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Myofascial

Decompression
Techniques; MFD

TM

A Movement Based Myofascial Course


Presented by

Christopher DaPrato, PT,DPT,SCS,CSCS,PES


Christy Kennedy MS,L.Ac.,Dipl.O.M.
Level 1 Course Syllabus
Copyright 2009

COURSE OUTLINE
8:00-9:00 Intro. Anatomy, histology, & physiology review.
East/West perspectives, cuptherapy historical perspective
9:00-10:30 Literature review, collagen, ECM, Tensegrity,
trigger point theory, fascial lines, and Janda syndromes
10:30 Getting started, operation/application. MFD
approach and techniques, precautions & contraindications.
10:45 Instrument Assisted Soft Tissue (IASTM) Demos..
11:30-12:30 Breakout labs: Junctional Zones. ITB. Upper
traps and levator scap, PNF patterns
12:30-1:15 Lunch
1:15-1:45 Recovery, sports medicine, and performance
1:45- 2:30 Treating T/L fascia, shoulder impairments
2:30-3:15 Treating PFPS, P/O ACL, flexion contractures,
Hamstring strain vs tears.
3:10-3:45 Treating lower leg dysfunction, ankle/foot.
Tendonosis.
3:45-4:30 Clinical case studies, appropriate athlete care,
future research/evidence. Summary, evaluations
* Course is 60% lab, and 40% didactic. Student to Faculty PT <=15:1

www.MyofascialDecompression.com

5/27/2015

Myofascial
Decompression
Techniques

TM

Negative Pressure STM


Level 1

Your Instructors
Christopher DaPrato
DPT,SCS,CSCS,PES, cert.SMT

Assistant Clinical Professor for UCSF


UC Davis Sports Medicine Team PT
Former UCSF Department Manager
3 years as PT for California Golden
Bears D1 Athletics Department
Prior Clinic Director for Physiotherapy
Associates in Denver, CO
BS in Human Physiology
Masters in PT from Long Beach
Doctorate from Temple University
CSCS since 2002
Performance Enhancement Specialist
from the NASM

Lab Assisting:

Meghan Slemenda, DPT, OCS

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What we are NOT doing this weekend:

What to expect from this course

A hands on experience
Tools you can use Monday morning; another tool in the box
Integration of concepts and physiologic principles
Fun and novel approach to STM and manual therapy

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Course Outline/Course Objectives


Understand the properties skin/fascia and its
interface with the musculoskeletal and neurologic
systems.
Demonstrate an understanding of the histological
subunits of myofascial layers.
Understand trigger points, common referred pain
patterns, fascial lines, and Jandas postural
syndromes.
Utilize manual applications of MFD to treat
orthopedic issues, sports injuries, and P/O
adhesions

Course Objectives
Implement basic neuromuscular
re-education principles after using MFD to
restore optimal function.
Understand proper documentation and
billing.
Integrate MFD into your manual practice to
expedite results, increase efficiency, and
drastically improve outcomes.

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Cupping: Many Cultures


Chinese: Taoist alchemist Ge Hong in 281A.D.
Egyptians
Used as a traditional healing
method in many Arab cultures
where it is called Al-hijamah

Native Americans
Mexican-American healer
Curandera
Sobadera

South Americans

Cupping: Many Cultures


Egemen O, et. Al. 2011
negative pressure wound therapy provides quick
wound-bed preparation and complete graft take in
managing wound care

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Cupping: Many Cultures


Lasheen AE et. Al. 2006
External tissue expansion using negative pressure; hand surgery

Landau AG, et. Al. 2008


The results of this study confirm that the use of Negative Pressure
Device enhances full thickness skin grafts take.

Roostayi MM,et Al. 2009


vacuum brace is able to create
joint distraction and useful
for changes in PFPS

What sparked this re-discovery?


29 y/o male, volleyball player, with
left shoulder pain,
Dx by ortho as Left SLAP
PT rehab 6 months, no Sx unless
blocking in volleyball, and
occasional sleeping on it;
frustrated
Tried acupuncture x 2-3 visits with
needle techniques, without much
change in Sx of function
Acupuncturist then tried 1 Tx of
cupping, similar to picture

No Sx and pain free for 2 months

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Evolution of MFDTM

Age of Healthcare Evolution


Outcomes needed quickly and effectively
Limited visits often enforced
Art of dovetailing patients
The manual therapy difference

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Reverse of the Norm


Most manual therapy we utilize is very
compressive in nature: STM, MFR, joint mobs.
MFD works in the decompression of adhesions;
better physiologic sense for flow, reducing
inhibition of fluids and nutrient exchange
Take the sore thumb out of integrating a strong
manual based approach to musculoskeletal
disorders

Integrate Eastern medicine tools with


Western evidence based physiologic
principles and movement patterns

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Treatment Targets for


MFD

TM

Anatomy, Physiology, Histology

Cups: Western Perspective


Treatment Targets:
1.
2.
3.
4.
5.

Mechanical connective tissue change


Trigger Points
Myofascial Lines
Scar adhesions, scar tissue
Upper crossed/Lower crossed
syndromes: hypertonic groups

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Integument

Epidermis: thin skin

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Epidermis: thick skin

Petechiae

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Fascial Layers

Superficial
Deep = Aponerotic & Epimysial
TLF, TFL, rectus sheath

Intermuscular
Visceral

Skin: more complex that we learned

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Retinacula Cutis

Fascia is analogous

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Muscles within the Fascial layers


Twitch of skin horse, cow, pig
Hair stand up - Arrector Pili
Myofibroblasts

Connective tissue development


Ectoderm and Mesoderm gives rise to
the CT of skin and fascia above and
around muscle tissue.

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Fascial Components
Fibroblasts
Make and secrete all fibers of areolar connective tissue

Collagen fibers
Strongest and most abundant; cross linking leads to immense tensile strength

Elastic fibers
Rubber like proteins which allow tissue to return to original shape

Reticular fibers
Connect vessels and nerves; have more give than collagen

Ground substance
Extracellular matrix that holds interstitial fluid via sugar-protein molecules that soak fluid like
a sponge; with increased inflammatory response it becomes more viscous

The Colloidal Matrix

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Viscoelastic properties of skin

REMEMBER:
THIS IS FASCIA
Living tissue is hydrated and dynamic

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Skin layers

Layers
Superficial fascia
Myofascial Decompression Techniques
very effective

Deep fascia
Around deep muscles, viscera
Visceral Mobilization
Gail Wetzler, RPT, CVMI
Barral Institute
Institute of Physical Art

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Fascial Contributions
Support structure, tension, and
suspension for tissues; scaffolding
Fluid mobility; high amount of plasticity
Connecting multiple muscles = functional
kinetic chain
Has been shown to have myofibroblasts
Contraction of myofibroblasts influences
movement?

Muscles within the Fascial layers


Twitch of skin horse, cow, pig
Hair stand up - Arrector Pili
Myofibroblasts

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Viscoelastic properties: Collagen


Dermis is made up of 80% collagen, dry weight,
and of that collagen, 85% is type I
Type 3 collagen is ~15% of dermal collagen, but
is higher in immature tissue
With age, ratio of type 1:3 collagen increases
Increased collagen fiber density with age=
decreased ground substance space

Viscoelastic properties

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Viscoelastic properties:

Ground substance with GAGs


Glycosaminoglycans
Proteoglycans and repeating disaccharide units
Commonly hyaluronan and chontratin sulfate;
including dermatan sulfate
Bind water in normal healthy tissue
In aged skin, less binding to water and bind
more to elastoic material= thickened

Viscoelastic properties:Thixotropic Effect


Thixotropy is the property of certain gels
or fluids that are thick (viscous) under
normal conditions, but flow (become thin,
less viscous) over time when shaken,
agitated, or otherwise stressed.

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Viscoelastic properties:
Creep and Hysteresis
In relation to MFR creep is the distortion of
tissues as a function of pressure over time
Hysteresis is the exchange of heat and
energy as tissues are distorted; permanent
deformation. Microtrauma.
With MFR 90-120 seconds is the time for
generally the first barrier (R1) to release and
push into new range of extensibility.
Tendon Hysteresis in 5-10 minutes(Kubo 2001)

Stress-strain curves; human tissue

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What really happens when we stretch?


Sensory endpoint theory (Weppler & Magnusson 2010)
Very little evidence that Torque/angle curves shift; even w/ 8 weeks
More likely that the perception of the stretch sensation occurs later
in the application of similar force

PF stretch doesnt change relfex pathway

(Hayes 2012)

Stretching

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Soft tissue mobility: Folding


CT ability to compress upon itself
Shoulder Elevation= inferior capsule and
axillary fold stretched, but also superior and
anterior structures need to fold

parallel fiber arrangement demonstrates


more elastic qualities, improved mobility

Tensegrity

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Tensegrity
Tensional integrity
Fuller 1950s first visualized by the sculptor
Kenneth Snelson (Snelson, 1996).Fuller
defines tensegrity systems as structures that
stabilize their shape by continuous tension
rather than by continuous compression
Micro: studies of both cultured cells and
whole tissues indicate that cell shape stability
depends on a balance between microtubules
and opposing contractile microfilaments

Tensegrity

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Used to purge bites,


pustules, infections
and skin lesions from
the body
Also used to draw
evil spirits out of
body and balance the
humors

Origin of cupping therapy


not clear
Ancient cultures used
hollowed-out animal horns,
bones, bamboo, nuts,
seashells and gourds
Cupping vessels also
created from earthenware
and iron before glass

Cupping shown in 3,500


year-old Egyptian
hieroglyphic writing;
Egyptians introduced to
Greeks
European and American
doctors widely used and
researched cupping into late
1800's

Ebers Papyrus, (1550 BCE )

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Abscesses
Intercostal neuralgia
Intestinal disorders
Rheumatism
Bronchial asthma &
congestion
Gynecological
disorders
Kidney disorders
Dispels colds and
respiratory infections
Constipation and
diarrhea

Do not use cupping in cases of:


inflamed or cut skin
serious heart disease
cases of high fever
convulsions or cramping
strong cupping to the face
pregnant women (the
lower abdomen, medial leg
and lumbosacral region
should be avoided)
Not be applied on the
portion where hernia exists
or has occurred in the past

Modern name for


cupping is baguanfa
Chinese believe cupping
dispels stagnation of
Blood and Qi, along with
external pathogenic
factors that invade a
weakened constitution.

Liver disorders
Gallbladder
disorders
Dermatologica
Depression
Anxiety & insomnia
Cellulite
Vertigo
Menopause
Gastrointestinal
symptoms

How do magnets affect the


body?

Increase blood flow;


Relax muscles and
connective tissues;
Flush lactic acid,
toxins;
Send oxygen,
nutrients to cells;

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Increase fluid exchange

No literature supporting

Increase ion flow in and out of


cells
No literature supporting

Increase production of ATP


Alkalinizes, neutralizes acidic
conditions.

Ancient medical treatment


involving repeated pressured
strokes over lubricated skin with a
smooth edge.
Tools used: ceramic soup spoon,
coin, honed animal bones, water
buffalo horn, jade; metal cap with
rounded edge.
Gua Sha literally means "to scrape
away fever" in Chinese (more
loosely, "to scrape away disease by
allowing disease to escape as
sandy-looking objects through
skin").

Must use liniment;


Friction causes sha (small
red petechiae);
Sha is not bruising;
immediate fading of
petechiae to echymosis,
and rapid disappearance
vs. bruising;
Sha disappears in 2-4
days;
Color and rate of fading
diagnostic and prognostic
indicators.

Gua means rub or


friction; Sha means
congestion of blood at
bodys surface.
Called "spooning" by English
speakers, also called "triboeffleurage by the French.
In Vietnam technique is
called Cao Yio (scrape
wind); in Indonesia:
Kerikan (scraping
technique)

Reduces stiffness/pain;
Increases mobility;
Restores normal metabolic
processes by movement of fluids
carrying nutrients to tissues and
removing metabolic waste;
Mimics sweating/reduces fever;
Moves stagnant blood, promotes
circulation to treatment area and
to tissues/organs, etc.
No pain;
Immediate relief;
Treats:
Cases of pain or discomfort
Upper respiratory issues
Fever

Patient must cover


area, avoiding:
wind exposure
Sun exposure
sudden temperature
change
Stretching also
recommended but no
heavy workout on day
of treatment;
Drink plenty of water.

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Treatment Targets for


MFD

TM

Trigger Points, Fascial Lines,


and Postural Syndromes

Trigger Points

Travel and Simons

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Trigger Points

Lower levels of oxygen, nutrients, blood


perfusion
Increased levels of Calcium, leading to
excessive chronic muscle fiber
contracture, spasms
Stress can lead to abnormal excess
afferent stimulation
Can have shortening of sarcomeres

Literature: Analysis of trigger points


Simons et al. (1999) and Sciotti et al. (2001):
(1) presence of a palpable taut band in a skeletal
muscle
(2) presence of a hypersensitive tender spot
within the taut band
(3) local twitch response elicited by the snapping
palpation of the taut band
(4) reproduction of referred pain in response to
TrP compression. A TrP was considered active if
the referred pain evoked by its compression
reproduced the same subjects head pain;
whereas a TrP was considered latent if the
evoked referred pain did not reproduce a usual
or familiar pain

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Literature:
Ge et al. 2008 studied involvement of central
sensitization mechanisms in local pain syndromes
pain perception may result from a deregulation in
peripheral afferent and central nervous system
pathways- chronic excitability

Infraspinatus and Teres Minor

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Infraspinatus and Teres Minor

Teres Major

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Teres Major

Gluteus medius

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Gluteus medius

Rectus Femoris

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Rectus Femoris

Neurophysiologic responses
tissues become ischemic
thereafter blood reenters areas as indicated
flushing, hyperemia
produce endogenous opioids or endorphins
that affect the limbic system and brain
stem, enkephalins that affect the central
nervous system
MFD therapy relieves pain by acting as a
counterirritant

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Neurophysiologic responses
Mechanoreceptors, the morphologic
substrate for proprioception and kinesthesis
Muscle spindles and Golgi tendon organs
(GTOs) are the best-known types of
receptors, but must also consider free
nerve endings.
Melzack and Wall's gate-control theory of
pain, the large diameter A-beta nerve fibers
that transmit superficial pain can inhibit the
small diameter A-delta and C nerve fibers
that transmit deep pain

Neurophysiologic responses
Simply mechanical decompression of a
Nerve Entrapment and/or Compression

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Myofascial Lines
Work of Thomas Myers
Myofascial Tracks= muscles,
tendons, ligaments and fascia
Bony Stations= joints or
insertional sites at bony landmark
Have to be of similar depth
Can be static or motion driven
Picture: Pec minor, biceps,
coracobrachialis, rectus abdominis

Superficial Back Line


Includes:
Plantar fascia
Achilles tendon and Gastrocnemius
Hamstings
Sacrotuberous ligament
Thoracolumbar fascia
Erector spinae
Scalp fascia

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Superficial Back Line

Lateral Line
Often involved with leg length differences
and pelvic obliquities
Includes:
Peroneals
Anterior ligament of the head of fibula
ITB and TFL
Superior fibers of glute max, medius
External and internal obliques
Splenius capitis and SCM

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The Spiral Line


The Serape=double spiral
Includes:
Splenius capitis and cervicis
Rhomboids
Serratus anterior
Ext/Int obl. & ab aponerosis
TFL and ITB
Tib anterior
Peroneals
Bicep femoris to sacrotuberous
ligament
Lumbar fascia and erector spinae

Fascial mechanics
Translating forces =Slings
Lats to TLF to contra glute max and
down lateral thigh =ITB Tx

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Fascia encapsulates and supports

Fascia encapsulates and supports

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Postural Syndromes
Vladimir Janda, MD, DSc
Czech neurologist and physiatrist
Described characteristic patterns and
syndromes of muscle imbalance that
lead to chronic pain and disability
The Sensorimotor system functions as one entity,
integrating the central nervous system (CNS) and
musculoskeletal system.
The muscles are often a window to the function of the CNS.
The CNS regulates two phylogenic subsystems: the tonic
muscle groups and the phasic muscles

Crossed
U
P
P
E
R

Inhibited:
Deep cervical flexors

Facilitated: Upper trap,


levator scap, Suboccipitals

Facilitated:
SCM /Pectorals

Inhibited: Lower Trap,


Serratus Ant., Middle Trap.

L
O
W
E
R

Inhibited:
Abdominals

Facilitated: Thoraco-lumbar
extensors, QL

Facilitated: Rectus
femoris / Iliopsoas, TFL

Inhibited:
Gluteus Min / Med/ Max

C
R
O
S
S

C
R
O
S
S

Figure 1 : Janda's Muscle Imbalance Syndromes

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Lower Crossed Syndrome


Tonic/Short

Gastroc-Soleus
Hip Adductors
Hamstrings
Rectus Femoris
Iliopsoas
Tensor Fascia Lata
Piriformis
Thoraco-lumbar
extensors
Quadratus Lumborum

Phasic/Lengthened
Peroneus Longus,
Brevis
Vastus Medialis,
Lateralis
Gluteus Maximus,
Medius, Minimus
Rectus Abdominus

Upper Crossed Syndrome


Tonic/Short
Pectoralis Major
Upper Trapezius
Levator Scapulae
Scalenes
Sternocleidomastoid

Phasic/Lengthened
Serratus Anterior
Rhomboids
Lower Trapezius,
Middle Trap
Deep neck flexors

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Postural Distortions
Therefore patterns of muscle imbalance may be
due to CNS influence, rather than structural
changes within the muscle itself.
The coordinated firing patterns of muscle are
more important than the absolute strength of
muscles; ie: HAMSTRINGS; function with hop
Sensorimotor Training- increasing proprioceptive
input into the CNS with a specific exercise
program using proper firing patterns and
recruitment = neuro re-ed

Why do cups work?


Release tonic, tight, facilitated muscles
Open up catches in myofascial layers
Release trigger points, bringing in blood
flow and nutrient exchange
Traction out deep connective tissue
elements that are in dysfunction; most
importantly collagen cross bonding and
mobilizing viscous ground substance

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Why do cups work?


Thixotropic effect: decreased viscosity
Gate control theory of pain, large A-beta
nerve fibers that transmit superficial pain
can inhibit the small diameter A-delta and
C nerve fibers that transmit noxious pain
Endogenous opioids or endorphins that
affect the limbic system and brain stem,
enkephalins that affect the central nervous
system

Why do cups work?

The site of pain is often not the


cause of the pain.

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What is included in your set

Getting Started

Negative pressure tools 101

Magnets

1 gauss 1 Mx/cm2
1 Gauss = 104 kg C1 s1 .
8-10 gauss: human brain magnetic field
0.310.58 gauss: the Earths magnetic
field
50 gauss: a typical refrigerator magnet
100 gauss: a small iron magnet

Shape Matters

Size Matters
Largest size cups = 3 in
Large = 2.5 in
Medium size cups = 2 in
small cups =1.5, 1.25 in
baby cups = 1, in

Working the pump

Flat based cups

Concave based cups


Slow and steady at first, but initial pump needs
to quick to initiate the seal.

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How many pumps?

Start with as little as needed to maintain suction


Proceed to patient tolerance or desired elongation
To assess initial treatment response 2-3 pumps
Veteran use can go as high as 8-10 pumps

To Lube or Not to Lube

If the intent is to slide or stretch at any point of


the treatment lube is necessary

Practice Attachment

Pressure Generated
Much > than fire cup
Max pressure =.07Mpa*
=525.05 mm Hg
=10.153 pounds/sq inch
=47037 pounds/sq ft
=70,000 Newtons /sq M
*per

manufacture correspondence

Types of Lube
Lotion:
Creams: biotone,
freeup, deep prep
Oils: vegetable oil,
Liniments
Analgesics:
biofreeze, flexall

Practice Removal
2-3 Fingers on cup
2-3 Fingers on top
valve

Contours dictate choice of cup size, shape

Push down with


bottom pull up
gently with top

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Practice Slow Release


2-3 Fingers on cup
2-3 Fingers on top
valve

How many cups?

May just need one


Or may increase as
needed to reduce
underlying restriction
Depends on the length
of fascial restriction
MOVEMENT is the
driver

But now gently rock


green valve laterally
while slightly
tractioning the valve

Cleaning and Disinfecting

Blown out cup repair


Take apart valve system from cup

Envirocide
Sani-wipes, lysol
Clorox diluted 10:1

Pull green valve hard


Be very careful with plastic seal
After cleaning push sealer hard back into top of cup position

Soaking in solution
Do not get rubber valve
in solution!!

Made in China

Unscrew canister
from trigger
Unscrew trigger
from valve
Add grease every 3-4
months

Troubleshooting
If your trigger pops
loose:
If you break a valve on
the cup:
If the valve inside the
canister flips:
If the cup valve does
not release while on:

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Starting Point: Junctional Zones

Junctional Zones: single cup

C7/T1
T12/L1
SIJ
Sacrum/coccyx
Antero-lateral hip superior to gr.
trochanter
Inferior angle scap
Lateral joint line knee

T/L Junction

Quick Exercise
Take a partner and measure
forward flexion ROM:
-where is limiting
structure???
Place 1 cup on that point
and one proximal to it,
go back into flexion x 510 times.
Was there change in testing
fingertip to floor reach?

GuaSha = IASTM

ASTYM
Graston
SASTM
FAKTR
Iamtools
GuaSha Orthopedic
Target Point
Fuzion Tool
BioEdge

GuaSha Lab
Basic Steps:
Watch the area with movement patterns
Sweep area with hands/fingers
Trace and Isolate
4 directions, find most limited. Compare contralateral

Superficial scrape
Sense percussive info from tool

Scrape parallel fibers


Diagonal and perpendicular
Add movement

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Mobilization
Techniques

Cup Techniques:
Choosing where to start
Examination:
Subjective report: Hx, Hx, Hx!
A&PROM, MMT
Palpation

Hypertonicity
Scar mobility
Fascial Adhesions

Symmetry of soft tissue


motion; passive and active
Functional movement patterns

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Techniques-Things to
consider

Near bony landmarks


Single vs. multiple cups
Time and placement
Anatomy: origin and
insertion. Fiber
orientation, shape
Patient positioning
Draping and covering
Hair

Cup Techniques

Length of time to leave


the cups on:

Hou CR et. Al. 2002


Kubo 2001

Avoid excessive pressure


to prevent autonomic
responses w/ involuntary
contraction

30-90 seconds
minimum

Similar to SCS and positional


release

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Color vs Porosity vs
thickening

Cup Techniques

Where is the most force directed?

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Cup Techniques:
Facilitory
Facilitation of lengthening:
Elongation

Tether down restriction


Move away from restriction

Proximal to distal
Distal to proximal

Cup Techniques:
Inhibitory

Static; inhibition of antagonist facilitates the agonist


PROM

AROM

Passive inhibition
Active inhibition

Must include neuro re-education

less frequently used

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Cup Techniques:

Single cup Static


Single cup Glide
Single cup High-Velocity
2 cup Anchored glide
Multi-cup Linear and Diagonal lines

w/PROM
w/AROM

Cup Techniques:
single cup Static

Cup is stationary
Point release

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Cup Techniques:
single cup Static

With AROM

Supination
with elbow
flexion and
wrist flexion

Cup Techniques:
single cup Glide

Similar to static, but with cup slid along restriction to


further promote elongation
Can be toward or away from restricted segment

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Cup Techniques:
single cup Glide

Cup Techniques:
single cup High-Velocity pop
Take the tissue to end range,
then pop cup off into the
direction of most restriction.

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Cup Techniques:
anchored glide

Anchored with another


cup; 2 total generally

Cup Techniques:
multi cup Linear and Diagonal lines

Similar to static, but with


cups along restriction line to
promote elongation

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Cup Techniques:
w/ROM

PROM is the
workforce

AROM is the
workforce

After application
Use a flushing out technique immediately
after removing cup:
STM long strokes, milking fluid, Graston
Light Therapy; 30-50second bouts x4-8 Tx
Pulsed ultrasound; 20% or 50%
Generally, do not use ice for ~30min-2 hours after. If very
severe effects and raised tissue you may need to use ice
immediately. May use ice after time period.

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Contraindications
Eyes and genitalia
Unhealed wounds
Hemophilia, leukemia, active TB
Thrombocytopenia
Later stages of pregnancy
Influenza of fever
Moderate/severe anemia
Moderate/severe cardiac
conditions, high BP
Vasculitis
Skin elasticity disorders-EDS??

Precautions
-Those that are over eager
- addictive personalities

-Blood thinners
-Healing or thin skin

Elderly, Psoriasis

-Pregnancy
-Areas of ecchymosis

Previous cupped, Graston, STM

-Venous stasis and varicose veins


-DM; tissue healing and neuropathy
-Swollen tissue

especially pitting edema

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Precautions
Vasovagal Response
Vasovagal syncope is a temporary failure of the
brain to maintain blood pressure and heart rate
that causes the individual to possibly lose
consciousness. Causes of vasovagal syncope
include fear, pain, anxiety, trauma, blood loss,
extreme exertion, prolonged static standing,
physical or emotional stress, or an unpleasant
sight, sound, or smell.

Post-Surgical:
o

Can treat distal and proximal lesions early


o Early fibroblastic activity and collagen
proliferation at 4-7 days
Typical wait time 1-2 weeks near surgical site,
3-4 weeks directly over portals, 5-6 over open

Precautions
**Nearly always neuromuscular re-education is needed

to follow up with techniques.


Bobble

head effect

Techniques take years to master, just like


all other STM techniques. Modalities in combo.
Be smart about application and start simple.

11

5/27/2015

Documentation
MFD; (-) pressure STM
IE: ITB MFD; (-) pressure STM, Obers position

with PROM hip ADD, anchored glide.


or Teres Major MFD; (-) pressure STM sidelying, w/
PNF posterior depression.

Utilizes MFR and STM

Often a functional mobilization, then adding


neuro re-ed with PROM or AROM
Can be 97140 manual therapy, or 97112

Warning the patient

Significant other
Domestic abuse
Drinking water next 24 hours

Warning the MD

Call your MDs (Che-Wei Lin, 2009)


Instruct patient to explain releases
connective tissue adhesions or scar
mobility

12

5/27/2015

C. DaPrato DPT,SCS,CSCS

Pre

and Post testing

ROM, MMT, gait analysis


Trigger

point assessments
Functional activity
tolerance
squats, lunge, hop tests,

overhead activities, stairs


Sport

specific training

T-test, pro-agility, SL vertical


Kick, throw, swing, volley

5/27/2015

Testing for Dx =
Patient positioning =
Cup placement =
Time and motion =

Most

important key to making your ROM


and soft tissue extensibility changes stay
Usually target underused synergist or
contralateral, but may also be the agonist
Follow-up immediately after response
testing objective measures
Finish with self Foam Roller, stick to
mobilize fluid for lymphatic drainage

5/27/2015

Origin: anterior iliac crest outer lip, anterior border of the ilium, outer
surface of anterior superior iliac spine
Insertion: iliotibial band of fascia lata on lateroanterior aspect of thigh,
about 1/3 of the way down; inserts proximally into the lateral
epicondyle of the femur then passes in its broad expansion between
lateral aspect of patella; inserts distally on gerdy's tubercle: on the
lateral aspect of tibia tubercle
Action: thigh flexion at the hip, abduction, and medial rotation;
stabilizes the knee laterally; iliotibial band moves forward in extension
and backward in flexion but is tense in both positions

5/27/2015

Testing for Dx = Thomas test, Lateral line, leg


length, Noble compressionObers?
Patient positioning = Sidelying, or Thomas test

Cup placement = 1@ superficial oblique


retinaculum, 1 near Gerdys tubercle, 1@ distal
thigh, 1@ TFL
Time and motion = 3 static, 1 into hip ext/add &
knee flexion, with hold relax technique

5/27/2015

Lateral

plank with hip ABD (selkowitz 2012)


Standing Clam (Lee/Powers 2013)
Single Leg Step downs
Lateral band squats
Pilates reformer hip ABD
Hip rotators ER theraband

5/27/2015

Testing for Dx = cervical ROM testing, palpation


for trigger points
Patient positioning = sidelying or sitting into
prone
Cup placement = 1@ superior angle scap, 1@
paravertebrals C5/6, 1@ T4, 1 @ near the end
of the spine of scap

Time and motion = 3 static, 1 with stretch using


ipsilateral UE, PNF posterior depression

5/27/2015

Cervical

retractions
Posterior depression PNF
Wall retractions with shoulder ABD
High row for Lower trap= elbows
straight

5/27/2015

Testing for Dx = Rotational spine tests,


forward trunk flexion, end range
shoulder motion, gait
Patient positioning = Barrel rotation, or
prone on ball, or childs pose
Single vs.multiple cups, and placement =
vary
Time and motion = 4-5 static, add reaching
into forward flexion ipsilateral, rotate

5/27/2015

Posterior

tilt patterns
Pelvic Clock sitting on ball
Foam roller 1 foot march
Bridge with posterior tilt
Glute med/max retraining
Lower abdominal ball roll
Nordic Hamstring

Teres

Major and
Infraspinatus
Tricep proximal
Lateral lat. line

5/27/2015

Testing for Dx = Scapulohumeral rhythm, A&PROM,


flexion>ER ROM restriction, lateral scapular
border, symmetry of angle of medial border
Patient positioning = sidelying on contralateral, arm
flexed to pain free tolerance
Cup placement = 1@ infraspinatus laterally and 1
near medial border, 1@ t. minor and major, 1 @
inferior angle scapula, 1 @ triceps proximally

Time and motion = 2-4 static, then proceed with arm


elevation and ER PROM

10

5/27/2015

ER

bilateral with Scap squeeze

French doors
Doorway

pec stretch
High row for Lower trap
Wide grip lat pulldowns
Foam roller is a must
Dont forget Subscap and Pec minor manual release

11

5/27/2015

Testing for Dx = Thomas test, gait, prone knee


bend <130, patellar mobility/face
Patient positioning = Sitting edge of table.
Progress to supine with bent knee, or bolster
supported. Thomas test position more
aggressive
Cup placement = VL(2-3), lateral retinaculum,
patellar ligament
Time and motion = 1-2 static sitting back, 1-2
ADD with knee flexion

12

5/27/2015

VMO

phasic timing with QS, SLR,

SAQ (Lynch et al, 2012 JOSPT)


NMES VMO, or Russian stim
Glute medius
Posterior tib heel raises
Patellar tendon eccentrics
Decline single leg step-downs

Anterior knee pain

13

5/27/2015

Testing for Dx = Gait, visual, ROM


Patient positioning = Prone with knee off
table. Pre-treat with MHP and t-b weight
Cup placement = superficial back line @
distal h/s, posterior jt line, and lateral
gastroc belly

Time and motion = 4 static, 1 anchored


glide

Gait

on tredmill- retro walking


VMO phasic timing with QS, SLR, SAQ
TKEs- ball to wall, theraband, planks
Glute medius

14

5/27/2015

End

range flexion
restriction secondary to
posterior knee pain
Posterior capsule
edema leading to
popliteus and lateral
head of gastroc
After MFD with AROM
retest flexion and most
pain should be anterior
scar site

15

5/27/2015

Testing for Dx = Supine AKE-popliteal


angle; Slump, SLR
Patient positioning
a) Prone; fascial line, generally medial>
lateral, and always intersection of gastroc
to H/S. Active quad set and DF ankle
b) Supine with contralateral leg hooked
over table; anchor proximal, glide distal
end

16

5/27/2015

(b)

Pes Anserine

FC

17

5/27/2015

Glute

firing pattern

Prone hip extension= ipsi glute, contra, ipsi


Eccentric

unilateral bridge
H/S ball curls with core and obliques
Lateral band squats
Pilates reformer hip ABD
Clam shells

Ajimsha

(Truyols-Dom JOSPT 2013)


(Renan-Ordine JOSPT 2011)

18

5/27/2015

Testing for Dx = DF ROM loss, pain SLB, LE


kinetic chain dysfunction
Patient positioning = prone with STJ clear
of end of table
Cup placement = 1@ posterior lateral joint

line, 1 @ lateral gastroc muscle belly,


sometimes 1 @ distal lateral hamstring,
1@ achilles

Time and motion = 3 static, 2 with DF/PF

19

5/27/2015

Testing for Dx = palpation, decreased DF


ROM, patient Hx and S/S
Patient positioning = supine or prone- knee
at 90 PROM w/ankle motion, minus achilles
Cup placement = Anchor at proximal or distal

and ROM through glide or static. May also


use medium or small cup over heel pad

Time and motion = move into DF and hallux


extension

20

5/27/2015

Case Presentations

MFD Results

Rib dysfunctions

21 y/o lacrosse
player, chronic rib
tension T6 facet
and down rib 5,
four weeks
HVLAT and MFD
diagonal line ,
resolved after 2
sessions

5/27/2015

A/C joint Impingement

45y/o female
Short head BB and
pec minor
restrictions after
SAD and mumford
Chronic anterior
shoulder pain
MFD anchored
glide with AROM

Weight lifting injury

22 y/o rugby
player in 2 weeks
after max squat
Moderate flexion
restrictions, but
tolerates prayer
well.
4 treatments over
3 weeks and back
to practice

5/27/2015

Lumbar pain with running

22 y/o male elite


distance runner
Left lumbar pain
with >1 mile runs
MFD over L5/1 and
L glute medius
MFD 2 cup static
with childs pose

Bicipital tendonosis

22y/o softball
player
Pre treat flexion
painfree ROM=135
MFD BB long head
above bicipital
groove, and short
head to coracoid
Post treat flexion
painfree ROM=158

5/27/2015

Chronic LBP

47 y/o female with


9 weeks chronic
LBP, secondary to
increased activity
Limited SB AROM
to 3 inches
fingertip to knee
MFD Erectors and
QL diagonal line,
with ipsilateral
gapping and PNF

Nerve Entrapments

32y/o radiculitis
SLR pre-Tx
=30 degrees (+)
MFD spiral line and
superficial back
line
SLR post-Tx
= 57 degrees,
mild L/S referral
only, with Add/IR

5/27/2015

Upper trap overuse II

NCAA National
champion relay
swimmer
Anterior
Impingement
and A/C joint
irritability
No pain after 2
treatment
sessions

Chronic H/S tension

21y/o decathlete, with L H/S pulled 1 y/a


Sensations of getting tight again
MFD in elongated position, with secondary
thickened indurated prominence

5/27/2015

Pain with running

31y/o male,
training for
marathon
R lateral/superior
knee pain greater
than 3 miles
Elys Prone knee
bend R=128,
L=140
MFD linear line
with PROM

Post-Op Bankart

5/27/2015

Scoliotic soft tissue changes

29 y/o grad
student with
bilateral L>R
interscap pain with
lifting and working
on computer
Mild levoscoliosis
FRS correction and
MFD L interscap
and lat chain
release

THANK YOU!!!

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http://www.imtsglobal.com/
http://www.neseminars.com/store/comersus_listItems.asp?Clini
cian=28
http://comptsig.org/page-1589803
http://rolandlucaspt.com/
http://www.naiomt.com/www.naiomt.com/index.html
http://www.richardjacksonseminars.com/
http://www.usa.edu/continuing_education.aspx
www.physicaltherapycontinuingeducation.co/ContinuingEducation-Course-Schedules.htm
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NAME:_____________________________

DATE:__________

Overhead Squat Test


Anterior View

Right
YES

Foot

Foot Turns Out

Knee

Moves Inward

Left
YES

Moves Outward

Lateral View
(Right Side)
L-P-H-C Excessive
Forward
Lean
Low Back
Arches
Low Back
Rounds
Arms Fall
Upper
Forward
Body

YES

Posterior View

Right
Yes

Left
YES

Heel of Foot
Rises

Foot

Foot Flattens
L-P-H-C

Asymmetrical
Weight Shift

MODIFIED:
HEELS ELEVATED

ARMS DOWN

FEET
KNEES
LPHC
UPPER

NOTES:

Single Leg Squat Test


RIGHT Leg

LEFT Leg
Right
YES

Left
YES

Foot

Foot Flattens

Foot

Foot Flattens

Knee

Moves Inward

Knee

Moves Inward

Moves Outward
L-P-H-C

Hip Hike

Moves Outward
L-P-H-C

Hip Drop
Upper Body

Inward Trunk Rotation


Outward Trunk Rotation

NOTES:

Hip Hike
Hip Drop

Upper Body

Inward Trunk Rotation


Outward Trunk Rotation

Overhead Squat Solutions Table CES

Anterior

View

Checkpoint

Compensation

Probable Overactive
Muscles

Probable Underactive
Muscles

Example Flexibility Exercise


(SMR & Static)

Example Strengthening
Exercise

Foot

Foot Turns Out

Soleus
Lat. Gastrocnemius
Bicep Femoris (short head)
Tensor Fascia Latae

Med. Gastrocnemius
Med. Hamstring
Gluteus Medius/Maximus
Gracilis
Popliteus

Calf Stretch
Hamstring Stretch
Standing TFL Stretch

Single-leg Balance Reach

Knee

Moves Inward

Adductor Complex
Bicep Femoris (short head)
Tensor Fascia Latae
Vastus Lateralis
Lat. Gastrocnemius

Gluteus Medius/Maximus
Vastus Medialis Oblique (VMO)
Med. Hamstring
Med. Gastrocnemius

Adductor Stretch
Hamstring Stretch
TFL Stretch
Calf Stretch

Lateral Tube Walking


Ball Squat
w/Abduction
Ball Bridge w/Abduction

Moves Outward

Piriformis,
Biceps Femoris
Tensor Fascia Latae
Gluteus Minimus/ Medius

Adductor Complex
Med. Hamstring
Gluteus Maximus

Piriformis Stretch,
Hamstring Stretch
TFL Stretch

Ball Squat w/Adduction


Ball Bridge w/Adduction

Excessive
Forward Lean

Soleus
Gastrocnemius
Hip Flexor Complex
Abdominal Complex (rectus
abdominus, external oblique)

Anterior Tibialis
Gluteus Maximus
Erector Spinae

Calf Stretch
Hip Flexor Stretch
Ball Abdominal
Stretch

Ball Squat

Low Back Arches

Hip Flexor Complex


Erector Spinae
Latissimus Dorsi

Gluteus Maximus
Hamstrings
Intrinsic Core Stabilizers
(transverse abdominis,
multifidus, internal oblique,
transversospinalis, pelvic floor
muscles)

Hip Flexor Stretch


Latissimus Dorsi Stretch
Erector Spinae Stretch

Ball Squat
Floor Bridge
Ball Bridge

Low Back Rounds

Hamstrings
Adductor Magnus
Rectus Abdominus
External Obliques

Gluteus Maximus
Erector Spinae
Intrinsic Core Stabilizers
(transverse abdominis,
multifidus, internal oblique,
pelvic floor muscles,
transversospinalis)

Hamstring Stretch
Adductor Magnus Stretch
Ball Abdominal Stretch

Floor Cobra
Ball Cobra
Ball Back Extension

Arms Fall Forward

Latissumus Dorsi
Pectoralis Major/ Minor
Teres Major
Coracobrachialis

Mid/Lower Trapezius
Rhomboids
Rotator Cuff
Posterior Deltoid

Latissumus Dorsi Stretch


Pec Stretch
SMR Thoracic Spine

Floor Cobra
Ball Cobra
Squat to Row

Forward Head
(pushing/pulling
assessment)

Levator Scapula
Sternocleidomastoid
Scalenes

Deep Cervical Flexors

Levator Scapula Stretch


Sternocleidomastoid Stretch
Scalene Stretch

Tuck chin, keeping head in


neutral position during all
exercises

Shoulder
Elevation
(pushing/pulling
assessment)

Upper Trapezius
Sternocleidomastoid Levator
Scapulae

Mid/lower Trapezius
Rhomboids
Rotator Cuff

Upper Trapezius Stretch


Sternocleidomastoid Stretch
Levator Scapulae Stretch

Floor Cobra
Ball Cobra

Foot Flattens

Peroneals
Lat. Gastrocnemius
Bicep Femoris (short head)
Tensor Fascia Latae

Anterior Tibialis
Posterior Tibialis
Med. Gastrocnemius
Gluteus Medius

Peroneal Stretch
Calf Stretch
Hamstring Stretch
Standing TFL Stretch

Single-Leg Balance Reach


Single-leg Medial Calf Raise

Heel Rises

Soleus

Anterior Tibialis

Soleus Stretch

Single-leg Balance Reach


Single-leg Squat

Asymmetrical
Weight Shift

Adductor Complex
Tensor Fascia Latae
(same side)
Piriformis
Bicep Femoris
Gluteus Medius
(opposite side)

Gluteus Medius
(same side)

Adductor Stretch
(same side)
Tensor Fascia Latae Stretch
Piriformis Stretch
Hamstring Stretch
(opposite side)

Gluteus Medius
(same side)

Lateral

L-P-H-C

Upper Body

Foot

Posterior

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L-P-H-C

Adductor Complex
(opposite side)

Adductor Complex
(opposite side)