Myofascial Release and MET Presentation Slides

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05/02/23 2

WelcomeAn introduction to Myofascial Release (MFR) and Muscle Energy Techniques (MET)

With Katie Emmett & Daniel Smith


3@Physiocouk #manchesterphysio facebook.com/physiocouk

Who are we?Katie’s LinkedIn: www.linkedin.com/katieemmett Twitter: @KatiePhysiocouk

Dan's LinkedIn: www.linkedin.com/danielsmith Twitter: @DanPhysiocouk

http://www.linkedin.com/katieemmett

http://www.linkedin.com/danielsmith

http://www.linkedin.com/danielsmith

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Let’s connectWebsite: www.physio.co.uk

Twitter: @physiocouk

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Aims of today


Learn and understand fascia structures and it's anatomy

Learn the different Myofascial release techniques and how to perform them

Learn the different types of Muscle Energy Techniques

Learn the handling of METs and when to use them

Itinerary


10.00 - 10.30 - Induction / Arrival10.30 - 11.15 - Theory: MFR 11.15 -12.00 - Practical: MFR12.00 - 12.30 - Lunch12.30 - 13.00 - Theory: MET 13.30 - 14.00 - Practical MET14.00 - 15.00 - Evidence and Case Studies

Theory: Myofascial Release


Definition


Myo = muscle

Fascia = a band or sheet of connective tissue

Release = the relaxation and/or stretching of tight structures

Definition


•Safe and effective hands-on technique that works on the fascia to release restrictions

•Based on both massage work and gentle stretchingWorks gently through the skin into the fascia surrounding the muscles

•Applied with a static, prolonged pressure to restricted tissue

•Aims to release tension and stretch out restricted parts of the fascia. Deeper layers can be reached as fascia releases

Definition


“Myofascial Release is a specialised physical and manual therapy used for the effective treatment and rehabilitation of soft tissue and fascial tension and restrictions”

Myofasical Release UK

“Myofascial release is a manipulative treatment that attempts to release tension in the fascia due to trauma, posture, or inflammation. Connective tissues called fascia surround the muscles, bones, nerves, and organs of the body. Points of restriction in the fascia can place a great deal of pressure on nerves and muscles causing chronic pain.

Practitioners of myofascial release employ long stretching strokes meant to balance tissue and muscle mechanics and improve joint range of motion in order to relieve pain”

Spine-health

What is fascia?


• Fascia is a layer of fibrous tissue that surrounds groups of muscle, bone, blood vessels and nerves

• It binds some structures together, while permitting other structures to glide smoothly over each other

• Fascia is classified depending on it’s distinct layers, functions and anatomical position – superficial, deep or visceral

• Fascia are dense regular connective tissues, containing closely packed bundles of collagen fibres orientated in a wavy pattern parallel to the direction of pull

Anatomy - Fascia


• Consists of cells and extra- cellular matrix (ECM) mainly fibroblasts and macrophages.

• The ECM is made up of fibres, predominantly collagen and elastin and ground substance

Anatomy - Fascia


Collagen is the fibre that makes fascia tough and durable. It is inelastic and provides tensile strength and integrity. It is stronger than steel!

Elastin - allows the fascia to stretch and absorb shock

Ground substance is a viscous gel which provides the immediate environment of every cell in the body

•It is similar to egg whites in it's consistency. •it is able to distribute forces whilst maintaining its shape•contains sensory receptors, mechano, chemo, noci and thermo receptors and therefore is a proprioceptive material•contains myofibroblasts which are able to contract in smooth muscle type manner and these are responsive to stimulation and involved with wound healingautonomic nervous system (ANS)

Anatomy – Muscle tissue


• Muscle is composed of fibres, nerves and connective tissues and account for over 40% of the body weight.

• The fibres contract to produce tension on the associated tissues or tendons.

• Muscle tissue is enclosed in fascia, which in turn is attached to other structures including ligament.

There are three types of muscle tissues • Skeletal• Cardiac• Smooth muscles.

Macro structure


. Muscle fibres are made up of bundles of fascicles

Several fascicles bound by epimysium to form whole muscle

Connective tissue fascial sheaths perimysium and endomysium join at end to form tendons

Muscles are as much fascia as muscle fibres hence term myofascial

Tendon inserts into periosteum



• All muscle tissues have a superficial covering of vary thickness of fascia, made of connective tissue and laced with adipose tissue.

• Inside the fascia, the muscle tissue is surrounded by epimysium and individual muscle bundles or fascicles are surrounded by perimysium.

• Endomysium is the connective tissue that separates muscle fibers within a fascicles.

• The unit of fascicles is a muscle fibre (or cell) called myofibril





Types of muscular tissue

Important when applying Myofascial release and MET’s as the orientation and direction of the muscle fibre dictate the direction/angle force is applied



Muscle Spindle Fibres

Sensory receptors within the muscle belly that detect changes to the length of a muscle. This information is relayed to the central nervous system and is processed by the brain to determine the positions of body parts

Golgi Tendon Organs

Are located in the tendon of skeletal musculature. They detect changes to the tension of the muscle providing proprioceptive feedback to the brain. They prevent damage by inhibiting contracting muscles if the force is great enough that there's a risk of tissue damage.

Function of fascia


Physical

•To reduce friction•Provide a sliding environment for muscles•Suspend organs in their “proper” place•Transmit movement from muscles to bones •Provide a supportive and protective environment for nerves and blood vessels as they pass through and between muscles.•Facilitates circulation – lymph and blood•Provides support and connection•Physiological adaptable - plastic

Function of fascia


Communication

•Mechanical pull and vibration – through the concept of “tensegrity”

•Fascia has piezoelectric force. i.e changing mechanical force in to electric energy

•A sensory proprioceptive organ receiving and responding to mechanical and chemical information via receptors. These sensory nerves also communicate with the ANS influencing blood flow and muscle tone.

Function of fascia


Movement facilitator

•Reduced friction at macro and micro level•Distributor of forces/shock absorber•Enhances force generated by muscle contraction – rebound•Provides a pre-tensioned background tone making muscle contraction more effective and efficient ( feel like being shrink wrapped)•Pre tensioned tone allows for maximum response during fight or flight

Fascia – why does it go wrong


• Age and injury can cause an increase of laying down of collagen, increased cross linkages and restrictions (adhesions)

• Fascia increases its density and looses its ability to slide freely when:

• Trauma and injury• Infections or disease• Over and under use• Ischaemia• Local and systemic inflammation• Tissue dehydration• Emotional stress and centralised pain

Fascia – when does it go wrong


For example: injury – micro tearing and fibrosis formation will affect

• Electrical conductivity in fascia• Cell to cell communication• Interfere with freedom of movement of fascial planes and

communication properties• Sensitisation of nerve endings• Influence plastic adaptation

SO – the local pathology will affect local fascial communication and cause a cascade of more remote symptoms.

Indications for Rx


•Loss of mobility and range of motion

•Increased amounts of scar tissue and adhesions

•Increased tone of over active muscles •Poor quality of movement

Contraindications to Rx


Local Systemic

Broken skin/Open cuts Cancer (Malignancy)

Skin conditions Acute Circulatory disorders

Haematoma Blood Thinning Medications (e.g. Warfarin)

Healing Fracture Bleeding disorders (e.g. Haemophilia)

Active infections Systemic Infection

Obstructive Oedema

Acute RA

Advanced Diabetes

Precautions to Rx


• Pregnancy

• Hypersensitivity

• Hyper or Hypo- tension

• Patient Anxiety

• Acute/ Inflammatory stage of healing

Aims and Benefits


Myofascial Release can decreases Pain: it is claimed that this technique can release the body’s natural painkillers, endorphins, by allowing the blood, lymph and nerve receptors to work efficiently so pain is relieved.

It helps to strengthen the immune system. When fascia is restricted, the lymphatic flow is slowed down, which affects the immune system (the body’s first line of defence against infection and primary aid to healing).

Myofascial Release increases the circulatory flow of lymph and therefore hastens healing of injuries or infections.

Myofascial Release Technique can work to relieve pressure which may be caused by fascial adhesions pressing on the nerves. Keeping a healthy circulatory system reduces stress on the heart and can prevent painful cramps, brings nutrients to the cells and takes away the waste; Myofascial Release Technique increases circulation and assists this process.

Release guidelines


• Gentle and sustained, pressure should be applied for a specific period of time – a minimum of 90 – 120 seconds

• This amount of time permits fascia to naturally elongate and return to normal resting length which will restore the healthy status quo, giving greater flexibility, mobility and eliminating pain.

• Techniques applied for less than 2 minutes will temporarily lengthen the elastic fibres in the muscles and fascia and the tissues will feel looser for a while but gradually tighten up again.

• It is like stretching a rubber band – if stretched for a short time it will quickly spring back to its original shape but if left stretched around an object for some time it will remain permanently lengthened.

Anatomy Trains – Tom Myers


Theory

•Certain fascial lines become identified as we commonly see restricted movement patterns

•If structures can be grouped together in recognised fascial lines then it is possible to release the tone in one structure and see it presented further along the line

•The point of restriction may be away from the point of pain (victim and cause)

Anatomy Trains


• Function is to support the body in full upright extension

• During child development it is this line we see mature to enable the child to lift its head, crawl and then walk

• With the knees extended the line is continuous

• It has a higher degree of slow twitch endurance muscle fibres and extra heavy sheets of fascia to overcome the postural demands (postural adaptations!)

• There is no deep back line although some aspects of the SBL are deeper than others. There is no consistent and connected layer deeper than the SBL

Superficial Back Line

SBL – myofascial tracts and bony stations


Anatomy Trains


Superficial Front Line

• Function is to balance the SBL and provide tensile support from the top to lift those parts of the skeleton which extend forward of the gravity line (pubis, ribcage and face)

• Viewing the patient from the side reveals the state of imbalance between the SFL & SBL

SFL – myofascial tracts and bony stations


Anatomy Trains


Deep Front Line

• Infused with slow twitch endurance muscle fibres, the DFL provides stability and subtle positioning changes to core structure.

• Restriction within this line is seen in every patient who is dominated by sitting

• Restriction within this line affects the ability of gaining extension at the hips and improving the postural alignment of the trunk and pelvis

• Working alongside the SBL it’s co function is to control our ability to work with gravity allowing our posture to selectively extend against or move with gravity

• Failure of the DFL does not cause an acute change but more functional restriction over a period of time which may appear in another line.

• Its role in surrounding the heart and lungs has a significant affect upon respiration and also the potential for CV function

DFL – myofascial tracts and bony stations


Anatomy Trains…


Demonstration of theory

Practical:Myofascial Release


Manual Handling and Body Position


• Posture– Bed height– Stance– Patient position

• Use different parts of your hands/ arms to apply pressure• Keep arms straight to utilise body weight when applying

pressure/resistance.• Move from the hips and knees as much as possible• Oil (or cream)- only needs to be a little bit.

Look after yourself before you look after the patient!

Post Treatment Irritation


Very common for people to experience irritation for up to 72 hours after treatment.

Side effects can include:• Bruising• Redness• Tenderness/Increased Sensitivity• Increased symptoms• Aching similar to DOMS

Post Treatment Irritation


Causes

• The release of toxins/waste products from muscular tissue • Neurological sensitisation• Increased blood flow and micro trauma can lead to bruising and redness

Advice

•Reassure the patient it's a normal response to be sore after soft tissue treatment•Advise them to use ice (safely)•Recommend they drink water to keep hydrated


Palpation Finding fascia…

1.Rest hand lightly on forearm – do not press into the arm. This is the superficial fascia2. Allow your hand to sink into the forearm, this is the deep fascia - the fascia of the forearm extensors3.Withdraw out of the fascial layers…..


Back 1. Gliding2. Erector Spinae frictions3. QL release


Shoulder 1. Upper fibre traps in side : Stripping Technique (1)2. Upper fibre traps : Technique (2)3. Pectorals


Glutes 1. Fix an stretch2. Fix and stretch in side lying


Hamstrings 1. Gliding2. Skin rolling/ Friction3. Tack and stretch


Calf 1. Stripping 2. Gliding3. Tack and Stretch 4. Gastroc on stretch - elbow stripping

Lunch


Theory:Muscle Energy Techniques (METs)



• "A manual medicine treatment procedure that involves the voluntary contraction of muscles in a controlled direction, at varying levels of intensity, against a counterforce applied by the operator.’’

(Greenman 1996)

• “Muscle Energy Techniques are a manipulative treatment in which patients muscles are actively used on request from a precisely controlled position, in a specific direction and against a distinctly executed counterforce.” (Ward 2003)

MET’s Definition


• Isometric Contraction• Reciprocal Inhibition• Post Isometric Relaxation

• Isotonic Eccentric Contraction• Isotonic Concentric Contraction• Isokinetic

MET’s Types

METs: Protocol


• With Isometric METs- the muscle/limb is moved until a barrier of resistance is reached.

• The isometric contraction is performed and held for 3-5 seconds.

• The muscle is then allowed to fully relax (this can also take a few seconds)

• Passive mobilisation is then used to stretch the muscle/limb until a new barrier of resistance is reached.

• The contraction/relaxation cycle is then repeated until normal movement is restored or no further benefit is gained (usually 3-5 repetitions at most).

METs: Isometric Contraction


Reciprocal Inhibition

Method

Resistance is applied by the therapist

The patient produces an isometric contraction of the muscle group that opposes the affected muscle

The contraction is held

The patient then relaxes and a stretch can be applied to the affected muscle.


Reciprocal Inhibition

Theory

•Agonist muscle contracts

•Muscle spindles are activated to send feedback on muscle length

•This causes the release of an inhibitory mediator at the spinal cord

•The motor neurone of the Antagonist muscle is inhibited by this, causing relaxation



Reciprocal Inhibition: Example

E.G. Hip Adductor Injury.

•Hip abduction is resisted by the therapist•Agonist group (hip abductors) contract•Antagonists (hip adductors) are inhibited as a result •Relaxation/Lengthening occurs in the adductors (affected) muscle group



Post Isometric Relaxation

Method

• Resistance is applied by the therapist

• The patient produces an isometric contraction of the affected muscle

• They then relax and a stretch can be applied




Post Isometric Relaxation

Theory

• Strong muscle contraction excites Golgi tendon organs

• This causes inhibition of the motor neurone to the muscle

• When the muscle contraction stops the muscle relaxes and lengthens as a result of this



Post Isometric Relaxation: Example

E.G. Hip Adductor Injury

•Resistance is applied against Adduction of the hip•Isometric contraction occurs•When the muscle relaxes it will lengthen•And the hip can be passively stretched further in to abduction

METs: Isotonic EccentricContraction


Method

•The patient contracts the affected muscle while the therapist applies a force stronger than the force of contraction.

•This results in the muscle being lengthened whilst contracting.

Theory

•Golgi tendon organs are excited by the contraction of the muscle. The muscle is also being stretched/lengthened during the contraction

• So when the muscles relaxes, these effects combine and this results in a lengthening/relaxation of the muscle.

METs: Isotonic Concentric Contraction


Method

•Therapist applies a resistance, the patient concentrically contracts the affected muscle and moves through range of movement against the resistance.

•This movement is then performed repeatedly

Theory

•This causes increased motor activity to a muscle which increases tone

•Over time alongside strengthening exercise hypertrophy would occur.

METs: Isokinetic


Method

• Varying amounts of force are applied by the therapist as the muscle is contracted through its full range of movement

• Force is altered to ensure the muscle moves at a constant speed through its full range

• (It’s considered a combination of isotonic and isometric contractions)

Theory

•Aims to increase strength and tone similar to isotonic concentric contractions.

METs:Contraindications and Precautions


METs: Practical


Remember: •Your body position and handling skills •Post Rx advice where appropriate



Neck and Shoulder 1. Supine Neck side flexion 2. Pec- abduction


Glutes • Internal/external rotation • Side lying


Hips1. Abduction 2. Adduction


Hamstrings1. Contract and Relax in Supine


Calf1. Resisted Plantarflexion

Case studies


Case Study: Neck Pain


PC/HPC: 25 year old female with an onset of neck pain and stiffness 1/12 following a RTC. Feels worse in the mornings and aggravated by sitting for long periods. Scores her pain 7/10 on the VAS scale.

SH: Work- Solicitor 85% desk based. Spends large amounts of time commuting in the car and traveling on trains.

Hobbies- attends the gym 2-3 times a week. Not able to go since the accident

PMH: None DH: Analgesics

Objective signs- increased uft tone R>L, Limited in all ROM of CX SP, TOP posterior neck muscles, uft and rhomboids, active TP in R uft, no neurological symptoms to note.



Objective signs

•Increased uft tone R > L

•Limited in all ROM of CX SP

•TOP posterior neck muscles, uft and rhomboids

• Active TP in R uft,

•No neurological symptoms to note



•Diagnosis?

•What MFR techniques could you use?

•Would you use METs? If so, why?

Case Study: Hamstring


PC/HPC: 30 year old male, 4/10 pain into R hamstring when running. Felt “pull” 2/52 ago towards the end of a 5k run. Instant pain and unable to continue run. No instant swelling of bruising. Pain eased 3/7 after – tried running but still feels pain. Also reports an increase of constant tightness.

SH: Work- Shop assistant. On feet all day. Training for Manchester 10k

PMH: L Shoulder surgery from cycling accidentDH: Nil to note



Objective signs-

• Sway back posture

• Reduced range in R hamstring in 90/90 test

•-ve neuro symptoms on SLR

• Palpation : area of adhesion located mid hamstring- tender on deep palpation.



•Diagnosis?



Case Study: Shoulder Pain


PC/HPC: 45 year old Male with and 8/12 History of Right shoulder pain that onset insidiously, coincided with being busier at work and doing longer hours.

SH: Work- Desk based- pain gets worse through the dayHobbies- Golf- unable to play due to pain

PMH: HypertensionDH: Ramipril, Occasional Ibuprofen

Case Study: Shoulder


Objective signs

•Protracted shoulder posture with increased Tx Kyphosis•Limited ROM of the right shoulder and the neck•Positive outcome on impingement tests• Patient indicates pain refers to the elbow•Tenderness on palpation of the right shoulder joint, pectorals rotator cuff, traps and thoracic spine musculature•Increased muscle tone and trigger points in the pecs and traps•Muscle weakness- on all shoulder movements•Joint stiffness in the right shoulder

Case Study:Shoulder


•Diagnosis?



Case Study: Sciatica


PC/HPC: 32 year old female with a 5-6 week history of back pain and pins and needles radiating down the left leg. Initially noticed it after lifting a heavy object at work

SH: Work- Cleaner- pain is aggravated by lifting and bent posturesHobbies- Gym- Spinning class and Zumba- unable due to pain

PMH: NilDH: Naproxen



Objective signs:

•Tenderness on palpation of the lumbar, gluteal and piriformis musculature•Muscular trigger points throughout the glutes and piriformis (which trigger lower limb symptoms)•Piriformis tightness on testing•Hip flexor weakness•Positive findings for neural tension/irritation on Straight leg raise •Pain limited lumbar flexion and hip flexion and internal rotation•Indicates pins and needles down the leg laterally to the foot•Neurological symptoms aggravated by putting pressure on the buttock (e.g. sitting)



•Diagnosis?



Evidence: METs


The Immediate Effects of Muscle Energy Technique on Posterior Shoulder Tightness: A Randomized Controlled Trial (Moore et al. 2011)

• Investigated the immediate effects of METs on shoulder horizontal adduction and internal rotation ROM

• Used Asymptomatic baseball players as their study sample• Compared 3 groups: MET for horizontal abductors, MET for external

rotators and a control group

• Found significant improvements in ROM using horizontal abductor METs

• Suggests benefits for injury prevention and rehabilitation.


Evidence: METsThe effect of isolytic contraction and passive manual stretching on pain and knee range of motion after hip surgery: A prospective, double-blinded, randomized study (Parmar et al. 2011)

• Compared Isolytic (Eccentric) MET to passive manual stretching for knee ROM.

• Used individuals post hip surgery following a fracture.• Assessed knee ROM and pain (VAS)

• Found significant improvements in ROM using both treatment techniques

• MET group had significantly better reductions in pain• Suggests METs are a better technique as they impact on ROM and pain.


Evidence: METsMuscle Energy Technique Versus Corticosteroid Injection for Management of Chronic Lateral Epicondylitis: Randomized Controlled Trial With 1-Year Follow-up (Küçükşen et al. 2013)

• Compared an isometric MET (resisted pronation) to Corticosteroid injections• Used patients with symptomatic Lateral Epicondylitis (Tennis Elbow)• Followed up at 6, 26 and 52 weeks to assess short and long term impact

• Cortisone injections showed better improvements in pain, grip strength and function initially but longer term follow-up found more benefit from METs

• METs are a better long term treatment for Lateral epicondylitis than Cortisone.


Evidence: MFRBenefits of Massage-Myofascial Release Therapy on Pain, Anxiety, Quality of Sleep, Depression, and Quality of Life in Patients with Fibromyalgia (Castro- Sanchez et al. 2010)

• A randomised controlled trial, used an experimental and placebo group

• Recruited patients diagnosed with FMS aged 18 – 65 years • Experimental group underwent a protocol of massage-

myofascial release therapy during a weekly 90-minute session for 20 weeks

• Pain was assessed with the Visual Analog Scale (VAS), which assesses the pain intensity and degree of relief experienced by the patient (score of 0 = no pain; 10 = unbearable pain)


Evidence: MFRBenefits of Massage-Myofascial Release Therapy on Pain, Anxiety, Quality of Sleep, Depression, and Quality of Life in Patients with Fibromyalgia (Castro- Sanchez et al. 2010)

Results:

•The experimental group significantly improved pain, anxiety, quality of sleep, and quality of life• The treatment reduced the sensitivity to pain at sensitive points, mainly at the lower cervicals, gluteal muscles, and right greater trochanter.•Release of fascial restrictions in these patients also reduces anxiety levels and improves sleep quality, physical function, and physical role•Massage-myofascial program can be considered as an alternative and complementary therapy that can achieve transient improvements in the symptoms of these patients.


Evidence: MFREffectiveness of Myofascial release in the management of chronic low back pain in nursing professionals (S.Ajimsha et al, 2013)

Results:

•MFR group performed better than the control group in 8 weeks and 12 week •McGill Pain questionnaire and Ouebec Back Pain Disability Scale was used to assess •MFR reported 53.3% reduction in pain compared to control groups 26.1% at 8 weeks•MFR group reported 29.7% reduction in functional disability compared to 9.8% by control group at 8 weeks•This study provides good evidence that MFR when used along side specific back exercises

http://www.ncbi.nlm.nih.gov/pubmed/?term=Castro-S%26%23x000e1%3Bnchez%20AM%5Bauth%5D

References


The Immediate Effects of Muscle Energy Technique on Posterior Shoulder Tightness: A Randomized Controlled Trial. Stephanie D. Moore, Kevin G. Laudner, Todd A. Mcloda, Michael A. Shaffer, Journal of Orthopaedic & Sports Physical Therapy, 2011 Volume:41 Issue:6 Pages:400–407.

The effect of isolytic contraction and passive manual stretching on pain and knee range of motion after hip surgery: A prospective, double-blinded, randomized study. Shraddha Parmar, Ashok Shyam, Shaila Sabnis, Parag Sancheti, Hong Kong Physiotherapy Journal, Volume 29, Issue 1, June 2011, Pages 25–30

Muscle Energy Technique Versus Corticosteroid Injection for Management of Chronic Lateral Epicondylitis: Randomized Controlled Trial With 1-Year Follow-up. Sami Küçükşen, Halim Yilmaz, Ali Sallı, Hatice Uğurlu, Archives of Physical Medicine and Rehabilitation, November 2013, Volume 94, Issue 11, Pages 2068–2074

Ward R.C. et al. Foundations of Osteopathic Medicine. 2nd Edition. Baltimore, MD: Williams and Wilkins, 2003. (page 881)

Greenman P. Principles of Manual Therapy. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996.

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Myofascial Release and MET Presentation Slides

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