By: Lynda Keene and Julia Meno, CTRS, CMT, ATRIC
July, 2020
Myofascial dysfunction and pain are rarely identified by our patients/clients and specific movement rarely provokes, reproduces or identifies their symptoms or the specific area of pain, unless the activity produces tension along one of the associated fascial line. There are exceptions to every rule however and the general laxity of hypermobility is one of those. With the widely accepted connectivity of every region of the body we must not rule out areas that would otherwise seem none related.
Here's The Fascial pathology:
Trauma: Past or present trauma causes inflammation which is a normal part of healing however too much or prolonged inflammation can lead to the binding down of the fascia and fibrosis.
Micro-injuries: Due to overloading, over training or heavy repetitive jobs
Immobility: From excessive bed rest or immobilization due to illness or injury or through being in a cast for a prolonged period of time
Surgery: The opening and exposure to the atmosphere plus the impact from scarring and adhesions.
Mechanical stress: As a result of poor body alignment and inappropriate mechanical loading.
Long-term systemic tissue inflammation: Chemical insult: toxins in the environment can affect the fascia as it can trigger the body’s defense and immune mechanism causing inflammatory response.
Endocrine effect: New research is investigating the response and changes that can occur in the endocrine system and its impact on fascia
Emotional stress: Stress of any description is known to create inflammatory chemicals in thebrain and body which leads to cellular degeneration. Within the brain it can manifest as memory deterioration with symptoms similar to dementia. If it occurs in the fascia which is where the body stores trauma be it physical, mental or spiritual the fascia becomes thickened which eventually leads to pain and loss in range of movement.
Whatever has caused the initial trauma a biochemical reaction will occur within the connective tissue which in turn will have an effect on the viscoelastic properties causing degeneration, decreased ranges of movement and thus increase pain potential. It has been proposed that tissue injury causes localized ischemia, a restriction of blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism, this leads to localized hypoxia. The subsequent oxygen deprivation promotes adhesion of the connective tissue
(Shah et al 2005, 2008). Ultimately collagen microfibers form in between adjacent layers of fascia binding them together causing fibrosis, adhesion formation or scar tissue. Thus preventing the normal slide and glide of the tissue, as the fascia thickens it can disrupt motor patterns, balance and proprioception. This can lead to chronic tissue loading, further injury and global soft tissue loading issues (Chaitlow & Delany 2000).
Fibrosis does not always dissipate after the healing process has finished and it can
accumulate over time. The more adhesions there are the more restriction and less elastic the area will become (Scheirling 2017). Restricted movement results in a loss of ground substance in the connective tissue resulting in a loss of lubricating effect, binding of fascial elements. Nutrition and blood supply will be limited. In addition the viscoelastic properties needed for smooth rhythmical movement for force transduction become thwarted and stagnate. This stagnation in the cells greatly reduces the biophysical communication of blood circulation , nerve conductivity and lymphatic flow in the affected tissues which in turn become hard and isolated in texture and movement. This previously described calcification and restriction within the fascial matrix becomes a burden to the system and can cause a build up emotions to further create a somatosensory response. “This can create physiological chaos and seems to point to a structural reason for some people’s depression, anxiety, pain and/or headaches.” (Barnes 2011) Clients may state “I feel disconnected” between their mind and body, which can create emotions, like resentment, mistrust, sadness and anger, that can lead to somatic dysfunction (Gusack 2018).
Myofascial Release (MFR) is the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function. (Barnes 1990) Myofacial release techniques are essentially of two categories, (Passive - direct and indirect in that the client is a passive receiver), and (Active - where as the client is an active participant). The techniques can be used independently or in combination with each other.
A water temperature of 87 0 – 92 0 F is an ideal environment for myofascial release therapies due to the inherent physiological response to immersion (Wilcock et al. 2006). The myofascial releases can be performed in a fluid three-dimensional space with ease of movement for both active and passive techniques. For fascial information gathering the MFR practitioner should always conduct a visual assessment on land preferably with a background grid to grade or photograph the notable restrictions, evident by postural rotations and/or shortening of muscles causing a visual discrepancy at bony landmarks
(Estes 2015). Then, in the water the practitioner should do an assessment of asymmetry in both the vertical position and the supine float position. For the assessment it is important to minimize turbulence whilst providing support, warmth and trust to maximize client/ pt. relaxation. The pronounced asymmetry will reveal fascial restrictions and adhesions that can interfere with functional ROM. Note in the vertical position to observe postural positioning
and bracing behaviour. Tight or shortened muscles and fascia will cause rotation in various planes (transverse, longitudinal, coronal, and sagittal). In the water, due to buoyancy and hydrostatic pressure, the client/pt. does not have the proprioceptive grounding that they have on land and the muscle imbalances cause rotation (Meno 2007).
Types of Aquatic Myofascial Release:
Direct Myofascial Aquatic Technique is when the practitioner directly manipulates the muscle tissue. Physically applying stretching, lifting, grasping, vibration, compression, needing, etc. as a means to lengthen or change the muscle fibers. Watsu™, Aquassage™ and Aguahara are all passive yet direct aquatic myofascial release modalities. Active aquatic positional release, a.k.a. AquaStretch™ (AS) is a direct yet active myofascial aquatic release. AS practitioners apply trigger points (TP’s) and reflex holds, in combination with active intuitive movement.
Aquatic fitness programs are the most common and universally performed myofascial mobilizations and releases. An example would be Aqua Yoga Stretches, or the use of a water noodle for a buoyancy assisted stretch and hold. For another active direct technique consider a foot planted in one spot on the pool bottom whilst the other foot- steps fwd., back, side to side and then on diagonals. This controlled movement around a fixed extremity in all directions increases proprioceptive awareness and lengthens fascial muscle chains. Now an example of a bilateral closed chain aquatic myofascial stretch: both hands holding
onto the pool edge or bar, the feet are fixed on the wall and the hips, knees and ankles are flexed. Then move either to the R or L by extending one leg to stretch adductors on the medial line as well as the gluts on the flexing leg.
Indirect Myofascial Aquatic Release, the practitioner should test the tissues elasticity and movement in all planes; up, down, side, to side, on the diagonal and when rotated. Find which direction the muscle and fascia move with ease and in which direction is met with resistance (Travell 1983). The client’s body will tend to move through the water when a restriction is found. The tissue will abruptly stop at a fascial barrier and client’s body on a whole will rotate in the water on whatever plane the restriction is in. The practitioner then follows the myofascia into its shortened state, the direction of least resistance, and holds the myofascia in that position for up to 90 seconds, taking up the slack in the tissues as it
releases. Once the practitioner feels a melting, stretching or shearing sensation between the hands they follow that movement with light compressive force in whatever direction it wants to move for a release. (Barnes 2010) Then, test to see if the restricted direction has improved.
Passive aquatic positional release is an indirect technique. First the practitioner finds a precise position that relaxes the body and is the most comfortable position for the client. Then the practitioner locates an active (TP) and maintains finger pressure whilst gently moving client’s body in the direction of least resistance. The client is passively brought through movement planes until there is no pain at the TP. Hold for at least 90 seconds until a release is felt.
Strain-Counter-Strain Release, developed by Dr. Lawrence Jones, is when after the muscle is stretched indirectly the practitioner then applies stretch in the opposite, more restricted direction and holds as the tissue releases. Douglas Kinnaird, NCTMB developed Trunk Act, a method of strain-counter strain performed on the client in the water.
Myofascial Unwinding (MFU) also called as indirect MFR technique is defined by (AACOM) as “a manual technique involving constant feedback to the osteopathic practitioner who is passively moving a portion of the patient's body in response to the sensation of movement. Its forces are localized using the sensations of ease and bind over wider regions” This MFU technique has been practiced in the water as Water Dance, Wassertanzen and most recently
as Mermaid Fascial Freedom™. As the client relaxes into the gentle sustained stretch, the practitioners direct MFR modalities turn to indirect, by following the tissue as opposed to moving or manipulating the tissues. The body moves, unwinds, encouraging muscles to find an easier, or more relaxed position (Minasny 2009). The unwinding is described as a profound energetic release and accompanied with spontaneous movements of the body. It is very freeing in warm water and clients feel a deep state of relaxation following an aquatic myofascial unwinding.
So, what does a myofascial release feel like? It is a melting, shearing, stretching sensation. Often accompanied with a sigh or a yawn. This a sign that the neuromuscular mechanism has relaxed the tension. As the client breathes, the tissue can now expand and contract. There is a profound shift in the body as the fascia releases and oxygenated blood, lymphatic flow and neuro-conduction are slowly being restored. As cellular rehydration occurs along with the removal of stagnated and congested fluids the body begins to heal itself. As the individual has the experience greater ROM and less pain he/she often feels an emotional
release as well. Clients who had previously lived in chronic pain have a sense of hope that they learn a new context of movement and control. The somatic effect of the release of fascial restrictions 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 (Adelaida María Castro-Sánchez, et al 2010).