BUTLER MOBILIZATION

(A BRIEF INTRODUCTION)

Application of movement testing of nervous system requires on understanding of the relationship of Neural Mechanics & Neural Physiology.

These two factors constitute normal function of nervous system.

     Over all function of nervous system is to provide communication while adapting to movements. Communication composed of 2 components Electrical & Chemical Mechanism. Collectively these components of communication are referred to as the Physiology or Function of Nervous system. Common form of communication of Nervous system is by Action potential. Second component of communication is identified as a chemical process which involves axoplasmic transport. This chemical communication provides nutrition & receives inflammation from the target tissues through axoplasmic flow.

This flow is Bidirectional & is identified by the terms antegrade & retrograde transport. There are two main Biomechanical concepts related to the nervous system.

1.  Mechanical interface and it s effect
2.  Neruo biomechanics

     The Mechanical interface may be defined as the tissues or material adjacent to the nervous system that can move independently to the system.

E.g. Supinator muscle for Radial nerve.

       Carpal tunnel syndrome for Median nerve.

 INTERFACES:

Pure Mechanical interfaces:

1. Fascial sheet
2. Blood vessels
3.  Muscle or ligament

Pathological Interfaces:

1.  Osteophytes
2.  Ligamentous swelling
3. Fascial scarring
4. Odema
5. Blood around nervous system
6.  A tight plaster or Bandage.

Interfacing tissues may be regarded as extradural or extra neural.

Neuraxial & Meningeal adaptive mechanisms:

During flexion the length of spinal cord increased 5—9 cm larger than the normal. During this the neuraxias and meninges elongate and more anteriorly in the spinal cord. During extension they more posteriorly allow relaxation of the neuraxis and create transverse folds in the duramater and tip of theca moves caudally. With lateral flexion movements the nervous system on the convex side elongates whereas concave side shortens.

In rotation nerve root gets stretched on the same side.

 TENSION POINTS:

     Tension points are those where no movement of nervous system takes place in relation to the interface

In spine: C6, T6, L4

Lower limbs: Posterior aspect of Knee & Hip

Upper limbs: Anterior aspect of Elbow.

Anatomy of Tension points:

Nervous system depends on adequate blood supply. In general extra neural vessels enter the nervous system in areas of little movement in relation to interface. These areas are tension points.

NEURODYNAMICS

            The normal function of the nervous system can be defined as Neurodynamics.

Neurodynamics is the relationship of normal physiology & normal mechanics.  Pathomechanics identifies as an abnormal component of physiology (pathophysiology) or an abnormal component of mechanics (pathomechanics) or combination Two. Explained in the figure 1. 

 

      Evaluation of the musculoskeletal system includes an appreciation of the interconnection between the physiology and mechanics of the neural elements.

Physiology of nerves are find out by conduction system of nerves. Neruodynamics testing also addresses the physical capabilities of the nervous system through manual positioning and loading. This type of examination identifies the load characteristic of the neural elements. There are multiple techniques that use positioning and movement to focus tensile load through the neural elements or unload the neural structures. This technique identifies the mechanics of the nerve or the nerve’s ability to move, including the ability to slide, angulate, glide, strain or compress.

The nerve bed can increase in length from 12—20 percent during limb. The nervous system has the ability to move, and this capacity to move has been described in tension tests.

BASE TESTS:

There are many test used to find out nervous system mechanics

These tests includes

1. Passive neck flexion (PNF)
2.  Straight leg raise (SLR)
3. Slump test
4. Prone knee bending (PKB)
5. Upper limb neurodynamic test (ULTT)

      These tests are designed to Bias the neural elements to a greater degree than the surrounding interface. These tests attempt to load specific nerve roots, nerve trunks, and localized regions of the central canal or even component of sympathetic nervous system.

INDICATIONS:

1.  A clinical reasoning hypothesis of movement dysfunction supporting neurogenic pain.
2.  An Aggravation of the pain pattern by a functional position or an ADL position that resembles a base test position.
3.  Positive conduction tests suggesting the neural involvement.
4.  To examine, normalize or improve the normal neruodynamic of the nervous system.

CONTRA INDICATIONS:

1. A tethered spinal cord or conditions with spinal cord adherence to the meninges or the spinal canal.
2. Increasing neurologic signs or neurologic injury when a load is likely to cause a rapid neurologic deficit.
3. Inflammatory, infectious, or viral conditions such as an Abscess, GBS.
4. Red flags found with a neurologic examination, such as extra segmental or multilevel loss of sensory or motor function, a positive babinski response.
5. Severe injury or abnormality of the interfacing tissue of the nervous system found with spinal instability, osteoporosis, and transient quadriplegia.
6. Severe pain as a result of any examination technique.

 SLUMP TEST

 

 SLR and its Modification

Prone knee Bending Test & its Modification

Upper Limb Tension Test.

Bibliography:

1) David Magee 

2) Butlers Neural tissue mobilization.

MYOFASCIAL RELEASE THERAPY

MYOFASCIAL RELEASE THERAPY--- A Brief Note

Myofascial release is a form of massage therapy that uses sustained pressure to loosen or release tightness in connective tissues (fascia). It is thought that tightness within the fascia causes restriction of muscle and other tissues, resulting in back pain and loss of motion. Injuries, stress, inflammation, trauma and poor posture supposedly contribute to this tightness. These myofascial restrictions can't be detected with standard medical imaging studies, such as X-rays or MRIs. It can be diagnosed by palpatory findings.

These techniques which depict hands-on treatment using the fascia have been recorded in the earliest of our historical references.  Items from Ayurvedic medicine, which goes back around 5000 years, Chinese and Egyptian depictions that go back around 3000 years, and Greek descriptions by Hippocrates and others which go back around 2300-2500 years, all show hands on approaches that most certainly utilized the fascia as an element of diagnosis and treatment.

v Uniqueness of Myofascial release therapy  against other stretching

Myofascial release therapy is a highly interactive stretching technique that requires feedback from patient’s body to determine the direction, force and duration of the stretch and to facilitate maximum relaxation of tight or restricted tissues.  Myofascial release appreciates that an individual muscle cannot be isolated from the other structures of the body due to the existence of fascia. (Manheim, 1994).

Barnes (1990) reported that Myofascial release therapy is a manually applied, whole body treatment approach which is aimed at fascial system. He contends that myofascial release is the only treatment that addresses the collagenous component of fascia via its effects on the viscosity of its ground substance. Whereas modalities, exercises, manual therapy, massage and muscle energy techniques only affect the muscle and elastic component of fascia.

Application of Myofascial release technique, the therapist monitors tissue tightness by developing a kinesthetic link with the patient touch. Through this link, the therapist feels the patient’s inherent tissue movement and underlying neurophysiologic tissue tone as well as the more overt muscle tone. Once adapt at sensing the patient’s muscle tone and tightness, the therapist is able to detect subtle restrictions can only be detected through touch and eliminated by using myofascial release technique. Thus, myofascial release technique focuses directly on the restricted myofascial elements while all other stretching techniques and commonly used active stretching exercises use relatively gross motions that may not stretch individual myofascial units that are restricted. (Manheim 2001).

v Principles of Myofascial release technique

The principles of myofascial release therapy includes

1.      Fascia covers all organs of the body

2.      Muscles and fascia cannot be separated

3.      All muscles stretching is myofascial stretching

4.      Myofascial stretching in one body area will be felt and will affect that and other body areas.

5.      Release of myofascial restrictions can affect other body organs through a release of tension in greater fascial system

6.      Myofascial release can alter body misalignment if structures are not fixed by bone remodeling.

7.      Myofascial release generally more comfortable than other stretching techniques.

8.      Progress is measured by improvement in postural asymmetry, reduction of subjective pain complains, and increased fluidity of movement.

9.      Treatment using myofascial release changes constantly in response to feed back.

v Protocols for myofascial release therapy techniques:

A) INDICATIONS:

Myofascial release is the treatment of choice in the following situations,

        i.  The patient’s pain compliant has not been alleviated by traditional physical therapy treatment.

         ii.   The patient has a complex, global, or specific pain compliant that does not follow dermatomes, myotomes, or visceral referred symptoms.

               iii.  The patient has an underlying chronic condition that causes tightness and restrictions in the soft tissues (e.g. fibromyalgia, and post-polio syndrome). 

                                iv.   The patient has painful complex postural asymmetries

                          v.  The patient has asymmetrical muscle weakness due to an acute or chronic peripheral or central neuropathy.

       vi.            The patient has impaired respiration and an inflexible rib cage due to chronic respiratory disease, central nervous system injury, or faulty mechanical relationships of the skeletal structure and soft tissues.

      vii.            The Patient has frequent, intense headaches that are triggered by a variety of stimuli including myofascial trigger points, tension in the posterior cervical musculature, temporamandibular joint dysfunction and symmetrical muscle tightness.

     viii.            The patient has impaired mouth closure, swallowing and phonation resulting in tightness and restriction of the hyoids and the muscles of mastication

         ix.            The patient experiences non-labyrinthine induced vertigo and dizziness secondary to active myofascial trigger points.

        x.            The patient is a competitive athlete or performer who needs subtle stretching to increase speed or accuracy and to prevent injury at the extreme range of motion.

B) CONTRAINDICATIONS:

Myofascial release should not be used in the following situations,

                    i.            The patient does not understand or respect boundaries.

                 ii.            The patient does not tolerate close physical contact or touch.

               iii.            The patient has an unstable medical conditions, e.g., unstable angina

               iv.            The patient has a dermatitis

                  v.            The patient has a contagious or infectious disease that is transmitted by the upper respiratory tract or by direct contact with the skin

               vi.            The patient does not trust the therapist

             vii.            The patient does not understand the concept of the “Good Hurt”.

          viii.            The patient is under the influence of the drugs or alcohol.

               ix.            The patient is unable to give informed consent to treatment due to his mental status.

                  x.            The therapist does not feel comfortable with the patient (i.e. after initial interview and evaluation, the therapist’s “gut response” says not to treat this patient with myofascial release or not to treat this patient at all).

C) PRECAUTIONS:

                    i.            Myofascial Release consistently lowers blood pressure. All patients must rest in a horizontal position for 10-15 minutes following treatment. The patient should get up slowly and not get off the treatment table until any dizziness has resolved. 

                 ii.            Myofascial release may lower blood sugar levels, particularly when deep trigger point releases are performed. Individuals who are diabetic should check their blood glucose level prior to treatment. Individuals who are prone to hypoglycemia should have a snack prior to treatment.

               iii.            Individuals with healing fractures or wounds may receive myofascial release to uninvolved areas.

               iv.            Individuals with compromised circulation may be treated with myofascial release to the uninvolved areas and to the area of compromise while being closely monitored.

                  v.            The patient is taking medication that increases blood-clotting times and causes the patient to bruise easily.

               vi.            When treating a child or a mentally incompetent adult, the caregiver or other responsible adult should always be present. The therapist should carefully explain the treatment to the caregiver.

v Theoretical framework behind the effectiveness of Myofascial release therapy

     It is assumed through the application of slow, steady force carefully directed against barriers, fascial restrictions release. They occur in four ways as described by Gould (1997).

1.      Forcible Separation or compression of joints.

As external loading either separates or compresses, everything from the skin surface to deepest component of spinal complex is forced to respond.

2.      General Myotactically, Controlled, Mechanoreceptors response.

Golgi tendon organs exit in all soft tissue including fascial sheaths. They do not exhibit neural plasticity and readily respond to outside force, such as manual therapies. They can assume new barriers either normal or pathological.

3.      Muscle Tightening and Asymmetries

Tightness and Asymmetries is maintained through 1a afferents. Gamma efferent effects are particularly important. Emotional and stress related mechanism often are major contributors. Traumatic forces massively stimulate 1a afferent. Descending, inhibitory factors are overwhelmed and unable to control inputs.

4.      Centrally controlled Relaxation

Effects occur as myofascial tightness and muscle spasm releases. Assertive, slow carefully directed soft tissue loading can overcome many of these effects assuming massive neutral and other soft tissue has not occurred. It is assumed such loading involves myotactic reflexes.

The Arndt-Schulz law states that gentle touch increases physiologic activity while heavy tough is inhibitory. Myofascial release therapy uses both types of touch, depending upon the need of the patient. Light touch and light stretching encourages release of asymmetrical soft tissue stresses and reflex relaxation of tissues both proximal and distal to the treatment site. This gentle touch also allows the therapist assess to area of tightness without triggering reflex muscle guarding. As new movement pattern are facilitated by the gentle stretch, central nervous system reeducation occurs. Heavier pressure is used during trigger point release to inhibit the micro-muscle spasm that perpetuates the trigger point. (Manheim, 1994).

When peripheral or central nervous system is stimulated, the stimulus is carried throughout the body in accordance with the law of diffusion. For example, while only the spinal column has been changed with the insertion of Harrington rod, the altered sensory input changes the patient’s perception of his entire body. There is no way to affect one area of the body without affecting the entire person. In contrast, the law of Avalanche states that multiple sensations may be aroused in the brain by a simple stimulus in the periphery. Many feelings and responses may be aroused by any peripheral stimulus. (Manheim, 1994).

FASCIA

     Fascia is a part of connective tissue system, fascia is a tough connective tissue that spreads throughout the body in a three dimensional web from head to foot without interruption.(Barnes,1990). Fascia covers all the structures includes bones, nerves, muscles, organs, vessels and even the cellular structures. Fascia consists of elastin, collagen, and a ground substance.

     Collagen fibers are protein that provides strength to prevent breakdowns due to tension. Elastin, which is also a protein is comparable to rubber and can easily stretch in both length and width. Elastin absorbs tensile forces along with the collagen fibers. (Barnes, 1990). Ground matter found between the fibers of collagen and elastin, is composed of proteoglycans and hyaluroinc acid. Proteoglycans allow ground matter to absorb and disseminate compressive forces throughout the body. Hyaluronic acid is viscous and provides lubrication to enable more easily gliding of collagen, elastin and muscle fibers over one another.

Structural arrangement of Fascia :

Fascia has two basic structural arrangements –

·   Loose areolar such as is found in fascial bundles, and

·   Dense irregular such as is found in fascial coverings of muscles and the connective tissue of tendons.

There are cellular components to fascia which are Fibroblasts that manufacture structural proteins, Mast cells that will degranulate releasing histamine in immune responses, and Histiocytes that are macrophages or immune cells. The cellular components have adaptability and will change based upon the stimulus.

There are also subcellular components to fascia which are Collagen that makes up the reticular fibers, Elastic fibers that give fascia its property of returning to its previous shape, and Glycosaminoglycans which are sugar-protein complexes that make up the ground substance within the fascia and of course the subcellular components also have adaptability.

The subcellular component that contributes greatly to the strength of fascia is Collagen. The collagen is arranged in such a way that it coils about itself in a triple helix pattern that is further supported by biochemical cross-linking that occurs in a regular pattern thus it has periodicity.  This arrangement and chemical bonding gives fascia great tensile strength making it resistant to tearing, but at the same time able to readily change its shape and length to adapt to demands that are placed upon it.

Collagen forms reticular fibers which are prominently seen in our bodies.  Scaffolding is the arrangement that is used when a sponge-like arrangement is needed.  This arrangement leads to turbulence of fluids which is particularly useful when immune responses are needed.  This arrangement is most prominently observed in lymphoid tissue such as the lymph nodes, thymus, and spleen.

Elastic fibers are another form of subcellular fascial component.  Elastic fibers possess cross-linkage as does Collagen fibers.  This gives it both strength and flexibility.  The term elasticity refers to the ability of something to return to its original shape after it has been distorted.  This is a very important property and good examples of this are seen in the tissue of the aorta and the lung.

The extracellular matrix is present in fascia and is made up predominately of Collagen and Glycosaminoglycans.  This combination is found in the ground substance and has a highly negative charge.  This is important because negative charges attract water. When water and proteins are mixed a gel is formed.  Gels will allow for diffusion of cells and nutrients.  Also, gels have particular properties that change with pressure and temperature which are important factors that are considered and utilized in myofascial release techniques.

The types of collagen present, amount of water available, and other mechanical factors will ultimately determine the nature of the fascia.  These factors will be altered in diseases, injuries, and somatic dysfunctions.

General Properties of Fascia

The properties of fascia are determined by its structure.

Viscosity – has two definitions –

·        A measurement of the rate of deformation of any material under load.

·        The capability possessed by a solid of yielding continually under stress.

Elasticity – the definition has already been given, but here it is again –

·        The ability of a strained body or tissue to recover its shape after deformation.

Plasticity – The ability to retain a shape attained by deformation.

·        These properties will prove to be very important later when we palpate and treat using myofascial release techniques.

FUNCTIONS OF FASCIA

ü  Mechanical,

o   Mechanical gives rise to support, compartmentalization, and conduits

ü  Metabolic, and

o   Metabolic gives rise to diffusion ,  has gel properties, and to energy storage in the concept of elastic potential energy as well as fatty storage for fuel.

ü  Immunologic. 

o   Immunologic has been addressed earlier as well, plus the additional concept of acting as a physical barrier.

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