Soft Tissue Quiz 2
Orientation of Hip
Femoral head: superior, posterior, medially Acetabulum: lateral, inferior
Orientation of patellofemoral joint
Femur: anterior Patella: posterior
Granulation and collagen synthesis during the proliferative phase
Fibroblasts are stimulated by ascorbic and lactic acid to synthesize collagen tissue and glycosaminoglycans -Wound has a little bit of strength and stiffness to it
Lateral Pterygoid Release
Finger is inserted into mouth Reach back towards zygomatic arch Between the cheek and the upper teeth
Capsular Pattern of Hip
Flexion Abduction IR
Lateral glide of the patellofemoral joint
Flexion Both thumbs glide patella laterally
Medial glide of the patellofemoral joint
Flexion Both thumbs glide patella medially
Inferior Glide of the patellofemoral joint
Flexion Knee in slight flexion although almost always in greater than resting position, manipulating hand glides patella inferiorly
Capsular pattern of patellofemoral joint
Flexion > Extension
Transudate
Fluid, made up of water and electrolytes 2 types: serosanguinous, serous fluid -Serosanguinous: thinner blood, not so bright red - pink in appearance -Serous fluid: normal to come out of wounds
Important variable to determine in a mobilization assessment
For both PROM and joint mobility: Is there a restriction? Where is the restriction? Pain with the restriction? - end feel
Grade V
High velocity thrust at limit of range
Indications for Joint Mobilizations
Joint hypomobility Pain relief Muscle guarding or spasm
What are causes of scar tissue formation?
Trauma Surgery Other wounds
Levator Scapula Trigger Point Release
Treating the upper TrP The lower TrP is located at sup. angle of scapula To stretch: neck flex, rotate and side bend to opposite side Stabilize scapula when stretching
how do pt's wear compression garments and bandages?
compression garments are worn during the day, low stretch bandages are worn at night
ted garments
compression garments worn in bed - designed for people who are immobile to reduce the risk of clots.
how does compression change interstitial pressure?
compression increases interstitial pressure - basically like an orthotic for the skin - helps reduce swelling.
anasarca
full body edema seen in the critically ill with poor nutrition. - often referred to as third spacing - as people get sicker, their albumin levels drop so blood volume can't hold on to fluid. - patients can gain 30-40 lbs over night.
bioimpedance
measurement of free fluid in soft tissue by passing a low voltage current thru limb. - useful only in early stage swelling - fibrosis affects discrimination - only useful in single limb edemas - must have unaffected contralateral limb as reference - most useful when reference value is available before edema presents - is reliable and valid with reference values.
evaluation of lymphedema - measures - subjective
measures - circumferential measurements - calculated volumes - AROM and strength - skin condition subjective - tissue texture
important lab values to check for kidney disease
- Blood urea nitrogen - creatinine elevated values indicative of disease
causes of bilateral swelling
- CHF - venous insufficiency - dependent edema - renal dysfunction - hepatic dysfunction - hypoproteinemia - medications - lymphedema
what is in the lymphatic load
- protein - water - cells: WBC, lymphocytes, cancer cells, bacteria, viruses - fat - cellular debris - other debris: tattoo dye
What are different types of petrissage?
1. Basic 2 handed kneading 2. One-handed kneading 3. Circular 2-handed petrissage 4. Alternating fingers-to-thumb petrissage 5. Skin rolling
What is included in informed consent?
1. Explain what you are doing 2. Why you are doing it (goals) 3. Describe what patient should feel/expect 4. List alternatives to treatment offered 5. Get consent (patient has right to refuse treatment at any point)
What are the general guidelines for massage and STM?
1. Strokes are unidirectional biased; usually towards the heart 2. Maintain contact 3. Regulate pressure as appropriate 4. Area defined by muscle groups or anatomical landmarks 5. Strokes can be done 1-handed, 2-handed, or using different parts of hand - can use forearm/elbow for deeper structures 6. You are assessing and treating simultaneously - talking to patient
peripheral resistance of arterioles drops pressure from what to what
120 to 35 mmHg in capillary beds
What are types of effleurage?
3 count Horizontal stroking
Diffusion
A constant process of movement from high to low concentration - flowing "downhill" - happens at rate of L/min - very rapid and constant - primary source of cellular nutrition - massive amount of fluid shift occurs to feed the interstitium
post-surgical/trauma edema
Active hyperemia - increase ultrafiltration - swelling from excessive accumulation of serous fluid in tissue. - as serous fluid goes into the tissue, it brings more proteins and draws in more fluid. - histamine release also makes capillaries more permeable. - if the surgery/trauma site is more dependent, there will be more swelling and it will last longer - lymphatic clearance of proteins is key to resolution of edema.
What are the common impairments treated with STM?
Adhesions/scars Decreased mobility of connective tissue Trigger points Tendinitis Muscle strains and tears Chronic venous insufficiency Lymphedema Pain (joint or soft tissue) Muscle guarding Postural faults
starlin's equilibrium of a venous limb
BCP = 15 mmHg COPp = 25 mmHg COPp > BCP result: -10 mmHg net reabsorption - water is attracted back into the capillary bed
starling's equilibrium of an arterial limb
BCP = 35 mmHg COPp = 25 mmHg BCP > COPp result: +10 mmHg net ultrafiltration - plasma can't hold onto the fluid volume
vasoconstriction - how does it change blood capillary pressure and arterial BP
BCP decreases Arterial BP increases
vasodilation - how does it change blood capillary pressure and arterial BP
BCP increases arterial BP decreases
important lab values to check for cardiac diseases
BNP - indicates fluid overload + heart failure CPK elevated values indicate disease
What is the best way to measure girth for edema?
Best way is volumetric - not practical Most practical way is a tape measure
What are important things to include when communicating with the patient?
Encourage them to relax Tune into non-verbal feedback Get specific feedback from patient: "is this the area that bothers you?", etc.
What is included in goal setting and assessment?
Every treatments should be tied to a goal Assess at the end of each treatment: palpation, ROM testing, Observation/posture, pain scale, functional activities, girth measurements
What does CT consist of?
Extracellular matrix (collagen, elastin, and reticular fibers) Ground substance (water and glycosaminoglycans (GAGs))) - ground substance lubricates fibers and allows exchange of oxygen, nutrients and cellular wastes Cells (e.g. fibroblasts, chondrocytes, tenocytes)
What is friction?
Fingers and skin more over deeper tissues Creates superficial heating Compressive force Creates movement b/t deeper tissues Usually circular motions performed 2-3 cycles then glide to next spot and repeat Increase depth gradually - work through superficial layers to the deep tissues Can be done with fingers, thumb, knuckle, heel of hand, elbow
What are the three most important things to include in a goal?
Functional - meaningful to the patient Time Measurable
What is included in a skin quality test and measures?
Integumentary integrity, color, presence or scar Looking at the color/integrity of the skin around the area you are working on
What are the test and measures done for pain?
Intensity: Numeric Pain Rating Scale - Most commonly used (0-10), rate best/worst pain in last 24 hours, give 0 and 10 in an understandable context Location Type: burning, aching, intermittent, constant Duration
how can K tape be used for hematoma?
K tape can stretch tissue over the hematoma and clear the blood from the tissue by stimulating and increasing reabsorption by the lymphatic system - used in breast cancer pts with lymphedema, too.
What is Petrissage?
Kneading manipulations Force is away from the body Purpose: 1. Increase soft tissue mobility 2. Increase circulation 3. Decrease pain
What does connective tissue (CT) include?
Ligaments, tendons, fascia, retinacula, and periosteum
What are the biomechanical effects of STM?
Muscle stiffness - no effect after 10-min effleurage Range of motion - less effective than stretching if used in isolation, effective when use with other techniques (stretching, PNF, joint mobilizations, etc.) in reducing shoulder impingement symptoms
What is included in the observation part of tests and measures?
Observation of body part and overall posture: looking for any abnormal findings from typical postures/symmetries side to side; looking for possible contributors to current dysfunction
PRICE
P- protection R- rest I- ice C- compression E- elevation
What all is included in tests and measures in an evaluation?
Pain (location, intensity, type, duration) Observation/Posture Integumentary integrity, color, presence of scar ROM testing Strength Palpation (superficial to deep)
What are the endangerment sites for STM?
Popliteal region Inguinal region Cubital fossa - anterior & posterior Axillary region Umbilicus region Posterior kidney region Front of neck Eyes
Why wouldn't you reassess MMT after STM?
STM typically decreases neuromuscular excitability - therefore there would be less strength
Interstitium
Soft tissue that is fed by capillary beds - there is a close relationship between the capillary beds and lymphatic vessels that exist in the same region.
What is tapotement?
Stimulatory/percussion technique Not often used as a soft tissue technique Chest clapping - Respiratory therapy
What is included in the palpation portion of tests and measures?
Texture - varies by age, sex, fitness, sport/activity body is subject to, lack of activity, occupation, previous injury 1) Hypertonicity and Muscle Tightness 2) Scar Tissue-new collagen to repair tissue 3) Adhesions-fibrous bands that inhibit movement between tissues - may feel stringy and "flick" if palpated 4) Edema and Swelling-acute or chronic - may feel spongy or pitting 5) General Rigidity-superficial fascia and myofascia Temperature is a sign of inflammation
Colloid Osmotic pressure
The ability of blood to hold on to it's water volume because the proteins in blood have a strong affinity to bind with water. - the amount of attractive force that the proteins have to hold on to water - the primary protein is albumin - COP of plasma is 7g% or 25 mmHg.
What causes blood pressure to drop in blood vessels?
The size of the lumen. smaller lumen makes the hydrolic pressure drops off. - blood pressure drops off the most at the level of the arterioles before the blood enters the capillary beds.
Cancer
Venous obstruction - passive hyperemia and increased ultrafiltration - increases risk for DVT - can precede or follow a cancer diagnosis (paraneoplastic syndrome) - diagnose by doppler US/CT/MRI
What is thixotropy?
Viscous fluids will become flexible and flow when agitated and return to more gelatinous state after static period
ascites
abdominal swelling in addition to LE swelling in systemic edema.
Arthritis
active hyperemia and increase ultrafiltration - chronic joint inflammation - inflammation -> vasodilation -> increase blood capillary pressure. - chronic med usage associated with edema - NSAIDS and steroids
what is the golden rule regarding unexplained unilateral limb swelling?
an unexplained unilateral limb swelling is a tumor or clot until proven otherwise.
perometry
computer generated calculated volume from limb contour changes as infrared beams are interrupted as carriage passes over the limb. - found mostly in research settings - position can be difficult - clinic space limitations - expensive
Colloid osmotic pressure of interstitium
concentration of protein in soft tissue that has a pressure and it assists in ultrafiltration - helps blood capillary pressure draw water into the soft tissue - reduces reabsorption
osmosis
diffusion through a semi-permeable membrane. water flows freely, but movement of molecules (like proteins) is hindered. - selective diffusion through blood capillaries - small contribution to normal nutrition of cells - 1-2 L/day of flow
is volumetry used a lot? why?
it's the gold standard, but it's not clinically applicable. - water gets everywhere - contraindications to submersion in water - limb doesn't fit in volumeter - infection precautions - need to constantly disinfect however, it is good for isolated hand or foot swelling
size of lymphatics relative to blood capillaries
lymphatic vessels are larger than capillaries because they are responsible for protein and fat transport, which are large macromolecules that cannot fit in capillaries
homan's sign
passively and abruptly dorsiflex the foot and squeeze the calf - positive sign = pain - supposed to indicate DVT, but not reliable because just because calf isn't painful doesn't mean the pt does not have a DVT
passive hyperemia - causes
pre-capillary arterioles dilate which causes higher pressure in the capillary bed via decrease venous outflow or venous obstruction. causes: - DVT - CHF - CVI - Tumor
BP and peripheral resistance
the narrower the lumen of the blood vessel, the greater the flow resistance and the lower the mechanical pressure for ultrafiltration
chronic venous insufficiency
venous obstruction - passive hyperemia - gaiter distribution - ankle to knee - brawny = hemosiderin staining - fibrosis of tissue - atrophy of skin, decrease hair, oil, and sweat - possible wounds - pain above the medial malleolus - DVT puts pt at high risk for venous insuffiency.
cardiac edema/CHF
venous obstruction - passive hyperemia - bilateral and symmetrical - pitting - resolves with elevation - no pain - associated with dyspnea, orthopnea, paroxysmal nocturnal orthopnea, and jugular vein distension.
why are we more prone to swelling as we age?
we lose protein and collagen content, so fluid leaves the cell and goes into the interstitium which causes swelling.
Venous Insufficiency Location
Malleolus - medial Medial aspect of leg superior to medial malleolus
What was the first state to allow Dry Needling into their physical therapy practice act?
Maryland
Arterial Insufficiency - Topical Therapy - Open Wound/Non-Necrotic
Moist wound healing Non-occlusive dressings Aggressive treatment of any infection
interstitial pressure
- stiffness of soft tissue that resists swelling and ultrafiltration (don't want extra fluid) - assists reabsorption
why are low stretch bandages better than high stretch?
- they don't squeeze the limb, they contain the limb. - enhances the musculoskeletal pump - it doesn't give - pt's begin to decongest immediately and the bandage will fall off - all over a much better treatment option.
Acupuncture
-Based on Traditional Chinese Medicine -Pulse and tongue diagnosis -Focuses on restoring imbalances in: Qj, Yin and Yang, Five elements -Treatment along meridians -3-4 years of schooling -Diplomate in Oriental Medicine -National exam for licensure National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)
Pathophysiology of Pressure Injury
-Capillaries nourish tissues (blood flow of 18-32 mmHg) -Tissue pressure > 18-32 mmHg results in ischemia -Ischemia for short periods can be tolerated - pressure and time demonstrate an inverse relationship -Tissue damage may be reversible or irreversible -Relief of pressure results in blood flow into the area causing erythema and warmth - erythema that blanches/disappears after 20-30 minutes is reactive hyperemia; erythema that does not blanch/disappear indicates tissues damage
Training Levels - Level 1
-Cervical Spine: suboccipitals, C5-T1 -Lumbar Spine: L4-S1 -Posterior Hip & Thigh -Adductors and Abductors -Anterior Thigh -Lower leg -Shoulder -Forearm -Pec Major and Lats
Proposed Physiological Effects of DN
-Increased blood flow: localized ischemia due to TP -Decreased banding: TP -Decreased spontaneous electrical activity: after stimulation of LTR due to TP -Decreased inflammatory marker: substance P, norepinephrine, TNF-a, IL-6 -CNS Changes: sudomotor (sweating), Pilomotor (goosebumps), Vasomotor (circulatory)
Moisture - pressure injuries
-Increases patient's risk for complications via a disruption/break in the skin's integrity through maceration and/or chemical erosion -Frequently results from drainage, perspiration and incontinence
Phases of wound healing
-Inflammatory phase - clinical manifestations: erythema, edema, heat, pain, necrotic tissue, exudate -Proliferative phase - clinical manifestations: granulation, contraction, epithelialization, transudate -Maturation/remodeling phase - clinical manifestations: vascularization decreases, tensile strength increases, scar size and color decrease
Rare/Very Rare complications with DN
0.01-0.1% Infection Pneumothorax
Uncommon complications with DN
0.1-1% Aggravation of symptoms Feeling faint or dizzy Stuck or bent needle Headache
What is muscle stripping/sweeps?
1 hand or finger stabilizes 1 hand or finger mobilizes Slow sweep along the length of muscle Thumb(s), funger(s), knuckle, heel of and, forearm, elbow
Common complications with DN
1-10% Needle insertion pain Muscle soreness Fatigue Bruising
Who is prone to fibromyalgia?
1-3% of general population 70-90% of fibromyalgia patients are women ages 20-50 yrs old 80-100% have disturbed sleep patterns Lack of exercise
Infection - local factors
10^5 organisms per gram of tissue All wounds are contaminated No longer take superficial swab cultures of wound - it is always going to come back positive Now take deeper swab cultures - what is growing in the bottom of the wound that is preventing it from healing
History of Dry Needling
1904 - term "fibrositis" was coined and muscled found to have palpable tenderness and hardness of the muscle 1928 - term "myofascitis" was coined and considered from an orthopedic perspective 1931 - first trigger point manual published 1938 - hypertonic saline injections use to irritate soft tissue and show pain referral patterns AND pain from muscles identified as myofascial pain and trigger points 1940 - needles can be used to treat orthopedic conditions 1983 - trigger point referral pain patterns identified and published in Myofascial Pain and Dysfunction: The Trigger Point Manual 2014 - Delaware accepts dry needling as part of the Physical Therapy practice act
Features of the dermis
2-layer underneath basement membrane: papillary layer, reticular layer -Vascular -Collagen (strength) and elastin (elasticity) fibers -Encloses epidermal appendages - hair follicles, sudoriferous and sebasceous glands: lined with epidermal cells which aid in epithelialization -Contains majority of skin sensory receptors: free nerve endings, Meissner's corpuscles, Ruffini's corpuscles, Krause's end bulbs, Pacinian corpuscles
DOF of Shoulder
3 motions Flexion/extension Abduction/Adduction IR/ER
DOF of Hip
3 motions Flexion/extension (sagittal) Abduction/adduction (frontal) External/internal rotation (transverse)
Resting Position of Shoulder
55-70 degrees abduction 30 degrees horizontal adduction Neutral rotation
What is a transverse friction massage?
A deep and very specific massage applied perpendicularly to the normal orientation of the fibrous elements May be helpful for chronic conditions of muscle, tendon, ligaments Used in chronic and acute conditions - not in an inflammatory process though
Total Contact Casting
A form of offloading Make a cast for the individual - build up areas that are not part of the wound and weight bear on the areas in a distributed fashion so the wound is suspend
What is a trigger point (TrP)?
A hyperirritable spot, usually within a taut band of skeletal muscle or its fascia
Joint Mobilization
A manual therapy passive movement of a joint in either "physiological" (angular) or "accessory" (glides, distraction) movements to either relieve pain or improve motion
Joint Manipulation/Thrust
A manual therapy passive movement used for increasing joint mobility or decreasing pain - a high-velocity, low-amplitude thrust
What is elastomer putty and how is it used?
A polymer with viscoelasticity Utilized in scar management to put pressure on and break up scar tissue Better grip on the skin to do scar tissue mobs at home
Muscle Energy
A technique that uses an active contraction of deep muscles that attach near the joint so that the line of pull with contraction causes the desired accessory motion
How does lymphatic dysfunction affect colloid osmotic pressure of the interstitium? example?
COP will increase, which causes increase ultrafiltration. ex: axillary node dissection causes loss of lymphatic function in that region. Protein will then accumulate in the interstitium and it will hold on to more water.
Suboccipital Trigger Point Release
Can be done in neutral or with some rotation Incorporate with suboccipital release
Where is scar tissue found?
Can occur in various connective tissues: Skin Muscle Ligament Tendons Joint Capsule
Venous Insufficiency Perfusion - Non-Invasive Vascular Testing
Capillary Refill: normal (less than 3 seconds) ABI to rule out arterial component
Arterial Insufficiency - Perfusion - Non-Invasive Vascular Testing
Capillary refill: delayed (more than 3 seconds) ABI < 0.9 TCPO2 < 40 mmHg TP > 30 mmHg
Peripheral Neuropathy Perfusion - Non-invasive vascular testing
Capillary refill: normal
Target tissue for joint mobilization
Capsule
Oxygenation/Perfusion - systemic factors
Cardiovascular insufficiency Arterial insufficiency - not getting healthy blood out to the area Venous insufficiency - overwhelming the region because blood isn't leaving
What are different types and techniques of massage and soft tissue mobilization?
Classic or General Massage Transverse Friction Massage Scar Massage Ischemic Compression Myofascial Mobilization/Direct Fascial Techniques Soft Tissue Release Techniques (STR) Lymphedema massage Instrument Assisted Soft Tissue Techniques (IASTM)
Stratum Lucidum
Clear band Increases skin thickness AKA the lucid layer
Development of Relative Capsular Fibrosis/Adhesions
Generally due to one or a combination of the following: - Resolution of an acute articular inflammatory process - A chronic, low grade articular inflammatory process - Immobilization of a joint
Surface of Shoulder
Glenoid: concave Humerus: convex
Joint Orientation of Shoulder
Glenoid: lateral, anterior, superior Humerus: medial, posterior, superior
Venous Insufficiency Topical Therapy
Goals: absorb exudates, maintain moist wound surface
Bloodbourne Pathogens
HIV: 0.3% rate of transmission Hepatitis B: 30% rate of transmission Hepatitis C: 10% rate of transmission If there is a needle stick, you HAVE to get tested
Dermal Functions
Hair production Sensation Elasticity - elastin Strength - collagen Sweat production Nourishment and waste removal
What is the effleurage technique?
Hands should be relaxed Stroke begins "light" and deepens over the bulkiest part of the muscle, then finishes "light" Return stroke should be light No pressure away from or into the body - gliding parallel to the skin
Medications - systemic factors
Healing delayed with: glucocorticoids (anti-inflammatory, immunosuppressant), antineoplastics (cancer chemotherapy agents), anticoagulants (prevent clotting), NSAIDs (anti inflammatory), antibiotics (toxic to some fibroblasts)
Regeneration
Healing whereby the tissue is replaced with like tissue Occurs in wounds of the epidermis and upper portion of the dermis (superficial and partial thickness wounds) Regenerating the body's natural tissues
Repair
Healing whereby the tissue is replaced with scar tissue (granulation tissues) Occurs in wounds extending to subdermal tissues (full thickness)
What is horizontal scar release?
Ideal for indented scars Horizontal stretch is applied along the length of the scar Hold, wait for release, and stretch again Perform at various angles
What is vertical scar release?
Ideal for scars that can be gripped between thumb and fingers Lift until resistance is felt, wait for release, then lift further
Pressure Injury Risk Assess
Identify at risk individuals through risk factor assessment -Utilize validated tool: norton scale, braden scale
Arterial Insufficiency - Topical Therapy - Dry, Non-Infected, Necrotic Wound
Keep Dry
What is the research on ultrasound as treatment for trigger points?
Literature does not necessarily support the effectiveness of ultrasound as a trigger point intervention
PUSH tool
Not a risk assessment Use for pressure ulcers to help track healing Total score - next time patient comes in, going to give a new total score and plot the score Trying to give a visual representation of the wounds healing
Unstageable pressure injury
Obscured full-thickness skin and tissue loss - you can't stage what you can't see
Patient expectations
Often involve trauma to periarticular structures Patient can expect to experience soreness If no soreness: can be more aggressive If soreness 4-12 hours: stay at the level If soreness > 12 hours: wrong technique or too aggressive
What is the cause of trigger points?
Often, 1 event initiates TRP activity, and other conditions perpetuate it Acute single-muscles TrPs can be managed quite easily We usually see the pt when it is a chronic condition
Dosage of DN
Under treatment - Wrong tissue treated, no twitch elicited - Important of constantly re-evaluating your patient's pain Over treatment - Overly aggressive, too sore post treatment Post treatment care - Fluids, rest, ice/heat, too little/too much activity
What is suboccipital release (SOR)?
Upward pressure of fingers into suboccipitals Gentle traction to take up the slack As fingers sink into tissue, take up slack and repeat sequence Follow with manual stretch Works well with headaches and neck pain, some arm pain as well
Peripheral Neuropathy - Topical Therapy
Use dressings that maintain a moist surface, absorb exudates and allow easy visualization Caution use of occlusive dressings
What is an algometer?
Used to quantify soft tissue tenderness - pressure-pain threshold (PPT) Trigger points: complains of pain at 2 kg/cm2 Tender points: complains of pain at 4 kg of force Used in research - informs what we know about pain conditions
When do you use mobilization?
Used when ligament or capsule resistance is encountered Used for tight articular structures Uses short-lever arm techniques
When do you use stretching?
Used when muscular resistance is encountered Used for tight muscular structures Uses long-lever arm techniques
How does trigger point dry needling use look in the US?
Varies by state Some states are debating the issue and some states do not allow it APTA: not an entry-level skill; requires specialized training
What is scar mobilization?
Various patterns/techniques utilized Can be painful Can help desensitize scar - important to teach area to respond to normal touch after nerves have been affected through injury/surgery
Why is communication with the patient important?
Very important for patient to relax and stay relaxed: make sure patient understands what he should feel with these techniques, avoid muscle guarding Use patient feedback (verbal and non-verbal) as a guide to depth and location
Masseration
Water logged tissue - typically changes in color (greyish white) With normal systems and it is transient, there is opportunity for drying out and turning back to normal consistency For patients with consistent water logging of tissue with excessive moisture - leads to masserations and improper wound healing - white and grey in the periphery of the wound -As a PT, need to put a drying dressing on, if it doesn't get better, going to need to debride the masserated tissue away
Trigger Point Physiology
When there is a trigger point, there is more spontaneous electrical activity of the muscle -Also get compression of the vessels which leads to the decreased energy supply
Tension theory
Wolfs law Where the lines of tension exist, it is going to allow collagen to lay down in different mechanisms and patterns By manipulating some of the area, about to help facilitate how collagen lays down
Clinical Interventions for Arterial Wounds
Re-establish circulation: angioplasty, revascularization procedures, pharmacologic agents Referrals: vascular surgery Topical therapy: wound cleansing, debridement only if unstable necrosis, topical agents and dressings Patient education: avoid LE elevation; avoid constrictive garments, trauma, exposure to cold; meticulous skin care; behavioral modification - smoking cessation, proper diet
Muscle spasm end feel
Rebound; usually accompanies pain felt at the end of restriction Pathologic
Clinical Outcomes of DN
Reduced Pain Improved ROM Improve Function
Importance of albumin - what do low and high levels mean?
albumin is the major plasma protein that circulates in the blood and it maintains colloid osmotic pressure in the vascular system. low = malnutrition, inflammation, liver disease high = dehydration
Compression
decreased space between articular surfaces (adds stability to joint)
pitting edemas
deep impressions left by pushing into the swelling - soft tissue has a gel like ground substance that slows down fluid movement through our soft tissue. - indicative of systemic edemas and only early stage traumatic edema or lymphedema - fibrosis reduces pitting in peristant edema or later stage lymphedema
Muscular end feel
Rubbery Normal Ex: tension of tight hamstrings
Clinical Interventions for Venous Wounds
Systemic Therapy: pentoxifylline (trental) - research shows increased healing when combined with compression therapy Compression therapy: sequential compression devices; compression bandaging systems/garments Topical therapy: wound cleansing, debridement, topical agents and dressings Patient education: compliance with LE elevation, compression therapy; meticulous skin care; nutrition
What is the lumbar release technique?
Take up the slack Hold until it "releases" Repeat last 2 steps until an end feel is reached Working through layers Direct of stretch may change depending on feedback of muscle
Differentiation portion of epithelialization
Takes on characteristics that it is supposed to have
Effects of Mobilization on Capsular Structures in the acute phase
Technique to inhibit pain Apply forces light enough to facilitate collagen alignment along lines of stress as initial tissue repair occurs Forces sufficient to keep collagen fibers lubricated during immobilization Grade I & II
Effects of Mobilization on Capsular Structures in the sub-acute phase
Techniques to promote remodeling of collagen tissue along lines of stress Application of "graded stress" Grade III & IV
DE State Physical Therapy Practice Act
To practice dry needling, a physical therapist must: -have two years of clinical experience treating patients -complete at least 54 hours of specialized training within a two year period -obtain a physician's referral specific for dry needling -obtain written informed consent from the patient before performing dry needling -perform dry needling only after examination and diagnosis
Moisture - local factor
Too much moisture or too little - makes for negative influence on a wound Can see that there is too much - can see it on a dressing: skin surrounding area becomes pruny and grey in color
Upper Trapezius Trigger Point Release
TrP often found at just lateral to angle of neck Pincer of flat palpation can be used Be careful to differentiate between muscle, nerve, TMJ, etc.
What are physical therapy interventions for trigger points?
TrP pressure release Direct fascial techniques PROM/self-stretches Modalities Dry needling Addressing any perpetuating factors Teach self-management techniques
Grades of Sustained Mobilizations
Traction I (piccolo) Traction II (take up the slack) Traction III (stretch)
What does it take to perform dry needling?
Training: several levels from pre-requisites required Knowledge of anatomy: 3D relationship as important as origins and insertions Patient Selection: patient trust & agreement; research slowly emerging to assist with patient selection (who will benefit most from dry needling)
Effect of motion of Joint Receptors
Types I-III active from beginning range to end rage of tension on capsule Capsular injury = receptor injury Joint proprioception affected
axillary nodes
drain arm, breast, and anterior/posterior trunk
cervical nodes
drain head and neck and about clavicular level
inguinal nodes
drain leg, anterior/posterior lower trunk, superficial genitals
Capsular end feel
firm Normal Ex: forcing the shoulder into full ER
when does lymphedema secondary to breast cancer occur?
generally occurs in a 3 year window after treatment
Assessment before apply soft tissue release
palpation - texture of tissue - hypertonicity -scar tissue - adhesions -rigidity of fascia inflammation - 7 second test muscle balance - upper vs lower traps, lateral vs medial quads
stemmer's sign
pinching the skin on the dorsal aspect of the toes - positive if the fold of skin lifted as base of toes is thickened or impossible to lift - indicative of the reactive fibrosis of soft tissue that is characteristic of lymphedema.
active hyperemia - causes
pre-capillary arterioles dilate, which causes higher pressure in the capillary bed via increased arterial flow causes: - heat - friction - trauma - infection - inflammation
lymphatic load and capacity
protein - 75-100 g/day water - 2L/day cells - RBC, WBC, lymphocytes, bacteria, viruses, cancer cells fatty acids transport capacity = 2L/day, but it can increase 10 fold.
Hi stretch ace bandages
short term use, somewhat effective - may constrict too much.
other diagnoses associated with lymphedema
venous stasis disease - morbid obestiy - post-phlebitic syndrome - previous DVT angiodysplasias lipedema
low stretch bandages
long term use, highly effective - no elastic - doesn't have recoil
why is assessment of ROM important for patients with lymphedema
need to see if they can touch their toes or reach shoulders because they need to be able to put on their own compression bandages at home.
edema of systemic disease
- bilateral LE always - usually pitting - ascites - anasarca
Proliferative Phase
-Occurs 3-21 days post-injury -Angiogenesis/ neovascularization -Granulation/collagen synthesis -Contraction -Epithelialization
Inferior Glide of the Shoulder
Abduction Flexion Stabilize scapula (table), glide humerus inferior (parallel to treatment plane)
Bony end feel
Abrupt Normal Ex: moving elbow into full extension
Arterial Insufficiency - Perfusion - Peripheral Pulses
Absent or diminished
Gangrene
Absolute complete ischemia Typically occurs in the periphery Overtime, area dies and it starts to shrivel up When it gets crisp - hoping there is a clear delineation of what is viable and what is not viable - hoping for autoamputation
Surfaces of Hip
Acetabulum: concave Femoral head: convex
An outbreak of what bacteria occurred with improper wound care treatments?
Acinetobacter Baumannii
Phases of soft tissue healing
Acute: days 1-3 Sub-acute: days 4-21 Transition from sub-acute to chronic-consolidation: days 21-60 Chronic: days 60+
What is the TrP pressure release technique?
Apply gently, gradually increasing pressure: increase in resistance; patient discomfort Precise control over direction and force Pressure maintained: palpable tension release, finger advance slightly, can be 30 seconds up to 1 minute Follow with a stretch Often incorporate petrissage strokes and stripping
Arterial Insufficiency Location
Areas exposed to pressure or repetitive trauma, or rubbing of footwear Lateral malleolus - most common Mid tibial Phalangeal heads Toe tips or webs spaces
Applying Joint Mobilization
Assessment of joint mobility, PROM, pain Place patient in loose-packed, resting position: the position of most comfort Determine the treatment plane of the joint - perpendicular: traction or distraction - parallel: oscillation or glide
Venous Insufficiency Assessment of Wound
Base: ruddy red; yellow adherent or loose slough; granulation tissue present, undermining or tunneling are uncommon Depth: usually shallow Margins: irregular Exudate: moderate to heavy Infection: less common
TMJ Pain
Be sure to assess: masseter, temporalis, lateral pterygoid Pt complains of headaches, tooth pain, ear pain, jaw pain Forward head posture, bruxism, teeth clenching are common
Key points
Be sure you are on the target tissue Know the direction of the tissue fibers Can teach patient technique Complementary techniques: petrissage, ischemic compression, direct fascial techniques
Localized Twitch Response - Why is it important?
Biochemical and electrical changes -Reduced of inflammatory markers -Decreased spontaneous endplate activity Can provide symptom relief
What is the incidence of latent trigger points?
By adulthood (27-50 yo) about 1/2 the population has TPs (latent) As high as 54% in women, 45% in men
Pressure injury staging system
Deep tissue injury Stage 1 Stage 2 Stage 3 Stage 4 Unstageable pressure injury
What are the common trigger point sites?
Deltoid Pectoralis Anterior Serratus Subscapularis Adductor Longus Vastus medialis Peroneus longus Tibialis anterior Long Extensors Abductor Hallucis Temporalis Masseter Splenius Capitis Sternocleidomastoid Upper trap Supraspinatus Levator scap Supinators Infraspinatus Longissimus Iliocostalis Multifidis Gluteus medius Gluteus minimus Biceps femoris Gastrocnemius Soleus
Peripheral Neuropathy Assessment of Nails
Onychomycosis; dystrophic nails; paronychia, hypertrophy
Treatment duration
Oscillations: 2-3 per second Traction: held 10-30 seconds followed by a period of rest for several seconds - both performed as much as needed but no more than necessary Manipulation: may perform multiple in a row as needed
Epidermis
Outer layer of the skin "Epithelial layer" Composed of 5 different layers - yet this is one of the thinest layers of the skin
Distraction of Hip
Pain, Flexion, Abduction Perpendicular to acetabulum Stabilized with belt around pt. pelvis; Pt. supine resting position, therapist hands around patient's ankle (or knee if can't pull through knee); therapist leans backward
Wet to dry dressing
Painful mechanism - rip off the dressing once it is stuck Should only be used when more than 50% of the wound is necrotic and in need of debridement When more than 50% of the dressing is clean - doing more harm than good
Peripheral Neuropathy Perfusion - Peripheral Pulses
Palpable/present
Surfaces of patellofemoral joint
Patella: convex Femur: concave
Quadratus Lumborum Trigger Points
Possible Causes: sudden trauma, awkward movements, motor vehicle accident Symptoms/Indications: low back pain, chronic myofascial pain syndrome, articular dysfunction, restricted forward bending, difficulty leaning to the opposite side, difficulty climbing stairs Pain patterns: lateral and posterior hip Associated TPs: external and internal obliques, psoas major, erector spinae, rectus abdominis Differential diagnoses: sacroiliac joint dysfunction, lumbar or sacral ligament pain, bursitis of hip
Trapezius Trigger Points
Possible Causes: sudden trauma, such as falling; whiplash injury; walking with cane; arm rests in high position Symptoms/indications: severe neck pain, headache, "stiff neck" Pain patterns: angle of mandible, temporal region, lateral and posterior sides of neck, upper back, medial border of scapula
Masseter Trigger Points
Possible Causes: sudden, forceful contraction; repetitive jaw habits; chronic mouth breathing; psychological stress Symptoms/Indications: temporomandibular joint symptoms; tension in masseter and temporalis; restriction of jaw opening and unilateral tinnitus Pain patterns: molars; temporomandibular joint; mandibular and eyebrow area Associated TPs: temporalis; medial pterygoid; sternocleidomastoid Differential Diagnoses: tinnitus, pulpitis; inflammation of the periodontal ligament; tension-type headaches; earache; toothache
Slide
Same point on one articular surface encounters new points on opposing articular surface - Pure glide never occurs because no joint surfaces are completely congruent
What does scar tissue look like?
Scar tissue is pink (vascular) Proliferation of fibroblasts (fibroblastic stage) Accelerated collagen synthesis
Secondary Wound (intention) Closure
Secondary intention closure: healing by regeneration or repair
Self-Mobilization
Self-stretching techniques using joint traction or glides that direct the stretch force to the joint capsule
Contributing factors to pressure injury
Shear (includes friction) - this is a newer change; friction used to be its own category Moisture
Grade I
Small amplitude movement at beginning of range Pain Control
Grade IV
Small amplitude movement at limit of range
starling's equilibrium
average blood capillary pressure = colloid osmotic pressure of the plasma
Myxedema
caused by thyroid disease - cutaneous and dermal edema caused by deposition of mucinous substances in the skin - seen with dry skin, brittle nails, thinning hair, decreased sweat, exopthalamos and abnormal thyroid tests - swelling is pre-tibial and has an orange peel appearance.
Mobilization portion of epithelialization
cells in the periphery are starting to flatten, getting ready to move
primary lymph edema
congenital diseases - depends on timing of presentation - at birth: milroy's disease (may be sex-linked) - at adolescence: lymphedema praecox (more in females) - after 35: lymphedema tarda
secondary lymph edema
damage to lymphatics from many sources - surgery - trauma - radiation therapy - filariasis (#1 cause worldwide) - infection: esp fungal. - metastatic cancer - iatrogenic
why is compression used for lymphedema?
it increases interstitial pressure and reduces ultrafiltration
Induction theory
the scar is trying to mimic the characteristics of the area it exists in
What is Myofascial Pain Syndrome (MPS)?
"A muscular pain disorder involving regional pain referred by trigger points within the myofascial structures local or distant from the pain" Often misdiagnosed or poorly diagnosed: muscle strain, LBP, fibromyalgia, neuralgia, systemic disease, drug reactions; no lab or imaging tests available
Mobilization with Movement (MWMs)
"Mulligan" technique Concurrent application of a sustained accessory mobilization applied by the therapist AND an active physiologic movement to end rage applied by the patient Seen mostly applied in ankle, low back (sacrum), hip and knee
regional lymph nodes
- 600-700 in the body - widely distributed - concentrated at neck, mesentary, and at root of limbs - each set of regional nodes is responsible for their limb and trunk quadrant. - they filter waste, fight infection via lymphocytes and regulate protein concentration of lymph fluid by adding/subtracting water.
Current Research - Dry needling vs. sham/no treatment (up to 12 weeks)
- Low quality evidence suggesting moderate effect on pain - Very low quality evidence suggesting a moderate effect on PPT - Low quality evidence suggesting a small effect on functional outcomes
Current Research - Dry Needling vs. sham/no treatment (up to 6 months)
- Moderate quality evidence suggesting a small effect on pain - Low quality evidence suggesting small effect on functional outcomes
Lymphatic system functions
- Number 1 role is to recycle proteins - capillaries can't reabsorb proteins because they are too big. - immune function - fights infection, fights cancer, removes debris and acts as a "garbage collector" - transports digested fats - the only way to access fat is through the lymphatic system
superficial lymphatics
- absorptive in subepidermal tissue - geographic distribution with discrete drainage to regional nodes - symmetrical - epifascial - drainage to deeper levels
causes of unilateral swelling
- acute DVT - pot-thrombotic - venous insufficiency - arthritis - cancer - trauma - complex regional pain syndrome (CRPS) - lymphedema
contraindications for compression
- acute infection- we can spread the infection. - arterial disease - making it harder for blood to get there -acute CHF - compression pushes blood back to heart which can cause pulmonary edema
compression garments
- after we decongest the limb, we want to maintain it with a compression garment that is elastic. - only worn during the day - medical grade garments come in several compression classes from 20-30 mmHg up to 40-50 mmHg. - made of many different materials - can be bought off shelf or custom made. - higher pressure garments are more effective
important lab values to check for liver disease
- bilirubin - albumin elevated values indicative of disease
thoracic duct
- brings fluid from the lower half of our bodies back to the heart - final common pathway before lymph mixes with blood just above the heart - negative pressure from heart sucks the lymph and blood back into the heart.
diagnosing lymphedema - what you need to know
- complete and accurate medical history - onset - presence of pain - asymmetrical or symmetrical - stemmer's sign - lymphoscintigraphy
precautions for compression
- decreased sensation - limb paralysis
How does interstitial pressure change with - reduced atmospheric pressure - aging - collagen content what is the net effect?
- decreases with reduced atmospheric pressure - decreases with aging - decreases with collagen content net effect: decreases reabsorption
signs and symptoms of lipedema
- fatty deposits from pelvic brim to the ankles - legs are very painful to touch - cauliflower texture from large adipocytes - resistant to diet and exercise - tissue easily bruises - symmetrical - orthostasis with dependency - negative stemmer sign
lipedema
- first described in 1940 - pathological deposition of fatty tissue below the waist resistant to diet - primary in women - may be hormonal or genetic - men affected only when there are associated hormonal disorders - "painful fat syndrome" - they can't eliminate the tissue in their legs - can be treated with lymphedema treatment to decrease pain.
technique for soft tissue release
- general warming/assessing of tissue - when a problem area is located, lock it into place with appropriate pressure. this is maintained while the tissue underneath is moved by the therapist or the patient. -localized lengthening, separation of the lesion with surrounding tissues. - general to specific: not all areas may need treatment, one adhesion release might also release its neighbors.
pre-capillary arterioles
- highly muscular and innervated by the autonomic nervous system - they shunt blood into soft tissue and other organs - gate keepers as blood enters the capillary beds.
When will a patient's albumin levels be tests?
- if they have a liver disorder/jaundice - nephrotic syndrome - swelling around the eyes, belly or legs - to check nutritional status
contraindications to soft tissue release
- infection that may be spread by lymph (cellulitis or febrile) - acute inflammation - bleeding in the area - open wounds - edema - presence of a thrombus - blood clotting disorders - over the site of a healing fracture
lymph transport
- intrinsic smooth muscle activity of lymphatic collectors (ANS innervated) - musculoskeletal pump - respiratory pressure changes - diaphramatic breathing is very important in lymphedema patients - proximity to pulsatile large vessels of CV system - gravity
Important questions to ask when taking patient history for a patient with edema
- is it unilateral or bilateral - how long has the swelling been evident - is it painful - ask for complete PMH: systemic illnesses, surgeries, meds. - is there a change in swelling with elevation - do they have sleep apnea - where do you sleep? - patient characteristics - habits
how is the lymphatic system integrated in the body?
- it's located in the subcutaneous spance - connects interstitial space to venous return and recycles proteins and dumps them back into the blood stream - lymphatic system is very geographic - there are "water sheds" based on regional lymph nodes.
precautions to soft tissue release
- low blood pressure - joint instability - impaired sensation - severe atherosclerosis - severe varicose veins - meds, esp. anticoagulants - anticoagulant/blood clotting disorders - recent psychological trauma - advanced diabetes - acute RA
Lymphatic system - pressure - direction - color
- lymphatic system is low pressure and relies on negative pressure to get back to the heart - one way system - lymph is white once it picks up fat from the gut
treatment options for edemas
- medical management of illness - PRICE for acute soft tissue injuries - Hi volt estim - poor evidence - k taping - compression bandaging and garments are key to reducing chronic edemas
is grading pitting edema reliable?
- not interrater or intrarater reliable - good for qualitative assessment of edema - is it present, yes or no
signs and symptoms of lymphedema
- numbness - tightness - stiffness - pain, aching, heaviness - infection or recurring cellulitis - redness/heat - swelling
lymphedema praecox
- onset at age 12 - insidious onset - pain free - no history of surgery, trauma, infection - asymmetric appearance - positive stemmers - one limb is huge compared to the other
Evidence supporting myofacial release
- overall, the studies had positive outcomes wit myofascial release, but because of the mixed quality of the studies, few conclusions could be drawn - craniosacral therapy improved pain in fibromyalgia patients - MFR may help lateral epicondylitis patients - however, in this study pts only received MFR, so this isn't super applicable. - may decrease the severity of vasospastic episodes in raynauds. - there was a review that found that MFR can be useful as an adjunct to conventional therapies, but this review was very biased. ** basically, what we know is that MFR is better than nothing, but maybe not as good as something else
Indications for soft tissue release
- pain - stiffness - decreased ROM - trigger points - postural defects
Evidence on foam-rolling
- quad foam rolling may increase acute knee ROM, but no muscle performance. - foam rolling and contract relax stressing was better than control in hamstring ROM - reduces pressure pain threshold associated with delayed onset muscle soreness - decreased muscle soreness after intense activity, while improving some physical performance measures, did impact some contractile properties. - increases sit and reach range without impairing muscle activation - foam rolling and stretching is better than stretching alone
circumfrential measurements
- routinely used in clinics - gold standard is using a truncated cone equation to solve for limb volume. (height = 4cm with known circumferences at top and bottom) - cannot be used interchangeably with other methods - systematic approach to measurement with reproducible landmarks
What are the four types of fluids that can drain into a wound/open area of the body after a injury/surgery?
- sanguinous - serous - serosanguinous - purulent they are all high protein fluids
stretching
- static stretching hold should be between 15-30 seconds - no increase in muscle elongation occurs after 2-4 repetitions - stretching may not necessarily increase tissue extensibility, but rather patient's tolerance to the stretch (increase in ROM) - PNF type techniques such as hold- relax can be beneficial, and may be more effective than static stretching in immediate ROM gains - more research is needed on the exact mechanisms, however clinically it may not really matter. -a regular stretching routine can be beneficial for adults over 65 - dynamic stretching is often integrated into neuromuscular injury prevention programs used as warm-ups which are effective in reducing sports related injuries.
Arguments against evidence based soft tissue release
- the application of MFR relies on clinician-patient interaction, therefore it cannot be a neutral treatment - the subjectivity of the interaction cannot be removed when we try to determine its outcome. - much of the effectiveness relies on the skill of the clinician and their ability to sense changes in the tissue. - the biological effects of touch can change the effectiveness of the treatment, depending on the state of either the clinician or the patient. - huge variability means that interrater reliability is low
where do lymph vessels reside and what do they look like?
- they are subepidermal - looks like fishnet, fine network - anchored in soft tissue - responds to stretch of soft tissue and with movement - valveless system - physical pores open in the walls of lymphatic capillaries to pull in macromolecules
measurement of peripheral edema
- volumetry by water displacement - gold standard - perometry - circumfrential measurements - figure 8 measurements - pitting edema assessment
Documented uses of DN - electrical stimulation
-32 weeks s/p anterior tib repair -Initial post op PT unable to regain DF strength -Returned to PT after a fall due to foot drop -2 visits estim with indwelling needles restored toe clearance
Why is it important to know what acupuncture is?
-Acupuncturists do not like PTs having the ability to perform dry needling -No single profession can have sole ownership of a tool or treatment intervention -The vast difference between the two professionals relates to their underlying philosophy, thought processes, and decision making; the only thing they have in common is the tool
Shear Forces
-Adjacent tissue surfaces slide across one another -Gravitational pull causes deep fascia and skeleton to slide downward while skin and superficial fascia remain stationary on bed or chair -Causes distortion of capillaries and tissue ischemia/necrosis occurs -Ulcers generally deep, undermined, irregularly shaped
Peripheral Neuropathy History
-Advanced Age -Alcoholism -Chemotherapy -Diabetes -Hansen's Disease -Heredity -HIV, AIDS, and related drug therapies -Hypertension -Impaired glucose tolerance -Obesity -Raynaud's Disease, Scleroderma -Smoking -Spinal Cord Injury and neuromuscular diseases
Venous Insufficiency History
-Advanced Age -CHF -Lymphedema -Obesity -Orthopedic Procedures -Pain reduced by elevation -Pregnancy -Previous DVT with Phlebitis -Pulmonary Embolus -Reduced mobility -Sedentary Lifestyle -Traumatic Injury -Vascular Ulcers -Work History
Peripheral Neuropathy Location
-Altered pressure points/sites of painless trauma/repetitive stress -Dorsal and distal toes -Heels -Inter-digital -Metatarsal heads -Mid-foot (dorsal and plantar) -Toe interphalangeal joints
Spinal Segmental Sensitization Model
-Andrew Fischer -Paraspinal muscle spasm can compress nerve roots, narrow the foramen and sprain the supraspinous ligament -Using a needle (wet or dry) to treat tender points or trigger points was optimal for long term pain relief -Greater focus on trigger points Putting needles in the multifidi along the spine
Arterial Insufficiency History
-Arterial Disease -Cardiovascular Disease -Diabetes -Dyslipidemia -Hypertension -Increased pain with activity and/or elevation -Intermittent Claudication -Obesity -Painful Ulcer -Sickle Cell Anemia -Smoking -Vascular procedures/surgeries
Arterial Insufficiency Assessment of Wound
-Base: Pale; granulation rarely present; necrosis, eschar, gangrene (wet or dry) may be present -Depth: may be deep -Margins: edges rolled (epiboly); punched out, smooth and undermining (rimming) -Exudate: minimal -Infection: frequent (signs may be subtle)
Peripheral Neuropathy Assessment of Wound
-Base: pink/pale; necrotic tissue variable -Depth: variable -Edges well defined -Exudate: usually small to moderate -Wound shape: usually rounded or oblong and found over bony prominence
Clean Needle Technique Principles
-Clean treatment field -Clean and well lit treatment area/room -Nearby sharps container -Keep needles and sharps containers out of reach of children -Wash hands between patients -Use sterile needles -Wear fitted gloves: ensures you are able to manipulate the needle accurately -Sanitize gloves -Immediately isolate and dispose of used needles
Documented uses of DN - compared to cortisone injection
-DN vs Cortisone: follow up 1, 3, and 6 weeks -DN group did not experience a worse result with regards to pain, function, and medication intake -Demonstrates a potential treatment alternative to cortisone
Clinical Interventions for Pressure Injuries
-Daily skin inspection with documentation -Skin cleansing at routine intervals and at time of soiling - minimize environmental factors that contribute to dry skin -Avoid massage over discolored, bony prominence -Control shear/friction forces -Provide adequate nutritional intake to support healing -Reposition high risk patients every two hours; use written schedule for turning/repositioning: protect bony prominences, suspend heels, do not use "donut" device -Utilize pressure reducing/relieving support surfaces
Types of Dry Needling
-Functional Dry Needling: do an exercise or movement, dry needle, see how it improves or doesn't improve -Trigger Point Dry Needling -Intra-Muscular Stimulation: doing electrical stimulation -Intra-Muscular Manual Therapy
Radicular Model
-Gunn - early pioneer of dry needling -Myofascial pain is always the rest of neuropathy or radiculopathy -Innervated structures (muscles) are dependent on the "unhindered flow of nervous impulses" -Treatment points are located near motor points or musculotendinous junction: treating the myotomal or dermatomal distribution -Limited focus on trigger points
Latent Trigger Point
-Hyperirritable spot in a taut band of skeletal muscle/fascia -Painful with compression -No referred pain/tenderness
Active Trigger Point
-Hyperirritable spot in a taut band of skeletal muscle/fascia -Painful with compression -Recreates: pain, referred tenderness, motor dysfunction, autonomic phenomena
Absolute Contraindications of Dry Needling
-Inadequate practical knowledge -Lack of patient consent -1st trimester of pregnancy -Compromised equipment -Scalp area of infants -Nipples, umbilicus, external genitalia -Area over pacemaker -Area over thoracic spine and rib cage without advanced training -Uncontrolled anti-coagulant usage -Compromised immune system -Local infection or active tumor -History of lymph node removal (lymphedema) -Occipital region of patient with known Arnold Chiari Malformation
Trigger Point Model
-Janet Travell -Most commonly utilized model -"Advocates the inactivation of MTrPs via dry needling is the fastest and most effective means to reduce pain, as compared to other conventional interventions" -LTR may interrupt motor endplate noise and induce analgesic effect -Combined with stretch may facilitate relaxation of restricted actin-myosin bonds -May help normalize muscle tone by facilitating changes in biochemical markers -Treating a MTrP is only one component of a POC
Current Research - Dry Needling vs. other treatments (up to 12 weeks)
-Moderate quality evidence suggesting a small effect on pain -Very low quality evidence suggesting a moderate effect on PPT -Very low quality evidence suggesting no treatment effect on functional outcomes
Documentation of DN
-Muscles treated -Technique utilized -Immediate response -Pre/Post testing -Additional considerations: number of needles used, size of needles used
Precautions for Dry Needling
-Needle eversion or phobia -Significant cognitive impairment -Communication barrier -History of traumatic or spontaneous pneumothorax -Severe hyperalgesia or allodynia -Metal allergy -Abnormal bleeding tendency -Vascular disease -Area of breast implant or spinal stimulator -Area of laminectomy -Severe osteoporosis
Billing for DN
-No CPT Code -Guide to Physical Therapy Practice: mobilization/manipulation sub category under Manual therapy techniques -Some insurances do not reimburse for Dry Needling -Emphasizes important of dry needling being one component of treatment: can bill under manuals but should be in conjunction with other techniques STM, joint mobilizations, manipulations, etc.; should always check with insurance company first
Peripheral Neuropathy Assessment of Surrounding Skin
-Normal skin tones -Trophic changes -Fissuring or callus formation -Edema: with erythema may indicate high pressure -Temperature: warm
Inflammatory Phase
-Occurs 1-10 days post injury -Vascular response and cellular response -Vasoconstriction (reflex), platelet plugging and neutrophilic margination -Vasodilation (of non-injured vessels) and increased vessel permeability - for chemotaxic agents, growth factors, WBCs, etc. -Clot formation -Phagocytosis -Fibrinolysin dissolves clots
Assessment of the Patient with a Wound - Medical History
-Overall physical/mental status of patient -Co-morbid conditions/past wounds and healing -Fractures or surgeries in area of current wound -Medications -Chemistry and hematology -Wound etiology/behavior of symptoms -Nutritional habits, activity level -Smoking/ETOH -Psychosocial influences: willingness to participate in plan of care; caregiver availability; equipment needs
Multifidus Lift Test
-PT: palpates multifidi at L4/L5 and L5/S1 spinal segments -Patient: flexes contralateral arm to 120 and bend elbow to 90 and raises arm off table 5 cm -Small sample size -Need more research to assess the responsiveness and clinical utility of this test
Arterial Insufficiency Assessment of Surrounding Skin
-Pallor on elevation -Dependent rubor -Shine, taut, thin, dry -Hair loss over lower extremities -Atrophy of subcutaneous tissue -Edema: variable; atypical -Temperature: decreased/cold -Infection: Cellulitis -Necrosis, eschar, gangrene may be present
Clinical Implications for TPs
-Palpable knot: tender spot in a taut band -Recreation of patient's pain: important component in any patient evaluation -Referral pain pattern -Muscle weakness: can precipitate reduced function -Reduced ROM
Relative Contraindications of Dry Needling
-Post Operative: Must get MD approval; 6 weeks - any tissue that communicates with surgical region; 12 weeks - local area of surgery -Controlled anti-coagulant usage -Auto-immune disorder -History of lymph node removal -Respiratory illness: don't want to confuse punctured lung sx with sx of their illness
Clinical Interventions for Neuropathic Wounds
-Pressure relief/off-loading -Glucose control -Control of infection -Topical therapy: wound cleansing, debridement, topical agents and dressings -Referrals: surgeon, pedorthist, podiatrist -Patient education: foot examination, meticulous skin care, proper footwear -Behavioral modification: smoking cessation; exercise prescription; weight control
Peripheral Neuropathy Perfusion - Measures to Eliminate Trauma
-Reduction of shear stress and offloading of neuropathic wounds (bedrest, contact casting, orthopedic shoes) -Use of assistive devices to provide support, balance and additional offloading -Appropriate footwear -Tight glucose/glycemic control -Aggressive prevention/treatment of infection (debridement of callus and necrotic tissue; pharmacologic treatment when appropriate) -Revascularization if ischemic -Complications: Cellulitis, osteomyelitis, gangrene, Charcot fracture
Healthy Skin
-Skin is the largest organ in the body - about 15% of body weight -Major interface between the external environment and the internal environment of the body -Skin is acidic in nature, elastic, and generally lubricated
Friction Forces
-Skin moves across the support surface -Occurs most often when patients cannot lift sufficiently during position changes to avoid dragging skin over the surface -Ulcers generally superficial and appear reddish or rough looking
Areas of caution for DN
-Supra-clavicular triangle -Thoracic Spine and ribcage -Thoraco-lumbar junction to L2: known as the watershed, doctors try to avoid this area too - any vascular compromise could lead to injury of the spinal cord -Iliac crest -Sacral/Coccyx/Buttock -Femoral triangle -Cubital and popliteal fossa
Training Levels - Level 2
-Upper Cervical Spine -TMJ -Thoracic Spine -Peri-Scapular Region -Abdomen -Hand -Foot -Pelvic Floor
Venous Insufficiency Assessment Surround Skin
-Venous dermatitis (erythematic, weeping, scaling, crusting) -Hemosiderosis (brown staining) -Lipodermatosclerosis; Atrophy -Blanche -Temperature: normal; warm to touch -Edema: pitting or non-pitting; possible induration and cellulitis -Scarring from previous ulcers ankle flare, tinea pedis -Infection: induration, cellulitis, inflamed, tender bulla
stage of lymphedema
0 - latency - reduced capacity, no clinically apparent swelling. I - pits with pressure - spontaneously reversible with elevation II - non pitting - not reversible with elevation III - elephantiasis - significan't skin changes, severe fibrosis and papillomas.
What year did the first state write Dry Needling into the physical therapy practice act occur?
1989
DOF of patellofemoral joint
2 Motions Flexion/Extension Medial/Lateral glide
Resting Position of Hip
30 degrees flexion 30 degrees abduction Slight ER
What is the protocol for post-surgical scar management?
4 weeks after surgery 2-3x daily for 3-5 minutes Application of petroleum jelly or moisturizing cream 3-4 months
Joint Motions
6 degrees of freedom for joint motions Flexion-Extension Abduction-Adduction Internal Rotation/External Rotation Medial-Lateral translation Anterior-Posterior translation Distraction-Compression
Other complications with DN
<0.01% Vasovagal response Fainting Forgotten Needle GI issues Neurological response Emotional response
What is a friction massage?
A repetitive, specific, non-gliding technique Produces movement between fibers Increases tissue extensibility Increases blood flow
What is Dry Needling?
A skilled intervention performed by a physical therapist that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular and connective tissues for the management of neuromusculoskeletal pain and movement impairments that is based upon Western medical concepts; and requires a physical therapy examination and diagnosis
Systemic Factors Impacting Wound Healing
Co-Morbidities Nutritional state Medications Oxygenations/perfusion Age
Collagen lysis balance
Collagen lysis exceeds synthesis - soft scar Collagen synthesis exceeds lysis - more firm scare - has the potential of becoming hypertrophic or keloid in nature
What are abnormal findings during skin quality checks?
Color: red, blue, white, darkened, etc. (bruising, etc.) Any injury to integrity of skin itself Scar tissue/wounds, etc.
Proliferation portion of epithelialization
Come across and start to pull down some layers of epithelium
Tunneling
Communication hole between two separate wounds Able to poke cotton applicator between the two
Accessory Movement Details
Component motions: motions that accompany active motion, but are not under voluntary control Joint play: motions that occur within the joint; determined by joint capsule laxity; can be assessed passively, but not performed actively
Localized Twitch Response - Is it necessary?
Conflicting research regarding it's importance Eliciting a LTR improved short term relief, but had no difference at 2 week follow up
What are the self-care instructions?
Correct self-stretches Gentle AROM through full range Moist heat Self-administered specific compression Effleurage and petrissage strokes Ergonomic and posture education
Nutritional Status
Critical nutrients that support tissue healing and repair: proteins, calories, vitamins, iron, zinc, albumin Interventions: -nutritional consult -Increase caloric intake to 30-35 Ca/Kg/day -increase protein to 1.5-2.0 g/Kg ideal body weight/day -good quality MVI daily, plus additional vitamin C
What are the neurological effects of STM?
Decrease muscle tension - reduction in neuromuscular excitability Decrease pain - may activate neural-gating mechanism, can increase serotonin, less pain, improved function in combination with exercise and postural/body mechanics
Age - systemic factors
Decreased epithelialization/contraction, decreased capillary, growth rate, delayed collagen remodeling, increased rate of dehiscence
Peripheral Neuropathy Perfusion - Pain
Decreased sensitivity to touch; if present, pain may be superficial, deep, aching, stabbing, dull, sharp, burning or cool; altered sensation not described as "pain" (numbness, warmth, prickling, tingling)
What is the dose-response to massage?
Dependent upon: Length of treatment Rate of stroke Depth of pressure Direction of stroke
How do you know what type of material to put into the wound?
Depends on the amount of fluid present
What is Acupuncture?
Describes a family of procedures involving the stimulation of points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, metallic needles that are manipulated by the hands or by electrical stimulation
Direction of Mobilization
Determine direction of mobilization using concave/convex rule or... where is it tight? How do you name the mobilization? What direction are you treating? Ex: Shoulder: inferior GR IV at 90 degrees abd 3x30 sec Ex: PA/AP to L4/5 GR III 4x30 sec
What are things to consider when taking informed consent?
Do we need to touch the patient? - as a PT, can do a lot without actually touching the patient Things to consider: where we need to touch the patient, Hx of abuse, cultural differences, personal preferences/space
Determine Treatment Plane
Draw a line from the center of rotation of the convex joint partner to the center of the articular surface of the concave joint partner The treatment plane (2 dimensions) is a plane perpendicular to that line Joint mobilizations are named depending on which plane you are planning on treating
Pain
Dressing type, repositioning, analgesics
Needle Stick Injuries
During the procedure - 30-50% Recapping the needle - 25-30% Disposal of the needle - 30%
How do you assess a patient's response to treatment?
During treatment: ask specific questions, observe patient's non-verbals After treatment: reassess - ROM, pain, functional movement
Arterial Insufficiency Assessment of Nails
Dystrophic
Anterior Glide of Humerus
ER Extension Manipulating hand positioned anteriorly, guiding hand supports the upper limb (patient prone or supine)
Capsular Pattern of Shoulder
ER > Abduction > IR
Anterior Glide of Hip
ER, extension Patient is lying prone with one or more pillows under the trunk and the hip positioned in abduction and external rotation Place the guiding hand over the posterolateral surface of the proximal thigh and then the mobilizing hand over the guiding hand The mobilizing/manipulating hand glides the femur in an anterior direction as the therapist leans on the patient's thigh
Layers of the skin
Epidermis Dermis Subdermal structures
What is a hypertrophic scar?
Erythematous, raised fibrous lesions Typically do not expand beyond the boundaries of the initial injury May undergo partial spontaneous resolution Arise in any locations; commonly occur on extensor surfaces of joints Fewer thick collagen fibers Scanty mucoid matrix Appear within one month
Contraindications/Considerations for Joint Mobilizations
Excessive pain/swelling (joint effusion in that specific joint) Acute inflammatory/infective arthritis/RA Osteoporosis Pregnancy (in the area) History of malignancy (in the area) Hypermobility (may use I/II for pain) Dizziness (need to know diagnosis causing dizziness) Neurological signs Spondylolisthesis Arthroplasty Rheumatoid collagen necrosis Fracture - recent or unhealed Excessive pain Neoplastic disease Fusion or ankylosis Osteomyelitis
What is the technique for TFM?
Expose part and locate lesion Clearly communicate with patient Neutral position of tension (varies) No lubricant Light to deep pressure 1-3 cycles/sec 5-10 min
Superior Glide of the patellofemoral joint
Extension Knee in slight flexion, glide patella superiorly
Ways to Utilize Dry Needling
For weak or underperforming muscles -Direct treatment of trigger points (active or latent TPs) -Application of e-stim For painful or irritated muscles -Direct treatment of trigger points (active) -Application of e-stim
Resting position of patellofemoral joint
Full extension
Closed Pack Position of Hip
Full extension, IR, and abduction (ligamentous) 90 degree, slight abduction, and IR (bony)
Close Packed Position of patellofemoral joint
Full flexion
Stage 4 Pressure Injury
Full thickness skin and tissue loss, exposed fascia, muscle, tendon, ligament, cartilage, or bone
Stage 3 Pressure Injury
Full thickness skin loss, exposed adipose (subQ fat)
How do we know if the capsule is involved?
General conditions which produce a capsule pattern of restriction Considerable joint effusion/synovial inflammation Relative capsular fibrosis
Where does STM fit in PT?
General massage in full form is not used that much - we do use components of it Complements other PT interventions
What is Effleurage?
Gliding strokes Light strokes: accustoms pt to your touch, relaxing, return stroke, terminal stroke Deep strokes: affect circulation, begin to see mechanical effects, transitions stroke
Partial thickness wounds
Goes through the epidermis and into but not through the dermis
Wagner Scale
Grade 0 - pre-ulcerous lesion; healed ulcer; presence of bony deformity Grade 1 - superficial ulcer without subcutaneous tissue involvement Grade 2 - Penetration through subcutaneous tissue; may expose bone, tendon Grade 3 - osteomyelitis; abscess Grade 4 - gangrene of a digit Grade 5 - gangrene of foot requiring amputation - just have to know that the wagner scale is for neuropathic wounds ONLY
Grades of Oscillatory Mobilizations for Glides (Maitland)
Grade I Grade II Grade III Grade IV Grade V
Inferior Glide
Hip flexion and IR and abd Patient is lying supine near the edge of the table with belt wrapped around the patient's leg and the therapist's leg In a lunge position with therapist facing patient, therapist applies a light distraction force by taking up the slack in the belt while moving the patient's hip into flexion
What are the theories for cause of fibromyalgia?
Hormonal disturbances Stress Genetics Most prescribe to it resulting from a combination of many physical and emotional stressors Low levels of serotonin > lower pain thresholds/increased sensitivity to pain > increased chemical called "substance P" (amplifies pain signals)
Joint Congruency
How well the joint surfaces match or fit
Ultrafiltration
Hydraulic pressure in blood capillaries that forces an additional amount of water to leave the blood and enter the interstitial space. - goes against COP pressure - this pressure is higher than the COP of the plasma when blood enters the capillary bed. - forcing more water into the soft tissue. - comes from blood pressure!
What happens if granulation is happening faster than epithelialization?
Hypergranulation tissue - often called proud flesh Want to put pressure for contact inhibition - going to also put a dressing on top that disrupts the oxygen supply May use sharp debridement, silver nitrate, etc.
Posterior Glide of Shoulder
IR Horizontal Adduction Manipulating hand glides humerus in a posterior direction, guiding hand controls the position of the humerus
Posterior Glide of Hip
IR, Horiz adduction Patient is lying supine and the therapist is supporting the patient's knee with the guiding hand If conservative techniques are indicated the hip joint is placed in the resting position If more aggressive techniques are indicated the hip joint is placed in the approximately restricted range of motion The mobilizing/manipulating hand is positioned on the anterior surface of the proximal thigh, the therapist applies a grade I traction to the joint and the mobilizing/manipulating hand glides the femur in a posterior direction
What is Dry Needling NOT?
IT IS NOT ACUPUNCTURE! It is also not: An entry level skill Allowed in every state Performed on every patient
What is included in treatment planning and decision-making?
Identify impairments - pain, decreased ROM, poor muscle performance, etc. Functional/Activity limitations - inability to drive > 10 min; inability to reach overhead due to neck pain, etc. Selection of STM techniques Other PT interventions
Concave-Convex Rule
If moving surface in concave - glide occurs in the same direction as bone movement Ex: Tibia on femur
Convex-Concave Rule
If moving surface is convex - glide occurs in opposite direction of bone movement Ex: gleno-humeral joint
Applying Mobilizations with pain
If pain occurs: Before resistance with PROM = do grade I & II oscillations/traction At the same point of ROM as the first barrier to motion = do grade III oscillations/traction After the first motion barrier = do grade III tractions and IV/V oscillations
What happens if contraction and granulation are not happening at the same rates and contraction is faster?
If the top closes before the bottom is built up - things could grow underneath and an abscess could form If wound is epithelializing faster than granulation tissue is building up - rough up edge of epithelialization and it will give it more time to granulate
Trauma - local factors
If wound is progressing along just fine and is traumatized - goes back to the beginning of the healing phase - if a wound is on the bottom of foot and walk on it every day - never going to heal - if a SCI patient develops pressure ulcers on bottom - need to find a way to alter seating to relieve pressure
What is the importance of relaxing during trigger point release?
Important for both the patient and the PT Diaphragmatic breathing - helps turn on the PNS and turn down the pain response Patient awareness of sources of tension (posture) Talk slowly and calmly Use a slow rhythm/rate
Overall, what is the evidence for STM?
Inconclusive Major design flaws in existing research studies: small sample size, no follow-ups, no randomization, clinical effectiveness, case studies or case series
What are the physiological effects of STM?
Increased skin/muscle temperature - increased intramuscular temperature to 2.5 cm; quickly returned to baseline Increased blood flow - inconclusive due to design limitations
Current Research on Multifidi and LBP w/ DN
Individuals who improved the most with DN demonstrated pain when contracting lumbar multifidi prior to treatment - trigger points can contribute to pain with muscular contraction - utilization of DN may have helped eliminate TP and contribute to short term relief of LBP LBP is associated with poor lumbar multifidus function After dry needling, the patients demonstrated an improved ability to unilaterally contract the lumbar multifidi
What are the general contraindications/considerations for STM?
Infection that may spread by sin or lymph Acute inflammation Bleeding in the area Blood clotting disorders Open wound Edema: unless doing a technique that is used to treat edema Presence of a thrombus Over a healing fracture
Potential complications
Infection, abscess, maggots, squamous carcinoma, etc.
What are the 4 stages of tissue healing?
Inflammatory Granulation Fibroblastic - repair/proliferation Maturation - remodeling
What is the medical management of trigger points?
Injections of procaine Medications: limited evidence and unclear benefit Dry Needling: "insertion & manipulation of a fine/flexible needle into TrP to produce a local twitch response (LTR), resulting in muscle relaxation"; state practice acts determine who is qualified to do this
Subdermal Functions
Insulation - adipose tissue Organ protection Energy storage Compartmentalization Provides function
Arterial Insufficiency - Perfusion - Pain
Intermittent claudication Resting; positional; nocturnal Painful Ulcer Paresthesias
What is trigger point dry needling?
Invasive technique to treat TrP Preliminary research: improves pain, reduce muscle tension, normalizes endplate dysfunction, facilitates accelerated return to active rehab Literature is still developing
Localized Twitch Response - What is it?
Involuntary muscle contraction
Capsular Pattern
Irritation of the joint capsule or the synovium producing characteristic, proportional limitation of movement Ex: Adhesive capsulitis (Frozen Shoulder) - ER > AB > IR
Neurophysiological Effects of Joint Mobilization
Joint mechanoreceptors are stimulated to inhibit nociceptive stimulation/decrease pain Affect muscle spasm and muscle guarding - nociceptive stimulation Increase in awareness of position and motion because of afferent nerve impulses
Close-packed/Close-pack position
Joint surfaces have maximum contact with each other Ligaments and capsules holding the joint together are taut Treatment position
Stratum Granulosum
Keratin granules Aids in water retention - don't want to dehydrate, keeps us from losing fluids Makes up Prickle Cell layer w/ stratum spinosum
Stratum Spinosum
Langerhans cells (immune function), Merkel's disks Protects basal layer Makes up Prickle Cell layer w/ stratum granulosum
Grade III
Large amplitude movement up to limit of range
Grade II
Large amplitude movement within range (but not at end of range) Pain Control
Joint Restrictions Caused by Non-Capsular Patterns
Ligament Adhesions Internal Derangement Extra-articular Limitation
Loose end feel
Ligamentous laxity; a hypermobile joint Pathologic
What is the classic massage stroke order?
Light effleurage Deep effleurage Petrissage Friction Tapotement Deep effleurage Light effleurage
Sinus Tract
Like going into a mine Occurs deep within the wound bed Extension of part of the wound cascades beyond a part of the wound
What is a pressure injury?
Localized area of tissue necrosis that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time
Why does fibrosis lead to a loss of range of motion?
Loss of mobility between adjacent fibers Attach of new collagen fibers (inflammatory phase) Increased friction between fibers Loss of water and proteoglycans - decreased lubrication (immobilization) Collagen fibers shorten by remodeling
What are the precautions for STM?
Low BP Joint instability (loss of joint integrity) Impaired sensation Fragile skin (loss of soft tissue integrity) Cancer (active and in the area, radiated skin) Severe artherosclerosis Severe varicose veins Certain medications: especially those that alter sensation, circulation, or mood Recent psychological trauma Advanced diabetes Acute RA
What are good guidelines to follow with STM?
Maintain a professional demeanor Good boundaries (draping) Good verbal communication When necessary, have a witness - more important for male therapists; want the witness to be someone on the staff; want witness to be the same sex as the patient being treated Document consent - if it isn't written down it didn't happen
What is the petrissage technique?
Many ways to perform Goal is to lift and squeeze/mobilize the soft tissue Do not pinch!
Closed Packed Position of Shoulder
Maximal abduction & ER
What are the hyperemia therapeutic effects of TFM?
May increase vasodilation/increased blood flow Imposes rhythmical stress transversely to the remodeling collagenous structures of the connective tissue and thus reorients the collagen in a longitudinal fashion
What is the research of trigger point compression and passive stretching?
May inhibit: pain, reflex motor and autonomic CNS responses Small increases in ROM Possible anti-inflammatory action
Stratum Basale
Melanocytes Constantly dividing to regenerate surface layers -Protection from sun AKA basal cell layer
Dermis
Middle Layer of skin Consists of Papillary layer & Reticular layer
Venous Insufficiency Perfusion - Pain
Minimal unless infected or dessicated Described as throbbing, sharp, itchy, sore, tender, heaviness Worsens with prolonged dependency
Risk Assessment
Mobility, continence, circulation, predisposing illness, nutrition, mental status, hydration, existing open wounds
Epithelialization Parts
Mobilization Migration Proliferation Differentiation
Effects of mobilization on capsular structures in the transitional/consolidation phase
Mobilization techniques have limited effect on tissue Remodeling occurs primarily around scar periphery Emphasis on functional restoration
What is the right environment for a wound to heal?
Moist wound healing - not too wet and not too dry -if it is seeping: add a dressing that is going to dry it up -if it is absolutely dry: add a dressing that is going to add a bit of moisture
Local Factors impacting wound healing
Moisture Necrotic tissue Wound temperature Trauma Infection
Stratum Corneum
Most external of the epidermus -Acidic, avascular -Keratinocytes, melanocytes -Replaced from basal cell layer every 28 days - sloughs off as dust AKA the horny layer
When is the best time to treat scars?
Most influence on scar occurs between 1-8 weeks post injury (except for burn) Old scars should be evaluated & treated, too If waiting 3-4 months to mobilize scars, not going to be able to have as much of an influence
Arthrokinematics or Accessory Motion
Motions of the bone surfaces within the joint (we can't see; we feel) Almost always accompany osteokinematic motion 5 motions: roll, slide, spin, compression, distraction Almost always have 3 components to all movements (roll, spin, slide) Necessary for FULL range of physiological motion
Gliding
Move the joint surface parallel to the treatment plane
Traction & Compression
Move the joint surface perpendicular to the treatment plane
Odor - local factors
Not all necrotic tissue smells If you take dressing off, need to cleanse the wound before judging the smell If it still smells after it is cleansed - can assume that something is going on and it is back in the inflammatory phase
How tight do you pack the wound?
Not too tight, not too lose Too lose - is like not packing it at all Too tight - won't heal - tissues feel full contact everywhere, thinks it must be healed - no room for it to heal and grow (contact inhibition)
What is the energy crisis theory for trigger point formation?
Muscle overload > abnormal release of acetylcholine > influx of calcium into sarcomeres > localized contraction of affected sarcomeres > contraction knots (develops into trigger point) > increase in metabolic demands > local ischemia > energy crisis > pain > influx of calcium into sarcomeres, etc.
When does wound closure typically occur?
Muscle, skin (5-8 days) Ligament, tendon (3-5 weeks)
Contraction during proliferative phase
Myofibroblasts pull wound edges together Trying to close in and reduce the size of the defect -Going to occur the fastest in linear type wounds -Circular wounds are the slowest contracting Is a time sensitive process - start to exert effect about 5 days after injury occurs - peaks at about 2 weeks and is over by 3 weeks time - going to start to see lines of pull - streaking of tissues as they pull together
Angiogenesis and neovascularization during proliferative phase
New blood vessels are growing Establishing new capillary networks Important to provide the nutrients to the would As you heal, you have higher metabolic demands - going to bring in the oxygen and nutrients needed to support wound healing -will be "beefy red" in appearance
Roll
New points on one articular surface meet new points on opposing articular surfaces (ex: femoral condyles)
Empty end feel
No resistance to motion
Is the epidermis just straight layers?
No, basale layer dips down into the dermis regions Really important for wound healing -even if the wound comes into dermal tissue, the wound can heal in part by the epidermis and epithelialization -epidermal appendages dip into dermis and give hop that epithelialization can occur even when the wound goes down into dermal tissue
What are the clinical characteristics of MPS?
Non-inflammatory Local pain and muscle stiffness: dull, non-pulsating; segmented distribution Presence of hyperirritable palpable nodules: in skeletal muscle fibers Palpation alters pain: + referred pain pattern Postural imbalance very common - can be done a lot during the subjective exam
Necrotic tissue - local factors
Non-viable tissue No matter what it looks like, it is dead tissue It keeps the wound in the inflammatory phase, carries a high bioburden - bacteria love necrotic tissue Can be sloughy or leathery -Slough: loose, stringy, pliable, tissue - can move it around and cut it away -Leathery: thick, hard, feels like leather - called eschar
What is fibromyaliga?
Nonarticular rheumatic disorder characterized by: Generalized musculoskeletal pain (in all 4 quadrants) for > 3 months Stifness Fatigue Disturbed sleep Tender points (11 of the defined 18) No lab findings for diagnosis
Stage 1 Pressure Injury
Nonblanchable erythema of intact skin, excludes purple or maroon discoloration
Maturation/Remodeling Phase
Occurs 9 days to 2 years post-injury Collagen synthesis-lysis balance: hypertrophic scar, keloid scar Collage fiber orientation: induction theory, tension theory Tensile strength increases as cross-linking occurs - reaches 70-80% of original tissue
Stage 2 Pressure Injury
Partial thickness skin loss with exposed dermis, includes serum-filled blisters, excludes MASD, MARSI, traumatic skin tears, burns, abrasions
Oscillatory (Maitland)
Passive oscillatory movements, two or three per second, of small or large amplitude, and applied anywhere in a range of movement - to decrease pain and/or increase ROM
What is POSAS (Patient and Observer Scar Assessment Scale)?
Patient and observer scores VSS plus surface area; patient assessments of pain, itching, color, stiffness, thickness, relief Scores range from 5 to 50 Valid and reliable tool Recent modification: pain, functional impairment
Distraction of the Shoulder
Perpendicular to glenoid, impart a lateral, anterior and inferior force
Deep Tissue Injury - Pressure Injury
Persistent nonblanchable deep red, maroon, or purple discoloration; includes blood filled blisters
Techniques for DN
Pistoning Pecking - to bone Threading - pull up tissue and thread across Coning
Position of a Joint
Place joint in the resting position (initial assessment glide done in this position) - to be more aggressive: move to more closed positions
Phagocytosis during inflammatory phase
Polymorphonuclear leukocytes first: secrete lysozyme into exudate - ingest some of the foreign material (lysozyme is the pus that you see in exudate) Monocytes and mononuclear leukocytes next - transform into macrophages - secrete by-products of ascorbic acid, hydrogren peroxide, and lactic acid
How do you evaluate a dermal scar?
Position in neutral position (some slack) Begin with light pressure Identify adherent areas (adjacent and deep to the scar): use clock positions for documentation (from anatomical position), skin rolling (actual pliability of the skin) Identify painful areas Observe color, puckered areas, measure size (done in cm using a tape measure)
Treatment Variables for Joint Mobs as a Treatment
Position of Joint Direction of mobilization Type-sustained or oscillatory Grade of mobilization Length of mobilization
Open-packed/Loose-packed position (aka resting position)
Position of maximum in-congruency Parts of the capsule and supporting ligaments are lax Intracapsular space is as large as possible Unlocked, inefficient for load bearing Assessment position
Temporalis Trigger Points
Possible Causes: Grinding or clenching of teeth; direct trauma, such as a fall; forward head posture Symptoms/Indications: head pain, toothache Pain patterns: upper row of teeth, temporal region, over the eyebrow Associated TPs: masseter on same side, temporalis on opposite side, medial and lateral pterygoids Differential diagnoses: temporomandibular joint disorder, diseased teeth, tension-type headaches, temporal tendinitis
Suboccipitals Trigger Points
Possible Causes: forward head posture, sustained forward flexion of the head Symptoms/Indications: headache, deep-seated pain in upper neck, difficulty rotating head Pain patterns: temporal and occipital regions Differential Diagnoses: tension-type headache, cervicogenic headache, occipital neuralgia, articular dysfunctions in upper cervicals
Lateral Pterygoid Trigger Points
Possible Causes: sternocleidomastoid TPs, mechanical stress caused by poor posture, excessive grinding of teeth, playing a wind instrument Symptoms/Indications: severe pain in the temporomandibular joint region, shortening of muscle, tinnitus, pain when chewing Pain Patterns: temporomandibular joint, front of face Differential diagnoses: medial pterygoid TPs, trigeminal neuralgia
Levator Scapula Trigger Point
Possible causes: Occupational stresses, typing with head and neck turned, holding the phone between ear and shoulder, sleeping with neck in tilted position walking with cane Symptoms/Indications: pain at the angle of neck, "stiff neck", torticollis, unable to turn head fully to same side or opposite side Pain Patterns: Posterior shoulder and neck, medial border of scapula Associated TPs: trapezius, rhomboids, splenius capitis Differential Diagnoses: splenius cervicis TPs, scapulocostal dysfunction, sternocleidomastoid TPs
Venous Insufficiency Perfusion - Peripheral Pulses
Present/Palpable - though they may not be if the edema is extreme enough
What are common errors in trigger point release?
Pressure applied too quickly - painful, tense response - less effective with rest on treatment Pressure exceeds patient pain tolerance Pressure not maintained on TrP Insufficient depth Passive stretch omitted Perpetuating factors not addressed
Primary Wound (intention) Closure
Primary closure (first intention closure): suturing of an incision or wound Delayed closure (third intention closure): approximation after infection is controlled or no longer present
How does TFM affect collagen fiber and CT alignment?
Promotes a normal orientation of collagen fibers Prevents/ruptures adhesions Crosslinks and adhesion formation are prevented
Epidermal Functions
Protection - from sun, environment, etc. Thermoregulation - keeps body heat in Conservation of body fluids Metabolism - vitamin D synthesis Excretion - helps eliminate waste through sweat Sensation - free nerve endings Personal identity - everyone has different features (finger prints)
Venous Insufficiency Perfusion - Measures to Improve Venous Return
Provided vascular studies have ruled out significant arterial disease -Surgical obliteration or damaged veins -Elevation of legs -Medications -Exercise -Education -Compression therapy to provide at least
Myofascial Stretch to QL
Pt can be in multiple positions for setup Cross-arm myofascial stretch
Quadratus Lumborum Trigger Point Release
Pt is sidelying with towel roll under unaffected side Ipsilateral arm is fully abducted and extended Ipsilateral leg is adducted to table *Aren't always going respond well to treatment - QL might be tight for stability and release will make them unstable
Self Stretch to QL
Pt standing with arm stretch overhead Leg adducted and extended behind Can have pt forward bend slightly to increase stretch
What is one of the best treatments for wound care today?
Pulsatile Lavage
Vascular Examination
Pulses, ABI, auscultation, special tests
What are the signs and symptoms of an active TrP?
Tenderness: very tender on palpation and possibly at rest Pain/Restricted ROM: pain with movement; restricted ROM Referred pain: usually has Referred Pain Pattern Patient awareness of trigger point: patient confirms presence
Temperature - Local Factors
Putting a thermometer into a crater wound - is going to be cooler than the body temperature because the skin isn't there to keep the heat in Wounds heal best in a normothermic environment At or 1 degree C above normal body temperature is the ideal temp for wound healing Dressing is supposed to act like skin - works to keep the heat in -every time you change the dressing, the heat dissipates - takes hours to reheat
Assessing physiological & accessory movements
Quantity Quality of motion Note where in the range pain was felt and where in the range resistance was felt End feel
Functional Evaluation
ROM, strength, transfers, gait, assistive devices, positioning
Masseter TrP Release
RPP: eyebrow, ear, TMJ, upper and lower teeth Use pincer palpation Very easy and very effective Assess opening ROM
Keloid scar
Raised scar that extends beyond the initial boundaries of the wound
Hypertrophic scars
Reactive hyperplasia It is caused by over proliferation of dermal collagen Raised scar that stays within the initial boundaries of the wound
Therapeutic Uses for Dry Needling
Reduced pain (NPRS) Improved ROM Reduced pain sensitivity Improved muscle function-short term
Arterial Insufficiency - Topical Therapy - Infected Wound/Dry or Moist Necrosis
Referral for potential surgical debridement/antibiotic therapy
What are the pain relief therapeutic effects of TFM?
Release of endogenous opiates Counter-irritant and gate theory - pain signals are goings to be thrown off by counter irritants Facilitates removal of chemical irritants
Application Principles
Remove jewelry/rings Be relaxed (both you and the patient) Always examine contralateral side Avoid pain/stop if painful Perform smooth, regular oscillations Follow mobs with AROM exercises
Acute DVT - what kind of hyperemia is it? - symptoms/clinical rules/diagnosis
Represents venous obstruction - passive hyperemia - sudden onset - painful - cyanosis - positive homan's sign is possible - PE may occur - Use well's rule - diagnosed by doppler US
Goal of Mobilization
Restoration of normal arthro-kinematics (joint play) to allow normal osteokinematic motion Determine the nature and extend of lesion Decide if joint mobilization is indicated Choose appropriate technique Skillfully apply techniques Use modalities to relieve pain and muscle guarding as adjuncts to mobilization
What is included in management for fibromyalgia?
Restore restful sleep: low-level antidepressant (elavil), muscle relaxer (flexeril) Injection to tender points PT - massage/STM, aerobic exercise, stretching, patient education, biofeedback
Chronic Wounds
Result from underlying process Fall off healing cascade due to prolonged inflammatory phase (infection, necrotic tissue, etc.) - need to figure out why it got stuck, eliminate the problem, and start again Require appropriate topical therapies and appropriate supportive therapies (pressure relief, compressive therapy, etc.) -need to make it an acute wound so that it can proceed through the healing cascade in an orderly fashion
What is a keloid scar?
Result of an overgrowth of dense fibrous tissue Tissue extends beyond the borders of the original wound Does not usually regress spontaneously Tends to recur after excision Commonly occur on the sternal skin, shoulders and upper arms, earlobes, and cheeks Grow for years Mucoid matrix Remain elevated more than 4 mm Appear at three months or later More common in darker skin types
Acute Wounds
Result of trauma or surgery Proceed through healing cascade in orderly fashion Requires appropriate topical therapies
Arterial Insufficiency - Perfusion - Measures to Improve Tissue Perfusion
Revascularization if possible Medications to improve RBC transit through narrowed vessels Lifestyle changes (avoid tobacco, caffeine, restrictive garments, cold temperatures) Hydration Measures to prevent trauma to tissues (appropriate foot wear) Maintain legs in neutral or dependent position Pressure reduction for heels and toes -refer patient for vascular surgery
Undermining
Rimming Able to poke a cotton applicator underneath in certain spots
Spin
Rotation around a stationary axis (ex: radioulnar joint)
What are tools the PT and patient can use for trigger point release?
Tennis balls Lacrosse balls Thera-cane or Body-Back-Buddy
Updates to the guidelines of Pressure Injuries
Shift of terminology from "pressure ulcer" to "pressure injury" Shift from Roman numerals to Arabic numbers Eliminate "suspected" from "Deep Tissue Injury" classification Included Medical Device Related Pressure Injury (uses staging system) and Mucosal Membrane Pressure Injury (does not use staging system)
Direct Technique
Should be initiated with the joint in the resting position - safest position to treat, minimal compressive forces, can observe patient response Not the most effective position in which to treat if the goal is to increase tissue extensibility The periarticular tissue that is limiting normal joint motion is most stretched when the joint is positioned as close to the restricted range as pain will allow
Traction I (Piccolo)
Small amplitude movement with no appreciable movement Neutralizes pressure in the jt. without actual separation Purpose is to relieve pain by reducing grinding when mob; ~Gr I
Soft Tissue end feel
Soft Normal Ex: flexing normal knee or elbow
Boggy end feel
Soft; mushy; joint effusion Pathologic
Internal derangement end feel
Springy; mechanical block such as torn meniscus Pathologic
Migration portion of epithelialization
Start to move closer to the wound defect - problem with scabs (crusts) as they start to move to the wound, hits the scab and thinks it must be healed - slows it down
Layers of Epidermis
Stratum Corneum Stratum Lucidum Stratum Granulosum Stratum Spinosum Stratum Basale
Mechanical Effects of Joint Mobilization
Stretch of the capsule can cause plastic deformation of collagen to improve motion Improve mobility of hypomobile joints (adhesions & thickened CT from immobiliz. Loosens) Maintains extensibility and tensile strength of articular tissues
Subdermal structure examples
Subcutaneous Tissue: adipose, connective, and elastic tissues; superficial and deep fascia Muscle, tendon, and bone -many wounds go down this deep
Subdermal structures
Subcutaneous tissue Muscle, fascia, tendon, bone
How do you identify a trigger point?
Subjective complaints/history, pain drawings Palpation: flat, pincer Referred pain pattern (RPP) Local twitch response (uncommon) Should correlate with other eval findings (ROM, MMT, Posture...)
Effects of Mobilizations on Capsular Structures
Sudden joint movements > stimulate type III receptors > reflex muscle contraction Gradual initiation of movement > stimulates type II receptors > small facilitative muscular response Gr V manipulation must be performed quickly enough that it is completed before type III receptors can produce a reflex muscle contraction
Adhesions and scarring end feel
Sudden; sharp arrest in one direction Pathologic
What is trigger point pressure release?
Sustained digital pressure, direct inhibitory pressure, static friction, acupressure, progressive pressure technique A non-gliding technique with its compressive force applied perpendicularly to the structure
Assessment Glide
Sustained mobilization into the end range of motion Called "stretch articulation" Sustained mobilization at Gr II-III amplitude (into end range)
Traction III (stretch)
Sustained movement at end of the range through the restriction Purpose is to increase mobility in a hypomobile joint
Traction II (take up the slack)
Sustained movement within the ROM to the restriction Effectively separates articulating surface and eliminates place in joint capsule Used to relieve pain; ~ to Gr IV mob
Sustained (Kaltenborn)
Sustained stretching often at the limit of the range - all assessment mobilizations are sustained Also used to decrease pain and/or increase ROM
What are the direct fascial techniques?
Sweeps/muscle stripping Clearing Releases Friction Bending
Nutritional Effects of Joint Mobilization
Synovial fluid movement because of distraction or gliding Movement can improve nutrient exchange due to joint swelling and immobilization
What are the challenges with fibromyalgia?
Tender point count was rarely performed by PCPs MDs often diagnosed fibromyalgia by symptoms If patients' symptoms improved with a decrease in tender points, they may not continue to meet the ACR criteria
What are the signs and symptoms of a latent TrP?
Tenderness: Pain on deep palpation Pain/Restricted ROM: No pain with movement; ROM may be restricted Referred pain: Does not typically have Referred Pain Pattern Patient awareness of trigger point: Presence not know unless probed - does not cause clinical pain complaints
What are the signs and symptoms of a tender point?
Tenderness: tender; generalized pain Pain/Restricted ROM: may/may not be painful with movement; hypermobility Referred pain: no referred pain pattern Patient awareness of trigger point: N/A
Full thickness wounds
Through epidermis, through dermis, into the subdermal (subcutaneous) tissues
How are trigger points characterized?
Tense bands Focal-asymmetrical distribution: regional pain, focal tenderness Rigid muscle palpation Restricted ROM/muscle stiffness Muscle weakness - might not be clinically weak, but doesn't have the endurance
What professional & legal issues come into play with STM?
The impact of touch Boundaries - be sensitive to cultural and gender issues Have proper communication with the patient
How is massage and soft tissue mobilization defined?
The intentional & systematic mechanical manipulation or soft tissues to promote health & healing
Extra-articular Limitation
The loss in joint mobility results from adhesions in structures outside the joint Movements that stress the adhesion will be limited and painful More of a muscle or something
Internal Derangement
The restriction in joint mobility is the result of a loose fragment within the joint The onset is sudden, pain is localized, and movements that engage against the block are limited, whereas all others are free Ex: Meniscus Tear
Physiologic Movements or Osteokinematic Motion
These are the traditional movements we think of like flexion, extension, abduction, rotation Motions/movement of the bones that we see in physiologic motion Result of concentric or eccentric active muscle contraction Bones are moving about an axis or through joint motions (flexion, extension, etc.)
Ligament Adhesions
These occur when adhesions form about a ligament after an injury and may cause pain or a restriction in mobility Some movements will be painful, some are slightly limited, and some are pain free
What is scar skin roll release?
Used for any scar that can be gripped without pinching Need max tissue slack Maintain stretch & slowly roll skin and scar Decrease lift slowly Treat based on what you feel
Exudate
Wound drainage - thick drainage Made up of proteins and leukocytes 3 types: sanguinous, purulent, seropurulent -Sanguinous: blood - thick, frank, bright blood -Purulent: pus - thick type of pus -Seropurulent: pus, but a little bit more dilute in nature
What phase is the wound in if you see necrotic tissue?
Wound is in inflammatory phase Need to get rid of necrotic tissue in order for the wound to progress through healing Typically dark: black, brown, leathery, sloughy, sometimes with a yellow tint)
what is the 7 second test
a test for inflammation and irritation - maintain even pressure on a spot for 7 seconds, if no better or worse continue with treatment, if worse then do not continue treatment. - a rough guideline to figure out what we can and cannot treat
Chronic regional pain syndrome 3 stages
acute - warmth, erythema, burning, edema, hyperalgesia, hyperhydrosis dystrophic - coolness, mottled coloration, cyanosis, brawny edema, dry brittle nails, constant pain, osteoporosis atrophic - atrophy of the skin and it's appendages.
Distraction
separation of bony surfaces
