Soft tissue mobilization Flashcards
Gel-to-sol model
- Connective tissue is a colloidal substance
- thixotropy
- heat or pressure changes ground substances from a dense gel to a more liquid state
Piezoelectric model
- Piezo (pressure) electricity exists in crystals
- CT behaves like a crystal
- fibroblast and fibroclast activity influenced by charge
- reticular crystal structure with simmetric disposition of positive and negative electric charges
- tetragonal structure (orthorombic) crystalles (dipoles) are with electric oriented charges
Stress strain curve
Viscoelastic properties of tissue
- Viscosity: ability to resist flow
- elasticity: ability to rebound from deformation
Stress strain curve: toe region
represents settling of the structure being tested, includes taking up slack
Stress strain curve: elastic zone
deformation within elastic group is reversible
Stress strain curve: plastic zone
usually results in permanent deformation
Stress strain curve: neck
after attaining ultimate stress the tissue begins to fail
* initally microfailure, tissues narrow (necking)
Stress strain curve: failure point
sudden decrease in stress while strain continues to rise
- decrease means that substance of the material has began to fail
Stress/Strain:Loading/ unloading
- discrepancy: during unloading the stress is lower for any given strain than during loading
- difference is called hysteresis represents energy lost during test
Stress/Strain: repeated loading
-stress/strain curve looks identical yet starts at the new length
Stress/Strain: creep
apply constant load to a structure and it lengthens over time
-greater length achieved with longer duration and less load
Stress/Strain: hysteresis
- heat generated by mechanically loading structures
- increase in temp can affect mechanical properties of a structure
Stress/Strain: effects of speed
most substances stiffer with higher loading rates, will fail at higher stresses and lower strains (tear paper or tape quick)
Stress/Strain: effects of temp
- most substances less stiff at higher temps, will fail at higher strain and lower stress
- tissues can be heated to easier induce plastic elongation, or cooled to be more brittle and easier to tear
Response of myofascial tissue to immobilization
Loss of ground substance
- glycosaminoglycans (GAG) and water
- loss of interfiber lubrication
- loss of interfiber distance
- results in new cross links that adhere to adjacent collagen fibers
- half life of collagen is 300-500 days half life of ground substance is 1.7-7 days
Traumatized vs untraumatized CT
Nontraumatized
- results in fibrosis
Traumatized
- results in scar tissue formation and contracture
Does the biomechanical model fit what we see in the clinic?
- Permanent elongation of collagen fibers requires a force to achieve 3-8% fiber elongation will result in fiber tearing and inflammation
- 1-1.5% elongation occurs after 80 minutes of continuous straining without fiber tearing
Muscle spindle type 1a receptors
- within muscle parallel to muscle fibers
- response to muscle stretch
- reduction in tone of antagonist, increased tone in agonist
Golgi type 1b receptors
- Musculotendonous junctions, attachment sites of aponeuroses, ligaments of peripheral joints, joint capsules
- response to GTO= muscular contraction
- response to GEO= too strong stretch only
- tonus decrease in associated motor units
Pacini and paciniform type II receptors
- myotendonous junctions, deep layers of joint capsules, spinal ligaments
- respond to rapid pressure changes and vibration
- Proprioceptive feedback for movement control
Ruffini type II receptors
- Ligaments of peripheral joints, dura mater, outer layers of jt capsules
- respond to sustained pressure, tangential forces ( lateral stretches)
- inhibition of sympathetic activity
Interstitial type III and type IV receptors (50% high threshold, 50% low threshold)
- most abundant receptor type
- found almost everywhere
- respond to rapid as well as sustained pressure changes; HPT, LPT
- changes on vasodilation, plasma extravasation
Mechanoreceptors and local fluid dynamics: interstitial (type III & IV)
- changes in vasodilation leading to changes in fascial arteriole and capillary pressure, plasma extravasation
Mechanoreceptors and local fluid dynamics: ruffini (type II)
inhibition of sympathetic activity
Mechanoreceptors and changes in hypothalamic tuning
Stimulation of interstitial mechanoreceptors will result in:
- increases in vagal tone
- trophotropic tuning of hypothalamus leading to more global neuromuscular, emotional, cortical & endocrine changes associated with relaxation
Fascia capable of spontaneous contraction??
Lumbodorsal fascia-study on fresh cadavers
- performed repeated dynamic and static traction loading
-confirmed concepts of creep, hysteresis, and stress relaxation
-also found ligament contraction> when repeatedly stretch & held at a constant length tissue increased its resistance
Fascia cruris in humans with electron photomicroscopy study:
- smooth muscle cells embedded within collagen fibers
- intrafascial capillaries, autonomic nerves and sensory endings
-Concluded- ANS regulated fascial pre-tension
Myofibroblasts
- formed from fibroblasts
- contain smooth muscle actin fibers
- can actively contract
- seen in Dupuytren’s contractures, RA, early wound healing
- Also seen in healthy skin, spleen, uterus, ovaries, circulatory vessels and periodontal ligaments
Types of soft tissue mobilization
- Passive stretching
- non-thrust joint manipulation
- proprioceptive neuromuscular facilitation
- myofascial release
- trigger point release
- spray and stretch
- Active release (ART)
- transverse friction massage
- tool assisted soft tissue mob (ASTYM, graston, augmented soft tissue mob)
- strain counterstrain
Myofasical release
Purpose:
-to relieve soft tissue from abnormal grip of tight fascia
Background:
- fascia: CT that surrounds all bodily tissue ( muscle, tendon, nerves, bone, organ etc)
-composed primarily of collagen with some elastic fibers
-fascial restrictions will limit movement of underlying tissue
Myofascial release fixed techniques
- localize the restriction
- move into direction of restriction
- progress from superficial to deep
- tissues stretched gently until a resistance to further stretch is felt
- hold stretch position until soft tissue is felt to relax; this is the release
- stretch further to take up the slack into a deeper restriction
- continue until no further stretch is tolerated
Myofascial release fixed technique examples
- Cranial base release
- pec major release
Myofasical release research lacking
- one study looked at several combos of interventions for treating myofascial pain and trigger points and found no clear cut best alternative
- other study did leg pull vs contract relax to inc hip flexion ROM and contract relax was found to be more effective than leg pull
Myofasical release trigger point release techniques
apply progressive pressure to the TP
- 30 sec to 2 mins
- superficial to deep
- flat vs pincer palpation
Myofasical release trigger point release techniques: myofascial stretching
- Place muscle at end range
- while exhaling allow muscle to realx and elongate
- hold new position during inhalation
- repeat exhalation holding 20-45 sec
- allow muscle to relax rather than be stretched
- must avoid positive stretch sign PSS
Myofascial release: spray and stretch technique
- Used to deactivate gamma spindle response
- uses vapocoolant spray
- technique
- pt relaxed, muscle in slight tension
- spray bottle- 12 to 18 inches above skin
- spray at 30 degree angle to skin
- spray from above TP into RPP area
- spray in parallel sweeps covering muscle
- apply gentle stretch to elongate muscle
- repeat 3 times
Myofascial release: active release technique
- Pin muscle to be elongated
- move into lengthened position
- active vs passive functional mvmt patterns
- direct technique: move into restriction
- indirect technique: move away from restriction
Patient and therapist position
- Efficiency
- pillows
- use of BW, weight shifting, and lever arms to maximize effect
Occiput release
-Patient: supine
- PT: place fingertips on occipital bone
-tech: move laterally to medially along occiput bony contour layer technique sup to deep, may move med to lateral but less commonly restricted
FMP: nodding, head rotation toward and away
Use: improves OA nodding, rotation, for headaches, everyone with forward head
Cervical lamina release
pt: supine
PT: fingertips on C-spine lamina
Technique: move proximal to distal along cervical spine to release restrictions
-FMP: nodding, head rotation toward to relax and away to stretch
-Use: improves all cervical motions
Upper trap/levator scapulae release
- pt: supine
- PT: standing at pts head one hand webspace prox to pts AC or carpals on spine of scapula medially, other hand contact occiput and C2
- Technique: apply inferior force to scapula to stabilize UT or LS. other hand rotates head passively away to stretch
- FMP: rotate head away
- Use: improves UT and LS mobility
Subscapularis release
- pt: supine
- PT: stands next to pt one hand uses either fist or digit 2-3 on subscapularis other hand grips distal humerus
- tech: while stabalizing scapula from abduction passively (or actively) elevate pts UE (ER>IR)
- use: improves UE elevation, ER, subscapularis flexibility
Piriformis release
- pt: prone, knee flexed to 90 degrees
- PT: standing on involved side, place PIP of index finger (PIP/DIP flexed) over muscle, other hand grasps distal tibia
- tech: apply slow and progressive deeper pressure on most tender part of piriformis, may wind or unwind, oscillate, LE into IR/ER, using assisting hand
- Use: improves hip IR, tx piriformis syndrome
Friction massage effect musculoskeletal structure of:
- ligaments
- tendons
- muscle
Friction massage purpose
- Loosen adherent fibrous tissue (scar)
- aid in absorption of local edema or effusion
- reduce local muscle spasm
- treat chronic inflammation in tendon
Friction massage indications
Muscular lesions - recent trauma - long-standing scars - lesion at musculotendinous junction Tendinous lesions - tendons with a sheath> move tendon within its sheath - tendons without sheath ligamentous lesion - recent sprain - chronic sprain
Friction massage used prior to & in conjunction with other interventions
- minor muscle tear
- ligamentous tears
- tendinous tears
Friction Massage research lacking
DTFM for treating tendonitis
-ITBFS
-DTFM combines w/ rest, stretching, cryotherapy and TUS
-No statistical difference after four sessions of DTFM
-ECRT
-No statistical difference after 9 sessions of DTFM compared w/ other modalities
TFM on shoulder impingement
-Intervention – TFM, Cold, TENS, Ther. Ex.
-Group treated w/ TFM had increased AROM, PROM, less pain, increased function earlier than control group.
Friction massage contraindications
- inflammation due to bacterial action
- traumatic arthritis of a joint
- ossification or calcification in soft tissue structures
- bursitis
- RA
- pressure on nerves
Friction massage relief of pain
- may be due to modulation of nociceptive impulses at spinal cord level
- due to concurrent activation of mechanoreceptors in tissues closes the gate to painful stimulus
- may stimulate diffuse noxious stimuli that imparts inhibitory controls
Friction massage effect on CT repair
- gentle TFM applied during early inflammation may inc rate of phagocytosis
- TFM during early remodeling can lead to formation and remodeling of collagen
- initally TFM must be light. as healing progresses TFM can be more intense
- friction prevents adhesion formation and ruptures unwanted adhesions
- friction induces a traumatic hyperemia > produces vasodilation and inc BF to area
Friction massage technique
- Right spot must be found
- therapists fingers and pt’s skin move as one
- friction across fibers, with sufficient sweep
- must be deep enough
- pt must adopt a suitable position
- muscle must be relaxed while being frictioned
- tendon with sheath must be kept taught
Tool assisted STM
- Uses specifically designed tools to assist with STM
- tool held at 30 degrees and 60 degree angle to target tissue
- tool slid along target tissue from superficial to deep feeling for irregularities in soft tissue
- continue 3-5 mins
- reassess
Purpose of tool assisted STM
- remove adhesions
- reduce tone
- enhance fibroblast proliferation
- improve circulation
Hamstring tool assisted STM
-pt prone
PT standing on involved side
- tech: move tool in direction that restriction is felt (generally prox to dist or reverse) repeat for 3-5 mins
- use: improve SLR, sciatic nerve mobility
ITB tool assisted STM
pt: sidelying
technique: move tool in direction of restriction
- use: improve hip IR, ITB friction syndrome, PF syndrome, trochanteric bursitis
Strain counterstrain
- Relieve pain by reduction and arrest of continuing inappropriate proprioceptor activity (muscle spindle)
- This is accomplished by markedly shortening malfunctioning muscle spindle by applying mild strain to antagonist
- inappropriate strain reflex is inhibited by application of counter strain
- joint dysfunction leads to muscle length imbalance
Strain counterstrain: tender points
- deep within muscle, tendon, ligament, or fascia
- measure 1cm or less across
strain counterstrain tx
-Locate and palpate the tender point
Have pt. rate as 10 on 0 – 10 scale
-Move patient into a position of ease or comfort. (markedly shorten the tissue) Pt pain should decrease to 3/10
-Maintain the position for a minimum of 90 seconds.
-Slowly return to neutral position
-Retest tender point
Posterior cervical strain counterstrain
-pt supine
PT standing/sitting at head of pt hands under occiput
- tech: bring upper c-spine into slight extension to release tension on upper cervical musculature hold 90 sec
-use: occipital HA, upper cervical pain
Trap/levator strain counterstrain
- Pt.: Supine
- PT: Standing/sitting at pt’s head. One hand palpates for active trigger point in UT/LS. Other hands under pt’s head
- Technique: Slowly SB head toward painful side to slacken the mm. Hold 90 sec. -Release
- Use: UT/LS trigger point
