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OMM: Intro to Myofascial Release and Ligamentous Release

Terms in this set (84)

List the 4 Osteopathic Principles
1) The body is a unit; the person is a unity of body, mind, and spirit.
(The body is completely united; the person is a fully integrated being of body, mind, and spirit - The Unity Principle)

2) The body is capable of self-regulation, self-healing, and health maintenance.
(--The Search for Health over Disease)

3) Structure and function are reciprocally interrelated.

4) Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.
for optimal function, there must be
integration of the various constituent functional levels, from subcellular to organ systems to the psychological.

When a breakdown in the integration of these functions develops, the individual can no longer maintain the best level of health, and disease symptoms are increasingly likely.

This leads to another of the basic tenets of the profession, that the underlying cause of disease is disturbance of function; homeostatic mechanisms can no longer ward off invasions of bacteria or viruses or contain the degeneration of aging or use."
Homeostasis
The tendency of an organism or a cell to regulate its internal conditions, usually by a system of feedback controls, so as to stabilize health and functioning, regardless of the outside changing conditions

The ability of the body or a cell to seek and maintain a condition of equilibrium or stability within its internal environment when dealing with external changes
Tensegrity and biology
The property of skeleton structures that employ continuous tension members and discontinuous compression members in such a way that each member operates with the maximum efficiency and economy
Tensegrity
(from Dr. Nuño's Posture lecture)

Key points:
1) Areas of HYPOmobile somatic dysfunction may cause COMPENSATORY HYPERmobility elsewhere

2) Hypermobility in one or more region may affect compensatory hypomobility elsewhere

3) Fascial patterning and musculoligamentous tensions = primary importance as the model's connecting elements

4) Explains why dysfunction distant from area of complaint may be the cause or contributing to the cause
Mechanobiology (Donald Ingber)
Mechanical forces: pushes, pulls, tensions, compressions

= Adaptation of mechanical tensegrity model to cellular structure and function

Mechanical forces as important regulators of cell development & behavior

Embryologic development relies heavily on mechanical forces to guide growth

o Forces occur that produces changes and growth in embrtyo and fetus - the forces themselves are the precursors to the function that follows


Mechanical forces and chemical cues are both important in genetic & molecular biology
Ingber proposed
Mechanical force on tissue is carried by integrins into the cytoskeleton and can:

--> change the conformation of a protein,

--> trigger a biochemical reaction,

--> stretch a chromosome & activate a gene.

Cellular chemistry processes vary depending on physical distortion
How can Tensegrity and "Mechanobiology" concepts inform our practice of Osteopathy?
1) The body is a unit; the person is a unity of body, mind, and spirit.

2) The body is capable of self-regulation, self-healing, and health maintenance.
-- "All elements of the body are shaped by their use (and disuse), function (and dysfunction). Through respecting embryological origins and generating forces, we are well-guided in the inherent template for health in the body."

3) Structure and function are reciprocally interrelated. This idea applies throughout - from the overall macro body structure down to the cell nucleus and cellular physiology to gene expression


4) Rational treatment is based on these principles
The 3 laws that help in the Exploration of Mechanical Relationships
Wolff's law

Hooke's law

Hilton's law
Wolff's Law
The principle that every change in the form and the function of a bone or in the function of the bone alone, leads to changes in its internal architecture and in its external form.

A law according to which biologic systems such as hard and soft tissues become distorted in direct correlation to the amount of stress imposed upon them.
Wolff's Law correlates Piezoelectricity
Piezoelectricity = current produced by a substance when it is subjected to stress. Mechanical stress is converted to electrical energy

Piezoelectric substances in the body include bone, collagen, and muscle

In bone, piezoelectric properties produce an electronegative charge with compression --> stimulate osteoblasts and electropositive charge with unloading --> stimulates osteoclasts. A biphasic signal in bone collagen directs bone remodeling during mechanical stress

In collagen, piezoelectric properties stimulate and direct the migration of connective tissue cells and activates embryologically plastic cells
Compression produces what kind of charge and what response?

Destraction produces what kind of charge and what response?
Theres an electronegative charge occurs with compression --> stimulates osteoblasts

Electropositive charge with destraction --> stimulates osteoclasts
What drives bone growth?
• Conversion of mechanical stress to electrical energy (piezoelectricity)

• Occurs Primarily bone, collagen, muscle

• Theres an electronegative charge that occurs with compression, and electropositive charge with destraction

electroneg charge stimulates osteoblasts

electropos. charge stimulates osteoclasts

• Stimulates osteoclasts with + charge, and osteoblasts with - charge

• This biphasic signal will drive bone growth

note: In collagen, the biphasic pizoelectic property will also drives cell migration and activates embryologic plastic cells
Hooke's Law
Law of elasticity

For relatively small deformations of an object, the displacement or size of the deformation is directly proportional to the deforming force or load

Under these conditions the object returns to its original shape and size upon removal of the load

If the distorting force exceeds the elastic limit of the material, permanent deformation results

Provides the basis for diagnosis using directed mechanical pressures and motions while monitoring tissue response

stress-strain relationship
Elastic vs Plastic regions
♣ Elastic region is a point at which we do a lot of work and helping make a change in elasticity. When something goes into the plastic region, that's when you get less reversible strains

♣ Failure point is when you have fracture or tissue disruption
Creep
Creep describes the phenomenon of deformation as a function of time under the action of a constant load.

Tissue will stretch in response to an initial load stress to a particular length and then if the initial load is maintained it will continue to stretch at a different rate to a new length; this phenomenon is called creep.

This is due to the viscous properties of the tissue.

Ex: (We are taller in the morning than in evening after having been on our feet all day)

Tissue creep occurs during the application of direct myofascial and ligamentous release. Load is placed into the direct barrier and tissue lengthens over time.
Creep is due to the ___ properties of a tissue
viscous
Creep occurs int he application of
direct myofascial and ligamentous release

Load is placed into the direct barrier and tissue lengthens over time.
In direct myofascial and ligamentous release, do you position the patient into the barrier or ease?
To the barrier
Relaxation
is the phenomenon in which stress or force in a deformed tissue decreases over time while the deformation is held constant
Hysteresis
o loss of energy when you put in a force

describes the energy loss of tissues during load and unload cycles of viscoelastic materials.

♣ Explains how when you first putin a force, there is not a lot of change that occurs. But then as energy release occurs, then the tissue response begins

Hysteresis concepts help explain the lag between input of treatment forces and tissue response. It also helps explain the warmth palpated during tissue releases.

Tissues have differences in response based on past experience. For example, T cell activation is faster in previously activated cells. OMT efficacy can increase over time with repeated treatments.
What explains why OMT efficacy can increase over time with repeated treatments?
Hysteresis

Tissues have differences in response based on past experience. For example, T cell activation is faster in previously activated cells. OMT efficacy can increase over time with repeated treatments.
Area under the curve for hysteresis
The area under the unloading curve is always LESS than that under the loading curve in biological tissues because energy has been LOST
Rate sensitivity
is the deformation sensitivity of tissue due
to rate of loading

o amount of force/intervention you need to put in, and the load rate
Hilton's Law
this is the observation that in the study of anatomy, one often finds that a nerve that innervates a joint also tends to innervate the muscles that move the joint and the skin that covers the distal attachments of those muscles.

Hilton went on to say "Every fascia of the body has a muscle attached to it, and that every fascia of the body must be considered as a muscle"
All fascia has
All fascia has muscle attached at some point, and every fascia should be considered as if it was a muscle

o Fascia has a muscle contractile quality to it, without having specific cellular mechanism
Every fascia should be considered as if it was a
muscle

o Fascia has a muscle contractile quality to it, without having specific cellular mechanism
What is fascia?
It is connective tissue and it wraps every part of the body

It is the largest component of white fibrous tissues containing linear sheets of collagen

Forms superficial, deep, and subserous layers

It binds structures of muscle, nerves, and blood vessels and allows sliding of one structure over another

Unifying structure relative to the 1st Osteopathic Principle

Completely integrated throughout the body
Unifying structure relative to the 1st Osteopathic Principle
fascia
Completely integrated throughout the body
fascia
Protection, encasement of muscles, allows for ligament gliding, passage for blood vessels, nervous structures, sliding of one structure over another
fascia
It is the largest component of white fibrous tissues containing linear sheets of collagen
fascia
Forms superficial, deep, and subserous layers

It binds structures of muscle, nerves, and blood vessels and allows sliding of one structure over another
fascia
It is connective tissue and it wraps every part of the body
fascia
Origin of fascia
o Its mesodermal origin
♣ Continuum of mesenchymal structures
Connective Tissue
Mesoderm of embryologic origin forms a continuum of mesenchymal structures that include: ground substance and undifferentiated cells capable of producing connective tissue - bone, cartilage, adipose tissue, lymphatic and vascular structures including blood

Fibroblasts are connective tissue cells which excrete extracellular matrix
Special considerations in tendons and ligaments:
Tendons attach to bones and transmit muscle forces

Ligaments restrain excess motion as well as guide joint motion

Ligaments have a less linear configuration of collagen than tendons, which allows them to act more like a spring. Known as crimping, a normal characteristic
Tendons
attach to bones and transmit muscle forces
Ligaments
restrain excess motion as well as guide joint motion

Ligaments have a less linear configuration of collagen than tendons, which allows them to act more like a spring.

Ligaments are less linear, they have an already present coiling property called crimping, when crimping is stretched and ligaments become straight --> strain.

Crimping and coiling of ligaments is a normal physiologic characteristic
When does strain occur?
Ligaments are not very linear, they have an already present coiling property called crimping. When crimping is stretched and ligaments become straight == strain.
What is the Function of Fascia/Connective Tissue?
Unifying structure relative to the 1st Osteopathic Principle

Protection, encasement of muscles, allows for ligament gliding, passage for blood vessels, nervous structures, sliding of one structure over another

Support, stabilization, and integration of musculoskeletal, nervous, lymphatic, visceral, and vascular tissues

Mediation of motion and stress

Provide proprioceptive input

Defense and protection in infective as well as mechanical trauma

Trigger for repair and strengthening process

Medium for metabolic and fluid exchange
Functions of Fascia
o Support and stabilization and integration throughout the body

o Mediates motion and stress

o Works in proprioception: as you have motion input, the fascial tissues and their relation to each other provide some proprioceptive info into the system

o Can protect against infection and mechanical trauma

o Fascial planes can also protect against infection transmission

♣ But if an infection has pierced an area, it can travel along fascial planes and produce infection elsewhere
Properties of Fascia/Connective Tissue
Colloidal Considerations
- Thixotropy
- Dilatantism

Traumatic Patterns
- Alterations in the extracellular fluid mediated by bioelectric potential changes in the collagen of fascia

Dynamic Remodeling
- Healing is a dynamic process of deposition and removal
Colloid
The particles of a colloid selectively absorb ions and acquire an electric charge. All of the particles of a given colloid take on the same charge (either positive or negative) and thus are repelled by one another

Colloid = a substance that consists of particles dispersed throughout another substance which are too small for resolution with an ordinary light microscope but are incapable of passing through a semipermeable membrane

♣ Colloidal tissues and fluids are VISCOUS and have RESISTANCE to flow. Can be fuid or semi fluid state
Thixotropy
Thixotropy is a property exhibited by certain gels (semisolid, jellylike colloids). A thixotropic gel appears to be solid and maintains a shape of its own until it is subjected to a shearing (lateral) force or some other disturbance, such as shaking. It then acts as a sol (a semifluid colloid) and flows freely. Thixotropic behavior IS reversible

Thixotropy = the property of gels of becoming FLUID when disturbed (as by shaking)
Dilatant =
increasing in viscosity and setting to a solid as a result of deformation by expansion, pressure, or agitation
What kind of force causes greater viscosity in a dilatant?
Force that is perpendicular
Viscosity =
the quality of being viscous; especially : the property of resistance to flow in a fluid or semifluid

♣ Force that is perpendicular =-> greater viscosity
The distinction between the "shaking" producing shear thinning with thixotropy and the "agitation" producing shear thickening with dilatant is
in the speed and intensity of the force.
Fascial Continuity
Preverterbral fascias are continuous with C-T-L spine

At base of skull sphenoid and pterygoid fascial bundles continue into the neck and viscera.

Pharyngeal and submandibular fascias continue into the anterior chest wall and upper extremities.

And so on through the rest of the body, including visceral structures
Myofascial release
= continual palpatory feedback to achieve release of myofascial tissues.

Direct, indirect, or combined treatment

Activating forces include:
- Inherent (intrinsic) force
- Respiratory force (cooperation/assist)
- Patient cooperation
- Physician-guided force
- Springing/vibration
Direct MFR
myofascial tissue restrictive barrier is
engaged for the myofascial tissues and the tissue is loaded with a constant force until tissue release occurs

engages restrictive barrier with a constant force
Indirect MFR
The dysfunctional tissues are guided along the path of least resistance until free movement is achieved
Balanced Ligamentous Tension
Sutherland's model, all the joints in the body are balanced ligamentous articular mechanisms.

The ligaments provide proprioceptive information that guides the muscle response for positioning the joint, and the ligaments themselves guide the motions of the articular components."
Ligamentous Articular Strain technique (LAS)
A manipulative technique in which the goal of treatment is to balance the tension in opposing ligaments where there is abnormal tension present.
Neuroreflexive Mechanism
An "event" occurs which is unexpected or causes the muscle fiber to stretch too quickly

This rapid movement creates a disparity between the intrafusal and extrafusal muscle fibers (they lengthen by different amounts), effectively INCREASING the gain in the GAMMA efferent system

The nerve overstimulation causes the muscle fibers to contract try to return the muscle toward its "normal" resting tone (the muscle is unable to relax)

This resting tone cannot be achieved
Muscle spasm results
A feedback loop is created
Neuroreflexive Mechanism in MFR
During myofascial release, the muscle is stretched in a controlled fashion utilizing the increased output from the afferent intrafusal fibers to "reset" the gain on the gamma efferent fibers

This input of force occurs beneath the threshold of the golgi tendon apparatus

Intra- and extrafusal muscle fibers return to a more normal length relationship. The gamma gain is turned down

*Recognize that the muscle stretch is produced by and during the release, rather than induced by force from the treatment
Patterson's Contributions
Directs us to Comprehensive OMT that affects not only the bony structures , but also works with central neural connections.

Patterson highlights the importance of indirect OMT to address neuronal firing

Reveals that all sources of neurological input, as contributory to the osteopathic lesion syndrome (somatic dysfunction), must be relieved sequentially

Shows that continued OMM treatments over time are sometimes necessary in order to decrease sensitization and return health to abnormally conditioned regions
Habituation
"reflex fatigue" decreased reflex output stream.

Due to repeated mild to moderate stimulus input.

It is a normal response that allows nonessential stimuli to have their reflex responses diminished or muted
Sensitization
reflex excitability or "wind up";

this is the opposite of habituation, a repeated stimulus causes an increase in neural firing response
Long-term sensitization
this is the case when sensitization does not return to normal levels, but the organism demonstrates increased excitability.

This excitability has been shown to being influenced by factors such as stress prior to stimulation, length and severity of stimulation, and the status of the spinal cord, whether intact or sectioned
Fixation
prolonged excitability over days may lead to continued activation of a pathway and the loss of inhibitory interneurons which would otherwise inhibit the process
Acyclic strain
Acyclic strain, representing somatic dysfunction, produced cellular changes with only moderate strain present for as little as 48 hours

Increases in pro-inflammatory cytokines of IL-6 and nitric oxide were measured

Cellular changes included loss of pseudopodia, hyperplasia, and changes in cellular alignment

Strained cells "treated" with "indirect OMT"
No strain for 60 sec
Reduced pro-inflammatory IL-3 & IL-6 (measured 24 hrs later)
Increased proliferation with "OMT"

conclusion =
Strain-induced inflammation is treatable with "OMT" (indirect)

Beneficial effects of "OMT" persisted even after the strain was restored

The effects of "OMT" persisted at 24 hrs

"OMT" not only reduced inflammation, but enhanced fibroblast proliferation (fighting disease and promoting health?)
Contractile Tissue in Fascia
Studies conducted on fascial tissues establish the presence of contractile tissue in fascia: myofibroblasts

Proper activity of myofibroblasts is important for wound healing but overactivity can produce fibrosis

Exercise training maneuvers can be applied to the fascia and produce improvements in performance

High performance athletes are shown to have LESS muscle firing rather than more, with fascial
resilience
What are the contractile tissues in fascia
myofibroblasts

Proper activity of myofibroblasts is important for wound healing but overactivity can produce fibrosis
Myofibroblast activity is important for
wound healing
Myofibroblast overactivity can lead to
fibrosis
High performance athletes
High performance athletes are shown to have LESS muscle firing rather than more, with fascial resilience
Direct techniques approach the ____ barrier
restrictive

(Initial restrictive barrier (feather's edge) for Muscle Energy Technique)

(Final restrictive barrier (hard end-feel) for High Velocity Low Amplitude (HVLA))
Indirect techniques
find a balance between the restrictive and physiologic barrier, as experienced with Counterstrain


With introductory-level Counterstrain, attention is on the characteristics of a specific point and positioning of a body region to affect the neuroreflexive characteristics of that point.

With myofascial and ligamentous techniques, attention is on the target tissues and balance is achieved in multiple planes of motion.
Physiologic barrier
the ends of the ACTIVE range of motion
Elastic barriers are
at the ends of PASSIVE range of motion

-- beyond this, you are going to hit ANATOMIC barrier
Barriers
1) Active range of motion --> Physiologic Barriers

2) Passive range of motion --> Elastic barriers

3) Past this, you hit anatomic barrier
Principles of Myofascial Release
Can be applied to any part of the body (with appropriate force considerations)

Can be used in a local/specific, or regional fashion

Can be used as an indirect or direct technique

Requires constant palpatory monitoring and probable adjustment of position with tissue release
Somatic dysfunction goes to what barrier
Only the physiologic barrier---
Direct Myofascial Release
Diagnostic assessment of the specific somatic dysfunction (SD) or fascial pattern

Positioning into the direction of barrier of the SD or traumatic pattern with engagement of the direct barrier

Apply an activation force (generally physician-guided force, inherent force, and/or respiratory cooperation)

Hold and monitor tissues until release is expressed. Characteristics of change in the tissues include: warmth, softening, increase in motion, palpation of fluid flow, or presence of primary respiration

Reposition as necessary until normal tissue balance is achieved
Characteristics of change in tissue with myofascial release
warmth
softening
increase in motion
palpation of fluid flow
presence of primary respiration
Indirect Myofascial Release
Diagnostic assessment of the specific somatic dysfunction (SD) or fascial pattern

Positioning into the direction of ease of the SD or traumatic pattern in as many planes of motion are possible

Apply an activation force (generally inherent force, physician-guided force, and/or respiratory cooperation)

Hold and monitor tissues until release is expressed. Characteristics of change in the tissues include: warmth, softening, increase in motion, palpation of fluid flow, or presence of primary respiration

Reposition as necessary until normal tissue balance is achieved
Principles of Ligamentous Release
Abnormal stresses in the collagen fibers of tendons and ligaments alters the basic function

Altered function in ligaments caused by abnormal joint motion or inflammation will alter the function as a reciprocal tension mechanism

Abnormal ligament function allows for continued abnormal joint motion

Treatment to restore normal function will produce changes not only in the joint and ligaments but also in the interstitium and fluids

Characteristics of change in the tissues include: warmth, softening, increase in motion, palpation of fluid flow, or presence of primary respiration
Ligamentous Release
uses disengagement (compression or traction) and exaggeration (carrying the affected part towards the position of injury) along with balanced tensions

Generally, the palpatory experience of direct myofascial release is the easiest to discern

The direction of ease for indirect myofascial release generally moves away from the restrictive barrier until there are the least tensions present

In contrast, balanced ligamentous tension involves moving the affected tissues until the tensions present are balanced amongst the associated structures

These are concepts which are best explored in lab and with patients
Balanced ligamentous tension (BLT)
uses inherent forces and sometimes respiratory assist
Both emphasize accessing the health of the patient to effect change in the overall system
LR and BLT
Why Myofascial and Ligamentous Release?
To correct somatic dysfunction

To make articular OMT easier and longer lasting

To expand the carrying capacity of blood and lymphatic vessels

To decompress nerve impingements

To reverse contractures of healed trauma or chronic tension

To make myofascial tissues softer & supple

To break adhesions between structures
Clinical Applications of MFR/LAR-BLT
Somatic dysfunction
Viscerosomatic reflexes
Sprains and strains/tendon/ligament injuries
Thoracic Outlet/Inlet, entrapment syndromes
Back pain, sciatica
Postural issues, scoliosis
Pelvic pain
Neck pain, headache
Edema, venous and lymphatic stasis
Joint restrictions, osteoarthritis
Restless Legs/Growing Pains
Visceral restrictions
GERD
Trauma
Birth strains, torticollis
Pneumonia, asthma
Stress reduction, health promotion
Etc.....Etc.
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