Bryan College Faculty of Massage Therapy Student Manual Techniques II PDF

Faculty of Massage Therapy Student Manual Techniques II MT-MT20 The information in this document is the property of Zehava Beauty School Ltd., o/a Bryan College of Applied Health & Business Sciences. It may not be copied, reproduced, sold, translated into any form or language, or transferred to an...

Faculty of Massage Therapy Student Manual Techniques II MT-MT20 The information in this document is the property of Zehava Beauty School Ltd., o/a Bryan College of Applied Health & Business Sciences. It may not be copied, reproduced, sold, translated into any form or language, or transferred to any individual or group of individuals, in whole or in part, for any purpose whatsoever unless permission is requested and granted in writing by the President. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 1 of 212 Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 2 of 212 STUDENT MANUAL MT-MT20 – Techniques II School Administration Office 416-630-6300 TO OBTAIN OTHER INFORMATION REGARDING COURSE ADMINISTRATION AND CONTACTS: PLEASE REFER TO YOUR INSTRUCTOR HANDBOOK. Course Scheduling Information: Class hours*: 93 Number of classes: 22 *Note: course hours include all scheduled examination time Pre – Requisites: Students must meet the entry requirements for the Massage Therapy program MT-MT10 Massage Theory and Techniques, MT-TR10 Therapeutic Relations, MT-AN10 Anatomy I, MT-AN20 Anatomy II, MT-PP10 Physiology I Completion of MT-CL10 Client Assessment I is strongly recommended Attendance Requirements: As outlined in the Academic Policies & Procedures Uniform Requirements: As outlined in the Academic Policies & Procedures Passing Requirements: As outlined in the Academic Policies & Procedures Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 3 of 212 Course Materials: Text: Outcome-Based Massage Author: Andrade, C-K; Clifford, P Publisher: Lippincott Williams & Wilkins, 2001 Text: Clinical Massage Therapy Author: Rattray, F; Ludwig, L Publisher: Talus Incorporated, 2000 Text: Management of Common Musculoskeletal Disorders 4th ed. Author: Hertling, D; Kessler, RM Publisher: Lippincott Williams & Wilkins, 2006 NOTE: It is the responsibility of the student to obtain course material, handouts and notes for missed classes. No extensions will be granted for assignments or presentations. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 4 of 212 Course Objectives Course Description: Students will learn advanced massage therapy techniques that can later be applied to more complex treatments. Theory & Skills Objectives: Theory: To reinforce and expand upon the knowledge and skills gained in Massage Theory and Techniques course I Skills: Students will revisit and practice all basic Swedish Massage Techniques: Posture and body mechanics Informed Consent Client care Draping Grading Methodology: Quizzes 10% (2x5%) Midterm Theory Exam 15% Midterm Oral Practical Exam 20% Final Theory Exam 20% Final Oral Practical Exam 25% Attendance 10% Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 5 of 212 Course Outline Note: The course outline is a guide only. To accommodate individual class progression, the instructor may modify the outline as needed. Students will be given as much notice as possible for any material changes. Inflammation Frictions Technique Manual Lymphatic Drainage Bursitis Passive Stretching Techniques Contusions Myofascial Trigger Point Techniques Dislocations Myofascial Techniques Fractures Proprioceptive Techniques Frozen Shoulder Joint Play Hypertension/Hypotension Class Schedule Class #1 – Inflammation Class – Midterm OP Class #2 – Manual Lymphatic Drainage Class #11-14 – Joint Play Class #3-5 – Passive Stretch Techniques Class #17 – OP Quiz #2; Bursitis Class #6-8 – Myofascial Trigger Point Techniques Class #9 – Myofascial Techniques OP Quiz #1 Class #10 – Proprioceptive Techniques Class – Review for Midterm Written and Oral Practical Exams Class – Midterm Written Class #15-16 – Frictions Class #18 – Contusions/ Fractures Class #19 – Dislocations/ Frozen Shoulder Class #20 – Hypertension/ Hypotension Class – Review for Final Written and Oral Practical Exams Class – Final Written Class – Final OP Note on Quizzes: Quiz dates and content may be changed at the discretion of the College; students will be notified of any changes as soon as possible. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 6 of 212 OP Expectations and Marking scheme OP Quizzes OP Rules ***Students should arrive AT LEAST 10-15 minutes early for their scheduled OPs as the time assigned by the instructor is when their OP starts, not when they should be arriving. Students that arrive late for their OP will not be permitted to complete their OP and will receive zero on the exam. Students must also take note of what time they are a body for the OP exam. If they are a body first the same above rule applies and they will not be permitted to complete their OP exam. Students must be in proper school uniform (scrubs) with long hair pulled back. No jewelry is permitted, no exceptions (rings, bracelets, watches, necklaces, etc). Nails must be short and trimmed with no nailpolish. If a student has nailpolish they cannot remove or any abrasions on their hands, they will be required to wear gloves. Students are not permitted to switch or trade partners or scheduled OP times. It is the responsibility of the student to inform their instructor of any accommodations or concerns well before the OP schedule is made. If a student is unable to take their OP for medical reasons a doctor’s note must be submitted to the instructor as soon as possible. A student who misses an exam for medical reasons will have the results of the final exam weighted to cover the missed exam. Some midterm OPs may be required to be completed at a later date if missed for a medical reason, this is at the discretion of the instructor and the course material.*** Quiz 1 you will be expected to perform a THOROUGH demonstration of a myo-fascial trigger point technique based on the muscle given. 5 minutes will be given to complete this technique. Quiz 2 you will be expected to perform a THOROUGH demonstration of a joint play technique based on the joint and range of motion limitation given. 5 minutes will be given to complete this technique. Midterm OP: Advanced Techniques You will be expected to demonstrate each of the following techniques on the muscle or region indicated on the OP stem. 2 minutes to read the given stem and 10 minutes to perform the indicated tasks will be given to each student. Example Stem: Demonstrate the following techniques in any order: 1. Manual Lymphatic Drainage to the Posterior leg 2. Passive stretch for Latissimus Dorsi muscle 3. Myo-fascial Trigger Point Technique to the Biceps Femoris muscle 4. Myofascial Skin Rolling Technique to the upper back 5. Proprioceptive O & I technique to Quadratus Lumborum Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 7 of 212 Final OP: Advanced Techniques & Scenario Station 1: You will be expected to demonstrate each of the following techniques which includes all 2 postmidterm techniques and 3 out of the 5 pre-midterm techniques on the muscle, joint, or region indicated on the OP stem. 2 minutes to read the given stem and 10 minutes to perform the indicated tasks will be given to each student. This OP will most closely resemble Station 7: Techniques of the CMTO OSCE. No warm up or transitional techniques are required for this station. Example Stem: Demonstrate the following techniques in any order: 1. Proprioceptive: GTO technique to the Gastrocnemius muscle 2. Joint play Grade 3 oscillation for pronation of the radioulnar joint 3. Frictions to the quadratus lumborum muscle 4. Passive Stretch of Rectus Femoris 5. Myo-fascial Trigger Point Technique to the Biceps Femoris muscle Station 2: You will be expected to formulate a 4 technique treatment based off of a given scenario that will indicate a client with either: bursitis, contusion or fracture, dislocation or frozen shoulder, hypertension or hypotension. 2 minutes to read the given stem and 10 minutes to perform the indicated tasks will be given to each student. This OP will most closely resemble Station 6: Treatments of the CMTO OSCE. Example Stem: Client: 30 year old male MMA fighter. Chief Complaint: contusion on his right tibialis anterior. Secondary Complaint: referral pain along his right anterolateral thigh traveling into the lateral aspect of the knee. Subjective findings: Client was kicked in the shin during a fight 2 and a half weeks ago. He could continue playing at the time, but with difficulty. He reports that he only has pain with direct compression over the bruise. Findings: The contusion is a faint yellow/green colour. Palpation reveals hypertonicity in the right tibialis anterior. Palpation reveals fascial restrictions in his right anterior leg. Palpation of his right anterolateral thigh recreates his referral pain. Testing: Strength testing reveals weakness in his right tibialis anterior. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 8 of 212 MT-MT20 Techniques II Class 1: Inflammation Inflammation: the bodies innate immune response to an irritant or injury. Causes of Inflammation: • • • • • • • • Pathogens (infective agents): bacteria, viruses, fungus, parasites Trauma: burns, radiation, physical damage Chemical: acids, poisons Immunological (distortion or disturbance of cells): cell-mediated and antigen-antibody reactions Extreme temperatures Obesity Diet Stress & Anxiety Signs & Symptoms of Inflammation: Two different ways of remembering the signs and symptoms: PRISH or SHARP. They are both the same. PRISH SHARP Pain (Dolor) Swelling (Tumor) Redness (Rubor) Heat (Calor) Immobility A loss of function Swelling (Tumor) Redness (Rubor) Heat (Calor) Pain (Dolor Function of Inflammation: If inflammation is a bad thing we want to avoid, why does our body do it? Because normal, controlled inflammation serves a very important purpose: • Destroys microbes, toxins, and foreign material • Prevents spread of harmful substances to other tissues (walls off the injured area - like a fence around a construction zone) • Prepares the injured area for tissue repair Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 9 of 212 3 Stages of Inflammation: 1. Vasodilation & Increased Permeability 2. Emigration of Phagocytes 3. Tissue repair Stage 1: Vasodilation & Increased Permeability Why is vasodilation needed? • It allows more blood flow to the injured area and removal of toxins and dead cells Why is increased permeability needed? • To allow substances such as phagocytes and clotting factors to pass through capillary walls • Increased permeability allows clotting factors to escape the bloodstream, enter damaged tissue and lay down fibers (fibrin threads) to localize and trap the components of inflammation (dead cells, damaged tissue, microbes/bacteria, etc) What causes vasodilation and permeability? • Histamine: produced and released by mast cells, basophils, and platelets in response to injury • Kinins: proteins formed in blood by kininogens (ex. bradykinin). Also attract phagocytes to the damaged area • Prostaglandins: released by damaged cells enhancing the vascular permeability effect of histamine and kinins. Also attract phagocytes to the damaged area • Leukotrienes: released by mast cells and basophils causing increased permeability, attract phagocytes and encourage them to bind with pathogens • Complement: a group of chemicals known as the complement system which promotes histamine release, attracts WBC’s, promotes phagocytosis, and destroys bacteria Vasodilation and increased permeability are responsible directly for 3 of the PRISH / SHARP signs: • Heat & Redness: this is due to the increased blood flow. The increased heat from the increased blood flow → increased metabolism → further increase in heat/temperature • Swelling: increased permeability causes fluid to move out of the bloodstream and into interstitial space → edema ie. Swelling Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 10 of 212 Vasodilation and increased permeability are responsible indirectly for 2 of the PRISH / SHARP signs: • Pain: result of damaged neurons but also due to the release of kinins and prostaglandins which intensify the neurons that signal pain (nociceptors). Pain can also result from the pressure caused by swelling • Immobility / A Loss of Function: can be due to the increased pressure of swelling making movement difficult Stage 2: Emigration of Phagocytes In the 1st hour: • Neutrophils slow down by sticking to the inner surface of the blood vessel near the damage. They then squeeze through the walls to travel to the site of injury - this is emigration • The neutrophils know where to go because of the chemicals (chemotactic factors) that have been released at the site of injury (kinins, prostaglandins, leukotrienes, complement system) - this is known as chemotaxis Following the 1st hour • Neutrophils will then destroy pathogens by the process of Phagocytosis (cell eating) • More neutrophils are made and recruited to help in the fight. An increase in WBC’s (usually seen during an infection) is called Leukocytosis • Once the neutrophils begin to die off, they need to be cleaned up, along with damaged cells and additional pathogens • This is where Macrophages come in. They are a bigger, more powerful phagocyte that has matured from a monocyte • Pus is the collection of dead tissues and WBC seen at the end of the inflammatory process (like what is left on the field after a battle) • Pus will either drain away or be reabsorbed by the body • Abscess is what occurs when there is pus that cannot be reabsorbed or drained and becomes walled off Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 11 of 212 Possible Outcomes of the Inflammatory Process • Complete resolution with no significant tissue changes (Stage 3: Tissue Repair) • Accumulation of scar tissue • Chronic inflammation (possible abscess formation) 4 Stages of Healing 1. 2. 3. 4. Acute Stage Sub-acute Stage (proliferative stage) Post-acute Stage (maturation stage) Chronic Inflammation Acute Stage • Initial inflammatory phase • Chemical released by damaged cells • exudate/edema develops • Cells arrive (platelets & WBCs) • May last 1-3 days Sub-acute Stage (Proliferative Stage) • Specific cells accumulate and work to fill in damaged tissue • New capillaries grow into the area for new cell growth • Scar tissue forms • WBCs clean up debris • Can last 2-3 weeks depending on severity Post-acute Stage (Maturation Stage) • New scar tissue (collagen fibres) is remodeled and reshaped • Becomes denser and aligns according to force (important not to limit mobility entirely during this stage in order to allow most ideal scar formation) Chronic Inflammation • Inflammatory process is not successful • Pathogens/irritants not removed Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 12 of 212 • Immune system continues to attack tissue • Musculoskeletal structures never regain full function Complications of Chronic Inflammation ▪ Cysts, abscesses ▪ Fistulae, sinuses ▪ Tendinosis ▪ Keloid scarring Treatment of Inflammation RICE - I • • • • • Rest Ice Compress Elevate Immobilize (sometimes and only for a specific period of time) Important! Inflammation should not be eliminated as it is necessary to fight infection and initiate repair. Treatment is only for the purpose of reducing pain and discomfort associated with inflammation (PRISH / SHARP) Massage? Risks: Acute localized infections are local contraindications to massage that increases circulation Benefits: In the post-acute stage (maturation/remodelling) fluid turnover (circulatory techniques) is beneficial. • Mechanical influence of massage can also help with alignment of scar tissue • Manual lymphatic drainage can help with the reduction of swelling in all the stages provided that the appropriate principles are followed for each respective stage Edema • Local or general accumulation of fluid in the interstitial tissue spaces. • It is not a disease itself. It may result from a local release of histamine after injury (as part of the inflammatory process) or it may result from a systemic disease i.e. heart failure or obstruction of lymphatic vessels. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 13 of 212 • Increased permeability of the capillaries from inflammation, tissue trauma, immune response or burns. • Obstruction of the lymphatic flow from infection, parasites in lymphatic system, lymphatic disease, surgical removal of lymph nodes, radiation treatment, scarring or a congenitally reduced number of lymph vessels. • Increased capillary pressure from heart failure, thrombophlebitis, pregnancy or a generalized allergic response such as hives. • Decrease of plasma protein with liver and kidney diseases, and starvation, and following extensive burns. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: July 2021 Page 14 of 212 MT-MT20 Techniques II Class 2: Manual Lymphatic Drainage The Lymphatic System: • Is a vital part of the body’s circulation system • Consists of: ▪ Collector vessels ▪ Lymph vessels ▪ Lymph nodes ▪ Lymph organs • Fluid that accumulates in the interstitial spaces (the space between cells and outside of vessels) is either reabsorbed into blood circulation or enters the lymphatic system and circulation • The circulatory system (blood) and the lymphatic system work in conjunction with each other to maintain fluid balance, fight infection, and promote healing • It is like a vacuum cleaning system of the body that transports large substances that due to their molecular size cannot be reabsorbed into the blood stream and must then be transported through the lymphatic system Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 15 of 212 Lymphatic Fluid: • Lymph fluid is similar in composition to blood except that is has no red blood cells or platelets • It is primarily composed of: ▪ Water ▪ Proteins ▪ Fats ▪ Cellular debris ▪ Bacteria ▪ Viruses ▪ Inorganic materials • This collective composition is referred to as the Lymph Obligatory Load (LOL) Lymphatic Organs: • Spleen: filters dead blood cells from the body ▪ Located in upper left quadrant of the abdomen just posterior and slightly inferior to the stomach • Tonsils: Filter and protect the body from bacteria and assist in white blood cell formation ▪ Mass of lymphatic tissue located in the mucosal membrane of the pharynx • Thymus: Important in newborns and young children for the development of the immune system and aids in the maturation of T-cell lymphocytes ▪ Lies just superior and anterior to the heart Lymphatic Vessels: • Lymph vessels are a one-way system and prevent/do not allow backflow • The tiny vessels are found in loose connective tissue • They transport lymph fluid from subcutaneous tissue, muscles, joints, and organs through clusters of lymph nodes • Ultimately the vessels return the fluid back to the circulatory system for re-circulation to maintain fluid balance • Lymph vessels connect with the blood circulatory system at the terminus (right lymphatic duct empties into the right subclavian vein, and the thoracic duct empties into the left subclavian vein) • Lymph vessels include: ▪ Initial Lymph Vessels (ILA) ▪ Precollectors (PC) ▪ Collectors (C) ▪ Lymph Angions (LA) Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 16 of 212 Initial Lymph Vessels: • These are small, valveless, blind or close-ended capillary like structures that collect fluid from just under the skin and superficial fascia • The sub-fascial layer carries fluid up and out of the muscles • The ends of these vessels are covered with a glue-like substance called hyaluronic acid: the purpose of this substance is to keep the vessels closed • Circulating in the interstitial fluid is a chemical called hyaluronidase: this chemical is a solvent which temporarily dissolves the ‘glue’ (hyaluronic acid) • Tiny, hair-like structures called anchoring filaments made of collagen fibers are attached to the endothelial flaps around these vessels ▪ The filaments are under tension and can pull back on these flaps or outer valves, allowing them to temporarily open and ‘suck in’ the surrounding interstitial fluid Pre-Collectors: • Collect fluid from the initial lymph vessels • They have one-way valves to prevent back flow Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 17 of 212 Collector Vessels: • Collect fluid from the pre-collectors • Collector vessels have alternate drainage routes (anastomoses) ▪ This is important because if one area becomes obstructed (nodes removed, scar tissue, massive inflammation, etc) fluid can be rerouted and drain to a different location Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 18 of 212 Lymph Angion aka ‘little heart’” • Fluid from the collector vessels eventually makes its way to lymph angions which will carry the fluid to the lymph nodes. • Most of the drainage humans do will have the greatest impact on these structures • They are complex structures that contain: ▪ One-way valves to prevent backflow ▪ Longitudinal and ring shaped smooth muscle fiber which contracts in response to a stimulus (media) ▪ Multiple nerve endings which are: ➢ SENSORY: stretch receptors which respond to filling from the inside (intima) or pressure from the outside (adventitia) o The adventitia sensory stretch receptors are stimulated by the longitudinal and transverse pressure applied from manual lymphatic drainage techniques → the stretch receptors stimulate a smooth muscle contraction much like the peristaltic action of the intestines ➢ MOTOR: causes smooth muscle to contract ➢ AUTONOMIC: sympathetic and parasympathetic nerve endings stimulate the motor nerve endings to contract the muscle on its own; this is called ‘automotoricity’ and contracts at a rate of 3-7x/minute Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 19 of 212 Lymph Node: • The human body contains over 600 nodes which are most commonly found around the joints • 160 are found in the neck alone • Their location around joints assists in movement of fluid via the pumping action created by the joints and muscle contraction • Lymph nodes act as filtering stations for a region or organ of the body. • Fluid from the lymph angion eventually flows into a group of lymph nodes where several important processes will occur Lymphatic Drainage Massage Procedure • All massage will affect the circulatory and lymphatic system to some degree. • When our primary aim is to reduce swelling (edema) however, we are really focusing our treatment on one body system (the lymphatic system) for a specific therapeutic aim • The more time we spend on working the lymphatic system the more profound the response will be. Effects of Lymphatic Massage • Drain a congested area and reduce edema such as in the event of an acute injury like a sprain or strain • Localize and reduce inflammation (post surgical) • Help remove metabolic waste, dead cells and debris (post surgical) • Re-route the lymph if there is an obstruction, such as scar tissue; this is typically performed by a certified lymphedema therapist Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 20 of 212 Indications for Lymphatic Drainage Massage: Metabolic Removal Local Inflammation Acne Gout Stress Constipation Bruising Sprains Strains Tendonitis Arthritis Burns Decongestive Bronchitis Carpal Tunnel Thoracic Outlet Syndrome Sinusitis Pre/Post Operative Mastectomy Breast Augmentation Breast Reduction Dental/oral Surgery Cosmetic Surgery Joint Replacement Scarring Contraindications • • • • Untreated/Undiagnosed cancer Acute infection (local or systemic) Thrombosis (blood clot) Heart related edema (congestive heart failure, advanced high blood pressure) Precautions • • • • • Tuberculosis Pregnancy (if history of miscarriage or in 3rd trimester) Diabetes (may cause insulin shock) Extreme low blood pressure (may cause fainting) Asthma (sternal work may cause asthma attack) Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 21 of 212 Application of Manual Lymphatic Drainage (MLD) • Many schools of thought but the two most prevalent are: Vodder Manual Lymphatic Drainage Technique and Swedish Lymphatic Drainage Technique • Pure lymphatic drainage should typically not be done in conjunction with General Swedish Massage (GSM) • • ▪ GSM petrissage techniques can increase interstitial fluid ▪ MLD techniques are designed to decrease interstitial fluid When the goal is to reduce the edema always finish your overall treatment with lymphatic drainage: ▪ Swedish drainage increases local circulation for 2-3 hours post massage ▪ Vodder MLD can stimulate and increase lymphatic movement for 16-24 hours post massage ▪ Compressing the tissue (such as with petrissage, effleurage or other GSM techniques) after you have stimulated the lymphatic system can stop the increase in flow that you worked so hard to achieve Lotion should never be used with MLD ▪ If GSM was done first, then the skin should be wiped clean or corn-starch can be used to prevent gliding over the skin • Always begin drainage at the neck no matter where the swelling is. The neck is the closest area to the left thoracic and right lymphatic terminus points before the lymph drains back into the subclavian veins to region the general circulation • Engage the skin, stretching it lightly in horizontal and transverse directions to stimulate the opening of lymphatic vessels (pulling on the anchoring filaments), do not glide over the skin • Pressure should be light and alternating. ▪ The movements are always circular (in a transverse/longitudinal direction) with a pressure phase and a release phase (zero phase) • Never Cause hyperemia (reddening of the skin); if anything, the skin should blanch • Work in the direction of lymph flow, moving lymph towards the nearest cluster of lymph nodes Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 22 of 212 • Divide the limb or torso into segments and begin at the most distal or furthest aspect of the most proximal or nearest segment to the lymph node cluster. ▪ For example: Working the arm: Start at the base of the deltoid and move fluid over the shoulder, then when that segment is complete, move to the elbow working the lymph fluid towards the axilla, then move to the wrist moving the lymph to the elbow • Movements are slow, rhythmical, and repetitive working in 3 sets of 5, 6, and 7 passes of a technique • MLD should never cause pain Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 23 of 212 Manual Lymphatic Drainage Protocol • Remove all constrictions to the affected area (tight underwear or clothing, pillows, draping) • Begin at the neck and pump the terminus • Always work towards nearest lymph node clusters • Techniques include: ▪ Stationary circles ▪ Pump ▪ Scoop ▪ Rotary ▪ Thumb circles • Acute: no treatment distal or through injury site • Early sub-acute: work around periphery of injury site • Late sub-acute: work to the sides of the injury and then center and proximal of injury site • Chronic: work distal and through injury site MLD Routine Incorporated into a General Swedish Massage 1. Elevate affected area (if possible) while performing GSM 2. Treat all other conditions first using GSM 3. Hydrotherapy vs No Hydrotherapy: • Acute: apply cold for 10 minutes • Sub-acute: apply contrast warm/cool for 5 minutes each, 3 sets • Chronic: warm to decrease gelling of edema (via Swedish techniques) 4. Perform Deep Diaphragmatic Breathing 5. Remove all pillowing and loosen draping 6. Begin treatment at the neck to clear the terminus 7. Work on the edematous area from furthest area of closest segment to lymph node cluster 8. Can close with 2 or 3 Swedish Lymphatic Drainage Techniques: • Light unidirectional effleurage • Light course running vibrations • Passive relaxed range of motion • Muscle setting • Shaving • Soothing stroking Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 24 of 212 Neck & Terminus Pumping • • • Lateral neck: Stationary circles at 2 points, 5x at each point ▪ Done at the same time bilaterally Scoops at the terminus 5x ▪ Done at the same time bilaterally Repeat above 2x Faculty of Massage Therapy MT-MT20-SM-08-39 weeks • • • Posterior neck: stationary circles at 2 points, 5x at each point ▪ Done at the same time bilaterally Scoops at the terminus 5x ▪ Done at the same time bilaterally Repeat above 2x Last Modified: August 2023 Page 25 of 212 The following are examples of regional routines to the various areas of the body and demonstrate the appropriate direction of MLD techniques: Upper Extremity (Anterior) • • • • • • • • • Start with neck & terminus pumping Unidirectional light effleurage to limb Pump deltoid and shoulder in 3 spots, 3x each spot, towards terminus ▪ Done once Use digits 2-5 (‘8 Little Soldiers’) on medial arm in 3 spots to pump towards axilla ▪ Done once Pump anterior and lateral arm in 5 spots towards axilla ▪ Done 2x Scoop to posterior arm in 3 spots ▪ Done once Pump to forearm in 5 spots towards cubital fossa ▪ Done 2x Thumb circles to dorsum of wrist in 3 spots ▪ Done 2x Thumb circles/pumping to hand & each finger towards wrist Swedish Drainage Portion • Finish with 2 of the following to the entire arm; direction is always towards axilla: ▪ Unidirectional light effleurage ▪ Running vibrations ▪ Stimulating stroking ▪ Passive range of motion to affected joint and/or joints above 7-10x Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 26 of 212 Lower Extremity (Anterior) • • • • • • • • • • Start with neck & terminus pumping Unidirectional light effleurage to limb 8 little soldiers to medial thigh in 3 spots, 5x each spot, towards inguinal nodes ▪ Done once Pump to anterior and lateral thigh with single hand or alternating hands in 7 spots, towards inguinal nodes ▪ Done once Alternating thumb circles to pes anserine in 3 spots ▪ Done 4x Stationary circles to popliteal space 5x Pump anterior lower leg in 5 spots, towards pes anserine & popliteal fossa ▪ Done once Stationary thumb circles to ankle in 2 spots ▪ Done 2x Stationary thumb circles to dorsum of foot ▪ Done 2x Squeeze ball of foot Swedish Drainage Portion • Finish with 2 of the following to the entire leg; direction is always towards greater trochanter: ▪ Unidirectional light effleurage ▪ Running vibrations ▪ Stimulating stroking ▪ Passive range of motion to affected joint and/or joints above 7-10x Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 27 of 212 Lower Extremity (Posterior) – Performed with client in prone • • • • • • • • Start with neck & terminus pumping Unidirectional light effleurage to limb Stationary circles/pump to glut region in 3 spots towards greater trochanter ▪ Done once 8 little soldiers to medial thigh in 3 spots, 5x each spot, towards medial inguinal nodes ▪ Done once Pump to posterior and lateral thigh with single hand or alternating hands in 7 spots, towards greater trochanter ▪ Done once Stationary circles to popliteal space 5x Pump/squeeze with whole hand to posterior lower leg in 5 spots, towards popliteal fossa ▪ Done once Stationary thumb circles to ankle in 2 spots ▪ Done 2x Swedish Drainage Portion • Finish with 2 of the following to the entire leg; direction is always towards greater trochanter: ▪ Unidirectional light effleurage ▪ Running vibrations ▪ Stimulating stroking ▪ Passive range of motion to affected joint and/or joints above 7-10x Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 28 of 212 Back Start with neck & terminus pumping • Work in upper quadrant above umbilical line towards axilla ▪ Pump from thoracic spine starting with lower ribs, middle ribs, and then upper ribs 5-7x • Move to quadrant bellow umbilical line and work towards inguinal nodes/greater trochanter ▪ Pump from lumbar spine starting just below umbilical line and moving inferiorly while pumping towards greater trochanter 5-7x • Angle drape gluteus region to greater trochanter and work from waist/midline towards greater trochanter 5-7x • Swedish Drainage Portion • Finish with 2 of the following to the entire section of the back treated; Upper quadrant is towards axilla; lower quadrant is towards the greater trochanter: ▪ Unidirectional light effleurage ▪ Running vibrations ▪ Stimulating stroking ▪ Deep Diaphragmatic Breathing Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 29 of 212 Direction Of Lymph Flow Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 30 of 212 MT-MT20 Techniques II Class 3-5: Passive Stretch Techniques Stretching • Therapeutic techniques designed to lengthen soft tissue structures, resulting in an increased range of motion. • Two types: ▪ Passive: often referred to as static stretching where the patient is relaxed while an external force (therapist’s force or machine force) is applied either manually or mechanically, to lengthen the shortened muscle. ▪ Facilitated: referred to as static progressive stretching where the shortened soft tissue is held in a comfortable lengthened position until a degree of relaxation is felt. The tissue is incrementally lengthened following a contraction in a new-end range position to inhibit tone. Flexibility: the ability to yield to a stretch (the ability to bend) Elasticity: the ability to return to its resting length after stretch Plasticity: assuming a new and greater length after a stretch Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 31 of 212 Physiology of stretching • When a stretch load is applied to a muscle, the contractile units (sarcomeres) respond by initially lengthening and then the stretch reflex causes the muscle to contract. • Once the stretch reflex contraction has subsided, the filaments of actin and myosin, lengthen the sarcomeres. • When the stretch is released, sarcomeres return to their resting length (elasticity). Mechanical characteristics of non-contractile soft tissue • Stress- Strain curve • Non-Contractile Soft Tissues consists of connective tissues, ligaments, joint capsule, tendons, fascia and skin • Collagen fibers resist tensile deformation and give strength and stiffness to tissue. They are wavy (bunched up) in nonstretched positions. (A consequence to this is they form cross-links and contractures which may inhibit full lengthening of tissues.) • When a load or stress is applied, initially the collagen fibers straighten and are the main source of tissue resistance. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 32 of 212 • If the load is gentle and held for about 30-90 seconds the cross-links will start to break and the tissue will elongate. (Fluids are displaced in the connective tissue matrix and heat will be released.) • Elasticity: If the stress is stopped at this point the tissue will return to its original shape and size while giving the client an increased ROM (elasticity). • Plasticity: If the stress is held for prolonged periods of time (greater than several minutes) the collagen fibers begin to fail and tissue will assume a new lengthened position permanently (plasticity). • The tissue will now have a new shape and size and may produce a significant change to the clients ROM. • The tissue will become more fragile and susceptible to rupture. • This type of stretch can significantly reduce stability and there is a danger of overstretching. If ROM is increased too quickly the client may injure themselves with simple daily movements. Indications for stretching • Limited ROM restricted by adhesions, contractures and scar formations. • When limited ROM interferes with Activities of Daily Living (ADLs) • When there is tissue shortened opposed by muscle weakness. Goals for stretching • To regain normal ROM • Improve tissue health • Prevent contractures • Increase flexibility prior to strengthening Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 33 of 212 Precautions • Do not passively force a joint beyond its normal ROM • Extra care should be taken with suspected or known osteoporosis • Prolonged use of steroids causes thinning of soft tissues • Prolonged immobilization leads to atrophy and tissue fragility • Strengthening exercises should be coupled with stretching at some point, so that the client develops a balance between flexibility and strength • Post-stretching, a client should feel muscle soreness lasting no more than 24 hours, if any, otherwise too much force was used during stretching • Edematous tissue is fragile • Overstretching weak postural muscles can increase muscular imbalances Contraindications • When a bony formation limits ROM ex. Osteophytes • Recent fracture • Muscles in spasm • Acute inflammation or infection • Acute sharp pain with movement • Severe contusion (bruising) or tissue trauma • Hypermobility • Paralysis or severe numbness Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 34 of 212 Passive Stretching Technique Procedure Prior to initiation of stretching 1. Explain the goals to the client 2. Position the client comfortably and in a stable position 3. Free the area of restrictions such as fixings or draping 4. Explain the procedure and that the client should try to breathe through the stretch 5. Warm structures using petrissage or hydrotherapy prior to stretching > increases extensibility and decreases risk of injury During the stretch 1. Stabilize the proximal segment of the joint and move the distal segment 2. Move the body segment in a slow, smooth, and gentle manner to the point of tissue resistance > do not spring or bounce the limb 3. Remind client to breath comfortably > do not hold breath or breathe aggressively 4. The client should not feel pain, only a mild pull of tissues 5. Hold the stretch for 30 seconds or longer if needed for sarcomeres to separate 6. Release the stretch slowly to prevent recoil of tissues 7. Allow for a rest period before you stretch again 8. Flush out after stretch: effleurage, petrissage, etc. Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 35 of 212 Cervical Spine Scalene Muscles Anterior Origin TvP of C3-C6 Insertion Rib 1 Action - Ipsilateral lateral flexion of the neck - Contralateral neck rotation - 1st rib elevation on forced inspiration Stretch Position Middle Origin TvP of C2-C7 Insertion Rib 1 Action - Ipsilateral flexion of the neck - Neck Flexion - 1st rib elevation on forced inspiration Stretch Position Posterior Origin TvP of C4-C6 Insertion Rib 2 Action - Ipsilateral flexion of the neck - 2nd rib elevation on forced inspiration Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 36 of 212 Levator Scapulae Muscle Origin Posterior tubercles of C1-C4 TvP Insertion Superior portion of medial border of scapula Superior angle of scapula Action - Elevation of scapula - Downward rotation of glenoid fossa Stretch Position Rhomboid Muscles Origin Nuchal ligament and C7-T5 SP's Insertion Medial border of scapula Action - Retraction and downward rotation of glenoid cavity, fix scapula to thorax Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 37 of 212 Trapezius Muscle Upper Fibers Origin External Occipital Protuberance, Nuchal line, Nuchal ligament Insertion Lateral 1/3 of clavicle Action - Elevation of scapula and upward rotation of glenoid fossa Stretch Position Middle Fibers Origin SPs of C7-T4 Insertion Acromion Action - Retraction of scapula Stretch Position Lower Fibers Origin SPs of T5-T12 Insertion Spine of the scapula Action - Depression of scapula and upward rotation of glenoid fossa Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 38 of 212 Sternocleidomastoid Muscle Insertion Mastoid process, Lateral superior nuchal line Action Unilateral: Contralateral lateral flexion of head; Contralateral rotation of head Bilateral: Flexion of cervical spine; Capital extension Sternal Head Origin Top of manubrium of sternum Stretch Position Clavicular Head Origin Medial 1/3 of clavicle Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 39 of 212 Splenius Muscles Action Unilateral: Ipsilateral head rotation and neck lateral flexion Bilateral: Head and neck extension Capitis Origin Inferior aspect of nuchal ligament; SPs of C7-T3 Insertion Mastoid process, lateral 1/3 nuchal line Stretch Position Cervicis Origin SPs of T3-T6 Insertion TvPs of C1-C3 Stretch Position Suboccipital Muscles Origin SP of C2, Posterior tubercle of C1, TvP of C1 Insertion Nuchal line and occipital bone, TvP of C1 Action Unilateral: Ipsilateral rotation and lateral flexion Bilateral: Capital extension Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 40 of 212 Glenohumeral Joint Deltoid Muscle Origin Lateral 1/3 of clavicle, acromion, and spine of scapula Insertion Deltoid tuberosity of humerus Anterior Action -GH Abduction, flexion, and internal rotation Stretch Position Middle Action -GH Abduction Stretch Position Posterior Action -GH Abduction, extension, and external rotation Stretch Position Supraspinatus Muscle Origin Supraspinous fossa Insertion Superior facet of greater tubercle of humerus Action - First 15 degrees of abduction of GH joint Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 41 of 212 Infraspinatus Muscle Origin Infraspinous fossa Insertion Middle facet of greater tubercle of humerus Action - External rotation, stabilize humerus in glenoid cavity Stretch Position Teres Minor Muscle Origin Superior part of lateral border of scapula Insertion Inferior facet of greater tubercle of humerus Action - External rotation, stabilize humerus in glenoid cavity Stretch Position Teres Major Muscle Origin Superior part of lateral border of scapula Insertion Crest of the lesser tubercle of humerus Action - Adduction, extension, and internal rotation Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 42 of 212 Subscaularis Muscle Origin Subscapular fossa Insertion Lesser tubercle of humerus Action - Internal rotation, stabilize humerus in glenoid cavity Stretch Position Latissimus Dorsi Muscle Origin SPs of T6-T12; thoracolumbar fascia; iliac crest and Ribs 10, 11, 12; inferior angle of scapula Insertion Floor of intertubercular groove Action - Adduction, extension, and internal rotation Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 43 of 212 Pectoralis Major Muscle Origin Anterior and medial 1/2 of clavicle, sternum, costal cartilages of Ribs 1- 6 and external oblique aponeurosis Insertion Crest of greater tubercle of humerus Action - Adduction, extension, and internal rotation Clavicular Head/ Upper division Action - Aids with flexion of humerus Stretch Position Sternal Head/ Middle division Action - GH extension when humerus is flexed Stretch Position Abdominal/ Lower division Stretch Position Pectoralis Minor Muscle Origin 3rd, 4th and 5th ribs near costal cartilages Insertion Medial and superior portion of coracoid process of scapula Action - Stabilizes scapula by drawing it inferiorly and anteriorly against thorax Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 44 of 212 Serratus Anterior Muscle Origin External and lateral surface of ribs 1-8 Insertion Anterior portion of medial border of scapula Action - Protraction, stabilizes scapula against thorax Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 45 of 212 Elbow Joint Biceps Brachii Muscle Origin Tip of coracoid process and supraglenoid tubercule of scapula Insertion Tuberosity of radius and forearm fascia via bicipital aponeurosis Action - Flexion and supination of forearm, assists with humeral flexion Stretch Position Brachialis Muscle Origin Distal 1/2 of anterior humerus Insertion Coronoid process and tuberosity of ulna Action - Flexion of forearm Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 46 of 212 Brachioradialis Muscle Origin Proximal 2/3 of lateral supracondylar ridge of humerus Insertion Lateral surface of distal radius Action - Flexion of forearm in midway position between supination and pronation; initiates pronation and supination Stretch Position Triceps Brachii Muscle Origin Infraglenoid tubercle, posterior surface of humerus Insertion Proximal end of olecranon of ulna and forearm fascia Action - Extension of forearm Stretch Position Pronator Teres Muscle Origin Medial epicondyle of humerus and coronoid process of ulna Insertion Middle and lateral surface of radius Action - Pronation and flexion of forearm Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 47 of 212 Wrist Joint Flexor Carpi Radialis Muscle Origin Medial epicondyle of humerus Insertion Base of 2nd metacarpal Action - Flexion and abduction/radial deviation Stretch Position Flexor Carpi Ulnaris Muscle Origin Medial epicondyle of humerus, olecranon and posterior border of ulna Insertion Pisiform, hook of hamate and 5th metacarpal Action - Flexion and adduction/ulnar deviation Stretch Position Palmaris Longus Muscle Origin Medial epicondyle of humerus Insertion Distal 1/2 of flexor retinaculum and palmar aponeurosis Action - Flexion of hand and tightens palmar aponeurosis Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 48 of 212 Flexor Digitorum Superficialis Muscle Origin Medial epicondyle, ulnar collateral ligament, coronoid process of ulna and superior /2 of anterior radius Insertion Bodies of middle phalanges of medial 4 digits Action - Flexion of MCP and PIP Stretch Position Flexor Digitorum Profundis Muscle Origin Proximal 3/4 of ulna and interosseus membrane Insertion Base of distal phalanges of medial 4 digits Action - Flexion of DIP, assists with flexion of PIP and MCP Stretch Position Extensor Carpi Radialis Longus Muscle Origin Lateral supracondylar ridge of humerus Insertion Base of 2nd metacarpal Action - Extension and abduction/radial deviation of hand Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 49 of 212 Extensor Carpi Radialis Brevis Muscle Origin Lateral epicondyle of humerus Insertion Base of 3rd metacarpal Action - Extension and abduction/radial deviation of hand Stretch Position Extensor Digitorum Muscle Origin Lateral epicondyle of humerus Insertion Extensor expansion of medial 4 digits Action - Extension of medial 4 digits at MCP, PIP and DIP Stretch Position Extensor Carpi Ulnaris Muscle Origin Lateral epicondyle of humerus and posterior border of ulna distal to flexor carpi ulnaris Insertion Base of 5th metacarpal Action - Extension, adduction/ulnar deviation of hand Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 50 of 212 Lumbar Spine Quadratus Lumborum Muscle Origin Medial 1/2 of inferior Rib 12, TvP tips of L1-L5 Insertion Iliolumbar ligament and internal lip of iliac crest Action - Extension, lateral flexion of trunk and fixes 12th rib during inspiration Vertical Fibers Stretch Position Oblique Fibers Stretch Position Extensor Spinae Muscles Origin Posterior iliac crest via aponeurosis, sacral and lumbar SPs and supraspinous ligament Insertion Iliocostalis: angles of lower ribs and C/S TvPs Longissimus: T/S and C/S TvPs and mastoid process Spinalis: SPs of upper T/S and C/S and skull Action - Unilateral: lateral flexion of trunk - Bilateral: extension of trunk and neck Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 51 of 212 Hip Joint Gluteus Maximus Muscle Origin Ilium posterior to posterior gluteal line, dorsal sacrum and coccyx and sacrotuberous ligament Insertion Iliotibial tract, lateral condyle of tibia and gluteal tuberosity Action Extension of thigh, assists with external rotation Stretch Position Gluteus Medius Muscle Origin External surface of ilium between anterior and posterior gluteal lines Insertion Lateral surface of greater trochanter Action Abduction and internal rotation of thigh, stabilizes pelvis Stretch Position Gluteus Minimus Muscle Origin External surface of ilium between anterior and inferior gluteal lines Insertion Anterior surface of greater trochanter Action Abduction and internal rotation of thigh, stabilizes pelvis Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 52 of 212 Tensor Fasciae Latae Muscle Origin ASIS and anterior iliac crest Insertion Gerdy's tubercle via Iliotibial band at lateral condyle of tibia Action Abduction and internal rotation Stretch Position Iliotibial Band Origin Conjoined aponeurosis of gluteus maximus and TFL Insertion Gerdy's tubercle at lateral condyle of tibia Action Non contractile tissue Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 53 of 212 Piriformis Muscle Origin Anterior sacrum and sacrotuberous ligament Insertion Superior border of greater trochanter Action Depends on amount of hip flexion: - Extended hip: external rotation - Flexed hip 90°: abduction - Flexed hip >90°: internal rotation Stretch Position Iliopsoas Muscle Origin TvP of L1-L5, lateral bodies and discs of T12-L5, superior 2/3 of iliac fossa, ala of sacrum and anterior sacroiliac ligament Insertion Lesser trochanter of femur Action Flexion of hip, lateral flexion of trunk and balances trunk on sitting Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 54 of 212 Rectus Femoris Muscle Origin AIIS and ilium superior to acetabulum Insertion Base of patella and tibial tuberosity via patellar ligament Action Extension of knee and steadies hip joint Stretch Position Adductor Longus/Brevis Muscle Origin Body of pubis and ramus Insertion Middle 1/3 of linea aspera and pectineal line Action Adduction of thigh Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 55 of 212 Adductor Magnus & Gracilis Muscle Stretch Position Gracilis Muscle Origin Body and inferior ramus Insertion Superior medial surface of tibia at pes anserine Action Hip adduction, flexion and medial rotation of knee Adductor Magnus Muscle Origin Inferior ramus, ramus of ischium, ischial tuberosity Insertion Gluteal tuberosity, linea aspera, medial supracondylar line, adductor tubercle Action Adduction Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 56 of 212 Knee Joint Quadriceps Muscle Origin Greater trochanter, linea aspera, anterolateral body of femur Insertion Base of patella and tibial tuberosity via patellar ligament Action Knee extension Stretch Position Hamstrings Muscle Origin Ischial tuberosity, linea aspera and lateral supracondylar line of femur Insertion Medial condyle of tibia and lateral fibula Action hip extension, knee flexion Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 57 of 212 Ankle Joint Gastrocnemius Muscle Origin Lateral aspect of lateral condyle of femur and popliteal surface superior to medial condyle of femur Insertion Posterior calcaneus via Achilles tendon Action Ankle plantar flexion and knee flexion Stretch Position Soleous Muscle Origin Posterior head of fibula, posterior 1/4 of fibula, soleal line and medial border of tibia Insertion Posterior calcaneus via Achilles tendon Action Ankle plantar flexion Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 58 of 212 Peroneus Longus/Brevis Muscle Origin Head and lateral fibula Insertion Base of 1st metatarsal and medial cuneiform, dorsal surface of base of 5th metatarsal Action Eversion Stretch Position Peroneus Tertius Muscle Origin Inferior 1/3 of anterior fibula and interosseus membrane Insertion Dorsal surface of base of 5th metatarsal Action Dorsiflexion and eversion of foot Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 59 of 212 Tibialis Anterior Muscle Origin Lateral condyle and superior 1/2 of tibia and interosseus membrane Insertion Medial and inferior 1st cuneiform and base of 1st metatarsal Action Dorsiflexion and ankle inversion Stretch Position Tibialis Posterior Muscle Origin Posterior tibia inferior to soleal line, posterior fibula and interosseus membrane Insertion Tuberosity of navicular, cuneiform, cuboid and base of 3rd and 4th metatarsals Action Ankle plantar flexion and inversion Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 60 of 212 Toes Toe Flexor Muscles Toe Extensor Muscles Origin The hindfoot Origin The hindfoot Insertion The forefoot Insertion The forefoot Action Plantar flexion of toes Action Dorsiflexion of toes Stretch Position Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Stretch Position Last Modified: August 2023 Page 61 of 212 Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 62 of 212 MT-MT20 Techniques II Class 6-8: Myofascial Trigger Point Techniques Indications • Pain • Autonomic and proprioceptive symptoms • Decreased range of motion Precautions • Avoid vigorous techniques on active trigger points. May cause “kick-back” pain • Full stretch of muscle with trigger points when hypermobility present. • Prolonged chilling of muscle, Ex. Draft from window Contraindications • Vigorous ischemic compressions done too quickly • Heat directly proximal to an acute injury i.e. to forearm with wrist sprain • Locally if there is a strain or sprain • Vigorous Ischemic compressions within the same treatment as friction technique. Possible overtreatment of tissue. Effects of Trigger Point Therapy • Increase local circulation • Reduce pain and sympathetic nervous system firing • Treat trigger point • Increase length of muscle • Decrease hypertonicity of muscle Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 63 of 212 Myofascial Trigger Point Technique Procedure Case History Questioning: Clue’s to identify trigger points • The patient is rarely aware of the trigger point (TrP) in the muscle that causes pain. Pain evoked by lying on an infraspinatus TrP at night is perceived in the shoulder, not at the guilty TrP in the muscle. However, when the patient stretches or loads the involved muscle, they are likely to feel discomfort in the regions of taut band attachments. Point to the area of pain. • Drawing the Pain Pattern ▪ Getting a clear description of where the patient's pain is felt can be diagnostically significant to identifying which TrP is contributing to their problem. ▪ Does the pain travel anywhere? (Know trigger point referral patterns) • Describe the pain: usually described as an achiness and stiffness. (Differentiate from radiating nerve pain). • Determine in detail which activities and postures aggravate the pain and which ones relieve it. • Limited Range of Motion: Check muscle length & strength!! ▪ Is rarely the chief complaint but it is a fundamental characteristic of TrP's. It is identified by pain that develops as the muscle approaches full stretch ROM. ▪ Observing the posture and examining for limitation in range of motion. Watch patient's spontaneous posture and movements while walking and sitting. Ex. does the patient turn their head by turning their shoulders as well? ▪ Often worse in the morning and recurs after periods of over-activity of the affected muscle(s). ▪ This is due to the abnormal tension of the taut band. ▪ TrP's can produce dysfunction without producing pain (latent trigger points). • Weakness ▪ Decreased range of motion and strength due to muscle fatigue and hypertonicity. (Without muscle atrophy or neurological deficit). • Other Non-pain Associated Symptoms ▪ excessive lacrimation/ tearing ▪ nasal secretion/ runny nose ▪ pilomotor activity/ hairs up ▪ changes in sweat patterns/ sweating ▪ postural dizziness ▪ spatial disorientation ▪ altered perception of the weight of lifted objects Faculty of Massage Therapy MT-MT20-SM-08-39 weeks Last Modified: August 2023 Page 64 of 212 • Sleep disturbances ▪ This can in turn increase pain sensitivity the next day (increases stress and therefore muscle tension/tone). • Motor function interruption ▪ Includes spasm of other muscles, weakness of the involved muscle, loss of coordination, decreased work tolerance. • Sudden Onset/Acute Overload ▪ "Do you remember the day your pain started ?" ▪ If yes, the details of the posture and movement occurring at the time of onset permit estimation of which muscles were involved, (MOI). ▪ An initial trauma overloads muscle fibres giving rise to the trigger point. Pain develops within the subsequent 12-24 hours post trauma of the muscle(s) involved. Examples of sudden onset events: ➢ wrenching movements ➢ automobile accidents ➢ falls ➢ fractures ➢ joint sprains ➢ dislocations ➢ direct blow to the muscle ➢ episodes of excessive or unusual exercise Ex. packing and moving boxes, gardening in the spring, “weekend warrior” ➢ intramuscular injections at the site of a latent TrP ➢ severe pain referred to a somatic area due to an acute visceral lesion ➢ latent TrP’s in a fatigued muscle may