventional CTS treatments.
Dr. Ajimshaw states that: “Myofascial Therapy is a gentle and gradual, but effective process. Even though patients usually experience relief from their symptoms in a few days, it is important that the full protocol is followed. Independent studies confirm over 95% high satisfaction with the Myofascial Therapy by patients receiving this unique therapy at SCeB CAPT.
You can take control of your carpal tunnel symptoms today with reliable soft Myofascial Therapy. So visit the SCeB CAPT clinic today and take an appointment with Dr. Ajimshaw. M.S

Anti-Obesity Mantra of SCeB CAPT

2008-08-03T01:32:00.000-07:00

Anyone who is overweight will testify that losing weight is not as easy as it seems. The people that are lean, or have gone from fat to skinny will say it’s just a matter of motivation and elbow grease. Although it is not as simple as that. Our environments have waged war on us. Their weapons are sedentary lives and trans fats of mass destruction. All is not lost though, here are some quick simple tips to get ahead!
Substitute Water. Our bodies are about 65-70% water. It follows that water would be not only essential, but the best possibly choice of liquids to ingest. In fact, our bodies will sometimes simulate a hunger response, when in reality the body is craving hydration. When hungry, drink a glass or two of water to check if it suppresses your hunger.
Chew Your Food. Chewing our food very slowly and deliberately has several benefits that are often overlooked. It gives us the ability to relax, and enjoy our meal. Slow chewing is the first, and highly important, step in a complex system of digestion. Besides, if we eat slowly, we might feel full before finishing the whole meal, and can leave the rest for the next meal.
Exercise daily. How silly of me to include something as obvious as exercise. I did a 30 day trial with waking up, and walking for 30 minutes first thing in the morning. My journal records that I was feeling amazing during the period of time that I was following this habit.
Publicize your intentions. Start a blog, join a forum, and have other people keep you accountable to help. Tell other people your plan, it would help you get the motivation to go with it!
Create a food schedule. Plan your day so that you’re eating at approximately the same time each day. This scheduling will incorporate itself into your circadian rhythm, and aid in digestion.
Do not over eat. Know your limit and stop eating when you are full. I have often been a victim of wanting to finish a meal so that it doesn’t go to waste. This has left me with many a stomach ache. Next time, doggy bag it for later, and don’t hurt yourself!
Choose your snacks wisely. Put down the Lays® and cheese puffs. Pick up the apple and baby carrots. Make the right decision, I know you can do it.
Lifestyle. Remember, it’s not about special diets, or special exercise programs. The real secret is in turning your health into a lifestyle, and focusing on this healthy lifestyle with every choice you make.

Use our specialized diet chart and exercise programs @ SceB CAPT

Good Posture Means Good at Heart…!

2008-07-27T04:18:00.000-07:00

Are you worried about looking like a hunchback? Here’s a pain free and effective method for safely assuming a ‘correct’ posture and improving muscle tone.
As a great side benefit, it would improve your self esteem and attitude! You will appear and feel more confident which improves your attitude and mood!
Know what good posture is believed to be. Most people think that to “stand up straight” means tensing your back to heave your chest ‘in and up’, and pulling your head back in to your chest. This is not so. The spine has two natural curves that you need to maintain called the ‘double C’ or ‘S’ curves, these are the curves found from the base of your head to your shoulders and the curve from the upper back to the base of the spine. When standing straight up, make sure that your weight is evenly distributed on your feet. You might feel like you are leaning forward, and look stupid, but you don’t.
Using a mirror, align your ears, shoulders, and hips. Proper alignment places your ears loosely above your shoulders, above your hips. Again, these points make a straight line, but the spine itself curves in a slight ‘S’. You’ll find that this doesn’t hurt at all. If you do experience pain, look at your side view in a mirror to see if you’re forcing your back into an unnatural position. If so, stop it!
Do exercises that strengthen the muscles across your upper back and shoulders. These do not have to be strenuous! Try the following, with or without hand weights:
Align your ears over your shoulders. Raise both arms straight up, alongside your ears. Remember to keep your ears aligned! Bend forearms toward shoulders to touch your shoulder blades. Do 10 repetitions with both arms, then alternate 10 reps for each arm singularly.
Align ears with shoulders. Raise both arms out to sides at shoulder length. Hold for a slow count of ten. Slowly lower arms to sides, counting ten as you lower. Slowly raise arms back to shoulder height, counting to ten as you raise arms. Do ten reps, constantly checking your alignment! If ten reps are too many to start, do as many as you can. You should at least feel a slight fatigue in the shoulder muscles.
Be a penguin. While you wait for a web page to load, toast to pop, or the microwave to beep, place elbows at your side, and touch your shoulders with your hands. Keeping your hands on your shoulders, and your ears aligned, raise both elbows (count one, two) and lower them back to your waist (count one, two). Do as many reps as your wait allows. You’ll be surprised how much exercise fits into 30 seconds.
Do stretches. This can greatly help if you find that you have a sore back or neck after a while.
Tilt (stretch) your head in all four directions over your shoulders (forward, back, left, right), and gently massage your neck. Avoid rolling in a circle, as it may cause further strain.
On your hands and knees, curl your back upwards, like a cat, and then the opposite. Think about being able to place a bowl in the hollow of your back.
Repeat the exercises a few times each day. Doing them in the morning helps your body stretch out the muscle lethargy of sleep, and periodically throughout the day helps raise your energy level without a heavy workout.
Doing yoga is also excellent for posture. You can take a class or find a good workout video.
Sitting
Sit in an office chair.
Align your back with the back of the office chair. Avoid slouching or leaning forward, especially when tired from sitting in the office chair for long periods. Keep your shoulders straight.
Flex your arms at a 75 to 90 degree angle at the elbows. You may have to adjust the office chair.
Make sure your neck, back, and heels are all aligned.
Keep both feet flat on the floor. If there’s a problem with feet reaching the floor comfortably, a footrest can be used along with the office chair.
Standing
Stand with weight mostly on the balls of the feet, not with weight on the heels. Avoid locking your knees.
Keep feet slightly apart, about shoulder-width.
Let arms hang naturally down the sides of the body.
Tuck the chin in a little to keep the head level. Be sure the head is square on top of the neck and spine, not pushed out forward
Stand straight and tall, with shoulders upright.
Stand against a wall with shoulders and bottom touching wall. In this position, the back of the head should also touch the wall - if it does not, the head is carried too far forward (anterior head carriage).
Walking
Keep the head up and eyes looking straight ahead. Avoid pushing your head forward.
Keep shoulders properly aligned with the rest of the body.
Carrying Objects
Always bend at the knees, not the waist.
Use the large leg and stomach muscles for lifting, not the lower back.
If necessary, get a supportive belt to help maintain good posture while lifting.
When carrying a heavy or large object, keep it close to the chest.
If carrying something with one arm, switch arms frequently.
When carrying a backpack or purse, keep it as light as possible, and balance the weight on both sides as much as possible, or alternate from side to side.
Driving
Sit with the back firmly against the seat for proper back support. The seat should be a proper distance from the pedals and steering wheel to avoid leaning forward or reaching.
The headrest should support the middle of the head to keep it upright. Tilt the headrest forward if possible to make sure that the head-to-headrest distance is not more than four inches.
Sleeping
A relatively firm mattress is generally best for proper back support, although individual preference is very important.
Sleeping on the side or back is usually more comfortable for the back than sleeping on the stomach.
Use a pillow to provide proper support and alignment for the head and shoulders.
Consider putting a rolled-up towel under the neck and a pillow under the knees to better support the spine.
If sleeping on the side, a relatively flat pillow placed between the legs will help keep the spine aligned and straight.
A great side benefit of keeping your head straight, and your ears/shoulders/hips aligned is an improvement in your self-esteem and attitude. If you walk with your head up, you appear more confident, and feel more confident, which improves your attitude and mood, making it easier to walk with your head up.

Myofascial Release FAQ

2008-06-22T10:23:00.000-07:00

Myofascial Therapy and Research Foundation
SCeB CAPT, Chemmanampady, Medical College, Kottayam
PH: 9495300913, 9846967728, 9846265331
http://scebcapt.blogspot.com

Advanced Diploma in Myofascial Therapy

Q: What will I learn from taking a course?

A: Our Myofascial Release courses are designed to introduce you to techniques that can help you treat difficult cases and chronic or deep-seated pain. We guarantee you will be able to use MFR immediately in your practice with confidence and success.

Q: How large are the classes and how many instructors are there?

A:There will be10 to 20 students in a class. Our instructors frequently work with assistant instructors to enhance participants' learning experience. Classes are kept small so you have lots of opportunity to ask questions and receive one-on-one instruction.

Q: What are the hours of your courses?

A: Our courses are two months in length. They are scheduled from 10 a.m. to 6 p.m.

Q: How much hands-on work is there? How much theory?

A: About 95% of the course is devoted to hands-on work. Emphasis is put on practical clinical application of MFR. The instructor starts with a short lecture (about a half-hour) to go over anatomy and theory related to the work, and then gets right into demonstration and practice time during the first morning.

Q: Does Myofascial Therapy and Research Foundation award certificates?

A: Yes. You will receive a certificate at the end of the course, provided you have completed all of the required hours of instruction.

Q: How is Myofascial Release different from Swedish massage?

A: The focus of the work is to release restrictions within the fascia, or connective tissue, which envelops the muscles, bones, ligaments, and organs. Rather than focusing on specific muscles and their origins and insertions, MFR requires you to shift your thinking to see the body in terms of the interconnecting fascial planes. MFR requires no oil and is very slow. The actual strokes are quite different because you are molding into the tissue to grab and move fascia, rather than working only muscle.

Q: What is the difference between the AJIMSHAW’s Approach of Myofascial Release and other styles of Myofascial Release?

A: The main difference is in approach. Some MFR work is primarily static, which means that it involves a lot of holding and stretching to release the tissue. While the AJIMSHAW’s Approach of MFR incorporates some static release, it focuses more on active, or direct, MFR techniques. In active work, the therapist goes directly into the tissue to move it to a better anatomical position and release restrictions that way.

Q: What is the difference between the AJIMSHAW’s Approach of Myofascial Release and Rolfing®?

A: Rolfing is a system of fascial manipulation developed by Dr. Ida Rolf. Our courses do not teach Rolfing and are neither affiliated with nor endorsed by the Rolf Institute. The AJIMSHAW’s Approach of Myofascial Release is similar to Rolfing in that both styles use techniques called myofascial release. They also share the same goal -- to improve clients' posture and body functioning, as well as relieve their pain. The primary difference between the two styles of work is the investment involved in learning each. The Myofascial Release techniques we teach are just as effective as other styles, but can be learned at a fraction of the cost and time.

Q: What are your instructors' qualifications?

A: All of our instructors have completed a recognized Myofascial Release program (Direct and Indirect) and have studied the AJIMSHAW’s Approach of Myofascial Release, which is taught by Dr. Ajimshaw. M.S.

“AJIMSHAW’s approach” to Fibromyalgia Syndrome

2008-06-22T05:44:00.000-07:00

Fibromyalgia Syndrome (FMS) affects 3-6 million individuals of which 90 percent are women between the ages of 40 and 60 years. It is the 3rd most prevalent rheumatologic disorder after osteoarthritis and rheumatoid arthritis.
The word “fibromyalgia” is a combination of Latin roots “fibro” (connective tissue), “al” (pain) and “gia” (condition of). The word syndrome simply means a group of signs and symptoms that occur together which characterize a particular abnormality.
The diagnosis of FMS is given when no specific underlying cause can be found for the following set of signs and symptoms: a complaint of wide-spread muscle pain on both sides of the body, above and below the waist for at least three months duration. In addition, midline body pain on the spine or chest must also be present. Additional symptoms include tension headaches, generalized stiffness, sleep disorders, debilitating fatigue and a high incidence of irritable bowel syndrome.
Although there is no cure for this syndrome, moderate to excellent results have been achieved through “AJIMSHAW’s approach” including MFR, Manipulations, MET, Relaxation practices, exercise, proper nutrition and stress reduction.
Hands on Therapists of SCeB CAPT are specially trained in “AJIMSHAW’s approach” to provide safe, effective treatment for many neuromusculokeletal conditions and allied disorders
If you are experiencing some or all of the symptoms above, or if you have any questions, contact Dr. Ajimshaw. M.S, Director, SCeB CAPT, Secretary, Myofascial Therapy and Research Foundation (India), Lecturer, Dept. of Physiotherapy, SME, Mahatma Gandhi University, Kottayam, Kerala. Ph: 91-9495300913

Repetitive strain injury

2008-06-22T05:24:00.000-07:00

Introduction
Repetitive strain injury (RSI) is a term that is used to refer to various kinds of injuries to muscles, tendons or nerves. These injuries are caused by repetitive movement of a particular part of the body. RSI can also be referred to as upper limb disorder (ULD). This is because the condition often involves the upper part of the body - the forearm, elbow, wrist, hands, and neck.
The most common RSI conditions include:
• Bursitis - inflammation and swelling of the fluid-filled sac near a joint at the knee, elbow or shoulder.
• Carpal tunnel syndrome - pressure on the median nerve passing through the wrist.
• Dupuytren's contracture - a thickening of deep tissue which passes from the palm of the hand into the fingers.
• Epicondylitis - inflammation of an area where bone and tendon join - for example, tennis elbow.
• Ganglion - a cyst in a tendon sheath, usually occurring on the wrist.
• Rotator cuff syndrome - inflammation of muscles and tendons in the shoulder.
• Tendinitis - inflammation of a tendon.
• Tenosynovitis - inflammation of the inner lining of the tendon sheath that houses the tendons that control the fingers and thumbs.
• Trigger finger - inflammation of the tendon sheaths of fingers or thumb accompanied by swelling of the tendon.
• Diffuse RSI - nerve damage.
RSI is often caused, or aggravated, by frequently repeated movements, such as a task or leisure activity - for example playing golf or tennis regularly. Symptoms usually persist over time if left untreated.
As the number of people using computers increases, the chances of developing RSI increases. The repetitive action of typing on a computer can cause painful symptoms in fingers and hands, such as a throbbing pain. RSI caused by typing on a computer is typically referred to as 'writer's cramp'.
RSI is also linked to many types of repetitive manual work, such as the use of vibrating equipment in factories.
If there are any symptoms, including painful, tingling or swollen hands, elbows, wrists or shoulders, it is important to get treatment quickly. The sooner treatment is started the better the chances of recovery.
Types of RSI
RSI can be categorised into two types, Type 1 RSI and Type 2 RSI:
• Type 1 RSI - this includes conditions that are due to repetitive tasks, but can also be common in people who do not carry out repetitive tasks. The main symptoms tend to be swelling and inflammation of muscles and tendons. Typical type 1 RSI conditions include carpal tunnel syndrome (pressure in the wrist), tendonitis (inflammation of a tendon), and tenosynovitis (inflammation of tendon sheath).
• Type 2 RSI - is when a person's symptoms do not fit into one of the above listed conditions. This is usually because there is no obvious inflammation or swelling in the affected area, merely a feeling of pain. This type is often called 'non-specific pain syndrome'

My Experiences with Pain

2008-06-22T05:16:00.000-07:00

What I do?

Some things in life can be pains in the neck or back but Dr. Ajimshaw can take care of a real pain in the neck, back or just about anywhere else. He uses AJIMSHAWs approach for managing various osteomyofascial dysfunctions.
As a Hands On Therapist, Ajimshaw views his profession as helping his patients achieve a "lifestyle of pain-free living," he said. "It's a very sensible approach to preventative care and wellness, not just for pain."
He said he focuses primarily on mobilize patients' spines and fascia to take pressure off the nervous system. Undue pressure on the spinal cord can cause other ailments, such as headaches or muscle pain elsewhere in the body, explained Ajimshaw.
With proper fascial and joint alignment, he said, the body can use its own ability to heal injuries.
" AJIMSHAWs approach enables the body to function at its best ability," Ajimshaw said.
Most of his patients are dealing with back or neck pain, migraines, sports strains and sprains, accident injuries.
Dr. Ajimshaw does most of this work with his hands, feeling the muscles and bones and adjusting them into proper alignment.
"Each patient is treated specifically for their condition," he said. "The treatments are tailor-made for each person — safe, precise and tailor-made."
Before he begins any therapy regimen, Dr. Ajimshaw takes X-rays to find out what's wrong and whether his services can help.
Not all ailments can be treated by AJIMSHAWs approach, he pointed out. Ajimshaw don't prescribe medicines, perform surgery or treat illnesses such as cancer or the flu — "nothing invasive," Dr. Ajimshaw said. He refers patients to physicians and specialists for ailments that are beyond the scope of his practice.

• Best part of my job?

"I know I can make a difference in someone's life, health and well-being," Dr. Ajimshaw said.

• Most challenging part?

"Convincing people who are in pain and have tried other methods of treatment that they should commit to a series of [AJIMSHAWs approach] treatments," he said. "It's not a one-visit program."
Dr. Ajimshaw said he achieves results over a course of visits, usually 10-20. "Results come with time and repetition," he said.

• What keeps me going?

"Knowing I can rely on my training and experience to offer the patients the expertise they're looking for," he said. "I see so many cases and remarkable recoveries."
• Preparation needed for this job: You have to believe in the body's ability to heal itself, " Dr. Ajimshaw said. " AJIMSHAWs approach is not the healer; the body is the healer."
He is running SCeB CAPT Clinic at Medical College, Kottayam, along with his lectureship in Dept. of Physiotherapy, Mahatma Gandhi University, Kottayam. He is the general secretary of Myofascial Therapy and Research Foundation of India - a foundation intended to give awareness and establishment to MFR and AJIMSHAW’s approach and to conduct Diploma Courses in the above.

AJIMSHAW’s Approach for Cervicogenic Headache

2008-06-22T03:03:00.000-07:00

A cervicogenic headache is a syndrome characterized by one sided head pain, referred from either bony structures or soft tissues of the neck. Sufferers usually complain of single sided headache which is side locked (meaning it does not change position between sides of the head). It can extend from the neck to the base of the skull and around to the front of the head. The symptoms are generally provoked by neck movements and sustained postures, usually being described as dull or moderate in intensity and worse in the mornings.
On examination, sufferers tend to have reduced neck range of motion, sore and tender neck muscles, reduced joint mobility with poor motor control of the deep neck flexors (stabilizing endurance muscles).
It is important you are assessed by a physiotherapist to differentiate if your headache is of a cervicogenic nature and therefore easily treatable by AJIMSHAW’s Approach, or in actual fact, other forms of headache just migraine.
How can cervicogenic headache be treated?

AJIMSHAW’s Approach for Cervicogenic Headache

Treatment plans

Moist Heat x 10mts
Myofascial Release of head and neck
Craniosacral Therapy
Ultrasound x 6mts (1Mhz) at trigger points
Cryotherapy
Relaxation Techniques

Follow Ups

Joint mobilisation/ manipulation
Myofascial Unwinding
Myofascial Rewinding
Aerobic Strengthening
Postural Correction
Home Programs

google3784304ebf258412.html

2008-06-13T11:50:00.001-07:00

google3784304ebf258412.html

2008-06-13T11:37:00.000-07:00

What are the True Benefits of a Sauna?

If you're serious about relaxation, then consider the many benefits and advantages of a Sauna. No chemicals to mix, no pumps to break, just a few simple heating elements and a stainless steel body in a fragrant, cedar-lined room. Relaxation and rejuvenation can be obtained during Sauna Sessions as brief as twenty minutes. As your pores open and sweat flows freely, so does the tension and stress of the day. There simply is no sensation quite like the Sauna Sensation. Lactic acid dissipates with the heat and muscles sore from strenuous exercise relax. Because so few modern-day people perform hard, physical labor for a living, most of us simply do not perspire enough. In addition, we clog our pores with the use of cosmetics, antiperspirants, smog, and other modern "conveniences." In a sauna, you expose yourself to a high enough temperature for a long enough time to cause perspiration. This perspiration cleanses the skin of impurities. The heat from the sauna also relaxes the muscles, relieving muscular aches and pains. It is a refreshing, revitalizing experience that helps both body and mind. Stress melts away, and the sauna helps many people sleep more soundly. Simply pouring some essence of Eucalyptus (a natural substance) in a ladle of water onto the Sauna rocks yields a fragrant and medicinal burst of steam. Steam is an excellent treatment for respiratory problems, such as; chest congestion, bronchitis, laryngitis and sinusitis. When taking a sauna, skin temperature rises to 40°C (104°F) and internal body temperature rises to about 38°C (100.4°F). Exposure to the high heat creates an artificial fever state. Fever is part of the body's natural healing process. Fever stimulates the immune system resulting in increased production of disease fighting white blood cells, antibodies and interferon (an anti viral protein with cancer fighting capability). Would you like to take sauna to another level than just sweat at the gym? Would you like to almost reach a high level of peace and serenity? For additional information contact - Sylita Thomas and visit the website http://www.saunasteampower.com/ and get a free chapter of "The Sauna and Steam Bath Guide Revealed".

SCeB CAPT RSI Clinic

2008-06-08T07:11:00.000-07:00

SCeB CAPT RSI Clinic

“A Most Modern, State of Art centre for Pain Management And Movement Rehabilitation, Managed Exclusively by Physical Therapy Specialists ”.

SCeB CAPT RSI Tips:-
12 tips for an Ergonomic Computer Workstation

1. use a good chair with a dynamic chair back and sit back in this
2. top of monitor casing 2-3" (5-8 cm) above eye level
3. no glare on screen, use an optical glass anti-glare filter where needed
4. sit at arms length from monitor
5. feet on floor or stable footrest
6. use a document holder, preferably in-line with the computer screen
7. wrists flat and straight in relation to forearms to use keyboard/mouse/input device
8. arms and elbows relaxed close to body
9. center monitor and keyboard in front of you
10. use a negative tilt keyboard tray with an upper mouse platform or downward tiltable platform adjacent to keyboard
11. use a stable work surface and stable (no bounce) keyboard tray
12. take frequent short breaks (microbreaks)

Just Make A Visit....Feel The Difference in You.......
Time: 9 AM to 9 PM (Sunday Holiday)

Visual Ergonomics in the Office

2008-06-08T06:52:00.000-07:00

Visual Ergonomics in the Office

Guidelines for monitor placement and lighting

 Eye-to-screen distance: at least 25", preferably more.
 Vertical location: viewing area of the monitor between 15° and 50° below horizontal eye level.
 Monitor tilt: top of the monitor slightly farther from the eyes than the bottom of the monitor.
 Lighting: ceiling suspended, indirect lighting. Use blinds and shades to control outside light.
 Screen colors: dark letters on a light background.
How do you set up a computer workstation? Do you buy monitor risers or remove the CPU from beneath the monitor. Will even lower monitor positions cause neck strain? Can you get away with tipping the monitor down to avoid glare or should you invest in indirect lighting? How about viewing distance? 16 inches? 25 inches? Or even farther? Does screen color make a difference? Is there any evidence that ergonomic workstations improve work performance?
This article suggests guidelines for monitor placement and lighting. They are based on the latest scientific research. Demonstrations illustrate the principles behind the recommendations.
Ergonomics seeks to adapt the work environment to the capabilities and limitations of the worker. The results should be increased productivity, user satisfaction, and reduced risk of injury.These guidelines are meant as such: guidelines. There are exceptions. The final criteria for judging the effectiveness of a visual environment is not how well it conforms to a set of rules, but rather how well it facilitates the ability of the worker to perform his or her work effectively and without injury.

Stimulation of myofascial trigger points causes systematic physiological effects

2008-06-08T06:45:00.000-07:00

Stimulation of myofascial trigger points causes systematic physiological effects

John Srbely and James P. Dickey
Purpose
Myofascial trigger points (TrP) are discrete palpable hyperirritable loci within taut bands of skeletal muscle; pressure application elicits a referral sensation/paresthesiae.1 There is growing body of evidence suggesting that a substantial proportion of common adult musculoskeletal pain syndromes are manifestations of myofascial trigger point activity.2 The possible role of neuroadaptive processes such as long-term potentiation/central sensitization, and potential management via modalities such as spinal manipulative therapy,3 is of special interest to the authors. This study will explore the neurophysiological interactions of the trigger point complex by evaluating whether stimulation of one TrP site can influence the pain sensitivity at another trigger point site innervated by the same neurological segment(s).

Methods
The study involves stimulation of a trigger point locus within the supraspinatus muscle (via intramuscular dry needling). The supraspinatus TrP will be confirmed by the presence of a visible local twitch response within the muscle, evoked during needle penetration. Raw pain-pressure threshold values (PPT) will be recorded from a trigger point site within the ipsilateral infraspinatus muscle at selected time intervals of 1, 2, 5 and 15 minutes. A baseline (pre-needling) reading will be recorded and the absolute PPT readings at each time interval (1–15 min) represented as a ratio of this baseline value.

Results
PPT readings in the infraspinatus sharply increase (i.e. decreased trigger point sensitivity) for the first two minutes post-needling. At the 2 minute mark, the PPT values tend to stabilize. Interestingly, the PPT values once again demonstrate a gradual, distinct rise between the 5 to 15 minute period, suggestive of a further decline in sensitivity at the infraspinatus site.
Conclusion
Preliminary results suggest that systematic physiological effects on a trigger point complex may be induced by stimulation of other trigger point sites specifically innervated by the same neurological level(s). This data may suggest two distinct processes at play in the neuromodulation effect: an early segmental effect which gives way to subsequent supraspinal/non-segmental effects.

References

Simons DG. Postgrad Med. 1983;73(2):66–68. 70–73.
Simons DG. J Electromyography and Kinesiology. 2004;14(1):95–107.
Boal RW. J Manipulative and Physiol Ther. 2004;27:314–326.