This document discusses myofascial pain syndrome (MPS), also known as chronic myofascial pain. MPS is characterized by chronic pain caused by multiple trigger points and fascial constrictions. Fascia is a layer of fibrous tissue that surrounds muscles, bones, blood vessels and nerves. Trigger points in fascia can cause focal tenderness and referred pain patterns. Myofascial release techniques aim to relax contracted muscles and stimulate the stretch reflex by applying sustained pressure to fascial restrictions to allow the tissue to elongate. MPS is a common cause of chronic pain that can be treated through myofascial release.

1. Dr,Navinder Pal Singh
Professor,
Jammu College Of Physiotherapy

2.  Fibroscitis [Sir.William Goyers]
 Myofascitis [Albee]
 Nonarticular rhuematism
 Tension myalgia
 MPS are among the most commonly
overlooked causes of chronic pain and
disability in medicine (Simons 1988).
 Travell described the term “Trigger point’ and
adopted the expression Myofascial pain
syndrome.“ fibrositis” myofascial pain
syndrome+ fibromyalgia

3.  MYOFASCIAL PAIN SYNDROME-Myofascial pain
 syndrome (MPS), also known as chronic myofascial
 pain (CMP), is a syndrome characterized by chronic pain
 caused by multiple trigger points and fascial constrictions.
 Characteristic features of a myofascial trigger point include:
 focal point tenderness, reproduction of pain upon trigger
 point palpation, hardening of the muscle upon trigger point
 palpation, pseudo-weakness of the involved muscle, referred
 pain, and limited range of motion following approximately 5
 seconds of sustained trigger point pressure

4.  Fascia is a layer of fibrous tissue that
surrounds groups of muscle, bone, blood
vessels and nerves
 • It binds some structures together, while
permitting other structures to glide
smoothly over each other
 • Fascia is classified depending on it’s
distinct layers, functions and anatomical
position – superficial, deep or visceral
 • Fascia are dense regular connective
tissues, containing closely packed
bundles of collagen fibres orientated in a
 wavy pattern parallel to the direction of
pull

5.  Consists of cells and extra- cellular matrix (ECM)
mainly fibroblasts and macrophages.
 • The ECM is made up of fibres, predominantly
collagen and elastin and ground
 substance

6.  Collagen is the fibre that makes fascia tough and durable.
It is inelastic and provides
 tensile strength and integrity. It is stronger than steel!
 Elastin - allows the fascia to stretch and absorb shock
 Ground substance is a viscous gel which provides the
immediate environment of every
 cell in the body
 •It is similar to egg whites in it's consistency.
 •it is able to distribute forces whilst maintaining its shape
 •contains sensory receptors, mechano, chemo, nocci and thermo
receptors and
 therefore is a proprioceptive material
 •contains myofibroblasts which are able to contract in smooth
muscle type manner
 and these are responsive to stimulation and involved with wound
healing autonomic
 nervous system (ANS)

7.  Muscle is composed of fibres, nerves and connective tissues and
 account for over 40% of the body weight.
 • The fibres contract to produce tension on the associated tissues
 or tendons.
 • Muscle tissue is enclosed in fascia, which in turn is attached to
 other structures including ligament.
 There are three types of muscle tissues
 • Skeletal
 • Cardiac
 • Smooth muscles.

8.  Muscle fibres are made up of bundles of
 fascicles
 Several fascicles bound by epimysium to
 form whole muscle
 Connective tissue fascial sheaths
 perimysium and endomysium join at end
 to form tendons
 Muscles are as much fascia as muscle
 fibres hence term myofascial
 Tendon inserts into periosteum

10.  All muscle tissues have a superficial covering of vary
thickness of
 fascia, made of connective tissue and laced with
adipose tissue.
 • Inside the fascia, the muscle tissue is surrounded
 by epimysium and individual muscle bundles or
fascicles are
 surrounded by perimysium.
 • Endomysium is the connective tissue that separates
muscle
 fibers within a fascicles.
 • The unit of fascicles is a muscle fibre (or cell) called
myofibril

11.  Physical
 •To reduce friction
 •Provide a sliding environment for muscles
 •Suspend organs in their “proper” place
 •Transmit movement from muscles to bones
 •Provide a supportive and protective environment for
nerves and
 blood vessels as they pass through and between muscles.
 •Facilitates circulation – lymph and blood
 •Provides support and connection
 •Physiological adaptable - plastic

12.  Movement facilitator
 •Reduced friction at macro and micro level
 •Distributor of forces/shock absorber
 •Enhances force generated by muscle contraction –
rebound
 •Provides a pre-tensioned background tone making
muscle
 contraction more effective and efficient ( feel like
being shrink
 wrapped)
 •Pre tensioned tone allows for maximum response
during fight
 or flight

13.  Communication
 •Mechanical pull and vibration – through the concept
of “tensegrity”
 •Fascia has piezoelectric force. i.e changing
mechanical force into electric energy
 •A sensory proprioceptive organ receiving and
responding to mechanical and chemical information
via receptors.
 These sensory nerves also communicate with the ANS
influencing blood flow and muscle tone.

14.  The single muscle theory
 The double bag theory
 Tensegrity

15.  Age and injury can cause an increase of laying down of
 collagen, increased cross linkages and restrictions
 (adhesions)
 • Fascia increases its density and looses its ability to slide
 freely when:
 • Trauma and injury
 • Infections or disease
 • Over and under use
 • Ischemia
 • Local and systemic inflammation
 • Tissue dehydration
 • Emotional stress and centralized pain

16.  For example: injury – micro tearing and fibrosis formation
will affect
 • Electrical conductivity in fascia
 • Cell to cell communication
 • Interfere with freedom of movement of fascial planes and
 communication properties
 • Sensitisation of nerve endings
 • Influence plastic adaptation
 SO – the local pathology will affect local fascial
communication
 and cause a cascade of more remote symptoms.

17.  Loss of mobility and range of motion
 Increased amounts of scar tissue and adhesions
 Increased tone of over active muscles
 Poor quality of movement

18.  Local Systemic
 Broken skin/Open cuts Cancer (Malignancy)
 Skin conditions Acute Circulatory disorders
 Hematoma Blood Thinning Medications (e.g.
 Warfarin)
 Healing Fracture Bleeding disorders (e.g. Hemophilia)
 Active infections Systemic Infection
 Obstructive Edema
 Acute RA
 Advanced Diabetes

19.  Pregnancy
 Hypersensitivity
 Hyper or Hypo- tension
 Patient Anxiety
 Acute/ Inflammatory stage of healing

20.  Myofascial release ( MFR) is a soft tissue therapy for the
 treatment of skeletal muscle immobility and pain. Principle of
 MFR is gentle application of sustained pressure into fascial
 restrictions. A low load applied slowly allows a viscoelastic
 medium to elongate.
 Self-myofascial release (or SMFR) This alternative
 medicine therapy aims to relax contracted muscles, improve
 blood and lymphatic circulation, and stimulate the stretch
 reflex in muscles.
 “Myofascial release" was coined in the 1960s by Robert Ward
 Ward, along with physical therapist John Barnes, are considered
 the two primary founders of MFR
 Direct release Indirect release
 Tissue is loaded with constant fascia unwind itself with
forces until ‘release’ occurs resistance until free movement
 is achieved

21.  Myofascial Release can decreases Pain: it is claimed that this technique can
release
 the body’s natural painkillers, endorphins, by allowing the blood, lymph and nerve
 receptors to work efficiently so pain is relieved.
 It helps to strengthen the immune system. When fascia is restricted, the
lymphatic
 flow is slowed down, which affects the immune system (the body’s first line of
defence
 against infection and primary aid to healing).
 Myofascial Release increases the circulatory flow of lymph and therefore
hastens
 healing of injuries or infections.
 Myofascial Release Technique can work to relieve pressure which may be
caused by
 fascial adhesions pressing on the nerves. Keeping a healthy circulatory system
reduces
 stress on the heart and can prevent painful cramps, brings nutrients to the cells
and
 takes away the waste; Myofascial Release Technique increases circulation and
assists this process

22.  DIRECT THERAPY
 Land on the surface of the
 body with the appropriate
 'tool' (knuckles, or forearm
 etc.).
 Sink into the soft tissue.
 Contact the first
 barrier/restricted layer.
 Put in a 'line of tension'.
 Engage the fascia by taking up
 the slack in the tissue.
 Finally, move or drag the fascia
 across the surface while
 staying in touch with the
 underlying layers.
 Exit gracefully.
INDIRECT THERAPY
Lightly contact the fascia with
relaxed hands.
Slowly stretch the fascia until
reaching a barrier/restriction.
Maintain a light pressure to
stretch the barrier for
approximately 3–5 minutes.
Prior to release, the therapist
will feel a therapeutic pulse
(e.g., heat).
As the barrier releases, the
hand will feel the motion and
softening of the tissue.
The key is sustained pressure
over time.

23.  Back Pain
 Bladder Problems (Urgency, Frequency,
Incontinence, Overactive Bladder,
 Leakage)
 Birth Injuries
 Bulging Disc
 Bursitis
 Carpal Tunnel Syndrome
 Cerebral Palsy
 Cervical and Lumbar Injuries
 Chronic Fatigue Syndrome
 Chronic Pain
 Degenerative Disc Disease
 Endometriosis
 Emotional Trauma
 Fibromyalgia
 Frozen Shoulder (Adhesive Capsulitis)
Herniated Disc
Headaches or Migraines
Infertility
Interstitial Cystitis
Menstrual Problems
Myofascial Pain Syndrome
Neck Pain
Osteoarthritis
Pelvic Pain
Plantar Fascitis
Pudendal Nerve Entrapment
Scars (hypertrophic, hypersensitive, painful, burn
scars, mastectomy scars)
Sciatica
Scoliosis
Shin Splints
Tennis Elbow
Tinnitus (Ringing of the ears)
TMJ Syndrome
Trigeminal Neuralgia
Vulvodynia
Whiplash

24.  Gentle and sustained, pressure should be applied for a specific period
of time
 – a minimum of 90 – 120 seconds
 This amount of time permits fascia to naturally elongate and return to
normal
 resting length which will restore the healthy status quo, giving greater
 flexibility, mobility and eliminating pain.
 Techniques applied for less than 2 minutes will temporarily lengthen
the
 elastic fibres in the muscles and fascia and the tissues will feel looser
for a
 while but gradually tighten up again.
It is like stretching a rubber band – if stretched for a short time it will
quickly
 spring back to its original shape but if left stretched around an object
for
 some time it will remain permanently lengthened.

25.  Skin Rolling
 The practitioner grabs a “roll” of skin and
subcutaneous fascia between his/her fingers and
thumb and rolls this skin or scar tissue while lifting it
away from the body.

26.  In this the therapist may use forearms, palms
 of the hands, or any broad surface. Remember that it is
 important to expedite the stretch to the fascia by either
using body positioning to elongate the myofascial
component or by anchoring with the other hand to
localize the stretch to the specific area needing
lengthening.

27.  These techniques are very useful in working with many
areas including the pectoralis major, the small muscles in
the forearm, the trapezius, and anywhere different muscles
overlap. The lateral leg easily demonstrates this principle,
working along the lateral border of the iliotibial band and
the vastus lateralis, separating the hamstring compartment
from more anterior or lateral muscles. Pressure should be
applied with relatively sharp or precise tools such as fingers
or knuckles, slowly moving up the border of the muscle or
fascial compartment visualizing gently prying the
compartments apart. Asking for active movement on the
part of the client will expedite the process.

28.  It is handy for use with large muscles,such as the pectoralis major or
gluteus maximus,this technique is most often used for long muscles such
as the quadriceps, biceps, triceps, and calf muscles. Slowly lift the muscle
away from the bone and roll it until resistance is felt.This technique is very
useful to improve “tracking”of joints that are disrupted by torsion—forces
that occur when muscles are not exerting their force in the proper line in
relation to the joint. The sternocleidomastoid muscle needs to be free from
adhesions to adjacent muscles in order to properly shorten and have a clear
line of pull to turn the head. Lifting the muscle with fingers (or knuckles)
and rolling or mobilizing with shearing force.

29.  This is done by placing the muscle into position of
relaxed stretch in this position the therapist will have
the advantage of beginning work at the end range of
fascial stretch instead of exerting effort to take up the
slack. Additionally, the release that occurs at the end
range of the relaxed stretch provides valuable
neurologic input to the stretch receptors.

30.  It is an applications of compression with movement. With
the anchor and stretch strategy, the force of the movement
or stretch is localized at specific areas of thickening or
adhesions. Rather than attempting to place the entire
muscle in a stretch, the therapist relaxes (shortens)the
muscle by flexing the joint, anchors on the area that is
fibrotic, and then extends the joint so that the stretch is
focused at a precise point where the force is applied. It is
crucial that the therapist anchor the point rather than
sliding over in a conventional massage manner.

31.  Another variant of the application of compression
 with movement is expedited lengthening. This variant
 is particularly helpful in teaching clients to work with
 tracking issues and movement patterns. As with anchor
and stretch strokes, the muscle is placed in a relaxed or
shortened position. Instead of stretching the muscle
against resistance, however, the therapist works in the
direction of muscle lengthening and guides the myofascial
compartment to efficiently lengthen in the most expedient
direction for the joint.

32.  1. Both hand move Longitudinally: in opposite direction
while stretching the tissue .Other variant only one hand
applies the treatment while other hand stabilizes or
supports the tissue. The treatment hand applies pressure
through the finger pads, thumb, knuckles or heel of hand.
The pressure can also be applied by forearm or elbow
depending upon size and location of tissue.

33.  J Stroke: Used in limited areas of tightness and on
longitudinal scars.
 Oscillations: Used in Muscle spasm .It involves
rhythmic, back and forth application of Low load
pressure while maintaining constant contact. Applied
with finger pads for small area and with the palms for
larger areas.

34.  Wringing: Used for areas of generalized and multi
directional restriction. Hands are placed on area in
similar position and then rotated in opposite direction
to twist or wring the tissue.
 Stripping: Used for deep tissue release .The pressure is
slow consistent and deep .Uncomfortable for patient
but if tolerated effective in breaking up deep
adhesions.

35.  Arm Pull and Leg Pull: These are gross techniques
applied to generalized tightness in upper and lower
extremity. It involves application of longitudinal
traction. As traction is applied extremity is moved in
abduction and rotation and when tissue resistance is
felt the motion is stopped and position is maintained
 until extremity is felt released .Once area is released
the extremity is moved through arc into new area of
restriction and sequence is repeated.

36.  1.Direct myofascial release
 2.Indirect myofascial release
 3.Self myofascial release

37.  The direct myofascial release method works
 directly on the restricted fascia.
 • The practitioners use Knuckles, elbows,or
 other tools to slowly sink into the restricted
 fascia applying a few kilograms-force or tens
 of newtons and then stretch the fascia. This is
 sometimes referred to as deep tissue work.
 Direct Myofascial Release seeks for changes in
 the myofascial structures by stretching,
 elongation of fascia, or mobilizing adhesive
 tissues.

38.  Land on the surface of the body with the appropriate
 ‘tool’(Knuckles,or forearm etc).
 Sink into the soft tissue.
 Contact the first barrier/restricted layer.
 Put in a ‘line of tension’.
 Engage the fascia by taking up the slack in the tissue.
 Finally,move or drag the fascia across the surface while
 staying in touch with the underlying layers.
 Exit gracefully.

43.  The indirect gentle stretch, the pressure is in few
grams, the hands tend to go with the restricted fascia,
hold the stretch, and allow the fascia to ‘unwind’ itself.
 The gentle traction applied to the restricted fascia will
result in heat, increase blood flow in the area.
 The intention is to allow the body’s inherent ability for
self correction returns, thus eliminating pain and
restoring the optimum performance of the body.

44.  With relaxed hand lightly contact the fascia. Slowly stretch
the fascia until reaching a barrier/restriction.
 Maintaining a light pressure to stretch the barrier and
 wait for approximately 3-5 minutes.
 Prior to release, the therapist will feel a therapeutic
 pulse(e.g. heat).
 As the barrier releases, the hand will feel the motion and
softening of the tissue. The Key is sustained pressure over
time.

45.  Self myofascial release(SMR) is when the individual
 uses a soft object to provide myofascial release
 under their own power.
 • Usually an individual uses a soft roll, or ball on
 which to rest one’s body weight,then,by using
 gravity to induce pressure along the length of the
 specific muscle or muscle groups, rolls their body
 on the object, slowly allowing for the fascia to be
 massaged.

46. Place hands behind head or wrap arms
around
chest to clear the shoulder blades across
the
thoracic wall.
• Raise hips until unsupported.
• Support your head in a “neutral”
position.
• Roll mid-back area on the foam roll.
• If you find a tender spot, stop rolling
and rest
on that tender spot until the pain
reduces by
60-75%

47.  Position yourself on your side lying
on foam roll.
 Bottom leg is raised slightly off
floor.
 Maintain head in “neutral”
position with ears aligned with
shoulders.
 This may be PAINFUL for many,
and should be done in
moderation.
 Roll just below hip joint down the
outside thigh to the knee.
 If you find a tender spot, stop
rolling and rest on that tender spot
until the pain reduces by
 60-75%

48.  Rolling one calf at a time, start
with the roller at your ankle
 Roll upwards towards the back
of the knee
 If you find a tender spot, stop
rolling and rest on that tender
spot until thepain reduces by
60-75%.

49.  Ahead to completely work
the entire hamstring
complex. Balance on your
hands with your
hamstrings resting on the
roller, then roll from the
base of the glutes to the
knee.
 To increase loading, you
can stack one leg on
 Top of the other.

50.  Hip Flexors: Balance on your forearms
 with the top of one thigh on the roller.
 Roll from the upper thigh into the hip.
 Try this with the femur both
internally
 and externally rotated. To do so, just
 shift the position of the contra lateral
 pelvis. (In the photo, Mike would
want to
 lift his right hip to externally rotate
the
 left femur).

51.  In the starting position, you'll be
lying on your side with the roller
positioned just below your pelvis.
From here, you'll want to roll all
the way down the lateral aspect of
your thigh until you reach the
knee. Stack the opposite leg on
top to increase loading

52.  Balance on your forearms with
the top of one of your inner
thighs resting on the roller.
From this position, roll all the
way down to the adductor
tubercle (just above the medial
aspect of the knee) to get the
distal attachments. You'll even
get a little vastus medialis work
in while you're there.

53.  This one is quite similar to the
hip flexor version; you're just
rolling further down on the
thigh. You can perform this
roll with either one or two
legs on the roller

54.  Lie on your side with the "meaty"
part of your lateral glutes (just
posterior to the head of the
femur) resting on the roller.
 Balance on one elbow with the
same side
 leg on the ground and roll that
lateral
 aspect of your glutes from top to
 bottom.

55.  Set up like you're going to
roll your hamstrings, but
 sit on the roller instead.
Roll your buttock
 This is just like the quad
roll, but you're working on
your shins instead.

56.  Start with your body in the same
position as you would for the
latissimus dorsi. Now, however, you'll
want to place the roller at the top of
your triceps (near your armpit) and
your noggin on top of your arm to
increase the tension

57.  Lie prone with the roller
positioned at an angle slightly to
one side of the sternum; the arm
on this side should be abducted
to about 135° (halfway between
completely overhead and where it
would be at the completion of a
 lateral raise). Roll toward the
humeral head (toward the
armpit).

60.  IASTM involves using a range of tools to enable
clinicians to efficiently locate and treat individuals
diagnosed with soft-tissue dysfunction.
 Many different materials have been used to make the
instruments (i.e. wood, ceramics, plastics, stone and
stainless steel).

61.  Cellular Level: Studies have addressed the benefits of
IASTM at the cellular level. Benefits include increased
fibroblast proliferation, reduction in scar
tissue, increased vascular response, and the remodeling of
unorganized collagen fiber matrix following IASTM
application.
 Clinical Benefits: Studies have also showed clinical benefits
of IASTM showing improvements in range of motion,
strength and pain perception following treatment.
 Benefit to Therapist: IASTM provide clinicians with a
mechanical advantage, thus preventing over-use to the
hands.Snodgrass SJ surveyed physical therapists and found
that after spinal pain, the second most common cause for
absenteeism from work was overuse of the thumb. Ninety-
one percent of physiotherapists using some sort of massage
had to modify their treatment techniques because of
thumb pain.

62.  Buffalo Horn-These tools are used by chinese Gua Sha
practitioner but can be used for IASTM too.However it does
not resonate well. Quite cheap to obtain.
Jade Tools - Much heavier and more slippery than the
above tool. Can break easily if dropped.
Plastic tools- New in the market. Lots of design suited for
Manual Therapy work. Largely used for training before
upgrading to the next class of tools.
Stainless Steel Tools- Best tools for IASTM.A must have
tool for Physiotherapist .The tissue resonates well when the
steel runs on it.Comes in different sizes for different parts
of the body depending on the company producing it.

64. THANK YOU