Module 2- Inhibitory Techniques Complete[1]

Inhibitory Techniques: Self-Myofascial Release

2 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release Copyright © 2007 National Academy of Sports Medicine Printed in the United States of America All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or any electronic, mechanical or other means, now known or hereafter invented, including xerography, photocopying and recording, and in any information-retrieval system is forbidden without the written permission of the National Academy of Sports Medicine. Distributed by: National Academy of Sports Medicine 26632 Agoura Road Calabasas, CA 91302 800.460.NASM Facsimile: 818.878.9511 http: www.nasm.org Authors: Micheal Clark, DPT, MS, PT, CES, PES Rodney Corn MA, PES, CES, NASM-CPT Scott Lucett MS, PES, CES, NASM-CPT

4 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release Introduction Corrective exercise is a term used to describe the systematic process of identifying a neuromusculoskeletal dysfunction, developing a plan of action and implementing the corrective strategy. This process requires knowledge and application of an integrated assessment process, corrective program design and exercise technique. Collectively, the three step process is to: 1. Identify the problem (integrated assessment) 2. Solve the problem (corrective program design) 3. Implement the solution (exercise technique) The focus of this module is on a component used in a corrective program design to solve the problem. Solving the identified neuromusculoskeletal problems will require a systematic plan. This plan is known as the Corrective Exercise Continuum (Figure 1) and will specifically outline the necessary steps needed to properly structure a corrective exercise program. A corrective exercise program will involve up to four primary phases known as the Corrective Exercise Continuum (Figure 1). First, is the use of inhibitory techniques. Inhibitory techniques are used to release tension, and/or decrease activity of overactive neuromyofascial tissues in the body. Second, is the use of lengthening techniques. Lengthening techniques are used to increase the extensibility, length and range of motion (ROM) of neuromyofascial tissues in the body. Third, is the use of activation techniques. Activation techniques are used to re-educate and/or increase activation of underactive tissues. Fourth, is the use of integration techniques. Integration techniques are used to re-train the collective synergistic function of all muscles through functionally progressive movements. The following text will detail the Inhibitory phase of the Corrective Exercise Continuum, specifically Self-Myofascial Release (or SMR).

5 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release Figure 1. Corrective Exercise Continuum Inhibitory Techniques The first phase in the Corrective Exercise Continuum (Figure 1) is to inhibit. More specifically, the term inhibit refers to decreasing overactivity of neuromyofascial tissue. The primary technique used here is Self-Myofascial Release, though many other manual techniques are also used (positional release, myopractic, soft tissue release, active release, joint mobilization, etc). Self Myofascial Release Over the past decade the use of a self-induced neuromyofascial release technique (i.e. foam rolling muscles seen in Figure 2) has emerged to become a relatively common and practical flexibility technique used within the health and fitness environment. This form of flexibility has been termed Self-Myofascial Release (SMR) by the National Academy of Sports Medicine (NASM). 1 Interestingly enough, there is little current research specific to SMR and its effects on flexibility or tissue response. This may lead many critics to question its usefulness or efficacy in a typical C ORRECTIVE E XERCISE C ONTINUUM I NHIBIT A CTIVATE I NTEGRATE Inhibitory Techniques Self-Myofascial Release Activation Techniques Positional Isometrics Isolated Strengthening Integration Techniques Integrated Dynamic Movement L ENGTHEN Lengthening Techniques Static Stretching Neuromuscular Stretching

7 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release Self-Myofascial release is therefore believed to stimulate the aforementioned receptors through sustained pressure at a specific intensity, amount and duration to produce an inhibitory response to the muscle spindle and decrease gamma loop activity. This concept has been supported in a randomized controlled trial study by Hou and colleagues 3 that found ischemic compression (pressure from an object) at a high intensity (max pain tolerance) for a low duration (30 sec) or a low intensity (minimum pain threshold) for a longer duration (90 sec) significantly reduced pain and trigger point sensitivity. Furthermore, when applied in conjunction with stretching techniques it was shown to significantly increase range of motion. 3 In an earlier study by Hanten and colleagues 2 it was demonstrated that ischemic compression and static stretching as a home program was significantly effective at reducing trigger point pain and sensitivity in individuals with neck and upper back pain. The practical significance is that by holding pressure on the tender areas of tissue (trigger point) for a sustained period of time, trigger point activity can be diminished. This will then allow the application of a stretching (or, lengthening) technique such as static stretching to increase muscle extensibility of the shortened muscles to reset the muscle lengths and provide for optimal length- tension relationships. With optimal length-tension relationships, subsequent use of corrective activation and/or integration strengthening exercises will ensure an increase in intra- and inter- muscular coordination, endurance strength and optimal force-couple relationships that will produce proper arthrokinematics. Collectively, these processes enable the human movement system to re-establish neuromuscular efficiency. This is the NASM rationale for establishing and using corrective flexibility and corrective exercise as a component of a complete programming system such as that seen in the Optimum Performance Training™ (OPT™) model. 1 Influencing the Autonomic Nervous System It should come as no surprise that manipulating one aspect of the human movement system (nervous system, muscular system and skeletal system) can have profound effects on the others. However, beyond the three listed systems of the human movement system there exist many support systems which include the cardiopulmonary system, endocrine system, etc. 12 When discussing the application of pressure and tension on the muscular system, it should be expected that there can and will be a concomitant effect on not only the nervous and skeletal systems, but

8 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release ultimately on all systems of the body. In fact, this is true with the application of pressure to the muscular system as seen in SMR and its impact on many aspects of the Human Movement System. Most discussions and textbooks detail the functions of the type I and type II sensory receptors that include the muscle spindle, GTO, Pacini corpuscles and Ruffini endings. However, these receptors are noted as only comprising about 20% of the receptor pool. 6 The remaining 80% is comprised of type III and type IV receptors that are called interstitial receptors and are often thought of as merely pain receptors. Their ability to respond to mechanical pressure and tension, however, has been noted and this constitutes a mechanoreceptor function. 6 These type III and type IV receptors (interstitial receptors) in conjunction with Ruffini endings have also been shown to have autonomic functions that include changes in heart rate, blood pressure, respiration, lowering of sympathetic tone (via the anterior lobe of the hypothalamus) which reduces overall muscle tonus, vasodilation and local fluid dynamics. This in turn changes viscosity of tissue. 6,7 Neuromechanically, these effects are significant to help decrease the overall effects of stress (emotional or physical) on the Human Movement System: • Increasing vasodilation, the tissue can receive adequate amounts of oxygen and nutrients as well as removal of waste bi-products (via blood) to facilitate tissue recovery and repair. Healthy tissue may be less predisposed to alter muscle recruitment patterns that may cause injuries. 13 • Changing the viscosity of the tissue allows for better tissue dynamics which may provide better overall muscle contraction and joint motion. Altering or improving respiration can dramatically impact the Human Movement System. 5,7 • Decreasing sympathetic tone reduces the prolonged faulty contraction of muscle tissue that can lead to a cumulative injury cycle. 7,14 • Affecting respiration can lead to better oxygen content in blood as well as decrease feelings of anxiety and fatigue. 15 It has been noted that faulty breathing patterns (shallow chest breathing versus proper diaphragmatic breathing) can alter carbon dioxide/oxygen

10 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release Table 1. Contraindications for Self-Myofascial Release Malignancy Osteoporosis Osteomyelitis (infection of bone tissue) Phlebitis (infection of superficial veins) Cellulitis (infection of soft tissue) Acute rheumatoid arthritis Blood clot Goiter (enlarged thyroid) Eczema and other skin lesions Open wounds Healing fractures Obstructive edema Advanced diabetes Hematoma or systemic/ localized infection Table1. Contraindications for Self-Myofascial Release The Effects of Tissue Pressure Figure 3 demonstrates the integrated process involved in tissue changes. Sustained or slow tissue pressure stimulates mechanoreceptors that send information to the central and autonomic nervous systems. In turn, the central nervous system’s response changes the muscle tonus (or, decreases hypertonicity) in skeletal muscle. The autonomic nervous system’s response also changes global muscle tonus as well as fluid dynamics to decrease viscosity and the tonus of the smooth muscle cell located in fascia. Figure 3. The Effects of Tissue Pressure (Adapted from Schleip R. Facial plasticity – a new neurobiological explanation: Part 2. J Bodywork Movement Therapies 2003;7(2):104-16.)

11 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release Acute Variables To be effective, SMR must follow sound acute variables (Table 2). At the current time, there are no known reasons that SMR cannot be performed on a daily basis. This is the current practice of NASM with apparently healthy individuals. However, this will ultimately be determined by the client, any possible precautions that exist and the advice of a licensed medical professional. One set per noted body region or muscle group is sufficient when held for up to 30 seconds for those who can tolerate a maximal pain threshold or up to 90 seconds for those who tolerate a minimal pain threshold. 3 Table 2. Acute Variables for Self-Myofascial Release Frequency Sets Repetitions Duration of Rep Daily (unless specified otherwise) 1 N?A Up to 30 seconds with maximal pain tolerance. Up to 90 seconds with minimal pain tolerance N/A = not applicable Table 2. Acute Variables for Self-Myofascial Release

13 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release References 1 National Academy of Sports Medicine. Optimum performance training for the health and fitness professional. Calabasas, CA: National Academy of Sports Medicine; 2004. 2 Hanten WP, Olson SL, Butts NL, Nowicki AL. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Phys Ther. 2000;80:997–1003. 3 Hou C-R, Tsai L-C, Cheng K-F, Chung K-C, Hong C-Z. Immediate effects of various therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil 2002;83:1406-14. 4 Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunction: the trigger point manual, the upper extremities. 2 nd edition. Baltimore, MD: Williams & Wilkins;1999. 5 Barnes JF. Myofascial release. In: Hammer WI (ed). Functional soft tissue examination and treatment by manual methods . 2 nd edition. Chapter 16. Gaithersburg, MD: Aspen Publishers, Inc; 1999. 6 Schleip R. Facial plasticity – a new neurobiological explanation: Part 1. J Bodywork Movement Therapies 2003;7(1):11-9. 7 Schleip R. Facial plasticity – a new neurobiological explanation: Part 2. J Bodywork Movement Therapies 2003;7(2):104-16. 8 Bandy WD, Sanders B. Therapeutic exercise: techniques for intervention . Philadelphia: Lippincott, Williams and Wilkins; 2001. 9 Jami L. Golgi tendon organs in mammalian skeletal muscle: functional properties and central actions. Physiological Rev 1992;73(3):623-66. 10 Alter MJ. Science of flexibility . 3 rd edition. Champaign, IL: Human Kinetics; 2004. 11 Moore JC. The Golgi tendon organ: a review and update. Amer J Occupational Ther 1984;38(4):227-36. 12 Saharmann S. Diagnosis and treatment of movement impairment syndromes . St. Louis, MI: Mosby, Inc; 2002. 13 Edgerton VR, Wolf SL, Levendowski DJ, Roy RR. .Theoretical basis for patterning EMG amplitudes to assess muscle dysfunction. Med Sci Sports Exerc. 1996 Jun;28(6):744-51. 14 Leahy PM. Active release techniques: logical soft tissue treatment. In: Hammer WI (ed). Functional soft tissue examination and treatment by manual methods . 2 nd edition. Chapter 16. Gaithersburg, MD: Aspen Publishers, Inc; 1999. 15 Timmons B. Behavioral and psychological approaches to breathing disorders. New York: Plenum Press; 1994.

14 Goniometric Assessments Inhibitory Techniques: Self-Myofascial Release 16 Ramsey SM. Holistic manual therapy techniques. Prim Care 1997;24(4):759-86. 17 Harris RE, Clauw DJ. The use of complementary medical therapies in the management of myofascial pain disorders. Curr Pain Headache Rep. 2002;6(5):370-374.