International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Myofascial Release

Salvi Shah1*, Akta Bhalara2

1Lecturer, SPB Physiotherapy College, Ugat-Bhesan Road, Surat, Gujarat 2Lecturer, Shree Swaminarayan Physiotherapy College, Khambhaliya highway, Jamnagar.

*Correspondence Email: [email protected]

Received: 10/04//2012 Revised: 28/04/2012 Accepted: 5/05/2012

ABSTRACT

Myofascial release (MFR) refers to the manual massage technique for stretching the fascia and releasing bonds between fascia and integuments, muscles, bones, with the goal of eliminating pain, increasing range of motion and balancing the body. The fascia is manipulated, directly or indirectly, allowing the connective tissue fibers to reorganize themselves in to a more flexible, functional fashion. The purpose of the myofascial release is to release restrictions (barriers) within the deeper layers of fascia. This is accomplished by a stretching of the muscular elastic component of the fascia, along with the crosslink, and changing the viscosity of the ground substance of the fascia. Evidence shows that MFR is safe, effective and designated to be utilized with appropriate modalities, mobilization, exercise and flexibility programs, neurodevelopment treatment (NDT), sensory integration and movement therapy. Key words: MFR, fascia, flexibility

INTRODUCTION Muscle and fascia are united forming the myofascial system. Myofascial therapy can be defined as The purpose of deep myofascial “the facilitation of mechanical, neural and release is to release restrictions (barriers) psycho physiological adaptive potential as within the deeper layers of fascia. This is interfaced by the myofascial system”. [1] accomplished by a stretching of the Fascia is located between the skin muscular elastic components of the fascia, and the underlying structure of muscle and along with the crosslinks, and changing the bone, it is a seamless web of connective viscosity of the ground substance of fascia. tissue that covers and connects the muscles, [2] Myofascial release is a collection of organs, and skeletal structures in our body. techniques used for the purpose of relieving International Journal of Health Sciences & Research (www.ijhsr.org) 69 Vol.2; Issue: 2; May 2012 soft tissue from an abnormal hold of a tight stress. Ground substance is a gel like fascia. [3] consistency of raw egg white. It reduces Direct bodily effects range from friction between muscle fibers creating ease alleviation of pain, improvement of athletic of motion. These single collagen molecules performance, and greater flexibility and ease line up side by side overlapping in a of movement to more subjective concerns staggered pattern akin to a brick wall. They such as better posture. More indirect goals are attached to each other through a process include emotional release, deep relaxation, of hydrogen bonding forming a tough stable or general feelings of connection and well- fabric. being. Rather than being a specific Throughout once life, fibroblasts retain technique, MFR is better understood as a the ability to migrate any point in the body. goal-oriented approach to working with They alter their internal chemistry in tissue-based restrictions and their two-way response to local conditions, manufacturing interactions with movement and posture. [4] specific forms of tissue according to needs of the body. Scar tissue is new collagen that Fascial system [5] has been secreted by ground substance, Fascia is a three dimensional web of which is manufactured by fibroblasts, will connective tissue which runs continuously help determine the way the molecules will throughout the body. This fascial continuity join together. The viscosity or density of the means that there is: ground substance can vary from very thick  Continuous networking from head to to watery. The thicker the ground substance, toe, the thicker and less mobile the tissue is.  Continuous networking from The fascia can be simply described as superficial to deep, consisting of three layers.  Continuous networking from 1. Superficial fascia microscopic to macroscopic. 2. Deep fascia Therefore, the fascial system is not 3. Subserous fascia segmented or divided structurally. However Subserous fascia lines the body cavities the tissue quality within this single system and surrounds the organs. It surrounds blood varies in terms of density and function. vessels and nerves as well. Here the ratio in Fascia is composed of an the number of fibers to fluid is low, giving it elastocollagenous complex with elastin a soft, flexible quality. This is the type of fibers, and collagen fibers, embedded in a tissue that supports shunts and gastric tubes. gelatinous ground substance which allows The superficial fascia lay directly under the fiber mobility, as well as cellular circulation. skin. It has a greater ratio of fiber to fluid The collagen molecule begins as a than the subserous but the fibers are fragile protein chain produced in a fibroblast arranged in a loose, irregular lattice pattern cell. This single protein chain is twisted into allowing for great mobility in all the a left handed spiral and floats inside the directions. With long term spasticity the fibroblast until it comes in contact with superficial layer losses its mobility, the skin other two single chains. These three single become shiny and taut. This is especially chains will align and spiral or twist around evident in the web space of the thumb in the each other toward the right, consequently spastic hand, over the flexor surface of the increasing its structural strength. This triple elbow and the adductor surface of the hip in helix forms the single collagen molecule. spastic diplegia. When released from the fibroblast, it The deep fascia has a more compact migrates through the body’s ground weave with a high fiber to fluid ratio. It has substance to the site of injury, infection or a irregular arrangement of fibers that modify itself depending upon the forces placed on it.

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Muscles are embedded in deep fascia. When bracing patterns encourage the development in the healthy state, this fascia is soft and of myofascial restriction. pliable, allowing the muscle fibers to The patterns of fascial restriction are contract and lengthen efficiently. This same like an historical account of the patients deep fascia, in a more compact form, creates adoptions to gravitational forces. When compartment that separate muscle from using myofascial release, the therapist alters muscle. It forms regional sheaths or the density of the ground substance, thus wrapping around the trunk and extremities. allowing the collagen fibers to separate. The It aligns itself in a compact, more orderly therapist gently lengthens the fibers, and parallel fashion to create tendons and following the release of associated ligaments. The deepest fascia forms the restriction throughout the body. Keep in dural tube which surrounds and supports the mind that the elastin allows the tissue to central nervous system. In children with return to its original form and flexibility, spasticity the deep fascia also becomes tight. thus returning the skeleton to proper biomechanical alignment. As we add graded Myofascial restriction [5] movement the patients immediately learns to Unwanted bonding may occur with use this new mobility, carrying it over into inflammation, injury, postural stress (such as functional skills. Combining the concepts of found in cerebral palsy) or lack of full, myofascial release and neuro-development active range of motion. In an attempt to treatment allows the patients to let go of the support the body, the system contracts and past and move forward towards independent bonds to neighboring structures in the same functions. shape and form as the asymmetrical skeleton. Structures that were originally Concepts in Myofascial release technique designed to be functionally separate will [6] form adhesions which will impair their The first concept in this system is ability to slide freely over one another. that of tight loose. This concept is tightness Where these adhesions develop, individual creates and weakness permits asymmetry. muscle action is impaired. Adhesions in the There are both biomechanical and neural neurologically impaired patients develop reflexive elements to this tight loose secondary to the imbalance in postural tone. concept. Increased stimulation causes an Unwanted bonding creates excessive agonist muscle to become tight, and the deposits of tissue. This results in thick tighter it becomes, the looser its antagonist bandaging around joints, fibrous masses, becomes by reciprocal inhibition. along with tough fibrotic ropes and cysts in Shortening of the fascia surrounding the the muscle bellies. hypertonic, contracted muscle requires Myofascial restriction weakens the loosening of the fascia in the opposite muscle and holds the skeleton in an direction in accommodation. In acute inefficient alignment, altering the condition the cycle can be described as kinesiological angle of pull. Excessive continuing spasm- pain-spasm. This results deposits of connective tissue correlate with in tightness and can progress from the acute areas of spasticity. Adhesions branch out to condition of the muscle contraction to actual neighboring structures from these central contracture of the muscle leading to points. chronicity. In chronic condition the cycle is Unwanted bonding can be the results described as pain-looseness-pain. The of faulty muscular activity. The child with application of the tight loose concept is fluctuating tone holds and braces posturally fundamental to the therapeutic use of the in an effort to grade the range and speed of MFR. movement. Over time, these holdings and

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The second concept is that of the tightness is sought to achieve improvement role of the palpation in myofascial pain in symmetry of function and form. syndromes. There are many diagnostic and therapeutic systems built upon peripheral Technique of Myofascial Release [5] stimulation .Palpation of the myofascial Making contact elements can frequently identify a safe site The process is begun by placing one of initiation for myofascial pain which can hand on the patient. Enough pressure should be therapeutically addressed by the hands. A be applied to take up the slack in the skin. significant proportion of the myofascial The pressure should be directed towards the sensitivity appears to be mediated by the supporting surface. The skin underlying the autonomic nervous system; some of the tissues should be felt like soft cushion. The symptoms found with myofascial pain are body’s connective tissue responds to probably mediated by sympathetic nervous pressure, traction (stretch) and the friction system reflexes. It is interesting to note the they generate. Therapist’s touch increases frequent occurrence of myofascial pain in body temperature and the energy level of the areas of soft tissue looseness. tissue, creating a greater degree of fluidity to The third concept deals with the the system. neuroreflexive change that occurs with the Evaluating for fascial mobility and tone application of manual force on the The examiner then slightly tracks the musculoskeletal system. The hands on skin and assesses the mobility of the tissues approach offers afferent stimulation through superiorly and then inferiorly, medially and receptors, which require central processing then laterally, clock wise then counter clock at the spinal cord and cortical levels for a wise. Comparisons can be made regarding response. Afferent stimulation frequently the direction of ease and greatest motion. In results in efferent inhibition. This principal one of the direction therapist may sense an is used in MFR technique when the afferent abrupt end to the tissue range, as if therapist stimulation of a stretch is applied and the running in to a wall, a fascial barrier. operator waits for efferent inhibition to The tone or quality of each person’s occur so that relaxation results in tight connective tissue is unique. The quality of tissue. Neuroreflexive response is the tissue will vary on different parts of the individualistic and appears to be modified same body. Restricted tissue feels sluggish by the amount of pain, the patient’s pain when moved. The tissue is dense and may behavior the level of wellness, tress feel dry, since the ground substance is less response and basic life style of the fluid. individual, particularly the use/abuse of Step I: Getting Ready alcohol, tobacco and drugs including The therapist’s hands should be medications. placed on the body using a light amount of The fourth concept is that of the pressure. Then lengthening of elastic “release” phenomenon. This concept is component of the tissues should be done shared with other forms of manual medicine; until palpation of first barrier or end range. particularly the cranio sacral technique and Sufficient traction should be maintained to the ease bind principle of functional indirect hold the tissue at its end range. Focus should technique. Release, in MFR concept, is the be on traction rather than on the pressure. tissue relaxation, which follows the Traction should be held for at least 90 to 120 appropriate application of stress on the seconds before the tissue will begin to soften tissue. The tightness “gives way” or melts and lengthen. Therapist should relax the under the application of the load. Release shoulders and gently lean in to the traction. becomes an enabling and terminal objective Since the therapist’s pressure and traction of the application of MFR. Release of create friction deep within the connective

International Journal of Health Sciences & Research (www.ijhsr.org) 72 Vol.2; Issue: 2; May 2012 tissue structure, build up of heat or a Removal of hand placement should be tingling, fluttering sensation may be felt. accomplished slowly. Tissue mobility and This feedback often occurs just prior to the range of motion should be reassessed. release. Step IV: postural integration Step II: The lengthening processes Follow up after MFR should be done with As the tissue begins to soften and guided antigravity motion. The therapist lengthens, the barrier slowly fades. guides body in motion in a way that Therapist will find himself making encourages the patient to use new alignment automatic adjustments in traction and and new available ROM. pressure as the tissue releases. These adjustments are rarely based on Types of MFR [7] preconceived logic. Rather, the tissue, at a MFR refers to soft tissue subtle proprioceptive level, seems to pull in manipulation techniques. It has been loosely or push out based on its need. Therapist used for different manual therapy, soft tissue should trust what he is feeling and respond manipulation work (connective tissue to it. massage, soft tissue mobilization, Rolfing, Following the tissue as it lengthens: strain-counter strain etc.) As the therapist moves through the 1. Direct myofascial release first barrier, he should follow the tissue 2. Indirect myofascial release rather than forcing it in a predetermined 3. Self myofascial release direction. The therapist will follow the tissue wherever it goes, resisting its tendency to Direct myofascial release shorten again. As the tissue lengthens itself The direct MFR method works from surrounding structures it may get directly on the restricted fascia. The caught in a loop or repetitive pattern. By practitioners use knuckles, elbows, ulnar gently holding the traction steady the border of the hands, fist or other tools to repetitive patterns can be resisted. It will slowly sink in to the restricted fascia then begin to release in a new direction. applying few kilograms force or tens of While moving through many barriers, Newton and stretch the fascia. (Figure I) therapist should wait at each barrier, with This is sometimes referred to as deep tissue patience. The therapist should ensure that work. Direct MFR seeks for changes in the his shoulders and neck are relaxed. myofascial structures by stretching, Therapist may shift body weight and elongation of the fascia, or mobilizing reposition himself, ensuring that the traction adhesive tissues. There can be is maintained. misconception that the direct method is Step III: Completion violent and painful. It is not essentially When movement or creep subsides aggressive and painful, as the practitioner or when meeting the end of an area for hand moves slowly through the layers of the placement therapist may come off the body. fascia until the deep tissues are reached.

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Trapezius Planter surface of foot

Figure I : Direct myofascial release

Technique of direct MFR  Maintain a light pressure to stretch  Land on the surface of the body with the barrier and wait for the appropriate “tool” (knuckles, or approximately 3-5 minutes. forearm etc)  Prior to release, the therapist will fell  Sink in to the soft tissue. a therapeutic pulse (Heat).  Contact the first barrier/restricted  As the barrier releases, the hand will layer. fell the motion and softening of the  Put in a “line of tension”. tissues.  Engage the fascia by taking up the  The key is sustained pressure over slack in the tissues. time.  Finally move or drag the fascia across the surface while staying it Self myofascial release touch with the underlying layers. Self myofascial release is when the  Exit gracefully. individual uses a soft object to provide MFR under their own power. Usually an Indirect myofascial release individual uses a soft roll, or ball(tennis ball, The indirect method gentle stretch, soccer ball) on which to rest one’s body the pressure is in few grams, the hands tend weight, then, by using gravity to induce to go with the restricted fascia, hold the pressure along the length of the specific stretch, and allow the fascia to “unwind” muscle or muscle groups, rolls their body on itself. The gentle traction applied to the the object, slowly(1-2 seconds an inch), restricted fascia will result in heat, increase allowing for the fascia to be blood flow in the area. The intension is to massaged.(Figure II) Upon any sharp pain, allow the body’s inherent ability for self individual must back up and hold the correction returns, thus eliminating pain and position, so as to not force undue stress upon restoring the optimum performance of the the fascia and muscle. By holding the roll body. just before the pain, it allows the myofascial Technique for indirect MFR time to relax and release before continuing  With relaxed hand lightly contact the through the roll. If the pain does not go fascia and slowly stretch the fascia away, one may have to use a softer object. until reaching a barrier restriction.

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Body is positioned prone with quadriceps on foam roll. It is very important to maintain proper Core control (abdominal Drawn-In position & tight gluteals) to prevent low back compensations. Roll from pelvic bone to knee, emphasizing the lateral thigh Quadriceps Figure II: Self myofascial release [8]

Benefits of self-myofascial release 3. The patient may experience an 1. Correct muscle imbalances autonomic nervous system response 2. ↑ Joint range of motion such as becoming light headed, 3. ↓ Muscle soreness & relieve joint change in body temperature or hear stress rate. Respirator cycles also may 4. ↓ Neuromuscular hyper tonicity change during the process. These 5. ↑ Extensibility of musculotendinous changes are temporary in reaction to junction the tissues opening and will reside 6. ↑ Neuromuscular efficiency momentarily. Caution should be 7. Maintain normal functional muscular taken to not to move quickly if these length reactions are occurring. 4. Muscular soreness may result from Reactions to myofascial release [9] the tissue lengthening. This should When utilizing myofascial methods be less than is experienced through for improving mobility of the structures traditional stretching. Encourage the symptoms may occur in the patient. These patient to drink water to flush the reactions to the tissue unwinding express system of any release of toxins themselves in several ways. The following is through the tissues opening up. a short list of possible reactions, which may 5. The patient may demonstrate an occur during of the following the treatment. emotional reaction to the physical 1. Vasomotor reactions to the release of the tissue. This may be elongation of the tissues may occur. observed in the form of laughter, The skin may flush and redness may sadness, expression of anger or fear be observable. The pattern of by the patients. It is important to distribution of this reddening may respect your patient individual travel beyond the placement of the reactions during this period of tissue hands. Vasomotor responses may release. You should supportive indicate other area of possible during the session as a natural part of restriction. being with your patient. 2. The perception of increased flow of energy in tight area, which is Myofascial release treatment can help in releasing. The therapist or the patient [10] may experience the perception of a 1. Chronic pain buildup of heat from the area, a 2. Backache and pelvic imbalance throbbing or vibration in the tissues 3. Neck & shoulder pain & tension or a pulsation below the hand. The 4. Headaches patient may describe itching, pulsing, 5. Jaw discomfort, teeth grinding & or burning sensation, which has a clenching crescendo or a rise and fall. 6. Sciatica 7. Carpal tunnel syndrome

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8. Tennis & golfer elbow child and they may attempt to hold 9. General discomfort & muscular their body stiff or hold their breath. spasm Slow progression is the key and 10. Trigger point formation maintaining a safe environment. 11. Muscle tightness and muscle When swallowing becomes spasticity disorganized follow up with head 12. Dizziness & vertigo and neck activation. When breath 13. Menstrual discomfort holding occurs gently remind the 14. Fibromyalgia child to breathe in. 15. Planter fascitis 6. When approaching a patient the 16. Sports injuries therapist should not demonstrate 17. Frozen shoulder intent to stretch the tissue. The 18. Whiplash approach should be supportive with a 19. Post surgical & injury scarring slow onset and termination of the Myofascial release treatment can also method .The goal of using this 1. Increase energy method is to permit the natural creep 2. Restore muscular function and of the connective tissue to allow for postural alignment elongation of the tissues under our 3. Relieve physical and emotional sustained touch. strain 4. Increase awareness of holding and Contraindications [11] bracing patterns Avoid MFR during the following conditions 5. Promote relaxation 1. Febrile states 6. Balance the body, mind and soul 2. Systemic or localized infections 7. Promote self healing 3. Surgical incisions and open wounds 4. Healing fractures Precautions [11] 5. Acute inflammation-Rheumatoid Precautions should be taken in the following conditions conditions: 6. Cancer or tumors conditions 1. Osteoporosis: Use gentle pressure. 7. Aneurysm 2. Hypotonia: when elongating tissue 8. Anti coagulant therapy follow with control as tissue 9. Osteoporosis or advanced tightness may some structural degenerative changes stability. 10. Hypersensitivity to skin 3. Athetosis: Tissue tightness may be 11. Advanced diabetes used to give integrity to structure and lengthening of the tissue should be Evidence for MFR use followed with activation of placing, There is no scientific evidence to holding and slow controlled support the use of rolfing (MFR) for any movements. medical condition. [12] 4. Scar tissue release: should be The idea that a rolfer can apply force provided slowly and over time in to fascia and lengthen it and remove tension order for the comfort of the patient. is completely false. [13] (Grimm 2007) 5. Breathe Holding and disorganized In 2004, a systematic review found swallowing patterns: demonstrate a that there is no evidence-based literature to loss of holding pattern, support rolfing in any specific disease disorganization in control and group. [14] (Jones 2004) possible resistance in the client. The In 2008, a systematic review was release may be frightening to the unable to find any evidence demonstrating

International Journal of Health Sciences & Research (www.ijhsr.org) 76 Vol.2; Issue: 2; May 2012 the efficacy of myofascial release 4. Michael R Barnes , review whatsoever. Just like rolfing, there was a management of spasticity, age and complete lack of evidence basis to support ageing 1998; 27: 239-245 its use. [15] (Remvig 2008) 5. Regi Boehme, Johm Boehme, Myofascial Release and its SUMMARY Application to Neuro- Developmental Treatment, 1991, pg. Myofascial Release is a very no. 5-8, 11-16, 80. effective, gentle and safe hands-on method 6. Ph. E. Greenman, Principles of of soft tissue mobilization, developed by Manual Medicine, 3rd edition, 2003, John Barnes that involves applying gentle pg. no. 157. sustained pressure to the subcutaneous and 7. Carol Manheim. 2001. The myofascial connective tissue. The goal of Myofascial Release Manual. 3rd myofascial release is to release fascia Edition. Slack Inc. restriction and restore its tissue. This 8. http://www.sport-fitness- technique is used to ease pressure in the advisor.com/self-myofascial- fibrous bands of the connective tissue, or release.html fascia. Gentle and sustained stretching of 9. John F. Barnes, Myofascial Release myofascial release is believed to free The ""Missing Link"" in Your adhesions and softens and lengthens the Treatment, PT Today, 1995 fascia. By freeing up fascia that may be 10. Copy right Nancy c. Rasch OTR impending blood vessels or nerves, rev.09/01 myofascial release is also said to enhance 11. Ward, RC, 2003, Integrated the body’s innate restorative powers by Neuromusculoskeletal Release and improving circulation and nervous system Myofascial Release, in Ward RC, transmission. This low load sustained stretch 2003, Foundations for Osteopathic gradually, over time, allow the myofascial Medicine, 2nd edition, Chapter 60, tissue to elongate and relax, thus allowing pp 932-968, Lippincott, Williams increased range of motion, flexibility and and Wilkins, Philadelphia decreased pain. 12. Rolfing ( Myofascial Release) Posted by Skeptical Health On January 16th, REFERENCES 2012 13. David Grimm Cell Biology Meets 1. Carol J. Manheim, The Myofascial Rolfing Biomedical Research.23 Release Manual, 3rd edition, 2001, pg November 2007; Vol 318 no. 2. 14. Jone TA. Rolfing. Phys Med Rehabil 2. John F. Barnes, Pediatric Myofascial Clin N Am. 2004; 15(4):799-809 Release, Physical Therapy Forum – 15. Lars Remvig, Richard M. Ellis, MFR Techniques, 1991 Jacob Patijn.Myofascial release: an 3. G. Sheean, The pathophysiology of evidence-based treatment approach? spasticity, Department of International Musculoskeletal Neurosciences, Medical School, Medicine. 2008; 30 (1) University of California ± San Diego, CA, USA

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