Myofascial Meridian Stimulation Therapy (MMST) 經筋動穴針法

Myofascial Meridian Stimulation Therapy


(MMST)經筋動穴針法

Dr. Seonghyung Cho, M.D.

Korean Integrative Medicine Institute



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 있어 Acupuncture 가 왜 동양의학에서만 받아들여지고 서양의학에서는 쉽게 받아들여지지 않는가에 대한 의문점에서부터 출발하게 되었습니다 .

그 이유는 Acupuncture 의 과학적 기전이 완전히 밝혀지지 않았기 때문이며 실제 임상에서 Acupuncture 를 사용하는 시술자들에게도 그 효과 자체가 수수께끼로 남아있기 때문입니다 .

하지만 서양의학적 시각에서 Acupuncture 자체가 동양 철학과 밀접하게 연결되있다는 것을 분명 간과해서는 안될 것으로 보입니다 .



ICMART 2004, 호주 시드니 Main Session 논문 발표



ICMART 2005, 체코 프라하 좌장 및 Full Time Workshop



MMST( 經筋動穴針法 ) Introduction

Western medicine: Myofascial

Oriental medicine: Meridian

Integrative approach: Stimulation Therapy



Western medicine: Myofascial

Myofascia 라는 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 .



Oriental medicine: Meridian

Meridian 이라는 개념은 움직임이나 자세를 통해서 근육을 따라 인체에 퍼져있는 경락 (Meridian lines) 의 변화를 통해 유지되는 네트워크 체계를 의미하는 것입니다 .

동양의학에서 사용되는 주관적이거나 비객관적인 진단 방법을 지양하고 이러한 움직임을 통한 경락의 네트워크 체계를 이용하여 보다 객관적으로 진단하는 것입니다 .



Integrative approach: Stimulation Therapy

Stimulation Therapy 라는 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 .



T.P(Trigger Point or Treatment Point) on the MMST

Segmental facilitation 에 의해 야기된 stress 는 muscle imbalance 를 통해 인체의 tensegrity 를 무너뜨리게 된다 .

그리고 이러한 유해성 자극 부위와 연속적으로 연결된 kinetic chain (myofascial line) 에 가장 취약한 부위가 발생된다 .

이러한 부위에서 referred pain 이나 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 concept 을 기초로 하여 선택된 meridian point 를 이용하여 치료를 한다 .



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 .



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



Tensegrity(Tension +Integrity) model

Bicycle wheels and similar structures with compression elements floating in a continuous tension network have been termed “tensegrity”s

tructures by Buckminster Fuller.

Compression

element Continuous

tension





Bio-tensegrity (Tensegrity Biomechanics) pr

oposed by Stephen M. Levin

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

Myofascial tension strut

CT

LS

Compression

element

Continuous

tension



Similarity of Tensegrity model between human and other structures

All human structures are similar to a tension icosahedron model because of they are formed of triang

ular truss type.

Tension Icosahedron

model

Tension Icosahedron

model



The kinetic chain concept of biomechanics

Weakest link in The same kinetic chain

Tissue lesion or dysfunctionin tensegrity structure

Symptoms:local inflammation

and pain

Strain orLimitation

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)

Primary: tissue lesion

Secondary:The weakest

link on remote area

As a result, Pain or Limitation on movement

Same kinetic chain or myofascial tension line



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.



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



Cause of kinetic chain dysfunction

Postural dysfunction

Joint dysfunction

Muscle imbalance

Decreased neuromuscular control

Myofascial adhesion and shortness

Decreased core strength



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



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



Ideal alignment and Optimum movement

Ideal alignment -> facilitate optimum movement

Malalignment due to repeated movement and sustained posture -> joint or surrounding support system 에 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



Good postural alignment



Hypothetical concepts of Connective tissue injury

Piezo(pressure)-electric charge

Interference field

Electromagnetic field



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



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

Indirect stimulation of these as a result of creation of activity in a serotonergic descending inhibitory system

The creation of activity in the descending nonadrenergic system

Blockade of intra-dorsal horn passage of MTrP’s nociceptive information

Alleviation of MTrP pain

PLUS

AND



Interference Field on tissue strain

Interference field of nerves, cells, muscles,

vessels & others

Cell,nerves,muscles,vessels,others

+ +++++ +

+++

+++

++- +-- -

----

- --- -

Normal membrane

Bio-electrical Potential

Disruption of membrane reverses normal Bio-electrical Potential – Dysfunction, Pain and Energy loss result

Damage

During an injury or other imbalance, the membrane is broken or disrupted. The electrolytes pass freely into or out of the membrane and walls



Electromagnetic FieldExtra-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.



Characteristics of Connective tissue

As a result,

Piezo-electric charges, Interference fields and Electromagntic fields in connective tissue resulting from constant strains can occur pain and dysfunction in the body.



fascial considerationSurrounding, 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



Myofascial line :

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

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 co

ncept of TCM

network system in the body that controls structure of posture and movement.

Bio-TensegrityMyofascial tension strut



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



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 overexcitable 되어져 아주 쉽게 활성화되고 hyperirritable해지는 경향이 있다 . -> “facilitation”



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



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.



The characteristics of the facilitated segment

Roots are overly sensitive or hair-triggered :hyperactive ventral motor root -> intervertebral foramen -> join the symp

athetic 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 t

he skin



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 de

scending stimuli of high level and intersegmental reflex.



Gray matter of Spinal cordAnterior(Ventral) Horn:

cell bodies of somatic efferent nerve fibers

Posterior(Dorsal) Horn: cell bodies of interneurons upon which afferent(sensory) neurons termi

nate

Intermediated gray(Lateral Horn in the thoracic segments): cell bodies of autonomic(sympathetic) efferent nerve fibers

Gray commissure ---- connection of left and right



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 cer

vical to the second lumbar spinal nerves.



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.



Secondary segmental relation

Segmental innervation: lateral horn 에 sympathetic nervous system 의 anatomy

Interconnection to lateral column of lateral horn: lateral horn 의 preganglionic cell body 가 efferent outflow 를 따라 머리와 사지로 가는 effector 의 segment

C8/T1/T2 C1/C2

T2/T3/T4 C3/C4

T5/T6 C5/C6

T7/T8/T9 C7/C8

T10/T11 L3/L4

T12/L1/L2 L5/S1/S2

The MMST uses lateral column of lateral horn toward head and extremities related to secondary segmental modulation



Somato-Visceral Point


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.



SomatoVisceral Points (SVP) consisted of .

Segmental innervation

Interconnection to lateral column of

lateral horn

C8/T1/T2 C1/C2

T2/T3/T4 C3/C4

T5/T6 C5/C6

T7/T8/T9 C7/C8

T10/T11 L3/L4

T12/L1/L2 L5/S1/S2

Sympathetic nervous system:

C8~L2

SomatoVisceral Points (SVP) consisted of UB meridian points on surrounding C8-L2 dermatome area.according to secondary segmental relation


Magnetic therapy on UB line

(paraspinal dermatome area)

UB line



T5

T6

Magnetic therapy on UB line

(paraspinal dermatome area) onT5-6

Somato-Visceral Point

C5/6

vasodilation (decrease sympathetic tone )


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 inc

reased in our clinical observation.



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.



Segmental innervation

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.

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 vasomot

or symptoms can occur.



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 scler

otome.



LU2

LI15

TE14

Somato-Somatic Point

Deep dry needling

Stimulate meridian points (combined area of dermatome,myotome and sclerotome on C5/6) by deep dry nee

dling

Stimulate skin, muscle and periosteum in order

Combined area of dermatome,myotome and

sclerotome on C5/6

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 dr

y needling



SomatoSomatic Point (SSP)LU2,LI15,TE14

ST36,GB34,BL53

LI11,LU5,TE9

LR8,KI10

GB30,BL60

Common Back pain

Common Knee pain

Common Shoulder pain

Deep dry needling

(combined area of dermatome, myotome, sclerotome)



Primary: TL junction

syndrome

Secondary: Pain on LS junction by ligament laxity

Compensatory reaction

Common Back pain:Lumbar pain with/without gluteal pain

1.Acute problem: occur suddemly

2.Iliac crest 의 허리볼기 지 역에 pain: neurotrophic change of cellulalgia

3.Typical facet locking

1.Chronic problem: TL problem이후에 occur

2.LS junction 부위에 pain:

-compensatory movement

-gluteus muscle 에 T.P.

-hypersensitivity of greater trochanter (sometimes)



Tenoperiosteal hypersensitivity

Cellulalgic zone

Common Knee painASIS

Q

ROM is not limited: Knee pain originated from the spine (L3-4)1.cellulalgic zone: L3-4 dermatome around the knee2.T.P.: Quadriceps femoris (Vastus medialis oblique)3.Tenoperiosteal hypersensitivity: pes anserinus area

Q increase: external

torsion of the proximal tibia

VMO 와 Medial retinaculum 의 작용에 의해 alignment 유지



Relationship between biomechanical overload and painful joints associated with MPS and muscle imbalance

Painful joint

Trigger point

Shortened muscle

Inhibited muscle

Faulty posture

Faulty movement

pattern

Cervico-cranial

SCM Suboccipitalis DNFs Head forward

Neck flexion

Gleno-humeral

Upper Trapezius

Levator scapulae or subscapula

ris

Lower trapezius

Rounded shoulder

Scapulo-humeral rhythm

Upper ribs

Scalenes Pectoralis Diaphragm

Slumped posture

Respiration

TMJ Lateral pterygoids

Masseter Digastrics

Chin poke Mouth opening

Common Shoulder pain



Injection Site: Facet joint & ligament

TL junction problem

transitional zone

Knee pain originated from the spine(L3-4)

LS junction problem:

ligament laxity

Posterior primary ramus 의 medial br

anch

UB line

GV line



Spinal transitional zone

LS junction

TL junction

CT junction

CO junction

Junction 에 variation 이 존재

Documents

Myofascial Meridian Stimulation Therapy (MMST) 經筋動穴針法