Soft Tissue I Final Exam

What is crossed syndrome?

-common postural dysfunctions that many individuals exhibit -considered crossed becasue on one side of the body are short and tight muscles and opposing those are long and weak

What are mechanical techniques?

-exert effect through direct application of force in order to promote histological change in myofascial structures -ex. rolfing, deep tissue, myofascial therapy, neuromuscular therapy, fascial trains, instrument assisted

How can you find trigger points?

-locate the point of pain with a strong muscle contraction with a resisted muscle test -palpate to find the one that may be inhibiting the muscle

What is the goal of treatment during the remodelling phase?

-optimizing tissue function -exercise focus is placed on: functional activities, sport-specific exercises, closed and open chain exercises, proprioception

How are postural muscles different?

-skeletal muscle that have higher predominance of Type I fibers = slightly resistant to fatigue -have a tendency to shorten and tighten when chronically stressed/injured

How are Phasic muscles different?

-skeletal muscles that have a higher predominance of Type II fibers= functionally utilized for quick movements and short bursts of activity -have a tendency to lengthen and weaken when chronically stressed/injured (but still palpate as tight)

What is the essential criteria of trigger point diagnosis?

-tender nodule within a muscle or tendon -must create the patient's "familiar pain" -muscle is short and tight and painful when stretched -possible referral of pain, local twitch response, muscle weak or inhibited

How do phasic muscles react?

-they fatigue easily and scream for oxygen once it has been used up= burning, aching pain -hard working postural muscles don't complain as much

What is the cumulative injury cycle?

1) actue injury= inflammation= adhesion-fibrosis= weak and tense= 2) repetitive injury= friction, pressure and tension= 3) constant pressure or tension= decreased circulation, edema= adhesion fibrosis

How should respiration movement progress?

1) movement initiate in abdomen 2) lower ribcage widens 3) upper ribs fan open

What are chronic conditions?

3weeks to 2 years post injury -ROM and strength often still decreased -increase activity and stretching

*What treatment pain intensity is thought to be sufficient to gain a desired therapeutic effect?

5-7/10

Post Isometric Relaxation (PIR) causes the agonist or antagonist to contract? For how long? At what percent of max contraction? Repeated how many times?

AGONIST contracts isometrically for 10 seconds using 20% of max contraction -then after complete relaxation ~5sec, tissue taken passively to new barrier -repeated 3-5 times

Reciprocal Inhibition is what?

ANTAGONIST contracts -same protocol as PIR

How can we evaluate key movement patterns?

Active Free Range of motion = can see and palpate altered firing patterns within synergistic groups of muscles

What are the different categories of myofascial trigger points?

Active TrP: symptom-producing + referred pain or paresthesia Latent TrP: does not trigger pain without being stimulated Key TrP: when treated= decreased activity in satellites Satellite TrP: when treated, usually do not decrease key activity. pain and referral patterns often return

What are the different theories of STM?

Autonomic theory: exerts therapeutic effect on ANS via skin and superficial CT -can directly influence damaged CT -general circulation effects -"cultivisceral reflex": can release nerve impulses along specific paths= reactions in distant organs Circulatory theory: the circulatory system allows for distribution of nutrients and the removal of waste for all the cells in our body. -ANS controls flow of blood Energy Expenditure theory: -the musculoskeletal system comprises 60% of the human organism and much of the energy expended by us -the more efficient= the more energy we have General Adaptation Syndrome (GAS): -the idea that we can only adapt to so much stress before we start to physically break down

What is the low back rehab and stability exercise protocol?

BIG 3: quadraped, dead bug/curl up, side bridge Others: prone, bridge, side-lying

Who is Vladimir Janda?

Created model for/identified reciprocal inhibition, Key movement patterns, crossed syndromes

Who sang: china grove?

Doobie brothers

What are clinical massage strokes (Swedish)?

Effleurage: light stroking movement Petrissage: muscle kneading Tapotement: rhythmic percussion, most frequently administered with the edge of the palm or the tips of the fingers Vibration: manual or mechanical shaking, stimulus is carried in dorsal columns with Wide Dynamic Range (WDR) neurons that inhibit nociceptive input

What are movement techniques?

Exert effects by changing aberrant movement patterns into more optimal ones: -Alexander technique -Feldenkrais Method -Trager -Functional movement assessment and treatment

Which muscle groups does the low back rehab protocol train?

Glut max Glut med Scapula stabilizers Abdominals Neck

What is the sprain/strain grading system?

Grade I: tearing of less than 50% tissue fibers Grade II: tearing of more than 50% of tissue fibers Grade III: complete tear Grade IV: complete tear occuring at the muscle's or ligament's attachment to the bone (avulsion fracture)

Which sprain/strain grades will we mostly deal with?

Grades I and II

What are two types of longitudinal massage?

Gua Sha Graston

What are key movement patterns?

Hip extension Hip abduction Trunk curl-up Shoulder abduction Push-ups Head flexion

Which functional movement pattern evaluation would you do for lower crossed syndrome?

Hip extension: checks gluts Hip abduction: checks adductors, QL Trunk flexion: check abdominals

Which sprain/strain grades are unstable?

III and IV

Who sang: Right back where we started from?

Maxine Nightingale

What does the Travell TrP treatment entail?

Muscle stretched, up to 20lbs of pressure 10-60seconds repeat until improved or up to 5 min moist hot pack, stretch after

What is the functional movement pattern evaluation of upper crossed syndrome?

Neck flexion- check neck flexors Trunk flexion- check abdominals Shoulder abduction- checks rhomboids Lowering from push-up with a plus- checks serratus anterior Breathing- checks over activity of secondary respiratory muscles= breathing pattern disorder

What is the neurological basis for the effects of MET?

Neurological basis for the effects of MET - post isometric relaxation (PIR) • a muscle that contracts isometrically will subsequently relax for a brief period during which stretch will more easily be achieved - reciprocal inhibition (RI) • when one muscle is contracted isometrically its antagonist will be inhibited allowing involved tissues to be stretched more effectively

What methods should be used in the inflammatory phase?

PRICE: protect, rest, ice, compression, elevation Modalities to control pain and swelling: e-stim, pulsed ultrasound, laser, IASTM NSAIDs, natural pain/inflammation relief

What postural evaluation would you do for lower crossed syndrome?

Pelvis: check lateral shift, A/P tilt Glut max: flattening, upper-outer quadrant sagging Adductors: Hamstrings: check overactivity in distal 1/3 Calf: soleus hypertrophy Lumbar erectors: should be stronger than TL erectors

What are the phases of soft-tissue healing?

Phase I: Inflammatory phase -48-72hrs Phase II: Repair phase -72hrs-6+ weeks Phase III: Remodelling phase ~6 weeks - up to 2 yrs

Which is the longest of the three phases?

Phase III: Remodelling phase

Who sang: another brick in the wall?

Pink Floyd

Which shoulder girdle muscles are postural? phasic?

Postural: -pec major and minor -levator scapulae -upper trap -biceps brachii Phasic: -rhomboids -middle trap -lower trap -triceps

Which is a good choice when you don't want to contract the injured muscle?

Reciprocal inhibition

What is reciprocal inhibition?

Reciprocal inhibition describes the process of muscles on one side of a joint relaxing (antagonist) to accommodate contraction on the other side of that joint (agonist). Joints are controlled by two opposing sets of muscles, extensors and flexors, which must work in synchrony for smooth movement. -inhibition is frequently found in muscles resulting from injury, inflammation or pain= reciprocal facilitation of its antagonists and aberrant behaviour of synergists. -hypertonicity in muscle= reciprocal inhibition of its antagonists

What are the general techniques?

Skin rolling: release adhesions in superficial fascia Myofascial release: release superficial and deeper fascial adhesions Holding (simple, intentional, with compression) Compression Pincer palpation/compression Stripping: linear strokes along fiber direction Friction massage: cross fiber, circular, multidirectional to reduce adhesions

What is the difference between Slow Twitch: Type I- Red Fibers and Fast Twitch: Type II- White Fibers?

Slow Twitch: Type I: Red fibers -contain *high* amounts of myoglobin, mitochondria and many blood capillaries= muscles are red -cleave ATP slowly -slow contraction rates -resistant to fatigue -generate ATP predominately through oxidative metabolic processes -often seen in postural muscles of the trunk Fast Twitch: Type II: White fibers -Type IIa and IIb -contain *low* amounts of myoglobin, mitochondria and relatively few blood capillaries but *large amounts of glycogen*= white -cleave ATP fast -fast contraction rates -fatigue easily -generate ATP by anaerobic metabolic processes -often seen in Phasic muscles of the arms and legs

What is the SAID principle?

Specific Adaptation to Imposed Demands

Who sang: Long cool woman (in a black dress)?

The Hollies

What happens during the remodelling phase?

The body redirects the healing fibers to increase strength and orient the tissue fibers along the lines of greatest stress

What are tissue characteristics and treatment protocols for Phase II: Repair phase?

Tissues regain tensile (functional) strength -Increases in aerobic exercise, stretching, and strength training are gradually employed

What are tissue characteristics and treatment protocols for Phase I: Inflammatory phase?

Torn tissues leak blood and exudates into the area -This causes swelling and irritation/pain to surrounding tissues -Key to controlling Phase I is controlling inflammation -Therapy modalities should be aimed at reducing swelling and pain -Early movement (with minimal weight bearing) is recommended

What is Soft Tissue Therapy?

a general term for a variety of myofascial techniques

What is Massage?

a number of styles of therapeutic manipulation of the soft tissues

What is muscle energy technique?

a soft tissue manipulation method that involves precisely directed and controlled contractions, isometric and/or isotonic, that are initiated by the patient directed against precisely controlled resistance from the therapist

What is Soft Tissue Manipulation (STM)?

a term that is often applied to manual techniques used by chiropractors to effect changes in soft tissues

What is neuromuscular efficiency?

ability of CNS to coordinate agonist, antagonist, synergist, stabilizers and neutralizers to work efficiently and interdependently during dynamic kinetic chain movements

What is functional strength?

ability of neuromuscular system to reduce force, produce force, and dynamically stabilize the kinetic chain during functional movement in a smooth coordinated fashion

In what part of the rehab program should core exercises be included?

all phases! essential to every aspect of the rehab process -muscles of lumbo-pelvic-hip complex function to dynamically stabilize entire kinetic chain during functional movement

What are common postural deviations?

anterior head carriage -shoulders will inevitably follow the head

What is Upper Crossed Syndrome?

associated with short tight postural muscles + long/weak antagonists - postural: cervical erectors, upper traps, levator, pectoralis, SCM, scalenes -phasic: mid thoracic erectors, mid and lower traps, rhomboids, serratus anterior, deep neck flexors -increased forward head posture with protracted shoulder and a tendency towards hyper-kyphosis = tight traps, levator, pectoralis (anterior head carriage and hunched shoulders) =weak deep neck flexors, rhomboids and serratus anterior (the ones that pull head and shoulders back)

What are myofascial trigger points?

can be a powerful source of spasm and refer pain to other muscles

What type of cell produces cartilage?

chondrocytes

Which is safer for healing structures, closed or open chain?

closed

What is a closed vs open chain?

closed kinetic chain: distal segment fixed -good for rehab, esp. lower ext. injuries -involve fixed joints with mobile joints in between (ex. leg press) open kinetic chain: distal segment mobile -isolated joint exercise: ex. seated leg extension -most upper extremity movements in sports are open chain with hand moving freely

What is soft tissue?

completely or mostly composed of connective tissue -Skin -Superficial fascia -Muscles -Tendons -Fascial planes -Intervertebral disc -Joint capsules -Ligaments -Cartilage -Periosteum -Peripheral nerves

When breathing becomes laboured, due to aerobic challenge, what happens to spinal stability?

compromised

What are tensegrity structures?

contain a series of isolated compression-resistant elements that resist the pull of surrounding tensile elements and impose a pre-stress that stabilizes the entire network

What do Key Movement Patterns (KMP) do?

deal with the quality and control of muscle firing that are necessary for efficient motion -can be used to identify recruitment of synergists when the agonist is injured or stressed -retraining and rebalancing muscular relationships is neccesary for long term change

What is the kinetic chain?

entire body is a kinetic chain that operates as an integrated functional unit

How to evaluate KMPs?

evaluate posture and gait first adequately expose area minimal verbal cues 3 or more trials observe both sides to compare muscle trembling is a positive finding= indicates weakness or fatigue -use changes in KMP as outcome measure

What are subacute conditions?

from 2 days to ~3weeks post injury -signs of inflammation decreasing -wounds closing -new tissue formation in process

What treatment should happen in the repair phase?

goal is to prevent muscle atrophy and joint deterioration while preventing destruction of new tissue -major goal: work through "full pain-free ROM" -accomplished through use of: -Isometric exercise -Isotonic exercise -Proprioception

What type of curve does good posture create? Bad posture?

good posture= S-shaped curve bad posture= C-shaped curve

What is the function of proteoglycans in tissues?

have high sugar concentrations= bind large amounts of water and reduce friction b/w adjacent tissues

What do fibroblasts do?

involved in collagen and CT formation -responds to loads by producing collagen and other molecules -proliferate in areas of stretching

What is the mechanism of trigger point treatment?

ischemic compression, reactive hyperemia

What are postural evaluation for upper crossed syndrome?

lateral view: -anterior head carriage -forward and rounded shoulders, scapular protraction -internally rotated humerus -thoracic hyperkyphosis -protruding abdomen

What are primary respiratory faults?

lifting up motion of ribcage chest movements dominate no lateral excursion of lower ribs abdominal movement paradoxical inability to maintain an abdominal brace and breathe normally

Which trunk muscles are phasic? *see charts of postural and phasic muscles

mid thoracic erectors longus capitus and colli (all others postural)

How many muscles of respiration are there?

more than 20

What is Sherrington's Law of reciprocal innervation?

muscle hypertonicity= inhibition in antagonists -spasms (hypertonicity) treated first

What causes myofascial triggers points?

muscle lesions= ruptures of the sarcoplasmic reticulum= uncontrolled release of Ca ions = persistent sarcomere contractions= taut band

What does the Nimmo TrP treatment entail?

muscle relaxed 3-7 seconds treat satellites first stretch after repeat until improved or up to 5 min stretch after

What does the Chaitow TrP treatment entail?

muscle stretched 5 seconds on, 2 seconds off for 20-30 seconds

What is an antagonist?

muscles that oppose the agonist

What is an agonist?

muscles that provide the major force to complete movement

What is a synergist?

muscles that stabilize a joint around which movement is occurring. helps agonist function effectively

What is a stabilizer?

muscles that stabilize the origin of the agonist and the joint that the origin spans in order to help agonist function most effectively

Should you perform key movement patterns on acute patients?

no!

What are signs of too much?

pain swelling loss/plateau of strength loss/plateau of ROM increased joint laxity re-start of inflammatory cycle

What is collagen?

provides CT's incredible strength

How can you differentiate muscle vs joint pain for TMJ?

restrictions in mouth opening that occur 8-10mm is more likely muscular in origin -restrictions in opening that occur at 25-30mm that cannot be opened wider -biting down unilaterally on tongue depressor on the involved side will often increase the pain of a muscular problem, but decrease pain of joint problem -biting down on opp side may have opp effect

What are key manipulations for respiration?

ribs 1-4 C3-4 T2-T9 (autonomic supply)

Needle bipsies of myofascial trigger points reveal which chemicals?

serotonin= vasoconstriction= ischemia bradykinin hyaluronic acid= swelling -all irritate sensory nerve

How does TrP treatment usually end?

stretching the treated muscle 3 FULL cycles of ROM -heat pack -patient should avoid strenuous activities of that muscle for the day homework: 3-4 repetitions of the stretch

What is the postural function of respiratory muscles?

the diaphragm contracts when a person stands on their toes

How should myofascial trigger points be treated?

treat most proximal, most medial, most painful trigger points first -avoid overtreating -limit treatment to 5 active points per session or less

What is lower crossed syndrome?

weak abdominals tight hip flexors (ilipsoas) tight erector spinae weak glutes

What body mechanics considerations are most important?

weight and gravity -use body weight, not muscle force, to apply pressure -keep joints locked using stabilization muscles, not ligaments -let weight pass through your joints in a relatively straight line -keep your body compact, elbows near your sides etc. -support your contact points when applying pressure as much as possible -move into and out of pressure slowly -keep your feet underneath you and move around as needed

What are contraindications of STM?

•Acute inflammation, osteitis, periostitis • Acute circulatory disturbance • Acute dermatological problem • Fever • Local infection • Local malignancy • New burns • Potential embolus/thrombus, varicosities • Abdominal tumor, aneurysm, (pregnancy, menstrual cramps)

What are the goals/effects of Soft Tissue Manipulation (STM)?

•mobilization of fluids/reduction of edema •Increase of local blood flow • Decrease muscle soreness stiffness and ↑ ROM • Prevention or elimination of adhesions • Reduction of pain • Eliminate Myofascial Trigger Points (MFTP) • Facilitation of relaxation, reduction of spasm, hypertonicity and/or overactivity • Restore balance to motion segment