1
Q
Edema Formation
A
- Edema composed mostly of blood plasma moves into the tissues in reaction to:
~ Increased blood vessel permeability.
~ Vasodilation
~ Altered Concentration Gradient
> Usually no or little difference is
present.
> With injury concentration
gradient shifts causing fluid to
flow into the tissues.
2
Q
Venous and Lymphatic Return
A
- Reduces Edema
~ Transports fluid (venous) and more
solid wastes/fluid (lymphatic) out of
the tissues and away from injury site - Arterial Pressure (heart) > Venous
Pressure - Lymphatic > Venous
3
Q
Venous and Lymphatic Return Mechanisms: Skeletal Muscle Contraction
A
- Veins and lymph vessels have one-
way valves.
~ Permit flow toward the heart
and prevent back-flow. - Vessel compression increases the
pressure which closes upstream
valves and opens downstream valves - Contraction forces blood and lymph
forward in the vessels
4
Q
Venous and Lymphatic Return Mechanisms: Respiratory Activity
A
- Both venous and lymphatic systems empty into the right atrium (RA).
~ Lymphatic fluid enters the venous
blood just prior to venous blood
entering the RA - Pressure in the RA is dependent on thoracic chamber pressure.
~ During Inspiration chest wall
expands and the diaphragm
descends causing a fall in thoracic
chamber pressure that leads to
expansion of the lungs, cardiac
chambers.
5
Q
Venous and Lymphatic Return Mechanisms: RA Pressure
A
- Expansion causes a decrease in RA pressure
~ A decrease in RA pressure alters the
pressure gradient causing increased
flow into the RA
6
Q
Venous and Lymphatic Return Mechanisms: Lymph Vessels are also Muscular
A
- When the vessels fill, pressure is exerted on the vessel wall causing a reflexive contraction of the musculature
7
Q
RICE: Compression
A
- Increases fluid pressure in tissues
~ Decreases flow of fluid into the
tissues
~ Encourages flow of fluid into the
vessels - Compression can take place of muscle contraction
- Prevents secondary damage, pain, and further damage
- RICE modifies concentration gradient
8
Q
RICE: Elevation
A
- Placing the limb in a nondependent position (elevated)
- Decreases fluid pressure in the vessels by decreasing fluid volume
~ Decreases flow of fluid into the
tissues.
~ Encourages flow of fluid into the
vessels.
~ Most effective when limb is at 90
degrees.
> Should at least be above level
of heart.
9
Q
Intermittent Compression
A
- Body part enclosed by a sleeve or appliance that’s filled with air or water
10
Q
Intermittent Compression: Circumferential
A
- Equal amount of pressure applied to all parts of the body part
~ Jobst Pump, Gameready
11
Q
Intermittent Compression: Sequential
A
- Compartments within the sleeve or appliance fill distal to proximal
~ Cryopress, Normatec
12
Q
Intermittent Compression: Mechanisms for Edema Management
A
- Increases pressure inside the tissues.
~ Changes pressure gradient. - Forces fluid forward in the venous and lymphatic systems.
~ Requires duty cycle or sequential
pressure for re-filling of venous and
lymphatic vessels.
13
Q
Intermittent Compression: Indications
A
- Edema
- Prevention of DVT (clotting)
14
Q
Intermittent Compression: Contraindications
A
- Fracture
- DVT
- Edema caused by congestive heart failure
- Dermatitis
- Thrombophlebitis (inflamed vein = clotting)
- Gangrene
- Compartment Syndrome
15
Q
General Procedures for Pressure
A
- Maximal pressure should not exceed diastolic BP
~ Blood wouldn’t be able to return to
heart if too high - Duty cycle of 3:1 (45s:15s) are commonly used
~ Can be modified
~ Cycle not well researched
~ Some off time required for pumping
action or sequential changes
16
Q
Traction
A
- Application of a longitudinal force to the spine distracting the vertebrae.
- Mechanical, Manual, Positional
- Traction is not a solution but a temporary pain reliever
17
Q
Traction: Indications
A
- Spinal Nerve Compression
- Disc Bulging/Herniation
- Facet Joint Pathology
- Muscle Spasm
18
Q
Traction Indication: Spinal Nerve Compression
A
- Pressure on the spinal nerve root.
- Result of bony abnormality (arthritic, anatomical), disc bulge/herniation or swelling mechanically impinging on the spinal nerve root as it passes through the intervertebral foramen.
- Separation of the vertebrae causes opening of the intervertebral foremen
~ Increased foremen can decrease
pressure on the spinal nerves
~ Different movements can make
foremen bigger/smaller which is very
important during rehab
19
Q
Traction Indication: Disc Bulging/Herniation
A
- Encourages the nucleus to migrate to the center
~ Removes compression on the disc
~ Elongates the annulus and causes
negative pressure
~ Puts tension on the posterior
longitudinal ligament - Disc Herniation typically goes posteriolateral due to bending forward being the most common MOI and the lack of ligament support in this direction
20
Q
Traction Indication: Facet Joint Pathology
A
- Facet joint pain due to arthritis, compression of facet surfaces or impingement of synovial membrane or oteochondral fragments.
- Flexion opens facet joints
- Extension closes facet joints
- Traction Effects
~ Decreases impingement
~ Allows synovial fluid exchange to
nourish the cartilage
21
Q
Traction Indication: Muscle Spasm
A
- Can relieve spasm caused by spinal nerve root compression
~ Can stretch/relax the paraspinals by
activating the GTO
~ Can reduce pain by activating
ascending pain mechanisms
22
Q
Traction Contraindications
A
- Acute Injury
- Unstable Spine
- Meningitis (coating that cover CNS)
- Vertebral Fractures
- Vascular Insufficiency
~ Arteries supplying the brain are
narrowed - Osteoporosis
~ Less density in bones = breaks
23
Q
Cervical Traction: Tension
A
- Least amount of force that reduces symptoms should be used
- Generally, a force = 20% of body weight will cause vertebral separation (supine)
~ More force needed in a seated
position due to gravity
24
Q
Cervical Traction: Angle of Pull
A
- Cervical spine is placed in 25-30 degrees of flexion
~ Straightens the lordosis
~ Opens facet joints
~ Widens the intervertebral foramen
25
Lumbar Traction: Tension
- 65-200 lbs for separation of lumbar vertebrae
- More force needed on non-split table
26
Lumbar Traction: Position
- Supine with hips flexed to 90 degrees to flatten spinal curve
- Prone with pillow under the abdomen to put hips into slight flexion
~ Used with a more flat postured
person
~ Used when other modalities are used
at the same time
27
Myofascial Release: Fascia
- Manual technique used to stretch fascia.
- Fascia
~ Connective tissue that suppors and
separates muscles and organs.
> Separates skin and adipose
from muscle.
> Surrounds nerves, muscles,
and blood vessels.
~ Similar composition to ligaments
except less dense and more irregular
in fiber alignment
> Fibers are multidirectional
• Shaped this way because
it needs to support the
body in many different
directions
> Fascia is interconnected
throughout the body
28
Myofascial Release: Theory
- Injury, immobilization, aging alter the structure of the fascia.
~ Fascia can become disorganized/
tight.
~ Tissues can be locked short or long
with abnormal cross links.
- Disorganization or tightness can lead to fascia restrictions that lead to movement restrictions, pain and resulting compensations.
~ Stretching the fascia removes the
restrictions to promote normal
function and decrease pain
29
Myofascial Release: Fascia’s Response to Stress
- Fascia doesn’t deform when exposed to quick, high intensity force
- Fascia will deform/stretch when a slow, moderate, sustained force is applied
- “Creep”
~ Tissue Lengthening
~ After initial slack is taken up
> The longer the force is applied
the more deformation will occur
30
Fascia: Hamstring Strain Example
- Fascia structure is altered in area of strain due to formation of scar tissue/immobilization.
- Alteration in hamstring fascia directly causes a restriction in the hamstring resulting in decreased hamstring flexibility.
~ Hamstring Restriction can also result
in limited lumbar spine flexion and
ankle dorsiflexion due to the
interconnected characteristic of the
fascia system
31
Fascia Evaluation
- Key to success is the ability to distinguish restricted from unrestricted fascia.
~ Apply firm pressure with palm or
pads of fingers and translate the skin
against the underlying tissues.
> Translate the skin inferiorly,
superiorly, laterally and medially.
> Note any restrictions in a
specific direction.
32
Superficial Myofascial Release Techniques: Superficial Translations
- Same technique as evaluating the restrictions
~ Remain in the restricted direction and
maintain pressure until tissue creep is
felt
- Reevaluate translations in all directions to assess effectiveness
33
Superficial Myofascial Release Techniques: J Stroking
- Used on small areas of restriction.
- One hand puts a stretch on the restriction.
- 2nd and 3rd finger of other hand used to stroke in the opposite direction forming a "J".
- Needs to go in all different directions
34
Superficial Myofascial Release Techniques: Skin Rolling
- Use pads of the fingers and thumb to lift the skin away from underlying tissue.
- Pull skin upward and towards restriction
35
Other Examples of Myofascial Release
- Anything that stretches/mobilizes the muscle and fascia
- Foam rolling
- Massage
- IASTM
- Arm/Leg Pulls
36
Tendinosis
- Degeneration of tendon with out inflammatory response
~ Due to excess, repetitive strain
~ Tissue damage, scar formation, and
white blood cells only found small
portion of the time
> Non-inflammatory
37
Tendinosis: Characteristics
- Proliferation of immature collagen fibers.
- Loss of proper alignment of fibers making them less stable
~ Does not resist load optimally.
- Increase in ground substance.
- Disorganized/Ineffective Vascularity
- Activity Related Pain
- Abnormal Cross Links
38
Tendinosis: Treatment
- Aside from removal of stress, Tendinosis can be treated by application of moderate mechanical force
~ Davis’ Law
~ High force is avoided as it’s the trigger
~ Manual therapy like Graston and
massage
39
Tendinosis: Effects of Appropriate Force
- Increased Fibroblast Activity
- Increased number of fibroblasts
- Proper Collagen fiber alignment
- Angiogenesis
~ Growth of functional blood vessels
40
Massage Effects
- Reflexive (always present)
~ Stimulation of afferents.
> Skin
> Muscle
> Fascia
~ Stimulated by physical touch
- Mechanical (sometimes present)
~ Making and actual physical change
in the tissues.
~ Stimulation of mechanoreceptors.
~ Stimulation of Fibroblasts
~ Stimulated by applied pressure
- Reflexive effects always happen regardless of the specific technique used
- Mechanical effects are a question of the amount of pressure used to cause physical change in the tissues
41
Reflexive Massage Effects: Pain Modulation
- Stimulation of skin, muscle, and fascia
sensory afferents
~ Ascending pain modulation
- Stimulation of pain afferents
~ Descending pain modulation
42
Reflexive Massage Effects: Circulation
- Stimulation of skin sensory afferents triggers dilation of capillaries
~ Increases O2 delivery to the area
~ Removal of pain chemical mediators
43
Mechanical Massage Effects: Venous and Lymphatic Return
- Increases tissue pressure
~ Promotes flow into vessels
~ Moves fluid forward in lymph vessels
and veins
~ Spreads fluid within tissues
> Exposes fluid to more lymph
vessels and vein surface area
44
Mechanical Massage Effects: Tissue Compression and Stretching
- Muscle
- Fascia
- Connective Tissue
45
Massage General Considerations
- If using massage to reduce edema, treatment should begin with the proximal area
~ Increases proximal venous and
lymphatic flow
~ Reduces resistance to more distal
venous and lymphatic flow
> “Uncorking Effect”
- Pressure in line with venous flow
- Positioning
~ Clinician should allow themselves of
free movement of the arms, hands,
and body
> Weight should rest evenly on
both feet
> Good posture
~ Athlete should be relaxed
> Treated body part should be
supported
> If prone, place pillow under
abdomen and ankles
> If supine, place pillow under
head and knees
46
Massage Techniques: Effleurage
- Stroking of the skin
- Superficial
~ Light touch
~ Accustom pt. to treatment
~ Triggers reflexive effects
- Deep
~ Use of increased pressure
~ Used to accomplish mechanical
effects in addition to reflective
47
Massage Techniques: Petrissage
- Lifting and kneading of skin and subcutaneous tissue
~ Effects are mostly mechanical, but
can manage pain by stimulating skin
and muscle afferents
48
Massage Techniques: Tapotement
- Tapping or pounding of skin
~ Mostly reflexive effects
~ Cupping: cupped hands
~ Hacking: “karate chops”
~ Pinching: alternating hands lift small
amounts of tissue between the first
finger and thumb
49
Massage Techniques: Vibration and Friction
- Vibration
~ Rapid shaking of the tissue
- Friction
~ Purposes
> Scar tissue breakdown
> Reduces spasm
> Reduce chronic inflammation
~ Technique
> Fingers move skin not over it
> Fingers move perpendicular to
tissue fibers or in a circular motion
50
Massage Indications
- Scar Tissue
~ Modifies and encourages Davis’ Law
- Swelling
- Pain
- Spasm
- Myofascial Restriction
~ Stretches fascia
51
Massage Contraindications
- Acute Injury
~ Fracture
~ Inflammation
- Skin Infections/Inflammatory Conditions
- Thrombophlebitis
52
IASTM
- Use of specialized instruments to identify and treat soft tissue and connective tissue hypomobility, degeneration, pain, and swelling
- Buffalo Horn
- Plastic
- Jade
- Stainless Steel
~ Graston
~ Hawk Grips
53
IASTM Tools
- Tools usually have concave and/or convex beveled edges
~ Concave tools are used to scan and
treat larger areas (less intense)
~ Convex tools treat smaller and more
precise areas (more intense)
54
IASTM Treatment
- Treatment is usually preceded by assessment
~ Concave tool scans tissue to identify
any roughness or resistance
~ Use long, overlapping sweeping in
multiple directions
- Treat with or without tissues on a stretch
~ Sweeping
~ Fanning
~ Brushing
~ Strumming
~ J Stroke
55
IASTM Indications
- Connective Tissue Hypomobility
~ Stretches tissues and removes
abnormal cross links
- Connective Tissue or Degeneration
~ Places moderate stress on tissue
> Takes advantage of Davis’ Law
- Pain
- Swelling
56
Myofascial Trigger Points
- Localized, tight, hyperirritable spot located in a muscle
~ Produces pain at specific spot and
often refer pain to a somewhat
predictable area
~ Produces twitch when pressure is
applied
- Cause
~ Can be chronic especially in postural
muscles or muscles used repetitively
~ Can be caused by acute trauma
57
Myofascial Trigger Points: Treatment
- Applying treatment to trigger point can reduce pain at the point and to the referred area
- Typically use direct pressure or friction massage techniques
~ Technique increases pain
58
Myofascial Trigger Points: Mechanism
- Breaking pain-spasm-stasis cycle
~ Modulation of pain
~ Since pain is increased most likely
utilizing descending pain modulation
> Stimulation of pain afferents
