STI 2

latissimus dorsi

Attachments: o Medial humerus, under bicipital groove o T7-L5 SP, iliac crest, sacrum, TLF, lower 3-4 ribs - Action: shoulder ER, ext

levator scapulae

Attachments: o Proximal: C1-4 TP o Distal: medial superior scapula - Action: elevate, dwn rotation of medial border; lateral cervical flex

Semispinalis capitis

Attachments: o Proximal: C2-5 SP o Distal: T1-6 TP - Action: B ext, u/l SB & rot

Obturator Externus

Attachments: o Proximal: obturator foramen & membrane o Distal: G trochanter - Action: hip ER

Spelnius Capitis

Attachments: o Proximal: occipital bone, mastoid process o Distal: ligamentum nuchae, SPs C7-T3 - Action: B ext, u/l SB & rotation

Rhomboid Minor

Attachments: o Proximal: C7-T1 SP o Distal: medial border of scapula - Action: retract & elevate scapula

vastus lateralis

Attachments: o Proximal: G trochanter o Distal: quad tendon, superior patella - Action: knee ext

Diaphragm

Attachments: o Proximal: L1-5, lower 1⁄2 costal cartilage, xiphoid process o Distal: central tendon - Action: inspiration

Rhomboid major

Attachments: o Proximal: SP T2-5 o Distal: medial border of scapula - Action: retract & elevate scapula

Rectus Femoris

Attachments: o Proximal: anterior inferior iliac spine o Distal: quad tendon, superior patella - Action: knee ext

Small Diameter muscle afferents

interstitial spaces of skeletal muscle and IV veins

vastus intermedius

Attachments: o Proximal: anterior lateral femur o Distal: quad tendon, superior patella - Action: knee ext

Anterior chest position with forward head position

myofascial structures are shortened

Long Axis Laminar Release

Deep Prep Octopus grip Thumbs can be to one side of SPs or on both Hands separate at sacrum and provide a traction force to the Iliac crests *Used for superficial to deep restriction, elongates and decompresses the spine* Targets erector spinae

Iliac crest release power grip

Deep Prep more aggressive then bony clearing *used for pts with limited forward bending, sidebending, anterior pelvic tilt* *contraindications: lumbar fusion, stenosis , spondylolisthesis* Targets: QL, thoracolumbar fascia, lats, erector spinae

How did James Cyriax contribute to our understaning of soft tissue dysfunction?

recognition, categorization and DD of the body's various soft tissues Pain can be caused by dysfunction of various or selective soft tissues End Feel

Seratus Anterior

Attachments: o Proximal: anterior surface of ribs 1-9 o Distal: medial border of scapula - Action: shoulder aBd, upward rotation, stabilization

What is the best treatment strategy for each phase of scar formation?

Inflammation: protect and immobilize Granulation: immobilize Fibroblastic/proliferation: gentle manual therapy Maturation: controlled stress and manipulation of scar tissue

Plantar aponerurosis

Attachments: o Proximal: calcaneal tuberosity o Distal: MT heads - Action: arch support

Iliacus

Attachments: o Proximal: iliac fossa o Distal: less trochanter - Action: hip flex, anterior pelvic tilt

gluteus maximus

Attachments: o Proximal: ilium, posterior sacrum, coccyx o Distal: ITB - Action: hip extension

Infraspinatus

Attachments: o Proximal: infraspinatus fossa o Distal: G tubercle of humerus - Action: shoulder ER

Why a medical professional shall be careful diagnosing FMS based on chronic widespread pain and presence of local tender points?

It is hard to distinguish FMS from other pain syndromes Using tender points to establish FMS can lead to many false positives. Clinicians should always explore the problem more deeply and not just use FMS as an end point

Cervical spine laminar release

Deep prep First ask pt to lean forward to show the motion you want PT uses two fists in power grip on bilat paraspinals. pt flexes down to end of upper thoracic range while PT glides hands down paraspinals *If targeting upper trap - head to armpit* *If targeting leveator scapulae - nose to armpit*

Myofascial manipulation of the hamstrings first distal to proximal/longitudinal stroking

Deep prep Loose fist with thumb down, bilat power grip, or forearm start distally and stroke proximally to progress have pt extend knee Preps hamstrings for aggressive stretching

Superior gemellus

Attachments: o Proximal: ischial spine o Distal: G trochanter - Action: hip ER, aBd, flex

Semimembranosus

Attachments: o Proximal: ischial tuberosity o Distal: medial tibia, pes anserine - Action: knee flex, hip ext & IR

Forward Bend Laminar Release (seated)

Deep prep PT power grip thumbs down on bilat paraspinals pt slowly flexes down to their toes while PT glides down their paraspinals Can be done unilateral if biasing a direction *Contraindications* discogenic patients*

Semitendinosus

Attachments: o Proximal: ischial tuberosity o Distal: medial tibial condyle - Action: knee flex, hip ext, IR

Inferior gemellus

Attachments: o Proximal: ischial tuberosity o Distal: G trochanter - Action: hip ER

Elbow/Forearm Technique

Deep prep PT relaxed forearm rests on *contralateral side* of spinous processes. Slack is taken up and then forearm is pulled along the back all the way to the table Increase depth with each stroke repeated until you feel a change Used for pts with medial to lateral restrictions

biceps femoris

Attachments: o Proximal: ischial tuberosity, linea aspera o Distal: fibula head - Action: knee flex, hip ext & ER

Obturator internus

Attachments: o Proximal: ischium, rim of pubis, obturator membrane o Distal: G trochanter - Action: hip ER

confirmatory observation to ID myofascial trigger point

Local twitch response Referred pain in the expected distribution of that muscle End plate noise or spontaneous electrical activity demonstrated by an electromyographic study

Golgi tendon organs

Located at the junction between skeletal muscle and its tendon Stimulated by tension in tendon Monitor external tension developed during muscle contraction inhibitory of the agonist

Ruffini corpuscles

Located in hairless and hairy skin Steady state positioning and tactile sensation

pacinian joint receptor

Located in the deep joint CT Active at start and stop of movement

Meissner's corpuscles

Located in the glaborous skin Adapt Rapidly Small Receptive Field

ruffini joint receptors

Located in the proximal extremity joints Static positioning information

Teres Major

Attachments: o Proximal: lateral border, inferior angle of scapula o Distal: medial lip of bicipital groove - Action: shoulder aDd, IR, ext

vastus medialis

Attachments: o Proximal: linea aspera o Distal: quad tendon, superior patella - Action: knee ext

Psoas

Attachments: o Proximal: lumbar TP 1-4 o Distal: lesser trochanter - Action: hip flex, trunk flex, hip ER

Sternocleidomastoid (SCOM)

Attachments: o Proximal: mastoid process, occipital bone o Distal: manubrium, medial clavicle Action: i/l SB, c/l rot

Teres minor

Attachments: o Proximal: middle lateral border of scapula o Distal: inferior aspect of G tubercle - Action: shoulder ER, weak aDd

gluteus minimus

Attachments: o Proximal: outer ileum o Distal: G trochanter - Action: hip aBd, IR

Erector Spinae

Attachments: o Proximal: ribs, SP & TPs of vertebra o Distal: sacrum, iliac crest, lumbar SP - Action: extension

Piriformis

Attachments: o Proximal: sacral border o Distal: G trochanter - Action: hip ER

pectoralis minor

Attachments: o Proximal: sternal ends of rib 3-5 o Distal: coracoid process - Action: anterior tipping of scapula

Subscapularis

Attachments: o Proximal: subscapular fossa o Distal: lesser tubercle of humerus - Action: shoulder IR

Supraspinatus

Attachments: o Proximal: supraspinatus fossa o Distal: G tubercle of humerus - Action -Abducts arm; stabilizes the head of the humerus in glenoid cavity; one of the "rotator cuff" muscles

Peroneus Brevis

Attachments: § Proximal: distal lateral fibula § Distal: tuberosity on 5th MT o Action: PF, ev.

Peroneus Longus

Attachments: § Proximal: fibula head § Distal: 1st cuneiform, MT o Action: PF, ev.

Tibialis anterior

Attachments: § Proximal: lateral tibial § Distal: base of 1st MT & medial cuneiform o Action: DF, slight ev.

flexor hallucis longus

Attachments: • Proximal: distal 2/3 tibial • Distal: base of 1st phalanx § Action: PF, 1st toe flex

Tibialis posterior

Attachments: • Proximal: lateral, posterior, prox tibia • Distal: navicular, cuneiforms, cuboid, MT 2-4, sustentaculum tali § Action: PF, inv.

Gastrocnemius

Attachments: • Proximal: m/l femoral condyles • Distal: Achilles tendon, calcaneus § Action: PT, knee flex

flexor digitorum longus

Attachments: • Proximal: medial, posterior tibia • Distal: base of 2-5 phalanges § Action: PF, toe 2-5 flex

Soleus

Attachments: • Proximal: posterior tibia & fibula • Distal: Achilles tendon, calcaneus § Action: PF

How to find the piriformis?

line between greater trochanter and PSIS middle of line slightly inferior should be piriformis confirm by palpating while pt move into hip ER

What of the two components of viscoelastic muscle tone?

Elastic component - myofascial CT Viscoelastic Component - fluid stiffness -non-sulfated GAGs -Sulfated GAGs -Actin - which is in a fluid form like syrup

pathology

Processes, causes, and effects of a disease; abnormality

Fibroblasts

Synthesize collagen, elastin, reticulum, ground substance

What chemicals can produce contractile response in myofibroblast?

histamine, oxytocin, mepyramine

Vastus lateralis trigger point refers pain where?

lateral thigh and knee

Wyke's

nociceptive free nerve ending

Shearing

occurs when one part of a tissue slides over another

Collagen

structural protein found in the skin and connective tissue very tensile

Reticulin

thin meshwork, branching fiber that supports glands and organs

Ground Substance

viscous gel with high water concentration provides medium in which collagen and cells lie

Macrophages (histiocytes)

"big eaters" found in traumatic, inflammatory or infectious conditions; clean and debride area of waste and foreign products.

What are the multi-planar motions typically used in the movement analysis?

*Forward bending with side bending and rotation to the same side* Looks at the flexibility of the myofascial planes on the contralateral side of the movement *Backward bending with side bending and rotation to the same side* Assess compressive joint lesions of the spine on the same side the movement is occurring

Stages of Scar Tissue Formation: Inflammatory

-0-48 hours -Histamine released by Mast Cells and vasodilation occurs -Tissue permeability increases to seal wound -Prostaglandins are released which produces pain which limits movement -Leukocytes fight intruders -Macrophages- phagocytosis - scar production -Plasma cells enter to produce antibodies

What are the effects of immobilization?

-Atrophy (Greatest within 1st week) -Sarcomeres shorten (40%) if casted in shortened position -Sarcomeres lengthen (20%) if casted in lengthened position -Cartilage dehydration -Connective tissue shortening -Loss of ground substance -Decreased nutrition and blood supply

Subclavius

-Attachments: o Proximal: 1st rib o Distal: subclavian groove - Action: clavicle depression, stabilization

Alexander Technique

-Method for improving ease & freedom of movement, balance, support, and coordination -Corrects unconscious habits of posture & movement (precursors to injuries) Mechanical approach

static nuclear bag fibers

-Nuclei are collected in a bundle in the middle of the fiber. -Signal information about the static length of a muscle.

Stages of Scar Tissue Formation: Proliferation

-Rebuilding of tissue begins -Fibroblasts migrate and begin collagen synthesis -Temporary seal gains strength as collagen fibers are laid down in a haphazard and disorganized fashion -Strength determined by collagen filaments and cross links -Gentile movement is good here -5-8 days (3-5 weeks for ligaments and tendons)

Stages of scar tissue Formation: Maturation

-Wound is closed (collagen still not at max strength) -3 weeks to 12 months -Manual therapy can help (low load prolonged stretch most effective) -Stress to the area is needed for scar formation to regain full functional strength,

Indirect myofascial release

-applied similarly to direct -amt of force is lower in intensity but much longer in duration (gives tissues an opportunity to release) -often used when pt's are tender or extremely guarded (pt feedback essential!)

Direct myofascial release

-intent: to improve mobility of soft tissues through application of a slow, controlled mechanical stress directly into a restriction -pressure gradually increased or repeated until mobility of tissue is felt to improve -tissue may be manipulated while pt is either passively or actively moving (depends on pt tolerance)

What kind of work task can cause myofascial pain?

-work tasks w/ high repetition frequency & static mm loading may actually decrease the pain pressure threshold & result in allodynia & hyperalgesia -constrained work postures result in decreased circulation & release of nociceptive substances directly into mm tissue -awkward postures are common in the workplace & include excessive wrist flexion & extension, ulnar & radial abduction, forearm sup/pron, extended reaches beyond the shoulder reach envelope & pinch grips that are either too wide/too narrow

What are the characteristics of the inflammation phase?

0-48 hours histamine released and vasodilation occurs tissue permeability increases (seals the wound) prostaglandins are released which produces pain which limits movement Leukocytes fight macrophages - phagocytosis - scar production plasma cells enter to produce antibodies immobilize and protect

What is the most commonly used definition of the myofascial pain?

A muscle pain disorder characterized by the presence of a myofascial trigger point within a taut band, local tenderness, referral of pain to a distant site, restricted range of motion, and autonomic phenomena (SIMONS et al)

Cycle of Fibrosis

1. chronic, low-grade irritant that triggers an inflammatory response. 2. macrophages begin to débride the area as they would in the normal healing process. 3. an increase in vascularity. 4. fibroblasts begin to synthesize immature collagen for tissue repair. 5. The immature collagen fibers are laid down in a haphazard formation and remain random due to the lack of appropriate stresses. 6. Myofibroblasts, which have also migrated to the damaged area begin to contract their actin and myosin components 7. shrinking the tissue, 8. impeding movement increasing tissue strain, Starts all over

Golgi-Mazzoni Corpuscles

A specialized mechanoreceptor located in the joint capsule responsible for detecting joint compression. Any weight bearing activity stimulates these receptors

Intermuscular force transmission

force is transmitted through the connective tissue between the neighboring muscles

How much is the half-life of collagen?

300-500 days in mature non-traumatized conditions

What are the characteristics of the direct insertions at the osteotendinous junction?

4 zones Zone 1: tendon or ligament Zone 2: consists of fibrocartilage Zone 3: Consists of mineralized fibrocartilage, where mineral deposits are found around collagen fibers Zone 4: Consists of bone, where the collagen fibers merge with the fibrils of the bone matrix

chronic fatigue syndrome

A debilitating and complex disorder characterized by profound fatigue that is not improved by bed rest and may be made worse by physical or mental activity.

What is the definition of a trigger point?

A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band

What is the basic premise of Tragering?

A mechanical soft tissue and neurophysiological reeducation approach Directed towards the unconscious mind of the patient gentle passive motions that emphasize mobilization techniques, concentrating on traction and rotation, and a system of active movements termed *mentastics* oscillations and rocking techniques serve as relaxation techniques that encourage the patient to gradually relinquish control Active movement serves as the neuromuscular reeducation technique to alter the patients neurophysiological set and give the patient tools to maintain the changes

Extra muscular force transmission

force is transmitted through various connective tissues such as compartmental fascia or general fascia/connective tissue surround blood vessels or nerves

Intramuscular force transmission

force is transmitted within the muscle from endomysial-perimysial fascial network onto adjacent fibers

What is the dysfunctional aspect of Wolff's law when applied to connective tissue?

Abnormal stresses chronically applied to connective tissue may result in dysfunction in the tissues and the adjacent structures supported by the tissue

8. Describe Wolf's law. How can this be applied to connective tissue?

Abnormal stresses chronically applied to connective tissues may result in dysfunction in the tissues and the adjacent structures supported by the tissues Normal stresses, or carefully controlled stresses, may positively change the metabolic and physical homeostasis of the tissue; laid down more organized in a direction more suitable for optimal tissue function

What is the process of collagen synthesis?

Absorption of amino acids including proline and lysine into cell assembled into polypeptide chains protocollagen is synthesized protocollagen strands are linked into a triple helix to form tropocollagen tropocollagen passes through cell membrane into interstitial space Tropocollagen strands are linked in series and in parallel in a quarter staggered arrangement to form collagen fibrils

What are the differences between active and latent trigger points?

Active TP has lower pain threshold than latent Active TP is painful with movement and postures Latent TP require mechanical stimulation to reproduce pain Active TP refers pain to distant site

What is the difference between an active and a latent trigger point?

Active trigger point produces symptoms, including local or referred pain or other paresthesia Latent trigger points do not induce pain without being stimulated

Tabery et al.

After 4 weeks the limb that was allowed to recover rapidly re-adjusted to its original length. The limb cast in a lengthened position produced 19% more sarcomeres in series. The limb cast in a shortened position lost 40% of the sarcomeres in series, presented with decreased extensibility and an increase of connective tissue found in the muscle belly, believed to prevent the shortened muscle from being over-stretched.

Tabery et al.

After 4 weeks the limb that was allowed to recover rapidly re-adjusted to its original length. The limb cast in a lengthened position produced 19% more sarcomeres in series. The limb cast in a shortened position lost 40% of the sarcomeres in series, presented with decreased extensibility and an increase of connective tissue found in the muscle belly, believed to prevent the shortened muscle from being over-stretched.

Mechanical approach to myofascial release

Aim to make mechanical or histological changes to myofascia by direct application of force (ex. skin rolling, elongation, stretching) Goal: improve mechanical mobility of tissue treated (should follow autonomic tx)

What chemicals were found in trigger points by Shah et al?

Analyzed the local biochemical milieu of trigger points using a sophisticated microdialysis system *Chemicals found: substance P, calcitonin gene-related peptide, bradykinin, serotonin, norepinephrine, tumor necrosis factor-a, and interleukin-1a* Acidic environment at active trigger point Expanded study found: interleukin-6 and interleukin-8

tensor fasciae latae

Attachments: o Proximal: external lip of iliac crest o Distal: lateral condyle of tibia, Gerdy's tubercle - Action: lateral knee stabilizer; asst hip ext, aBd, ER

Thoracolumbar fascia

Attachments Lats iliac crest, lumbar and sacral SPs

Trapezius

Attachments Proximal: occiput, ligamentum nuchae o Distal: lateral clavicle, acromion, spine of scapula - Action: scapula elevation, upward rotation, retraction, depression; cervical ext

Popliteus

Attachments • Proximal: lateral femoral condyle • Distal: proximal posterior tibia § Action: knee flex, IR, "unlocks" knee

pectoralis major

Attachments Proximal: medial 1⁄2 clavicle, sternum Distal: bicipital groove, G tubercle of humerus - Action: shoulder flex, aDd, IR and ext

What are the three categories of approaches to myofasical manipulation?

Autonomic approaches mechanical approaches movement approaches

Simons myofascial pain

Autonomic effect Referred pain ROM decrease Tenderness Taut band ARRTT

What are some distinct characteristics associated with poor head posture as it pertains to the cervical spine?

Cervical lordosis is decreased Cervical erector spinae in shortened position Anterior musculature is elongated

Movement approach

Changes abnormal movement patterns into optimal ones (active pt participation)

After an evaluation is complete, when should reevaluation take place and why?

Before, during, and after a treatment for the purpose of treatment modifications, to provide optimal outcomes and to accommodate for changes made

Hamstring splay

Beginning at posterior-middle, grasp the muscle belly with thumbs apply deep pressure by pulling thumbs apart and bringing elbows together *Used for previous hamstring strain or tear, specific to hamstrings*

What is soft tissue manipulation?

forceful passive movement of musculofascial elements through its restrictive directions beginning with superficial layers and progressing in depth while taking into account its relationship to the joints

L3 deep soft tissue manipulation

Chisel grip into soft tissue on pt side using either ischemic compression or cross friction Used for L3 hypomobility or prep for joint mobilizations Targets: CT in mid-lumbar area around L3

3. What are similarities between active and latent trigger points

Cause ROM restriction and muscle weakness inhibit muscle identified through palpation Produce mtr, sensory and autonomic changes

What is the histological make-up of the connective tissue?

Cells -Fibroblasts -Fibrocytes -Myofibroblasts -Macrophages -Mast Cells -Plasma Cells Extracellular matrix -collagen -elastin -reticulin -Ground substance

Tensegrity in the body

Cells make up tissues that provide specific functions or make up organs linear stiffness keeps the tissues intact and can prevent tissue damage Compression resistant bones pull up against gravity and yet remain stabilized by the continual tension produced by resistant muscles, tendons, ligaments, and fascia.

How can you apply this model (tensegrity) on the human body both at the microscopic and macroscopic level?

Cells rely on tensegrity to maintain a delicate balance between mobility and strength Microscopic: cells make up tissues that provide specific functions or make up organs linear stiffness keeps the tissues intact and can prevent tissue damage Macroscopic: compression resistant bones pull up against gravity and eyt remain stabilized by the continual tension produced by resistant muscles, tendons, ligaments, and fascia. The balance of the constant tension and localized compression has been experienced by anyone who has floated in water

2. Describe central and peripheral sensitization in detail as well as the role of these processes in chronic pain and trigger point referral.

Central Sensitization - hypersensitivity leads to increased responsiveness to non-painful stimuli and increased pain response evoked by stimuli outside of the injury site (expanded receptive field) -Changes in dorsal horn -Allodynia Peripheral Sensitization - after injury chemical mediators stimulate nociceptors & lower threshold causing hypersensitivity -Hyperalgesia

How do golgi tendon organs respond to tension of the collagen fibers?

Collagen strands in GTO are in braided pattern, when tension is applied the braided fibers approximate & compress the Ib afferent neurons within

Forward Bend Laminar Release (sidelying)

Deep prep *targets posterior myofascial tissue of the lumbar spine in order to elongate it and used for pts with increased lordotic curves* Muscles: -Erector spinae reassess forward bending pt top knee goes in PTs hip crease hands are together at the upper lumbar spine and the lower hand is moved down the back as the hip is flexed by the PT Used for specific segments of the spine

Examples of autonomic approaches

Connective tissue massage Hoffa Massage (effleurage, petrissage)

Anterior compartment

Contains the tibialis anterior, extensor digitorum longus, peroneus tertius, and extensor hallucis muscles.

Why do contractures occur in traumatized CT and not untraumatized CT after immobilization

Contractures occur in traumatized CT and not in untraumatized CT during immobilization due to presence of inflammatory exudate

What is the "cutivisceral reflex" described by Elizabeth Dicke?

idea that connective tissue massage can release nerve impulses along quite specific paths by means of reflexes that are locked into the CNS to create reactions in distant organs

fibromyalgia syndrome

idiopathic chronic widespread non-articular musculoskeletal pain Diffuse CNS disorder with pain and dysfunctional sensory processing pts also report sleep disturbance and fatigue upon waking

what are different types of stress?

tension, compression, shearing

Elongation of paravertebral muscles

Deep Prep Hands are placed under the upper thoracic spine Compress anteriorly and lightly stroke superiorly along cervical paraspinal muscles all the way up to the occiput w/out lifting the head Gradually increase depth *Used for prep for more aggressive myofascial and jt manipulation techniques* Targets: cervical paraspinals, superficial fascia Reassess cervical ROM

Sidebending elongation quadratus stretch

Deep prep *Non aggressive legs on table vs Aggressive legs off table* PT one forearm between greater troch and iliac crest One forearm over ribs pull forearms apart Strum/slide fingers with a lumbrical grip -medial to lateral over QL Then release *Lengthen strum release* Targets: *QL* tightness, pain and dysfunction, scoliosis on concave side, leg length discrepancy, SI dysfunction, weak hip abd, weak glutes/hip /

Unilateral P/A Articulation of First Rib

Deep prep *palpate first rib* 1. find T1 2. Find superior medial border of scapula 3. palpate between these two 4. if unsure find rib 2 and move up bottom hand mobilizes using oscillatory movement P/A Top hand feels for movement *Used for hypomobile first rib, rib dysfunction, increased tone in subclavicular area* Target: subclavicular tissue and subclavius reasses rib accessory motion

First Rib/Shoulder depression rocking technique

Deep prep Bottom hand on costovertebral junction Top hand is placed on superior aspect of lateral shoulder Bottom hand pushes first rib superior and the top hand depresses the shoulder in a oscillatory fashion *Used for inhibitory technique to relax the upper thoracic area, preps tissue for deeper more specific work*

Iliac Crest release bony clearing

Deep prep Chisel grip to scrub along iliac crest (oscillatory movements going deeper and deeper) progress to extending hip *used for pts with limited forward bending, sidebending, anterior pelvic tilt* *contraindications: lumbar fusion, stenosis , spondylolisthesis* Targets: QL, thoracolumbar fascia, lats, erector spinae

ITB Paratrochanteric Manipulation

Deep prep Distal femur is stabilized manipulating hand (power grip) lead with thumb running distally along IT band (j shape around Greater troch) *make sure to hit anterior border, posterior border, and direct* *Used for knee, hip, and/or low back dysfunction* Targets: IT band, vastus lateralis Progress by moving leg into adduction

Iliacus release

Deep prep Palpate the rim/top of iliac crest slowly grip fingers around iliac crest eventually moving tot he anterior surface of the ilium Scrub tissue parallel longitudinal or perpendicular *Used for limited hip extension, in conjunction with psoas release, and anteriorly tilted pelvis* Reassess anterior pelvis tilt and hip extension

Lateral Telescoping/anterior posterior techniques lateral elongation of upper thoracic area

Deep prep Post. hand superior to spine of scapula Ant. hand inferior to the clavicle mod compressive force between hands and move laterally More aggressive hands overlap anteriorly over inferior clavicle *Used for FHP, protracted shoulder girdle complex, excessive kyphosis, scapular tilting, post-op shoulder, pt who has been in a sling* Reassess posture progress to rip splaying

Greater Trochanter Rocking

Deep prep Proximal hand placed under superior greater trochanter Distal hand rocking the distal femur/proximal knee into IR *should be rhythmic motion* *Used for tight hips, limited hip IR, hip OA, tight/tendonitis of glutes, or deep hip rotators, bursitis* Targets: gluts, trochanteric bursitis, deep hip IR and ER Reassess Hip ROM Progress to more specific techniques (piriformis, hamstring)

Rib Splaying (Ribs 1-3)

Deep prep loose fist power grip - start medially between ribs 1-2 stroke laterally. Repeat for ribs 2 and 3 *Used for FHP, protracted shoulder girdle complex, excessive kyphosis, scapular tilting, post-op shoulder, pt who have been in a sling* Targets: intercostal space, tissues inferior to clavicle, subclavius reassess clavicular motion, rib accessory motion regress to lateral telescoping

Forward Bend Laminar Release (quadruped)

Deep prep pt on all fours and moves to child's pose PT glides fist led by thumb along the paraspinals as the pt moves. PT must follow pts speed to complete tx *contraindications knee replacements, knee pain/problems*

QL medial lateral pull away

Deep prep pt sidelying PT flat hands begin on contralateral side of low back compress and pull towards yourself by leaning back good prep technique for further QL *Used for very acute pt who need to be desensitized* (autonomic) Targets: *QL* tightness, pain and dysfunction, scoliosis on concave side, leg length discrepancy, SI dysfunction, weak hip abd, weak glutes/hip /

Diaphragm release

Deep prep pt slouches into bad posture PT reaches around and under their lower rib cage Reach deeper and deeper with each breath Once youve reached a significant depth have pt sit up with every breath without releasing hand position *Used for freeing up restrictions in the anterior fascia, manipulating the diaphragm, poor posture patients, cardiac, or abdominal surgeries, abdominal scar tissue, referral pain from diaphragm to shoulder*

Psoas Release

Deep prep pt's knee flexed to 90 degrees on bolster Find psoas, confirm by having them hip flex Sink in and move deeper withe very exhale Once you reach psoas perform cross friction or trigger point release *Used for hypermobility at L3-L5, cyclists, people who sit a lot, lower crossed syndrome, SI dysfunction, decreased ability to fire hip flexors, limited hip extension, forward bent posture, flat back posture* *Contraindications pregnancy, inflammatory bowel diseases* reassess hip flexion

Axial Flexion of Cervical Spine

Deep prep similar to elongation of paravertebral muscles but with a lift *Used for FHP, pt in an axillay extended posture* Targets paravertebral muscles and suboccipital muscles reassess axial flexion and extension

iliac crest release hip extension

Deep prep start with chisel grip and scrub along iliac crest progress to hip extension with use of 1 hand to continue to scrub *used for pts with limited forward bending, sidebending, anterior pelvic tilt* *contraindications: lumbar fusion, stenosis , spondylolisthesis* Targets: QL, thoracolumbar fascia, lats, erector spinae

Thoracic rotation laminar release

Deep prep *DRAPE* Assess thoracic rotation Stabilizing hand over GH joint Manipulating hand ipsilateral laminar groove Push pt into thoracic rotation as you glide fingers along laminar groove down to T12 -push to end range and stand up tall *used for pt with limited thoracic rotation

What is the diagnostic criteria and confirmatory observation to identify myofascial trigger point?

Diagnostic criteria: o Full-stretch, limited by pain o Taut band palpable o Tender spot or nodule within a taut band o Reproducible pain of patient's complaint Confirmatory observations o Local twitch response o Referred pain in the expected distribution of that muscle o End plate noise or spontaneous electrical activity demonstrated by an electromyographic study

Describe the two types of Myofascial Release, direct and indirect?

Direct: those that improve the mobility of soft tissue with the application of mechanical stress that is applied directly into the restriction Indirect: requires less force, longer duration hold, very gentile, better for pt that are tender and guarded

myofascial type pain syndromes How is the patient sleeping at night?

Disturbed sleep patterns is common in those with myofascial pain. They often wake up in the middle of the night and feel unrefreshed and fatigued in mornings

Latent Trigger Point

Does not cause spontaneous pain May restrict movement or cause muscle weakness Become aware of presence when pressure is applied

What physiological change does physical therapy dry needling cause in the muscle?

Dry needling can change the chemical environment of trigger points and may restore normal functioning of acetylcholinesterase and the acetylcholine receptors Superficial dry needling→ stimulates the Ad fibers, release oxytocin, activate mechanoreceptors coupled with C-fiber afferents to stimulate the anterior cingulate cortex

What are the differences between the functions of a muscle stretch reflex and Golgi tendon organs?

GTO is more complex due to MSR being monosynaptic GTO causes inhibition of agonist and MSR causes contraction of agonist Afferent info from GTO first synapses with interneurons then synapses with motor neuron Afferent info from MSR goes right to the motor neuron

What is the difference between dysfunction and pathology?

Dysfunction - a disturbance, impairment, or abnormality of the functioning of an organ Pathology - Processes, causes, and effects of a disease; abnormality A therapist diagnoses dysfunction in the same way a physician diagnoses pathology

How does fibromyalgia syndrome is related to abnormal central nervous system sensory processing?

Dysregulation of the pain pathways and neurotransmitter irregularities enable pain amplification, making individuals hypersensitive to both painful and non-painful stimuli such as touch, temperature, light, sound, and smell

List some examples of Hoffa massage techniques and describe the potential benefits of each.

Effleurage: relaxation - getting patient comfortable with touch, calming Petrissage: good for large muscle bellies to help lift the muscle mass from the bone Tapotement Vibration

6. Describe the viscoelastic model of connective tissue

Elastic component represents temporary change in length that occurs when it is subjected to stretch→ all stretch is lost over short period of time and tissue returns to original length Viscous component represents permanent deformation → part of length gained remains even after a period of time

What are the different components of the stress-strain curve?

Elastic or toe region point of yield plastic region point of failure

What is end plate noise and what does it indicates?

End plate noise is caused by excessive release of acetylcholine at the motor end plate; it is an indication of the irritability of trigger points but also an expression of sympathetic dysfunction

Presence of trigger point in what muscle can present as lumbar radiculopathy?

Glute min and piriformis

What is integrated trigger point hypothesis?

Excessive acetylcholine lead to motor end plate dysfunction and increased sensitivity of nociceptive receptors

What are some distinct characteristics associated with poor head posture as it pertains to the Lumbar spine

Excessive lumbar lordosis (lower cross syndrome) or Loss of lumbar lordosis (men w/ DJD)

Autonomic approach of myofascial manipulation

Exerts a therapeutic effect on the autonomic nervous system (skin and superficial fascia and connective tissue) stepping stone for more aggressive therapy

What is Ida Rolf's concept of a "fascial sweater"?

Fascia is like a sweater and fascial restriction in one area wills train areas away from the restriction and cause abnormal movement

What are the different metabolic and functional characteristics of different types of muscle fibers? *Type IIa*

Fast Twitch/oxidative (fast red) Moderately high concentrations of myoglobin, increased numbers of mitochondria, glycolytic/oxidative (mixed) metabolism Faster contraction times than Type I, less fatigue resistance

What are the different metabolic and functional characteristics of different types of muscle fibers? *Type IIb*

Fast twitch/glycolytic (Fast white) high glycogen content, glycolytic metabolism, decreased numbers of mitochondria faster contraction times, fatigues easily

What are the components of extra cellular matrix and what are their functions?

Fibers (Collagen, elastin, reticulin) and ground substance

What makes up the ground substance?

Glycosaminoglycans (GAGs) Proteoglycans Glycoproteins

What are the basic premises of Rolfing? What is the goal for the human body that all Rolfer's are striving for?

Goal: Correct inefficient posture or to integrate structure 1. respiration 2. balance under the body (feet/legs) 3. Lateral line - front to back (sagitial plane balance) 4. base of body/midline (balance L to R) 5. Rectus abdominis/psoas - pelvic balance 6. Sacrum - weight transfer from head to feet 7. Relationship of head to rest of body-primarily occiput/atlas (OA) relationship, then rest of the body 8.9 Upper and lower half of body relationship 10. Balance throughout system

What does Janda suggest for the approach of treatment forward head posture?

First: focus on restoring proper length to the tonic muscles before strengthening the phasic muscles Based on Sherrington's law of reciprocal inhibition

7. What techniques that we covered in class have contraindications/precautions. List them with an explanation why.

Forward Bend Laminar Release Quadruped -Knee replacements, knee pain/problems Forward Bend Laminar Release Seated (cervical and whole back) -Discogenic patients Bony Clearing of Iliac Crest and Iliac release -Lumbar fusion, stenosis, spondylolisthesis Psoas Release -Pregnancy, Inflammatory bowel disease

Merkel's receptors

Found in epidermis of hairless skin Function response to very small stimuli and localizes well due to small receptive field. responds to light touch Fiber type: AB

Pacinian corpuscles

Found: Both hairless and hairy skin and fibrous CT and ant/post horns of meniscus Function: detect skin "flutter" compressive stimuli. Sensitive to mechanical energy rapidly adapting and large receptor field Fiber type: AB

Meissner's Corpuscles

Found: Glaborous skin (palms, soles, lips) Basic Function:adapt rapidly to stimulus, small receptive field (easy to pinpoint stimulus) Fiber type AB

Ruffini corpuscles

Found: hairless and hairy skin but also in superficial layers of the joint capsules and surrounding connective tissue Function: slow adapting and continue to fire as long as stimulus present large receptor field Used in steady state positioning and tactile sensation Fiber types AB

Describe the history of osteopathic medicine.

Founded by Andrew Taylor Still in 1874 Basic Theory: human organism has the innate strength to combat disease and would remain healthy as long as it remained structurally normal Cases of diseases was dislocated bones, abnormal/dislocated ligaments or contracted muscles putting mechanical pressures on blood vessels and nerves to produce ischemia and necrosis

What are the specific muscle nociceptors?

Free nerve endings connected to the CNS by thin myelinated (group III) or unmyelinated (group IV) afferent fibers Particularly effective in inducing neuroplastic changes in the spinal dorsal horn

Diagnositc criteria to identify myofascial trigger points

Full-stretch, limited by pain Taut band palpable Tender spot or nodule within a taut band Reproducible pain of patient's complaint

Stages of Scar Tissue Formation: Granulation

Granular look due to capillary buds formation Fragile tissue Easily re-injured

5. List EVERYTHING you have learned about ground substance, what it is, the function, what is it made of etc...

Ground substance: viscous gel with high water concentration. Provides medium in which collagen and cells lie o Diffusion of nutrients and waste products o Mechanical barrier against bacteria o Maintains critical interfiber distance, preventing micro-adhesions o Provides lubrication between collagen fibers o More abundant in early life; decreases with age

What are the focus points of the myofascial evaluation in this chapter, i.e. history, movement analysis, etc.?

History, postural and structural evaluation, movement analysis, and palpatory examination

What abnormalities are observed at the supraspinal level in patients with fibromyalgia?

Hypoperfusion -anterior and posterior cingulate -the amygdala -the medial frontal -parahippocampal gyrus -the cerebellum hyperperfusion -radioligand within the somatosensory cortex

Difference between fibromyalgia and chronic fatigue syndrome

Immunological dysregulations, such as abnormal 2'-5' oligoadenylate synthetase/RNase L pathway have been found in pts with CFS and not FMS Pts with CFS also show significantly lower blood perfusion in the brain stem compared with controls Pts with FMS have higher substance P levels than those with just CFS

What are some distinct characteristics associated with poor head posture as it pertains to the Thoracic spine

Increased kyphosis Pec major and minor and upper trap in shortened positions Middle and low trap and rhomboids weaken Anterior diaphragm is compromised from poor posture which facilitates accessory breathing muscles

Scapular framing

Indications: Myofascial restrictions surrounding scapular borders. Scapulothoracic rhythm dysfunction. Dysfunction of upper thoracic, mid-thoracic, cervical spines, and shoulder. post-op shoulder, RTC surgery Reassess shoulder motion

12. What are indirect insertions as described in the book. Describe them and the relevance to MF techniques.

Indirect insertions aka Sharpey's fibers= type 1 collagen fibers that blend into periosteum-- do not have fibrocartilage transitional zone, relatively avascular

The process of scar formation can be broken into what four distinct phases?

Inflammation Granulation Fibroplastic/proliferation Maturation

What are the components of a muscle spindle and how do they affect movement?

Intrafusal fibers - special muscle fibers located in spindle Sensory axons - terminate in a spiral ending in intrafusal fibers Motor axons - adjust the sensitivity of muscle spindle detect change in length and make sure the muscle is firing properly to accommodate that lengthening

What is the significance of local twitch response during physical therapy dry needling?

It can reduce the concentrations of several nociceptive substances in the immediate environment of active trigger points

QL Rotation above 1st then legs off table

Legs off table Rotate trunk from T12 to S1 pull apart QL with forearm contact between iliac crest and greater trochanter and lower ribs Strum medial to lateral with one hand Targets: *QL* tightness, pain and dysfunction, scoliosis on concave side, leg length discrepancy, SI dysfunction, weak hip abd, weak glutes/hip /

Non-aggressive vs Aggressive QL techniques

Legs on the table vs legs off the table

What are the characteristics and examples of *dense regular* connective tissue?

Ligaments and tendons dense, parallel arrangement of collagen fibers proportionally less ground substance *least responsive to manual therapy*

18. Describe all the of the detrimental effects of immobilization.

Loss of ground substance affects critical interfiber distance and lubrication bw tissues Collagen cross-link formation &/or fibrofatty infiltrate limits tissue mobility Loss of sarcomeres, decreased fiber diameter, fibrotic damage of myofibrils Loss of nutrition & blood supply from micro-adhesions preventing tissue mobility Disuse atrophy Pain

Based on the evidence, what physical therapy approach is considered best for the fibromyalgia?

Low intensity aerobic exercise with or without biofeedback -Resisted strengthening, stretching -land based aerobic exercise, pool exercises and a combination o 2-3x/week o Increase intensity slowly o Avoid exacerbation of pain/exercise induced pain

10. Describe the thoracolumbar fascia including the type of tissue, function and role.

Made up of dense irregular CT allowing pull in multiple directions during spine's normal fxn Function - transmits load between compartments Role- stabilizes during movement

What are three major categories of nociceptors and how do they function?

Mechanical - stimulated by AB fibers very fast Thermal - stimulated by AB fibers very fast Polymodal - stimulated by C fibers -slow

Feldenkrais Method

Mechanical approach Consists of two interrelated, somatically based educational methods. The first, awareness through movement (ATM), is a verbally directed technique designed for group work. The second, functional integration (FI), is a nonverbal manual contact technique designed for people desiring more individualized attention

Aston Patterning

Mechanical approach importance of the body position of the person providing the technique; soft hands; asymmetry is natural; we want balance in posture and movement

What are the four major categories of receptors in the human body?

Mechanoreceptors Nociceptors Thermoreceptors Chemoreceptors

Bony clearing of the tibia

Minimal deep prep pt can be supine, prone, or hooklying Can add active PF and DF to increase effect of technique *Used for clearing the fascia of the anterior and posterior compartments that adhere to the tibia* Reassess pain level and DF

How did Stanley Paris define "joint play motions"?

Motions not under voluntary control, which occur only in response to outside forces

PNF (proprioceptive neuromuscular facilitation)

Movement approach inhibiting unwanted reflex activity or reducing sensitivity via nervous system and using the change to improve mobility

11. What is a muscle play technique and what is the purpose?

Muscle play = ability of muscle to expand & move within it's compartment independent of joint movement or voluntary contraction Muscle play technique = mb CT sheath to enhance muscle contraction, circulation to muscle group and movement in the area

Can you explain to a patient the difference between a muscle spindle and a Golgi tendon organ?

Muscle spindles lie within the muscle fibers and simply detect the change in length and makes sure the muscle is firing properly to accommodate that lengthening GTOs detect any sort of tension, and act as a protector to prevent injury to the tissue from over stretching

What are the motor and mechanical dysfunctions caused by trigger points?

Muscle weakness without atrophy: due to pain, restrictions in ROM, kinesiophobia, inhibition of gamma motor neuron activity or reflex inhibition of anterior horn cell function Anatomical variations: i.e. leg length discrepancy, small hemipelvis, short upper arm syndrome, and long second metatarsal syndrome Abnormal postures: i.e. forward head posture where muscles adaptively shorten or lengthen Sustained work postures and repetitive arm movement

myofascial type pain syndromes Quality of pain?

Myofascial pain usually dull, achy, diffuse pain type syndrome where sharp and specific pain is often a specific pathology

17. Describe the type of collagen cross links that form with immobilization. How is this relevant to soft tissue treatment?

Newly synthesized collagen forms cross-links with mature collagen fibers as an effect of immobilization Early cross-links are formed with hydrogen bonds & with time are replaced by covalent bonds Micro-adhesions further impede tissue mobility, resulting in decreased cellular activity and therefore decreased blood supply and nutrition to the affected tissue MFM ruptures cross-link formations and/or fibrofatty infiltrate

Quadricep muscle play

No Deep Prep 3 versions (both hands, one hand, posterior force) *used for patellofemoral pain, IT band tightness, TKR, post op knee, lateral release, quadricep tightness, limited knee flexion d/t quad tightness, quad strain Reassess knee flexion after

Sternocleidomastoid longitudinal stroking and muscle play

No Deep Prep One hand cradles head/occiput Other hands find SCOM (confirm by SB to same side) Stroking - along SCOM from top to bottom Muscle Play - grasp SCOM and push and bend it - be careful of throat Trigger point - find taut band apply pressure until it dissipates *Used for FHP, rounded or protracted shoulders, tigger points, increased SCOM tone*

Superficial Long Axis Distraction of Connective Tissue of the Spine

No deep prep PT hands should be placed 2-3 segments apart elbows and forearms should be parallel to the pt back held until creep/movement felt *used for superior/inferior restrictions, limited in flexion, posterior pelvic tilt, reverse lordosis* Reassess superficial fascia

Hamstring muscle play

No deep prep Stabilizing hand is on the distal hamstring Manipulating hand pushes/bends muscle *Used for restrictions in fascial sheath surrounding the hamstrings, hamstring strain, prepare the hamstring for stretching* Reassess hip flexion and knee extension after

Gastroc/soleus muscle play

No deep prep Two versions: distal hand stabilizing or both hands used to manipulate *used for manipulate the fascial sheath surrounding the gastroc/soleus muscle group to allow room for more efficient contraction and expansion of the muscles Reassess PF after

Subscapularis muscle play

No deep prep pt arm at 90-170 degrees of flexion and elevation. Slight traction force applied to shoulder *can use palm or thumb or half chisel* use oscillatory movement along muscle *Used for post-op sling, overhead athlete, subscapularis tears, IR strength limitations, FHP, protracted shoulder* Reassess shoulder ER and pain level *crap picture*

Anteriorfascial elongation of the superficial fascia

No deep prep pt shoulder at 120-170 degrees flexion stabilizing hand around pt elbow manipulating hand contacts abdominal fascia Stabilizing hand provides a traction force to the shoulder and the manipulating hand pushes superficially down the body *Used for restricted shoulder elevation, mastectomy, any burning or scarring in the area* Reassess shoulder elevation and skin/fascial mobility

What did Mennell suggest should be addressed to promote normal arthrokinematics of our joints?

Normal anatomical ROM in synovial joints (pre req to efficient pain free motion) *joint play* loss of joint play results in a mechanical pathological condition manifested by impaired (or lost) function and pain. This is *joint dysfunction* Mechanical restoration of joint play by a second party is the logical treatment of joint dysfunction *joint manipulation*

What is the functional aspect of Wolff's Law when applied to connective tissue?

Normal stresses or carefully control stresses may positively change the metabolic and physical homeostasis of the tissue; laid down more organized in a direction more suitable for optimal tissue function

Glute Medius

O: outer surface of ilium I: lateral surface of greater trochanter A: hip abduction

Mandible position with forward head position

Open masseters and temporalis are engaged to keep the mouth closed—degenerative changes in the TMJ

Quadratus Lumborum

Origin: Iliolumbar ligament and iliac crest Insertion: Inferior border of twelfth rib and transverse processes of L1- L4 Action: Together: Pull 12th ribs inferior during forces exhalation, Extend vertebral column Singly: Laterally flex vertebral column

Movement approach examples

PNF Alexander technique Feldenkrais method

Quadratus lateral erector spinae release (forearm or hand contact)

PT distal hand under iliac crest pushing superiorly to shorten QL Proximal hand/elbow strums medially through QL Targets: *QL* tightness, pain and dysfunction, scoliosis on concave side, leg length discrepancy, SI dysfunction, weak hip abd, weak glutes/hip /

Cross friction of gastroc and soleus musculotendinous junction

PT grasps mid calf Curls fingers and digs them into middle of the muscle belly Applies firm pressure by moving elbows and seperating fingers Move medial and lateral in muscle belly in a cross friction manner *Used for fascial thickenings and good for ballistic type athletes* reassess PF and pain level

Allodynia

Pain due to a stimulus that does not normally provoke pain From changes in the dorsal horn (unmasking of "sleeping" receptors from afferent receptors of skin, joints, viscera which leads to spatial summation of dorsal horn and appearance of new receptor fields. Therefore, previously ineffective regions can now stimulate neurons. Thus, previously non painful stimuli now perceived as painful)

Describe the history of chiropractic medicine

Palmer founded in 1895 based on ancient hippocratic methods but claimed it was new science based on the "law of the nerve"

What are the 5 major features of a trigger point based on which excellent interrater reliability was established?

Palpable taut band Tenderness Local twitch response Referred pain Reproduction of pain

What three components are typically involved in a palpation examination for myofascial conditions?

Palpation of the myofascial structures in the form of layer palpation Palpation of the joint structures Assessment of passive segmental mobility

What are three clinical implications concerning traumatized connective tissue?

Patients entering PT for rehab following injury or surgery and subsequent immobilization will have connective tissue changes A combo of scar formation and fibrosis are occuring Traumatic exudates infiltrate these surrounding, non-traumatized areas and acting as chemical catalysts create changes in the connective tissue

Mobilization of OA with occiput stabilized

Place one hand under the occiput, cradling the head without lifiting it up the other hand grasps the occiput Place shoulder on pt forehead pt pushes into your hands (isometric) holds for 5 seconds pt then pushes into your shoulder (isometric) for 5 seconds *muscle energy technique* *Used for OA hypomobility, FHP, rounded or protruded shoulders* Targets: subcranial flexors and extensors Reassess OA motion, subcranial flexion and extension strength

What is modified convergence projection theory and how does it explain referred pain?

Proposed by ​Mense​ based on the pathophysiological unmasking process of interneurons within the dorsal horn He injected a painful dose of bradykinin into a muscle to mimic myofascial trigger points. After just 5 minutes the receptive field had expanded, and after 15 minutes the receptive area not only responded to painful stimuli but also mechanical stimuli. He believes that because of the interneurons, pain can be felt elsewhere from the original trigger point

What are the structures palpated in an examination from superficial to deep?

Skin subcutaneous fascia blood vessels muscle sheaths muscle bellies musculotendinous junctions tendons deep fascia ligaments bone and joint spaces

myofascial type pain syndromes Can a position of comfort or relief be identified?

Pts should be able to find some (at least temporary) pain relief by switching positions and unloading stressed tissues. In case of active trigger points, position of relief is often alternating pattern of contracting and resting the muscle in mid-range position

What are four key questions to consider when looking for myofascial type pain syndromes?

Quality of pain? Sleeping? Pain Pattern? Position of comfort or relief possible?

What are the characteristics of the Proliferation/Fibroblastic phase?

Rebuilding of tissue begins Fibroblasts migrate and begin collagen synthesis temporary seal gains strength as collagen fibers are laid down in a haphazard and disorganized fashion Strength determined by collagen filaments and cross links Gentle movement is good here 5-8 days (3-5 weeks for ligaments and tendons)

Joint receptors

Receptors in and around a joint that respond to pressure, acceleration, and deceleration of the joint. located in the connective tissue of joints

Golgi tendon organs

Receptors sensitive to change in tension of the muscle and the rate of that change Located in musculotendinous junction Fiber type Aa II

4. Describe the chemical changes associated with fibromyalgia and the mechanism for the pain distribution. What are the most evidence based treatment options.

Reduction in serotonin and norepinephrine (contributes to central sensitization) Elevation of Substance P and glutamate (contributes to central sensitization) Treatment Low intensity aerobic exercise with or without biofeedback Resisted strengthening, stretching land based aerobic exercise, pool exercises and a combination 2-3x/week Increase intensity slowly Avoid exacerbation of pain/exercise induced pain

What are the sensory dysfunctions caused by trigger points?

Referred pain or referred paresthesia Hypersensitivity of the nervous system (physiological tone at rest may stimulate active trigger points) Gradual spectrum from latent to active trigger points, where more active TrP present with more features of peripheral and central sensitization

What are the components to the lower crossed syndrome?

Tonic posterior thoracolumbar erectors and phasic gluteus med and max Anterior postural hip flexors (iliopsoas, rec fem) and phasic abdominals Pt presents with forward pelvic tilt, increased lumbar lordosis, and slightly flexed hip

What are the principles associated with forward head posture developed by Janda and their meaning to clinical application?

Relationship between tonic and phasic muscles and their correlation to agonist/antagonist muscle groups Tonic muscles increase tone and phasic muscles become weak/inhibited in response to dysfunction Upper cross syndrome: posterior short/tight tonic (upper trap and levator scap), phasic scapular stabilizers (low and mid trap) and anterior postural musculature (SCM, pec major/minor) and weak inhibited phasic scap stabilizers (low and mid trap) and weak cervical neck flexors

Mechanical approach examples

Rolfing Trager Myofascial Release

What are the four types of joint capsule receptors and how does it relate to the types of mechanoreceptors previously learned?

Ruffini Pacinian Golgi-Mazzoni Wyke's

What trigger point refers pain to the shoulder, posterior arm, back of head, around eye and over the forehead?

SCOM

Describe Janda's lower cross syndrome

Tonic posterior thoracolumbar erectors and phasic gluteus med and max. Anterior postural hip flexors (iliopsoas, rec fem) and phasic abdominals. Pt presents with forward pelvic tilt, increased lumbar lordosis, and slightly flexed hips

What cardinal planes should be assessed with active movement analysis?

Sagittal (forward bending) Frontal (side bending) Transverse (rotation)

Pectoralis Minor muscle play

Same set up as pec major Scrub muscle with your thumbs -ischemic compression -trigger point *used for improved pec minor muscle movement and contraction in the surrounding fascia*

What is the difference between the fibrotic process and the scar formation process?

Scar formation is a linear process and fibrotic is cyclical scar formation is localized tot he traumatized area fibrosis is a homogenous change in the fabric of CT Fibrotic changes can make the entire tissue less extensible

Describe Janda's layer syndromes

Seen in posterior view. Top to bottom an alternating pattern adaption can be seen in the tonic and phasic muscles. Tonic upper traps and levator scapulae, phasic mid and low traps, tonic thoracolumbar erectors, phasic glute med/max, tonic hamstrings

What is energy crisis hypothesis?

Simons and Travell *explains the pathogenesis of trigger points; ongoing contractures compromise local circulation & reduce the O2 supply 1) low O2 2) lack of adenosine triphosphate* Ongoing contractures compromise the local circulation and reduce the oxygen supply triggering a vicious cycle Decrease in O2 leads to hypoxia, decreased pH and hypoperfusion. Production of ATP is impaired, leading to an increase in acetylcholine and increase in Ca2+ Hypoxia also leads to excessive release of bradykinin, substance P, and calcitonin The acidic pH also increases Calcitonin release which sensitizes nociceptive receptors and causes hyperalgesia

What are the different metabolic and functional characteristics of different types of muscle fibers? *Type I*

Slow twitch high concentrations of myoglobin, increased number of mitochondria, low content of glycogen, oxidative metabolism Slow contraction times, fatigue resistant

Presence of trigger points in what muscles can present as carpal tunnel syndrome?

Sternocleidomastoid and cervical paraspinal muscles have asymmetrical loading Trigger points in infraspinatus muscle

Effects of immobilization on joints according to Akeson, Amiel, Woo

Stress deprivation alters the morphologic, biochemical, and biomechanical characteristics of various components of joints -fibrofatty CT found (adherence) -Adhesions between synovial folds -atrophy of cartilage -ulceration (cartilage to cartilage) -disorganization of cellular and fibrillar alignment -Decreased load to failure capacity -reduced energy absorption *collagen mass declines by 10%* proteoglycan and h2o decrease

What chemicals are elevated in the cerebrospinal fluid of the patients of fibromyalgia and how does these chemicals contribute to the central sensitization symptoms?

Substance P and glutamate -modulate postsynaptic responses by aiding in transmission of pain signals via primary afferent neurons -Substance P elevation lowers the threshold for excitability in the spinal cord

What are the different metabolic and functional characteristics of different types of muscle fibers? *Type IIm*

Super fast contains unique myosin configuration, high glycogen content, glycolytic metabolism Very fast contraction times

1. How do you identify a trigger point?

Systematic palpation of taut bands with a hypersensitive palpable nodule in the taut band, review of the patient's history, and by a thorough msk examination (including posture and functional movement patterns). Patients recognition of the referred pain elicited by the trigger point

Why would the presence of a trigger point in a muscle lead to dysfunction?

TPs demonstrate localized electrical activity in the confined area of the TP lack of appropriate relaxation between contractions abnormal mechanical stimulus would result in alteration in the cumulative position sense information

What is the difference between a taut band and spasm? What is the gold standard to differentiate between the two?

Taut band→ an endogenous localized contracture within the muscle without activation of the motor end plate Spasm→ electromyographic activity as the result of increased neuromuscular tone of the entire muscle and are the result of nerve-initiated contractures *electromyography is the gold standard*

Gerwin trigger point

Tenderness Referred Reproduction of pain palpable taut bant LTR TRRPL

9. What is the tensegrity model and how does it apply to connective tissue?

Tensegrity is used to describe architectural structures that are kept mechanically stable by distributing and balancing stresses; the stability is not dependent on the strength of the individual members of the structure, but instead the combined effort of resisted compression and tension Cells rely on tensegrity to maintain a delicate balance between mobility and strength

Tensegrity

Term coined by Buckminster Fuller that refers to a skeletal structure in which compression and tension are used to give a structure its form, providing stability and efficiency in mass and movement.

ruffini joint receptors

Type I Located in proximal extremity joints (hip and shoulders) slow adapting good for postural info in static positions postural stability is needed for dynamic movements

What type of collagen is manual therapy aimed at?

Type I - CT proper (loose and dense)

What are the characteristics of the myotendinous junction?

The cell membrane: -forms a continuous interface between intercellular components of muscle fibers and extracellular components of connective tissue -at the junction becomes highly folded or convoluted, allowing the contractile intercellular components to interdigitate with the extracellular components - is highly resistant to shear forces -Folds increase the potential adhesive area in the musculoteninous junction. (decreases load per unit area being transmitted from the muscle) -decreased sarcomere length and extensibility which makes it more vulnerable to tearing

pacinian joint receptor

Type II Located in deeper layers of the joint and fat pad and near bony attachments of joint capsule activated during start and stopping of movement

What are the characteristics of the indirect insertions at the osteoteninous junction?

The connective fibers tend to blend more with the periosteum and are sometimes referred to as Sharpey's fibers no defined zones

What imaging techniques are used to view trigger points?

Ultrasound

What are the autonomic dysfunctions caused by trigger points?

Vascular changes Secretory, pilomotor, and trophic changes Ptosis Changes in skin temperature Hypersecretion

What is the main criterion for the diagnosis of myofascial pain?

The presence of an active myofascial trigger point, an exquisitely sensitive region in a taut band of skeletal muscle

Thixotropy

The property of certain cells of becoming fluid when shaken, and then becoming solid again.

What causes Excessive lumbar lordosis (lower cross syndrome)?

Tight erector spinae, psoas group, iliacus, and TFL Weak abdominals and glutes Hypomobility and tightening of posterior structures

What causes loss of lumbar lordosis?

Tightness in hamstrings and posterior hip structures pulls spine into flexion folding erector spinae in lengthened position leading to progressive weakness ▪ Joint hypermobility and eventual instability

What are the characteristics of a soft tissue mechanical dysfunction?

Tissue has failed due to trauma or overuse patients can reproduce their pain or make it better Can be medically dx, seen on imaging -structural or functional asymmetry -abnormal texture -ROM abnormality Tx -POLICE in early stages, work in controlled movements, and controlled stresses throughout normal stage of healing

What is crimp and what is its significance?

Undulating configuration that is though to be responsible for the mildly elastic characteristics of the ligament ligament functions as a spring until all the crimp has been taken out

myofascial type pain syndromes What pattern does the pain follow during the day?

Usually increased pain/stiffness in the morning that may reduce symptoms in mid-morning but remains somewhat constant throughout the day. Increased activity usually flares up myofascial pain pattern

What is spine engine model?

When connective tissue is mobile, the system is much more efficient as the foot hits the ground, eccentric contractions are produced to control forward movement and prevent falling, just like the viscoelastic qualities of connective tissue allow it to absorb ground reaction forces through LE connective tissue, even reaching the spine to produce rotation

What is the updated criteria to diagnose fibromyalgia syndrome?

Widespread pain index score >7 and symptom severity scale score >5 OR WPI score=3-6 and symptom severity score >9 Symptoms have been present at a similar level for at least 3 months The patient does not have a disorder that would otherwise explain the pain

What of the clinical concerns of forward head posture on diaphragmatic breathing?

With anterior thorax shortened, diaphragmatic breathing is compromised, and the accessory muscles of respiration are facilitated leading to a potentially elevated rib (compromises the costoclavicular space and increases risk of thoracic outlet syndrome)

What are the characteristics of the maturation phase?

Wound is closed -collagen still not at max strength 3 weeks to 12 months Manual therapy can help -low load prolonged stretch most effective Stress to the area is needed for scar formation to regain full functional strength manipulation of the scar

What does gel-sol theory explain about the plastic characteristics of the connective tissue?

a colloid substance can function in two different forms: -gel -sol Gel state is thick and dense. Heat or mechanical stimulus can be used to make gel more fluid or soluble (sol) (ketchup analogy)

Dysfunction

a disturbance, impairment, or abnormality of the functioning of an organ

dynamic nuclear bag fibers

a type of muscle spindle fiber that provides information about the velocity of change in the length of a muscle

What are the two types of tensegrity structures?

buckminster fuller kenneth snelson

Accessory motion

ability of joint surfaces to glide, roll and spin on each other

What was the role of James Mennell in the understanding of joint and soft tissue dysfunction?

accessory motion believed in facet hypothesis *early recognition of periarticular soft tissue dysfunction as a causative factor in back pain *

What are the components of myofibroblast that is responsible for its contractile ability?

actin microfilaments non-muscle myosin

Peripheral sensitization

after injury chemical mediators stimulate nociceptors & lower threshold causing hypersensitivity -Hyperalgesia

What are the characteristics and examples of *dense irregular* connective tissue?

aponeurosis, periosteum, joint capsules, dermis of skin, areas of high mechanical stress dense, multidirectional arrangement of collagen fibers, able to resist multi directional stress

The cycle of fibrosis is generally initiated by a low-grade irritant. What are examples of low grade irritants?

arthrokinematic dysfunction poor posture/habit patterns overuse structural and movement imbalances

Elastin

protein base similar to collagen that forms elastic tissue found in lining of arteries

Shoulder girdle complex position with forward head position

protracted position with GHJ in internal rotation

Active Trigger Point

causes pain at rest, firm pressure over the area causes person to jump, tender to palpation and can cause refrred pain. - found most commonly in muscles of postural support Active trigger point produces symptoms, including local or referred pain or other paresthesia

Where does the pectoralis minor trigger points refer pain?

chest, shoulder, and medial arm

What is the purpose of ground substance?

diffusion of nutrients and waste products mechanical barrier against bacteria maintains critical interfiber distance, preventing microadhesions provides lubrication between collagen fibers more abundant in early life; decreases with age

Why does the connective tissue adaptively shorten if the stress are on applied on it for a long period of time?

collagen is laid down in the context of the length of the tissue and lack of stress applied to it

What was Freddy Kaltenborn's definition of mobilization?

component of manual therapy referring to any procedure that increases mobility of the soft tissue and or the joints

Myofibroblasts

contract via actin and myosin to pull tissues together

Lateral sacral release chisel grip

lateral sacrum is scrubbed with oscillatory movements deep circles performed when restrictions found *Used for SI pain, hip surgery, hip pain, trochanteric bursitis, buttock pain, leg pain, diffuse hip and leg pain proximal to the knee* Targets: fascia on lateral border of sacrum, glute max, piriformis

What are immobilization effects dependent on?

lengthened or shortened type of immobilization (passive or active) Innervated or denervated fast twitch or slow twitch highly metabolic tissue

Plantar fascia manipulation

deep prep Stabilizing hand: bring them into DF Manipulating hand: gentle fist stroke longitudinally beginning at calcaneus and ending at prior to toes *Used for restrictions in the plantar aponeruosis and superficial tissues, plantar fasciitis, or recently out of a cast* Reassess reactivity levels and toe extension

Plastic region

deformation is permanent but no rupture

What is strain?

deformation or change in tissue as a result of stress expressed in deformation per unit length or percent change

What are myofibroblast and why are they unique?

derived from fibroblasts and are responsible for the synthesis of collagen, elastin, reticulin, and ground substance most often seen during tissue repair

nuclear chain fibers

detect static changes in muscle length slow changes tonic muscles

What are the different components of the viscoelastic model of connective tissue?

elastic component viscous component

Elastic or toe region

elastic component of connective tissue temporary length changes in the tissue

What is the role of endomysium and perimysium discussed in biomechanics of muscle?

endomysium closely approximates the individual muscle fibers perimysium provides both a cushioning effect through force transmission, and a stiffening effect in tonic muscles

Flowers and Pheasant study

examined the results of immobilizing the PIP joint of healthy physical therapy students using an external cast for 1, 2, 3, 4, 5 and 6 weeks. No significant difference was found between the groups. All of the joints easily regained full passive flexion using 16 oz of pressure for 20 minutes

Hyperalgesia

excessive sensitivity to painful stimuli from changes in the dorsal horn and peripheral sensitization

Healing time can be predicted using

extent of the injury type of injury type of tissue state of health age

Upper thoracic area position with forward head position

facets are in forward bend position with posterior myofascial structures on stretch

Upper cervical and sub-cranial area position with forward head position

facets joints are in down and back position/backward bent—compression of the facet joints can lead to hypomobility and shortening of the posterior myofascial structures

How does fascia act as a force transmitter?

fascia is a continuous tissue -acts as energy broker -stores PE -restrictions decrease efficiency and force muscles to work harder

Lateral compartment muscles

fibularis longus fibularis brevis

Mast Cells

found in the connective tissue of the dermis; respond to injury, infection, or allergy by producing and releasing substances, including heparin and histamine

What trigger points mimic sciatic nerve pain?

glute min piriformis

What are the characteristics of the granulation phase?

granular look due to capillary buds formation macrophages and histiocytes debride the area fragile tissues (immobilize) easily re-injured (avoid excessive movement)

Where are myofibroblast located in the body?

granulation tissue normal human fascia, fascia lata, plantar fascia, lumbar fascia

Lower extremity posterior quadrant fascial elongation

grasp pt ankle proximal to malleoli slightly flex and IR hip Distract leg as a slow progressive stretch during this slowly adduct and flex hip across the body done 2- 3 times takes 3-4 mins each time *Used for pt with fascial restrictions due to the entire posteriorlateral chain, elongate the superficial fascial sheaths* reassess posture and functional limitations

Central sensitization

hypersensitivity leads to increased responsiveness to non-painful stimuli and increased pain response evoked by stimuli outside of the injury site (expanded receptive field) -Changes in dorsal horn -Allodynia

erector spinae group

iliocostalis, longissimus, spinalis

Physiologic fixation

impaired ROM voluntary or involuntary muscle guarding following -tendonopathy -non-specific low back pain -headache or neck pain -unsecured or braced sprain

Give at least three primary effects of soft tissue mobilization for muscle tissue:

increase in blood flow increased metabolism changes in scar healing and collagen distribution

What chemicals may be associated with increased autonomic activity in the motor end plate of trigger points?

increased levels of norepinepherine and serotonin (Shah)

What trigger point mimics C6 n distribution? (radiculopathy, carpal tunnel)

infraspinatus

Which theory explains the short-term vs long term changes in the connective tissue?

intrafascial circulation loop

What were the causative factors of joint pain that were outlined by John Mennell?

intrinsic joint trauma immobilization (therapeutic, disuse, and aging) Healing of a more serious pathological condition in the msk system

Kenneth Snelson

involves compression-resistant structures and tensile-resistant structures that are organized in a way that prestresses them

Free Nerve endings joint receptors (Wyke's)

location - fibrous joint capsule, fat pads, ligaments, and walls of blood vessels High-threshold, non-adapting pain receptors

Golgi-Mazzoni Corpuscles

location: joint capsule sensitivity: compression of joint capsule most active at extreme positions of flexion/extension or other movements that stress ligaments primary distribution: knee joint, joint capsule

Immobilization results in:

loss of ground substance collagen cross link formation loss of sarcomeres loss of tissue nutrition and blood supply disuse atrophy pain (can happen in 4-10 days)

What are the effects of immobilization in muscle?

loss of sarcomeres decline of muscle fiber diameter fibrotic damage of myofibrils

General restricted motion results

loss of sarcomeres degeneration of cartilage loss of ground substance, glycosaminoglycans, loss of lubricating effect binding of fascial elements loss of nutrition and blood supply to region impaired

What makes up the reticuloendothelial system?

macrophages, mast cell, plasma cell phagocytotic and immuno cells

Fibrocytes

mature version of fibroblast found in stable mature connective tissue

Lateral fascial distraction of the tibia

minimal deep prep pt prone rest lower leg on shoulder lateral/distal hand stabilizest he lower leg Manipulating hand: palm contacts mid-belly of gastroc/soleous as close to tibia without touching it and pushes muscle belly laterally *Used for stretching of posterior compartment fascia, lower leg compartment syndrome, shin splints* Reassess PF

Lateral elongation of peroneal tissue

minimal deep prep pt sidelying Stabilize on anterior side of proximal lower leg using fist or two finger contact to trace the peroneal muscles to distal of fibula *Used for elongating tissue on lateral leg, address restrictions that may develop between tib ant, ext digitorum, peroneus longus, and gastroc/soleous Reassess pain level, PF, and eversion Progress by adding in inversion

Tabery Take home message

muscle tissue adapt to the change in length/position of the muscle by altering the number or sarcomeres to put its own sarcomeres in optimal length muscle tissue adapts quickly to immobilization whether artificial fixation or physiologic

Where does the piriformis refer pain?

pain to sacrum and buttock

Akenson, Woo, Amiel

performed a number of immobilization studies using internal fixation devices. One of their most significant studies analyzed tissue samples after nine weeks of immobilization. In a nutshell, the immobilized tissue appeared dry and less glistening than the control tissue. It resembled aged tissue. Fibrofatty infiltrate was found in the capsular recesses with the potential to create intra-articular adhesions with maturation.

Piriformis elbow direct pressure

place proximal 1/3 of forearm over piriformis apply slow increasing pressure as the muscle relaxes and pain decreases can move hip ER/IR to increase effectiveness *Used for hypertonic piriformis, piriformis syndrome* Targets: piriformis

20. Describe Janda's upper cross,

posterior short/tight tonic (upper trap and levator scap) phasic scapular stabilizers (low and mid trap) and anterior postural musculature (SCM, pec major/minor) weak inhibited phasic scap stabilizers (low and mid trap) and weak cervical neck flexors

What are the similarities and differences in direct and indirect insertions?

presence of superficial and deep fibers junctional zones of ligament, tendon, and capsule are relatively avascular compared with the tissue on either side of the zone

Plasma Cells

produce antibodies present in infectious conditions

QL superficial elongation

pt arm is moved to full flexion and then legs are then moved off the table PT distal hand is placed on proximal QL proximal hand is placed on distal QL (arms crossed) PT leans down and attempts to pull apart QL Targets: *QL* tightness, pain and dysfunction, scoliosis on concave side, leg length discrepancy, SI dysfunction, weak hip abd, weak glutes/hip /

Compress and hold of piriformis

pt knee flexed to 90 degrees and slight ER at the hip (held with PT distal hand) Force is generated through the palm of the hand over the piriformis Sink and hold until muscle relaxes and move deeper as allowed *Used for hypertonic piriformis, piriformis syndrome* Targets: piriformis

pectoralis major muscle play

pt shoulder in 90-120 degrees flexion and IR. Can be placed on PT knee for support Thumbs go under pec major and it is grasped. Bend and lift muscle. (sustained hold or oscillatory) *Used to improve pectoralis major movement in surround fascia reassess shoulder movements

Tension

pulling force along the length of the tissue

Muscle Spindles

receptors sensitive to change in length of the muscle and the rate of that change

Muscle Spindles

receptors sensitive to change in length of the muscle and the rate of that change located in striated muscle Fiber type Aa Ia

Superficial, gentle soft tissue manipulation can produce the following effects

relaxation, release of muscle spasms, contraction or tension increase tissue temperature mast cell stimulation capillary dilation increase in blood flow increase in fibroblastic recruitment proper collagen fiber alignment

How does the viscous component of the viscoelastic model explain the characteristics of connective tissue when placed under stress?

represents permanent deformation -> part of length gained remains even after a period of time

How does the elastic component of the viscoelastic model explain the characteristics of connective tissue when placed under stress?

represents temporary change in length that occurs when it is subjected to stretch -> all stretch is lost over short period of time and tissue returns to original length

polymodal nociceptors

respond equally to all kinds of damaging stimuli response ranging from muscle guarding to inhibition of muscle

Pacinian corpuscles

respond to deep pressure and vibration Located in all skin and fibrous CT

Electrogenic muscle tone

resting muscle tone: no activity in EMG, but cross bridges form from endogenous shortening of sarcomere electrogenic spasm: involuntary contraction that is directly associated with EMG measurement from that muscle voluntary muscle contraction

Buckminster Fuller

rigid, compression-resistant frames int eh shapes of triangles, pentagons, or hexagons are fixed so as to produce continual tension across all members

What is intra-facial circulation loop theory?

ruffini organs and interstitial receptors are found within connective tissue and respond to *slow, deep, steady pressure delivered in a tangential direction.* manual stimulation produces changes in *tone, vasodilation, and local fluid dynamics via the autonomic nervous systems*

mechanical effects of soft tissue manipulation

rupturing fibrofatty adhesions and/or cross link formations between collagen fibers

What is end plate integrated hypothesis?

sarcomeres w/in the trigger point are hypercontracted & are transmitting increased resting tension through the neighboring sarcomeres Effectiveness of manual trigger point release via light pressure pinch/palpation while pt performing light contact/relax of affected muscle to return sarcomere to normal length is based on this hypothesis

What chemical levels are reduced in patients with fibromyalgia that contributes to central sensitization?

serotonin and norepinepherine

Choice of soft tissue technique should be determined by?

stage of healing effects of immobilization and how to best reverse it

Soft tissue manipulation will

stimulate ground substance production (rehydrates tissue) Maintain critical interfiber distance increase lubrication promotes proper collagen alignment

Progressive soft tissue manipulation and movement can

stretch out abnormal fibrous tissue release fascial adhesions restore proper tissue mobility and length prepare the tissue for improved movement patterns and function

What are the characteristics and examples of *loose connective tissue*?

superficial fascial sheaths, muscle and nerve sheaths, support sheaths of internal organs *greatest potential for change when manipulated*

Suboccipital muscles

superior and inferior oblique capitis Rectus capitis major and minor

How did Stanley Paris define "component motions" ?

those motions that occurring in a joint during active motion necessary for the motion to take play normally

Point of failure

tissue ruptures

Merkel's corpuscle

touch, light pressure Located in epidermis of hairless skin

How and when a fibroblast transforms in to a myofibroblast?

transforming growth factors B1 and mechanical stress are required for the transformation to take place fibroblasts first differentiate into *proto-myofibroblasts* by forming cytoplasmic actin containing stress fibers If exposed to growth factor and mechanical stress they will further differentiate into myofibroblasts

Immobility is due to

trauma habit patterns postures strain from over exercising metabolic factors Imbalances

Midcervical facet joint position with forward head position

up and forward position/forward bent—loss of lordosis with tendency toward hypermobility

What is a tensegrity structure?

used to describe architectural structures that are kept mechanically stable by distributing and balancing stresses; stability is not dependent on the strength of the individual members of the structure, but instead the combined effort of resisted compression and tension

Lateral sacral release bilateral with thumbs and fingers

used when you need to address both sides scrub superior to inferior (oscillatory) good prep for sacral manipulations *Used for SI pain, hip surgery, hip pain, trochanteric bursitis, buttock pain, leg pain, diffuse hip and leg pain proximal to the knee* Targets: fascia on lateral border of sacrum, glute max, piriformis

Cross Friction over ischial tuberosity

using finger tips, thumb, chisel grip Oscillate/scrub in a medial/lateral direction Used for patients with injury or dysfunction at the ischial tuberosity

Piriformis fingers two PIP

using two index fingers sink slowly into muscle with increasing pressure. Flex and extend wrist joint sinking deeper and deeper should be rocking whole body with this one *Used for hypertonic piriformis, piriformis syndrome* Targets: piriformis, glut max, glut med, glut min

What does Thixotropy explain about the plastic characteristics of the connective tissue?

viscous transition from gel to sol piezoelectric principle results in increased mobility of tissue as pressure that is applied to tissue disrupts the balance of charges, stimulating fibroblasts to produce collagen

Layer Palpation

visual inspection Light touch (temp, moisture, texture) Pull skin in all directions Skin roll/tissue rolling in all directions

Further results of restricted motion

weak muscle through full ROM Restriction in joints fascial restrictions self image/body language bony structure changes

What is creep?

when load is applied to a tissue over a prolonged time, gradual elongation occurs

What is the "leg carry trunk" model?

when tissues become restricted and more rigid, they lose their ability to absorb energy. ex. running in sand

Point of Yield

where deformation becomes permanent

extensor digitorum longus

§ Attachments: • Proximal: lateral tibial condyle, superior fibula • Distal: phalanges 2-5 § Action: DF, toe ext

How would you define posture?

• Posture can be defined as balance and muscular coordination and adaptation with minimal expenditure of energy. It is the position the body assumes in preparation for the next movement; it is not necessarily a static position. Posture is dynamic, requiring muscular forces and creation of connective tissue tensions