Myofascial Meridian Stimulation Therapy (MMST) - A Holistic Approach for Pain Relief

1. Myofascial Meridian Stimulation Therapy (MMST)經筋動穴針法 Korean Integrative Medicine Institute Dr.Seonghyung Cho, M.D.

2. MMST(筋經動穴針法) History • 통증 치료에 있어 “HOW”가 아니라 “WHY”라는 하나의 접근 법으로서 MMST(經筋動穴針法)를 저의 스승이신 김일환 M.D.선생님의 도움아래 고안하게 되었습니다. • MMST(經筋動穴針法)는 근골격계와 자율신경병에 기인한 만성 통증에 있어Acupuncture가 왜 동양의학에서만 받아들여지고 서양의학에서는 쉽게 받아들여지지 않는가에 대한 의문점에서부터 출발하게 되었습니다. • 그 이유는 Acupuncture의 과학적 기전이 완전히 밝혀지지 않았기 때문이며 실제 임상에서 Acupuncture를 사용하는 시술자들에게도 그 효과 자체가 수수께끼로 남아있기 때문입니다. • 하지만 서양의학적 시각에서Acupuncture 자체가 동양 철학과 밀접하게 연결되있다는 것을 분명 간과해서는 안될 것으로 보입니다. Korean Integrative Medicine Institute

3. ICMART 2004, 호주 시드니 Main Session논문 발표 Korean Integrative Medicine Institute

4. ICMART 2005, 체코 프라하 좌장 및 Full Time Workshop Korean Integrative Medicine Institute

5. MMST(經筋動穴針法) Introduction • Western medicine: Myofascial • Oriental medicine: Meridian • Integrative approach: Stimulation Therapy Korean Integrative Medicine Institute

6. Western medicine: Myofascial • Myofascia라는 개념은 근막통증증후군(MPS)의 발통점(Trigger Point)과 연관된 근막(Myofascia)을 의미하는 것이 아니라 우리 몸 전체에 두루 퍼져있는 해부학적 근막선들(Myofascial lines)의 연결을 뜻하는 것입니다. • 이러한 근막선들의 네트워크를 통해 인체의 긴장통합체(Bio-tensegrity)와 분절성 신경 체계(Segmental Nervous System)를 유지할 수 있는 것입니다. Korean Integrative Medicine Institute

7. Oriental medicine: Meridian • Meridian이라는 개념은 움직임이나 자세를 통해서 근육을 따라 인체에 퍼져있는 경락(Meridian lines)의 변화를 통해 유지되는 네트워크체계를 의미하는 것입니다. • 동양의학에서 사용되는 주관적이거나 비객관적인 진단 방법을 지양하고 이러한 움직임을 통한 경락의 네트워크 체계를 이용하여 보다 객관적으로 진단하는 것입니다. Korean Integrative Medicine Institute

8. Integrative approach: Stimulation Therapy • Stimulation Therapy라는 개념은 근막선(Myofascial line)의 해부학적 구조와 경락의 경로(Meridian pathway)간에 상호 연관성과 분절성 신경 체계를 통해 선택된 경혈점(Meridian point)을 다음과 같은 방법으로 자극을 하는 것입니다. • Acupuncture, Dry needling, Injection, Magnetic therapy, Subcutaneous taped acupuncture, Myofascial release. • MMST(經筋動穴針法)는 이와 같이 임상의의 치료범위나 선호도에 따라 치료방법을 결정할 수 있습니다. Korean Integrative Medicine Institute

9. T.P(Trigger Point or Treatment Point) on the MMST • Segmental facilitation에 의해 야기된 stress는 muscle imbalance를 통해 인체의 tensegrity를 무너뜨리게 된다. • 그리고 이러한 유해성 자극 부위와 연속적으로 연결된 kinetic chain (myofascial line)에 가장 취약한 부위가 발생된다. • 이러한 부위에서 referred pain이나 hypertonic muscle 그리고 sympathetic dysfunction 등과 같은 비정상적인 증상이 일어나는데 이를 T.P.(Trigger Point or Treatment Point)이라 한다. • MMST(筋經動穴針法)에서는 이러한 T.P.를 서양 의학적인 concept을 기초로 하여 선택된 meridian point를 이용하여 치료를 한다. Korean Integrative Medicine Institute

10. MMST(經筋動穴針法) Introduction • “古爲今用”을 통해 MMST(經筋動穴針法)는 동양의학과 서양의학에 있어 장점을 포용하고 단점을 보완하여 진단과 치료를 할 수 있는 동서양 의학의 통합적 접근법(Integrative approach)으로 이루어졌습니다. Korean Integrative Medicine Institute

11. A prospective view of the western medicine • Stephen M. Levin : Bio-tensegrity(tension + integrity) model • Thomas W. Myers : Anatomy of myofascial connections • Autonomic nervous system and its relation to voluntary nervous system Korean Integrative Medicine Institute

12. Tensegrity(Tension +Integrity) model Compression element Continuous tension Bicycle wheels and similar structures with compression elements floating in a continuous tension network have been termed “tensegrity”structures by Buckminster Fuller. Korean Integrative Medicine Institute

13. Korean Integrative Medicine Institute

14. Bio-tensegrity (Tensegrity Biomechanics) proposed by Stephen M. Levin CT Compression element Myofascial tension strut Continuous tension LS He asserted the bio-tensegrity model that the human body structure is maintained by bony frame embedded in myofascial tension strut just as a bicycle wheel structure is maintained by reciprocal tension of strut Korean Integrative Medicine Institute

15. Similarity of Tensegrity model between human and other structures Tension Icosahedron model Tension Icosahedron model All human structures are similar to a tension icosahedron model because of they are formed of triangular truss type. Korean Integrative Medicine Institute

16. Tissue lesion or dysfunction in tensegrity structure The kinetic chain concept of biomechanics Secondary: The weakest link on remote area Weakest link in The same kinetic chain Same kinetic chain or myofascial tension line Strain or Limitation Primary: tissue lesion As a result, Pain or Limitation on movement Symptoms: local inflammation and pain Owing to ceaseless connection of the whole myofascia, a disorder in one region may be expressed in the form of pain and limitation on certain movement in other part of body mainly in the same kinetic chain(myofascial tension line) Korean Integrative Medicine Institute

17. Definition of Kinetic Chain • Three system: Myofascial, Articular, Neural system • Work as an integrated functional unit to provide structural and functional efficiency during integrated activities. Korean Integrative Medicine Institute

18. Why Kinetic Chain is so important in MMST? • Efficiency of Movement and Posture: tensegrity and alignment of kinetic chain • Dysfunction of tensegrity and alignment in any kinetic chain: compensatory reaction for maintaining the balance of kinetic chain -> serial distorsion pattern of kinetic chain • Compensatory reaction(excess adaptive potency (flexibility, force, neuromuscular control) on tissue): tissue failure and overload -> cumulative injury cycle -> symptom and sign Korean Integrative Medicine Institute

19. Cause of kinetic chain dysfunction • Postural dysfunction • Joint dysfunction • Muscle imbalance • Decreased neuromuscular control • Myofascial adhesion and shortness • Decreased core strength Korean Integrative Medicine Institute

20. Dysfunction mechanism • Altered length-tension relationship (Reciprocal Inhibition) • Altered force couple relationship (Synergistic Dominance) • Altered arthrokinematic relationship (Joint Dysfunction) Result of these relationship: ->Altered neuromuscular control ->Decreased neuromuscular efficiency ->Tissue fatigue and failure ->Cumulative Injury Cycle ->Pain and other signs and symptoms Korean Integrative Medicine Institute

21. Importance of optimum posture and alignment on the MMST • Help to prevent serial distorsion pattern • Help to provide optimal shock absorption • Help to provide weight acceptance and transfer of force during functional movement • Help to prevent the initiation of the cumulative injury cycle Korean Integrative Medicine Institute

22. Ideal alignment and Optimum movement • Ideal alignment -> facilitate optimum movement • Malalignment due to repeated movement and sustained posture -> joint or surrounding support system에 micro-trauma 유발 가능성이 증가 (ex:spinal segment-> degenerative change) • 자동차의 wheel movement -> wheel balance and good alignment for optimum rotation ->자동차와 지지면 사이에 있는 타이어가 균일하게 마모 Korean Integrative Medicine Institute

23. Good postural alignment Korean Integrative Medicine Institute

24. Hypothetical concepts of Connective tissue injury • Piezo(pressure)-electric charge • Interference field • Electromagnetic field Korean Integrative Medicine Institute

25. Piezo(Pressure)-Electric charge • All the tissue of the body generate electrical fields when they are compressed or stretched • Mechanical force -> structural deformation -> piezo-electric effect • Muscles are under a constant strain. And also the strain creates a piezo-electric charge that runs through the fascia within and around the muscle • On the body surface, the electrical resistance of strained point(acupuncture point) is lower than in its surrounding area. • Low resistance point: meridian point, strained point, myofascial trigger point Korean Integrative Medicine Institute

26. Segmental superficial dry needling’s MTrP(strained point) pain-relieving mechanism Insertion of needle into tissue immediately overlying active pain-producing MTrP Stimulation of A-delta sensory afferents Direct arousal of activity in dorsal horn-situated enkephalinergic inhibitory interneuron PLUS Indirect stimulation of these as a result of creation of activity in a serotonergic descending inhibitory system AND The creation of activity in the descending nonadrenergic system Blockade of intra-dorsal horn passage of MTrP’s nociceptive information Alleviation of MTrP pain Korean Integrative Medicine Institute

27. Interference Field on tissue strain During an injury or other imbalance, the membrane is broken or disrupted. The electrolytes pass freely into or out of the membrane and walls Damage Cell,nerves,muscles,vessels,others + + + - - - + - - + - + + - + + - + - + Interference field of nerves, cells, muscles, vessels & others - + - + - - + + + Disruption of membrane reverses normal Bio-electrical Potential – Dysfunction, Pain and Energy loss result Normal membrane Bio-electrical Potential Korean Integrative Medicine Institute

28. Electromagnetic Field • Extra-cellular matrix synthesis and repair are subject to regulation both by chemical agent(cytokines and GF) and physical agents,principally mechanical and electrical stimuli. • In soft tissue, alternating current electrical fields induce redistribution of integral cell membrane proteins which could initiate signal transduction cascades and cause a reorganization of cytoskeletal structures. • All physical and mental functions are controlled by electromagnetic fields produced by movement of electro-chemicals within the body. • When an injury occurs and tissue is damaged, positively charged ion move to affected area, causing pain and swelling. Korean Integrative Medicine Institute

29. Characteristics of Connective tissue • As a result, Piezo-electric charges, Interference fieldsandElectromagntic fieldsin connective tissue resulting from constant strains can occur pain and dysfunction in the body. Korean Integrative Medicine Institute

30. fascial consideration • Surrounding, supporting, separating, wrapping of the body • Be surrounded from sole to skull as one soft tissue structure • Function: ~innervated by many nerve ending ~elastically contraction & relaxation ~muscle attachment ~support & fix for balance ~all exercise ~blood & lymphatic circulation ~change earlier than chronic degenerative disease ~chronic passive tissue congestion ~tissue congestion(formation of fibrotic tissue) d/t H ion increase in the joint area ~stress band in overloading area ~burning nature pain d/t stress injury ~inflammatory action ~mediator:transport of the body fluid & inflammatory substance ~surround the CNS Korean Integrative Medicine Institute

31. Superficial back line Superficial front line Lateral line Spiral line Deep front arm line Superficial front arm line Deep back arm line Superficial back arm line Functional line Deep front line Myofascial line : Recently, a model suggested by Thomas W. Myers in his book Anatomy Trains try to explain this concept of the myofascial tension line anatomically and to integrate with meridian concept of TCM Bio-Tensegrity Myofascial tension strut network system in the body that controls structure of posture and movement. Korean Integrative Medicine Institute

32. Relation between myofascial connections and the kinetic chain concept on tensegrity • Dysfunction due to total myofascial connections-> limitation of movement • Sensitive tender point -> pain on remote area (압통점을 못 움직이도록 고정시키기 때문에 오히려 그 긴장도가 멀리 말초까지 뻗치게 됨) • 주된 장해부위로부터 사지를 움직이려 할 때에 조직의 tensegrity 구조물들은 어떤 강도의 감소 없이 그대로 힘을 전달 받아 우리 신체는 외부의 역학적 영향상태에 놓이게 되는 것이다. 또한 한쪽이 고정된 상태에서 완전 가동운동을 일으키려 시도하면 인체는 보상작용을 하게 마련이다. • As a result, dysfunction in excess movement -> repeated stress (local inflammation and pain) -> 발통 물질 and biomechanical failure Korean Integrative Medicine Institute

33. Dysfunction according to Muscle imbalance on movement • Nociceptive stimuli -> postural muscles (tight:facilitated) & phasic muscles(weak:inhibited) • chain reaction -> imbalanced pattern and movement dysfunction • hypoxia -> ischemic state -> pain -> continue feed-back cycyle -> hyperactivty on neural stimulation -> imbalance and dysfunction • 신체의 한 부위가 반복적이고 만성적인 스트레스를 받을 때, 그 부위에 신경 구조들은 overexcitable되어져 아주 쉽게 활성화되고 hyperirritable해지는 경향이 있다. -> “facilitation” Korean Integrative Medicine Institute

34. Segmental facilitation by I.Korr • Spinal segment: not independently • Principal of reciprocity -when the threshold of the segment is reached, all neurons will fire. • The segment in lesion has a lower threshold and is hyper-reflexive. • “lens” for afferent input collecting facilitatory or inhibitory afferents from segment above and below. • occur at areas of focus for postural stress(muscle imbalance), trigger point, visceral problem Korean Integrative Medicine Institute

35. In sequence of Segmental facilitation in disturbed lesioned segment • Facilitation of the sensory pathways -> easier access to the nervous system including the higher centers • Facilitation of motor pathways -> sustained muscular tensions, exaggerated responses, postural asymmetries and limited & painful motion. • Since the muscles have rich sensory as well as motor innervation, under these condition, they and related tendons, ligaments, joint capsules may become the source of relative intense and unbalanced streams of impulses. Korean Integrative Medicine Institute

36. The characteristics of the facilitated segment • Roots are overly sensitive or hair-triggered :hyperactive ventral motor root -> intervertebral foramen -> join the sympathetic nerve chain -> in a state of chronic overactivity, result in damage to target organ • Produce a palpable change in tissue texture :local paravertebral muscle & connective tissues develop a shoddy feel :joints in the area are less mobile :the tissues are tender to touch :often painfully irritable • Sympathetic system dysfunction :changes in skin texture, sweat gland activity & capillary blood supply to the skin Korean Integrative Medicine Institute

37. Pathway of Sensory information:Transmit information to spinal cord through dorsal horn • via ascending fibers to higher centers • via intrasegmental fibers to the anterior horn(somatic nervous system) • via intrasegmental fibers to the lateral horn(autonomic nervous system) Transmission of sensory information through dorsal horn is modulated by descending stimuli of high level and intersegmental reflex. Korean Integrative Medicine Institute

38. Gray matter of Spinal cord • Anterior(Ventral) Horn: cell bodies of somatic efferent nerve fibers • Posterior(Dorsal) Horn: cell bodies of interneurons upon which afferent(sensory) neurons terminate • Intermediated gray(Lateral Horn in the thoracic segments): cell bodies of autonomic(sympathetic) efferent nerve fibers • Gray commissure ---- connection of left and right Korean Integrative Medicine Institute

39. Anatomy of Autonomic nervous system Parasympathetic nervous system is divided into cranial outflow and sacral outflow In sympathetic nervous system, the axon of the sympathetic preganglionic neurons leave the spinal cord with the ventral roots of the eighth cervical to the second lumbar spinal nerves. Korean Integrative Medicine Institute

40. Division of Autonomic lateral horn • Medial column is comprised in cell bodies of preganglionic fibers toward internal organs • Middle column is comprised in cell bodies of preganglionic fibers toward trunk • Lateral column is comprised in cell bodies of preganglionic fibers toward head and extremities Three columns are related to secondary segmental modulations through various and numerous interneurons. Korean Integrative Medicine Institute

41. Secondary segmental relation The MMST uses lateral column of lateral horn toward head and extremities related to secondary segmental modulation Korean Integrative Medicine Institute

42. Somato-Visceral Point • Secondary segmental relation • For example, In C5/6 dermatome area pain, T5/T6 – C5/C6 : secondary segmental relation We can explain that SomatoVisceral Points (SVP) for treating abnormal somatovisceral reflex use the anatomy of autonomic nervous system through extremities and head and the secondary segmental relation. Korean Integrative Medicine Institute

43. SomatoVisceral Points (SVP) consisted of . SomatoVisceral Points (SVP)consisted of UB meridian points on surrounding C8-L2 dermatome area.according to secondary segmental relation Sympathetic nervous system: C8~L2 UB line Secondary segmental relation Magnetic therapy on UB line (paraspinal dermatome area) Korean Integrative Medicine Institute

44. Somato-Visceral Point vasodilation (decrease sympathetic tone ) C5/6 Secondary segmental relation T5 T6 Magnetic therapy on UB line (paraspinal dermatome area) onT5-6 In the selection of points for treating abnormal somatovisceral reflex on common C5 segment area, we used magnetic therapy on UB meridian line of trunk related to anatomy of sympathetic nervous system and secondary segmental relation (C5/6-T5/6) instead of using acupuncture needle. SomatoVisceral Points (SVP) consisted of UB meridian points on surrounding T5-6 dermatome area. In using acupuncture needle on T5-6 segment of UB meridian line, the blood vessel tone was increased on C5-6segment area. But in using magnetic therapy, we found the blood vessel tone was not increased in our clinical observation. Korean Integrative Medicine Institute

45. Magnetic Therapy • The application of magnetic field to injured area helps to restore the normal electromagnetic balance. • The magnetic field relaxes capillary walls, as well as surrounding muscle and connective tissues, allowing for increased blood flow. • More oxygen and nutrients are transferred to the injury site, while pain and inflammatory-related electro-chemicals are more efficiently removed. • The overall process restores the normal electromagnetic balance of the area, relieving pain and inflammation and promoting accelerated healing. Korean Integrative Medicine Institute

46. Segmental innervation If nociceptive stimuli occur in a certain segment, these stimuli will influence same innervated segment (dermatome, myotome, sclerotome and viscerotome). As a result, referred pains, hypertonic muscles, activated trigger points, trophic changes and autonomic symptoms such as vasomotor symptoms can occur. • Dermatome, myotome and sclerotome derived from the same somite embryologically have the same nervous pathway and a referral common afferent pathway. • Relation with sclerotome and dermatome: Anterior and posterior surface of plevis attached to iliolumbar ligament accord with L2 sclerotome. Also, Area of referred pains in iliolumbar ligament accords with L2 dermatome. • Referred pain pattern by ligament laxity follows the pattern of segmental dysfunction. Korean Integrative Medicine Institute

47. Somato-Somatic Point • Area in accordance with dermatome, myotome and sclerotome • For example, In C5/6 dermatome area pain C5/6 segment Treatment points in the MMST for abnormal somatosomaic reflex use common segment area in accordance with dermatome, myotome and sclerotome. Korean Integrative Medicine Institute

48. Somato-Somatic Point Deep dry needling In the selection of points for treating abnormal somatosomaic reflex on left shoulder pain, we applied SSP to common C5 segment area (dermatome,myotome and sclerotome). These points consisted of LU2, LI15 and TE14. Also, we stimulated these points by deep dry needling Stimulate meridian points (combined area of dermatome,myotome and sclerotome on C5/6) by deep dry needling TE14 Combined area of dermatome,myotome and sclerotome on C5/6 LU2 LI15 Stimulate skin, muscle and periosteum in order Korean Integrative Medicine Institute

49. SomatoSomatic Point (SSP) LU2,LI15, TE14 Common Back pain Common Shoulder pain LI11,LU5, TE9 GB30,BL60 LR8,KI10 ST36,GB34,BL53 Common Knee pain Deep dry needling (combined area of dermatome, myotome, sclerotome) Korean Integrative Medicine Institute

50. Common Back pain:Lumbar pain with/without gluteal pain Primary: TL junction syndrome Compensatory reaction 1.Acute problem: occur suddemly 2.Iliac crest의 허리볼기 지 역에 pain: neurotrophic change of cellulalgia 3.Typical facet locking Secondary: Pain on LS junction by ligament laxity 1.Chronic problem: TL problem이후에 occur 2.LS junction부위에 pain: -compensatory movement -gluteus muscle에 T.P. -hypersensitivity of greater trochanter (sometimes) Korean Integrative Medicine Institute