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EFFECTIVE SELF-MANAGEMENT OF MYOFASCIAL DYSFUNCTION

Presented by:Jonathan Reynolds, PT, PhDHogsback, Inc.

Myofascial Pain Syndrome• Sensory, motor and autonomic symptoms caused by

myofascial trigger points de Baillou (1538-1616)

• Nodular tumors and thickenings which were painful to the touch and from which pain shot to neighboring parts. Balfour 1816

• Small, tender and apple-sized nodules and painful pencil-sized to little finger-sized palpable bands Strauss 1898

• Hyperirritable spot in skeletal muscle….taut band…which is tender when pressed Travell and Simons, 1983

Myofascial Pain Syndrome• Motor effects:

• Disturbed motor function

• Muscle weakness• Muscle stiffness

• Restricted range of motion

• Sensory effects• Local tenderness

• Referred pain• Peripheral sensitization

• Central sensitization

• Signs of peripheral and central sensitization• Allodynia – pain hypersensitivity induced by innocuous stimulus

• Hyperalgesia – increased sensitivity to pain

Motor Effect

Motor inhibition is often identified clinically as muscle weakness, but treatment often focuses on strengthening exercises that only augment abnormal muscle substitution until the inhibiting TPs are inactivated –

McPartland and Simons in Myofascial Trigger Points by Dommerholt and Huibregts

Myofascial Pain Syndrome• Most missed diagnosis:

• 95.5% of 110 people with lower back pain had MPS in paraspinal, piriformis or tensor fascia latae – Wiener et al, 2006.

• 94% of headache symptoms reproduced with manual stimulation of cervical and temporal MTPs compared to 29% of controls – Calandre et al,

2006.• 30% of migraine sufferers had MTPs that triggered full-blown

migraine when MTPs were manipulated - Calandre et al, 2006. • MTPs found with:

• Radiculopathies• Tendinitis• Disk pathology• Computer-related disorders• Carpal tunnel syndrome• Whiplash• Pelvic pain, etc.

Myofascial Trigger Point – Causes

• Low level contractions• Uneven intramuscular pressure distribution• Direct trauma• Unaccustomed eccentric contractions• Eccentric contractions in unconditioned muscle• Maximal or submaximal concentric contractions

Dommerholt, Bron, Fransen: Myofascial Trigger Points: An Evidence-Informed Reviewin Myofascial Trigger Points by Dommerholt and Huibregts

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Myofascial Trigger Point – Contributors

• Overuse• Chill• Muscular strain• Fatigue• Improper nutrition• Ergonomic stress• Caffeine intake• Nicotine use

Travell and Simons, 1999

Myofascial Trigger Point Etiology• Motor End Plate (MEP) Hypothesis – (Simons)

• Ca2+ influx into MEP bouton → excessive ACh release• Spontaneous Electrical Activity (SEA)• “End plate noise” on EMG • 1% increase in muscle stretch → 10% increase in Ach

(Chen and Grinnell, 1997)

Endplate Hypothesis – Motor Component

• Contraction knots• Sensory nerve compression → Increased ACh release• Blood vessel compression → Oxygen depletion +

Increased metabolic demand → ATP depletion (ATP crisis)• ATP crisis:

• Pre-synapse → ↑ ACh• Post synapse ↓ Ca2+ re-uptake → ↑ contractile activity (spasm)

• MTPs can excite or inhibit motor activity (local or functionally related muscle.

• Strengthening effects:• Muscle substitution• Poor coordination• Muscle imbalance

McPartland and Simons, 2006

Endplate Hypothesis – Sensory Component

• ATP energy crisis → K+, proton, free O2 radical release• Histamine released from mast cells migrate to damage• Serotonin released from platelets• Bradykinin released from serum protein • Histamine, serotonin and bradykinin initiate action potential• Sensitizer (prostaglandin, leukotriene, substance-P) release → ↓ neuron activation threshold → peripheral sensitization

• Central sensitization → • allodynia (pain in normally non-painful areas) and

• hyperalgesia (↑ sensitivity to pain).

Endplate Hypothesis – Autonomic Component

• Sweating• Vasoconstriction• Vasodilation• Pilomotor activity (goose bumps)• Head and neck:

• Lacrimation

• Coryza

• Salivation

• Vessel sympathetic neurons can terminated on muscle spindle → disruption of muscle length feedback control → ATP crisis.

Manual Techniques• Massage

• Rolling

• Friction (Deep Transverse Friction – Cyriax)

• Ischemic compression (Travell and Simons, 1983)

• Press and Stretch (Travell and Simons, 1999)

• Integrated Neuromuscular Inhibition Technique (INIT)• Muscle Energy Technique (MET)• Spray and Stretch

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Traditional Self-Care• Ball:

• Tennis

• Lacrosse

• Golf

• Softball

• Thera Cane, Backnobber• Knobbler• Stretching

• Frequency

• Appropriate

• Neurophysiology

• “Weakness”

• Pressing, rubbing, manipulating: skin, muscles, tendons, ligaments, fascia

• Reduces• Stress• Pain• Muscle Tension

• Benefits• Headaches• Myofascial pain syndrome• Soft tissue strains or injuries• Sports injuries• Temporomandibular joint pain

Massage

Ref: Mayo Clinic

&Self-Management

Why Self-Management• Better outcomes

• Lower cost• Lower levels of pain-related disability (Blyth et al, 2005)

• Less reliance on medication (Blyth et al, 2005)

• Patients feel empowered (Smith and Elliot, 2005)

• Massage* with exercise better than joint mobilization, PT, self-care education and acupuncture (Furlan et al (Cochrane Review), 2010)

• Convenient• No or fewer appointments• Better compliance with treatment programs (Smith and Elliot, 2005)

• Speed up recovery• Manual therapy familiarity• Unaddressed causative factors

• Ergonomics• Overuse• Biomechanics

* Delivered by hand or device

Pitfalls of Self-Management• Missed diagnoses of serious illnesses

• Cardiac disease (Owen-Smith et al, 2003)

• Cancer (Auvinen and Karjalainen, 1997)

• Sequelae of inappropriate self-medication (Downie et al, 2000)

• Inappropriate targeting (Smith and Elliot, 2005)

• Lack of training in the implementation (Smith and Elliot, 2005)

• Ineffective intervention (Smith and Elliot, 2005)

Case Study• 59 year old business executive (multi-national)• Medical history

• Lumbar and cervical disk injuries (lumbar fusion)• Rotator cuff repair• Achilles tendon repair• Upper crossed syndrome (Janda) with associated

increased kyphosis

• Recreation• Grouse hunting• Sailing (44’ trimaran)• Intense home gym workouts (2 hours a day)

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Case Study• Self-management

• Foam roller work• Rumble roller• TOLA system

• Neck• Shoulder girdle (levator scapulae, rhomboid, upper trapezius)• Gluteus medius• Occiput• Thigh

• Stretching exercises• Strengthening

• Lower trapezius• Serratus anterior• Gluteus maximus

Case Study50

40

30

20

10

011/21/2011 11/28/2011 1/12/2012 2/8/2012 5/31/2012

Deg

rees

Thoracic Minimum Kyphosis

• Physical therapy• Monthly• 6 monthly• Yearly

• Outcome• Normal kyphosis• No neck pain• Fully functional• Pistol

Self-Management• Traditional home exercise program

• Strengthening

• Stretching

• Balance work

• Plyometrics etc.

• Manual Therapy option

•Release

•Stretch

•Strengthen

Self-Treat Tools

• Balls• Tennis

• Golf

• Lacrosse

• Rollers• Foam

• Rumble

• Canes• TheraCane

• Backknobber

• Others

• Background• About Hogsback• Design characteristics

• Tola Point• Tola Wedge• Tola Rocker• Tola Strap

• Pressure• Force per unit area

• Force (body part)

• Area (Point)

Lower Back Pain

• Compensatory mechanics• Trigger points

• Gluteus medius

• Piriformis

• Hamstrings

• Hip flexors

• Paraspinals

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Case Study – Lower Back• 58 y.o. male, warehouseman (forklift operator) • Tripped and fell: herniated L3/4, L4/5 July 2010• Failed conservative treatment• Laminectomy: August 2010• No relief• Oxycontin and Oxycodone • Previous history of substance abuse• Examination suggested myofascial dysfunctionLumbar ROM Norm Result Difference % Norm

Lumbar Flexion 60° 9° 51° 15%

Lumbar Extension 25° 7° 18° 28%

Lumbar Lateral Left 25° 7° 18° 28%

Lumbar Lateral Right 25° 4° 21° 16%

Motion Range

Straight Leg Raise Left 17°

Straight Leg Raise Right 17°

Case Study – Lower Back• Deep trigger point release, stretch to:

• Gluteus medius

• Piriformis

• Hamstrings

• Paraspinals (erector spinae, quadratus lumborum)

• Core strengthening exercises• TOLA instruction on 11/10/2011

Algometry Left Right

Test Norm Cutoff Avg C/O Diff Bilateral Diff Avg C/O Diff

Gluteus medius 14.1 lbs 9.5 lbs 6.2 lbs -3.3 lbs -0.4 L 6.6 lbs -2.9 lbs

L4 Paraspinals 17.6 lbs 12.3 lbs 6.9 lbs -5.4 lbs -2.4 R 4.5 lbs -7.8 lbs

80

64

48

32

16

09/15/2011 11/2/2011 11/10/2011 11/16/2011 1/6/2012 1/16/2012

Degrees

Inclinometry - Lumbar Flexion Norm Flexion

80

64

48

32

16

09/15/2011 11/2/2011 11/10/2011 11/16/2011 1/6/2012 1/16/2012

Degrees

Inclinometry - Straight Leg Raise Left Right

15

12

9

6

3

09/15/2011 10/6/2011 11/2/2011 11/10/2011 1/6/2012 1/16/2012

Force (lbs)

Algometry - Gluteus medius Left Right

20

16

12

8

4

09/15/2011 10/6/2011 11/2/2011 11/10/2011 1/6/2012 1/16/2012

Force (lbs)

Algometry - L4 Paraspinals Left Right

Headache• Upper trapezius: temporal area and eye• Sternocleidomastoid: top of the head, around

the eye, or across the forehead.• Temporalis: side of the head, jaw and teeth. • Splenius:• Capitus: top of the head • Cervicis (suboccipital muscles): side of the

head and to the outside of the eyes.• Semispinalis:• Cervicis: occiput • Capitus: temporal region, side of the eyes.• Levator scapulae: side of the head, forehead.

Case Study – Headache• 48 year old woman• 6 year history of temporal and frontal headache• Treated with medication• Missed work• Trigger points in splenius capitis, upper trapezius, sterno-

cleidomastoid• Responded well to manual therapy

• Deep trigger point release

• Occipital release

• Transverse mobilization to C1 in rotation

Case Study – Headache• 3 sessions of PT• TOLA system taught at 2nd session• Discharged with

• TOLA

• Stretching exercises

• Postural correction exercises

• Ergonomic checklist for seated workstation

• 3 months:• Mild headaches

• Less frequent

• Mostly hormone related

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Frozen Shoulder• Lateral arm fascia• Posterior capsule• Anterior capsule/biceps• Infraspinatus• Rhomboid• Self-Treat (Release, Stretch, Strengthen)• RRE

• Overall average visits: 8

• Self-treat 30% (Tola release, stretch, strengthen)

• Average visits after Tola: 3.5

Case Study• 64 year old man• No thyroid disease• No diabetes• Insidious onset of adhesive capsulitis• Non-dominant side• Niel-Ascher Technique

(www.frozenshoulder.com),• Maitland mobilization• Proprioceptive neuromuscular facilitation

(PNF)• Stretching exercises• Strengthening exercises.

Case Study• TOLA System added at 5th visit

• Lateral upper arm fascia

• Posterior capsule

• Anterior capsule

• Infraspinatus

• Rhomboid

• Stretching• Discharged after 7th visit

• Fully functional in ADLs

• Independent in:• TOLA application• Stretching

80

100

120

140

160

180

1 2 3 4 5 6 7

Flexion (Degrees)

Visit Number

Flexion Active Range of Motion

Pre- and Post-Treatment

Flexion (Pre-Treatment)

Flexion (Post-Treatment)

80

100

120

140

160

180

1 2 3 4 5 6 7

Abduction (Degrees)

Visit Number

Abduction Active Range of Motion Pre- and Post-

Treatment

Pre-Treatment

Post-Treatment

Muscle Strains• Hamstrings• Gastrocnemius• Soleus• Quadriceps• Shoulders• Hip flexors• Hip external rotators• Pectoralis major/minor• Back• Neck• Feet

•Questions

Information on the TOLA System:www.tolapoint.com

Information on purchasing the TOLA System:www.optp.com