Soft tissue FINAL
According to the proper treatment sequence, what should you start with an why?
1. Apply soft tissue manipulation first; direct before indirect, superficial to deep. Treat restrictions within tissue. Once the restriction is found, directly manipulate restricted tissue superficial to deep. If the patient does not tolerate direct (mechanical) manipulation for any reason then apply an indirect (autonomic) technique. Do not think this negates the need to take a few minutes to apply Hoffa's effleurage as discussed in Unit 1. You still need to prepare the tissues for deeper techniques
What are hypo-echoic nodules?
"Knots" Many trigger points in one area, that changes muscle pressure, due to ischemia
Set you patients up for success and minimize his/her frustration by applying the following treatment sequence: Describe the main sequence
1. Apply soft tissue manipulation first; direct before indirect, superficial to deep. 2. Apply joint mobilization after the myofascial tissue has been normalized. 3. Elongate joint and myofascial tissues. 4. Provide neuromuscular 5. Provide postural instruction for long-term self-care.
What are 3 different types of stress?
1. Tension: pulling force along the length of the tissue a. Ex: whiplash injury 2. Compression: stress is applied along the length of a tissue, causing the tissue to decrease in length and increase in perimeter a. Ex: forces on the IVD of the spine in the upright position 3. Shear: when one part of a tissue slides over another a. Ex: when L5 slides forward over S1
In immobilized, nontraumatized joints, the stress deprived CT cell can change in as little as how many days?
4-10 days
What are the 5 major features of a trigger point based on which excellent interrater reliability was established? p.130
5 Major Features Palpable taught band Tenderness Local twitch response Referred pain Reproduced pain
What is end plate integrated hypothesis? 147
A trigger point release involves sustained pressure applied to the trigger point as the pt contracts. This technique is based of of this hypothesis which states that sarcomeres within the trigger point are hypercontracted and are transmitting increasing resting tension through the neighboring structures This pressure calms the area down and this relaxation is when the sarcomeres return to their regular position
What is the connective tissue proper?
Abdundent throughout body and forms superficial and deep fascia. Base of skin and supporting framework for organs, adipose tissue and nerve/muscle sheaths.
What is a muscle play?
Ability of the muscle to expand and move within its compartment independent of joint movement or voluntary muscle contraction
Skeletal or striated muscle is constructed by what contractile proteins?
Actin and myosin filaments. Form a sacromere.
What happens, according to the energy crisis hypothesis, when the calcium pump does not work?
Actin myosin filament becomes continuously activated since calcium is increased
What technique is used for better acuoustic production and TMJ disorders as well as mandibular position?
Alexander
How do you perform the anterior fascia elongation, of the arm?
Anchor in anterior thorax, near distal ribcage. Arm is overhead in flexion and abduction. Distal arm pushes towards the umbilicus, and the other arm is pulling the shoulder in flexion and having a distraction force. (TAKE IT SLOW) Make it more aggressive by having ipsilateral knees go to other side
What is the purpose of ACTIN?
Another fluid component of myofascial tissue is actin. Although actin certainly comprises a large complement of muscle itself, it is also abundantly present in noncontractile fluid and serves cell motility and intracellular structure functions. This protein is actually fluid in its purified form and, much like syrup, will form strings when picked up on a glass rod or other stirring devi
How does the forward head posture affect the ribs? Elevation of first rib.
Anterior and posterior restriction of first rib articulations = Tendency for TOS
Muscle pain activates what part of the brain?
Anterior cingulate gyrus
What happens to the tissues for a person with forward head posture?
Anterior superficial fascia has adapted to a shortened position, applying effort to achieve and maintain an erect posture
What is a DIRECT myofascial release?
Application of slow, controlled mechanical stress. They supply directly into restriction. PASSIVE OR ACTIVE
How can you reverse the effects of immobilization?
Applying controlled stresses to tissue can reverse the effects of immobilization.
What is a tensegrity structure?
Architectural structures that are kept mechanically stable by distributing and balancing stresses Describes the balance of forces mobbing back and forth between structures (forces moving from muscle to connective tissue to bone, etc)
Describe the mechanical approach to myofascial manipulation
Attempt mechanical changes in myofascial by direct application of force
What soft tissue manipulation approach is intended to produce a therapeutic effect through the autonomic nervous system?
Autonomic/reflexive
How are trigger points identified?
Both latent and active trigger points are identified through palpation, both produce motor, sensory and autonomic changes within the muscle and both refer pain according to a specific pattern.
According the Alexander, new postures and movement patterns are done through what?
Both tactile and verbal feedback. Instructions promote slow, deliberate learning through positive feedback.
What is Neural tension soft tissue manipulation?
Butler, Elvey. MF techniques for treatment of peripheral entrapment neuropathies...
What are the components of myofibroblast that is responsible for its contractile ability?
Contractility is due apparatus consisting of actin microfilaments and non-muscle myosin. Identified in tissue by expression of alpha-smooth muscle actin, a common and reliable molecular marker
What is the best treatment for a tissue in the fibroplastic phase of healing?
Controlled movement will cause the fibrils to align lengthwise along the line of stress of the healing structure. Gentle manual therapy Soft tissue mobilization designed to break up scar tissue will inflame the wound, leading to further deposition of collagen
According to the cycle of fibrosis, it begins with a Chronic, low-grade irritant that triggers an inflammatory response. As the area is inflammed macrophages begin to do what?
Debride area as they would a normal healing process
What is strain?
Deformation or change in length that occurs in a tissue in response to a stress Compares change in length vs. normal length
What technique is characterized by the following? Application of slow, controlled mechanical stress. They supply directly into restriction. PASSIVE OR ACTIVE
Direct myofascial release
The Trager approach is directed towards what part of our brain?
Directed towards unconscious mind of patient
What type of muscle spindles are responsible for relaying info regarding rapid change of muscle length. Also found in abundance in phasic muscles!
Dynamic nuclear bag fibers
What are the 3 types of muscle spindles?
Dynamic nuclear bag fibers Static nuclear bag spindles Nuclear chain fibers
What is a Disturbance, impairment or abnormality of the functioning?
Dysfunction
What is the difference between dysfunction and pathology? 183
Dysfunction: How PT's dx stuff: via a cluster of findings impaired/altered function/altered mechanics/palpable changes of integrity, increased/decreased mobility and autonomic changes B. Pathology: I. How MD's dx stuff: via a cluster of findings during their examination
How is connective tissue massage systematic and protocol oriented?
Each stroke performed 3 times with R first. lube never used. and using middle finger to treat Treat low back and sacral first.
What is the Gold Standard to differentiate taught bands from contracted muscle fibers
Electromyography
What is a taut muscle band?
Endogenous localized contracture within the muscle w/o activation of motor endplate
Briefly describe the endomysium, perimysium and epimysium
Endomysium surrounds each muscle fiber and fills the space between them. Perimysium forms a sheath around the fascicle as well as fills the spaces between them. Epimysium encapsulates the entire muscle providing a slippery surface between the muscle and fascia sheath surrounding the muscle.
When is the autonomous approach most useful?
Especially in acute patients, and is stepping-stone to mechanical work. Sub-acute for beginning and end of treatments
What is the significance of local twitch response during physical therapy dry needling?
Established that causing a local twitch response with a solid filament needle can reduce the concentrations of several nociceptive substances in the immediate environment of active trigger points
Describe the fascial sweater concept with ROLFING
Established that fascial network is continuous throughout the body and becomes denser and shorter as it heals Thickenings, if left untreated, can transmit strain in many directions and lead to distal restrictions
Describe the structure and characteristics of dense irregular CT
Ex. Joint capsule, aponeurosis, periosteum, dermis, fascial sheaths Dense, multidirection fiber resistance, more cells and ground substance.
What is the cutivisceral reflex?
Ex. Mom's warm hand on kid's stomach to remove stomach ache? With superficial touch, there is response through nervous system to influence variety of structures. (nuerons)
CT resists deformation and is capable of change. When is it commonly damaged?
Excessive or repetitive tensile stresses or shearing forces. Yields well to compressive forces used in massage
The following are characteristics of what disorder? Chronic, widespread pain, 11/18 pain points and sleep disorders. Along with severe fatigue, waking up tired despite a full night's sleep
Fibromyalgia. "*Not considered a true muscle pain syndrome"
What kind of patients would benefit from Mechanical techniques?
Focused on minimizing abnormal/dysfunctional movement patterns.
According to rolfing, functional disorganization are a direct result of export to the continuous force of what?
GRAVITY
What is the ground substance? What is the main function?
Gel-like medium in which fibers and fixed cells are suspended. ALLOWS nutrients and wandering cells to travel.
The gluteal region, is one of the 9 areas of tender point sites for fibromyalgia. Where in the gluteal region would you apply your less than 4Kg force to check for fibromyalgia?
Gluteal: Upper outer qudrant of buttock
What muscle can refer pain in the L5 S1 nerve root area?
Gluteus medius trigger points
What makes up the ground substance?
Glycosaminoglycans and water
What structures are extremely sensitive to changes in tension?
Golgi Tendon Organ
Due to this substances, dense capillary network it is key for cellular nutrition. What is this?
Ground substance
What is a Myofascial trigger point?
Hyperirritable spot associated with a hypersensitive, palpable nodule in a taut band of skeletal muscle.
Describe how forward head posture affects the muscles in the cervical spine and jaw.
Imbalance between SCOM, levator scap and traps. Imbalance between anterior cervical muscles such as suprhyoid and infrahyoid and posterior cervical extensors Hyperactivity of masseter and temporalis
According to the cycle of fibrosis, it begins with a Chronic, low-grade irritant that triggers an inflammatory response. How is the tissue mobility further inhibited, due to the myofibroblasts leading to a chronic problem?
Immature collagen form cross-links decreasing mobility, with lack of appropriate stress. Myofibroblasts migrate to area, and actin and myosin of structure shrink area to decrease movement. This produces another tissue strain and cycle continues
When does the inflammation phase occur after an injury?
Immediately after injury and continues for 48 hours.
The following are results of what? Loss of sarcomeres Decline of muscle fiber diameter Fibrotic damage of myofibrils
Immobilization of muscle
Describe collagen synthesis
In rough EP reticulum of fibroblast, which creates protocollagen, which links together Tropocollagen is release from cell in ECM, where it hydrostatically bonds with other tropocollagen The hydrostatic bond is replaced by covalent bond Fibrils mature into a collagen fiber
Quadratus Elongation and Stretch in Side Lying - Non aggressive
Indications: Tight QL
What is a myotendinous junction?
Insertions of ligaments, tendons and joint capsules
What is Mentastics in relation to the Trager approach?
Instruction is provided in active movements for the purpose of neuromuscular re-education and coordination. Once learned this technique should be used in daily life for to maintain freer movement, flexibility, tension relief and maintain more normal movement patterns
What are receptive fields?
Isolated areas of the skin that can be stimulated and the area that is perceived to be stimulated
Why is it important to go from the superficial layers of the tissue to deeper layers? (4 reasons)
It will be more comfortable for patient. Won't miss any layers of restriction or immobility It will be easier and more effective to work on deeper tissue You'll get more comprehensive treatment as you work through each layer.
How do you perform the transverse fascial stretch of the biceps?
Lightly scour biceps over humerus. Good with stretching and a prolonged hold. (3-5 sec) Move lateral to medial first, or you can do medial to lateral. ***Good for splaying neurovascular bundle in anterior arm, and for median nerve.
During the inflammation phase of injury, what cells fight bacter?
Local leukocytes
What are some examples of phasic muscles?
Longus colli, scalenes, longus capitis Lats Mid/lower trapes Rhombs UE extensors ABS Glutes max,med Vastus medialis Dorsiflexors
Where are Muscle spindles and GTO's located?
MS: Areas of striated muscle GTO's: Suspended, interwoven or wrapped in CT
What are wandering cells?
Macrophages, leukocytes, plasma and mast cells, which migrate in and out of CT.
What kind of cells constantly move through tissue and release anticoagulants, heperin, into the blood stream?
Mast cells
What soft tissue manipulation approach aims to correct aberrant postures, restoring muscle balances, reducing abnormal stresses on tissue/joints and improving inefficiency of movement?
Movement approach
Describe sequencing of treatment for soft tissue mobilization
Myofascial manipulation of involved and regional areas... Direct before indirect and superficial before deep Joint manipulation after treatment of myofascial structures Neuromuscular reeducation Postura linstruction
What is the primary diagnostic criteria of myofascial pain syndrome?
Myofascial trigger points
What are the definitive medical tests to diagnose FMS?
No definitive medical tests Medical work-up including imaging and bloodwork are most often normal
What are thermoreceptors? What is there function?
Non-specialized sense receptors , or receptrive portion of a sensory neuron, that codes absolute and relative changes in temperature, primary within the innocuous (non-painful) range
What muscle spindles are responsible for relaying information regarding slow change in muscle length and are heavily concentrated in tonic or postural muscles?
Nuclear chain fibers
The occiput, is one of the 9 areas of tender point sites for fibromyalgia. Where in the occiput would you apply your less than 4Kg force to check for fibromyalgia?
Occiput: Suboccipital muscle inerstions
What are the 9 tender point sites in relation to fibromyalgia? (Bilaterally makes 9)
Occiput: Suboccipital muscle inerstions Low cervical: Anterior aspect of C5-C7 intertransverse spaces Trapezius: Midpoint of Upper boarder Supraspinatus: At orgins, above spine of scapula Second Rib: Second costochonral junction Lateral epicondyle: 2 cm distal to epicondyle Gluteal: Upper outer qudrant of buttock Greater trochanter: Posterior to tronchanteric prominence Knee: Medial fat pad proximal to joint line
Postural or Phasic: Glut med/max/min, Vastus medialis
Phasic
Postural or Phasic: Longus coli, capitis, scalenes, Lats
Phasic
Postural or Phasic: MId trap, Rhoms, UE extensors
Phasic
Tonic or Phasic: respond to dysfunction by becoming inhibited.
Phasic
What muscles can refer pain in area of SI joint pain?
Piriformis
What is the result of passive tension on our CT?
Poor attenuation of forces in viscoelastic structures Tissue held in shortened range Loss of sarcomeres in muscle
Mid-Thoracic Lamina Release with Rotational component
Previous techniques emphasized the scapulothoracic and scapulahumeral relationships and musculature. This technique penetrates to the depth of the paravertebral muscles, manipulating the muscles and, to a certain extent, the joints into a rotational direction. Pt. in SL. Contact with 3&4 fingers onto laminar groove, push shoulder post into spinal rot. Meet rot with location of laminar contact. Start at superior border of scapula and follow through to the bottom of the ribs coming slightly ant.
During the inflammation phase of tissue damage, prostaglandins are released from the cell membrane and serve what purpose?
Produce pain to limit movement and further damage from the tissue
What are symptoms of latent trigger points?
Produce symptoms only when stimulated or stressed via palpation, contraction or stretch
What is the purpose of the Trager approach?
Provide increased mobility to tissue and give movement sense of effortlessness.
According to the proper treatment sequence, we should start with applying soft tissue manipulation first, then applying joint mobilization after the myofascial tissue has been normalized. Then elongate joint and myofascial tissues, and then do what and why?
Provide neuromuscular reeducation exercises. Retraining of weak muscles is performed to gain optimal muscle control and balance for restoration of correct movement patterns. This may be done through isolated exercise/stretching, PNF techniques or specific functional tasks
What is the best psychological interventions for patients with fibromylagia?
Psychologists are able to give the patient life skills to deal with their pain. Refer patient, very important
Termination of muscle contraction is normally accomplished by pumping what; on a physiological level?
Pumping calcium against a large concentration gradient into cytoplasm
How do you perform the muscle play of forearm?
Push down on forearm, and push medial muscles off radius. Can do medial or lateral.
The thoracolumbar fascia provides support to what muscle? What ligament?
QL and erector spinae are encapuslated within a seperate fascial sheath Iliolumbar ligament.
James Mennel, stated that there are what 2 possible effects of massage?
Reflex (Autonomic) Mechanical
What is the autonomic purpose of soft tissue techniques?
Release of muscle spasm, contraction or tension
What are the characteristics of phasic muscles?
Respond to dysfunction by becoming inhibited
How do you perform a scapular/thoracic laminar release with thoracic rotation?
Rotate pt back, by retracting scapula, while your other hand is pressed on lamina, as you rub down, mainly using digits 3rd and 4th. Make sure that you go all the way down to T12
Where are collagen fibers synthesized?
Rough endoplasmic reticulum of fibroblasts, where amino acids form into polypetide chains.
Describe the Akeson, Amiel and WOO histological study...
SAYS THAT ALL CT responds the same way to immobolity. Post immobilize has loss of ground substance and cartilage. Therefore soft tissue helps to prevent loss of sarcomeres and ground substance.
How does the pain threshold change with LATENT trigger points?
Sensory changes in pain threshold did not involve the skin. Only the muscle
The autonomic or reflexive approach is based on the use of what?
Sensory receptors in the skin and superficial fascia to affect specific areas related to corresponding dermatomal patterns
What is layer syndrome a sign of?
Severe and deeply fixed central motor deregulation accompanied by very bad movement patterns. With very unstable low back
What are the symptoms a patient would complain of if they had fibromyalgia?
Severe fatigue, widespread pain. Waking up tired despite a full night's sleep
What is the typical sex, age and healing stage of fibromyalgia?
Sex: Women 7x greater then men Age: Childbirth age around 20-50 and pre-menopausal Healing stage: Chronic > 3 monts
What is the typical sex, age and healing stage of myofascial pain syndrome?
Sex: non-specific Age: non-specific Healing stage: acute to chronic
Describe the lower postural crossed syndrome
Shortened trunk extensors (ES) Shortened hip flexors (iliopsoas) Inhibited ABS and Gluteal muscles
What does the end plate noise tell you?
Shows trigger point irritability and expresses sympathetic dysfunciton
What may prevent or at the least minimize the development of intra-articular adhesions?
Small inter-articular movements
What is the difference between common and special properties of adult connective tissue proper?
Special: Reticular, Adipose and pigmented Common: Dense, regular and irregular vs loose irregular
How do you perform the bilateral upper thoracic release?
Start at about T4, and the power fingers and in the laminar groove. Palms are in the upper trapezius region, and you are rocking back and forth, while incorporating a P/A force, even so the feet are rocking. Work up towards the next level. Fingers are extending and flexing as you rock.
Describe the soft tissue intervention assessment, before working with a patient
Start with a structural inspection, looking at forward head posture, arch height, rotation components, scoliosis and shoulder height Then begin palpating structures, such as acromions vs. inferior scapular boarder. Palpate height of iliac crests, PSIS to ASIS (1 in), PSIS to PSIS, Fibular heads, navicular tuberosities and arches After look at AROM, starting with general trunk flexion, extension, rotation and side-bending. Look for tonic bands, shaking and juddering. look at QUANTITY< QUALITY< SYMPTOM Behavior (pain) Integumentary check, looking at skin for moles. Then check skin temperature with back of hand. (should be warm near heart and lumbar spine) Then assess skin and mobility (glide hands from medial to lateral on skin, and superior/inferior) Skin lift, lift 1 level at a time, to see how much it lifts off Skin rolling, and feel for any limitations
What type of muscle fibers or responsible for relaying information regarding tone?
Static nuclear bag spindles
What are the advantages of autonomic techniques? (3 advantages)
Stepping stone to more aggresive mechanical techniques. Good for acute and sub-acute Good to start or end treatment for relief and reduce muscle guarding as it is lighter and makes patient feel good.
What are the 4 different junctional/transitional zones of the spine?
Subcranial region Cervicothoracic region Thoracolumbar region Lumbosacral region
What are some common examples of mechanical approaches?
Superficial tissue rolling to mobilize adhesions (cross friction) Elongation of a superficial fascial plane Stretching of a muscle
The supraspinatus, is one of the 9 areas of tender point sites for fibromyalgia. Where in the supraspinatus would you apply your less than 4Kg force to check for fibromyalgia?
Supraspinatus: At orgins, above spine of scapula
What is a trigger point release therapy?
Sustained pressure applied to myofascial trigger point using a flat palpation, while patient performs gentle muscle contraction
Describe the structure and characteristics of dense regular CT
Tendon and Ligament Closely packed, parallel fibers, few fibroblasts, dispersed between fibers, little ground substance and resists tensile forces
Physiologic fixation could come by way of impaired range of motion, voluntary or involuntary muscle guarding following what pathologies?
Tendonitis Non-specific low back pain HA or neck pain Unsecured or braced sprain
What type of information does GTO's transduce?
Tension on tendons
The affects immobility has on muscle tissue are dependant upon the what?
The affects immobility has on muscle tissue are dependant upon the position of immobilization, (lengthened or shortened) as well as the type of immobilization (passive or active).
Anterior Fascial Elongation of the Superficial Fascia
The anterior fascial planes are often restricted, especially in the slumpedposture or invariousshoulderpathologies. The purpose of this technique is to elongate the superficial fascia sheaths of the anterior thorax. Pt. supine, flex arm and support it with your Iliac Crest. Apply a slight distraction of the arm. Then place pressure on the chest to elongate the skin. Should be a fascial burning sensation. Do different angles
According to the cycle of fibrosis, it begins with a Chronic, low-grade irritant that triggers an inflammatory response. As normal macrophages debride the area, and there is increased vascularity. Fibroblasts then synthesize immature collagen and lay down in what fashion, which may cause issues due to lack of appropriate biomechanical stress of a chronic irritant?
The immature collagen fibers are laid down in a haphazard formation and remain random due to the lack of appropriate stresses.
The inflammation phase of injury begins immediately after an injury and continues up to 48 hours. What psysiological factors happen at the injury site?
The injury disrupts the local mast cells resulting in a release of histamine and subsequent vasodilation. Vasodilation increases tissue permeability and enables an influx of exudate, which temporarily seals the wound. Released prostaglandins cause pain, which also results in a type of natural casting. Local leukocytes begin the process of phagocytosis as macrophages begin to infiltrate the area. Additional cells such as plasma cells begin to migrate to the damaged area The increase of cellular activity necessitates supporting vascular structures.
According to the 1972 study by Tabery, what was found about the change in sacromeres in series, for a cast in a lengthened position?
The limb cast in a lengthened position produced 19% more sarcomeres in series.
Forward Bending Laminar Release (better for pt. with stenosis or pregnant) Quadruped
The purpose of this technique is to elongate the posteior soft tissues of the lumbar or thoracic spines. This technique may serve as an alternative to the forward-bending laminar release in side-lying position. If the patient is too large for the therapist to manage in side-lying, the quadruped position may be used. Specificity is sacrificed somewhat in order to gain some mechanical advantage One advantage to this technique is that the patient actively participates rather than remaining passive. Quadruped: use of power grip (contact with middle phalanx and thumb), you can have pt. bring butt down to feet as you go down/up (pillow on ankles). Similar to active release technique (ART)
Bilateral Upper Thoracic Release
The purpose of this technique is to release the deep paravertebral musculature of the upper thoracic spine. The technique is accomplished in two distinct maneuvers, The first is moderate depth, cephalic—caudal movement, and the second is a deep anterior—posterior movement. Don't need a lot of lotion. Supine PT seated at top of table, scoop hands down to T4, start with Bilat rocking to find rhythm then start doing a P/A with fingers in the Lamin—start working upwards slowly when release is felt (only the thoracic spine)
Subscapularis
The subscapularis is generally not an area reported by the patient to be painful; however, the area may be significantly restricted and extremely tender to palpation. Because the internal rotators are held in a shortened position during the forward-head, protracted-shoulder posture, the subscapularis and the surrounding myofascia become restricted, acting as barriers to efficient postural reeducation, Pt. supine, flex arm and support it with your Iliac Crest. Flat hand contact to the lateral portion of subscapularis. Direct hold, cross friction. If fingers are too pokey you can use the heel of your hand—good for if they are really sensitive)
Briefly describe the granulation phase
The tissue takes on a granular look as capillary buds form. Although the wound has been contained now for some time, the tissues are still fragile and could be easily re-injured, starting the inflammation process all over.
What term describes the stiffness of a fluid that is dependent on the history of movement? Physical property of muscle and other CT
Thixotrophy
True or False: Myofascial pain characteristics does not follow dermatomal, myotomal or sclerotomal patterns
True
Describe Myofascial release
Two distinct styles of MFR exist: direct/indirect Direct: intent to improve the mobility of soft tissue through application of a slow, controlled mechanical stress directly into a restriction, as pressure is gradually increased Indirect: applied similarly with a drastic difference in the amount of force used ● Lower in intensity, longer in duration, to give tissue time to, "melt" and considered gentler to reduce guarding BY WARD, CHILA AND PECKMAN
What type of collagen fibers are located in the bone, CT proper and are highly resistant to tensile forces
Type I
What type of collagen fibers are rich in proteoglycans and are located in hyaline cartilage?
Type II
Tissue damage usually heals in a linear fashion. Healing process may become cyclic, when what happens?
Typically due to overuse or structural imbalances that resulted in improper biomechanics. fibrotic tissue develops
How does layer syndrome affect the anterior musculature?
Weak rectus/TA Hyperactive obliques
What are some things to consider when observing posture?
What is patient's body type What are their fulcrums and levers in relation to long waist, legs, or where they bend? Ex. of tissue hypertrophy/atrophy Are muscular imbalances more superior or left vs. right..
What is creep?
When a load is applied to a tissue over a prolonged period of time, as in progressive stretching to allow for gradual elongation. A lesser load over a greater period of time will produce a larger amount of creep and less tissue stiffness
What is the clinical application of the viscoelastic model and the stress strain curve?
When a restricted joint capsule is stretched, you can achieve a certain increase in ROM post treatment session. When the patient returns on their next visit ROM is greater than the original, but less than that achieved at the end of the previous treatment THAT ROM lost is due to the elastic component
Describe the basic neurology of CT, and how afferent information changes signals
When abnormal afferent information is provided there will be an abnormal efferent response... Mechanoreceptors closely knit to CT. Signals are altered when CT becomes fibrotic Abnormal firing patterns, muscle inhibition and abnormal movement patterns result
What are the functions of grund substance?
a. Diffusion of nutrients and waste products b. Provides a mechanical barrier against invading bacteria and microorganisms c. Maintain the critical interfiber distance Ground substance can maintain the distance between fibers, preventing microadhesions and maintaining extensibility
16. How and when a fibroblast transforms in to a myofibroblast?
a. Fibroblasts are responsible for synthesis of collagen, elastin, reticulin, and ground substance Fibroblasts, which are protected in ECM, may get injured, and when protection is jepordized they differentiate into myofibroblasts through a 2 step process
How does exercise influence patients with fibromylagia?
aerobic exercise caused patients to rate themselves as much better in 3 months time, decreased number of tender points, and improved scores using the Fibromyalgia Impact Questionnaire
Connective tissue utilizes two physical properties: What are they?
elasticity and viscosity.
What muscles can refer pain in area of lumbar radiculopathy?
gluteus minimus
Describe the role of mast cells
i. Mobile and important defensive cells ii. Formed primarily in loose connective tissue iii. Responsible for constantly secreting small amounts of the anticoagulant heparin
What are the structures palpated in an examination from superficial to deep? 195
skin, subcutaneous fascia, blood vessels, mm sheaths, mm bellies, musculotendinous junctions, tendons, deep fasica, ligaments, bone, and joint spaces
What are some commonly taught PNF techniques?
▪ Rhythmic initiation, rhythmic stabilization, contract-relax, hold relax
After there is pain reduction including manual inhibition pressure, spray and stretch and dry needling, what should treatment include for areas of myofsacial with trigger points? (6 things)
1. restoration of tissue mobility, 2. restoration of joint restrictions, 3. elongation of joint and myofascial tissue, 4. neuromuscular re-education and 5. postural correction, but more on this in Unit 6.
What two factors and steps are required for a fibroblast to transform to a myofibroblast?
2 factors 1. Transforming growth factor-Beta1 (TGF-B1) [primary factor] a. Produced from platelets, macrophages, parenchymal cells, injured epithelial cells 2. Mechanical stress ***most often seen during tissue repair ii. 2 step process: 1. Fibroblasts first differentiate into proto-myofibroblasts 2. If continually exposed to both TGF-B1 and mechanical stress, the proto-myofibroblasts further differentiate into a myofibroblast, gaining the ability to contract
What are the two types of tensegrity structures?
2 types i. Rigid, compression-resistant frames in the shapes of triangles, pentagons, or hexagons are fixed so as to produce continual tension across all members Involves compression-resistant structures and tensile-resistant structures that are organized in a way the prestresses them 2. The compression-resistant structures provide tension on the tensile-resistant, and the tensile-resistant structures provide compression on the compression-resistant, each balancing out the other 3. Benefit: provides both strength and movement and can be applied to nature and to the entire human body
Describe the epidemiology of fibromylagia.
2% of US. Women 7x > Men 20-40 y/o
What is the prevalence of fibromyalgia and what is the main characteristics?
2% of adult population in U.S chronic, widespread pain and sleep disorders. **11/18 pain points
What does the results say about the ground substanace within CT, following immobilization?
30% decrease in chondroitin-4 and 6 and 40% decrease in hyaluronic acid. HA results in loss of water content
How much is the half-life of collagen?
300-500 days, in mature nontraumatized conditions
Describe the 3rd, 4th and 5th layers of layer syndromes of the posterior spine
3rd layer: Hypertrophic trunk extensors Layers 4: Hypotonic scapular stabilizers, lower to mid thoracic spine Layer 5: Hypertrophic upper trapezius muscles
What % of muscle is fascia?
50-60%. Muscle play will stretch this fascia, and allow further muscle movement
Describe the autonomic approach to myofascial manipulation
: exert therapeutic effect on autonomic nervous system
The release of cross-bridges for muscle contraction is dependent on what factors?
ATP Titin Nebulin Niacin
What muscles would be affected by the iliac creast release?
Abdominals, QL, multifidus and paraspinals
How does the student learn the alexander technique?
Activate their primary locus of control in the head and neck and keep it functioning during ADLs.
How is muscle pain distinctly different than cuteaneous pain?
Activates specific cortico structures such as the anterior cingulate gyrus
In regards to muscle nociceptors, under non-pathological circumstances there is a dynamic balance between what?
Activation of dorsal form neurons and descending inhibitory pain modulating pathways which are very effective in inhibiting muscle pain
What are the symptoms of active trigger points?
Active trigger points produce symptoms constantly
Describe the diagnosis process for myofascial pain syndrome
Active/Latent myofascial trigger points
Ground substance is a medium for CT fibers and cells, what is the 4 main functions of ground substance?
Acts as lubricant for CT fibers Maintain interfiber distance to prevent adhesions Aids in nutrient diffusion Acts as mechanical barrier
What are the contraindications for dry needling?
Acute trauma/ hematoma Circulatory disorders (varicose veins, lymphedema) Skin lesions Infection or inflammation Unstable bone/joint Malignant tumor Uncooperative patient
For patients with acute myofascial pain syndrome, what causes decreases in ROM? What causes decrease in ROM in the chronic pahse?
Acute: Primarily due to shortening of muscle fibers, pain and kinesiophobia Chronic: Joint adhesions can further contribute to restrictions in ROm
What is autogenic relaxation?
Administration of sympathetic blocking agent reduces activity of muscle trigger points. Shows how trigger points are associated with autonomic nervous system
What is the recommendation for fibromyalgia aerobic exercise treatment?
Aerobic exercise at moderate intensity two-to three times a week Avoidance of exercise induced pain. Increase program very slowly
What is the best treatment for fibromyalgia?
Aerobic exercises with education about the condition, lead to improvements in mood. Decreased anxiety, pain and depression Improve feeling of well-being
What are the significant findings, after muscle immobilization according to the study of Tabery?
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.
According to the 1972 study by Tabery, what was found about the length of muscles after 4 weeks of immobilization?
After 4 weeks the limb that was allowed to recover rapidly re-adjusted to its original length.
When are wandering cells, macrophages and luekocytes found in CT?
After trauma, or during infection
In the Flowers and Pheasant study, they 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. What was found following passive flexion, using 16 oz of pressure for 20 min?
All joints easily regained full passive flexion
What is the Cornerstone of the Feldenkrais method?
All persons exhibit some abnormal movement either from previous trauma or old habit patterns
What is the mechanism of allodynia and hyperalgesia of a myofascial trigger point? P. 142
Allodynia is explained by the following changes of the dorsal horn Persistent nociceptive activity is a prerequisite Changes in the dorsal horn and peripheral sensitization can cause hyperalgesia
What is the purpose of the elastic nature of CT?
Allows for temporary deformation. Allows for spring of tissue. Can pull with stretch and recoils to original length when released
What is the purpose of the viscous nature of CT?
Allows tissue to absorb stresses but enables permanent change.
An ongoing barrage of nociceptors afferent information from trigger points into the dorsal horn can lead to what?
Alter responsiveness of the dorsal horn and lead to increased local pain or referred pain to other spinal cord segments
What is the main idea for Trager massage?
Alter the patient's neurophysiological set and give the pt the tools to maintain the changes Alter the neuromuscular set to establish more normal movement patterns
How can electormyography be used to treat muscle trigger points?
Although it is not gold standard to differentiate taut bands, it be used to: Assess and treat abnormal tension and dysfunctional movement patterns
When the ground substance losses hyaluronic acid and hydrophilic components, the collagen fibers begin to approximate due to decreased interfiber distance and lubrication. Does this factor prevent cross-link formation and decrease in tissue mobility?
Although the fibers approximate, their distance still remains too great to cross-link themselves, but it does not prevent newly synthesized fibers from lying down and cross-linking.
When organizing your treatment session, how should you sequence your treatment. Stretching and muscle elongation or exercise?
Always restore normal length before progressing the strength of tissues.
When organizing your treatment session, how should you sequence your treatment. superficial or deep techniques?
Always start superficial and most likely you may see a change in the deeper tissues as they may not be as restricted anymore.
When organizing your treatment session, how should you sequence your treatment. Direct techniques or indirect techniques first?
Always start with direct techniques at the target muscle, then you can try indirect techniques of surrounding tissues
Transverse muscle bending of the forearm
Analogous in theory to previously described muscle bending techniques,the purpose of this technique is to manipulate the forearm musculature in a transverse direction. This allows the contractile tissues to move more freely in their respective fascia] compartments Patient position: Supine. Therapist position: Standingor sitting at patient's side, using leg to stabilize patient's forearm. Hands: One hand stabilizes the forearm distally. The other hand gently grasps the flexor (or extensor) surface of the forearm. Execution: The palm of the hand pushes the muscle mass of the forearm firmly in a transverse direction through the elastic range and into the plastic range to encourage permanent deformation of the fascia (Figure 8.145). Multiple angles can be applied. For example,the flexor mass may be pushed away from or toward the ulna. The brachioradialis may be pushed anterior or posterior. The extensor surface can also be moved in either transverse direction.The therapist must"think with the hands" to determine where the restrictions are, and move in the direction of the restriction.
When performing your observation do so systematically and with a particular routine. For example, view the full body feet to head from what views first to last?
Anterior angle, then lateral angle then posterior angle. Facing patient in beginning lets them see what you are doing. Also easy to see structural abnormalities.
What happens to the tissues for a person with forward head posture?>
Anterior superficial fascia has adapted to a shortened position, applying effort to achieve and maintain an erect posture
What of the clinical concerns of forward head posture on diaphragmatic breathing? 187
Anterior thorax is in a shortened Accessory mm are facilitated which leads to an elevated first rib, a compromise of the costoclavicular space, and an increasing susceptibility to thoracic outlet-type symptomatology→ think big red and blue and where the brachial plexus is
According to the proper treatment sequence, we should start with applying soft tissue manipulation first, then doing what and why?
Apply joint mobilization after the myofascial tissue has been normalized. Once soft tissue restrictions have been released and the tissue moves more freely, re-evaluate joint mobs and treat if necessary. All too often, what is thought to be a restriction in the capsule is nothing more than a holding pattern of the contractile tissues. Once the soft tissue mobility has been normalized the joint restriction may still exist but maybe less severe or in another direction. Either way, your work as a therapist will be less strenuous and will most likely be better tolerated by your patient.
Briefly describe the Feldenkraise Method
Approach based on idea that movement abnormalities occur in response to past trauma, rendering one more susceptible to reinjury 2 basic approaches ▪ Experimental approach "awareness through movement" Pt receives a series of verbal commands designed to weaken old movement patterns and to establish new ones ▪ Hands on approach "functional integration"
Where are Pacinian Corpuscle located?
Area of hairless and hairy skin, fibrous periosteum of ligamentous attachments, and menisucs horns of knee
Where are Ruffini Corpuscle located?
Areas of hairless and hary skin, superficial layers of joint capsules and CT
Where are Meissner's Corpuscle located?
Areas of hairless skin and dense in palm of hands
How do you perform the subscapularis muscle play?
Arm is abducted and flexed up. Abduction pulls scapula out away from rib cage. Take hand and curl into the anterior lateral of the scapula. Use the thumb, if finger contact is too tender. Least aggressive is heel of hand.
Low grade irritation leading to the cycle of fibrosis is induced by what factors?
Arthokinematic dysfunction Poor posture Overuse Structural and movement imbalances
Muscle Play - Hamstrings
As described in the earlier section"Transverse Muscle Play of Quadriceps,"the concept of transverse muscle play can be used to manipulate the fascial sheath surrounding the hamstrings to provide more space for the hamstrings to contract and expand. Pt. prone, stabilize at the knee, then push across (med or lat) you don't have to lift the skin up on this one if too tender you can do a post or ant force and push/pull into the table—can do an oscillation (high level of pain) or a hold—can also use a dummy thumb to work out adhesions (parallel 1st)—use palm for force
What is the granulation phase in relationship to soft tissue repair?
As tissue produces vascular structures it takes on a granular look from the forming of capillary buds. Tissues are still fragile and could be easily re-injured, starting the inflammation process all over.
What is the best and worst type of treatment for a tissue in the inflammation stage of healing?
At this point, movement in this area would be disadvantageous and could lead to further tissue and/or clot disruption. Modalities aimed at decreasing inflammation, proper positioning, and appropriate anti-inflammatory medications are of the most value at this point
Describe the movement approach to myofascial manipulation
Attempt to change aberrant movement patterns and establish more optimal ones
What is an Movement soft tissue manipulation technique?
Attempts to change abnormal movement patterns to establish more optimal ones.
What is the transverse muscle bend of the erector spinae used for?
Autonomic and mechanical effects to release adhesions and increase tissue mobility. Muscle and surrounding fascia no longer resist motion and are able to benefit from additional strength and proprioception training.
What kind of technique is connective tissue massage?
Autonomic approach.
What are the autonomic dysfunctions associated with myofascial trigger points?
Autonomic components are affected by vasoconstriction, vasodilatation, a local twitch, sweating or a feeling of nausea.
What are 3 categories of approach to myofascial manipulation?
Autonomic/reflexive Mechanical Movement
What is the Feldenkrais 2-system approach to improve functional awareness?
Awareness through movement and Functional integration
What is Feldenkrais, two system approach to improve functional awareness?
Awareness through movement, is often conducted in group lessons organized around a specific function Functional integration is a hands-on approach using tactile feedback to produce movements with less effort.
How can forward head posture affects the upper cervical arthrokinematics and muscle length, along as the nerves in the area?
Backward bending or extension of occiput on atlas Shortening of sub-occipital muscles result in in impingement of greater and lesser occipital nerves
What are some results of forward head posture?
Backward bending or extension of occiput on atlas Shortening of sub-occipital muscles result in in impingement of greater and lesser occipital nerves Forward bending of midcervical facet joints Cervical imbalance with a tendency toward a degenerative joint disease from C5-C7. Imbalance between SCOM, levator scap and traps. Imbalance between anterior cervical muscles such as suprhyoid and infrahyoid and posterior cervical extensors Hyperactivity of masseter and temporalis Shoulder girdle protaction with internal rotation Shortening with the shoulder girdle internal rotation with lats, subscapularis, pecs and teres major. Muscle imbalances leading to abnormal firing patternns
Posture is a state of dynamic equilibrium which includes what?
Balance Muscular coordination with adaptation with: Minimal energy expenditure and stress on non-contractile tissues Position that moves with body DYNAMIC
Describe the modified convergence projection theory proposed by Mense
Based on pathophysiological process of: Unmasking process of interneurons within the dorsal horn Interneurons are located in variuos segments, and pain is expereinced outside segmental innervation.
What is modified convergence projection theory and how does it explain referred pain?
Based on the pathophys unmasking process of interneurons within the dorsal horn Explains the idea of referred pain High concentrations of bradykinin was injected which increases pain and ischemia, static mm contractions, and inflammation The activity of the neuron corresponding with the receptive field has expanded, but the original injection point did not hurt as much Pain may be experienced in regions outside the segmental innervation of the myofascial trigger point, which distinguishes Mense's hypothesis from the conventional convergence theory
What is ground substance?
Basis for lubrication and diffusion of nutrients in connective tissues 1. Ground substance: the viscous, hydrophilic, gel-like medium in which the cells and fibers are embedded
What were the 3 different empahsis on, when considering the history of soft tissue from: Before 19th century: Early 20th century Mid to late 20th century: Present:
Before 19th century: Joint position Early 20th century: Mobility Mid to late 20th century: How MT effects the biomechanics of tissue Present: Neural mechanisms of back pain and movement reduction
Clinicians need to consider the early changes in the immobilized connective tissues and adjust their treatment plans accordingly. How should we apply stress to healing tissues?
Before 4-6 wks, weakened cells may require gentle mid-range movement and protection from excessive forces. After 6 wks, treatment should incorporate sufficient stress to induce CT remodeling to accommodate lengthened positions until full joint mobility is achieved.
What is the purpose of local leukocytes in the inflammation stage of healing?
Begin fight against bacteria. Macrophages continue the process of phagocytosis, and influence scar production
When observing posture, begin in what manner, and progress to what?
Begin globally from head to toe and progress to regional and specific areas
Briefly describe the inflammation phase of soft tissue repair
Begins immediately after injury for 48 hours. Disrupts local mast cells resulting in histamine release and vasodilation. Tissue permeability also increases, which allows influx of exudate and interstitial fluid to seal wound. Prostaglandins are released to produce pain to limit movement and further damage. Leukocytes begin fight against bacteria, macrophages continue phagocytosis and influence scar tissue Plasma cells begin to migrate into area to produce antibodies and body increases supporting vascular structures
4. What is the process of collagen synthesis?
Begins in fibroblast by absorption of amino acids in cells In Rough ER, amino acids synthesize into polypeptides chains Protocollagen from polypeptide is precursor of collagen Strands of protocollagen are linked into triple helix in cell to form strands of tropocollagen Tropocollagen is molecular unit of collagen and passes through cell membrane into interstitial space ECM, tropocollagen are linked in-series and parallel into collagen fibrils Collagen fibrils band together to form collagen fibers
If a person has a long waist how would they compensate?
Bends at low back more than at the hips
Briefly describe the maturation phase of tissue healing
Between 5 days to 5 weeks depending on the type of tissue, the maturation/remodeling phase begins. Although the wound is closed, the collagen is immature and has not yet reached its maximum strength. This phase may take 3 weeks to 12 months, again, depending on the type of tissue damage.
What kind of grip is used for the bilateral lamina release technique?
Bilateral thumb supported grip
How can botulinum toxin affect myofascial trigger points?
Blocks the release of acetylcholine from presynaptic cholinergic nerve endings Anti-nociceptive effects, by blocking CGRP from nerve terminals
What is intertwined within the irregular connective tissues?
Blood and nerve vessels
Which structures in the body are load bearing? Which are tensile components and provide stability to joints and absorbing forces?
Bones, which are solid component to body's tensegrity Myofascial element is tensile component
Which of the following is NOT a characterisitcs of myofascial pain? A. Dull and Aching B. Often deep C. Disturbed sleeping patterns with stiffness occuring later in the day D. With rest or motion E. Areas of local tenderness
C. Sleeping patterns with be disturbed, but stiffness is usually associated with morning stiffness.
What are the different schools of thought leading to soft tissue manipulation?
CT massage Hoffa Cross friction Rolfing PNF Aston Patterning Feldenkrais Alexander Traeger Neural tension
What is wolf's law?
CT, cartilage tendons, ligaments, and fascia as well as bone, adapt to stresses applied. **not just bone
What leads to the exposure of myosin actin binding sites, leading to formation of cross bridges and causes a muscle contraction?
Calcium ions are released from the Sarcoplasmic reticulum they trigger a shift in the position of tropomyosin in the muscle sarcomere
How do you perform the muscle splaying of the forearm? (sitting or standing)
Can be performed on extensors or flexor group. Ironing technique, which is full flat hand contact. Start superficial and run between flexor and extensor group. Then move to more powerful technique, you can me wrist into extension/flexion (antagonist) or into pronation to get supinator.
How does hypoxia cause myofascial trigger points?
Causes excessive local release of multiple nociceptive substances including CGRP, bradykinin and substance P
What are myofibroblasts?
Cells with ability to contract Derived from fibroblasts, responsible for synthesis of collagen, elastin, reticulin, and ground substance
Trigger points are not only the source of efferent nociceptor input, efferent barrage of input from joints and skin can also lead to what?
Central sensitization by unmasking of sleeping receptors and lowering threshold mechanosensitivity neurons
What are the advantages of the movement soft tissue manipulation technique?
Change abnormal movement patterns. Movement re-education. Useful when combined with other techniques.
How can physical therapy dry needling evoke a change in the muscle response?
Changes chemical environment of trigger point. Restores normal function of acetycholinesterase and acytlcholine receptors as part of muscle regenerative process
What physiological change does physical therapy dry needling cause in the muscle?
Changes the chemical environment of trigger points and restore normal functioning of acetylcholinesterase and the acetylcholine receptors as part of the mm regenerative processes Superficial stimulates a delt fibers, releases oxytocin, activate mechanoreceptors coupled with c-fibers afferents, or stimulate the anterior cingulate cortex Basically stimulates the central nervous to calm the area down
What are characteristics of loose irregular tissue?
Characterized by a sparse, multidirectional framework of collagen and elastin Contains a greater amount of ground substance per unit area Because of sparse concentrations of collagen, this tissue type is the most elastic and typically has the greatest potential for change when manipulated by external forces Ex: superficial and some deep fascia, muscle and nerve sheaths, and framework of the lymph system and the internal organs
What are the characteristics of ligaments which are dense regular tissues?
Check excessive motion in joints and guide joint motion Less consistent parallel arrangement b. Orientation of the collagen in ligament shows undulating configuration. (crimp) c. Ligament functions as a spring until all the crimp is straightened out, then becomes more tensile when collagen fibers are stressed
Recent research indicates pain experiences by Fibromyalgia, may be a result of what?
Chemical changes within the central nervous system resulting in a centralized hypersensitivity
Within the ground substance, what provides cohesiveness to tissue? What is responsible for lubrication and is extremely hydrophilic?
Chondroitin-4 and chondriotin-6-sulfate provide cohesiveness to tissue. GAG, hyaluronic acid (HA), is responsible for lubrication and extremely hydrophilic.
What are the findings that differentiate between chronic fatigue syndrome and fibromyalgia syndrome?
Chronic fatigue syndrome Show significantly lower blood perfusion in the brainstem Do not have elevated levels of substance P where and FMS does
Describe the cyclic cycle of tissue healing and how fibrotic tissue develops.
Chronic low-grade irritant --> Macrophage infiltration and activation --> Vascular support system increased --> Fibroblast infiltration and activation --> Increased collagen synthesis --> Myofibroblast infiltration and activation --> Connective tissue shrinkage --> Impeded movement, altered biomechanics --> chronic low-grade irritant
According to the cycle of fibrosis, it begins with what?
Chronic, low-grade irritant that triggers an inflammatory response
Fibromyalgia is not considered a true, "muscle pain" syndrome. It is a disorder characterized by what?
Chronic, widespread pain, 11/18 pain points and sleep disorders. Along with severe fatigue, waking up tired despite a full night's sleep
Describe the characteristics of the Hoffa massage and some techniques incorporated in Hoffa massage
Classical message techniques ---Effleurage: slide or glide over the skin with a smooth, continuous motion ----> Pressure light/moderate to stimulate the parasympathetic nervous system and promote relaxation ---Petrissage: lift, wring, or squeeze soft tissue in a kneading motion or press or roll the tissues under or between the hands ---Tapotement: series of brisk percussive movements following each other in rapid, alternating fashion
Based on the evidence, what physical therapy approach is considered best for the fibromyalgia?
Cognitive-behavioral therapy and pain science education will be huge for FMS patients. Also, massage for relaxation and strengthening due to likely sedentary behaviors secondary to pain.
What is the most abundent protein in the body?
Collagen
Ground substance is the viscous nature and high water content of ground substance that allows the lubricating qualities. When the GAG and water is removed the result from ground substance, what happens to collagen?
Collagen fiber approximation
What are the 3 types of CT proper?
Collagen fibers Elastic fibers Reticular fibers
What are characteristics of dense irregular tissue? Examples?
Collagen fibers aligned multidirectional to withstand multidirectional stresses Ex: joint capsules, aponeuroses, periosteum, and fascial sheaths
Within the loss of ground substance, there is a critical loss of water and lubrication. Why is this bad?
Collagen fibers begin to approximate, with a loss of critical interfiber distance.
Between collagen, elastic and reticular fibers, what has the strongest resistance to high tensile forces?
Collagen fibers, which have wavy resting shape.
Can carefully controlled stresses, positively change the metabolic and physical homeostasis of the tissue?
Collagen production is thus less haphazard, more organized, and laid down in a quantity and direction more suited to optimal tissue function, with controlled stress
What are the fibers of CT proper?
Collagen, Elastic and reticular fibers
Breifly describe the 3 types of CT proper
Collagen: Wavy, flexible but practically non-extensible. (STRONGEST OF THREE) Elastic: Thinner, branching fibers that are highly elastic Reticular fibers: Small branching fibers, that form mesh-like supporting framework
What was Freddy Kaltenborn's definition of mobilization?
Component of manual therapy referring to any procedure that increases mobility of the soft tissues and/or the joints
What modulates acetylcholine release? What causes it's release?
Concentration of acetylcholinesterase Influx of calcium ions in muscle cause it's release. From alpha motor nerve impulse to create calcium channel openings
What are the 3 important effects of connective tissue massage?
Connective Tissue Massage can be used to directly affect local, altered connective tissues. Connective Tissue Massage can be used to improve circulatory impairments in local tissues. Connective Tissue Massage can use specific neural pathways of the central nervous system to release nerve impulses to affected tissues or organs
What usually forms between the muscular sheaths of any muscles limiting mobility and causing pain?
Connective tissue adhesions
What is the function of collagen?
Connective tissue fibers are the basis for the mechanical support Collagen: Most tensile resistant and most common Wavy, flexible but practically non-extensible
What are the different Autonomic soft tissue manipulation techniques?
Connective tissue massage Hoffa
Describe the 2 common examples of autonomous approach
Connective tissue massage: Releases nerve impusles along specific CNS pathways. Directly influences CT that is locally altered. Sets general circulation in order Hoffa Massage: Classical effleurage, slide or glide over skin... petrissage.. Tapotement... massage never for more than 15 min.
What has the purpose to fill every nook and space in body and helps hold the body together and gives us shape and form? Also suspends and cushions viscera and vessels.
Connective tissue proper
How does cross friction help with tissue healing? How is it applied?
Considered a controlled irritant, resulting in micro trauma and an inflammatory response to promote healing. (Applied in perpendicular orientation to fibers)
What does the surplus of acetylcholine in the motor end plate cause?
Constant activation of muscle contractile system
What are the different metabolic and functional characteristics of Type IIM superfast muscle fibers?
Contains unique myosin configuration High glycogen content Lycolytic metabolism **jaw muscles** Very fast contraction time
Describe the superficial anterior fascia?
Continuation of posterior fascia, wraps around trunk and meets at linea alba, which attachs superiorly to xiphoid and inferiorly at pubic symphysis. Also anchors at clavicle, sternum, inguinal ligament and iliac crest. More mobile superior than inferior
What is the purpose of macrophages in the inflammation phase of scar tissue formation?
Continue the process of phagocytosis, influence scar production.
What is a trigger point?
Contracted sarcomere where the bond between the actin the myosin filament is not released after contraction. Muscle fiber is in constant state of contraction
What is crimp and what is its significance?
Crimp: responsible for the mildly elastic characteristics of ligament Allows more yield in the ligaments (than tendons)
What technique has a Primary effect on the non-vascular tissues such as tendons, ligaments, muscles, MT junctions? What is the goal?
Cross friction massage Trigger inflammatory process with controlled stress and help with healing process
What is the purpose of macrophages and leukocytes? (wandering cells)
Debride through tissue through process of phagocytosis. Consumes damaged cells, tissue, foreign objects and bacteria.
What is the treatment goals of myofascial pain sydnrome?
Decrease source of pain/sustained posture Look for underlying causes (posture) Restore muscles to normal length and tone Breathing exercises and relaxation techniques
Why does the diaphramatic technique affect the somatosensory system?
Decreased length of tissues can lead to increased activity from tension receptors Increased tension from GTO's can lead to central tendon of diaphragm to inhibit external intercostal mms on diaphragm Inhibitory signals over time result in reduced lung volume and CT would remodel to a new length
Where in the muscle/tendon is there decreased sacromere length and extensibility?
Decreased sarcomere length and extensibility at the MTJ Tissue is more vulnerable to tearing in terminal areas
Patients with trigger points will often complain of what?
Deep, poorly localized ache and in some cases burning or tingling.
The following describes which type of CT? Dense, multidirection fiber, more cells and ground substance. Resists multidirectional force
Dense irregular
What type of CT tissue has a greater proportion of ground substance which allows for movement and increased vascularity to heal faster?
Dense irregular CT
There is a superficial and deep fascia, what does the deeper layer usually comprise of?
Dense irregular connective tissue.
What are the 3 types of CT?
Dense regular Dense irregular Loose irregular
The following describes which type of CT? Closely packed, parallel fibers, few fibroblasts, dispersed between fibers, little ground substance and resists tensile forces
Dense regular CT
What type of CT is not highly metabolic, poor vascularized and requires more healing time, due to it's little ground substance?
Dense regular CT
What is the characteristics of dense regular tissue?
Dense, parallel arrangement of collagen fibers High proportion of collagen to ground substance and parallel arrangement account for the high tensile strength and limited extensibility Not highly metabolic and not very vascular, accounting for the increased healing time required after trauma Ex: tendon and ligaments
3. What is the "cutivisceral reflex" described by Elizabeth Dicke?
Describes how superficial touch can cause a response of the nervous system and influence a variety of structures you are not touching. ▪ Ex: how a mother's warm hand on a child who has a stomach ache can alleviate symptoms CMT can use specific neural pathways of the central nervous system to release nerve impulses to affected tissues or organs
What is energy crisis hypothesis?
Developed by Simons and Travell in 1981 Shark: long story short, decreased nutrition is going to have a negative domino effect on the normal function of muscle at the cellular level
Describe the history of Rolfing?
Developed by psychologist, Ida ROLF Fascial sweater. (if you have soft tissue restriction in R hip. That can influence problems in L shoulder) Realignment of body posture through systematic aggressive soft tissue work.
Describe the pyschological factors with diagnosing someone with fibromyalgia
Diagnosis of fibromyalgia may be a relief for some, because they have been given a label and explanation for their pain. It may be a significant blow to others, because there is no cure. It is a condition that needs to be managed.
What is the diagnostic criteria and confirmatory observation to identify myofascial trigger point? p.130
Diagnostic Criteria Full stretch, limited by pain Tent band palpable Tender spot or nodule within a taut band Reproducible pain at patient's complaint Confirmatory Observations Local twitch response Referred pain in the expected distribution at that muscle Endplate noise or spontaneous electrical activity (SEA) demonstrated by an electromyographic study
Diaphragm release
Diaphragm release techniques are designed to free up restrictions in the anterior fascia just caudal to the ribcage and to manipulate the diaphragm In a forward<head, protracted-shoulder, slumped position, the anterior elements collapse, thereby reducing diaphragmatic excursion, which can lead to increased activity in the secondary accessory breathing muscles. Also, for the patient to perform postural reeducation techniques successfully and elongate the thoracic area, the contracted area of the anterior chest and abdomen must be supple and mobile. Any of these techniques can be used successfully to eliminate pain referred to the shoulder via the diaphragm. Three techniques are shown, ranging from the least aggressive to the most aggressive, the general progression should follow the patient's tolerance level. Pt. with shoulder pain when running—release on same side as pain. Pt. seated in slight slouch. Slide from xiphoid process down or you can do cross friction.
What technique uses a progression from a gentle stretching of superficial and middle layers in supine and side-lying positions to deeper layers that have the patient in a seated position and use the patient's breathing to increase depth?
Diaphragmatic technique
29. What are the characteristics of the direct insertions at the osteotendinous junction?
Direct insertions: have 4 zones Zone 1: actual tendon or ligament Collagen fibers are found here embedded in the matrix or ground substance, as are fibroblasts Zone 2: fibrocartilage Cells in this region resemble chondroblasts or chondrocytes Zone 3: mineralized fibrocartilage of bone Where mineral deposits are found around collagen fibrils Zone 4: bone Where the collagen fibrils merge with the fibrils of the bone matrix
Describe the two types of Myofascial Release, direct and indirect?
Direct: ▪ Improve the mobility of soft tissue with an application of slow controlled mechanical stress that supply directly into a restriction, active or passive. (traction included) o Indirect ▪ Less force, longer duration hold. ▪ Good for pt who are tender or guarded ▪ inherent rhythmic motions
What are the different types of myofascial release?
Direct: Improve mobility of soft tissue with application of slow, controlled mechanical stress. They supply directly into restriction. PASSIVE OR ACTIVE Indirect: Require less force and require longer duration hold. Very gentle Better for patients that are more tender and guarded.
What is the direct method of myofascial release?
Direct: intent to improve the mobility of soft tissue through application of a slow, controlled mechanical stress directly into a restriction ● Pressure is gradually increased
The ground substance has a dense capillary network which is key for cellular nutrition. How does it participate in the bodies defense system?
Disease must pass through ground substance to overcome CT defense
What is a dysfunciton?
Disturbance, impairment or abnormality of the functioning
What are the results of restricted motion in the CT in the physiology of our CT?
Disuse atrophy of supporting musculature Loss of sarcomeres Degeneration of cartilage Loss of ground substance Binding of fascial elements Nutrition and impaired blood supply
What are the 5 D's of chronic pain?
Dramatization Drug misuse Dysfunction Dependency Disability
Describe how to complete the rib splaying technique
Draw across from medial to lateral from 1 rib interspace to the next. Ribs 2-4 Use power grip, with thumb as plow and index finger. Go just inferor to SC joint and sweep towards the axilla.
What is the most promising treatment for myofascial trigger points?
Dry needling. Based off of local twitch response it can help reduce the electrical activity and reduce contraction of muscle
What is the role of contractions on myofascial trigger points?
Due to eccentric contractions, concentric contractions, submaximal concentric contractions and low level contractions over long period of time
What are the typical myofascial pain characteristics?
Dull and aching Often deep Low grade to severe Pain with rest or motion Areas of local tenderness disturbed sleeping patterns with morning stiffness Does not follow dermatomal, myotomal or sclerotomal patterns
What is the best treatment for the maturation phase of healing?
During this time, the scar tissue is responsive to manual therapy but the progress will be somewhat slowed. Without controlled stress or mobilization during this phase, however, tensile strength of the scar will not improve and optimal function wiJl be diminished.
What has been found to reduce levels of norpinephrine and 5-HT both required to modulate and/or inhibit the release of neurotransmitters involved in pain, such as substance P and excitatory amino acids such as glutamate and aspartate?
EXERCISE
What is the role of endomysium?
Each myofibril is surrounded by endomysium Endomysium = Surrounds individual muscle fibers. Allows for penetration of nerves and blood supply to provide diffusion of nutrients and ions as necessary for muscular metabolism and excitation Myofibril = the muscle's cellular unit Actin+myosin = myofilaments → myofibril → fasciculus → fasciculi
Describe the differences of using myofascial manipulation with early cross-link formations vs. long-standing formations
Early cross-link formations can be broken with relative ease as they are formed with hydrogen bonds. Long-standing or chronic conditions of immobility may also be reversed but require more time and greater force. Eventually, the hydrostatic bonds are replaced with stronger covalent bonds.
Muscles have specialized muscle nociceptors, that are female endings connected to the CNS by a thin myelinated or unmyelinated afferent fibers. What are they very effective at doing?
Effective for nueroplastic changes in the spinal dorsal form
8. What are the different components of the viscoelastic model of connective tissue?
Elastic component represents the temporary change in length that occurs when it is subjected to a stretch/deformation ---post-stretch recoil where all length or extensibility gained during the stretch/manipulation is lost over a short period of time as the tissue returns to its original shape ii. Viscous component represents the permanent deformation characteristic 1. After a stretch/manipulation, part of the length or extensibility gained remains even after a period of time
What is effected first when a strain is applied to the tissue, the elastic elements or the viscous elements?
Elastic elements and slack is initially taken up first. Then when stress is enough, the viscous portions begin to change and the viscous portion may have permanent deformation
What is end plate noise and what does it indicates? P. 139
Electrical activity of trigger points is in fact endplate noise resulting from an excessive release of acetylcholine at the motor end plate. Indicates irritability of trigger points and is an expression of sympathetic dysfunction
Exercise has been found to reduce levels of norpinephrine and 5-HT both required to modulate and/or inhibit the release of neurotransmitters involved in pain, such as substance P and excitatory amino acids such as glutamate and aspartate. Why does this relate to fibromyalgia?
Elevate levels of substance P have been found in the CSF of those diagnosed with FMS
What is elevated in CSF for patients with fibromyalgia? How does this cause central sensitzation?
Elevate substance P and glutamate. Substance P Lowers the excitability threshold, which results in sensitizing neurons away from the local stimulus. Can span long distances in spinal cord and give nociceptive and non-nociceptive inputs in different spinal segments. **LEAD TO WIDESPREAD DIFFUSE PAIN
Elevated substance P and glutamate corresponds to what other measurment?
Elevated levels of pain intensity
What has been found to be elevated in patients with fibromyalgia?
Elevated levels of substance P. Which is involved in pain and other excitatory pathways, which may lead to hypersensitivity of nerves for patients with chronic pain
How does the forward head posture affect the ribs?
Elevation of first rib. Anterior and posterior restriction of first rib articulations = Tendency for TOS
Who coined the following definition? Cutivisceral reflex: even with superficial touch, there is a response through our nervous system that can influence a variety of structures you are not touching
Elizabeth Dicke
Describe the History of Autonomic techniques, in relation to Elizabeth Dicke
Elizabeth Dicke founded CT massage in 1920's. Was bed rest and couldn't use her legs. She realized that working on soft tissue in back, returned her normal use in legs Cutivisceral reflex
According to the proper treatment sequence, we should start with applying soft tissue manipulation first, then applying joint mobilization after the myofascial tissue has been normalized. Then what? Why?
Elongate joint and myofascial tissues. If soft tissue and joint mobility have been restored, decompression and stretching techniques may be applied to gain full A/PROM as well as to for greater tissue extensibility. Optimal tissue length allows for greatest contractile efficiency
What theory supports trigger point release therapy?
End-plate hypothesis
What are the 4 effects of posture?
Environmental (girls slouching, to not feel tall as an adolescent) Genetic Occupational Recreational
Describe the structure and characteristics of loose irregular CT
Ex. Superficial and deep fascia, neural sheaths, muscle sheaths, internal organ supporting framework Thin and sparse fiber content, collagen, elastic and reticular fibers in multidirectional
What may cause excessive acetylcholine, which will create a constant activaiton of muscle contractile system?
Excessive acetylcholine due to: Insufficience of acetylcholinesterase Hypoxia Lack of ATP Acidic Ph Medications that increase sensitivity of nicotinic acetylcholine receptors across membrane Injections by botox can deactivate myofacsial trigger points
Describe autonomic apprach to myofascial manipulation and how it exerts effect.
Exert effect through the skin and superficial connective tissues. STM for autonomic effect stimulates SENSORY receptors in the skin and superficial fascia → these pass through afferent pathways to spinal cord and channeled through autonomic pathways. EFFECTS areas corresponding to the dermatomal zones mobilize
What is an autonomic soft tissue manipulation technique?
Exerting therapeutic effect over Autonomic nervous system. Stepping stone to more Aggresive mechanical techniques. Good for acute and sub-acute and is good to start or end treatment for relief
Once calcium ions are released from the Sarcoplasmic reticulum they trigger a shift in the position of tropomyosin in the muscle sarcomere, which in turn does what?
Exposes myosin actin binding sites, leading to formation of cross bridges and causes a muscle contraction
True or False Posture is mainly static
FALSE Posture is mainly dynamic
True or False: Cross-links can increase tissue mobility since the structure is unified in parallel fashion
FALSE! Cross-links limit tissue length
True or False: You should strengthen an inhibited muscle before stretching a shortened muscle
FALSE!! Due to reciprocal inhibition, the shortened muscle must be stretched before attempting to strengthen the inhibited muscle
True or False: Myofascial Pain syndrome is the same as Fibromyalgia.
FALSE!!! DO NOT CONFUSE THEM
True or false: Since fibromyalgia is a chronic pain syndrome, exercise as a PT intervention is no longer deemed effective, which is why soft tissue manipulation is so important
False: C'mon, of course exercise is effective
True or False: Immobilization to tissues can not be reversed, so you better get moving and exercising!
False: Keep sitting on the couch till you make a dent
True or false. There are many rigid procedure or protocols for the Trager approach
False: No rigid procedures or protocols Uses gentle passive motions that emphasize mobilization techniques, concentration on traction and rotation and a system of active movements termed Mentastics
What is the typical O2 saturation in a trigger point? What does this cause?
Far below normal levels Leads to hypoxia, hypoperfusion and decrease in pH Production of ATP is impaired Lack of ATP maintains the actin myosin cross bridges and contractures Lack of ATP also leads to increase of acetylcholine, failure of calcium pump and increase in calcium ions All reinforce muscle contraction
What are myofibroblast and why are they unique?
Fascia has an active role through myofibroblast contraction Myofibroblast are derived from fibroblast after a trauma. i. Contractions are unique because the can produce a shortened collagen matrix, which results in longer term changes without an ongoing contraction, and help with wound closure. Contraction of collagen matrix or connective tissue may contribute to vertebral stability or harm by becoming stiff and preventing freedom of movement
What is the tissue of focus for rolfing?
Fascia, as it constantly reorganizes and responds to stress
What is Ida Rolf's concept of a "fascial sweater"?
Fascial restriction in one area will strain areas away from the restriction and cause abnormal movement patterns Tightness in one area of the body could cause problems in another location
What is Ida Rolf's concept of a "fascial sweater"?
Fascial sweater. (if you have soft tissue restriction in R hip. That can influence problems in L shoulder) Pulling and restrictions in one spot, effect the rest of the connected body
What are the patients symptoms associated with myofascial pain syndrome?
Fatigue Sedentary lifestyle Sleep disturbances
Describe the age, gender, pain descriptipon and medical work-up of fibromyalgia
Female 10x> men 20-50 years Diffuse, widespread and chronic pain Negative bloodwork and imaging
What cells are senstive to physical stimuli and are unable to distinguish between good and bad stresses?
Fibroblasts 1. Stresses applied through the tissue will induce fibroblast proliferation and collagen alignment according to the direction of stress 2. Prolonged stresses will result in a denser, more tightly structured connective tissue and in some cases less mobile
According to the cycle of fibrosis, it begins with a Chronic, low-grade irritant that triggers an inflammatory response. As normal macrophages debride the area, and there is increased vascularity. What then occurs?
Fibroblasts begin to synthesize immature collagen for tissue repair.
What happens with the fibroblast in the fibroplastic phase of soft tissue repair?
Fibroblasts migrate to the area and begin collagen synthesis. (Collagen fibers laid down haphazardly)
What types of mesenchymal cells differentiate into CT?
Fibroblasts, which become fibrocytes and CT proper
What is the primary fixed and most prominent cell within CT? What is the function?
Fibrocytes. Function to synthesis of all CT componenets and synethesizing collagen, elastin, reticulin, ground substance and other fibroblasts.
According to the study of Akeson, Woo and Amiel about immobilization, what was found in the capsular recesses within tissue that was immobilized?
Fibrofatty infiltrate, with potential to create intra-articular adhesions with maturation
The following conditions are commonly associated with what pathology? Myofascial pain syndrome Migraine headaches Chronic fatigue syndrome Irritable bowel syndrome Restless leg syndrome TMJ pain History of depression or anxiety disorders
Fibromyalgia
What is a diffuse central nervous system disorder with dsyfuncitonal sensory processing?
Fibromyalgia
What pathology is a result of chemical changes within the central nervous system resulting in a centralized hypersensitivity?
Fibromyalgia
Your patients comes in. They have a 5 month history of widespread pain. They have 15 out of 18 tender spots with little force. They complain of sleep disturbances. What do they have?
Fibromyalgia
Patients with ______________________ had a lower state level of cerebral blood flow in the thalamus and caudate nucleus which also suggests that _______________________ is the final common pathway for the development of abnormal pain perception.
Fibromyalgia; Central sensitization;
According to research on myofascial release: Muscle responds best to __________________ Fascial lining and neighboring fascia responds better to ____________________________
Firm strokes: Gentler, sustained forces
When organizing your treatment session, how should you sequence your treatment. Joint manipulation first, or myofascial techniques?
First free up the soft tissue, and then you can try and free up the joints
How did James Cyriax contribute to our understanding of soft tissue dysfunction?
First to recognize discogenic pathology with back pain. Coined accessory motion, "involuntary motions that are necessary in a joint for proper movement" First to introduce concept of "end-feel" and how Pain could be caused by dysfunction of various or selective soft tissues is a foundation of soft tissue manipulation today
In the Flowers and Pheasant study, they 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. Following passive flexion, all joints regained full passive flexion. Why is this the case, since immobilization should restrict motion in the long term?
First, no inflammatory response was triggered by the external fixation. Therefore no fibrofatty infiltrate was produced. Second, although immobilized in theory, the external cast allowed for some isolated movements similar to intra-articular movements seen in isometric exercises.
How do you palpate different layers?
First: layers of myofascial tissues Then: joint structures passive segmental mobility
Myofascial Manipulation of the Hamstring (A&B pt. supine /c leg flexed and on your shoulder. C pt. prone /c leg bent onto your quads) - Fist distal to proximal - Splaying with thumbs
Fist distal to proximal: rock back and forth into flex/ext to find tension. Start with fist at top (most people are tender in the middle). Can work into hip flexion to elongate the fibers at the end/attachment Splaying with thumbs: separating the muscles into lat direction. Start by sinking in with hands in clam shape, slight motion.
Is the following fixed or wandering cells? Fibrocytes. Function to synthesis of all CT componenets and synethesizing collagen, elastin, reticulin, ground substance and other fibroblasts Unable to distinguish between good and bad stress
Fixed CT cells
When would you use the skin rolling technique?
For restrictions of the superficial fascia.
What is stress?
Force acting on tissues
How does fascia act as a force transmitter?
Force is transmitted through fascia via intramuscular, intermuscular, or extramuscular force transmission
What is soft tissue manipulation?
Forceful passive movement of the musculofascial elements Moves through restrictive directions Begin superficial and progress into depth
What is the definition of Soft Tissue Manipulation?
Forceful passive movement of the musculofascial elements through its restrictive directions beginning with its most superficial layers and progressing into depth while taking into account its relationship to the joints concerned.
Why should the deepest muscle layers be treated to remove connective tissue adhesions?
Forces trasmit through muscles and pull on bone, which creates thickenings in CT
What is the definition of soft tissue manipulation? Describe the process, we should utilize and why we should use soft tissue mobilization
Foreceful passive movement of musculofascial elements. Use it through restrictive directions. Begin with most superficial layers and progress into depth
How does forward head posture, change the arthorkinematics of the midcervical facet joints, and what facet joints may have DDD?
Forward bending of midcervical facet joints Cervical imbalance with a tendency toward a degenerative joint disease from C5-C7.
What is the role of macrophages?
Found primarily in traumatized or infections states Responsible for phagocytosing waste products and damaged tissue, debriding area for repair In inflammatory states, macrophages are capable of phagocytosing bacteria May be signal for vascular regeneration to begin
What are the primary components of ground substance?
GAGs and water a. GAGs: can be sulfated or nonsulfated i. Nonsulfated GAG ex: hyaluronic acid ii. Sulfated: chondroitin b. Hyaluronic acid and chondroitin injections purportedly help restore joint function
Trigger point release should always be followed up with what?
Gentle 30 to 60 stretch to involved muscle Gentle myofascial manipulation to muscle released
What is the main feature of the Treager Approach? What are some examples of the technique?
Gentle, rhythmic, passive movements to release adhesions and decrease tension within the muscles. Examples of these techniques are trochanter rocking and 1 st rib manipulation with oscillations
What are the most meaningful parts of Soft tissue mobilization?
Goes SUPERFICIAL TO DEEP. Very important to work through the layers of the tissue It's a passive technique. Provider delivers direction and amount of force. Relationship of joints concerned. (Find mobility and ROM deficits will be resolved.)
What kind of mechanoreceptors are critical in transmitting information regarding muscle tension from musculotendinous junction? Also are highly sensitive to changes in tensile forces on connective tissues.
Golgi tendon organs
What structures are suspended, interwoven or wrapped in connective tissue, they are affected by changes that occur in their respective connective tissues?
Golgi tendon organs
What kind of patients would benefit from Autonomic techniques?
Good for acute patients for pain relief, guarding and tone Good stepping stones to mechanical and movement technique Beginning and end of session Good results via autonomic nervous system effects
What does a soft tissue look like in the granulation phase of healing?
Granular look from the forming of capillary buds.
The greater trochanter, is one of the 9 areas of tender point sites for fibromyalgia. Where in the greater trochanter would you apply your less than 4Kg force to check for fibromyalgia?
Greater trochanter: Posterior to tronchanteric prominence
The following are 3 critical functions of what? Provides medium of diffusion for cellular nutrients and waste Provides a mechanical barrier against foreign bodies and bacteria to fight infection Provides medium in which the collagen fibers can slide and glide when providing strength to tissue
Ground substance
What is the medium for CT fibers and cells, and acts as lubricant for CT fibers?
Ground substance
What are the 3 stages of conscious learning to improve posture, via Alexander?
Habit Awareness Habit Inhibition Habit conscious control
What are the 3 stages of conscious learning according to alexander?
Habit awareness --> inhibition --> conscious control
How do you perform the lamina release in quadruped?
Have pt sit back, you use a key grip and slide your thumb through laminar groove when pt sits back into lumbar flexion.
What is the Hoffa massage technique used for?
Help patient relax and prepare the superficial tissue. Without it the deep pressure can cause microtrauma and pain when getting to deeper structures.
How can cross friction help stimulate the natural healing process?
Helps stimulate phagocytosis and removal of waste products. Stimulates Fibroblasts to lay down new collagen and connection of tissues. Use in conjuction with support techniques, such as stretching and PROM
When would you use the long axis laminar release?
Helps to release the erector spinae and rotatores from the lamina. Make sure hands have full contact on back, with thumbs going down to saccrum. Iliac crest is cupped into palms and you lunge into it to distract iliac crest 1 side lamina lane at a time.
What are the different metabolic and functional characteristics of Type I Slow twitch muscle fibers?
High concentrations of myoglobin Increased numbers of mitochondria Low content of glycogen Oxidative metabolism **postural muscles** Slow contraction times Fatigue resistant
What are the metabolic and functional characteristics of Type IIb fast twitch/glycolytic muscle fibers?
High glycogen content Glycolytic metabolism Decreased numbers of mitochondria Fast contraction times, fatigues easily
What are the characteristics of postural muscles?
Higher resting tone and are stronger than phasic Responds to dysfunction by shortening and atrophy less quickly than phasic muscles
What increases tissue permeability, enabling influx of exudates and interstitial fluid which temporarily seals the wound?
Histamine
During the inflammation phase there is trauma to tissue, that disrupts local mast cells and reults in what?
Histamine release and consequently vasodilation
19. What chemicals can produce contractile response in myofibroblast?
Histamine, Oxytocin, and Mepyranime produce significant contractile responses and are known to produce sufficient force for wound closure
What is the criteria to diagnosis fibromyalgia?
History of chronic >3 month widespread pain Pain in at least 11 out of 18 anatomically defined tender spots with application 4 Kg force Sleep disturbances
How do you perform the O/A with occiput stabilized mobilization?
Hold at end range of mid-cervical flexion and bring head up. Go into different diagonal directions. Checking O/A sidebending and extension. checking mainly tissue tension. Then to mobilize the tight area, go out and around in J technique.
What is the purpose of CT?
Holds us together Transmit forces during movement Holds organs in place. Makes up 16% of body weight, and 23% of body of water
Describe the characteristics of sub-acute pain
Hours to days Resolves with recovery Nociceptive and neuropathic input Protective recover function
Andrew Taylor Still founded Oseopathic medicine in 1874. After losing his 3 children to spinal meningitis he was tired of traditional practice. What is his basic theory about the causes of disease?
Human organisms had innate strength to combat disease and would remain healthy if body remained structurally normal. If not = adverse effects All cause of disease is from, "dislocated bones, abnormal ligaments or contracted muscles particularly in spine, putting pressure on blood vessels and nerves.
How does salmon define a trigger point?
Hyper irritable spot in skeletal muscle that is associated with hypersensitive palpable nodule in a taut band
What is an RSD or reflex sympathetic dystrophy back
Hyperactivity of the sympathetic nervous system that creates -- chronic intense pain and hypersensitivity ---cold clammy feeling, cold sweat in the area, nausea with attempted palpation ----shiny skin and bone and hair loss
Changes in dorsal horn and peripheral sensitization can cause what effect with myofascial trigger points?
Hyperalgesia
What are the sensory dysfunctions associated with myofascial pain syndrome?
Hypersensitive skin over active trigger points Referred pain Significant lowering of pain threshold over active pain thresholds
What abnormalities are observed at the supraspinal level in patients with fibromyalgia?
Hypoperfusion of ant and post cingulate gyrus, amygdala, medial frontal gyrus, parahippocampal gyrus, and cerebellum. Hyperperfusion of radioligand in somatosensory cortex All of this disturbs sensory processing Decreased domapinergic activity(modulates pain perception) and reduced availability of M-opiod receptors (for pain relieving agonists like morphine, etc)
According to Alexander approach to posture, what happens if posture is changed to early?
If new posture is emphasized too early, the pt often may not have the body awareness or the ability to assume it The new posture then can increase original pain and establish negative reinforcement loop
What is the treatment principle of ROLFING?
If tissue is restrained and balanced movement demanded at a nearby joint, tissue and joint will relocate in a more appropriate equilibrium Strives to integrate the structural with psychological
How does genetic effect posture?
If you have OA, Diabetes or poor spinal curvature then genetics change dictate posture
Why a medical professional shall be careful diagnosing FMS based on chronic widespread pain and presence of local tender points? 151
If you simply rely on this dx, you may be missing on more serious conditions ( hypothyroidism, metabolic insufficiency) that present the same FMS is like your last go to dx when all else is not fitting the description of the pt's symptoms
What is the best and worst type of treatment for a tissue in the granulation phase of healing?
Immobilization is essential during this phase to permit vascular regrowth and prevent further microhemorrhages acute inflammation fibrous repair remodelling and contraction and tissue breakdown.I,lo Heat application at this point may cause increased bleeding in the fragile healing tissues
What is the results of immobility in connective tissue?
Immobilization results in loss of ground substance, collagen cross-link formation, loss of sarcomeres, loss of tissue nutrition and blood supply, disuse atrophy, and most of the time, pain.
Muscles quickly adapt to immobilization, whether artificial fixation or physilogic. What are examples of artificial fixation?
Immobilized shoulder or knee following surgery Neck immobilized in a collar following a whiplash injury Back immobilized by a TLSO status post laminectomy or other surgery Splinted finger or ankle following a fracture
What main general factor results in loss of ground substance, collagen cross-link formation, loss of sarcomeres, loss of tissue nutrition and blood supply, disuse atrophy, and most of the time, pain.
Immoblization
What is a somatic dysfunction?
Impaired or altered funciton of related components of somatic system State of altered mechanics, palpable changes of integrity, increased or decreased mobility autonomic changes and emotional "muscular armor"
With a critical interfiber distance loss and collagen fiber approximation with immobility, micro-adhesions are formed. What does this result in?
Impeded tissue mobility. Decreased cellular activity Decreased blood supply and nutrition
How can you apply this tensegrity model on the human body both at the microscopic and macroscopic level?
In essence, force directs the function of the cell to either divide, die or differentiate into specific tissues Macroscopic level: the compression-resistant bones pull up against gravity and remain stabilized by the continual tension produced by resistant muscles, tendons, ligaments, and fascia. Balance of constant tension is experienced by anyone who has floated. For example, when gravity is taken out and the body is in rest, all the extremities, and trunk flex slightly and do not straighten out
Muscle Play Pectoralis Major and Minor
In the forward head posture, the pectoralis major and minor may become shortened and restricted. This shortening creates an inability to stand or sit erect without significant effort from the patient. Before neuromuscular reeducation or postural training can occur effectively. the pectorals must have adequate extensibility Major: pt. supine, your leg supports their arm in flex. Bend the m. A/P Minor: same position. Bring hands more post, you will hit the rib, then go more med until you hit a little mountain (aka the minor)—can do a longitudinal stroke working into cross friction
Erector Spinae Muscle Play
In this technique, the therapist manipulates the fascial sheath or casing surrounding the erector spinae. Muscleplay is defined as the ability of the muscle to expand and move within its compartment independent of joint movement or voluntary muscle contraction. Many fascial restrictions occur in planes perpendicular to or diagonal to the direction of the muscle fibers Muscle sheaths are classified as loose connective tissue that has multidirectional fiber orientation. By manipulating the connective tissue sheath surrounding or encasing the muscle or groups of muscle, muscular contraction can occur more efficiently, circulation to the muscle is improved, and movement in the localized and general areas is improved. Little lotion needed. Relatively superficial. Pushing the muscle in a direction that it can't functionally perform in. Flat hand contact, use of palms to bend muscles like you would a tube. Don't flex/ext the arms, just add/abd them. Fast/slow, get a rhythm and work your way up/down the muscles.
How do myofibroblasts help with wound healing?
In wound healing, they use actin and myosin to draw damaged tissues together Found in both fascia and intramuscular connective tissue Exist in high densities within the perimysium PLAY A ROLE IN PASSIVE MUSCLE STIFFNESS OR RESTING TENSION U-SHAPED STIFFNESS
What causes chronic pain?
Increase in temporal summation which causes sensitization of peripheral and central nervous system. Pt feels pain after injury is healed.
How does forward head posture change the curves of the thoracic and lumbar spine?
Increase thoracic kyphosis with decreased lumbar lordosis
During the inflammation phase, what is the purpose of histamine?
Increase tissue permeability, enable an influx of exudates and interstitial fluid, which will seal the wound.
Describe the pathomechanics of slumped posture on the sternum and abdomen
Increased FHP can lead to ribs and sternum moving inferior and posterior Shortening of CT in abdomen and thorax Secondary respiratory muscles become more active, because diaphragm doesn't contract properly
How does forward head posture affect breathing and muscles of respiration?
Increased activity of accessory respiratory muscles due to poor diaphragmatic breathing and core expansion of lower ribs
What chemicals may be associated with increased autonomic activity in the motor end plate of trigger points? 144
Increased levels of NE and serotonin in the immediate milieu of active trigger points
What are the chemical changes and central sensitization associated with fibromyalgia?
Increased levels of substance P and glutamate Reduced levels of norepinephrine and serotonin Reduced blood flow to brain Reduce dopaminergic activity and availability of opoid receptor
During the inflammation phase there is trauma to tissue, that disrupts local mast cells to release histamine and consequently vasodilation. What does histamine do?
Increases tissue permeability, enabling influx of exudates and interstitial fluid which temporarily seals the wound.
First Rib/Shoulder depression rocking technique
Indications: Decrease generalized myofascial tone in upper thoracic area. Preparatory for deep work, and joint mobilization.
Iliacus
Indications: Decreased hip extension. Presence of anteriorly rotated pelvis, backward bending dysfunction of lumbar spine.
Psoas
Indications: Decreased hip extension. Presence of forward head posture. Decreased lumbar spine mobility (forward bending). Shortened psoas. Contraindications: Pregnancy, endometriosis, gastric colitis, pelvic anuerysm
Lateral telescoping of the T-spine
Indications: Elongate anterior and posterior structures of the upper thoracic area
Transverse Soft Tissue Manipulation of the Quads (Lumbopelvic and LE)
Indications: Facilitate stretching of surrounding fascial sheath
SCM Muscle Play
Indications: Increased tone in SCM. Overuse.
Greater Trochanter lumbopelvic Rocking
Indications: Internal rotation restriction(via inhibition of lateral hip rotators) of the hip. Restrictions in hamstring. Limited straight leg raise. Preparatory for pirirformis, posterior hip, and hamstrings.
Unilateral P/A Articulation of First Rib
Indications: Joint manipulation for first rib due to dysfunction from restricted subclavicular myofascia, scalene muscles.
Superficial Long Axis Distraction of the Connective Tissue of the Spine
Indications: Longitudinal adhesions. Caution: Discogenic back
Bilateral Sacral Releases
Indications: Myofascial conditions or mechanical dysfunctions of the parasacral region
ITB/Paratrochanteric area
Indications: Myofascial restrictions at junction of ITB and quadriceps and/or junction between ilio-tibial band and hamstrings. Lower kinetic chain problems. Knee, trochanteric, and low back dysfunction
Scapular framing
Indications: Myofascial restrictions surrounding scapular borders. Scapulothoracic rhythm dysfunction. Dysfunction of upper thoracic, mid-thoracic, cervical spines, and shoulder.
Cross Friction of Ischial Tuberosity and Hamstring Insertion
Indications: Myofasical restrictions in surrounding area. Junctional zone for healing and restoration of function
Elongation of Paravertebral muscles
Indications: Preparatory for deep soft tissue work and joint manipulation
Preparatory Techique for Scapula-Thoracic Myofascial Manipulation.
Indications: Preparatory for deeper scapula-thoracic techniques.
Medial to Lateral Stroking of the Lumbar Spine in Side Lying
Indications: Preparatory for deeper work. When autonomic approach is needed
Myofascial Manipulation of Hamstring
Indications: Preparatory for hamstring stretching.
Manipulation of Deep Mid-Lumbar Myofascial Tissues
Indications: Preparatory for joint mobilization and manipulation of mid-lumbar area. Restricted mid-lumbar rotators and QL.
Forward Bending Lamina Release Sitting
Indications: Preparatory for joint mobilization. Patient to therapist size ratio is too large. Utilizing active release technique. Patient is unable to assume quadruped position. Contraindication: Discogenic back
Forward Bending Lamina Release in Side Lying
Indications: Preparatory for joint mobilization. Presence of hyperlordotic postures
Forward Bending Lamina Release Quadruped
Indications: Preparatory for joint mobilization. Presence of hyperlordotic postures. Patient to therapist size ratio is too large. Utilizing active release technique
Diaphragm
Indications: Restricted anterior fascia due to forward head, protracted shoulder, and slumped postures. Evidence of reduced diaphragmatic excursion and increased tension in accessory breathing muscles. Preparatory for neuro re-ed
Anterior Lateral Fascial Elongation of Superficial Fascia
Indications: Restricted anterior fascial planes due to slumped posture or shoulder pathologies.
Iliac Crest/Sacral Release
Indications: Restricted backward (anterior fascial planes), forward (posterior fascial planes), and side bending. Lateral shift. Restricted connective tissue over iliac crest Contraindications: Spondylolisthesis, spondylosis, severe DJD.
Iliac Crest Release- Aggressive with Backward Bending of Lumbar spine
Indications: Restricted backward bending. Lateral shift Contraindications: Spondylolisthesis, spondylosis, severe DJD
Muscle Play for Erector Spinae (lumbar)
Indications: Restricted connective tissue sheaths surrounding the erector spinae group. Optimize the environment for the muscle to contract.
Bilateral Upper Thoracic Release
Indications: Restricted deep paravertebral musculature of the upper thoracic spine.
Quadratus Elongation and Stretch - Aggressive
Indications: Restricted general myofascial and tight QL Contraindication: Possible discogenic low back pain
Mid-Thoracic Lamina Release With Rotational Component
Indications: Restricted paravertebral muscles.
Axial Flexion of C-spine and O/A
Indications: Restricted subcranial myofascia due to forward head posture. Restricted subcranial extension
Piriformis Release in Prone: 4 options
Indications: Restricted/hypertonic piriformis.
Piriformal Release Side Lying
Indications: Restricted/shortened piriformis
Rib Spaces 1-3
Indications: Restriction in anterior, lateral, posterior structures of the upper thoracic area
Friction of Piriformis Insertion
Indications: Restrictions in musculotendonous junction and tinperiosteal junction of performis insertion
Long Axis Lamina Release (lumbar)
Indications: Restrictions in side and forward bending. Localized lesions. When decompression of the spine is needed
Muscle Play Pectorals
Indications: Shortened anterior musculature due to forward head posture. Preparatory for neuromuscular re-ed.
Subscapularis
Indications: Shortened internal shoulder rotators due to forward head and protracted shoulder posture. Restricted surrounding myofascia
Elbow/Forearm Technique
Indications: Superficial myofascial adhesions (can be used for deep adhesions)
Tissue Rolling
Indications: Superficial myofascial adhesions of the spine. To assess for myofascial restrictions
Where do indirect insertions tend to blend with direct insertions at? What is there function?
Indirect insertions tend to blend directly into the periostium and then into bone by way of SHARPEY FIBERS Transmit tremendous forces and are therefore common sites of soft tissue injury and/or failure, leading to myofascial restriction
What is a indirect junctional zone insertion?
Indirect insertions tend to blend directly into the periostium and then into bone by way of Sharpey's fibers. They transmit tremendous forces and are therefore common sites of soft tissue injury and/or failure, leading to myofascial restriction.
What is the difference between Direct and indirect junctional zones?
Indirect insertions tend to blend directly into the periostium and then into bone by way of Sharpey's fibers. They do not have zones, like direct junctional zones. Indirect insertions do not utilize fibrocartilage as opposed to direct insertions. Lastly, depending on the attachment site the amount of force transmitted through the junction will differ. For instance, greater force will transmit through the tendon-bone junction due to the force generation of the muscle compared to the ligament and joint capsule bone junction.
What are the characteristics of the indirect insertions at the osteotendinous junction?
Indirect insertions: where the connective tissue fibers blend with the periosteum which in turn attaches to bone (Sharpey Fibers) The fibers are described as originating in the periosteum, and perforating the underlying bone, anchoring the periosteum to underlying bone. ***No fibrocartilage is seen in Direct insertions***
Indirect or direct technique? Require less force and require longer duration hold. Very gentle Better for patients that are more tender and guarded.
Indirect myofacsial release
What is the indirect method of myofascial release?
Indirect: applied similarly with a drastic difference in the amount of force used Lower in intensity, longer in duration to give tissue opportunity to "melt" or release. ● Considered gentler and used more often when patients are tender or guarded
What are the 4 stages of scar tissue formation?
Inflammation Granulation Fibroplastic/proliferation Maturation
What does the diaphragm sending inhibitory signals to the GTO's lead to over time
Inhibitory signals over time result in reduced lung volume and CT would remodel to a new length
What is neubulin?
Inhibits cross-bridges formation until actin is activated by calcium Contributes to cytoskeleton stability and integrity
Describe the characteristics of latent trigger points
Inhibits muscle Prevent full muscle length Disturb motor function Restrict motion Unable to relax muscles NO SPONTANEOUS PAIN
Describe the characteristics of active trigger points
Inhibits muscle Prevent full muscle length Disturb motor function Restrict motion Unable to relax muscles SPONTANEOUS PAIN
Efferent input from newly made receptors following the unmasking process may result in spatial summation following increased nociceptive input in the dorsal horn and the appearance of new receptive fields. What does this mean?
Input from previously ineffective regions can now stimulate neurons. These create alloydinia of myofascial trigger points
What kind of patients would benefit from Movement techniques?
Intended for mechanical change in tissue. Increasing mobility of tissue Lengthening tissue Neurophysiology's response via touching patient and effecting pt stretch response.
What intensity and techniques are part of the Trager method?
Intensity in moderate range Integration of cervical and lumbar traction Osciallations and rocking techniques serve as relaxation Active movements serve as neuromuscular reeducation technique like FELDENKRAIS
What differentiates Menses convergence projection theory from convential theory
Interneurons are located in variuos segments, and pain is expereinced outside segmental innervation.
What are the intra, inter, and extra muscular pathways of force transmission?
Intramuscular force transmission: force is transmitted within the muscle from the endomysial-perimysial fascial network onto adjacent fibers Intermuscular force transmission: force is transmitted through the connective tissue between the neighboring muscles Extramuscular force transmission: force is transmitted through various connective tissues, such as compartmental fascia or general fascia/connective tissue surrounding blood vessels or nerves
In regards to soft tissue lesions, what is the appropriate treatment mangement depending on patients stage of healing
It is important to remember soft tissue lesions are most fragile during the inflammation and granulation stages. Gentle, controlled stresses may be applied using soft tissue techniques during the fibroplastic/proliferation stage to promote tissue alignment, but care must be taken. Manual techniques have their greatest effect during the maturation stage, at which time tissue remodeling occurs as immature collagen begins to change to form a more permanent scar.
What happens when CT becomes restricted?
It would become fibrotic and the afferent signals are altered.
What does Aston patterning consider in terms of symmetry and soft hands?
It's not symmetry we should strive for. Asymmetry is natural. Balance is what we need with posture to deliver force with soft hands Learning how to impart force with soft hands as a PT
What is the medial-latera fascial elongation technique used for? (elbow forearm technique
Keep global contact with elbow/forearm. Elbow molds iliac crest. Helps to start superficial and work toward deeper and deeper layers.
How do you perform a pec minor muscle play?
Keep thumbs in hallow, underneath the muscle belly in armpit and move thumbs medial until hit a mound (speed bump) which is pec minor. Should be under pec major. Find a rib (4 or 5), which is slightly inferior to coracoid process. Hold the pressure --> Go longitudinal --> then go to cross friction.
What is the importance of Presence of excessive acetylcholine at the motor end plate.
Key factor in presence of myofascial trigger points
The knee, is one of the 9 areas of tender point sites for fibromyalgia. Where in the knee would you apply your less than 4Kg force to check for fibromyalgia?
Knee: Medial fat pad proximal to joint line
What does gel-sol theory and thixotropy explain about the plastic characteristics of the connective tissue?
LONG TERM CHANGES IN CT Rolf explained that tissue, as a colloidal substance, can function in 2 different forms: A gel and a sol i. Gel state: thick and dense ii. Heat or a mechanical stimulus can make the gel more fluid or soluble (sol) b. Piezoelectric effect: results in increased mobility of tissue as pressure that is applied to tissues disrupts the balance of charges, stimulating fibroblasts to produce collagen
According to the energy crisis hypothesis, ATP is lacking, why does this lead to contractures?
Lack of ATP maintains the actin myosin cross bridges and contractures Lack of ATP also leads to increase of acetylcholine, failure of calcium pump and increase in calcium ions All reinforce muscle contraction
What is the main issue for patients with fibromyalgia leading to increases in pain sensitivity?
Lack of descending anagesic activity, to prevent pain
What is the role of titan
Largest vertebrae protein connects myofilament of Z line, which crosslins to the sarcomere
What are the two types of myofascial trigger points?
Latent and active
The lateral epicondyle, is one of the 9 areas of tender point sites for fibromyalgia. Where in the lateral epicondyle would you apply your less than 4Kg force to check for fibromyalgia?
Lateral epicondyle: 2 cm distal to epicondyle
What muscles attach to the thoracolumbar fascia?
Lats, Glutes, external/internal oblique muscles, multifidus, transverse abdominis, Trapezius and quadratus lumborum
What are the 3 layers of palpation?
Layer 1: Palpate for skin temperature, moisture, texture. Test mobility of superficial fascia Layers 2: Palpate from superficial fascia to muscle bellies. Note taut bands, tension, differences in texture Layers 3: Palpate through muscle belly to muscle insertions and periosteal layers. Not lamina of vertebrae and joints
Describe the 1st and 2nd layers of layer syndromes of the posterior spine/legs
Layer 1: Shortened, hypertrophic hamstrings Layer 2: Hypotonic glueteal muscles
What syndrome is a sign of severe and deeply fixed central motor dereguation acompanied by very bad movement patterns?
Layer syndromes
What does vasodilation lead to in relation to myofascial trigger points?
Leads to activation of mechanoreceptors and increased sensitivity of nociceptors
What are the characteristics of reticulin fibers?
Least tensile of the connective tissue fibers Small branching fibers, forms mesh-like supporting framework Found primarily in the delicate meshwork supporting the body's internal organs and glands
What are the 5 main factors that effect immobilization effects of muscles?
Lengthened or shortened Active or passive immobilization Innervated or denervated muscels Fast vs. slow twitch Highly metabolic muscles
What is a soft tissue dysfunction?
Like a hamstring tear or mcl sprain...
What is the difference in limitation in mobility caused by scar tissue vs. fibrotic tissue?
Limitation in mobility caused by scar tissue results from the lack of extenstbil ity of the scar tissue and from the adhesions formed with healthy connective tissue. Limitation in mobility caused by fibrotic changes results from the lack of extensibility of the entire tissue.
Sacromeres line up and form what? Which form what else?
Line up to form bands or striations. Series of sacromeres is a myofibril (surrounded by endomysium) Group of myofibrils form a fascicule. (surrounded by perimysium) Fascicules groups for muscles. (surrounded by epimysium)
Briefly describe Pacinian Corpuscles
Located in both hairless and hairy skin. Found in fibrous periosteum near ligaments attachments and in anterior/posterior horns of knee meniscus Very sensitive in sensing stimuli, but are poor at localizing it.
Briefly describe Meissner's Corpuscles
Located in hairless skin such as palms and soles of feet. Particularly dense in palm and hands. Very sensitive, rapidly adapting to mechanical stimuli and are able to locate the source of stimulus with great accuracy.
Briefly describe Ruffini Corpuscle
Located in hairy and non-hairy skin, but also found in superficial layers of the joint capsules and surrounding connective tissues Slow adapting receptors contributing to steady-state position sense and tactile stimulation. Interwoven with local CT, which stimulates them as movement displaces the collagen fibers
Briefly describe muscle spindles
Located in striated muscle transmitting information regarding changes in muscle length. 3 kinds: Dynamic nuclear bag fibers, static nuclear bag spindles and nuclear chain fibers
22. Which theory explains the short-term vs long term changes in the connective tissue?
Long-term theory: Gel-sol theory and piezoelectric effect Short-term theory: intrafascial circulation loop Short-term and long-term soft tissue changes produced by MF manipulation include several combined processes including: intrafascial circulation loop, regulation of hypothalamus and central nervous system, and the contractility of connective tissues
What fills the gaps within the muscles and encapsulates it?
Loose connective tissue
The following describes which type of CT? Thin and sparse fiber content, collagen, elastic and reticular fibers in multidirectional, abundance of elastic fibers and ground substance that resists multidirectional force
Loose irregular CT
What type of CT has increased ground substance, cellular and vascular support which makes it more pliable than the other too and gives it greater capacity for change?
Loose irregular CT
What are the 3 main effects of immobilization of muscle?
Loss of sarcomeres Decline of muscle fiber diameter Fibrotic damage of myofibrils.
What are the results of restricted motion in general?
Loss of sarcomeres Degeneration of cartilage Loss of ground substance and lubricating effect Binding of fascial elements Nutrition and blood supply impared
The Low cervical area, is one of the 9 areas of tender point sites for fibromyalgia. Where in the lower cervical would you apply your less than 4Kg force to check for fibromyalgia?
Low cervical: Anterior aspect of C5-C7 intertransverse spaces
What is the Physical Therapy managment for fibromyalgia?
Low intensity aerobic and eventually low-resistance exercises are the best approaches to long-term self-management.
(High or Low) intensity aerobic and eventually (High or Low) resistance exercises are the best approaches to long-term self-management of fibromyalgia
Low intensity aerobic and low resistance exercises are best approaches
Why does myofascial pain syndrome develop?
Low-level muscle contractions, uneven intramuscular pressure distribution, direct trauma or eccentric contractions
Describe the normal treatment sequence for your intervention plan, for a patient with soft tissue restrictions
MFM of regional and involved areas, with local targets Direct before indirect Superficial to deep Joint manipulation after MFM treatment Joint and myofascial manipulation Neuromuscular reeducation Postural education
What are elastic fibers?
Made of elastin protein fibers. Interwoven within collagen fibers, they are yellow and thin. Significant part of elastic portion of viscoelastic property of CT.
4. List some examples of Hoffa massage techniques and describe the potential benefits of each.
Main benefit for all: relax the patient, reduce pain, guarding and tone Effleurage ---Slide or glide over the skin with smooth, continuous motion May stimulate the parasympathetic nervous system and evoke the relaxation response Can help facilitate venous return in heavily muscled areas Petrissage, Efflourage, Tapotement
When would you use forward bending lamina release in sidelying?
Main contact is 3rd and 4th fingers. Pull weight of leg in, like pulling into lumbar flexion via hip flexion. Contact on lamina, and 3rd and 4th fingers will stroke down back.
What is the purpose of mechanical approach?
Make mechanical, or histological, changes in the myofascial structures PURPOSE is to improve mechanical mobility of tissue treated
What is an mechanical soft tissue manipulation technique?
Making direct changes to myofascial application of force
Psoas Release
Manipulation of the psoas muscle is clearly indicated when actual shortening exists, which may create mobility problems into hip' extension as well as the lumbar spine, especially with forward-bent posture. In an axially extended posture (flat-back posture), however, the psoas may be hypertonic in" an effort to increase lordosis or to guard a lesion, where axial flexion of the lumbar spine is the primary dysfunction producing symptoms. In either case, a restriction maybe present or pain may be referred to the low back. Supine: can be hook-lying or with feet up on a chair, palpate laterally through the Transverse Abdominis with a chisel grip to the spine (have pt. do a baby leg lift to confirm you're on the Psoas muscle belly)—work longitudinal then perpendicular; if you find a trigger point hold pressure SL, 90 deg hip flex: same technique as above
What is the effects of manual therapy on soft tissue repair in the maturation or remodeling phase?
Manual therapy can extend tissue, but progression is somewhat slowed. ***Low-Load prolong stretched is most effective*** Stress is needed in area to regain full functional strength
What is the typical Pt management of myofascial pain syndrome?
Massage + stretch Spray + stretch Stretching + exercise Postural instruction Dry needling/injection
According to Hoffa massage, how should this approach be used?
Massage <15 min Emphasize autonomic technique to mechanical technique Myofascial is prepared for other techniques
What are the components of extra cellular matrix?
Matrix is composed primarily of connective tissue fibers (collagen, elastin, and reticulin fibers), and ground substance
What soft tissue manipulation approach seeks to produce a change in the physical properties of soft tissue using directed force?
Mechanical
What are the 3 categories of myofascial pain syndromes?
Mechanical dysfunction Myofascial pain syndrome Fibromyalgia
Briefly describe the Trager approach to massage
Mechanical soft tissue and neurophysiological reeducation approach developed by Trager o Uses the nervous system to make changes ▪ The practitioner "uses the hands to communicate a quality of feeling to the nervous system, and this feeling then elicits tissue response within the client"
Which of the following is false about mechanical techniques? ▪ Mechanical techniques should be performed following some movement technique ▪ Tissue mobility should not be forced ▪ Clinician should make changes gradually, going through the "layers", superficial to deeper structures
Mechanical technique should be performed following some autonomic techniques
How does myofascial manipulation change the cross-link formation of immobilized tissues?
Mechanically myofascial manipulation is also effective in rupturing fibrofatty adhesions and/or cross link formations between collagen fibers.
What are the 4 categories of receptors in the skin that are triggered from a stimuli?
Mechanoreceptors Nociceptors Thermoreceptors Chemoreceptors
Where is the thoracolumbar fascia anchored?
Medially to thoracic/lumbar and sacral spinous process/vertebrae. Laterally from sacrum and iliac crest to angles of rib. Continuous with soft tissues of Lats, Glutes and external obliques Up to trapezius and down to inferior sacrum
What are the 6 main functions of ground substance?
Medium for CT and cells Acts as lubricant for CT fibers Maintains interfiber distance to prevent adhesions Aids in nutrient diffusion Acts as mechanic barrier Tissue fibers and cells
What kind of mechanoreceptors are very sensitive, rapidly adapting to mechanical stimuli and are able to locate the source of stimulus with great accuracy.
Meissner's Corpuscles
What are the main structures that provide afferent information that effect firing patterns and synchorization?
Meissner's Corpuscles Pacinian Corpuscles Ruffini Corpuscles Muscle spindles Golgi Tendon Organs
What kind of mechanoreceptors are located in hairless skin such as palms and soles of feet and are particularly dense in the palm and hands?
Meissner's corpuscles
What are the main mechanoreceptors that are affected by tissue manipulation?
Meissner's corpuscles Pacinian Corpuscles Ruffini Copuscles Muscle Spindles Golgi Tendon Organs
What are the characteristics of the myotendinous junction?
Membrane at this junction becomes highly folded or convoluted, allowing the contractile intercellular components to integrate with the extracellular components This folding increase the surface area, thereby reducing the stress per unit area on the membrane. The folds hold the membrane at a low angle in relation to the forces combing from the muscle fibers, placing the membrane primarily under shear forces
What is the purpose of the membranous folds of the MTJ?
Membranous folds increase potential adhesive area in the MTJ, thereby decreasing the load per unit area being transmitted from the muscle
The following definition is associated with what idea and approach? Instruction is provided in active movements for the purpose of neuromuscular re-education and coordination. Once learned this technique should be used in daily life for to maintain freer movement, flexibility, tension relief and maintain more normal movement patterns
Mentastics, via the Trager approach
What are the most peripheral of all receptors?
Merkel's receptors
What type of receptors are slowly adapting but have very small receptors?
Merkel's receptors
What kind of mesenchymal cells differetiate into cartilage?
Mesenchymal cells differetiate into chorndroblasts, to form cartilage
What kind of mesenchymal cells differetiate into bone?
Mesenchymal cells differetiate into immature osteoblasts, to form bone.
From what does CT originate from?
Mesoderm; Mesenchymal cells
When the ground substance losses hyaluronic acid and hydrophilic components, the collagen fibers begin to approximate due to decreased interfiber distance and lubrication. Newly synthesized fibers are still laid down and cross-linking forms. What is this called?
Micro-adhesions, which impede tissue mobility
What is Trager soft tissue manipulation?
Milton Trager, MD Use of oscillations to free up inert tissues and inhibit contractile tissues. Use nervous system to make changes
What is the goal of myofascial trigger point interventions?
Minimize or resolve the pain produced by the MTrP in order to restore proper tissue mobility, strength, posture and ultimately, function.
Describe the cervicothoracic region or transitional zone of the spine?
Mobile cervical spine transitions to rigid thoracic spine due to increase in articulations from ribs 45 degree facet orientation of cervical spine to 65 degree facet or thoracic spine 1st rib articulates with superir demifacet, other ribs articulate with superior and inferior facet of vertebrae Muscular origin of anterior and middle scalene to 1st rib pulling it superior into thoracic outlet
Describe the lumbosacral region or transitional zone of the spine
Mobilie lumbar spine to rigid pelvis Saggital facet orientation to coronal orientation Shearing forces at L5/L1 due to flexion and wedgin of L5 disc Region of facet tropism L5/S1 has smallest neural formina Iliolumbar ligament to reinforce L4/L5 for women and L5 for men Most common place for disc herniation is L4-S1!!!!!
How does applying controlled stresses to tissue reverse the effects of immobilization?
Mobilization stimulates ground substance production, re-hydrating the tissue. Increased fluid restores the environment to maintain critical interfiber distance. Increases lubrication and promotes proper collagen alignment.
What are the different metabolic and functional characteristics of Type IIa Fast twitch/oxidative muscle fibers?
Moderately high concentrations of myoglobin, and increased mitochondria Mixed metabolish (gly&oxi) Faster contraction times than Type I, and less fatigue resistance
What theory offers the explanation in referred pain phenomena?
Modified convergence projection theory. Patients have referred pain with tension type headaches and migraines
What are the effects of moist head and massage on patients with fibromyalgia?
Moist heat and massage feel good and help reduce stress but produce short-term results. EXERCISE IS ALWAYS BEST
Describe the characteristics of chronic pain
Months to years of pain Persistent that may exceed resolution of tissue damage Neuropathic and nociceptive input Psychological and cognitive components of pain
Describe the thoracolumbar region or transitional zone of the spine
More rigid thoracic spine to more mobile lumbar spine 60 degree facet to more saggital orientation of lumbar spine Ribs 10-12 have similar attachments like 1st rib
How does Lord/Savior Stan Paris describe component motions?
Motions that take place in a joint complex or related joint to facilitate a particular active motion Used to detect dysfunctions in joint complex or related joint that may be interfering with passive motion
What are the motor dysfunctions of myofascial trigger points?
Motor components are affected through disturbed function, muscle weakness/inhibition, stiffness and decreased ROM
What is Feldenkrais pattern used for in terms of soft tissue mobilization?
Movement approach developed through personal struggles with repeated injuries Motor learning approach --> Awareness through movement. FUNCTIONAL INTEGRATION and NOT DEVELOPING compensatory movement patterns Very gentle approach.
Osteopathy is a system of therapeutics which lays chief emphasis upon the diagnosis and treatment of structural and mechanical derangement of the body. What are the 3 areas of osteopathic medicine currently applicable to myofascial manipulation?
Muscle energy techniques Positional release techniques Strain and counterstrain techniques.
How are myofascial trigger points formed?
Muscle overload Eccentric loading Sustained contractions due to posture Trauma
What is myofascial pain syndrome?
Muscle pain disorder, characterized by myofascial trigger points, by a taut band which can refer pain, due to autonomic dysfunctions. Usually have more trigger points that healthy patients, along with headaches. Any age or gender. Regional pain acute or chronic Negative testing, which makes it commonly missed.
According the Dr. Rob ward, what does the muscle and facial lining respond best too?
Muscle responds best to firm strokes Fascial lining and neighboring fascia responds better to gentler, sustained forces
As with muscle splay of the hamstring, the idea is to stroke deeply in the fascia] planes separating muscles or muscle groups. When muscle groups slide more freely on one another,their ability to be actively shortened or passively lengthened is enhanced, creating a greater efficiency of contraction and/or flexibility. Treatment of the flexor surface is described here.but the extensor surface may be treated as well. Patient position: Supine or sitting. with forearm on treatment surface. Therapist position: Standing or sitting lateral to patient, facing patient. Hands: One hand flexes the patient's wrist, while the index and middle finger find a "wedge" between muscle groups.Alternately, the thumb can be used,but the therapist must be careful to avoid overuse injury of the thumb.Muscle splay of the forearm
Muscle splay of the forearm
What kind of muscle fibers are more susceptible to strain injuries?
Musculoskeletal junctions a. Muscles that have a greater percentage of Type II fibers, that cross two joints, and that work eccentrically
What is the most commonly used definition of the myofascial pain? p. 128
Myofascial Pain By Simons et al., "A muscle pain disorder characterized by the presence of a myofascial trigger point within a taught band, local tenderness, referral of pain to a distant site, restricted range of motion and autonomic phenomena."
What Syndrome may develop due to the following? Low-level muscle contractions, uneven intramuscular pressure distribution, direct trauma or eccentric contractions
Myofascial pain syndrome
What syndrome is defined as sensory, motor and autonomic symptoms caused by the Myofascial Trigger Point (MTrP)?
Myofascial pain syndrome
What are the typical additional characteristics of fibromyalgia?
Myofascial pain syndrome Migraine headaches Chronic fatigue syndrome Irritable bowel syndrome Restless leg syndrome TMJ pain History of depression or anxiety disorders
What soft tissue manipulation technique is described as... Release adhesions between layers of fascia so they can move independently
Myofascial release
What are the different types of mechanical techniques of soft tissue manipulation?
Myofascial release Cross friction Traegering Rolfing Neural tension
What is defined as a hyperirritable spot associated with a hypersensitive, palpable nodule in a taut band of skeletal muscle?
Myofascial trigger point
The following reasons are suspected causes of pain due to what? Over-loading of motor units, An increase in calcium (Ca 2+) in the skeletal muscle Excessive acetycholine (ACh) at the motor endplate Vitamin deficiency and impaired circulation due to an increase in intramuscular pressure.
Myofascial trigger points
According to the cycle of fibrosis, it begins with a Chronic, low-grade irritant that triggers an inflammatory response. As normal macrophages debride the area, and there is increased vascularity. Yet due to inappropriate stress, immature collagen form cross-links with each other and decrease tissue mobility. What is the role of myofibroblasts, in the next process?
Myofibroblasts, which have also migrated to the damaged area begin to contract their actin and myosin components, shrinking the tissue, further impeding movement, increasing tissue strain, producing pain and once again triggering an inflammatory response
What are Nociceptors and what is there function?>
Nerve fibers that are selectively responsive to stimuli that may potentially damage tissue or stimuli from actual tissue damage
What soft tissue manipulation technique is described as , treatment of peripheral entrapment neuropathies...
Neural tension
How long should a Hoffa massage be? It is used as a gentle and light handed technique causing little discomfort as possible
Never more than 15 min
What is the typical Pt management of fibromyalgia?
No cure Team approach Correct any mechanical dysfunction Low-impact aerobic Low-resistance exercises
What are the associated disorders with soft tissue lesions/mechanical lesions?
Non-specific
What neurochemicals are reduced in patients with fibromyalgia leading to central sensitization
Norepinephrine and Serotonin
What chemical levels are reduced in patients with fibromyalgia that contributes to central sensitization? What chemicals are elevated in the cerebrospinal fluid of the patients of fibromyalgia and how does these chemicals contribute to the central sensitization symptoms?
Norepinephrine and serum serotonin(inhibits substance P transmission) are reduced FMS patients have higher levels of substance P, which is a neurotransmitter in the pain signaling process. Glutamate is also elevated. These contribute to central sensitization.
What did John Mennell suggest to promote normal arthrokinematics?
Normal range, is prerequisite for pain-free movement Mechanical restoration of joint play, by moving joints in selective way and improving extensibility of surrounding tissue
How does Stan P. Describe a joint play motion?
Not under voluntary control and only occur in response to outside force. Detects joint ability to relieve and absorb extrinsic forces Typically a distraction force and is within all classical ranges of motion
What kind of work task can cause myofascial pain?
Occupational groups with constrained work postures and repetitive arm movements Work tasks with high repetition frequency and static muscle loading may actually decrease the pain pressure threshold and result in allodynia and hyperalgesia
What type of information does Ruffini's corpuscles transduce?
On skin, and respond to steady indentation. Fibrous CT responds to tension on ligaments
How is the movement approach different?
One the patient actively participates in therapy Clinician guides the patient through a series of movements to change aberrant patterns and retrain into more efficient movements and postures
What is the energy crisis hypothesis in the explanation of myofascial muscle trigger points ?
Ongoing contractures compromise the local circulation and reduce the oxygen supply which triggers many vicious cycles... O2 in trigger points is far below normal levels Leads to hypoxia, hypoperfusion and decrease in pH Production of ATP is impaired Lack of ATP maintains the actin myosin cross bridges and contractures Lack of ATP also leads to increase of acetylcholine, failure of calcium pump and increase in calcium ions All reinforce muscle contraction
Following immobilization or aging, CT is presented with more significant changes within the ground substance or significant loss of collagen?
Only significant changes in loss of ground substance, and not collagen
According to Dr. Janda's clinical experiences, how do opposing muscles interact?
Opposing shortened agonist muscles inhibits an antagonist muscle
What is Aston Pattering soft tissue mobilization technique?
Outgrowth of Rolfing "soft hands" - how to impart an effective force with hands but still keep it comfortable for pt Practitioner must be in an efficient posture for treatment to translate to pt Not necessarily symmetry we aim for but balance (ASYMMETRY IS OKAY)
What is Aston patterning pattern used for in terms of soft tissue mobilization?
Outgrowth of Rolfing. Talks about body position of therapist and patient to have good position/body mechanics. Soft hands and better efficiency in delivery of technique
Why does the connective tissue adaptively shorten if the stresses are not applied on it for a long period of time?
Over time, new collagen is laid down to replace old collagen. If no stress is placed on the tissues for a period of time, the collagen laid down will cause the adaptive shortening
What are the suspected causes of pain via myofascial trigger points?
Over-loading of motor units, An increase in calcium (Ca 2+) in the skeletal muscle Excessive acetycholine (ACh) at the motor endplate Vitamin deficiency and impaired circulation due to an increase in intramuscular pressure.
Describe the Flower and Pheasant study from 1998 about PIP fixation.
PIP fixation for multiple weeks, which was just immobilized. All PIP returned to full range after giving controlled stress for 20 min.
What technique uses diagonal movements based on synergistic patterns to effect the nervous system and improve posture? This technique is also used to address dysfunction caused by muscle weakness, poor coordination, and joint restriction
PNF
What are the 3 main types of movement theories?
PNF ALEXANDER FELDENKRAIS (ASHTON PATTERNING AS WELL)
What are the techniques that focus on movement and eliminating abnormal movement patterns as a soft tissue manipulation technique?
PNF Aston Patterning Feldenkrais Alexander
What kind of mechanoreceptors are very sensitive in sensing stimuli, but are poor at localizing it?
Pacinian Corpuscle
What kind of mechanoreceptors are located in both hairless and hairy skin. Also found in fibrous periosteum near ligamentous attachments and in anterior/posterior horns of knee meniscus?
Pacinian Corpuscles
What may cause muscle weakness with myofascial pain syndrome?
Pain Restrictions in ROM Inhibition of gamma motor neuron activity Reflex inhibition of anterior horn cell function as a result of painful sesnsory input.
According to John Mennell, what are causative factors of joint pain?
Pain arose from synovial joints in back From: Intrinsic joint trauma Immobilization, aging, disuses Healing of more serious pathology
Describe the diagnosis process for fibromylagia
Pain description Wolfe pain questionnaire
Describe the typical pain patterns, lifestyle pattern, causes and medical work-up of soft tissue dysfunction
Pain pattern: Localized Lifestyle: non-specific Causes: Trauma/mechanical Medical work-up: Positive
Describe the typical pain patterns, lifestyle pattern, causes and medical work-up of myofascial pain sndrome
Pain pattern: Regional Lifestyle: De-conditioned Causes: Central and peripheral sensitization Medical work-up: Negative
Describe the typical pain patterns, lifestyle pattern, causes and medical work-up of fibromyalgia
Pain pattern: Widespread Lifestyle: De-conditioned Causes: Central sensitization Medical work-up: Negative
What are ways for pain reduction for myofascial trigger points?
Pain reduction may be initiated using a variety of techniques including manual inhibitive pressure, spray and stretch, dry needling or injections.
Exercise has been found to reduce levels of norepinephrines and 5-HT, both required to modulate and/or inhibit the release of neurotransmitters involved in what?
Pain, such as susbstance P and excitatory amino acids such as glutamate and asparate
What should be done, in a manner that is superficial to deep, from the lightest touch of the skin down to the periostrium when the muscle attaches to bone, if tolerated?
Palpation
How do you confirm a trigger point? What is a local twitch response?
Palpation of a taut band, which elicits a local twitch response. Local twitch response: Brief involuntary contraction of the top band, that can be palpated
What three components are typically involved in a palpation examination for myofascial conditions?
Palpation of myofascial structures in the form of layer palpation Palpation of joint structures Assessment of passive segmental mobility
If your patient presents with a relatively flat spine or with excessive curvature, what would the muscle imbalance be?
Paraspinal muscles may be more developed in lumbar spine and less developed in thoracic spine
What are the 6 characteristics of trigger points?
Patients complain of a deep, poorly localized ache and in some cases burning or tingling Active trigger points produce symptoms constantly Latent trigger points produce symptoms only when stimulated or stressed via palpation, contraction or stretch. The presence of trigger points is one of the primary diagnostic criteria of myofascial pain syndrome as they are the source of motor, sensory and autonomic changes within the tissue. Motor components are affected through disturbed function, muscle weakness/inhibition, muscle stiffness and decreased ROM. The sensory components are affected by local tenderness, referred pain and peripheral and central sensitization further resulting in allodynia and hyperalgesia. The autonomic components are affected by vasoconstriction, vasodilatation, a local twitch, sweating or a feeling of nausea.
What muscles can refer pain in area of shoulder?
Pec minor
What is the location of the target tissue of the anterolateral elongation technique?>
Pectoralis major and the external oblique abdomina Is, the sheath is continuous from the proximal humerus, clavicle, and anterior shoulder down to the contralateral crest of the ilium, thoracolumbar fascia, anterior superior iliac spine, inguinal ligament, and the pubis.
More active trigger points seems to present with more features of what feature that decreases the pain threshold?
Peripheral and central sensitization
Both active and latent trigger points show what pathological process being taken place?
Peripheral sensitization along with neuroplastic changes within the spinal dorsal horn
Active and latent trigger points show features of what kind of sensitization?
Peripheral sensitization and neuoplastic changes in spinal dorsal horn
What is mechanoreceptors? What is there function?
Peripheral sensory receptors of mechanical events. Transduce mechanical energy into nerve impulses that are transmitted to CNS. Located throughout MSK system, vascular tree and skin
What is a prerequistie for dorsal horn changes?
Persistent nociceptive activity
Postural or Phasic: ABS
Phasic
Postural or Phasic: Dorsiflexors
Phasic
Passive tension on the tissues due to poor posture results in what 3 main things?
Poor attenuation of forces in viscoelastic structures Tissues held in shortened range Loss of sarcomeres in muscles Abnormal firing patterns Ligamentous creep Circulatory stasis and delay in healing
Postural or Phasic: Iliospoas, rect fem, TFL, hamstrings, prifiromis
Postural
Postural or Phasic: Pecs, UE flexors
Postural
Postural or Phasic: Plantar flexors
Postural
Postural or Phasic: QL, ES< rotators,
Postural
Postural or Phasic: SCOM, UT, LS
Postural
How does posture lead to dysfunction?
Postural and habitual patterns cause tissue adaptation and dysfunciton
What is the main differences between postural and phsaisc muscles?
Postural muscles are said to be older genetically and are those which maintain posture during gait. Postural muscles tend to have a higher resting tone and are stronger than phasic. They respond to dysfunction by shortening and atrophy less quickly than phasic muscles. Phasic muscles respond to dysfunction by becoming inhibited.
Phasic or Tonic: They respond to dysfunction by shortening and atrophy less quickly
Postural or tonic
Soft tissue restrictions in the diaphragm can lead to or be a result of what?
Postural problems such as forward head, protracted shoulders or general slumped posture in sitting
What is the balanced position in which you hold your body that is the most energy efficient?
Posture
The pain resulting from trigger points can be quite debilitating. As muscles are inhibited, MTrP's may lead to further changes in what?
Posture Movement patterns Loss of function
What is defined as posture?
Posture is defined in your assigned reading as balance and muscular coordination and adaptation with minimal expenditure of energy.
Describe the Gratz study on tissue from 1938?
Precourser for neural tension and myofascial release studies. IMPLIES THAT FASCIA CAN CREATE PERIPHERAL ENTRAPEMENT AND NEUROPATHY. You need different layers to move. All layers must move unless you may have entrapment.
Prepatory technique for scapula-thoracic myofascial manipulation
Preparatory technique for scapula-thoracic myofascial manipulation: med (close to spine) to lat stroking
What is the key factor in the current thinking of myofascial trigger points?
Presence of excessive acetylcholine at the motor end plate.
What is the main criteria of myofascial pain?
Presence of myofascial trigger points
Where are myofibroblast located in the body?
Present and active in granulation tissue (part of mechanotransduction system) Also present in normal human fascia, specifically the fascia lata, plantar fascia, and lumbar fascia
What are plasma cells and when are they found in the body?
Present primarily during infectious states. Part of immune system and responsible for synthesizing antibodies.
What type of information does muscle spindles transduce?
Primary: respond to dynamic change in muscle length Secondary: Muscle length in static position
What happens when fibrotic tissues restricts CT, and afferent signals are altered?
Produce abnormal firing patterns, possible muscle inhibition, aberrant movement patterns and eventually dysfunction
Low intensity aerobic and low resistance exercises are best approaches for fibromylagia. What else do programs include?
Programs including strength and flexibility activities have shown to improve mood and physical function. Those including aerobic exercise caused patients to rate themselves as much better in 3 months time, decreased number of tender points, and improved scores using the Fibromyalgia Impact Questionnaire
The diaphragmatic techniques are used for correcting restrictions in diaphragm and inferior border of rib cage. Also with difficulty with postural reeducation. How is this technique performed?
Progression from a gentle stretching of superficial and middle layers in supine and side-lying positions to deeper layers that have the patient in a seated position and use the patient's breathing to increase depth
The following are effects of what? Stretch out abnormal fibrous tissue Release fascial adhesions Restore proper tissue mobility and length Prepare tissue for improved movement patterns and function
Progressive soft tissue manipulation and movement on immobilized tissue
What are the goals of PNF?
Promote functional movement through facilitation, inhibition, strengthening, and relaxation of muscle groups
Muscles have a wide-range of nociceptors for what substances?
Prostaglandins, Proteins Serotonin ATP's Glutamate
When tissue is damaged in the inflammation phase, what is released from cell membranes, to produce pain to limit movement and further damage to the tissue?
Prostaglandins. **tells brain to not move area, to prevent further injury
According to the proper treatment sequence, we should start with applying soft tissue manipulation first, then applying joint mobilization after the myofascial tissue has been normalized. Then elongate joint and myofascial tissues, and then do neuromuscular reeducation exercises. What is the last step of the treatment sequence and why?
Provide postural instruction for long-term self-care. Tissue mobility has been restored, joint mechanics are normal, and the surrounding tissues have appropriate length and strength to begin postural instruction/corrections. If given too early, these instructions might frustrate your patient. If your patient just needed to simply "stand-up straight", he or she certainly could have. I'm sure a family member would offer to bark out those orders. But once you have taken your patient through the previous steps, he/she not only will have the ability to make the necessary postural changes, but will most likely have the desire to maintain them because you set him/her up to succeed.
What are the 3 critical functions of the ground substance?
Provides medium of diffusion for cellular nutrients and waste Provides a mechanical barrier against foreign bodies and bacteria to fight infection Provides medium in which the collagen fibers can slide and glide when providing strength to tissue
How do you perform scapular framing?
Pt in S/L with arm you want to treat up. Strength comes from body weight shift and pulls up on scapula with soft hand contact. Start superior, then go medial to lateral. Retract then scoop under medial boarder. Retract shoulder with alternate hand by pushing anterior shoulder in posterior direction. Then both hands are on superior medial boarder out to acromion for next stroke. Must go from C/T junction ALL THE WAY OUT TO ACROMION. Then stroke out to lateral boarder. ***Can use as a preparatory technique for scapular distraction
How do perform the cross friction of the gastroc-soleus?
Pt in prone with pillow under stomach. Knee flexed to 70 degrees. Put finger contact in V-portion of gastroc, where it splits into medial and lateral. watch out for popliteus pulse. 4 finger contact of 2nd-5th digits, and wiggle back and forth. Can also do prolonged ischemic pressure.
How do you perform the lateral elongation of peroneals?
Pt in sidelying with leg you want to work on up. Pillow under leg. Use a 2 finger contact with 2nd digits down the leg surrounding fibula. To make more aggressive use the thumbs. Work inferior down leg to lateral malleolus. Then you can work peroneals by moving slightly posterior. ***Make more aggressive by using power grip and knuckles, which provides broader contact on target tissue.
How do you perform the tibial clearing technique?
Pt in supine: Put thumb on lateral aspect of tibial crest, and full hand contact on medial aspect of tibial crest. Hand should be tight together, to protect MCP joint. This technique can be used on medial calf as well.
How do you perform the lateral tibial fascial distraction?
Pt is in prone, and knee is flexed to 70 degrees, and you push calf medial and distract muscles off bone. Knee also straight and push down on lateral side to distract peroneals off fibula
What is the process to learn functional awaraness via Feldenkrais?
Pt is verbally directed in a sequence of movement. Movement repeated slowly and with slight variations to correct abnormal
How does pain points indicate fibromyalgia?
Pt must have 11/18 to have fibromyalgia
Superficial Fascial Elongation of the Caudal Trunk Fascia
Pt. supine, forearm on ant/proximal thigh, cross arms and have other hand on abdomen (similar to long axis distraction). Good to perform after Psoas and Iliacus Release. Elongation stretch
Plantar fascia manipulation
Purpose: Although the plantar aponeurosis is cushioned by a thick layer of adipose tissue, restriction may result in' dysfunction or foot pain. Patients diagnosed with plantar fasciitis often find relief through manipulation of the plantar fascia. The purpose of this technique is to manipulate both the aponeurosis and the superficial tissues overlying the aponeurosis. (This technique is shown with the patient in prone position but may also be performed with the patient in a supine position.) Patient position: Supine. Therapist position: Standing at foot of table. Hands: Both hands are used to grasp the patient's ankle and provide a gentle distraction of the lower extremity. Execution: Beginning at the calcaneus, the therapist applies a longitudinal stroke to the full length of the plantar surface of the foot,from proximal to distal. The stroke is initially applied with the foot in plantar flexion,allowing the tissues to have some slack, but the foot may be taken into dorsiflexion as mobility improves or the subject's reactivity decreases. The pressure of the stroke may also be increased with decreased subject reactivity but should always begin gently and superficially. Movement may be added to this technique, either passively or actively. Passively. the therapist may further elongate the tissues by simultaneously stroking in a proximal-to-distal direction while taking the foot into dorsiflexion.
Cross friction of gastrocnemius soleus musculotendinous junction
Purpose: Many patients involved in ballistic-type sports and activities develop fascial thickening in' the musculotendm'ous junction of the gastrocnemius—soleus muscle group This phenomenon may occur with or without muscular shortening. The purpose of this technique is to manipulate the musculotendinous junction and the fascia immediately surrounding it. Patient position: Prone, with lumbar spine in neutral position, the knee flexed to 90°, and the foot moderately plantar flexed. Therapist position: Seated at srd'e of table at lower leg of patient. The patient's leg is resting against the therapist. Hands: The therapist's hands gently grasp the patient's lower leg so that the fingers come to rest directly over the musculotendinous junction of the gastrocnemiussoleus muscle group. Execution: The therapist applies firm pressure over the musculotendinous junction using the fingers and applies a firm cross-frictional movement across the junction, watching for the patient's response (Figure 8.107). This area can be exquisitely tender in active patients participating in' ballistic-type sports and activities. The therapist holds the tissue in the shortened range, which creates slack and allows for access to deeper tissues. A stretch can immediately follow the application of this technique.
Lateral Telescoping Lateral Elongation of Upper Thoracic Area
Purpose: The purpose of this technique is to elongate the soft tissuestructures ofthe upperthoracic area (posterior and anterior). Thetechniqueis especially applicable for patients with protractedshouldergirdlecomplexesand forward-head postures. After application ofthe technique. the shoulder girdle and upper thoracic spine assume a more relaxed and retracted position. This technique should be used before attempting postural reeducation techniques. Initially, the clinician emphasizes both the anterior and posterior structures ofthe upper thoracic area. As the technique progresses. more emphasis is placed on the anterior structures. Three alternate hand placements are described, each of which progresses in'to deepertissues ofthe anteriorchest. Pt. supine. Sit on the diagonal of the pt. and have an A/P stance when seated. Anterior hand on SC jt,, other hand will wrap around to the spinous process superficial slide lateral towards acromion then back medial to those locations.
Lower extremity/posterior quadrant fascial elongation
Purpose: The superficial fascia of the lower extremity is one continuous cylinder anchon'ng to the sacrum and Him crest. Changes in the lower extremity fascia often result in changes within" the lumbar spine, and vice versa. The purpose of this technique is to elongate the superficial fascial sheaths continuously as they travel up the posterior-lateral lower extremity and into the lumbar spine. Because the primary target is loose connective tissue, elongation is time dependent. Patient position: Supine. Therapist position: Standingat footoftable. Hands:The therapist uses bothhandsto graspthepatient's ankleand provide agentledistraction ofthe lowerextremity. Execution: As the lower extremity is distracted, the therapist slowly applies forces, taking the lower extremity into flexion, 'mternal rotation, and adduc'tion (Figure8108). As the tissues creep, movement shouldcontinue through thelower extremityinto the posterior knee, then into the hip, and eventually into the low back and trunk Themovement iscontm'ued until'the patient's leg iscrossed and the patient's lowertrunk is fully rotated into side—lying, but this is not necessary and depends on the flexibility of the tissues
Describe how to complete the unilateral rib P/A. How about the first rib and shoulder depression rocking technique.
Put middle finger on anterior aspect of first rib, which is just inferior to SC joint and is a bony nubbin. Other middle finger on posterior rib, through the Upper trapezius, and get a rhythm as you pass the rib, back and forth with your middle fingers. First rib and shoulder depression Rocking technique: Depress the scapula, by putting hand contact on shoulder and other hand is on posterior rib, which is pushing the rib anterior.
What are the mechanical dysfunctions associated with myofascial pain syndrome?
Range of motion restrictions Muscle weakness without weakness Due to pain and shortness of muscle fibers
6. What are the basic premises of Rolfing? What is the goal for the human body that all Rolfer's are striving for?
Realignment of body posture through systematic, aggressive soft tissue work o Balance and harmony of movement, which soft tissues will directly influence quality of movement ▪ 1 hour session with the potential of a "post-ten" GOAL: the goal of such treatments is to help the body become more efficient in posture, balancing itself against the force of gravity
What happens when two acetylcholine molecules bind to a nicotine acetylcholine receptor across a synaptic cleft in the muscle?
Receptor opens the cation channels which in turn facilitates a sodium influx and potassium efflux across the membrane This will depolarize the post-synaptic cells and trigger a miniature endplate potentionls. Enough of these will produce a AP which travels along the P-tubules which trigger the receptors in the sarcoplasmic reticulum and causes release of calcium ions for SR
What happens to a muscle nociceptor following noxious stimulation?
Receptors release severeal neuropeptides including substance P and CGRP
The shortened muscle must be stretched before attempting to strengthen the inhibited muscle based on what concept?
Reciprocal inhibition
Who was James Mennell and what role did he have in understanding joint and soft tissue dysfunction?
Recognized lack of mobility of the facet joints is causative factor in back pain This soft tissue dysfunction as causative factor in back pain → lead to development of theoretical basis of soft tissue manipulation
Why is exercise effective for fibromyalgia patients?
Reduced levels of norpinephrine and 5-HT both required to modulate and/or inhibit the release of neurotransmitters involved in pain, such as substance P and excitatory amino acids such as glutamate and aspartate.
What is myofascial pain syndrome characterized by?
Regional myofascial pain
What does it mean for a CT to be fixed?
Regularly found in CT (fibroblasts) (Fixed vs. wandering)
Briefly describe the Alexander technique
Relationship of the head and neck posture in relation to voice projection Objectives are improvements in both posture and body mechanics Position and motion of the head and neck are the CORNERSTONE of the Alexander technique
What are the effects of superficial, gentle soft tissue manipulation on immobilized tissue?
Relaxation, release of muscle spasms, contraction or tension Increase in tissue temperature Mast cell stimulation Capillary dilation Increase in blood flow Increase in fibroblastic recruitment Proper collagen fiber alignment
What is Myofascial release technique of soft tissue manipulation?
Release adhesions between layers of fascia so they can move independently. May be direct traction or inherent rhytmic motions of human body
What are the many purposes of soft tissue techniques?
Release of muscle spasm, contraction or tension Stretching out of abnormal fibrous tissue Release of fascial adhesions Alter spinal reflex activity Increased blood flow, relieve pain Create structural harmony and balance
What happens to mast cells when they are distrubed?
Release vasodilators, histamin, which dilate blood vessels to increase blood flow and tissue permeability increases to allow influx of interstitial fluid
What are the benefits of Connective tissue massage?
Releases nerve impusles along specific CNS pathways. Directly influences CT that is locally altered. Sets general circulation in order. Allows pt to grow accustomed to hands Provides good entry to deeper tissues
What is an INDIRECT myofacsial release?
Require less force and require longer duration hold. Very gentle Better for patients that are more tender and guarded.
Describe the dynamic nuclear bag fiber muscle spindles
Responsible for relaying info regarding rapid change of muscle length. Found in abundance in phasic muscles!
Describe nuclear chain fiber muscle spindles
Responsible for relaying information regarding slow change in muscle length and are heavily concentrated in tonic or postural muscles
Describe static nuclear bag spindles
Responsible for relaying information regarding tonic information about spindle length
What is the effect of prolonged stresses on fibroblasts in the CT?
Results in denser, more tightly structured connective tissue and in some cases less mobile.
What are the most primitive form of CT in adults and form the meshwork structure which provides a supporting framework?
Reticular fibers
Rib splaying/space of Ribs 1-3
Rib Splaying: Ribs 1—3 Note:This hand placement provides the most aggressive form oflateral elongation ofthe upper thoracic area. The depth of penetration is to the m'tercostal Pt. supine. Power grip to scour btwn ribs. Can time with breathing. Good to help with pt.'s recovering from mastectomy or those with FH/RS posture.
Describe the subcranial region or transitional zone of the spine?
Rigid occiput transitions to mobile cervical spine Transverse facet orientation of O/A and A/A transitions to 45 degrees facet orientation in frontal plane for cervical spine. **Goes into excessive extension with FHP No disc between O/A or A/A for reinforcement Bi-convex facets at A/A Multiple ligament reinforcement between O/A and A/A with prolific CT
What is the pathogenesis of myofascial trigger points?
Role of acetlycholine and calcium. Normal: Alpha motor nerve inpulse creates depolarization of nerve cell membrane, causing calcium channels to open, and there is influx of calcium ions in muscle and release of acetylcholine, ATP into synaptic cleft
What technique has the idea with realignment of body posture through systematic aggressive soft tissue work?
Rolfing
What are the 3 main techniques that use mechancial approaches?
Rolfing Trager Myofascial release
What type of mechanoreceptors are Located in hairy and non-hairy skin, but also found in superficial layers of the joint capsules and surrounding connective tissues?
Ruffini corpuscles
What types of mechanoreceptors are Interwoven with local CT, which stimulates them as movement displaces the collagen fibers?
Ruffini corpuscles
What types of mechanoreceptors are Slow adapting receptors contributing to steady-state position sense and tactile stimulation?
Ruffini corpuscles
What type of skin receptors has a major advantage since it is slowly adapting and has large receptive fields? what is the advantage?
Ruffini corpuscles They do not "turn off" which means they contribute to steady-state position sense and tactile sensation
What is the cornerstone of osteopathic thought?
Rule of the artery and the rule of structure governing function
What are the examples of postural muscles?
SCOM UT LS Pecs UE flexors QL, ES, roatores Iliopsoas, Rect fem, TFL Hamstrings, piriformis Hip adductors Plantar flexors
21. What is intra-facial circulation loop theory?
SHORT TERM CHANGES to CT Interstitial myofascial receptors (i.e.: Ruffini organs, and interstitial muscle receptors) are key to short-term changes i. These receptors are found in CT and respond to slow, deep, steady pressure ii. Manual stimulation of the receptors produces changes in tone, vasodilation, and local fluid dynamics via the autonomic nervous system - process termed intrafascial circulation loop
How can restricted motion be reversed?
STM of involved and regional areas associated with local involvement Joint mobilization after normalization of soft tissues Joint and soft tissue elongation Neuromuscular re-education Postural instruction to remove levers and stresses for HEP
Describe the progression, we need to use as physical therapist to help reverse restricted motion
STM of involved and regional associated areas Joint mobilization after normalization of soft tissue Joint and soft tissue elongation (AROM/PROM) Neuromusclar re-education Postural instruction to remove levers and stresses
How would the diaphragmatic technique alter motor control?
STM would allow for new length and postulated reduction in the inhibitory activity of GTO's
Using a clinical example of the shoulder: Pectoralis major and upper trapezius (postural) shorted Pectoralis minor and mid/lower trapezius (phasic) are inhibited To restore muscular balance, first do what?
STRETCH tight/strong postural muscles to minimize phasic inhibition. Then strengthen phasic muscles and incorporate proper movements to restore normal shoulder functions
Why does sustained pressure help release myofascial trigger points, while the patient performs gentle contractions? (end-plate hypothesis)
Sarcomeres within trigger point are hyper contracted Transmit increased resting tension to neighboring sarcomeres While patient is contracting and relaxing, tension is release and pain and nodule are reduced. Resets sarcomere length
What muscles can refer pain in area of Wrist pain?
Scalenes, SCOM and cervical paraspinals
Scapula framing o Medial border o Superior border o Lateral border
Scapular framing is designed to manipulate myofascial restrictions on all three borders of the scapula. This technique should routinely be performed on scapulothoracic problems, problems of the upper thoracic and mid-thoracic spine, cervical problems, and certain' shoulder problems. Medial border (good technique to use before applying scapular distraction): start at superior angle and work to inferior angle while simultaneously pushing shoulder post for scapular retraction motion (too far = spinal rot) Superior border: similar to telescoping, pull med to lat (one hand on top of the other) all the way to the acromion—shift body weight instead of pulling Lateral border: cross hands, caudal hand stabilizes the shoulder, cephalic hand strokes down the lat border towards inf angle with palm of hand (BW is force)
Where are reticular fibers synthesized and what is the primary function?
Schwann cells and fibroblasts Fills space within body and supports viscera and lymphatic system
The second rib, is one of the 9 areas of tender point sites for fibromyalgia. Where in the second rib would you apply your less than 4Kg force to check for fibromyalgia?
Second Rib: Second costochonral junction
What are the advantages of the mechanical soft tissue manipulation technique?
Seek mechanical and histological changes. Applying force over same period of time, or direct force to take past area of restriction.
What are the sensory dysfunctions of myofascial trigger points?
Sensory components are affected by local tenderness, referred pain and peripheral and central sensitization further resulting in allodynia and hyperalgesia.
What is the definition of myofascial pain syndrome?
Sensory, motor and autonomic symptoms caused by the Myofascial Trigger Point (MTrP).
What is the typical sex, age and healing stage of soft tissue lesions?
Sex: non-specific Age: non-specific Healing stage: acute to chronic
Studies show that cell membranes of myotendinous junctions are highly resistance to what?
Shear forces that would increase their surface area. The design of the folds allows for much higher force transmission before tissue rupture
Describe the upper postural crossed syndrome
Short-ended cervical extensors and pecs Inhibited Deep neck flexors and lower scapula stabilizers, rhombs, traps
How does layer syndrome effect back muscles. This leads to a very unstable back
Shortened hamstrings (postural) Weak gluteal muscles (phasic) Hypertrophic trunk extensors Hypotonic scaps stabilizers and lower to mid thoracic Hypertrophic upper trapezius
What is the layer syndrome?
Shortened hamstrings (postural) Weak gluteal muscles (phasic) Hypertrophic trunk extensors Hypotonic scaps stabilizers and lower to mid thoracic Hypertrophic upper trapezius
Describe how a forward head posture may affect the shoulder girdle and muscles around the shoulder complex
Shoulder girdle protaction with internal rotation Shortening with the shoulder girdle internal rotation with lats, subscapularis, pecs and teres major. Muscle imbalances leading to abnormal firing patternns
How do you perform the pec major muscle play?
Shoulder is flexed up past 90. On the anterior pec muscle. Position thumbs underneath the pec muscle in the hallow. Other fingers are overtop. Draw elbows in. Create a convexity on anterior part of muscle. Fingers go out.
How does the pain threshold change with ACTIVE trigger points?
Significant lowering of pain threshold over active trigger points. In skin and muscle tissue
How does psychological arousal or stress influence myofascial trigger points?
Significantly increases electrical activity of myofascial trigger points
What are the similarities and differences in direct and indirect insertions?
Similarities Presence of superficial (attach to periosteum) and deep fibers (attach to bone via fibrocartilage) The junctional zones of ligament, tendon, and capsule are relatively avascular compared with the tissue on either side of the zone? Differences Main difference is that direct insertion has a ***fibrocartilaginous transitional zone*** and indirect DOES NOT!
What is Alexander pattern used for in terms of soft tissue mobilization?
Singers and Actors, used with voice projection, as posture efficiency affects voice (Habit awareness, habit inhibition, habit conscious control)
Describe the technique for lateral telescoping
Sitting at 45 degrees and perpendicular to clavicle. Feet on diaganol stance, as weight shift should be used during technique. Contact on inferior border of clavicle and superior margin of spine of scapula. Sweep across from medial to lateral. Pressure does NOT come from hands, it comes from shift of body. Sternum to acromion on anterior and lateral boarder of scapula to spine
Presence of trigger points in what muscles can present as carpal tunnel syndrome? P. 135 = Presence of trigger point in what muscle can present as lumbar radiculopathy?
Skubick et al. demonstrated that asymmetrical loading of the SCOM and cervical paraspinal muscles can result in CTS. A more recent study showed that 30% of patients suspected of having CTS presented with trigger points in the infraspinatus muscle. Glutes Pg 136 figure 6.1: referred pain patterns of the gluetus MINIMUS mimics sciatic nerve pain Pg 138: "pain down the leg could originate in the gluteal muscles", paragraph right before the Autonomic Dysfunction section Love, shark
What are the associated disorders with fibromyalgia?
Sleep disorders Psychological distress Multiple additional syndromes
What are the associated disorders with myofascial pain syndrome?
Sleep disturbances in late stages Any number of musculoskeletal dysfunctions Poor posture
How does Alexander propose posture efficiency?
Slow and gentle process, where we have: Habit awareness Habit inhibition Habit conscious control
What are mesenchymal cells?
Small, spindle shaped cells that eventually differentiate into adult connective tissue, from the mesoderm Develop into CT, Bone, cartilage or muscle
What is the main differences in location of soft tissue dysfunction, vs. myofascial pain syndrome vs. fibromyalgia?
Soft tissue dysfunction is localized to tissue damage that is acute Myofascial pain syndrome is regional pain problem Fibromyalgia is widespread and chronic
What is the Forceful passive movement of the musculofascial elements through its restrictive directions beginning with its most superficial layers and progressing into depth while taking into account its relationship to the joints concerned?
Soft tissue manipulation
What are the 5 reasons from the book, that suggest why you should always treat superficial to deep tissues?
Soft tissue manipulation to restore tissue mobility Joint mobilization after soft tissue has been normalized Joint and soft tissue elongation Neuro- Re-education to correct aberrant motion Postural instruction to remove levers and stresses
What is the Augment soft tissue manipulation approach?
Soft tissue manipulation used for the purpose of stimulating fibroblastic proliferation to promote healing. Uses specifically designed tools to "catch" and potentially break fibrotic adhesions in order to trigger an inflammatory response. The inflammatory response stimulates tissue healing and aids in debridement. Following each treatment session, patients are encouraged to maintain an active lifestyle as well as perform stretches/exercise NEUROMOTOR
The following is a definition of what? Impaired or altered funciton of related components of somatic system State of altered mechanics, palpable changes of integrity, increased or decreased mobility autonomic changes and emotional "muscular armor"
Somatic dsyfunction
Describe the 3 main mechanics of thixotroy in muscles
Some cross bridges remain connected even in absence of action potential. Viscoelastic properties of relaxed Skeletal muscle are related to titin filaments which link thick myosin filaments to z-lines of muscle Thought to explain the palpable muscle spasm with manual trigger points
What are chemoreceptors? What is there function?
Specialized sensory receptor cells which responds to chemical substances and generates a biological signal
Describe the diagnosis process for soft tissue lesions/mechanical lesion
Specific examination to support somatic dysfunction
Describe the cutivisceral reflex according to Ms. Dicke.
Specific organs and superficial tissues shared a common segmental innervation, of which, the highly innervated and vascularized skin is a key tactile stimulus receptor. Treating skin can help treat visceral organs and impaired organs can effect skin and pain in areas.
What is the end plate noise?
Spontaneous motor activity that occurs at the motor endplate in relation to myofascial trigger points
What is end plate noise?
Spontaneous muscle electrical activity in trigger point, when it is not present in rest of muscle band
How do you perform elongation of paravertebral muscles?
Start at about T4, and the power fingers and in the laminar groove. Pull up the groove and work up towards the occiput.
How should you start the diaphragmatic technique? What would you progress too?
Start in supine and if patient tolerates this, then goes to S/L More slack in superficial CT. Will engage the more deeper CT. Top hand moves medially to caudally. Then progress to seated technique where the patient's breathing makes the technique more aggressive
How should you approach relaxing a taut band?
Start with a prolonged hold. Then PARALLEL with fibers. Then you can go more aggressive by going PERPENDICULAR, once the tissue is more relaxed.
How do you perform the axial flexion of the cervical spine and O/A?
Start with fingers in the lamina of the lower cervical area. Use trunk extension to really perform the technique. Neck should be extending at point of contact and flexing neck below point of contact. Fingers slide out at end, while thumbs cup the ear.
Describe the history of current theories of myofascial manipulation/soft tissue treatment.
Started in ancient history to the 19th century, there was emphasis on Joint position. In early 20th century the emphasis was on mobility In mid to late 20th century emphasis was on how manual therapy effects the biomechanics of tissue. Present: Neural mechanics of back pain/movement reduction
How does occupation affect posture?
Static vs. repetitive postures lead to adaptation of tissues.
What type of information does Merkel's corpuscles transduce?
Steady indentation and pressure
Moving a substance with thixotropic properties will decrease what?
Stiffness.
What is the role of substance P and CGRP, in the muscle?
Stimulate vasodilation and increase the local microvasculature
During the fibroplastic phase, the temporary seal of the wound, gains strength as collegen fibers are laid down? What type of movement is good in this phase, and what determines the strength of the tissue?
Strength determined by collagen filaments, cross links, allowing for controlled movement. Gentle movement is good here. 3-5 weeks in this phase for ligaments and tendons PROM
What determines strength of a wound in the fibroplastic phase of healing?
Strength of the wound is determined not by the amount of collagen laid down but by the bonding of the collagen filaments or crosslinks
When organizing your treatment session, how should you sequence your treatment. muscle strengthening or neuromuscular reeducation?
Strengthen the muscles, and then you can teach them to make sure they are activated properly
What are the effects of progressive soft tissue manipulation and movement on immobilized or fibrotic tissue?
Stretch out abnormal fibrous tissue Release fascial adhesions Restore proper tissue mobility and length Prepare tissue for improved movement patterns and function
What are we stretching during a muscle play?
Stretch the muscle sheath, which allows more freedom for muscle to move. Break up adhesion of fasicule
Dr. Janda's complete treatment sequence is what? Starts with mobilize mainly soft tissue and joints if necessary
Stretch tight and shortened muscle using a combination of inhibitory techniques, which influence more muscle fibers and spindles. Strengthen weakened muscles using reflex methods such as PNF. Work/exercise within good/proper movement patterns.
What is the mechanical purposes of soft tissue techniques?
Stretching out of abnormal fibrous tissue Release of fascial adhesions
Rolfing is also termed what? How long is treatment
Structural integration. Treatment is 10: 1 hour sessions
What is thixotrophy?
Study of muscle and tissue mechanics "State of stiffness of a fluid that is dependent on history of movement" Physical property of muscle and other CT. Moving substance with thixotropic properties will decrease stiffness...
What are the substances in myofascial trigger points that cause increase in pain?
Substance P Bradykinin CGRP Stimulate free nerve endings that trigger nociceptor input. Very acidic enviornment
Elevated levels of Substance P is found in patients with Fibromyalgia, why is this important?
Substance P creates excess hypersensitivity of pain pathways, leading to chronic pain
Describe substance P's influence on fibromyaglia.
Substance P is higher in patients. It usually is neuropeptide in areas of inflammation
What chemicals were found in trigger points by Shah et al? P 143
Substance P, calcitonin gene-related peptide, bradykinin, serotonin, norepinephrine, tumor necrosis factor-alpha, and interleukin-1alpha, interluekin 6 and 8
What did Vladimir Janda focus on?
Suggested that function is not limited to joint mechanics Movement is dictated by muscular activity regulated by the CNS Balances will intensify in predictable patterns
Is connective tissue massage more of a superficial or deep form of myofascial manipulation?
Superficial
What composes the superficial structures of the lumbar spine?
Superficial fascia Thoracolumbar fascia, with deep irregular CT.
The following are effects of what? Relaxation, release of muscle spasms, contraction or tension Increase in tissue temperature Mast cell stimulation Capillary dilation Increase in blood flow Increase in fibroblastic recruitment Proper collagen fiber alignment
Superficial gentle soft tissue manipulation on fibrotic tissue
Where is the superficial fascia most mobile, where is it least mobile?
Superficial posterior fascia is mobile laterally and medially it is anchored to superficial bony structures, such as scapulae spinae, acromion, iliac crests and sacrum.
What is the typical Pt management of soft tissue lesions/mechanical lesions?
Support tissue healing Promote movement, strengthening and conditioning according to stage of healing
What are the basic concepts of the fascial sweater from IDA ROLF?
Sweater is analogous to superficial connective tissue Restriction in one area can lead to problems in another. Restriction in the shoulder can lead to problems in the hip
What is a motor endplate? What are the terminal branches for?
Synapse between the terminal end of motor neurons and skeletal muscles Terminal branches are single motor neuron ending in multiple presynaptic neurons
What is the difference between a taut band and spasm? What is the gold standard to differentiate between the two? P. 131
Taught Band An endogenous localized contracture w/in the muscle w/o 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 contractions.
What are the diaphragmatic techniques used for?
Techniques for correcting restrictions in diaphragm and inferior border of rib cage. Pt with difficulty with postural reeducation
What are the characteristics of tendons, which are dense regular CT?
Tendons: attach muscle fibers to bone and transmit forces expended by muscle to the bone allowing for tension or joint movement a. Collagen fibers are parallel in arrangement, providing the highest unidirectional tensile strength possible
What is a term describing an architectural principle where a combination of elastic and solid materials work together to make a structure stable but light.
Tensegrity: Like construction, used to withstand earthquakes For human body it is biotensegrity
What is tensegrity?
Term describing an architectural principle where a combination of elastic and solid materials work together to make a structure stable but light. For human body it is biotensegrity
Muscle Play - Quads
The concept of muscle play is applied to the quadriceps muscle where the surrounding fasciae are manipulated to provide more room for the quadriceps to contract and expand. The "bending of the water hose" analogy applies, but the technique has a different "look" compared with the muscle play of the erector spinae (Figure 8.19) because of the size of the quadriceps. compared with that of the erector spinae, and the location around the femur. Pt. supine, one hand stabilizes above the knee, lifts the tissue up and then across to the medial side—do it through the length of the muscle (you can be seated or standing—press down/posteriorly) if too tender you can do a post or ant force and push/pull into the table—can do an oscillation (high level of pain) or a hold—can also use a dummy thumb to work out adhesions (parallel 1st)—use palm for force
How do components of viscoelastic properities change with placed under stress?
The degree of deformation is determined more by the duration than amount of force Applied to Stress/Strain: Rapid elongation, representing the "taking up slack" which is elastic portion. As time passes, less elongation is achieved, representing the contribution of the viscous portion. When the stress is eventually released, the elastic portion recoils as some of the gained length is lost, while the changes in the viscous portion remain
Muscle Play - Gastrocnemius/Soleus
The fascial sheath surrounding the gastrocnemius—soleus muscle group is manipulated to increase extensibility and allow for more efficient contraction and expansion of the muscle group. Longitudinal stretching is also facilitated after application of this technique. Pt. prone, stabilize above the ankle—push the gastroc med/lat if too tender you can do a post or ant force and push/pull into the table—can do an oscillation (high level of pain) or a hold—can also use a dummy thumb to work out adhesions (parallel 1st)—use palm for force
Iliac Crest Release
The iliac crest release and lateral sacral release techniques are used to manipulate the fascial planes in the area of the il'iac crest. the top one-third of the ilium.and the lateral border of the sacrum. The area of the iliac crests contains connective tissue thickenings from various muscular and fascial attachments and is vulnerable to myofascial restrictions. Movement restrictions in forward bending, side bending, and backward bending can originate here. The posten'or portions of the fascia] planes create the forward-bending restrictions, whereas the anterior portions create backward—bending restrictions. Chisel Grip (keep your fingers flat/don't curve them [less aggressive this way]) OR Power Grip
ITB/Paratrochanteric Area (Elongation Stroke)
The iliotibial band (1TB) is an area commonly involved in lower kinetic chain problems, kneedys function, and hip and low back dysfunction. Many diffuse "referred pain" syndromes in the lower extremity can be traced to iliotibial dysfunctions. Treatment of this area becomes important to a variety of problems, even if the patient has no conscious awareness ofpain in thearea. Many times the patientwill be exquisitelytender over thearea ofthe 1TB and surrounding tissues when other dysfunctions are symptomatic nearby. This technique actually addresses four distinct areas: (1) the connective tissue "groove" between the [TB and the lateral hamstrings, (2) the groove between the ITB and the lateral quadriceps, (3) the superficial tissues overlying the ITB, and (4)the ITB itself. Because loose irregular connective tissue is the most easily manipulated, the surrounding connective tissue will more readily respond than the [TB. This technique also addresses the paratrochanteric area. The connective tissue surrounding the greater trochanter is also often dysfunctional; this includes tissue that is superior, inferior, anterior, and posterior to the greater trochanter. -Use lotion (more hair = more lotion); Pt. supine /c hook lying—can also bring them into greater amounts of tension (foot on top of knee) 1. Ant Margin: stabilize knee, use power grip to sweep down all the way around GT into ER 2. Post Margin: switch hand contacts—stabilize knee, use power grip to sweep down all the way around GT into IR
According to the 1972 study by Tabery, what was found about the change of sarcomeres of a limb cast in shortened position
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.
What is the main criterion for the diagnosis of myofascial pain? P.129
The presence of an active myofascial trigger point (an exquisitely sensitive region in a taut band of skeletal muscle)
What is the primary component of noncontractile fluid?
The primary component of noncontractile fluid component is water, which is retained by the nonsulfated glycosaminoglycans ( GAGs) and makes up about 70% of the extracellular matrix.ce.
Myofascial Manipulation of the Hamstring (A&B pt. supine /c leg flexed and on your shoulder. C pt. prone /c leg bent onto your quads) - Cross Friction over the ischial tuberosity and Hamstring Insertion
The purpose of these techniques is to manipulate the hamstrings in preparation for aggressive stretching. the hamstrings may be restricted in a longitudinal direction,medial—lateral direction, or in a diagonal plane. Identifying and treating lesions in the appropriate plane and position may release specific restrictions and may increase flexibility of the hamstrings prior to stretching. Cross Friction over the ischial tuberosity and Hamstring Insertion: chisel grip onto insertion and saw med/lat; can also use the dummy thumb to do this technique
QL Erector Spinae Release Manipulation of Deep Mid-Lumbar MF tissues
The purpose of this technique is to alter the connective tissue in the mid-lumbar area, and specifically around the L3area. Because L3 is generally the apex of the lumbar curve, and the site of hypomobility, myofascial preparation of the area is necessary prior to joint manipulation. The transverse process ofL3,being the longest in the lumbar spine, can easily be palpated. o Treatment triangle- find lateral aspect of L3 TP o Move fingers cephalad, caudad, medial, lateral- mobilize any lesions
QL Erector Spinae Release Scouring QL through web space while other hand brings pelvis caudally
The purpose of this technique is to alter the connective tissue in the mid-lumbar area, and specifically around the L3area. Because L3 is generally the apex of the lumbar curve, and the site of hypomobility, myofascial preparation of the area is necessary prior to joint manipulation. The transverse process ofL3,being the longest in the lumbar spine, can easily be palpated. passively hike the hip with bottom and and manipulate with top hand or forearm
QL Erector Spinae Release Shorten and manipulate
The purpose of this technique is to alter the connective tissue in the mid-lumbar area, and specifically around the L3area. Because L3 is generally the apex of the lumbar curve, and the site of hypomobility, myofascial preparation of the area is necessary prior to joint manipulation. The transverse process ofL3,being the longest in the lumbar spine, can easily be palpated. passively hike the hip with bottom and and manipulate with top hand or forearm
Bony clearing of the tibia
The purpose of this technique is to clear fascia from the anterior and posterior compartments as they adhere to the tibia. Many lower kinetic' chain problems, especially in" athletes participating in ballistic sports (running. basketball, soccer, etc.), develop fascial adhesions related to so-called shin splints. the bony clearing techniques are effective in manipulating the fascia as it adheres to the tibia.This technique can be used for both anterior and posterior compartmental syndromes. Patient position: Supine. Therapist position: Standing or sitting at foot of table. Hands: The thumb pushes off the border of the tibia, creating a "wedge" between the bone and the approximating soft tissue. The thumb is positioned either anterior or posterior, depending on the compartment that is affected. Execution:A small amount of lubrication is used. The thumb drives a wedge between the bone (tibia crest) and the approximating soft tissues distally. The thumb then moves proximally, continuing to stay in the wedge. and also continuing to approximate the tibia (Figure 8.98). In compromised areas, either the wedge will not be as deep or adhesions will make the wedge nonexistent. These adhesions need to be manipulated. To manipulate tissues from the posterior side, the patient's knee is bent, and the foot is placed on the table to provide slight slackin the tissues
Forward Bending Laminar Release (better for pt. with stenosis or pregnant) Cervical Spine Laminar Release UT/LS
The purpose of this technique is to elongate the posterior myofascial structures of the lumbar, thoracic, and to a certain extent, cervical spines. As with the previously described quadruped technique. the patient actively participates in' the technique; the technique also allows for working with patients larger than the therapist or with patients who cannot assume a quadruped position because of a knee or shoulder impairment. Specificity is somewhat sacrificed. but significant mechanical advantage is gained in performing the technique in a sitting position. Cervical Spine Laminar Release UT/LS: hold top of pt.'s head, start at the Occiput and have the pt. nod head downward to ~T4—bias with flex/rot to opp side
Forward Bending Laminar Release (better for pt. with stenosis or pregnant) Seated
The purpose of this technique is to elongate the posterior myofascial structures of the lumbar, thoracic, and to a certain extent, cervical spines. As with the previously described quadruped technique. the patient actively participates in' the technique; the technique also allows for working with patients larger than the therapist or with patients who cannot assume a quadruped position because of a knee or shoulder impairment. Specificity is somewhat sacrificed. but significant mechanical advantage is gained in performing the technique in a sitting position. Seated: Power grip is used (straight and with bias left and right): as the pt. reaches forward run down the lamina—bias a side by having pt. flex/rot to the opp side
Forward Bending Laminar Release (better for pt. with stenosis or pregnant) SL
The purpose of this technique is to elongate the posterior myofascial tissues of the lumbar spine. This may be necessary in hyperlordotic postures or in preparation for joint manipulations. As discussed earlier, soft tissue and joint manipulation have a unique relationship in that either the soft tissues or the joint may be contributing to a hypomobility. Passive segmental mobility of a joint may change dramatically after releasing soft tissue. On the other hand, joint manipulation may have a profound effect on the surrounding myofascial tissues by way of stimulating joint receptors. This technique is often performed before, during. and after joint manipulation to complement specific joint maneuvers. SL: top leg bent, one arm stabilizes with flat hand, the other hand is flat and rakes down the lamina in a curved motion with the middle and ring fingers—promoting flexion
Long Axis Distraction of Superficial Connective Tissue
The purpose of this technique is to elongate the superficial connective tissues, usually in the cephalic—caudal direction. Because the subcutaneous connective tissue is multidirectional in fiber orientation, diagonal restrictions may occur and should be treated, This technique can also be performed on a deeper level to provide an elongation of the spine itself. Pt prone. No lotion. Cross arms with broad contact of the hand: sacrum and lower end of thoracic spine. Sustained hold for ~1-2 min, you should feel the creep/give and the skin will elongate. Fascia has smooth muscle that is tied in with the ANS. You can move at a diagonal, hold tissues or oscillate. [hands inside elbows and keep arms flat on pt]
Medial-Lateral Fascial Elongation
The purpose of this technique is to elongate the superficial fascia in the medial—lateral direction The most superficial application of the technique is autonomic, whereas any deeper application is primarily mechanical A minimal amount of lubricant is applied to the patient's back to prevent skin irritation. Pt prone. Apply very little cream. Flat arm contact with hand flat, pull med to lat—as far lat as the tissues will let you go. Start superficial, this is good for when you do want to become more aggressive (lean in more—use olecranon process to slide around Iliac Crest and onto QL, erector spinae, and obliques). Squat with the motion—not an arm movement
Transverse fascial stretch of the biceps
The purpose of this technique is to increase the medial-lateral mobility of the biceps in preparation for stretching or strengthening Certain low-grade peripheral entrapment neuropathies respond well to stretching of the biceps in a medial-to-lateral direction. This seems to free up the nerves as they pass through just posterior and medial to the biceps. Certain' proximal humeralfracturescause the binding down of the biceps,and this transverse fascial stretch will be beneficial for this type of condition as well. Patient position: Supine. Therapist position: Standing outside patient's arm if treatment is applied in lateral-to-medial direction, and inside patient's arm if technique is applied in medial-to-lateral direction. Hands: The heel of the therapist's hand is placed lateral to the muscle if the technique is going from lateral to medial and is placed media] to the muscle if the technique is going from medial to lateral. Execution: The heel of the hand pushes the biceps in a transverse direction (lateral to medial. or medial to lateral) until all the "slack" istaken out ofthe muscle. Once the tissue is at the end ofthe elastic range, the therapist pushes intotheplastic rangetoget thefinal stretch (Figure8ll4l). The stretch is held 3—5 secondsand then repeated.
QL Erector Spinae Release Medial to Lateral Stroking of L/S in SL (elongation)
The purpose of this technique is to prepare the quadratus lumborum and the lateral fascial structures of the lumbar spine for elongation and stretch techniques. The technique involves sustained pressure and has the primary goal of reducing active tonic contractions of the quadratus lumborum. After the tone in the quadratus is diminished, the elongation and stretch techniques applied are more effective and efficient. Medial to Lateral Stroking of L/S in SL (elongation): full hand contact, gliding on superficial tissue and work deeper
Lateral fascial distraction of the tibia
The purpose of this technique is to stretch the posterior compartment fascia that is adhered to the tibia medially. As with the bony clearing of the tibia technique, described above, this technique is effective in the treatment of lower leg compartment syndromes, shin splints, and so forth, that are caused by excessive ballistic lower kinetic chain activity. Therapist position: Seatedon side of table at patient's lower leg. Hands: The lateral hand isplaced distally and will be used as a cantilever. The palm of the medial hand is placed on the mid-belly of the gastrocnemius-soleus muscle group, as close to the tibia as possible without actually contacting it. Execution: The therapist puts a medial—to-lateral pressure on the gastrocnemius—soleus muscle group, pulling it away from the tibia. The technique starts lateral fascial distraction of the tibia. in the mid-belly but can move proximally or distally, depending on the location and severity of the restriction. The therapist carefully attempts to push the muscle laterally into the plastic range. keeping an eye on patient reaction This technique can be quite painful if the fascia along the tibia—gastrocnemius borderis compromised.
Lateral elongation of peroneal tissue
The purposes of this technique are to elongate the soft tissue structures of the lateral leg and to address restrictions that may have developed between the tibialis anterior, extensor digitorum, peroneus longus, and triceps surae. The fascia of the lateral lower extremity is continuous from the iliotibial band down across the peroneal group to the foot. Patient position: Side-lying, withlower leg supported on pillow. Therapist position: Standing or sitting at foot of table. Hands: The therapist provides slight anterior-posterior stabilization by cupping the lower leg between the leg and pillow. The manipulating hand, in the shape of a loose fist, is placed on the distal aspect ofthe peroneal group muscle bellies. Execution: Using a small amount of lubrication, the therapist applies sufficient lateral-to-medial force to reach the level ofthe subcutaneous fascia. Acaudalto-cephalic force is applied to distract the subcutaneous fascia. The stroke should end just distal to the superior fibular head. The therapist repeats the stroke, gently progressing in depth, being careful not to press into the periosteum of the fibula. The technique may be applied more specifically and between muscle bellies using a tw0 finger contact or with active movement from the patient Contact is made with the middle finger supported by the index finger. The stroke is applied in the same depth and manner, caudal to cephalic, but can be applied between muscle belliesand/orwith active ankle inversion/eversion.
What accounts for tissue cohesiveness?
The second component is the sulfated version of GAGs, which account for the tissue cohesiveness.
Long Axis Laminar Release
The first purpose of this technique is to elongate and decompress the spine. The second purpose is to identify localized lesions in the medial border of the erector spinae. As the therapist identifies these lesions, the motion maybe stopped and a sustained pressure maybe applied. Multifidus, Medial Erector Spinae. Superficial to deep. Similar to effleurage. Pt. prone. Stand at the pt.'s head. Put thumbs together with one thumb in the grove of the other. Use flat hand contact to run downward across the lamina. At the end push down into the Iliac Crests to distract (cup them with the palm of your hands). The motion is a slide, the PT leans into it. Repeat as needed. Not always a good option for acute disc herniation—it helps to improve flexion and we don't want this with this type of pt. (protect the outer annulus of the disc). → You can put the pt.'s arms down by their sides so that you're not laying on them
What type of information does Meissn'ers corpuscles transduce?
There located on the skin and respond to touch
piriformis release
These techniques are used ifthe patient's dysfunction lies in a hypertonic muscular state of the piriformis rather than in a connective tissue dysfunctional state. These techniques are designed primarily to decrease underlying muscle tone and secondarily to affect connective tissue. The techniques are performed in a graded fashion depending on the overall pain and reactivity of the piriformis muscle. Cross Friction of Piriformis Insertion: palpate superior/ posterior tip of Gr Troch, bend pt. leg and rot in/out Passive ART: slackening and stretching the muscle—do the cross friction action but slower and with holding Palm of Hand: full contact approach/ flat hand with the palm sinking in deeper, compress and hold—can add buffering in as well Elbow direct pressure—start with forearm flat, begin by scouring the sacrum (bending the elbow increases aggressiveness, can include cross friction); work parallel first, then perpendicular Fist - wrist flex/ext to knead the Piriformis B PIP Jts: first two PIPs - wrist flex and extend
Briefly describe Golgi Tendon Organs and there function
They are critical in transmitting information regarding muscle tension from musculotendinous junction. Highly sensitive to changes in tensile forces on connective tissues Interwoven or wrapped in CT, they are affected by changes that occur in respective CT
What characteristics explain why Meissn'ers corpuscles have superior spatila resolution
They are mechanically coupled to the surrounding subcutaneous tissues by thin strands of connective tissue. These strands promote the transmission of adequate stimulating force to several surrounding corpuscles for a given pinpoint stimulus area. The second characteristic is related partially to this mechanical coupling but mostly to the fact that the receptive{teld for Meissner's corpuscles is very small
What type of information does Pacinian corpuscles transduce?
They are on skin, and respond to flutter FIbrous CT responds to compressive stimuli
What is the purpose of plasma cells in the inflammation phase?
They begin to migrate into damaged areas to produce antibodies.
How do adolescent females, having a hit a growth spurt prior to the males, changes there posture?
They develop a slouched posture
What is the issue with pain pathway s for patients with fibromyalgia?
They have dysregulation of pain pathways and neurotrasnmitter irregularities, that ENABLE PAIN AMPLIFICATION Make individuals hypersensitive to painful and non-painful stimuli
Muscles feature specialized muscle nociceptors. Describe them.
They have female endings connected to the CNS by a thin myelinated or unmyelinated afferent fibers. Effective for nueroplastic changes in the spinal dorsal form
Why do Pacinian corpuscles have poor localization?
They have large receptive fields, but they are very sensitive to mechanical energy
How do low level contractions lead to myofascial trigger points?
They lead to muscle fiber degeneration, increase release of calcium ions and cytokines energy depletion. Known factors in trigger point development
What happens with the disruption of mast cells?
They release histamine 1. Histamine causes vasodilation in neighboring non-injured vessels Mast cells can be hypersensitized by certain antigens, facilitating cell production of histamine Can explain why individuals with numerous allergies and diffuse myofascial pain can have an increased histamine response to soft tissue manipulation
What is the superficial fascia in the back?
Thin, continuous sheet of loose connective tissue found just under the dermis. AKA HYPODERMIS
What are the characteristics of elastin?
Thinner than collagen, branching fibers, highly elastic Ex: lining of arteries and ligamentum nuchae of spine contain a high percentage of elastin
When does CT begin to develop?
Third week of embryonic development and 3 layered disk develops during gastrulation. From the mesoderm
Elongation of Paravertebral Muscles
This is a preparatory technique for other more aggressive myofascial and joint manipulation techniques, As defined early in this chapter, elongation differs from stretching in that elongation's purpose is not necessarily to lengthen the muscle but rather to elongate the spine (the analogy of elongating an accordion maybe helpful). This technique, used with superficial penetration, also has a strong autonomic inhibitive effect Basically a Laminar release but with the pt. supine and PT using flat hand contact. Use lotion. Start ~ T4 (push into the table to get your hands under) and travel to the Occiput. Good technique to do leading into subcranial inhibition. Good for pt.'s with neck pain, postural issues, upper crossed syndrome, HAs
Greater Trochanter Rocking
This technique is designed for gentle inhibition of the lateral rotators of the hip and for the hamstrings. This is an excellent preparatory technique for more extensive work in the piriformis, posterior hip. and hamstrings Application of this technique will generally yield an increase in straight-leg raise and in hip internal rotation. Pt. Supine. Find GT, wrap fingers around to post aspect of GT (should not see finger tips but keep them curled and don't let them lock out, primary force hand) and then sort of flick ant—other hand at distal femur to rock into IR (find bodies rhythm)
Bony Clearance of the Iliac Crest
This technique is designed to first evaluate the fascial attachments at the iliac crest and then soften the fascia, especially at the insertion of the deep erector spinae and quadratus lumborum (Figures 8.22 and 8.23). This technique also serves to prepare the iliac crest surface area for the next series of techniques Prone Scour down the Iliac Crest OR do a scrubbing motion (with chisel grip) Aggressive: hip extended/BW bending of L/S spine Good if pt. has limitation in SB away
- Unilateral P/A articulation of First Rib
This technique is essentially a joint manipulation technique, but it blends well with the lateral elongation and n'b techniques, especially if rib dysfunction is present. With increased myofascial tone in' the subclavicular area, the upper thoracic area. and the scalene muscles, joint mechanics in the first rib can easily become dysfunctional. The purpose of this technique is not to change the position of the first rib but rather to increase mobility. Top hand on ant 1st rib, bottom hand contacting post aspect of 1st rib (don't confuse with med border of scapula), rock ant/post
First Rib/Shoulder Depression rocking technique
This technique is largely inhibitory m' nature, although the first rib can be gently articulated. The rhythmcreated bytherib and shoulderarticulation provides a form of biofeedback for the patient and can indicate to the clinician, as well as to the patient, the degree ofinherent relaxation or tension in' the upper thoracic area. This subtle form ofbiofeedbackhelps release tone in the upper thoracic area. prepares thetissue for deeper ormore specificmyofascial work, and facilitatesjoint manipulation Top hand on ant 1st rib, bottom hand contacting post aspect of 1st rib (don't confuse with med border of scapula), depress shoulder and rock 1st rib—same time or opp times depending on the pt.
Axial Flexion of the Cervical Spine (pt. supine, PT sitting)
This technique is one ofthe few described in this text that can be used as either a direct or an indirect technique. The idea behind its use as an indirect technique is to take the neck into the direction of restriction. there by freeing the restriction and allowin'g greater axial extension A useful analogy is that Axial flexion with medial to lateral pressure from fingertips (on the lamina)- move up a level each time until at base of occiput (don't let subcranial spine fall into ext—keep face level with the table). Go to ~C7. Lift by ext trunk not with your arms Diagonal component for restriction in one direction: move towards the restriction then in the shape of a J through it
Cervical laminar release
This technique is used to elongate the cervical paravertebral musculature and to improve cervical forwardbending Patientposition: Sitting. Therapist position: Standing behind patient. Hands: In the bilateral technique, both hands are placed on the paravertebral muscles with the thumbs and PIP) om'ts of the index fingers contactin'g the patient In the unilateral technique, one hand is on the patient's head to monitor the diagonal movement of the patient's head and neck. Execution: The therapist first asks the patient to forward-bend the cervical spine segmentally. As the flexion occurs, the therapist's hands stroke caudally through the mid-cervical, cervicothoracic, and upper thoracic areas. Ifunil'ateral technique is preferred,the monitoring hand gently guides the patient into a diagonal pattern as the other hand gently strokes unilaterally through the cervical. cervicothoracic,and upperthoracic areas
Lateral Sacral Release
This technique is very similar to the iliac crest release but targets a different tissue: the fascia of the lateral border of the sacrum. the piriformis attaches close by, and patients with low back1 hip, sacroiliac, and leg pain can benefit from this technique, especially those with diffuse hip and leg pain proximal to the knee. The lateral sacral release is an excellent technique to use in conjunction with the bilateral sacral release technique Chisel grip: scrub method across—towards/away from Sacrum (almost like you're flicking) Buff sacrum with hand: almost seems like you're trying to grab it but then are using the scrubbing technique (Bilateral Sacral Release) Wax on/off with palm of hand OR just lean into the area with the palm of your hand Dummy thumb: to wax on/off where you feel tension or the pt. feels tenderness
QL Erector Spinae Release Aggressive (legs off table)
This technique should be used generally to elongate the posterolateral and anterolateral fasciae of the lumbar and thoracic spines and. specifically. to stretch the quadratus lumborum. In chronic unilateral pain conditions, the painful side often retracts, contracts. and generally shortens. The manifestation of such a condition can be assessed posturally or with active movements. Both the connective tissues and contractile tissues may become dysfunctional and exhibit changes consistent with immobilization. More specifically,this technique may be used to prepare for correction of lat— eral shift conditions of more than 3 weeks' duration. As discussed in Chapter 3, "Histology and Biomechanics of Myofascia," muscle decreases in length by losing sarcomeres—the process takes approximately 3 weeks. Tissue held in a shortened range for longer than 3 weeks has undergone contractural changes. which must be addressed before shift correction can be attempted. Finally, this technique may be used to decompress compression lesions such as nerve impingement syndromes. Aside from backward bending, sidebending is the least stressful movement on the disc, followed by, in increasing order of stress, forward bending and rotation. In rehabilitation of discogenic lesions, the side bending elongation maneuver may decompress a nerve root by taking the disc into the second—least-stressful maneuver. SB and strum Superficial fascial elongation- arm draped over head, legs off table Rotation from above 1st then legs off table- just open them up (shoulder rotated back but do not have lumbar rot)
Why must be stretch the shortened muscle before attempting to strengthen the inhibited muscle?
This way the inhibited muscle will not have to work against the passive tension in the shortened muscle. (reciprocal inhibition)
When two acetylcholine molecules bind to a nicotine acetylcholine receptor across a synaptic cleft in the muscle, Receptor opens the cation channels which in turn facilitates a sodium influx and potassium efflux across the membrane. What then happens?
This will depolarize the post-synaptic cells and trigger a miniature endplate potentionls. Enough of these will produce a AP which travels along the P-tubules which trigger the receptors in the sarcoplasmic reticulum and causes release of calcium ions for SR
What is thought to explain the palpable muscle spasm with manual trigger points?
Thixotrophy
What mechanism or idea is thought to relate to cross bridges that remain connected even in absence of AP?
Thixotropy
How do you perform the bilateral thumb supported grip?
Thumb and thenar eminence support each other as both hands form a broad "palmar" surface.
Temporal summation may lead to satellite trigger points in area of enlarged receptor fields. The temporal delay oberseve in the onset of referred pain is due to what?
Time needed to unmask interneurons with substance P and glutamate
Describe the fibroplastic phase of soft tissue repair
Tissue finally begin to rebuild during the fibroplastic/proliferation phase. Fibroblasts migrate to the area and begin collagen synthesis. The temporary seal gains strength as collagen fibers are laid down in a haphazard fashion.
Briefly describe the fibroplastic phase of tissue healing
Tissue finally begins to rebuild during the fibroplastic/proliferation phase. Fibroblasts migrate to the area and begin collagen synthesis. The temporary seal gains strength as collagen fibers are laid down in a haphazard fashion.
Phasic or Tonic: Tend to have a higher resting tone and are stronger.
Tonic or postural
Describe the Hoffa technique
Traditional massage technique. Simple yet effective. Like, efflourage, pettrasage, and kneeding techniques. Reduce pain relief, muscle guarding and reducing stress.
What soft tissue technique, uses oscillations to free up inert tissues and inhibit contractile tissues?
Trager. Considers mind and body connections
When organizing your treatment session, how should you sequence your treatment. Neuromuscular reeducation or postural education
Train the muscles to activate appropriate so they can get in proper posture alignment
Besides suspending and cushioning viscera and vessels, what is the purpose of connective tissue proper?
Transmit forces within muscle and between muscle and bone. helps to transmit neurological impulses as well and ability to contract
Why does junctional zones a common site of ST injury/failure leading to MF restrictions?
Transmit tremendous forces due to folded recesses which increases the surface area. Slower healing times
What technique uses both autonomic and mechanical effects to release adhesions and increase tissue mobility? this is done to erector spinae and surrounding fascia to no longer resist motion and benefit from additional strength and proprioception training?
Transverse muscle bend of the erector spinae
The trapezius, is one of the 9 areas of tender point sites for fibromyalgia. Where in the trapezius would you apply your less than 4Kg force to check for fibromyalgia?
Trapezius: Midpoint of Upper boarder
What 6 things lead to immobility?
Trauma, past or present Habit patterns Postures Strain from over exercising metabolic factors Leg length discrepancies and imablances, which lead to overall body problems.
What does Janda suggest for the approach of treatment forward head posture? 189
Treatment first focuses on restoring proper length to the tonic mm before strengthening the phasic
What is the medical management plan for patients with fibromyalgia?
Tricyclic medication Treating impairments Low-intensity aerobic, light strengthening exercises
What is the best medical management for fibromyalgia?
Tricyclic medication to help sleep patterns. Pain medications
The following describes what technique? Sarcomeres within trigger point are hyper contracted Transmit increased resting tension to neighboring sarcomeres While patient is contracting and relaxing, tension is release and pain and nodule are reduced. Resets sarcomere length
Trigger point release
True or False: The definition of fibromyalgia has changed within the last 10 years, and is now commonly categorized as a chronic pain syndrome and no longer considered a muscle pain syndrome
True
True or False: The process of scar formation is continuous
True
True or false: During the maturation phase, the collagen is immature and has not yet reached its maximum strength
True
True or False: Newly synthesized collagen (red) forming cross-links with mature collagen fibers as an effect of immobilization. Fortunately, this can be reversed
True dat
True or false: Fascia helps us maintain posture
True! Fascia not only helps support local tissues but help us maintain posture; transmit forces (see tensegrity model) and neurological signals and may even be able to contract.
What are fibroblasts?
True, fixed connective tissue cells - most common in connective tissue Primary secretory cells, responsible for the synthesis of all components of connective tissue, including collagen, elastin, and ground substance Adhere to and lay down the fibers. In highly cellular tissues, they may mix with collagen fibers to become reticular cells
How do you perform a muscle play of erector spinae?
Trying to move erector spinae perpendicular. Thumbs on lateral border with hands in W. Elbows adduct then abduct. USE: increased erector spinae tone, or a myofacsial restriction. Improves sidebending and flexion
What are the 4 types of collagen?
Type I: found in ordinary loose and dense connective tissue ***Manual therapy techniques are most likely to affect Type I collagen*** ii. Type II: found primarily in hyaline cartilage iii. Type III: found lining the fetal dermis iv. Type IV: found in basement membranes
What are the 4 types of collagen?
Type I: most common, resists tensile forces Type II: Rich in proteoglycans and located in hyaline cartilage Type III: located in fetal dermis, and arteries, intestine, and uterus Type IV: Located in basement membrane of the epithelia
What type of collagen fibers are located in fetal dermis and linings of arteries, intestine, uterus and lungs?
Type III
What type of collagen are located in basement membrane of the epithelia?
Type IV
Define pain
Unpleasant sensory and emotional experience associated with actual or potential tissue damage
What position are the joints of the cervical spine with forward head posture and the implications of these positions? 186-187
Upper cervical: down and back Compensation to keep eyes horizontal Compresses the fact joints→ hypomobility and shortening of the posterior myofascial structures Midcervical: up and forward Loss of lordosis in this area, with a tendency of hypermobility in the segments Upper thoracic Facets are in a forward bent position, placing the posterior myofascial sturcutres on a stretch
Describe the layers of muscles which is seperated by the fascia
Upper layer: Traps, Lats, TA, Internal Obliques Middle layer: Splenius capitus Levator scapulae Rhomboid minor/major Serratus posterior inferior Deep layer: Capitus group, spinalis, longissimus and iliocostalis Deepest layer: Costal levators Multifidus, deep rotators, intercostals, QL
How do you perform the mobilization of O/A with occiput stabilized?
Use anterior shoulder on forehead. Hands on O/A. Give the pt just a slight chin tuck. Make pt push in with just the slightest of resistance. Keep head up so it's not awkward. Use an isometric contraction, about (3-5 lbs)
Why is PNF pattern considered part of soft tissue mobilization?
Use of diagonal patterns to facilitate proper movement Considered soft tissue manipulation since it has same effects through nervous system of myofascial techniques.
What is Augmented Soft tissue manipulation?
Used for PURPOSE of stimulating fibroblastic proliferation to promote healing. Tools to break fibrotic adhesions in order to trigger an inflammatory response/stimulate debridement. Promote stretching after and active lifestyle.
Briefly describe rolfing
Used to correct inefficient posture or to integrate structure Rolf believed that myofascial components determined the adequacy of the joint. integrating myofascial to normal or more toward normal, the pt will have more "normal" movement
What is the purpose of iliac creast release?
Used to release restrictions in CT of thoracolumbar fascia, muscles and ligaments, attaching to the crest Release restricted originated from this area since they may produce abnormal afferent signals
Mobilization of OA with Occiput Stabilized/ (Book: Manipulation of Subcranial and OA Myofascia)
Useful for releasing subcranial fascia and for manipulating the 0A joints This technique allows patient participation and,therefore, maybe considered a muscle energy technique. The idea behind the technique is stabilization of the occiput and movement of the atlas. The patient is axially flexing and extending the neck while the occiput is held rigid. PT standing, pt. supine. One hand on OAs Nuchal Line, opp shoulder on their forehead. Have pt. do slight chin tuck then have them push into the table then into the shoulder.
What are the autonomic dysfunctions associated with myofascial pain syndrome?
Vascular changes Ptosis Changes in skin temperature
What muscles can refer pain in area of PFPS, or knee pain?
Vastus lateralis
David Daniel founded chiropartic practice in 1895. What original premise summed up the law of the nerve?
Vertebra become subluxed. Affects structures through IV foramen Can impair nerve conduction impulses Innervations change and disease results Adjustment can restore normal innervation
Fibroblasts are very sensitive to what stimuli, and are unable to distinguish what?
Very sensitive to physical stimuli and are unable to distinguish between good and bad stresses
What are the advantages of cross friction?
Very simple and can be self treatment for patients.
What are the 3 stages of conscious learning according to alexander?
Via palpatory and verbal feedback. 3 stages "conscious learning" ---Awareness of the habit ---Inhibition of the habit ---Conscious control of the habit
What is the physical property that resists and allows deformation in CT proper?
Viscoelasticity
Is the following fixed or wandering cells? Plasma cells create antibodies that boast the immune system. Macrophages, leukocytes, and found after infection
Wandering CT cells
Immobilization will lead to secondary complications such as what?
Weak muscles through ROM Restrictions in joints Fascial restrictions Self image/body language Bone changes
What does restricted motion in CT result in, from an overall body perspective?
Weak muscles through a full ROM Restrictions in joints Fascia restrictions Self image and body language (proprioception) bony structure changes
What are four key questions to consider when looking for myofascial type pain syndromes? 184
What is the quality of the pain? Myofascial is dull and aching and poorly localized How is the patient sleeping at night? Pt will report difficulty going to sleep and frequent awakenings during the night; fatigued and groggy in the morning What pattern does the pain follow during the day? Stiff in morning, and gets a little better during the day. Activity will aggrevate Can a position of comfort or relief be identified? /c myofasical, pt can identify a position even if it's temporary relief
Structural inspection or Rolfing, can be effective because is helps the body become more efficient in posture, balancing itself against force of gravity. What then does this lead to?
When the body gets working appropriately, the force of gravity can flow through. Then, spontaneously, the body heals itself.
What is a soft tissue dysfunction?
Where tissue has failed, because of inability to resist 1 time for or repetitive stress over time. NO differences between gender, age. NO sleep disturbances Will have strength and ROM dysfunction Localized pain if acute. Imaging findings show tissue tears or breaks..
The way you approach and touch your patient can affect your treatment outcome according to what 4 factors?
Where to touch your patient Whether or not you use lubrication The depth of your contact The amount of surface contact
Temporal summation is common in what conditions?
Widespread pain conditions. May result in satellite trigger points in enlarged receptor fields leading to chronic pain conditions
How can calcium ions cause myofascial trigger points?
With elevated calcium pump, we have increased calcium. Impaired reuptake of calcium in Sarcoplasmic reticulum causes myofascial trigger points
What does an acidic area cause in relation to down-regulating aceytlcholinesterage and causing hyperalgesia and hyper pain areas.
With hypoxia, there is excessive release of CGRP, which leads to hyperalgeasia
Describe acute pain
Within seconds, pain is instantaneous Nociceptive input reaches brain and withdrawal reflex occurs
7. What is the basic premise of Tragering?
Work mechanically to free up fascial planes and inhibit resting tone Using oscillations to free up inert tissues and inhibit contractile tissues Using the nervous system to make changes rather than trying to make direct mechanical changes to the tissues themselves with direct treatment Examples of these techniques are trochanter rocking and 1st rib manipulation with oscillations. ▪ The purpose of his techniques is to provide increased mobility to tissue and give movement sense of effortlessness. Such techniques are usually applied in supine. -Emphasized and influenced MF1
Describe the history of cross friction?
Work of Dr. Cyriax. Primary effect on the non-vascular tissues such as tendons, ligaments, muscles, MT junctions. Goal: HELP WITH HEALING PROCESS
Briefly describe the maturation phase of soft tissue repair
Wound closes, anywhere between 5 days to 5 weeks depending on the type of tissue. Wound is closed, the collagen is immature and has not yet reached its maximum strength. This phase may take 3 weeks to 12 months, again, depending on the type of tissue damage
The granulation phase of soft tissue repair is so called because as the tissue produces vascular structures it takes on a granular look from the forming of capillary buds.
Wound is contained, but tissue is still fragile and could be easily re-injured
7. What are the different components of the stress-strain curve?
Y = stress, X = strain c. Toe region: represents the elastic component of connective tissue d. Elastic region: represents temporary length changes in the tissue e. Point of Yield: point tissue must stretch beyond for the deformation to become permanent f. Plastic region: region where tissue is permanently deformed but does not rupture g. Point of failure: tissue reaches its limit and you see macro-damage and failure
Superficial and deep fascia are quite thin. Can they actually restrict movement?
Yes, they are really tough. It can hinder or support movement, depending on how tight it is.
What are the 4 types of direct junctional zone insertions?
Zone one is the actual tendon or ligament. This area has collagen fibers and fibroblasts embedded within the matrix. Zone two consists of fibrocartilage. Zone three has mineralized fibrocartilage. Zone four consists of bone, where collagen fibers join with fibrils of bone matrix.
What is the best management of fibromyalgia?
a multidisciplinary approach. Team should include a physician, psychologist and, of course, a physical therapist. Additional medical professionals and family members. Medical, psychological and physical affects should be addressed.
How does Wolf's law when applied to the connective tissue has a functional and a dysfunctional aspect?
a. Abnormal stresses chronically applied to connective tissues may result in dysfunction in the tissues and the adjacent structures Ex: in pt with spondylolisthesis, you can see hypertrophic banding that occurs due to the spine not being capable of withstanding the shearing forces
What are the different cells of the connective tissue and what are their functions?
a. All CToriginates from the mesoderm Mesenchymal cells, from the mesoderm, are small spindle shaped cells 1. Osteoblasts→osteocytes→bone 2. Chondroblasts→chondrocytes→cartilage 3. Fibroblasts→fibrocytes→connective tissue
1. What is the histological make-up of the connective tissue?
a. Connective tissue is subclassified into i. Connective tissue proper ii. Cartilage iii. Bone b. Connective tissue proper is subclassified by i. Orientation ii. Density of fiber types c. 3 basic connective tissue types i. Dense regular ii. Dense irregular iii. Loose irregular
What is the "legs carry trunk" model?
a. The role of fascia as a force transmitter can be seen throughout ambulation As the foot hits ground and the center of gravity moves over foot, energy is absorbed, stored, and reused through CT. The actual force production by the muscle is thereby reduced significantly. When tissues become restricted and rigid, their ability to absorb energy lessens. Muscles therefore work harder to produce mechanical energy as potential energy is lost. When connective tissue is mobile, the system is much more efficient = legs carry trunk model
24. What is spine engine model?
a. The viscoelastic qualities of connective tissue allow it to absorb ground reaction forces through the lower extremity connective tissue, even reaching the spine to produce rotation b. A contraction of the glute max, along with the swing of the opposite arm, preloads the thoracolumbar fascia, preparing it to further absorb ground reaction forces as potential energy. c. As the forces transmit through the connective tissues, they are eventually released as kinetic energy as the thoracolumbar fascia springs back, reversing the rotation of the spine and initiating opposite hip flexion and arm swing, creating a pendulum effect
What is the role of Perimysium?
c. Groups of myofibrils = fasciculus and is surrounded by perimysium Perimysium = Cushioning effect through force transmission, and a Stiffening effect, particularly in tonic muscles, as they contain much more Perimysium
What is the goal of rolfing?
goal of balancing the body with the forces of the gravitational field via 10 1 hour sessions, where they start in periphery and work in
What is the integrated trigger point hypothesis?
more developed energy crisis hypothesis that incorporates more recent research including that of pain science Excessive acetylcholine at the motor end plate Extra research, but you know how they work: 141 Dommerhold and shah suggest that at the sarcomere elvel, myosin filaments may actually break through the actin-titn barrier because of the excessive actylcholine levels→ makes them sticky→ why it's difficult to stretch a taut band
What is the purpose of the anaterolateral fascial elongation technique?
primarily stretches the superficial fascial sheath in a diagonal pattern across the anterior surface of the body. In doing so, the technique is designed to treat number of restrictions
Layer Palpation
systematic method of assessing the mobility and condition of the myofascial structures, starting from the most superficial structures and progressing into the deepest palpable structures
Iliacus Release
the iliacus muscle can be treated for limited extension of the hip or as an extension of a psoas release. Even though the iliacus does not have a insertion into the spine. a shortening dysfunction of the iliacus can anteriorly rotate the pelvis, creating a backward-bending dysfunction of the spine. Iliacus Release Pt. supine with legs supported by chair, find ASIS and curl into the Ilioinguinal Ligament and perform cross friction
QL Erector Spinae Release NON-Aggressive (legs on table)
the purpose of this technique is to prepare the quadratus lumborum and the lateral fascial structures of the lumbar spine for elongation and stretch techniques. The technique involves sustained pressure and has the primary goal of reducing active tonic contractions of the quadratus lumborum. After the tone in the quadratus is diminished, the elongation and stretch techniques applied are more effective and efficient. NON-Aggressive (legs on table) SB and strum: pt. SL, forearms against pt. and separate ribs and pelvis, strum the QL Extend hip/knee & elongate (stretch/lengthen only) can do C/R: pt. SL with top leg straight, hook onto Iliac Crest or Greater Trochanter and distract pelvis to stretch QL—PT lunges into it
Briefly describe the 3 main principles of PNF
▪ Always keep the treatment approach positive...reinforce ▪ Help pt's achieve their highest level of function ▪ Direct the entire human being in each treatment, not a specific problem or body segment
