External Myofascial Mobilization

Myofascial Mobilization (MM) is a specialized manual therapy technique employed to address fascial dysfunction in a systematic anatomical pattern. It can be applied either externally or internally, depending on the specific needs of the individual. External myofascial mobilization (EMM), in particular, is an approach that draws upon the principles of myofascial connectivity (Ajimsha et al., 2020) and myofascial force transmission (Ajimsha et al., 2022), as established by research. In EMM, the therapist carefully examines and mobilizes the fascia to identify and alleviate myofascial dysfunction. The key aspect of this technique lies in following a traceable pattern, allowing for a methodical and targeted treatment approach. The most commonly utilized procedures within EMM are myofascial release (MFR) and fascial manipulation (FM). MFR involves the application of variable loads and sustained stretches to the myofascial complex. This technique aims to restore optimal length, reduce pain, and improve overall function (Barnes MF, 1997). On the other hand, FM focuses on manipulating the fascia through predefined myofascial units. By appropriately treating these units, the therapist endeavors to restore tensional balance within the fascial system (Stecco L, 2004). The External Myofascial Mobilization (EMM) technique, developed and refined by Dr. Ajimsha MS, a dedicated researcher and enthusiast in the field of fascial studies, provides a personalized and comprehensive approach to managing fascial dysfunction. By utilizing a combination of scientifically derived fascial mobilization methods, the EMM approach effectively addresses complex soft tissue dysfunctions and associated pain in a traceable and anatomically precise manner. The primary goal of EMM is to restore normal mobility and function to the affected area by examining and mobilizing the fascia in a systematic and traceable pattern. Although the evidence supporting the effectiveness of EMM is largely anecdotal, it has shown promising results in treating a variety of musculoskeletal conditions. For example, a recent study conducted by Ajimsha et al. (2021) demonstrated the efficacy of EMM when applied to the pelvic area, leading to a reduction in pain and improved function in patients with chronic pelvic pain. Similarly, another study (Ajimsha 2023) found that EMM effectively improved pain and functional status in patients with moderate Fibromyalgia syndrome. EMM is a safe and non-invasive technique that can be used as a standalone treatment or in combination with other therapeutic modalities to address osteo-myo-fascial dysfunctions. It serves as a valuable tool for healthcare professionals seeking an effective and evidence-based approach to manual therapy. By integrating the principles of myofascial connectivity and force transmission, EMM offers a comprehensive approach to managing fascial dysfunction and promoting overall well-being (Ajimsha MS).

Soft Tissue Rolling In Practice (STRIP)

Soft Tissue Rolling In Practice (STRIP) 'Soft tissue rolling in practice' (STRIP) is a versatile and systematic approach to the evaluation and management of soft tissue alterations, pathologies, body dysfunction, and pain, where patient education and follow-up are given more emphasis (Ajimsha MS). Soft Tissue Rolling Soft tissue rolling, a form of self-myofascial release, is a soft tissue mobilization approach that aims to improve tissue mobility and flexibility, thereby modifying the functional potentials of the human body through its intricate interconnections. This technique involves the use of cylindrical or spherical instruments to apply pressure and soft tissue gliding to targeted areas of the body (Ajimsha MS). Goal of STRIP The intended goal of STRIP is to alter the biomechanical, histochemical, and neuronal properties of the tissue, which is typically performed for longer durations. STRIP can have a variety of effects on the body, both locally and systemically, including tissue alteration, hydration, improved tissue gliding, enhanced neural control, tissue healing, improved immune function, and a return to homeostasis. Soft tissue rolling has been proven to be effective in increasing proprioception, improving blood circulation, lymphatic drainage, range of motion, muscle activation, improving posture, inducing relaxation, reducing pain and muscle soreness. By addressing multiple aspects of tissue function and health, STRIP can be a valuable tool for improving physical and mental performance. Moreover, soft tissue rolling can have pro and anti-inflammatory effects. The benefits of STRIP extend beyond the physical, as it can also help to improve mental relaxation and reduce stress, making it a valuable technique for athletes, individuals recovering from injury, or anyone looking to improve their overall well-being (Ajimsha MS).

Effectiveness of myofascial release in the management of plantar heelpain: A randomized controlled trial

Core Stabilization Program for Low Back Rehabilitation

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.

References

Bergmark, A. Stability of the lumbar spine: A study in mechanical engineering. Aeta Orthop. Scand. 230(Suppl.):20-24. 1989.
Cresswell, A.G., L. Oddsson, and A. Thorstensson. The influence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing. Exp. Brain Res. 98:336-341. 1994.
Cresswell, A.G., and A. Thorstensson. Changes in intra-abdominal pressure, trunk muscle activation, and force during isokinetic lifting and lowering. Eur. J. Appl. Physiol. 68:315-321. 1994.
Johnson, P. Training the trunk in the athlete. Strength Cond. J. 24(1): 52-59. 2002.
Mcgill, S.M. Low back stability: From formal description to issues for performance and rehabilitation. Exere. Sport Sci. Rev. 29(1):26-31. 2001.
Mggill, S.M., S. Grenier, N. Kavcic, and J. Cholewicki. Coordination of muscle activity to assure stability of the lumbar spine. J. Electromyogr. Kinesiol. 13:353-359. 2003.
Panjabi, M.M. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J. Spinal Disord. 5:383-389. 1992.
Panjabi, M.M. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J. Spinal Disord. 5:390-397. 1992.
San Francisco Spine Institute. Dynamic Lumbar Stabilization Program.
San Francisco: San Francisco Spine Institute, 1989.
Nitz, A.J., and D. Peck. Comparison of muscle spindle concentrations in large and small human epaxial muscles acting in parallel combinations. Am. Surg. 52:274. 1986.
Verstegen, M., & P. Williams. Core Performance. New York: Rodale, Inc., 2004.
Hodges, P.W., & C.A. Richardson. Inefficient muscular stabilization of the lumbar spine associated with low back pain: A motor control evaluation of transversus abdominis. Spine. 21:2640-2650. 1996.
Allison, G.T., P. Godfrey, and G. Robinson. EMG signal amplitude assessment during abdominal bracing and hollowing. J. Electromyogr. Kinesiol. 8:51–57. 1998.
Axler, C.T., and S.M. Mcgill. Low back loads over a variety of abdominal exercises: Searching for the safest abdominal challenge. Med. Sci. Sports Exerc. 29:804–811. 1997.
Barnes, D. What type of strength training do distance runner do or need? Modern Patient Coach 40:27–37. 2002.
Bartonietz, K., and D. Strange. The use of Swiss balls in athletic training—An effective combination of load and fun. New Stud. Athletics 13:35–41. 1998.
Behn, D.A., K. Anderson, and R.S. Curnew. Muscle force and activation under stable and unstable conditions. J. Strength Cond. Res. 16:416–422. 2002.
Carriere, B. The Swiss Ball. Theory, Basic Exercises and Clinical Applications. Berlin: Springer, 1998.
Check, P. Swiss ball exercises for swimming, soccer and basketball. Sports Coach 21:12–13. 1999.
Cram, J.R., and G.S. Kasman. Introduction to Surface Electromyography. Gaithersburg, MD: Aspen Publishers, Inc., 1998.
Cusi, M.F., C.J. Juska-Butel, D. Garlick, and G. Argyrous. Lumbopelvic stability and injury profile in rugby union players. N. Z. J. Sports Med. 29:14–18. 2001.
Franklin, B.A. ACSM Guidelines for Exercise Testing and Prescription. Philadelphia: Lippincott, Williams, and Wilkins, 2000.
National Institute of Occupational Safety and Health (NIOSH): National Occupation Research Agenda. Washington, D.C.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, NIOSH; 1996.
Morse L, Owen D, Becker CE: Firefighter's health and safety. In Environmental and Occupational Medicine Edited by: Rom WN. Boston: Little Brown; 1992:197-1204.
Rivera F, Thompson D: Systematic reviews of injury- prevention strategies for occupational injuries. Am J Prev Med 2000, 18:1-3.
Firefighter Injuries for 2003. NFPA Journal 2004, 1:56-78.
U.S. Fire Administration. Topical fire research series 2001, 2:2-22.

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

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

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

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

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

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

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

Myofascial Release for Athletes

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

Works Cited

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

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

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

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

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

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

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

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

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

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

Home based MFR managements for pelvic floor dysfunctions

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

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

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.