Addressing the myofascial component of musculoskeletal pain

Scientific Presentations by:Leon Chaitow DO, ND

Siegfried Mense MDJay Shah MD

Terry Loghmani PT, PhDTom Findley MD, PhD

Michael Schneider DC, PhD

Workshop Presentations by:Michael Leahy DC, CCSPTom Hyde DC, DACBSPAaron Mattes MS, LMT

Julie Ann Day PTLeon Chaitow DO, ND

Sponsored by University of Pittsburgh,

School of Health and Rehabilitation Sciences,Department of Physical Therapy

&University of Bridgeport,College of Chiropractic

MAY 7th & 8th

Course Overview

This two-day conference will address the various types of manual treatment for myofascial disorders that are commonly used to treat the myofascial component of painful musculoskeletal conditions. The morning sessions of this conference will feature guest speakers who will present information regarding the basic science evidence and existing literature support for the mechanisms of pain and dysfunction arising from these soft tissues: muscle, ligament, tendon, and fascia. The afternoon sessions will feature a variety of manual techniques taught within the context of smaller break-out workshops in which the instructor will combine lecture with hands-on demonstration of their respective methods. The overall schedule for the conference is listed below:

Friday May 7, 20108:00 -8:30 am - Registration8:30 – 9:30 - Leon Chaitow, DO, ND The role of soft tissue manipulation techniques in treating musculoskeletal dysfunction9:30 – 10:30 - Tom Findley, MD Fascianating Findings from the Fascia Research Congress 2007 & 200910:30 – 11:00 - Coffee break11:00 – 12:00 noon - Terry Loghmani, PT, PhD Instrument-Assisted Soft Tissue Mobilization: A Conservative Treatment Alternative to Enhance Connective Tissue Healing12:00 – 1:00 – LUNCH1:00 – 3:00 – Workshops (see registration page)3:00 – 3:30 - Coffee break3:30 – 5:30 - Workshops (see registration page)

Saturday May 8, 20108:30 – 9:30 - Sigfried Mense, MD Peripheral and central mechanisms of myofascial pain9:30 – 10:30 - Jay Shah, MD New Frontiers in the Pathophysiology of Myofascial Pain: Enter the Matrix10:30 – 11:00 - Coffee break11:00 – 12:00 noon - Michael Schneider, DC, PhD Systematic reviews of the myofascial pain and fibromyalgia literature

12:00 – 1:00 – LUNCH1:00 – 3:00 – Workshops (see registration page)3:00 – 3:30 - Coffee break3:30 – 5:30 - Workshops (see registration page)

Leon Chaitow DO, ND

Dr. Chaitow is an Honorary Fellow, University of Westminster, London, and is the Editor-in-Chief of the Journal of Bodywork & Movement Therapies (Elsevier). He is also a Consultant Osteopath and Naturopath, Marylebone Health Centre, London, England. He has published over 70 books including; Positional Release Techniques, Modern Neuromuscular Techniques, Muscle Energy Techniques, Clinical Applications of NeuroMuscularTechnique, and Fibromyalgia Syndrome: A Practitioner’s Guide to Treatment.

Dr. Chaitow will present an overview of the importance of including soft tissue manipulation techniques into the manual therapist’s clinical repertoire. While high velocity low amplitude (HVLA) thrust manipulation has been shown to be an effective and safe method for restoring joint motion, there are many other non-thrust techniques that restore joint motion by affecting the myofascial tissues associated with joint dysfunction. Dr. Chaitow will review some of the traditional osteopathic approaches to joint mobilization, including Muscle Energy Technique (MET) which utilizes variations of isometric contractions of the muscles associated with joint restriction, as well as Strain/Counterstrain (SCS) Technique, a positional release method that disengages from the restriction barrier and is believed to invoke neural responses that lead to spontaneous release of joint restriction. Current research that offers alternative explanations for the efficacy of SCS and MET, will be reported. He will also discuss the various myofascial release and fascial manipulation methods that are popular with manual therapists and body workers, and review the rapidly growing clinical research evidence that helps explain the mechanisms involved in the use of these soft tissue manipulation methods, either as alternatives to HVLA use, or as preparatory approaches to HVLA application.

The role of soft tissue manipulation techniques in treating joint and myofascial dysfunction

Siegfried Mense MD

Dr. Mense is a professor in the department of neuroanatomy at Heidelberg University, Medical Faculty Mannheim, Germany. He is considered a world authority on the neuroanatomy and neurophysiology of muscle pain, and has published over 180 scientific articles and book contributions on these topics. He is the primary author of the textbook “Muscle Pain” which is a definitive resource on the principles of the diagnosis and treatment of muscle pain syndromes.

Dr. Mense’s presentation will include four sets of data which lead to four main conclusions: 1) that excitation of muscle nociceptors and hence the occurrence of muscle pain depends on the balance of sensitizing and desensitizing chemical factors in the muscle; 2) for central sensitization to occur, sub-threshold synaptic potentials are sufficient; 3) spinal glial cells are important factors for muscle pain and hyperalgesia; 4) many cases of unspecific LBP may be due to input from the thoraco-lumbar fascia rather than from input from muscles of the low back. The results were obtained from anesthetized rats by recording the impulse activity of unmyelinated muscle afferents and dorsal horn neurons. Additional data were obtained in behavioral experiments on rats. The work was supported by grants from the German Research Association and the Federal Ministry for Education and Research.

Peripheral and central mechanisms of myofascial pain

Jay Shah MD

Dr. Shah is the Director of the Medical Rehabilitation Training Program and Senior Staff Physiatrist within the Rehabilitation Medicine Department at the National Institutes of Health in Bethesda, MD. His clinical research interests include the pathophysiology of myofascial pain and the integration of physical medicine techniques with promising complementary approaches in the management of neuromusculoskeletal pain and dysfunction. He has given many invited lectures and workshops on the mechanisms of chronic pain, myofascial pain, acupuncture techniques and other related topics. Dr. Shah and his co-investigators are using novel applications of ultrasound technology to visualize and characterize myofascial trigger points (MTrPs) and surrounding soft tissue, and innovative microdialysis techniques to study the biochemicals associated with pain, sensitization and inflammation at MTrP sites.

During this presentation, Dr. Shah will facilitate an informative session on how to evaluate and identify MTrPs and their referral patterns of pain; discuss the unique neurobiology of muscle pain; understand the roles of sensitization and neuroplasticity in generating, amplifying and perpetuating chronic musculoskeletal pain; demonstrate that active myofascial trigger points have elevated levels of biochemicals (e.g., inflammatory mediators, neuropeptides, catecholamines, cytokines, etc.) known to be associated with persistent pain states,  inflammation, and sensitization; and introduce novel applications of ultrasound techniques to visualize MTrPs, measure their stiffness properties and local blood flow.

New Frontiers in the Pathophysiology of Myofascial Pain: Enter the Matrix

Terry Loghmani PT, PhD

Terry Loghmani is an Associate Clinical Professor at Indiana University Dept. of Physical Therapy and a doctoral candidate in Anatomy & Cell Biology at the Indiana University School of Medicine. She has published numerous articles and textbook chapters on the use of instrument-assisted soft tissue mobilization methods. Many of her publications are based upon original basic science research in which she studied the effects of cross fiber massage on the biomechanical and histological properties of the healing of medial collateral ligaments in a rat model. Terry will discuss how musculoskeletal injuries involving the connective tissue are common clinical conditions that can lead to functional limitations, disability and disease. There is a need for conservative treatment alternatives that either accelerate or augment connective tissue healing. Manual therapy interventions such as soft tissue mobilization (STM) are often used by clinicians in the management of connective tissue disorders. Instrument-assisted soft tissue mobilization (IASTM) is a type of STM that uses rigid devices to help manipulate the soft tissue. Since connective tissue cells are mechano-sensitive to their environment, the mechanical stimulation provided by IASTM has the potential to directly influence connective tissue healing. Preliminary evidence suggesting IASTM enhances tendon and ligament healing is presented. The effects of IASTM on biomechanical, histological and vascular properties in connective tissue are discussed. Mechano-transduction is introduced as a mechanism for the therapeutic effects of IASTM. IASTM is a cost-effective and readily available manual therapy that may be used to promote optimal therapeutic outcomes.

Instrument-Assisted Soft Tissue Mobilization: A Conservative Treatment Alternative to Enhance Connective Tissue Healing

Tom Findley MD, PhD

Dr. Thomas Findley is the Executive Director of the International Fascia Research Congress which was held in 2007 at the Conference Center, Harvard Medical School, in 2009 at Faculty of Movement Sciences, Vrije Universiteit, Amsterdam, and is planned for Vancouver in 2012. He is an active clinician (Certified Advanced Rolfer™) as well as a researcher and is the recipient of the prestigious 2009 Northup Award from the American Osteopathic Association for his paper Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy. He will present key findings from both fascia research congresses, which form a broad base for both scientific and clinical investigations. These findings span the effects of physical forces on fascial cellular structure to laboratory models of acupuncture and of repetitive strain and subsequent myofascial treatment and their effects on fibroblast cells. They also cover fascial anatomy and biomechanics and transmission of mechanical forces through the fascial network in lieu of conduction down the more traditional muscular pathways, as well as direct mechanical coupling of the muscle and local blood vessels through the extracellular matrix. Dr Findley will take you through highlights of both congresses, including his keynote address, and encourages you to explore full text articles in the program book and the keynote addresses from both congresses, available from www.fasciacongress.org.

Fascianating Findings from the Fascia Research Congress 2007 & 2009

Michael Schneider DC, PhD

Dr. Schneider is an Assistant Professor in the School of Health & Rehabilitation Sciences at the University of Pittsburgh. He served as the chairman of the soft tissue committee of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP). He managed a team of reviewers who evaluated and rated all of the literature related to chiropractic management of myofascial pain and fibromyalgia through 2006. He has published the results of these systematic reviews in the Journal of Manipulative and Physiological Therapeutics ( JMPT).

Dr. Schneider will give overviews of the salient results from his published systematic reviews of the literature, and discuss the evidence rating tables for both conditions and focus on what conservative therapies have the most evidence based support from the literature. He will also discuss the emerging concept of central sensitization and the idea of several subsets of fibromyalgia patients, with the need for matching them with different treatment approaches. Dr. Schneider will outline some of his thoughts regarding the research directions he believes are necessary for soft tissue therapies to achieve more recognition in the fields of physical medicine, chiropractic and physical therapy.

Systematic reviews of the myofascial pain and fibromyalgia literature

Michael Leahy DC, CCSP

Dr. Leahy is a Doctor of Chiropractic and Certified Chiropractic Sports Physician. He developed a soft tissue management system named Active Release Techniques® (ART) by utilizing his background in aeronautical engineering and anatomy to effectively treat soft tissue problems, which were not responding to other traditional treatments. The goal of ART® is to restore optimal texture, motion, and function of the soft tissue and release any entrapped nerves or blood vessels. This is accomplished through the removal of adhesions or fibrosis in the soft tissues via the application of specific protocols. Adhesions can occur as a result of acute injury, repetitive motion, and constant pressure or tension. ART® eliminates the pain and dysfunction associated with these adhesions. This session will focus on the principles of ART® soft tissue diagnosis and treatment in a practical setting. We will cover how current thought on fascia affects diagnosis and treatment. The use of motion, manual contact, tension and relative motion during treatment will be explained.

The hands on portion of the program will consist of:1. The analysis of a participants golf swing using Doppler radar.2. Breakdown of biomechanics from swing dynamics to

individual tissues.3. Treatment of individual tissues.4. Post treatment analysis of the swing with doppler radar.5. Conclusions concerning effects of treatment.

Active Release Techniques: Practical Demonstration

Tom Hyde DC, DABSP

Dr. Hyde is a Doctor of Chiropractic and Diplomate of the American Chiropractic Board of Sports Physicians. He has served as a consultant to United States Olympic Committee and the Miami Dolphins. He has published numerous papers in peer reviewed journals and the textbook; “Conservative management of Athletic Injuries” ( Jones and Bartlett 2007).

Dr. Hyde will present an overview of the Graston Technique®, which is a type of instrument-assisted soft tissue mobilization (IASTM) that uses stainless steel instruments to detect and treat musculo-skeletal and fascial disorders. The technique consists of 7 different strokes applied at various angles and depths of penetration, depending on the type of soft tissue lesion being treated. Treatment is not only rendered over areas of local pain, but also at other related soft tissue locations within the kinetic chain. Functional and Kinetic Treatment with Rehab, Provocation and Motion (FAKTR-PM) is a concept created by 2 clinicians trained in Instrument Assisted Soft Tissue Mobilization (IASTM) who discovered that IASTM is more effective when the patient is treated dynamically, during the functional movements and positions that reproduce or provoke their pain. In addition to the use of IASTM during motion, resistance exercise may also be incorporated into the treatment which addresses the entire kinetic chain.

There are a number of relative and absolute contraindications to the use of IASTM which will be discussed; as well as the appropriate indications for their clinical use. Early animal studies have indicated that by using IASTM over an area of suspected adhesions within the soft tissue, that there is evidence to support breaking down those adhesions and influencing new fibroblastic activity. The amount of pressure exerted by the instruments also appears to be proportional to the increase of infiltration of plasma cells, phagocytes, and mast cells. There remain many unanswered questions about how IASTM actually works suggesting a need for further research. During this workshop, the clinical application and use of Graston instruments, other methods of IASTM, and FAKTR-PM methods will be demonstrated.

Graston Technique® and FAKTR-PM

Aaron Mattes MS, LMT

The Mattes Method of Active Isolated Stretching is a system of fascial release which provides effective dynamic facilitated stretch of major muscle groups, but equally important functional and physiological restoration of superficial and deep fascial planes. The Mattes Method consists of performing an active isolated stretch of no greater than 1.5 seconds. This allows the target muscle to optimally lengthen without triggering the protective stretch reflex and subsequent reciprocal muscle contraction. As the isolated muscle and fascia achieves a state of relaxation, maximal beneficial stretch can be accomplished without opposing tension or resulting trauma. Attendees will participate by seeing live demonstrations and hands-on techniques applied to the shoulder, wrist and hand regions.

Active Isolated Stretching Protocols for the Shoulder, Wrist and Hand

Julie Ann Day PT

Julie Ann Day is a physiotherapist who has worked most of career in the orthopaedic field, specializing in connective tissue massage. She is currently part of the staff of the Physiotherapy Department of the Ospedale dei Colli, Ulss 16 in Padova, Italy. Julie supervises a number of 3rd year Physiotherapy students from the University of Padova during their Orthopaedic clinical practice. Since 1999, she has been involved in Fascial Manipulation, as taught by Luigi Stecco, and from 2002 is a part of the authorised teaching group.

Julie will present a workshop on the Fascial Manipulation© Technique, which is based on the concept of Myofascial Units united in Myofascial Sequences, and involves manual friction over specific points on the deep muscular fascia. Localised friction causes hyperaemia and it is hypothesised that this could modify the extracellular matrix, restoring gliding between endofascial fibres and intrafascial planes. Any impediment to gliding could cause anomalous tension on mechanoreceptors embedded within fascia, generating uncoordinated joint movements due to altered proprioceptive afferents. This underlying rationale and the resultant analytical process guide practitioners in selecting the combination of points to be treated. The types of musculoskeletal disorders commonly treated include low back pain, tendinitis, ligament sprains, peripheral nerve compressions, and cervicocephalalgia.

The objective of this workshop is to inform participants about this new biomechanical model and to stimulate reflections and discussion as to its implications, as well as providing an opportunity to observe an application of the Fascial Manipulation© Technique.

An Introduction to Fascial Manipulation

Leon Chaitow DO, ND

Dr. Chaitow is a UK based osteopathic practitioner, author and educator. This workshop on Muscle Energy Technique (MET) will focus on the use of this well validated method in joint mobilization. Both traditional osteopathic variations (including the superbly gentle pulsed MET) as well as modern modifications, will be demonstrated. Some research evidence will be presented, however this workshop is designed to highlight the actual clinical application of MET.

The practical component of the workshop will include:1. The importance in MET methodology of identifying the ‘first sign of

resistance’ as joints are taken to their restriction barriers2. The different approaches used when MET is used in chronic and

acute situations3. The use of mini (pulsed) isometric contractions in treatment of

painful joints, in order to achieve both circulatory and neurological responses, as well as proprioceptive reeducation

4. Protocols regarding the length and strength of isometric contractions in different therapeutic settings

5. Particular attention to use of MET in cervical dysfunction, where the feature of spinal coupling allows for ultra-safe methods that may sometimes replace,  or can regularly precede, HVLA manipulation

6. Use of MET as part of an integrated sequence during trigger point deactivation, will be demonstrated

NOTE: Although not essential as a prerequisite, reading of Chaitow’s Muscle Energy Techniques (3rd edition, 2006, Elsevier) is recommended.

Muscle Energy Techniques

Leon Chaitow DO, ND

Dr. Chaitow is a UK based osteopathic practitioner, author and educator.  This workshop on osteopathic Positional Release Techniques (PRT) will explore the various models and methods associated with this indirect, functional approach to normalization of soft tissue and joint pain and dysfunction. Current research (University of Arizona) will be presented that helps to explain the extremely rapid changes that can occur when tissues are placed in a pain-free state of ease, for brief periods. Additional research (University of Colorado) will be outlined that helps explain the effects of facilitating forces (gentle crowding or distraction) of tissues that are being held ‘in ease’.

Both Functional PRT and Strain-Counterstrain (SCS) variations will be demonstrated. In addition, comparison of PRT with aspects of SOT, Mulligan’s Mobilization with Movement methods, McKenzie’s protocols, and unloading taping, will be outlined.

The practical component of the workshop will include:1. Explanation and demonstration of functional, strain-counterstrain,

and functional positional release variations of PRT2. Shortcut approaches to PRT using guidelines developed by George

Goodheart DC (“Goodheart’s guidelines”) will be outlined and practiced

3. The demonstration will focus on the use of PRT/SCS to treat cervical dysfunction, and extremity joint pain and/or dysfunction (elbow, wrist etc)

4. The use of PRT as part of an integrated sequence during trigger point deactivation will be demonstrated

NOTE: Although not essential as a prerequisite, reading of Chaitow’s Positional Release Techniques (3rd edition, 2007, Elsevier) is recommended.

Positional Release Techniques

TuitionAdvanced Registration ..............................................................$395(if received by April 16th)On-site Registration .................................................................$450 (for on-site or late registration)Discount Rate for full-time Students & Faculty ......................$195*Copy of Student/Faculty ID required with registration(if received by April 16th)

Note: Seating is limited due to the hands-on nature of this course. We cannot guarantee availability for on-site registrations and strongly recommend advance registration.

Registration FormName: ______________________________________________

Address: ____________________________________________

City: ________________________________________________

State: _______ Zip: ____________________________________

Phone: ______________________________________________

Fax: ________________________________________________

Email: ______________________________________________

Payment:Check Enclosed: $ _____________________________________(make checks payable to "University of Pittsburgh")NOTE: University of Pittsburgh can not accept credit card payments.Mail completed form and check to the course chairman:Michael Schneider, DC, PhD6035 Forbes TowerPittsburgh, PA 15260Email your questions to Dr. Schneider at mjs5@pitt.edu

Workshop Choices W1 - 1:00 - 3:00 W2 - 3:30 - 5:30

Active Release Techniques®Graston Technique®Active Isolated StretchingFascial ManipulationMuscle Energy TechniquesPositional Release Techniques

Friday Saturday W1 W2 W1 W2 W1 W2 W1 W2 W1 W2 W1 W2 W1 W2 W1 W2 W1 W1 W2 W2

Please pick one choice for a W1 workshop and one choice for a W2 workshop on both Friday and Saturday; you can pick two workshops each afternoon. Attendance at each workshop is limited to the first 40 people who sign up for that particular workshop.

Special Rate of $125 at Wyndham Hotel Pittsburgh-University Place for University of Pittsburgh. Address: 3454 Forbes Avenue, Pittsburgh, PA 15213 • Phone: 412-683-2040

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