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Toward More Effective Manipulative Management of Chronic Myofascial Strain and Stress Syndromes

A large segment of the population exists in a state somewhere between vital well being and frank illness. For many, "health" is simply the absence of any readily demonstrable evidence of disease. The major factor in the chronic problems suffered by many people often is built in myofascial strain and stress, a factor not sufficiently appreciated by many physicians. This paper reviews the physiologic basis for chronic myofascial syndromes and the way in which the myofascial component of the neuromuscular system manifests the "stress of life". The author describes the approach to recognizing and evaluating these structural disorders and discusses how myofascial strain and stress patterns can be released through manipulative management.
Author
Translator
Pages: 12-25
Year: 1969
Dr. Ida Rolf Institute

Bulletin of Structural Integration Ida P. Rolf

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A large segment of the population exists in a state somewhere between vital well being and frank illness. For many, "health" is simply the absence of any readily demonstrable evidence of disease. The major factor in the chronic problems suffered by many people often is built in myofascial strain and stress, a factor not sufficiently appreciated by many physicians. This paper reviews the physiologic basis for chronic myofascial syndromes and the way in which the myofascial component of the neuromuscular system manifests the "stress of life". The author describes the approach to recognizing and evaluating these structural disorders and discusses how myofascial strain and stress patterns can be released through manipulative management.

Osteopathy began as one man’s dissatisfaction with the philosophy and methodology of treating human ills in vogue at the time he practiced the healing arts. (1) (2) The early success and acceptance which Andrew Taylor Still and his students achieved was the result of utilizing new applications of basic principles long known, but infrequently used.

These clinical successes were primarily with health problems unresolved by the modes of medical practice then current and gave osteopathy a rather unique and enviable, but somewhat limited reputation.

External and internal pressures such as legal restrictions, educational demands, new scientific discoveries, and the needs of a growing population have broadened the scope of practice. As a result, osteopathic physicians today are well trained physicians handling most of the health needs of average families.

In this process one of the basic concepts of osteopathic philosophy and teaching has been neglected and is all too infrequently, or ineffectively, utilized for the relief of disease and the restoration of vital well being.
This almost lost concept is, of course, the adequate evaluation and management of the musculoskeletal system as a major etiologic factor, and a powerful avenue of treatment. Much lip service is offered, but little real emphasis is evident in the average osteopathic physician’s clinical practice.

Because of the demands for emergency care and short term relief of acute problems, there is also a whole segment of the populace which receives little help or, at most, temporary palliation. This croup of patients is made up of those who are neither sick enough to be absent from their daily occupations nor vitally alive and well. They have learned to ignore or to live with their chronic aches and pains. Rarely do we find an individual who exhibits the lose de vivre, the energy, and the contentment associated with really good health. Most are satisfied to drag along with a state of “health” that consists of the absence of any readily demonstrable evidence of disease. Dr. Still said, “To find health should be the object of the doctor.”(3)

Among the many factors which nay account for these chronic problems are inherited abnormalities, poor nutrition, inadequate exercise, psychosomatic factors, and trauma of various types. However, I believe that the one major, and often overlooked, cause for half-sick and half-well individuals is to be found in the built in myofascial strain and stress patterns exhibited by the majority of adults and by many young people. Little real appreciation of the importance of these patterns or knowledge of techniques for modifying and releasing them is evident in most physicians’ management, or lack of management, of these cases.

Practicing in a resort area Hawaii, crossroads of the Pacific provides many opportunities to see patients from other areas. It is disheartening to hear of their need and desire for treatment and the unavailability of the kind of help they are seeking.

It in the purpose of this paper to review briefly the physiologic basis for, and discuss manipulative evaluation and management of, these chronic myofascial syndromes, in the hope that a more careful recognition and a more effective approach to the handling of these problems will result.

The neuromusculoskeletal system,
the instrument of life

The musculoskeletal system alone comprises more than 60 per cent of the total mass of body structure and consists of bones, muscles, tendons, ligaments, and fascia or connective tissue.

The importance of the musculoskeletal system was dramatically described by Korr and Buzzell (4) in their seminar presentation “Biologic Fundamentals Underlying Osteopathic Diagnosis and Manipulative Therapy. “They discussed the neuromusculoskeletal system as the primary machinery of organismic life.

The chief components of this complex self contained mobile mechanism are the following:

1. Muscles with their extensions and attachments, which serve as motors acting on the levers of the skeletal system.

2. Motor neurons activators of muscles the signal conveyors and tropic conditioners.

3. The sensory input from special sense organs, peripheral and visceral vascular sources and proprioceptive sources acts as a feedback mechanism moderating organismic activity.

4. The central nervous system, which receives data, collates them and issues commands.

These four major components constitute the machinery through which the organism can react to and modify both itself and its environment. This machinery provides for a panorama of activities that is practically limitless.

Korr and Buzzell (4) further stated that this primary machinery is the main consumer of the body the variable utilizer of availably energy. Energy is provided by the secondary machinery the “boiler works” of the body. This secondary machinery consists of the internal organs, whose purpose is the care and maintenance of the primary machinery through the following systems;

1. Supply for the conversion of food into fuel utilizable by the primary machinery.

2. Removal for the elimination of waste produced by muscular activity and internal organ function.

3. Homeostasis for the maintenance of the constancy of the internal environment.

4. Defense and repair

5. Growth and development.

The tremendous range and variety of activities of the primary mechanism requires constant and rapid modification on the part of the maintenance and supply machinery. This “demand-response” is achieved through two types of communication:

1. Circulatory system Activity of the primary machinery produces changes in the chemical content of the blood, which then modify the response of the secondary mechanism. This is a relatively slow, long range demand response system.

2. Nervous system This provides a high speed communications network for rapid demand response activity.

Normally the direction of signaling is from the musculoskeletal system to the viscera; seldom does the internal environment signal the primary machinery. Muscles have little responsibility to the internal organs other than in supplying fuel, removing waste, or reproduction. In some pathologic situations viscera do signal the primary mechanism.

Most activity of the musculoskeletal system is reflex and verycomplex. Actions of the musculoskeletal system are dependent on the integration of the nervous system, and its response is on the basis of complex patterns rather than individual signals. Voluntary activity is a small proportion of cortical activity. Action is the result of the integration of thousands of input signals, much of which occurs in the spinal cord before being transmitted to the brain. The brain reacts in terms of total activity.

Life is a process of adaptive adjustment to alterations and stresses in both the internal and external environments. These responses may produce either desirable or undesirable patterns of reaction in the neuromusculoskeletal system, particularly in its myofascial components, (5)(6)

Ill health is a breakdown in this adaptive adjustment, with inadequate communication between the primary and secondary machinery, and produces disturbances in the machinery or in its patterns of response. For example, when the demands of the musculoskeletal system are too great for the internal organs to supply because of inadequate fuel, breakdown can occur. Many life situations create high demands and result in inadequate or inappropriate response. Such patterns of response tend to be cumulative and modify the built in patterns of the musculoskeletal system. The body acts to protect itself by attempting to limit the recurrence of damaging activity.

The myofascial component

Medical literature contains considerable data mostly descriptive about the musculoskeletal system generally, but relatively little information about the myofascial components. Only in the last two or three decades has such literature begun to concern itself with the connective tissues, and the primary interest has been with the minute physiology of this widespread tissue.

Osteopathic physicians have dealt with the musculoskeletal system since Still began to realize its importance, (7) but the chief emphasis has been on the articular lesion. Only in the past 25 or so years has there been a revival in the study of the fascia, particularly in its dynamic and functional aspects, which Still viewed as of the greatest importance. Sutherland (8)(9) and Kauffman (10) privided the impetus for this renewed emphasis.

An appreciation of the functional physiology of the myofascial mechanism is important to therapeutic management, and worthy of much study. Three levels need to be considered, and can only be discussed briefly: (1) the motive and supportive functions, (2) the biochemical activities, (3) the bio energy factors.

Motive and supportive functions

Anatomists refer to muscles as structures comprising not only muscle cells, but also all of their appurtenances interstitial connective tissue, fasciae, tendons, and even bone and ligaments,(11) It is generally considered that these structures have complete structural continuity, hence the term “musculoskeletal system”. This system provides for movement and support. Movement is a prime characteristic and a fundamental function of animal and human life.

Support and cohesiveness of body structures is provided by the fascial components. Not only are the muscles permeated with intra muscular connective tissues and ensheathed in fascia, but all structures of the body have a fascial framework which is continuous throughout. Functionally it forms one system, the myofascial mechanism. Page (12) said:

“If it were possible to remove all of the tissue elements of the body with the exception of connective tissue, the superficial appearance of the body would not be greatly altered. The skeleton would remain intact … Aside from the bony skeletal structure most of this connective tissue is arranged in the form of fascia.”

Snyder (13) stated that “…the connective tissues not only bind the various parts of the body, but, in a broader sense, connect the numerous branches of medicine.

“Korr and Buzzell (4) pointed out that myofascial activity is a complex, highly integrated pattern. The classic approach has been to study the effect of individual muscles on joint action. But this is not physiologic. Normal muscle action is the patterned response of groups of muscles. Muscles may have anatomic individuality, but they do not have functional individuality.

The modus operandi of this complex patterned activity has been studied by many investigators, and elaborate programs of training in a variety of skills have been developed. Many of the patternings are valuable, but some are damaging to the organism. Erroneous and distorted patterns of response that are detrimental can be built into the myofascial mechanism as well as helpful and useful skills.

Biochemical activities

The biochemical activities of muscle and fascia are likewise complex and fascinating. Snyder (13) pointed out that modern physiology has opened up many avenues of investigation into the microphysiology and biochemical activities of the connective tissue and the metabolism of introcellular substances. Electron and phase microscopy and x-ray diffraction have aided in the determination of connective issue structure.

Kauffman, (10) in describing the biochemical activity occurring in the intercellular and intracellular spaces of the connective tissues likened these spaces to a chemist’s retort. Magoun (7) and Snyder (15) said “…this tissue presents a constantly fluctuating equilibrium in an attempt to maintain a condition of homeostasis in surrounding tissues.” There is much additional material in this area available to the searcher.

Erlingheuser, (16) in writing about the circulation of the cerebrospinal fluid through the connective tissue, reviewed the microphysiology of the fascia, emphasizing the significance of the tubular form of the collagen fibrils which pervade all body tissues. He indicated the widespread effects that the activity and the functional physiology of the fascia and connective tissue can have in health and disease because of the circulation and participation of the lymph and cerebrospinal fluid throughout the cellular substance of the body. The fascia thus is the key to the body economy. As Still said more than half a century ago: “The fascia is the place to look for the cause of disease and the dace to consult and begin the action of remedies…” And again, “By its action we live and by its failure we die.”

Bioenergy factors

In discussion “Bioenergetics of Man,” Taylor (19) stated that the body is a thermodynamic system. He described physiochemical changes in the intercellular and intracellular fluids of the body in such bioelectrical terms as viscosity, surface tension, pH, colloidal osmoticpressure, electrophoretic charges, and energies. These changes, he said, are measurable and subject to exact thermodynamic laws.

Among these laws is one that states the total energy of such a system and its surroundings must remain a constant though the energy may be changed from one form to another. Such a system may gain or lose energy in two ways: (1) because of some change in the position of the system as a whole in respect to its surroundings and (2) because of changes in its internal makeup. Taylor (20) continued:

“Each and every part and parcel of the body of man finds itself noised between two forces gravitational forces of the earth with a downward vector and some supporting force or forces such as the bony structure with an upward vector.
As lone as the resultant of these forces supports the center of gravity of the body, all is well; but, whenever poor posture shifts the resultant of force away from the center of mass of the body, the downward vector of the earth’s pull causes some Dart or parts of the body’s mass to spill over the side of the container, so to speak. rote the bulging, overhanging abdomen of many people, or the stilted gait of the individual with the center of gravity of the body shifted forward over the toes. Such shifting of parts of the mass of the body results in abnormal stresses and strains at various points in the supporting structures of the body. These areas of stress and strain are deprived of the normal amounts of free energy and thereby become areas of stagnation and stasis.”

Taylor (21) indicated that the areas of particular susceptibility to energy loss, and therefore to stagnation and stasis, are the ground substance and the fibro areolar laminae of the fascia. He said:

“It is the law of the physical universe that every (thermodynamic) system, if left to it self, chances spontaneously either slowly or rapidly in such a way as to approach a definite final state of rest or equilibrium. Likewise, it is also a law of the universe that once this state of rest or equilibrium has been reached, no reverse change of moving away from equilibrium can be brought about without the application of some form of energy. This is the thermodynamic concept and is simply stated: a system and its surroundings are in equilibrium in such a way that any change in the energy of the eye tem will result in a change in the energy of its surroundings. Energy can enter or leave a system only through its surroundings.”

One of the phenomena of thermodynamics is that of thixotrophy, a property of certain gels; they become more fluid with the addition of energy and more solid with the loss of energy. This property is the essential basis for many of the changes in tissue feel detected by trained palpation and for the modification of such changes by manipulation.

Thus, loss of energy is the origin of pathologic processes. Reverse the process, restore energy, and health will result. Health is the result of normal energy interchange. Disease is the result of abnormal energy function. The problem than becomes how best to restore and maintain normal energy flow. (19) Taylor has also stated positively that manipulative pressure and stretching are the most effective ways of modifying the energy potentials of abnormal tissues.

In addition to the mechanical effects of manipulative pressure and stretching, a powerful thermodynamic effect can be, and usually is, produced by the bio energy mechanism of the physician on the bio energy field of the patient.
The more we understand this process, the more effective will be our ability to add or remove the proper kind and degree of energy to produce the desired changes. Constant awareness of this fact can make the difference between mediocre and remarkably effective manipulative therapy.

Stress and myofascial structures

In his monumental study and analysis of the effects of stress on all aspects of the human organism, Selye (6) called stress the nonspecific element in the production of disease. He says disease is not mere surrender to pathology, but also a fight for health. The concept of illness presupposes a clash between forces of aggression and deterioration and those of defense. Most diseases have certain non specific features in common, the so-called general syndrome of sickness.

Selye described the “aereral adaptation Syndrome,” or GAS, with its three stages the alarm reaction, resistance, and exhaustion. He also discussed the LAS, or local adaption syndrome, and the interrelationships between these two types of response to stress.

Among the regulators of the stress syndrome, Self listed the connective tissue and described the inflammatory reaction of this tissue to stress and its experimental production in the artificially produced connective tissue pouch. He indicated that the stress syndrome leads to premature aging by the depletion of adaptability and loss of adaptation energy:

“Adaptation energy seems to be something of which everybody has a given amount at birth, an inherited capital to which we cannot add, but which we can use, more or less thriftily in fighting the stress of life. still, we have not fully excluded the possibility that adaptation energy could be regenerated to some extent, and perhaps even transmitted from one living being to another, somewhat like a serum.

Selye (23) called for a new approach to treatment, the essence of which consists of combating disease by strengthening the body’s own defenses against stress: “In analyzing our stress-status we must consider the built in pattern, the factors which have produced this situation and what we can do to modify it toward normal.”

Thus, any patient coming to a physician for help presents the sum total of the stresses of life, physiologic and psychologic, to which he has been subjected until that moment modified, of course, by the degree to which he has been able to overcome or adapt to these stresses. These events arc recorded as built in patterns in the neuromusculoskeletal system and particularly in the myofascial portions of that system. They can be generally ascertained by examination and modified by various therapeutic procedures.

A variety of approaches is possible. The latest insult as indicated by the presenting complaint or preliminary examination may be relieved in any one of a number of ways. Such treatment could be considered by some as an adequate service rendered. Often, however, when indicated by the history and examination, the patient should be told that this current episode is only one in a long series of events, each of which has left its physiolocic imprint in the myofascial tissues. Because of these events, the limits of activity have probably been lessened and the margin of tolerance to stress narrowed. Adaptation energy is thus reduced, and in time a whole complex of symptoms nay result. Depending on the circumstances and the desires of the patient, much can and should be done to reverse the process and help correct these factors.

In trying to help patients visualize these principles it is useful to liken the present condition of their structure, with its built in stress and strain patterns and accommodative errors, to a tangled ball of yarn full of knots and snarls. If our task is to straighten out a ball of yarn we try to locate the loose end that can be most readily and effectively utilized in the unraveling process. As additional snarls are uncovered they are dealt with in sequence. The physician’s task is to evaluate the over-all problem and to determine where and how to begin changing it. It is primarily a musculoskeletal pattern, as many problems are, the manner of beginning the reversal process and a specific area must be chosen. It is important to keep in mind the general problem and the goal desired. It must also be remembered that these stress and strain patterns in the myofascial tissues have been superimposed on one another through the years, and as they are released, the patient may experience some of the symptom syndromes that occurred during the process of production.

Recognizing and evaluating
structural strain and stress disorders

As has been indicated, a major factor in solving any problem is the way in which it is viewed. Both the physician’s image of the patient and his problem and his concept of the. direction and degree of possible resolution determine the mode and effectiveness of treatment. With an understanding of the musculoskeletal system and particularly the myofascial mechanism its physiology, its accommodative responses to stress, and its efforts to normalize one can provide a service that will gradually reverse the built in patterns. Often a surprising increase in range of activity and general wellbeing results.

Each patient becomes a challenge, a challenge that changes with each visit. Seldom is a patient treated the same way on successive visits, and no two patients are treated identically. When an explanation of this is given, patients can understand their problem and the goal desired and can appreciate the process involved and progress toward the goal. Under such circumstances, they usually will better accept the time needed to make the necessary changes and will cooperate more fully. This approach provides for the physician a continually increasing understanding of the marvelous responsive mechanism that is the human body and encourages the use of an ever-expanding armamentarium in trying to release the built in patterns.

A rather rapid evaluation of the myofascial status of a patient can be achieved by three relatively simple procedures the first two through observation and the third through palpation.

First, observation of the body in motion or dynamic postures.How appropriately, how gracefully does the patient move, walk, bend, and function in special ways? Rolf (24) said:

“…posture, in its wider sense, is the momentary, ever changing balance of body components in space, as they relate to the force of gravity at any given instant and in any given position. A posture which can truly be called integrated or dynamic indicates that the body weight is adjusting itself to the gravitational pull with the least effort.”

How well does this patient fulfill these requirements, and how can we begin to help this body achieve a more dynamic posture? Experience and training help in this evaluation, nut little is known about what constitutes a normal body.
Certainly average is not normal.

Often the patient is requested to move certain areas or portions of the body to facilitate better visualization of the patterns present. Any physician, especially any osteopathic physician, by using a bit of imagination, can visualize the direction toward which the myofascial tissues should be guided to achieve a more normal functional posture. Probably the ideal for any individual can never be achieved, but it is a rare body that cannot in some degree be assisted toward a more efficient and normal activity.

The second procedure for evaluating the myofascial status is observation of the static body posture standing, stirring or bring. How well is the body aligned? As Rolf (24) said: “The word ‘posture’ in its physical sense has been commonly accented to mean a static alignment of body parts, one above the other, rather like stacked suitcases or boxes.” By observation one can quickly acquire an appreciation of how the patient is “stacked” in comparison to what would be a more normal or desirable arrangement of body masses for that structure. General myofascial tension as well as areas of localized tension can be visualized.

The third procedure concerns the palpatory impressions. With trained hands and perception, one can determine an over-all impression of the status of myofascial strain and stress patterns in the standing patient. By rather lightly passing the hands, one anteriorly and one posteriorly, down the torso from the occiput to the sacrum, or vice versa, the physician can detect areas of increased tissue density, altered temperature, and changed configuration. Applying deeper pressure in such areas further delineates and helps visualize the patterns present. Similar evaluation can be made of the extremities in the same position. If necessary, similar determinations can he made with the patient sitting, supine, or prone.

Many clues indicating areas of major or compensatory stress will be noted.
Then the problem is considered in the light of the history or through additional inquiry, it is not too difficult to determine an area in which to initiate the releasing or unwinding process. Experience produces more rapid and efficient approaches. In addition to the preliminary evaluation, constant awareness is necessary during treatments awareness of the changes occurring in the myofascial tissues, of the patient’s responses to the procedure, and of progress being made toward the desired goals. Thus examination and treatment are usually concurrent.

The quick standing evaluation may be repeated two or three times during a treatment period to check on response and progress. Naturally one repeats this evaluation at the beginning of each treatment period to note changes which may have occurred between treatments anti to determine the area needing attention next. Often the patient will indicate such an area by reporting changing areas of discomfort or temporary symptoms of soreness as the mechanism adapts to changes being made.

During the examination or treatment process, certain tender or painful spots may be found, which when stimulated by pressure will elicit a reproducible pattern of pain or other response not apparently related by segmental nerve distribution to these “trigger spots”. Considerable work has been done by several investigators in mapping these trigger areas, which have been variously called zone reflexes, (25) Chapman’s reflexes, (26) and, more recently, travel’s triggers. (27)

In a paper titled, “The Myofascial Genesis of Pain,” Travel (27) discussed these reflex phenomena. Investigation showed that the site of these triggers is in the fascia, but “no evidence (was found) of any inflammation, nor of anything that can be determined as an abnormal relationship.” These triggers can usually be readily located and identified through a know ledge of pain patterns, together with the patient’s description of rain distribution and motions that produce it. The trigger can be palpated as a definite localized area of induration.

Travall (27) Fund that several procedures seemed equally effective in dissipating the trigger and often miraculuously eliminated the pain pattern. Among these were the administration of local anesthetics ( injectable or topical), needling with a hypodermic needle, or just steady pressure. It would seem that this phenomenon is explainable by the alteration of the energy level of localized areas in the fascia with the accumulation or loss of energy referred to above.

Osteopathic physicians have for years relieved fibrositis, myalgia, neuritis, neuralgia, and related symptom syndromes by disrupting these trigger areas, often non-specifically, and by interfering with the reflex cycle of pain distribution.

Release of myofascial strain and stress patterns
through manipulative management

After preliminary evaluation and decision on the initial site of approach, the physician should select desirable and appropriate therapeutic procedures on the basis of the principles of tissue energy interchange and the effective techniques and methods available to him in accordance with his skill and experience. All types of therapy can and should be judged as to their probably effectiveness in treating any presenting problem. Medication may be appropriate for temporary relief of symptoms and chance of energy levels prior to and during the management of the basic problem. Detoxification procedures are often valuable as aids to removal of barriers to tissue response. Nutritional advice and/or supplementation should be provided to facilitate better response to the repair process.

Remedial exercises and prophylactic training can help in the return to desirable patterns of activity. Training in how to stand, breathe, sit, lie down and use the body mechanism physiologically and protectively can assist in maintaining improvement. The recent interest in jogging and the evaluation of the effectiveness of exercise through aerobics (29) have led to the development of valuable techniques.

Physiotherapy, hydrotherapy, massage, and other such modalities may be useful if properly applied, but are usually not necessary. Each of these subjects could be discussed in the light of thermodynamic principles of enemy accumulation or loss, but time and space do not permit.

A natural question is the relationship of particular mobilization or correction of the osteopathic (Still) lesion to this approach. It is one method of altering energy levels, and at appropriate times during the process can be effectively used in restoring such levels toward normal. Depending on the status of the myofascial tissues, the appropriateness of the technique to the problem, and the skill of the physician, the task of releasing the built-in patterns can be shortened and progress hastened by proper skillful articular mobilization.

The goal, then, is to release and unwind as rapidly and as effectively as possible the built-in stress and strain patterns, to disorganize the organized compensations, and to reintegrate the mechanism into a functionally dynamic whole. The focus should be on evolving the best ways of restoring and maintaining a balanced rhythmic interchange in tissue energy levels. Through the ages there have been many evolutions and revolutions in the treatment of ill people. Manipulation of various types has been used effectively with not too much understanding of the basic physiology involved, osteopathy with its individualistic physicians has explored and devised many techniques and manipulative approaches in the search for results. Each physician meeting the problems of daily practice develops valuable ideas and approaches.
Unfortunately many of these have not been recorded and are therefore lost.

The techniques of postural release taught by Rolf (24) and discussed by Solit (29) seem to be among the more effective methods of managing myofascial tissues manipulatively. Modifications in the application of these principles are made in accordance with the presenting problem and the physician’s personal experience and aptitude.

Essentially this method utilizes at various times the fingers, knuckles, forearm, and particularly the elbow of the practitioner to exert pressure and stretching forces on the areas of detected myofascial strain and stress. This pressure, judiciously and slowly applied in specific directions with awareness of the changes taking place during the process, results in myofascial lengthening and softening and lessened tension. The tissues become more fluid and less jelled. Patient assistance through positioning, breathing, and resistive movement is variously utilized to aid in the localization and effectiveness of the pressure.

The release of the strain and stress patterns proceeds sequentially, area by area, level by level, in the manner of unraveling the ball of yarn.

After even partial release, patients report feeling lighter and freer and often friends tell them they look better. This result helps the patient become an enthusiastic co operator toward a desirable, attainable goal. Perhaps by this process it may even be possible to restore partially Selye’s depleted capital of inherited adaptation energy.(6)

Two illustrative applications of these principles will help to indicate the therapeutic approach. In lumbosacral problems with the usual areas of tension and restriction in the myofascial tissues of he lumbar, gluteal, and lateral thigh areas, the patient may be Placed on his side on the treating table.
By using fingers, forearm or elbow, the physician can apply gentle, firm, and gradually increasing pressure, with some degree of longitudinal stretching, to the gluteal and lateral thigh areas first. Changes in the quality of the tissues will be noted not only in the area of application, but often in the lumbar tissues as well. While the patient is in this position, release of the quadratus lumborum and psoas muscle masses can be gained through the anterolateral lumbar area.

For further release of the often deep seated myofascial strainsin the lumbosacral area, the patient may be placed prone across the mid region of the table with head and arms off one side, and feet on the floor of the opposite side of the table. Additional padding with pillows under the pelvis and upper chest is desirable. Again using the elbow, the physician can produce much release of spasm and contracture by means of seep steady pressure over the lumbodorsal fascia and through it to the iliocostalis lumborum, the longissimus, the multifidus and even the interspinales. After the condition of the superficial layers is improved, the deeper layers may be reached and release?. Patient co-operation by breathing in and “tucking” the pelvis as the whipped dog tucks his tail further facilitates release. This cooperative assistance can also be used in the side position described above.
Often a circumduction of the upper thigh and leg will assist in myofascial release, and occasionally articular correction will occur.

The epigastrium is an area where much myofascial tension is frequently found, often due to psychogenic factors. Welcome release can be secured with the patient supine by gentle digital pressure and stretching of the anterior fascial layers of the abdomen and the rectus abdominis, followed by deeper elbow release of the fascial attachments of the organs and margins of the diaphragm.

Many other manipulative techniques utilizing fascial release have been taught and used effectively through the years, notably by such osteopathic innovators as W.A. Shwab, H.H. Bryette, PT , Wilson, W.G. Sutherland, T.I. Ruddy, R.E. Becker, and E.L. Mitchell, but the basic principle which makes all technique more or lees effective is modification of the organism’s built in adaptive patterns through altering the mercy level of the thixotropic colloids of myofascial structures.

Summary

A paradox is evident in the broadened scope of osteopathic practice when one considers the segment of the population characterized by neither frank illness nor vital well being. Although built in myofascial strain and stress patterns often constitute the major factor in the chronic problems of such persons, in treating them many osteopathic physicians exhibit little real appreciation of the importance of these patterns or knowledge of techniques for modifying and releasing them. Thus one of the basic concepts of osteopathic medicine adequate evaluation and treatment of the musculoskeletal system is being neglected or infrequently utilized. This paper presents the aplication of this concept in the management of these chronic myofascial syndromes, discussing first their physiologic basis in the neuromusculo skeletal system, with a description of the myofascial component and its manifestation of the “stress of life”. The procedures comprising the approach to recognition and evaluation of myofascial strain and stress disorders are then presented. The release of abnormal patterns through manipulative management and the adjunctive use of other modalities are discussed. Two techniques are described to illustrate the specific application of manipulative principles.

References

1. Booth. E.R.: History of osteophaty and twentieth-century medical practices. The Caxton Press, Cincinnati, 1924.

2. Northup, G.W.: Osteophatic medicine: An american reformation. American Osteopathic Association. Chicago, 1966.

3. Still, A.T.: Philosophy of osteophathy. Published by the author. Kirksville, Mo., 1999, p.28.

4. Korr, I.M., and Buzzell, K.A.: seminar on biologic fundamentals underlying osteophatic diagnosis and manipulative therapy. Presented and Ottawa, Ontario, Canada, May 5, 6, 1967.

5. Rosborough, P.M.: Physical fitness and the child?s reading problem. The report on a technical study of twenty ?problem readers? their physical handicaps and therapy. Exposition press, Inc., New York, 1963.

6. Selye, H.: The stress of life. Mc-Graw-Hill Book Co., New York, 1956.

7. Magoun, H.I.: Fascia in the writings of A.T. Still. J. Osteopath Cranial Ass., pp. 16-25, 1954.

8. Lippincott, H.A.: Respiratory technic according to the principles of Wm. G. Sutherland, D.O. In Academy of Apolied Osteophaty year book 1948.

9. Lippincott, H.A.: The osteopathic technique of Wm. G. Sutherland, D.O. In Academy of Apolied Osteophaty year book 1949.

10. Kauffman, C.H.: Connective tissue and osteophaty (Resume by A.R. Becker). In academy of Applied Osteopathy year book 1945.

11. Grant, J.O.B., et al., Eds.: Morris? human anatomy. Ed. 10. The Blakiston Co., Philadelphia, 1946.

12. Page, L.E.: The role of the fasciae in the maintenance of structural integrity. In academy of Applied Osteopathy year book 1952.

13. Snyder, G.E.: Fasciae ? Applied anatomy and physiology. In academy of Applied Osteopathy year book 1956, p. 66.

14. Snyder, G.E.: Embryology and phisiology of fascia. J. Osteophaty Cranial Ass, pp. 4-15, 1954.

15. Op. cit., ref. 13, p.71.

16. Erlingheuser, R.F.: The circulation of the cerebrospinal fluid through the connective tissue system. In academy of Applied Osteopathy year book 1959.

17. Truhlar, R.E.: Doctor A.T. Still in the living. Privately published, Cleveland, 1950, p.54.

18. Still, A.T.: The philosophy and mechanical principles of osteopathy. Hudson-Kimberly Publishing Co., Kansas City, Mo., 1902, p.60.

19. Taylor, R.B.: Bioenergetics of man. Academy of Applied Osteopathy year book 1958.

20. Op. cit., ref. 19, p.94

21. Op. cit., ref. 19, p.93

22. Op. cit., ref. 6, p.303.

23. Op. cit., ref. 6, p.267.

24. Rolf, I.P.: Postural release, an exploration in structural dynamics. Published by the author. New York, 1957, p.3.

25. Ingham, E.D.: Stories the feet can tell. Arrow Publishing Co., Rochester, N.Y., 1941.

26. Owens, C.: An endocrine interpretation of Chapman?s reflexes, by the interpreter. Published by the author, 1937.

27. Travell, J.: The myofascial genesis of pain. Read before a conference on connective tissues sponsored by the Josiah Macy, Jr., Foundation, New York, 1952.

28. Cooper, K.H.: Aerobics. M. Evans & Co., Inc., New York, 1968.

29. Solit, M.: A study in structural dynamics, JAOA 62:30-62.

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