Stanbridge - T5 - Ortho1 - W2 - Manual Mod Tissue Injury and Repair

• These notes summarize manual modalities, tissue injury, and repair, focusing on orthopedic interventions

Correct Manual Technique Applications

• Duration, type, and irritability of symptoms should be considered
• Clinician and patient positioning must be considered
• Hand placement needs to be correct
• Specificity must be ensured
• The direction of force for joint mobilizations could be direct or indirect
  • Direct force moves toward the barrier or restriction
  • Indirect force moves away from the motion barrier or restriction
• Reinforce any gains that are made

Joint Mobilization Criteria

• Know the open-packed position of the joint
  • Resting position with least pain vs open-packed if the position is painful
• Understand the convex/concave rule regarding joint shapes
  • With convex on concave, the joint surface moves opposite to the bone movement
  • With concave on convex, the joint surface and bone movement occur in the same direction
• Review Appendix F for Open and Closed-packed positions

Manual Therapy Indications & Contraindications

• Manual therapy is indicated for:
  • Mild musculoskeletal pain relieved by rest
  • Musculoskeletal conditions provoked by motion but improve quickly with rest
  • Soft tissue tightness and adhesions
  • Contractures
  • Edema/effusion
  • Pain relieved or provoked by motions or positions
  • Pain related to changes in sitting or standing posture
• Absolute contraindications include:
  • Bacterial infection, malignancy
  • Systemic localized infection
  • Recent fracture, cellulitis, febrile state, hematoma, acute circulatory condition
  • Open wound, osteomyelitis, advanced diabetes
  • Hypersensitivity of the skin, inappropriate end feel, severe pain, radiation of pain
  • Pain unrelieved by rest, severe irritability
• Relative contraindications include:
  • Joint effusion and inflammation
  • Rheumatic arthritis and neurologic signs
  • Osteoporosis, hypermobility
  • Pregnancy, dizziness
  • Steroid or anticoagulant therapy

Massage vs Soft Tissue Mobilization (STM)

• Massage causes decreased tension via stroking, rubbing, kneading, tapotement, and vibration which is a general concept
  • CPT code 97124: Massage including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) for 15 minutes
• STM addresses functional goals by creating beneficial effects on body systems, which involves specific assessment, evaluation, and treatment of soft tissues
  • CPT code 97140: Manual therapy techniques (e.g., connective tissue massage, joint mobilization and manipulation, and manual traction) for 15 minutes is soft tissue mobilization

Massage and STM

• Massage and STM produce reflexive effects and pain reduction
• Facilitate healing and increase lymphatic circulation and metabolism
• Help decrease muscle spasm and atrophy
• Loosen adhesions and decreased anxiety/tension
• STM and Massage indications include:
  • Alleviating adhesions, decreasing neuromuscular excitability, and edema
  • Decreasing intermittent claudication and removing lactic acid
  • Reducing migraine headaches and muscle spasms/cramps
  • Addressing Raynaud's syndrome, increase venous return, tendonitis, and trigger points
• Contraindications:
  • Arteriosclerosis, Thrombosis, and Embolism
  • Severe varicose veins
  • Acute phlebitis, cellulitis, or synovitis
  • Infection
  • Over areas of malignancies or recent radiation treatment
  • Acute inflammatory conditions
  • Undiagnosed or gross edema

Specific Massage Techniques

• Stroking-Effleurage
• Pétrissage- kneading, skin rolling, picking up
• Tapotement/percussion- clapping, beating, hacking, pounding
• Vibration and shaking
• Friction massage
• Trigger Point
• Cupping
• Augmented Techniques

Qualities of Touch

• Depth and Pressure varies
• Deeper pressure has a broader base of contact
• Drag: Amount of pull on the tissue
• Direction of Massage: - Centrifugal moves pressure from the center of the body out
•  Centripetal moves pressure from the extremities to the center of the body
• Rate of Movement (Speed) varies

Frequency and Rhythm

• Rhythm should have regularity of the application of the technique
• Frequency should have a rate of the method that repeats itself within a given time frame
• The method is repeated three times in a typical setting
• The first pass over the tissue is an assessment
• The second pass over the tissue is the treatment
• The third pass over the tissue is a post assessment
• Duration refers to the length of time that the method lasts.

Components of Massage Application

-Compression described as depth of pressure affects circulation, nerve stimulation, and connective tissue pliability -Two ends of structures are pulled apart from one another using tensile forces that drag, glide, lengthen, and stretch

• Bending is a combination of compression and tension, with one side of a structure compressed, and the other exposed to tensile forces

• Shear involves sliding force, with significant friction created between two structures to create therapeutic inflammation and increased connective tissue pliability

• Torsion is a twisting force such as a kneading technique

Stroking

• Stroking utilizes the palmar surface of the hands/digits with variable pressure and speed to increase relaxation and blood flow
• Allows for assessment of the patient's tissues
• Direction of force is parallel to the long axis or across it, using slow or rapid movements
• Superficial Stroking has rapid centrifugal or centripetal movement
• Deep Stroking has slow centripetal motion known as Effleurage

Effleurage

• Effleurage is slow, deep stroking of the veins and lymph (centripetal direction) with increased pressure to stimulate circulation
  • Can be used in the acute stage to promote tissue healing
  • Uses the palmar surface of the hands while molding to the massage surface at a rate of ~7in/sec. with significant pressure

Pétrissage

• Several massage stokes characterized by firm pressure to the tissues and Used in the subacute phase of tissue healing
• Goal: Mobilize deep muscle and tendon or the 4 Types of Strokes: Compression Kneading, Picking up, Wringing (not practicing), and Skin Rolling

Picking Up

• Use a lumbrical grip to squeeze the muscles while simultaneously lifting them away from the underlying tissues and then releasing them along the long axis Aim to mobilize the muscle groups with slow, continuous, and rhythmic motion Apply significant pressure needed to grasp the muscle

Skin Rolling

• The therapist grasps the skin and subcutaneous tissues with a lumbrical grip
• The goal is to mobilize the skin, increase circulation in the underlying tissue, and help over the spinous process and scars
• Move slowly with enough pressure to the skin but not pinch

Friction Massage

• Small, deep movements performed on a local area with the of the tip of the middle finger (transverse or circular motions)
• Goal: Creates therapeutic inflammation, and Prevents and breaks up local adhesions in connective tissues
• Treats localized, chronic musculoskeletal lesions, and chemicals released help with tissue repair mechanisms with deep and firm pressure
• Slowly and steadily use fingers and do not use lubricant then the area may be tender for up to 48 hours due to the inflammatory response

Augmented STM

• Use of deep massage has has specially designed handheld devices to mobilize scar tissue
• Can use IASTM, Graston, ASTYM, and/or coining
• Use a Solid instrument with angled edges using a lubricant, like cocoa butter
• Apply Longitudinal strokes that are applied parallel to the fiber alignment
• Start with Initial strokes that are smooth and flowing, then they become more concentrated over the fibrosis
• Duration: Stroking motion is for 5-10 minutes
• Localized erythema and ecchymosis is normal but you Must get certified and always follow up with stretching and strengthening

Cupping

• Suction is applied over a painful or acupuncture area, using Subacute phase of tissue healing and 4-6 weeks after incision
• Two types exist:
  • Dry cupping is used to suction dry skin into the cup
  • Use Wet cupping to lacerate the skin to draw blood into a cup to expand the capillaries and burst them to leave red marks
• Believed to improve circulation, lymphatic drainage, and the immune system
• It contains dry cupping evidence to suggest superiority found compared with conventional drug therapy in patients with low back pain and cancer pain

Trigger Points

• Use Myofascial Trigger Point (MTrP) Therapy that is not a form of Pétrissage
• MTrP is a sensitive spot on the body that, when stimulated causes local and referred pain
• Commonly found in taut bands which are often found as knots in the muscle
• Goals: Relieve pain and tightness of the involved muscles and use Ischemic compression
• To Ischemic pressure tothe trigger point, Hold pressure 5-10 sec to evaluate response
• Then Positive response- pain decreases or remains the same
• But If a Negative response- pain increases then repeat and only use total treatment time to equal about 1-5 minutes