| Functional Perspective |
Exploring a Functional Approach
A number of approaches exist when approaching the treatment of a myofascial pain disorder.
These are outlined in the tab for Perspectives in Myofascial Trigger Point Therapy. This section
explains the use of a functional perspective. The Functional Perspective is developed by utilizing
the 3 wall charts available at Cafe Press. These wall charts are developed from the research of
Gabriel Sella MD and are a summation of over a decade of research utilizing S-EMG
Biofeedback.
Definition: Treating muscles on the basis of what they actually do.
A functional approach will treat the muscles on the basis of what they have been documented to
do, Dr. Sella states that, “This is as opposed to the “classic but unclear definition of muscular
relationships as given in textbooks without actual proof of such relationships.” Traditionally, the
Terms Agonist, Antagonist, and Stabilizer are defined anatomically according to where they are
located in relationship to other muscles around a joint.
This approach involved locating muscle attachments and determining what would happen if the
ends of the muscles were approximated. This view is often taught today by putting a string
between points of attachment and asking students what will happen when the string is
shortened. It was assumed that the main function of the muscle was to shorten and produce
movement. S-EMG was utilized to document that indeed, when the muscle shortened it was
active. This further entrenched the concept that the shortening of the muscle was its “job.”
A Functional Approach
“Agonism-Antagonism-Stabilizer relationships are functional and Physiological rather than
anatomical.” This statement from Dr. Sella is made on the basis of 5,940 S-EMGs of 138
muscles over 10 joints. These muscles were tested bilaterally and the information put into a
database. This data is put into a visual chart format on 3 charts available at www.cafepress.
com/paineducation.
The utility of a functional approach is that for the first time in history we actually know what the
muscles do! The data demonstrate that long held assumptions in our anatomy, physiology and
kinesiology texts are often less than accurate. One instance of this is the concept of reciprocal
inhibition. The common understanding of the concept is that when muscles on one side
contract, those on the opposite side are inhibited. However, according to Dr. Sella’s data,
“SEMG studies on thousands of muscles pertaining to 10 major joints have shown every single
time that all the muscles of a given primary myotatic unit are active to a different extent during any
given motion whether the muscles are symptomatic or asymptomatic.”
The extent of this activity is documented on the chart series in the following ways. First, the
percentage of effort of each motion at the joint is documented. This will allow the practitioner to
know which motions to train in proper order for rehabilitation. Second, the amount of effort for the
combination of movements per muscle at each joint is presented. This allows treatment to be
performed on the most active muscles for chronic pain or in cases of phase 1 myofascial pain
disorders. Third, the muscles responsible for each motion are listed. This allows treatment of
phase 2 myofascial pain disorders to be treated in a very substantive manner taking guess work
out of the procedure.
Where does a Functional Approach Appear in the Treatment
Regimen?
I utilize a Functional Approach after establishing proper biomechanical relationships and treating
the neurological aspects of the presenting complaint. If I were addressing a knee complaint the
first issue would be to correct issues related to the mechanics of the foot and ankle inferiorly and
the hip joint superiorly. Treatment of the lumber paraspinal muscles to address the neurological
component would follow. Then the functional component is ready to be addressed.
There are a number of possible functional approaches that can be developed. In order to
determine the type of functional approach to be used it is necessary to determine the phase of
the Myofascial pain disorder as described by Janet Travell in her Mysteries of the History article.
Phase 1 is characterized by constant pain. It is not possible to determine what alleviates the
pain. Phase 2 is recognized by the ability of the patient to describe what postures or movements
exacerbate the pain. Phase 3 is stiffness. We will focus on the knee. Similar approaches are
available for each joint.
A Rehab Joint Functional Approach – would look at the motions available at the knee. The knee
is balanced between flexion and extension. The elbow is similarly balanced in its motions.
These are the only joints that exhibit this characteristic. A rehab joint functional approach at this
joint can retrain either flexion or extension followed by retraining the other motion. Rehabilitation
of motion should be done when the patient can perform the motion without pain. Retraining
should go from motions requiring the least toward the greatest effort. This approach is suitable
for Phase 3
A Pain Functional Approach – would be used with a phase 1 myofascial pain disorder. The
overall activity of the individual muscles in the joint of the symptomatic muscle would be
evaluated. The muscles performing ½ of the overall activity would be evaluated and treated for
trigger points and restricted ROM along with the symptomatic muscle. At this joint the muscles
most active in overall motion are from greatest to least: Plantaris, Sartorius, Popliteus, Gracilis,
and Biceps Femoris. Theses are seen in pie chart form on the Muscle Activation Per Joint chart
for the Lower Extremity at www.cafepress.com/paineducation. It will be observed that the
forgoing list of muscles is unusual given current theories of treatment.
A Movement/Posture Pain Approach – can be utilized when the patient is able to determine what
postures or movements exacerbate the pain. The patient would have a phase 2 myofascial pain
disorder. The muscles that cause pain in that movement, in addition to the symptomatic
muscles are treated. We recommend treating the muscles that perform the first 50% of the
movement. In the case of knee extension beginning with the most active muscles and going
down would be: Plantaris, Semitendinosis, Popliteus, Bicep Femoris, Gracilis, and Rectus
Femoris. It will be noticed that the foregoing list of muscles does not follow most current
assumptions.
A Muscle Specific Approach – Is presented in the text “Myofascial Pain Syndrome: Manual
Trigger Point & S- EMG Biofeedback Therapy Methods” currently available as a CD at GENMED
Publishing. The myotatic relationships for the Plantaris muscle at the primary myotatic unit of the
knee are as follows:
Agonists: Popliteus, Gastrocnemius, Semimembranosis, Semitendinosis, Biceps Femoris,
Gracilis, Soleus, Vastus Medialis/Lateralis and TFL
Antagonists: Sartorius and Rectus Femoris
Stabilizer: Gluteus Maximus
Conclusion
The utilization of a Functional Approach is most effective following treatment of the biomechanical
and neurological aspects of the patient’s pain complaint. Functional treatment is based on what
the muscles actually do. Specific joint rehab is essential following approaches treating the pain
in phase one and two.
A number of approaches exist when approaching the treatment of a myofascial pain disorder.
These are outlined in the tab for Perspectives in Myofascial Trigger Point Therapy. This section
explains the use of a functional perspective. The Functional Perspective is developed by utilizing
the 3 wall charts available at Cafe Press. These wall charts are developed from the research of
Gabriel Sella MD and are a summation of over a decade of research utilizing S-EMG
Biofeedback.
Definition: Treating muscles on the basis of what they actually do.
A functional approach will treat the muscles on the basis of what they have been documented to
do, Dr. Sella states that, “This is as opposed to the “classic but unclear definition of muscular
relationships as given in textbooks without actual proof of such relationships.” Traditionally, the
Terms Agonist, Antagonist, and Stabilizer are defined anatomically according to where they are
located in relationship to other muscles around a joint.
This approach involved locating muscle attachments and determining what would happen if the
ends of the muscles were approximated. This view is often taught today by putting a string
between points of attachment and asking students what will happen when the string is
shortened. It was assumed that the main function of the muscle was to shorten and produce
movement. S-EMG was utilized to document that indeed, when the muscle shortened it was
active. This further entrenched the concept that the shortening of the muscle was its “job.”
A Functional Approach
“Agonism-Antagonism-Stabilizer relationships are functional and Physiological rather than
anatomical.” This statement from Dr. Sella is made on the basis of 5,940 S-EMGs of 138
muscles over 10 joints. These muscles were tested bilaterally and the information put into a
database. This data is put into a visual chart format on 3 charts available at www.cafepress.
com/paineducation.
The utility of a functional approach is that for the first time in history we actually know what the
muscles do! The data demonstrate that long held assumptions in our anatomy, physiology and
kinesiology texts are often less than accurate. One instance of this is the concept of reciprocal
inhibition. The common understanding of the concept is that when muscles on one side
contract, those on the opposite side are inhibited. However, according to Dr. Sella’s data,
“SEMG studies on thousands of muscles pertaining to 10 major joints have shown every single
time that all the muscles of a given primary myotatic unit are active to a different extent during any
given motion whether the muscles are symptomatic or asymptomatic.”
The extent of this activity is documented on the chart series in the following ways. First, the
percentage of effort of each motion at the joint is documented. This will allow the practitioner to
know which motions to train in proper order for rehabilitation. Second, the amount of effort for the
combination of movements per muscle at each joint is presented. This allows treatment to be
performed on the most active muscles for chronic pain or in cases of phase 1 myofascial pain
disorders. Third, the muscles responsible for each motion are listed. This allows treatment of
phase 2 myofascial pain disorders to be treated in a very substantive manner taking guess work
out of the procedure.
Where does a Functional Approach Appear in the Treatment
Regimen?
I utilize a Functional Approach after establishing proper biomechanical relationships and treating
the neurological aspects of the presenting complaint. If I were addressing a knee complaint the
first issue would be to correct issues related to the mechanics of the foot and ankle inferiorly and
the hip joint superiorly. Treatment of the lumber paraspinal muscles to address the neurological
component would follow. Then the functional component is ready to be addressed.
There are a number of possible functional approaches that can be developed. In order to
determine the type of functional approach to be used it is necessary to determine the phase of
the Myofascial pain disorder as described by Janet Travell in her Mysteries of the History article.
Phase 1 is characterized by constant pain. It is not possible to determine what alleviates the
pain. Phase 2 is recognized by the ability of the patient to describe what postures or movements
exacerbate the pain. Phase 3 is stiffness. We will focus on the knee. Similar approaches are
available for each joint.
A Rehab Joint Functional Approach – would look at the motions available at the knee. The knee
is balanced between flexion and extension. The elbow is similarly balanced in its motions.
These are the only joints that exhibit this characteristic. A rehab joint functional approach at this
joint can retrain either flexion or extension followed by retraining the other motion. Rehabilitation
of motion should be done when the patient can perform the motion without pain. Retraining
should go from motions requiring the least toward the greatest effort. This approach is suitable
for Phase 3
A Pain Functional Approach – would be used with a phase 1 myofascial pain disorder. The
overall activity of the individual muscles in the joint of the symptomatic muscle would be
evaluated. The muscles performing ½ of the overall activity would be evaluated and treated for
trigger points and restricted ROM along with the symptomatic muscle. At this joint the muscles
most active in overall motion are from greatest to least: Plantaris, Sartorius, Popliteus, Gracilis,
and Biceps Femoris. Theses are seen in pie chart form on the Muscle Activation Per Joint chart
for the Lower Extremity at www.cafepress.com/paineducation. It will be observed that the
forgoing list of muscles is unusual given current theories of treatment.
A Movement/Posture Pain Approach – can be utilized when the patient is able to determine what
postures or movements exacerbate the pain. The patient would have a phase 2 myofascial pain
disorder. The muscles that cause pain in that movement, in addition to the symptomatic
muscles are treated. We recommend treating the muscles that perform the first 50% of the
movement. In the case of knee extension beginning with the most active muscles and going
down would be: Plantaris, Semitendinosis, Popliteus, Bicep Femoris, Gracilis, and Rectus
Femoris. It will be noticed that the foregoing list of muscles does not follow most current
assumptions.
A Muscle Specific Approach – Is presented in the text “Myofascial Pain Syndrome: Manual
Trigger Point & S- EMG Biofeedback Therapy Methods” currently available as a CD at GENMED
Publishing. The myotatic relationships for the Plantaris muscle at the primary myotatic unit of the
knee are as follows:
Agonists: Popliteus, Gastrocnemius, Semimembranosis, Semitendinosis, Biceps Femoris,
Gracilis, Soleus, Vastus Medialis/Lateralis and TFL
Antagonists: Sartorius and Rectus Femoris
Stabilizer: Gluteus Maximus
Conclusion
The utilization of a Functional Approach is most effective following treatment of the biomechanical
and neurological aspects of the patient’s pain complaint. Functional treatment is based on what
the muscles actually do. Specific joint rehab is essential following approaches treating the pain
in phase one and two.
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