MYOFASCIAL MANIPULATIONS

TherapyProtocols

MYOFASCIAL MANIPULATIONS OF THORACOLUMBAR FASCIA & LUMBAR MASS

Sagar Naik, PT, Dr. Saravanan, Dr. Prerana, Dr. Bhargav Desai
1) Sustained Inhibitory Pressure produces Neuromuscular Relaxation:

2) Longitudinal Muscle Play or Parallel Stretching: Force applied in the direction of the long axis of the muscle is generally called longitudinal, parallel, or linear stretching. Any muscle or muscle group that allows the placement of two hands or even two fingers can be relieved of myofascial restrictions. For a large muscle group better leverage is achieved by crossing the arms and using the entire surface of both hands.

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Treatment with tissues on slack or the shortened range is followed by treatment in the resting position (neutral) and finally in the lengthened range.

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Sustained pressures involve the application of direct pressure to discrete areas of local soft tissue dysfunction, such as tendons, the muscle belly, and origins or insertions of a muscle, for 1 minute or more in a "make and break" manner to reduce hypertonic contraction or for its reflex effect. Sustained pressures works well over broad flat tendons adjacent to or over the osseous junction, or muscles such as the psoas major or pectoralis major. Initially, to obtain an environment of comfort, respective tissues are placed on slack by altering the surrounding tissue by positioning and/or by using one hand to place the tissue on slack.

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Both hands apply slowly increasing pressures proximal to the attachment of the muscle to be stretched in the direction of the muscle fibers. Just enough pressure is applied to stretch the superficial skin, fascia, and underlying muscle(s). This position is held until the soft tissue is felt to relax. Longitudinal stretching continues by taking up the slack created by the release.

3) Longitudinal stretch of the trunk:

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4) Passive Stretching:

Typically this sue stretching technique employs the use of both forearms and hands to stretch or elongate the myofasical structures. This technique is typically used on lumbar spine with forearms or hands on the sacrum and lower thoracic spine. Stretch is performed with forearms and hands in opposite directions to extend muscles and spinal joints that are restricted and tight. Alternatively, one arm may stabilize as the other stretches. Greater stretch can be further achieved by increasing trunk motions.

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5) Manual stretch & soft tissue manipulation of mass of lumbar muscles:

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Manual stretch and soft tissue manipulation of the lumbar mass with counter pressure of the legs. Slow and very rhythmic transverse pull on the mass of lumbar muscles is applied toward the therapist as the knees are pushed away. This maneuver should be applied slowly and rhythmically.

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The region is distracted on the ipsilateral side with the tips of the fingers applied against the spinous processes and lateral borders of the sacrum. While using this leverage formed by the wrist and forearm, pressure is also applied upward with the fingers. This combined pressure-distraction is maintained for some time, then released to be applied again. This maneuver has a very sedative effect in acute low back problems. It is also an effective technique in mobilizing the connective tissue along the borders of the sacrum before attempting to mobilize the sacrum out of various positions of dysfunction.

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Static stretching is a method of stretching in which a stationary position is held for a period during which specific joints are locked into a position that places the muscles and connective tissues at their greatest length. Passive stretch may be applied either manually or by sustained mechanical stretch. Manually applied stretching is usually applied for 15 to 30 seconds. The advantages of manual static stretching when compared to ballistic stretching are Energy requirements are lower There is little danger of exceeding the extensibility of the tissues involved Muscle soreness is less likely and may be relieved Minimizes impact of the Ia and II spindle afferent fiber stimulation and minimizing the impact of Golgi tendon organ, thereby decreasing the contractile elements of resistance to deformation

MYOFASCIAL MANIPULATIONS

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SOFT TISSUE MANIPULATION FOR RELEASING SACRUM

1) Position of patient: Prone Procedure: Therapist places one hand over the sacrum with the heel over the base and fingertips over the apex of the lateral angles. The other hand is placed on the top as shown in figure.

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Therapists hand pressure is applied anteriorly and inferiorly with the rocking motion from side to side, forward and backward, and across the oblique axis.

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Manual stretch and soft tissue manipulation of the mass of erector spinae, thoracolumbar fascia, and quadrates lumborum muscles. The myofascial structures are placed in some degree of stretch (by using a roll under the lumbar spine and flexing the patient's bottom leg). The therapist applies outward pressure with both forearms. Alternatively, the therapist may apply transverse soft tissue stretch with the myofascial tissues on stretch. Further stretch can be achieved by flexing both legs towards the chest and the therapist's using his or her thighs to push the patient's knees further into lumbar flexion to the desired degree of stretch. Alternating pressure on the knees varies the tension on the myofascial structures. Rhythmic motion against the knees, counterbalanced by the pulling action to the hands, is an effective way of releasing the connective tissue and sacrospinal muscles.

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2) Self-treatment to release the thoracolumbar fascia, erector spinae and sacral pad with the use of a ball

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Mobilization of the sacrococcygeal joint and the surrounding soft tissues can be used to free up sacral extension so that the sacral base can tip anteriorly (which is the physiologic movement of the sacrum that occurs with lumbar extension) and enhance the mobility of the coccyx. 1) Release of the intercoccygeal ligaments and gluteal fibers The patient lies prone with a pillow under the pelvis. The operator sits next to the patient and places one thumb on the restricted area. To release the intercoccygeal ligaments, impart alternating small adduction-abduction movement of the thumb and work the posterior aspect of the coccyx. To release the gluteal fibers the thumb contacts the area between the muscle and the lateral border of the coccyx. Apply up and down movements along the edge of the bone.

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Self-treatment for increasing the extensibility of the sacral pad, erector spinae aponeurosis, and the L4-L5 segments can be done with the use of a small ball to apply slow, prolonged stresses to this region, creating both a stretch of the elastic tissue and relaxation of the collagen. Self-stretching in this way allows for release of the tight shortened back muscles at the lumbosacral junction as well as the sacral pad and surrounding ligamentous and muscular attachments of the sacrum. The ball can either be rolled across the region into the areas of restriction (in supine or sitting) or the patient may simply rest on the ball (positioned under the apex of the sacrum) for a period of time, allowing the surrounding tissues to release. The patient may then slowly and gently press into the ball to engage more of the low back with lengthening of the abdominals in the same process. Slow gentle repetitions for 10 to 15 minutes is recommended.

COCCYGEAL SOFT TISSUE MANIPULATIONS

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2) Release of the coccygeal muscle to enhance mobility of the coccyx The patient is sitting near the end of the treatment table, with arms crossed holding the elbows. The operator stands to the side of the patient and grasps under the patient's arms, the other hand with the index finger on the coccygeus muscle besides the coccyx. Have the patient slump sit and shift weight onto the operator's finger ("sit on finger"), thus increasing the ischemic pressure and releasing the muscle.

MYOFASCIAL MANIPULATION OF SACROTUBEROUS LIGAMENT

Patient Position: Prone Therapists Position: The operator at the side of the table places his or her hands over the buttock in contact with the sacrotuberous ligament at the inferior lateral angles of the sacrum.

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Reference: Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods
by Darlene Hertling & Randpolh M. Kessler (4th Edition)

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Tension in the sacrotuberous ligament is tested for symmetric balance. The hands are twisted in counterclockwise and clockwise directions, sensing for tightness and looseness. The operator then applies load to balance the tension in the sacrotuberous ligament while the patient performs enhancing maneuvers (e.g., respiration, contraction of the gluteals).

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