How does muschle change extensibility?
- Mechanical Theory
- Viscoelastic deformation (transient in nature; wears off in 3-60 seconds)
- Plastic deformation (stretch must be efficent enough to stretch in the “plastic” region. NO EVIDENVCE FOR THIS
- Increase in sarcomeres
– Only occurs with LONG DURATION stretching
Accompanied by decrease in sarcomere length - Sensory Theory
- stretching teaches muscles and tendons to tolerate mrore tension in a stretch
- Change in mm length is due to change in patient sensation of stretch
– Central phenomenon: changes in perception of stretch in the cortex
– Peripheral phenomenon: changes of perception of stretch in the peripheral nervous system
What other things impact soft tissue mobility?
Nerves, tendons, fascia, blood vessels, skin, lymphatics
Think of how deep surgeons cut
Properties of Musculotendinous units
PEC=Parallel elastic component
SEC=Series elastic component
CC=Contractile component
NEURAL COMPONENTS:
- Resistance of stretch may come from the CC (gamma motor neurons) or from PEC/SEC
- Muscle Guarding/Tone
What tissues are we targeting?
- Fascia
- Muscle
- Tendon
- Neural tissue
- Vascular tissue (venous return, lymphatics)
What conditions are associated with soft tissue mobility deficits?
- Long term immobilization
- Acute onset of pain with associated muscle guarding
- Sensitivity of myofascial trigger points (persistent pain)
- Postural faults
- High anxiety/stress
- Soft tissue swelling with impaired lymphatic activity / venous return
- Tissue adaptation to activity
Long Term Immobilization
- Loss of ST pliability after periods of immobilization (loss of ground substance leading to “cross linking” of collagen); Don’t like to slide by each other.
- Following healing from trauma (muscle tears, lacerations, contusions) or surgery (incisions), the arrangement of collagen is “disorganized” and soft tissue will lose its extensibility
- Goal: Break collagen bonds (“plastic deformation”) (more vigorous STM techniques- Static stretching)
Acute onset of pain with associated muscle guarding
- Pain and increase muscle tone is the body’s natural protective mechanism
- Muscle typically very sensitive to light touch
- Goal is to provide comfort and decrease tone (less vigorous STM techniques – dynamic stretching)
– Progressive “load” to the muscle tissue to facilitate relaxation; Gradual increase in intensity
– May work with breathing to facilitate parasympathetic response
Increase blood flow, ROM, tissue mobility
Sensitivity of Myofascial Trigger Points associated with persistent (chronic) pain
- Trigger Point: Hyper irritability, when compressed is tend and hypersensive leading to referred pain and tenderness.
Trigger Point Identification
* Specific area of muscle that is sensitive
* Palpation elicits response:
– May elicit twitch response
– Localized tenderness
– Typical referral pattern
* Active vs. Latent (feel it but not sending pain along pathway)
* More sensitive in tonic mm (more likely to have referral)
* Associated with “joint dysfunction”
* Goal: decrease sensitivity of trigger point (Varying levels of vigor for STM and stretching); Want to make it more latent than active
What muscles are more prone to “irritable” trigger points?
Tonic Muscles!
Upper Crossed Syndrome
* Upper trapezius
* Levator scapulae
* Suboccipitals
* SCM
* Scalenes
* Latissimus dorsi
* Pec major / minor
Lower Crosse Syndrome
* Iliopsoas and rectus femoris
* Adductors
* Latissimus dorsi
* Erector spinae
* Iliopsoas
* Hamstrings
* IT band
* Hip adductors
* Gastrocnemius
Address postural Faults
Improve flexibility (decrease tone) of “tight” (“tonic”) muscles to enhance posture and enhance agonist activation (associated with trigger points – Varying levels of vigor)
High Anxiety and Stress
- Enhance relaxation and decrease stress (very superficial STM techniques – stretching with breathing)
- Ex: Square Breathing (Inhale, Hold, Exhale, Hold - all 4 seconds)
- Ex: In through nose, out through mouth; pursed lip breathing
- Ex: Touch - Foam rolling
- Ex: Anything that stimulates the 5 senses and gets you out of your mind
- Ex: Water on your face, drinking cold water, cold blast of air.
- Ex: Laughing and Singing - Stimulate Vagus N.
^All Short Term Examples
Sunlight is long term.
Soft tissue swelling with impaired lymphatic activity / venous return
- Ex: When someone has a virus, swelling in the neck
- Ex: Post surgery if lymph nodes are removed or tested
Tissue Adaptation
Not Enough
- Stagnation, Dysfunction, Pain
Just Right
- Growth and Healing
Too Much
- Irritation, Oversuse Injury, Pain
Where does STM and Stretching “fit” in PT Interventions?
- Identify findings that soft tissue mobility deficits exist (ROM, palpation, trigger point identification)
- Identify irritability and severity
- Establish goals of intervention
- Treat with use of manual STM and/or stretching to the area of soft tissue mobility restrictions or symptoms
- Use a part of a multimodal approach along with:
– Self STM and stretching techniques
– Other manual techniques: Passive motion or joint mobilization
– Motor control: of agonist mm to enhance activation
– Motor strengthening in newly acquired ROM - Example:
– Pt with cervicogenic headaches
IF YOU DON’T ADDRESS THE ISSUE AFTER FIXING IT WILL RESULT IN THEM REGRESSING BACK; Need exercise
Examination findings associated soft tissue mobility deficits
Subjective: Tightness and/or referres pain in similar pattern with muscle, Pain with static posture
AROM: Loss of motion with feeling of tightness on opposite side of direction of motion (antagonist mm); Ex: Quads with knee flexed.
PROM/Overpressure: Increase muscle guarding/Elastic end feel. Reproduce pain (“their pain”)
Palpation:
– Tenderness areas of muscle with or without pain referral that REPRODUCES patient’s pain OR increase muscle tone to palpation
– Decrease soft tissue/scar mobility following trauma/surgery (and appropriate healing has occurred); Ex: Try to move it and it stays tethered and adherred in place
Motor: Poor activation of agonist mm; Ex: Pec is tight, test rhomboids and middle/lower trap.
Irritability Levels - Soft Tissue Levels
What are some intervention options for Soft Tissue Mobility Deficits?
- Soft tissue mobilization techniques:
* Manual (with hands)
* Instrumented (with tool)
* OTHERS (ex: dry needling, cupping, etc) - Stretching:
* PT assisted stretching
– Static
– PNF
* Pt self-stretching
– Static
– PNF
Soft Tissues Mobilization Mechanisms
- Biomechanical Effects (Breaking up cross bridges; Changing actin/myosin crossbridges)
- Physiological Effects (Increasing blood flow, nutrients, stimulating parasympathetics)
- Neurological Effects (decrease sensitivity - touch is okay!; decrease pain and muscle tension signals)
- Psychological Effects (increase relaxation and decrease anxiety)
Biomechanical/structural effects
- Break up adhesions
- Mobilize scar tissue
- Increase extensibility of connective tissue
- Increase ROM of underlying joint
- Decrease perceived stiffness of limb
Physiological Effects
- Increase in tissue temperature
- Histamine response of the tissue (vasodilation) - Increase in circulation
- Parasympathetic response
- Increase metabolic processes of the targeted tissue
- Enhance lymphatic function/ venous return
Neurological Effects
Peripheral mechanisms
* Decrease pain through gate control system
* Stimulation of large diam. (A-beta) afferent fibers via mechanoreceptors
* Stimulation of substantia gelatinosa in SC inhibits smaller (A-delta, C) afferent fibers, blocking part of pain message
* Decrease tone in the muscle
Central pain processing effect
* Affects supraspinal centers of brain diminishing pain perception
Psychological Effects
- Relaxation
- Diminish anxiety
- Placebo?
- Perceived improvement after treatment
Lymphedema
- Fluid isn’t getting pulled through lymphatics as normal
- Start proximal where problem is, using light touch to clear, then work distal to proximal
- Support through compression or muscle pump to work.
Patechia
Blood vessels bursting, purple or little dots, try to blanch will not change
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Intro and Phases of Intervention28
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Therapeutic Alliance15
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Addressing Joint Mobility Deficits with the use of Joint Mobilization Techniques38
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Soft Tissue Mob30
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Soft Tissue Mobilization and Stretching26
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Neurodynamic Mobility23
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Motor Control and Coordination40
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Balance19
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Proprioception7
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MC/Strength/Endurance of Trunk34
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Strengthening25
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Creating a Strengthening Program11
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Graded Exposure/Exercise15
