Manual Therapy (BASPT 218) PDF

Manual Therapy (BASPT 218) Faculty of Physical Therapy, Delta University, second year Manual Therapy By Dr. Fatma Mohammed Alfeky Assistant professor at Basic Science Department, Faculty of Physical Therapy, Benha University 2023...

Manual Therapy (BASPT 218) Faculty of Physical Therapy, Delta University, second year Manual Therapy By Dr. Fatma Mohammed Alfeky Assistant professor at Basic Science Department, Faculty of Physical Therapy, Benha University 2023 1 Ass.Prof. Dr. Fatma Alfeky  Introduction and Myofascial release (MFR) Definition and aims of Manual therapy: Manual therapy is a skilled, specific hand on approach to diagnose and treat soft tissue and joint structures for the purpose of decreasing pain, improving joint range and alignment, improving contractile and non-contractile tissue repair, improving extensibility and stability and facilitating function. The musculoskeletal system is a system of chains and links united in function and enveloped by fascia. No part of the body functions independently.  This functional chain consists of the osseous component (bone and joint), the soft tissue component (muscle, fascia and ligaments) and the neural component (central and peripheral). Management of musculoskeletal dysfunction is often symptom based. The pain is often treated as opposed to the cause of the pain. Manual therapy is a science of not just technique but also a science of somatic diagnosis. The detection of aberrant function of the functional chain as a whole and correlating it to the existing pathology is the essence of the art and science of manual therapy. Manual therapy concerns itself with the treatment of both functional disturbances in the spine or the extremity joints and abnormal muscle function, including the shortening, weakening and imbalance of muscles. Types of tissues: 1. Connective tissue 2. Epithelial tissue 3. Muscle tissue 4. Nerve tissue 2 Ass.Prof. Dr. Fatma Alfeky Connective tissue (CT) It maintains the form of the body and its organs, and provides cohesion and structural support for the tissues and organs.  CT derives its name from its function in connecting or binding cells and tissues. It can be considered the ‘glue’ that holds the body parts together. CT has three main components: cells, fibers and extracellular matrix (ECM) Myofascial system Myo means ‘muscle’, and fascia means ‘band’. Fascia  Fascia is a connective tissue a weblike, three-dimensional matrix that intertwines, protects and supports every other structure of the human body. It surrounds all muscles, bones, nerves and organs.  It is a single, uninterrupted sheet of tissue that extends from the inner aspects of the skull down to the soles of the feet and from the exterior to the interior of the body, ultimately making up the shape and form of the body itself. Due to this interconnectedness, restriction in one area will result in reduced range of motion in another local or distal area  Fascia is an innervated, continuous, functional organ of stability and motion.  Fascia possesses 10 times more sensory nerve receptors than its muscular counterpart so it is considered a mechanosensitive system that adapts its fibers arrangement and density according to the local and tensional demands placed on it.  The body is a system of interconnecting tubes made of connective tissue fascia and possesses an interlocking of fascial planes that connect one muscle group with another. Due to this interconnectedness, restriction in one area will result in reduced range of motion in another local or distal area 3 Ass.Prof. Dr. Fatma Alfeky Elements of fascia: 1.Collagen: Collagen fibers give tissues their tensile strength, resiliency and structural integrity 2.Elastin: provides an elastic quality that allows the connective tissue to stretch to the limit of the collagen fibers’ length whilst absorbing tensile force. 3.Ground substance: a viscous, transparent fluid, like raw egg whites. It surrounds all the cells in the body  The primary components of the ground substance are: 1. Glycosaminoglycans (30%) – sometimes called mucopolysaccharides 2. Water (70%)  It acts as a mechanical barrier to foreign matter and is a medium for the diffusion of nutrients and waste products.  It maintains lubrication between the collagen fibers  It maintains the critical distance between adjacent collagen fibers. This distance allows for some of the extensibility of fascia by reducing the number of microadhesions that can occur between collagen fiber Types of fascia 1. Superficial fascia 2. Deep Fascia (axial or investing fascia) 3. Meningeal fascia: surrounds the nervous system and the brain. 4. Visceral fascia: surrounds lungs, heart and abdominal organs 4 Ass.Prof. Dr. Fatma Alfeky 1. Superficial fascia  It is a thin fibrous layer of loose connective tissue beneath the skin, attaching the dermis skin to the underlying tissues. It separates the skin from muscle to allow normal sliding action on each other. It is connected to deep fascia.  Through it, blood vessels and nerves pass to and from deeper structures  It is fibrous highly elastic with variable fat content  It provides insulation and shock absorption (ankle)  It is involved with thermoregulation, circulation and lymphatic flow.  It regulates fluid and provides space for the accumulation of fluid and metabolites.  It contains inflammatory exudates.  When it is injured or damaged, it becomes shorter, condensed and tighter. Trigger points mainly manifest in the myofascial tissue; the contracture of this fascia gives rise to nodules underneath the skin.  Load aiming to enhance length has been suggested to require light elongation pressure sustained for minutes not seconds. The ideal degree of stretch, required to lengthen loose connective tissue, should not exceed 20% of the available elasticity, with 5% to 6% usually being adequate 2. Deep fascia (axial or investing fascia)  It is tough, tight, compact inelastic clefts and septa that cover muscle.  There are three layers of fascia in every muscle, the endomysium, the perimysium and the epimysium.  It surrounds and merges the major muscles, tendons, ligaments, and aponeuroses of the trunk, extending into the limbs, providing protection and lubrication.  It transfers force (load) during muscle contraction and has a role in postural stabilization. 5 Ass.Prof. Dr. Fatma Alfeky Healthy fascia:  As fascia is a tensional force transmission system (tensegrity), it adapts to demands. The tissue is quite adaptable to change and moves relatively freely with other body tissues, thus allowing muscles to shorten and lengthen. When the fascia is damaged, fascial restrictions occurs where the tissue does not slide easily over other tissues in the body.  This inflexibility causes movement to become more difficult and can restrict the range of motion. Furthermore, these restrictions can create tightness and tension throughout the fascia and muscular systems causing pain and limiting function, resulting in a myriad of symptoms distant to the site of the original injury. Causes of Fascia Restriction (fascial dysfunction): 1. Poor posture 2. Injury or trauma to surrounding tissues: as a fall, blow, cut or burn and surgery. 3. Inflammation: creates an imbalance in cellular fluids and possible cell death from lack of oxygen resulting in scar formation and fascial adhesions 4. Inactivity: e.g. Sitting behind a desk for prolonged periods without performing stretches may cause the development of adhesions in the thoracolumbar fascia in the lower back area  With immobility, changes in the ground substance occur, including losses of glycosaminoglycans and water so, interfiber distance is not maintained and adjacent collagen fibers move closer together and microadhesions occurs. 5. Overuse: repetitive strain e.g. Overuse of extensor muscles in the forearm may cause Tennis elbow 6 Ass.Prof. Dr. Fatma Alfeky  6. Muscle strains 7. Old age: The ground substance in fascia is less of a liquid, and becomes a harder gel so, the movement is limited. Consequences of Facial Restrictions: 1. Reduced flexibility 2. Limitation of motion 3. Myofascial (i.e. trigger point related) pain 4. Muscle weakness 5. Neural symptoms such as numbness and tingling in certain parts of the body 6. Postural deviations and misalignments: frequently involving chain reactions of adaptation and compensation – commonly associated with impaired coordination and motor control  e.g. For example, after a total mastectomy (removal of breast tissue), the anterior thoracic fascia develops adhesions, which limits the elasticity of the fascia. Due to this restriction, forward head posture often occurs in such patients 7. Autonomic imbalance – including sympathetic arousal, or chronic fatigue 8. Recurring injuries 9. Headache 10. Unbalanced load transfer  Pain in the medial knee could, for example, have connections with dysfunction involving the thoracolumbar fascia, or the contralateral latissimus dorsi. 7 Ass.Prof. Dr. Fatma Alfeky  Myofascial release (MFR) Definition: Myo= Muscle Fascia = a band / sheet of connective tissue. release = relaxation/ stretching of tight structures. Myofascial release (MFR) is specialized physical and Manual Therapy (Hand on Technique) used for diagnosis and treatment of myofascial tension and restrictions. Effects of MFR  Supply mechanical and thermal energy that converts the ground substance into gel state again  Rearrange and allow sliding movement of the collagen and elastin fibres  Cross linkages between the fibers are broken.  The interfiber distance is increased so that fiber affinity is reduced, resulting in increased extensibility in the tissue.  Local circulation (waste and nutrient exchange) improves  The soft tissue proprioceptive sensory mechanisms are reset.  Promotion of relaxation and a sense of well-being  Elimination of general pain and discomfort  Re-establishe and improve joint range of motion and muscle function  Improve digestion, absorption and elimination  Restore balance and promotion of correct posture 8 Ass.Prof. Dr. Fatma Alfeky  Indications of MFR Facial restriction as in: 1. Ankle: Achilles tendinitis, plantar fasciitis, Tarsal tunnel syndrome, Pes cavus (claw foot), Inversion sprain, Ligament sprain 2. Knee: Osteoarthritis, Chondromalacia of patella, Patellar tendinitis, Bursitis. 3. Hip and Thigh: Trochanteric bursitis, iliotibial band syndrome, Piriformis syndrome, Psoas dysfunction, Adductor tendinitis, Ligament sprain 4. Low Back and Hip: Lumbar and sacral strain, Lumbar spondylosis, Sciatica, Lumbar disc prolaps, scoliosis. 5. Neck: Traumatic cervical sprain, torticollis, Thoracic outlet syndrome, cervical spondylosis and disc prolapse. 6. Shoulder: Adhesive capsulitis, Rotator cuff syndrome, Supraspinatus tendenitis, Biceps tendinitis, Ligament sprain, Bursitis. 7. Wrist and Hand: Carpal tunnel syndrome 8. Cranial Region: TMJ, Tension headaches 9. Systemic Musculoskeletal: Fibromyositi, Neuralgia, neuritis, Dysmenorrhea 10. Systemic Nervous: Bell’s palsy, Trigeminal neuralgia Contraindications of MFR A. Global Contraindications 1.Fever 2.Systemic infection 9 Ass.Prof. Dr. Fatma Alfeky 3.Acute circulatory disorders 4.Deep vein thrombosis 5.Aneurysm 6.Uncontrolled hypertension usually involving anti-coagulant therapy 7.Severe undiagnosed swelling 8. Severe undiagnosed pain B. Local Contraindications 1. Open wounds 2. Acute rheumatoid arthritis 3. Acute trauma/inflammation 4. Recent Fracture 5. Infectious skin or sunburn 6. Radiation therapy 7. Localized infection 8. After Cortisone therapy 9. Osteomyelitis 10. Osteoporosis 11. Severe varicose veins 12. Haemarthrosis 13. Malignancy or tumors 11 Ass.Prof. Dr. Fatma Alfeky MFR Application important notes: 1. Follow steps in section 1: Instructions, Observation and palpation 2. Physical Therapist should be prepared mentally and physically to treat a client. 3. Apply moist heat (20 minutes) before MFR and each day after for 3 days to increase blood supply 4. Ask the patient to take deep breaths into the area that you are working to increase awareness, decrease intense sensation and integrates the nervous system with the myofascia (avoid holding breath) 5. All techniques must be performed skin on skin, not through drapes, towels or clothing. 6. The patient’s skin must be dry with no oil or lotion. 7. The patient needs to be verbally empowered to tell the therapist when to stop, when to slow down, and when to back off MFR rules: 1. Find Tissue barrier of resistance by moving in slowly at a 90-degree angle: the point at which the tissue changes from a relaxed, or soft, state of give to a subtle but definitive state of resistance.  It can be felt in every plane as well as in the direction of unique pull of restriction through a patient’s body. Because fascia is a three-dimensional matrix, the barrier of resistance can also be felt on multiple planes. 2. Maintain a continuous stretch to rearrange the collagen and elastin fibres:  MFR techniques are performed for two to five minutes to influence the entire fascial network 11 Ass.Prof. Dr. Fatma Alfeky   The initial 90 seconds of stretch only affect the elastin fibers (feeling the elastic barrier release).  Another 90 seconds needed to unwind of collagen fibers. The ground substance needs time to go from a gel to a liquid (in a liquid state, the collagen fibers can begin to lengthen). As this lengthening occurs, cross-linkages within the fascia begin to break. 3. Use light pressure. Collagen fibers lengthen under gentle, sustained pressure.  The Arndt-Schultz law: states that weak stimuli increase physiological activity and very strong stimuli inhibit or abolish activity.  Less pressure applied to tissue results in a greater response  Firmer and quicker pressure results in tissue resistance. 4. Depth barrier: the tissue barrier of resistance fell when leaning into the patient’s body. Place hands gently on the patient’s body, leaning into the depth barrier of tissue resistance or tractions to meet the tissue barrier of resistance, and wait for a sensation of yielding. 5. As the musculoelastic tissue depth barrier softens, pressure maintained gently and the slack taking up to meet the next subtle barrier of tissue resistance. 6. Flow with the tissue. As the tissue unwinds, the direction of force changes, follow the unwinding to be most effective. 12 Ass.Prof. Dr. Fatma Alfeky  Trigger points (TrPs) Definition of Trigger point: Hyperirritable spot within a taut band of a skeletal muscle that is painful on compression, stretch, overload or contraction which responds with a referred pain that is perceived distant from the spot. Difference between trigger point and a spasm  Spasm is a sudden, hard contraction of the entire muscle.  Trigger point and its associated taut band are a contracture of only a small area within the muscle.  Trigger points can induce a whole muscle spasm Myofascial syndrome (MFS) MFS refers to all of the symptoms caused by myofascial trigger points. Myofascial pain syndrome (MPS) MPS refers to a MFS where the main symptom is pain and can represent a complex psychological and physiological event in the sense of a chronic pain syndrome. 13 Ass.Prof. Dr. Fatma Alfeky  Signs and symptoms of Myofascial trigger points 1. Palpable taut band (or Small nodules, Large lumps; cord; Rope-like) in a skeletal muscle: perpendicular to the fiber direction. 2. Presence of a hyperirritable spot in the taut band. 3. Palpable local twitch response (sudden involuntary contraction of the taut band) on snapping palpation (or needling). 4. Jump sign: by pressure, the patient often winces from the pain 5. Pain generated by trigger points can range from a vague aching to pain so severe 6. Presence of referred pain elicited by stimulation or palpation of the hyperirritable spot. 7. Pain on contraction in the shortened position. 8. Physical dysfunctions: e.g. muscle weakness, inhibition, increased motor irritability (spasm), muscle imbalance; incoordination, altered motor recruitment, in either the affected muscle or in functionally related muscles and limited range of motion. 9. May be a loss of skin elasticity in the region of the trigger point. 10. May be hotter (or colder) than the surrounding tissues. 11. May be moister than the surrounding tissues. 12. In EMG: high-frequency, spontaneous, low-amplitude electrical activity (spontaneous electrical activity). In resting state, electrical activity in muscles is 'silent'. 13. Autonomic effects:  Reddening and excessive tearing of the eyes, blurred vision, a droopy eyelid, excessive salivation, and a persistent runny nose.  Trigger points in neck muscles can bring about dizziness, poor sense of balance, a chronic cough, sinus congestion, and chronic sinus drainage.  Trigger point in the pectoralis major that can cause an irregular heartbeat. 14 Ass.Prof. Dr. Fatma Alfeky   Trigger points in the infraspinatus can even cause excessive sweating in the hands Trigger Point Classification 1. Primary (or Central) Trigger Point  These are the most well-established and 'florid' when they are active  Always exist in the center of the muscle belly, where the motor end plate enters the muscle. 2. Secondary (or Satellite) Trigger Point  It is created as a response to the central trigger point in neighboring muscles that lie within the referred pain zone.  The primary trigger point is still the key to therapeutic intervention and the satellite trigger points often resolve once the primary point has been effectively rendered inactive. 15 Ass.Prof. Dr. Fatma Alfeky 3. Attachment Trigger Points  As myofascia is a continuum. The area where the tendon inserts into the bone (tendino- osseous) is often 'exquisitely' tender. This may well be the result of the existing forces travelling across these regions.  It may result from an associated chronic, active myofascial trigger point.  If a chronic situation occurs where the primary and attachment trigger points remain untreated, 'degenerative changes' within the joint may be precipitated and accelerated 4. Diffuse Trigger Points  Trigger points can sometimes occur where multiple satellite trigger points exist secondary to multiple central trigger points.  These diffuse trigger points often develop along lines of altered stress and or strain patterns.  e.g. Severe postural deformity such as a scoliosis, and an entire quadrant of the body is involved: diffuse secondary trigger points. Active and Latent Trigger Points 1. Active Trigger Points  Symptomatic pain at rest or with motion or pressure.  This can apply to central and satellite trigger points. A variety of stimulants can activate an in-active trigger point such as forcing muscular activity through pain.  Common when increasing activity post road traffic accident (RTA), where multiple and diffuse trigger points may have developed. 16 Ass.Prof. Dr. Fatma Alfeky 2. Inactive (or Latent) Trigger Points:  No Symptomatic pain at rest. The pain elicited with pressure.  Inactive trigger point can turn into active trigger point  These can develop anywhere in the body; and are often secondary.  The presence of inactive trigger points within muscles may lead to increased muscular stiffness.  These points are more common in those who live a sedentary lifestyle.  These points may re-activate if the central or primary trigger point is (re)stimulated, or following trauma and injury. Theories of pathophysiology of trigger points Trigger points begins with sudden muscle overload, sustained low-level isometric contractions, eccentric contraction, chronic muscle tension, gross trauma, overuse, or sustained rapid movement. All of these factors activate the release of acetylcholine (ACh), which causes the sarcomere to contract and constrict the capillaries that supply the muscle’s metabolic need 1. Motor end plate theory: The electrical activity of active trigger points arises from dysfunctional extrafusal motor end plates rather than from muscle spindles. This sustained dysfunction and sarcomere contraction leads to local intracellular chemical changes including:  Localized ischemia  Increased metabolism needs  Increased energy required to sustain contraction  Calcium is unable to be taken into the actin and myosin myofilaments, leading to sarcomere 'failure'.  Localized inflammation (to facilitate repair) 17 Ass.Prof. Dr. Fatma Alfeky   Compression on local vessels  Production of inflammatory agents, which sensitize local autonomic and nociceptive (pain) fibres.  Energy crisis 2. Energy crisis theory:  The body attempts to resolve sarcomere and end plate failure by changing the blood supply to the sarcomere (vasodilation).  Migration of localized acute and chronic inflammatory cells occurs.  Inflammation brings with it sensitizing substances such as substance P, a peptide present in nerve cells, which increases the contractions of gastrointestinal smooth muscle, but also causes vasodilation.  This has the effect of stimulating both local (small) pain fibres and local autonomic fibres. This in turn leads to increased acetylcholine production and hence a vicious cycle.  Eventually the brain sends a signal to rest the muscle in which the trigger point manifests. This leads to muscle weakness, shortening, fibrosis and reflex inhibition of other muscle groups.  Treatment is thus aimed at interfering and attenuating this vicious cycle. 3. Pain–spasm–pain theory Causes of trigger points 1. Acute Myofascial pain: as blunt muscle trauma (contusion), pulled muscle (usually eccentric muscle strain), torn muscles (complete or incomplete, usually caused by eccentric muscle strain), sprain, dislocation of joints, increased isometric muscle contractions as carrying bags, Shortening of the muscles and increase in muscle tension caused by climate. 18 Ass.Prof. Dr. Fatma Alfeky 2. Postural Stress: e.g. Strained or awkward positions in work 3. Vitamin and Mineral Insufficiencies:  Water-soluble vitamins B1, B6, B12, C, and folic acid.  Vitamin D  The minerals: calcium, iron, magnesium, potassium, and zinc 4. Metabolic Disorders:  Hypothyroidism, low testosterone, low estrogen, hypoglycemia, anemia, prolonged breastfeeding, and high levels of uric acid in the blood.  Nicotine, caffeine, and alcohol cause enough irregularity in metabolism 5. Psychological Factors: Tension, anxiety, chronic depression, and common nervousness 6. Other factors:  Ageing  Chronic bacterial infections, including an abscessed tooth, sinusitis, and urinary infections  Lack of sleep or sleep that isn’t restful  Weight gain  Congenital malformation Fibromyalgia syndrome Fibromyalgia means pain in the fibrous, connective and tendinous tissues of the body. Fibromyalgia is a complex syndrome characterized by pain amplification, musculo-skeletal discomfort, and systemic symptoms. Fibromyalgia syndrome is characterized by widespread diffuse musculo-skeletal pain and fatigue. 19 Ass.Prof. Dr. Fatma Alfeky  It is linked to psychological depression (as trigger point). It is a disorder for which the cause is still unknown. More women than men are affected by fibromyalgia, but there is no age profile. Trigger points Fibromyalgia Pain location Specific and discrete General Type of pain Referred in specific pattern Vague, aching, burning, diffuse, widespread Pain mediation Locally in the region of the motor end plate from the Centrally (CNS) peripheral nervous system (PNS). Muscular quality Tight and stiff Doughy and soft on palpation To qualify for a diagnosis of fibromyalgia:  The number of painful body regions (at least eleven of eighteen points for three months)  Tender points in all four quadrants of the body  Severity scale of Cognitive symptoms, unrefreshed sleep, fatigue and number of somatic symptoms 21 Ass.Prof. Dr. Fatma Alfeky  Therapeutic massage Definition of Therapeutic massage: It is the systematic manual or mechanical manipulations of the soft tissues of the body for therapeutic purposes. Types of massage therapy: 1. Swedish: The most common type of massage to relax and energize the body. 2. Medical: For muscle damage from injury, such as back strain 3. Sport massage: To help prevent athletic injury, keep the body flexible and help recovery Physiological effects and indications of therapeutic massage The immediate effects of massage are noticeable on the skin. The physiologic effects of massage are not limited to the skin. The body as a whole benefits by the stimulation of muscular, glandular, and vascular activities. 1. Physical effects When pressure is applied to the muscles, blood, and lymph vessels, or to any internal structure, both reflex and direct mechanical effects are experienced. 1. Mechanical effects are direct physical effects of the massage techniques on the tissues that they contact.  It enhances circulation to and from the muscles  It stretches and compresses various connective tissues.  It increases pliability in connective tissue 2. Reflex effects: indirect responses to touch that affect body functions and tissues through the nervous or energy systems of the body. Gentle stimulation of the sensory nerve endings in the 21 Ass.Prof. Dr. Fatma Alfeky  skin, as in superficial stroking has reflex reactions affecting the autonomic nervous system, neurotransmitters in the brain, pain perception, or the underlying joints and muscles of the areas being massaged.  Pressure on reflex points, active trigger points, and other pressure points reflexively affects functions or areas of the body away from the actual point of contact. 2. Circulatory effects Massage techniques are movements or strokes directed toward the heart (centripetal) to enhance venous blood and lymph flow and therefore are directed toward the heart and the eliminative organs.  Promoting circulation of the blood and lymph: thereby improving the delivery of oxygen and nutrients to the cells as it enhances the removal of metabolic wastes.  Accompanying the increased flow of blood, there is a slight reddening and warming of the skin.  Nutrition to the skin is improved. Massage treatments over time impart a healthy radiance to the skin, making it softer, suppler, and of finer texture. Massage movements affect blood and lymph channels in the following ways: 1. Light stroking produces an almost instantaneous, although temporary dilation of the capillaries, whereas deep stroking brings about a more lasting dilation and flushing of the massaged area. 2. Friction and stroking movements heighten blood circulation to the skin and increase the activity of the sweat and oil glands. 3. Petrissage and compression movements stimulate the flow of blood through the deeper arteries and veins. 22 Ass.Prof. Dr. Fatma Alfeky  3. Muscular System effects 1. Massage releases muscle spasms 2. Massage prevents and relieves soreness of muscles. 3. Massage lengthens shortened muscles. 4. Massage releases fascial restrictions and reduces the thickening of connective tissues, allowing more flexibility and easier, pain-free movement. 5. Friction massage prevents and reduces the development of adhesions and excessive scarring after trauma. 6. Massage reduces trigger point activity. 7. Massage enhances metabolism and healing process. 8. Massage improves range of motion of limbs that have a limited range because of tissue injury, inflammation, muscle tension, or strain. 9. Massage overcomes musculoskeletal imbalance and improves posture 4. Autonomic Nervous System Effects 1. Initially, massage stimulates the sympathetic nervous system. Short, invigorating massage, such as pre-event sports massage stimulates the body, leaving it more alert and energized. 2. Longer, relaxing massage, however, seems to affect the autonomic nervous system by sedating the sympathetic nervous system and stimulating the parasympathetic nervous system. As a result, blood levels of epinephrine and norepinephrine are reduced, heart rate and blood pressure are reduced, and the relaxation response is increased. 23 Ass.Prof. Dr. Fatma Alfeky  5. Psychological and Neurotransmitters effects 1.Massage promotes relaxation and relieves stress. 2.Massage reduces anxiety and depression. 3.Massage reduces the blood levels of the stress-related adrenal hormones epinephrine and norepinephrine and increases the levels of serotonin, dopamine, endorphins, and enkephalins neurochemicals that elevates moods, controls pain, controls appetite and enhances of the immune system. 6. Pain Modulation 1.Massage reduces the sensation of pain by increasing the concentration of endorphins and enkephalins and other pain-reducing neurochemicals in the CNS and bloodstream. 2.Mechanical stimulation by massage stimulates A-beta nerve fibers (gate control theory of pain). 3.Massage relieves referred myofascial and ischemia-related pain by releasing hypersensitive trigger points and restoring circulation to hypertonic muscle tissue. 4.Chemical pain reduced through increase blood flow and encourage removal cellular waste products 5.Massage interrupts pain spasm pain cycle. 24 Ass.Prof. Dr. Fatma Alfeky  Massage can be stimulation and inhibition 1. Stimulating massage techniques a. Percussion (light tapping and slapping movements) increases nervous irritability. Strong percussion for a short period excites nerve centers directly. Prolonged percussion tends to anesthetize the local nerves. b. Vibration stimulates peripheral nerves and all nerve centers with which a nerve trunk is connected. 2. Sedative effect of massage techniques a. Gentle stroking produces calming and sedative results. b. Light friction and petrissage produce marked sedative effects. c. Holding pressure (ischemic compression) on a sensitive trigger point desensitizes the point and helps to release the pathophysiologic reflex cycle N.B. When treating athletes, massage and stretching can decrease muscle power so it should be used cautiously in a pre-event setting. Also, deep tissue massage should not be used to treat athletes immediately following an event because there could be trauma to tissues that might be aggravated by compression and stretching. Contraindications of Massage Systemic contraindications: 1. Sever uncontrolled hypertension 2. Fever 3. Osteoporosis 4. Cancer 25 Ass.Prof. Dr. Fatma Alfeky 5. Blood Thinning Medications (e.g. heparin ,Warfarin) 6. Bleeding disorders (e.g. Hemophilia) 7. Hemorrhage 8. Systemic Infection 9. Acute inflammatory stage following a soft tissue injury Local contraindications: 1. Acute injuries 2. Hypermobility or unstable joints 3. Local contagious conditions 4. Over deep vein thrombosis 5. Over varicose veins 6. Open wounds 7. Fractures Preparation and general considerations for massage 1.The massage takes place in the privacy of a room that is well ventilated and a comfortable temperature, with indirect lighting and few distractions. 2.A massage table of the proper height for the comfort and safety and well-padded for the patient’s comfort is draped with appropriate linens. 3.Clean, fresh linens are used for each patient to provide warmth and a modest cover while they receive massage. 4.Drape the patient’s body with sheet or towel, with the exception of the part to be massaged. 26 Ass.Prof. Dr. Fatma Alfeky 5.The part that will be treated should be well supported and comfortably placed. Bolsters and pillows to support and position the patient for the utmost comfort. 6.Wash and sanitize hands. 7.Therapist’s hands should be warm, soft and with no long nails or accessories. 8.Massage oils, gel, creams, or lotions are used as lubricants when performing the massage to allow smooth continuous movement (not too little to avoid increased friction and not too much to avoid sliding). The choice of lubricant is determined by the therapist’s preference as well as the patient’s safety, preference, and special needs. 9.Moist heat is used to heat the area before massage to promote relaxation. 10. Starts with non-painful areas first then painful areas. 11. Movement should be slow, rhythmic and in the same direction (distal to proximal or in the direction of venous return and lymphatic drainage). 12. Drink water after massage to assist waste products removal. Massage Techniques 1. Touch 1. Superficial 2. Deep 2. Gliding 1. Feather stroking (nerve stroking) 2. Superficial Gliding strokes (Effleurage) 3. Deep gliding (stripping) 3. Kneading (Petrissage) 1. Kneading 2. Fulling 27 Ass.Prof. Dr. Fatma Alfeky 3. Skin rolling 4. Friction 1. Circular friction 2. Transverse (cross-fiber) friction 3. Longitudinal friction 4. Compression 5. Rolling 6. Wringing 7. Shaking 8. Rocking 9. Vibration 5. Percussion (Tappotement) 1. Tapping 2. Slapping 3. Cupping 4. Hacking 5. Beating 28 Ass.Prof. Dr. Fatma Alfeky  Manual Lymphatic Drainage (MLD) The lymphatic system: Lymphatic system is a part of circulatory system made up by an extended network of capillaries, vessels, trunks, ducts, as well as other aggregated structures as lymph nodes, spleen and the thymus. It is a one-way drainage system leading fluid from the tissues of the body to the veins in the neck Tiny lymph vessels converge to form larger vessels which pass through a series of lymph nodes to drain into two ducts, the thoracic duct and the right lymphatic duct, and finally empty into the venous system. Function of lymphatic system: 1. A waste disposal function: carry off wastes, toxins, proteins, viruses, bacteria, excess water, dead cells, etc. from the interstitium (loose connective tissue). 2. Removal of proteins from the interstitium by the lymphatics. By removing proteins from the interstitium, the lymph vessel system helps to maintain an osmotic balance in the tissues and thus prevents the excess accumulation of fluids.  Blockage or damage to the lymph vessels or nodes can result in lymphedema and congestion.  If the proteins are not removed, they become stagnant and attract water toward them, which causes more congestion and lymphedema. These stagnant proteins also gradually start to break down, and an inflammatory process is initiated. The body reacts to this by stimulating fibroblast activity, and hardening or fibrosis of the tissues may eventually occur. 3. The lymph vessel system removes water from the tissues through the pumping action in the lymph angions. 4. An immunological function: absorbing microorganisms and defending against infections. Both B and T lymphocytes constantly circulate through the lymph vessels and nodes. 5. The lymph vessel system also plays a role in the removal of fats from the small intestines. 29 Ass.Prof. Dr. Fatma Alfeky  Lymphedema Definition: is the accumulation of excessive lymph fluid in the subcutaneous tissues because of the lymphatic system’s inadequate transit capacities. Types of Lymphedema: primary or secondary, terms which refer to the cause of its development. 1. Primary lymphedema: developmental abnormality occurring within the lymphatic system (congenital or hereditary). 2. Secondary lymphedema: caused by dissection of lymph nodes, infection, inflammation, trauma, surgery, radiation, malignancies, chronic venous insufficiencies and immobility For example, in breast cancer patients who have undergone lymph node dissection and/or radiation therapy, the prevalence of lymphedema can range from 6% to 44%. Clinical features 1. Edema 2. Tissue changes: initially, pitting edema as the fluid is displaced. As the condition progresses the tissues harden due to the fibrotic changes. 3. Dry Skin 4. Pain and discomfort 5. Psychological and psychosocial problems Management strategy for lymphedema (combined decongestive therapy) It is divided into two stages: Intensive and maintenance A. Intensive treatment phase: lymphedemas may reduce by 40% to 50% or more during this intensive phase. 1. MLD: 5 days per week with at least one or two 60-minute sessions per day over a 2- to 4- week period. 2. Low-stretch compression bandage system to maintain the reductions achieved by MLD and to prevent worsening or refilling of the limb: when a patient exercises while wearing bandages, the firm compression resists muscle contraction, and this has the effect of stimulating fluid movement, decreasing filtration rates from the blood capillaries, and encouraging a softening of any fibrosis. 31 Ass.Prof. Dr. Fatma Alfeky  3. Exercise 4. Skin care. B. Maintenance phase: 1. Wear a compression garment: To maintain the reduction attained during the intensive treatment and prevent refilling of the limb 2. Toward the end of the intensive phase, wear compression sleeve for the arm or stocking for the leg 3. Self MLD 4. Exercises Manual Lymph Drainage (MLD) Definition: Manual Lymph Drainage (MLD) is a systematic gentle, light, rhythmic manual technique directed toward the superficial tissues, with the intent of enhancing lymph circulation Vodders’ MLD treatment techniques consisted of gentle, rhythmic motions that focused on moving fluid toward the lymph nodes The primary aim of MLD is to improve the functioning of the lymphatic system. A series of pumping and stretching hand movements in a range of sequences are used to move the skin in specific directions based on the underlying structure and physiology of the lymphatic system. The movements influence the lymph vessels which transport lymph towards the lymph nodes. MLD increases lymphatic contractile function and lymph flow by up to 28% stretch the skin in the direction of lymph flow Effects of MLD 1. Increase in lymph production:  increase activity in normal lymphatics and improve their function  open the flow of lymph fluid  encourage lymph fluid to flow along alternative drainage routes  aid lymph drainage from congested areas. 31 Ass.Prof. Dr. Fatma Alfeky  2. Effect on the Nervous System:  Very light, gentle manual technique induces deep relaxation  Sympathicolytic effect: lowering of sympathetic nerve firing in the body which lead to more parasympathetic response  Analgesic effect: Gate-control theory 3. Effect on Smooth Muscles of the Blood and Lymph Vessels  MLD increases the speed of blood flow through an increase in vasomotion caused by a contraction of arteriole smooth muscle (A relaxation of the precapillary smooth muscle sphincter in the arterioles is mediated by the sympathicolytic effect). MLD facilitates the drainage without increasing blood pressure.  In specific and precise movements of Dr. Vodder’s MLD: When the walls are stretched, the stretch receptors are stimulated and elicit firing along a nerve that eventually results in contraction of the smooth muscles. By mechanically pushing the lymph forward, MLD may also increase the filling of the lymph vessels ahead of the therapist’s hand.  The smooth muscle of the lymph collectors is innervated by the sympathetic nerves. A lowering of sympathetic nerve firing also causes dilation or filling of the vessel. 4. Effect on Drainage:  Protein removal into the lymphatic system is enhanced, and consequently the colloid osmotic pressure in the tissues is lowered: less water is attracted toward the tissues and the edema is reduced.  The main use for this drainage effect is in the reduction of edema caused by interventions in cancer therapy (e.g., postmastectomy lymphedema)  The goal of manual lymph drainage in the treatment of lymphedema and related conditions is to reroute the lymph flow around blocked areas into more centrally located healthy lymph vessels, which drain into the venous system 32 Ass.Prof. Dr. Fatma Alfeky  Indications of MLD MLD reduces edema, reduces pain, increases mobility, and improves function in many cases as in: 1. Edema: lymphedema (primary and secondary), Post operative, post traumatic, venous insufficiency edema (excess fluid accumulation in the interstitial spaces caused by increased venous blood pressure), lipedema (abnormal, symmetrical fat deposition with accompanying edema) 2. Orthopedic conditions (e.g., posttrauma, fractures, strains, inflammation in joints as osteoarthritis, ligament and tendon injuries, frozen shoulder, hip replacement, arthritic joints). 3. Neurologic disorders: neuropathic pain, facial nerve paralysis, fibromyalgia, stroke 4. Dermatologic disorders as burn, acne and dermatitis 5. Connective tissue disorders: lupus erythematosus, scleroderma 6. Digestive disorders: constipation Contraindications of MLD General contraindications 1. Acute infection or inflammation 2. Active, untreated malignant disease. 3. Acute deep vein thrombosis. 4. Cardiac insufficiency 5. Renal failure Local contraindications 1. Carotid-sinus syndrome: hypersensitivity of pressure receptors on the carotid bifurcation may cause cardiac arrhythmia. 2. Hyperthyroidism: MLD on the neck may accelerate the release of thyroid hormones and/or medications into the blood 3. Pregnancy 33 Ass.Prof. Dr. Fatma Alfeky  4. Recent abdominal surgery 5. Acute infection or inflammation 6. Acute deep vein thrombosis. 7. Bleeding, hemorrhage Basic principles of MLD 1. Warm, comfortable, soothing environment. The fewer distractions there are during treatment, the more a patient is likely to be able to relax and encourage the parasympathetic system to predominate 2. No oil is necessary when MLD is performed unless the skin is very hairy, in which case a few drops of oil can be used. 3. Begins proximally and progresses distally: The neck is always treated first to enhance drainage of the major lymph ducts into the venous arch and back into the blood circulatory system. After the neck, localized affected areas are treated, and, in general, treatment patterns progress from proximal to more distal parts of the body. However, each section undergoing treatment is worked in a distal to proximal direction. 4. Works in the direction of lymph flow. The initial lymphatics are opened up by a straight motion performed with light pressure on the skin in order to stretch it gently, followed by a lateral motion to stimulate the initial lymphatics to drain. The initial lymphatics then need to close to ensure that the lymph drains, so the pressure is released and the stretched skin springs back to its normal position 5. The unaffected lymph nodes and region of the body are treated first. 6. Working phase and the resting phase:  In the working phase of a stroke, stretch stimuli are applied to the subcutaneous tissues, resulting in the manipulation of anchoring filaments of lymph capillaries and the smooth musculature in the wall of lymph angions. The light directional pressure in the working phase also serves to move lymph fluid in the appropriate direction. The pressure in this phase should be sufficient enough to stretch the subcutaneous tissue against the underlying fascia to its elastic capacity.  In the resting phase, the pressure is released, in which the elasticity of the skin moves the therapist’s hand passively back to the starting position. In this pressure-free phase, initial lymph vessels absorb tissue fluid from the interstitial spaces. 34 Ass.Prof. Dr. Fatma Alfeky 7. Each working phase should last about 1 second and should be repeated five to seven times in the same area in either a stationary or a dynamic pattern 8. The correct pressure is used on the skin.  Should not cause pain or reddening of the skin (erythema may be possible with sensitive skin)  If the pressure used is too deep, the initial lymphatics may become damaged or collapse so that drainage does not occur.  If the pressure is too light, the fingers will slide over the skin 9. The movements are completed by one or both hands slowly, rhythmically and repetitively. 10. Engages and moves the skin rather than sliding over it. 11. Breathing techniques are commonly used with MLD, often combined with controlled hand pressures by the therapist, to influence drainage in the deep abdominal lymphatic vessels and nodes 12. During the treatment sessions, the patient is encouraged to relax and following completion of the treatment, a simplified form of self-massage is usually taught for the patient to continue independently. Regular follow-up sessions of MLD may occur at weekly or monthly intervals to maintain lymph drainage. 13. Treatment times are from 30 minutes to 90 minutes. 14. The frequency of treatment depends on the condition being treated. For example, patients with lymphedema may require daily treatment for a 2 to 4 week period. 35 Ass.Prof. Dr. Fatma Alfeky  L6: Integrated neuromuscular inhibition technique (INIT) Ischemic compression (IC) Strain-counter strain (SCS) Spray and stretch technique All areas that palpate as painful are responding to, or are associated with, some degree of imbalance, dysfunction or reflexive activity that may well involve acute strain or chronic adaptation. Integrated neuromuscular inhibition technique (INIT) An integrated neuromuscular inhibition technique (INIT) includes the sequence of the ischemic compression technique (IC), the strain-counter strain technique (SCS), and the muscle energy technique (MET) to release myofascial trigger points and fascial tightness. 1. The sequence commences with the identification of a tender/pain/trigger point.  Tender points are localized areas, associated with distressed and dysfunctional tissues  Tender points, in contrast to myofascial trigger points are not associated with hyperirritable bands of tissue, but are discrete areas of tissue tenderness that can occur anywhere in the body 2. This is followed by application of gentle sustained pressure by thumb or fingers or knuckle or elbow for a long enough time to inactivate the trigger points called intermittent ischemic compression for 30-60 seconds (this is optional and is avoided if pain is too intense or the patient too fragile or sensitive). Pressure reduces pain by stimulation of A-beta fibers (gate control theory of pain).  It reduces the circulation to the trigger point though decreasing the inflammatory process and pain.  When the pressure releases, the circulation increases 3. This is followed by strain counterstrain for 90 seconds or more 4. After an appropriate length of time, during which the tissues are held in ‘ease’, the patient is asked to introduce an isometric contraction into the affected tissues (muscle energy technique) for approximately 5 seconds. 5. After the contraction, the local tissues surrounding the trigger point are stretched for up to 30 seconds. 36 Ass.Prof. Dr. Fatma Alfeky 6. An isometric contraction and stretch involving the whole muscle is then performed again for up to 30 seconds. Strain counterstrain (SCS) Strain counterstrain is a positional release therapy that uses a position of greatest comfort (ease) of the body to reduce pain, spasm, and loss of range of motion as a result of somatic dysfunction. Somatic dysfunction is defined as the impaired function of related components of the somatic system, including the skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements.  Somatic dysfunction involves failed or failing biomechanical adaptation, possibly involving: Overuse, e.g. repetitive strain Misuse, e.g. poor posture Underuse and disuse, e.g. lack of exercise Abuse, e.g. trauma or surgery.  Ageing, inflammation, fibrosis and adhesions, as well as pathologies (e.g. arthritic changes), may all be involved in the evolution and/or maintenance of somatic dysfunctions, as may a variety of biochemical (nutritional, toxic, hormonal, etc.) and psychosocial (chronic depression, anxiety, anger, fear, etc.) factors. General dysfunction indicators Crossed syndrome patterns: indicators of relative postural alignment together with representative functional assessments. 1. Upper crossed syndrome This pattern is characterized by the following features: 1. Shortness and tightness of pectoralis major and minor, upper trapezius, levator scapulae, the cervical erector spinae and sub-occipital muscles 2. Lengthening and weakening of the deep neck flexors, serratus anterior, lower and middle trapezii. 37 Ass.Prof. Dr. Fatma Alfeky As a result, the following features develop: 1. The occiput and C1/2 become hyperextended with the head pushed forward (‘chin-poke’). 2. The lower cervical to fourth thoracic vertebrae becomes posturally stressed as a result. 3. The scapulae becomes rotated and abducted. 4. This alters the direction of the axis of the glenoid fossa, resulting in the humerus needing to be stabilized by additional levator scapula and upper trapezius activity, together with additional activity from supraspinatus.  The result of these changes is greater cervical segment strain plus referred pain to the chest, shoulders and arms. Pain mimicking angina may be noted plus a decline in respiratory efficiency.  The solution is to be able to identify the shortened structures and to release (stretch and relax) them, followed by re-education towards more appropriate function. 2. Lower crossed syndrome This pattern is characterized by the following features: 1. Shortness and tightness of quadratus lumborum, psoas, lumbar erector spinae, hamstrings, tensor fascia lata and possibly piriformis, 2. Lengthening and weakening of the gluteal and the abdominal muscles.  The result of these changes is that the pelvis tips forward on the frontal plane, flexing the hip joints and producing lumbar lordosis and stress at L5–S1 with pain and irritation.  A further stress commonly appears in the sagittal plane leading the pelvis to be held in increased elevation, accentuated when walking, resulting in L5–S1 stress in the sagittal plane. One result of this is low back pain. The combined stresses described produce instability at the lumbodorsal junction, an unstable transition point at best.  The treatment is to identify the shortened structures and to release them, followed by re- education of posture and use. 38 Ass.Prof. Dr. Fatma Alfeky  Benefits of strain and counterstrain 1. Neurological changes  Alterations in load application, for varying durations modify neural function: Muscle, fascial and joint mechanoreceptors (such as Ruffini corpuscles, Golgi tendon organs, muscle spindles) as well as pain receptors.  It decreases stretch reflex arc, Gamma activity and motor end plate activity 2. Proprioceptive theory  When a disturbed relationship exists between muscles and their antagonists, following strain, the positioning of these tissues into an unloaded, ease position allows spindle re- setting and partial or total resolution of inappropriate motor impairment. 3. Altered fibroblast responses  Changes in the shape and architecture of cells by means of mechanotransduction (cellular responses to different degrees and forms of load) can lead to reduced inflammation. 39 Ass.Prof. Dr. Fatma Alfeky 4. Other effects:  SCS decreases inflammatory metabolites, acetylcholine and Calcium release  SCS increases ATP and tissue perfusion  SCS reduces pain levels first to allow better application of more involved techniques to achieve the desired goals  SCS reduces muscle overactivity that increases blood flow, improves movement, and promotes healing and function.  SCS normalizes fascial tension  SCS reduces joint hypomobility  SCS decreases swelling  SCS increases strength  SCS enhances movement Indications of SCS As primary treatment or in conjunction with other approaches for the treatment of acute, subacute, and chronic somatic dysfunction in people of all ages as in: 1. Acute, subacute, and chronic pain 2. Neuropathic pain 3. Somatic dysfunction 4. Muscle spasm 5..Muscle spasticity 6. Range of motion deficit 7. Joint hypomobility 8. Fibromyalgia 9. Headache 10. Myofascial pain syndrome 41 Ass.Prof. Dr. Fatma Alfeky 11. Cumulative trauma 12. Lymphatic compromise 13. Muscular weakness 14. Visceral dysfunction Contraindications of SCS A. Absolute Contraindications: 1. Systemic localized infection 2. Open wounds 3. Acute nerve root compression 4. Infection 5. Deep vein thrombosis 6. Pain or neurologic symptomology during treatment 7. Healing fracture 8. Hematoma 9. Acute concussion B. Relative Contraindications: 1. Herniated disc 2. Vertebral stenosis 3. Sutures 4. History of motor neuron disease 41 Ass.Prof. Dr. Fatma Alfeky  Strain and Counterstrain Technique steps 1. Locate the worst tender point. 2. Find the position of comfort or ease (mobile point): the point of maximum tissue relaxation beneath the monitoring finger where joint movement in any direction will increase tissue tension 3. Monitor the point response but take the pressure off the tissue. 4. Hold the mobile point for at least 90 seconds.  The first 10 to 15 seconds: the neurologic component of the somatic dysfunction is reset.  Reduced neurogenic inflammation change a circulatory. A therapeutic pulse may be palpated as the tissues attempt to perfuse and clear the area. This pulsing time lasts about 30 to 45 seconds. The tissues are ridding themselves of toxins, and during this time the patient will likely release a deep sigh in an attempt to exhale excess carbon dioxide.  During the next 30 to 45 seconds, a lymphatic phase occurs, and this allows the tissues to release from their taut state to a more relaxed, soft state.  As the time approaches the very end of the 90-second period a further release of the previous tender point tissue occurs, which may represent a reduction of the autonomic component of the somatic dysfunction—more precisely, the sympathetic activity. 5. Return to neutral slowly with the patient remaining relaxed and passive. 6. Recheck the tender point. If the tender point itself is at least 70% less tender and less congested to palpation, then enough healing has occurred and the point does not need to be treated again. 7. Treat the next worst tender point. General Rules of SCS 1. The mobile point should be held for no less than 90 seconds. 2. The return to neutral should be executed very slowly, with the patient remaining passive. 3. Anterior tender points are usually treated with the affected body part in flexion. 42 Ass.Prof. Dr. Fatma Alfeky For example: A person with acute low back pain – locked in flexion – tender points will usually be located on the anterior surface of the abdomen, in the muscle structures that were shortened at the time of strain (when the patient was in flexion), and the position that removes tenderness from such a tender point will, as in previous examples, usually require flexion and possibly some fine tuning involving rotation and/or side-bending 4. Posterior tender points are usually treated with the affected body part in extension. 5. Tender points on or near the midline of the associated joint are treated with the affected body part in near pure flexion if found anteriorly and with the affected body part in near pure extension if found posteriorly. 6. Tender points found more lateral to the midline of the joint anteriorly are treated with the affected body part in flexion and with more side bending and rotation to achieve the mobile point. 7. Tender points found more lateral to the midline of the joint posteriorly are treated with a component of extension and side bending and rotation to achieve the mobile point. 8. With multiple tender points, the most severe is treated first. 9. If tender points are in rows, the one in the middle is treated first because this may reduce adjacent tender points. 10. Tender points do not necessarily correlate with where the patient complains of having symptoms. Most of the time the patient will complain of pain in the posterior aspect of the spine even when the tender points are anterior. So both the anterior and posterior tender points should be checked. 11. As this position is held, the patient may be requested to produce a full cycle of breathing, and the patient should be asked to maintain (for as long as is comfortable) the position where – in that cycle – the operator determines the tissues to be even more ‘relaxed’. There is a mechanical effect of respiration on resting myofascial tissue 1. Movement into flexion of the lumbar and cervical spines is assisted by exhalation 2. Movement into extension of the lumbar and cervical spine is assisted by inhalation 3. Movement into extension of the thoracic spine is assisted by exhalation 4. Thoracic flexion is enhanced by inhalation. 43 Ass.Prof. Dr. Fatma Alfeky  Advice after SCS 1.Drink at least 8 to 10 glasses of water a day to reduce soreness by flushing the body and to avoid caffeinated drinks and drinks high in sugar that dehydrate the body. 2.Avoid activities that contain a component of quick, jerky movement until the tissues can handle that stress better. 3.Introduce a little activity such as 5 to 10 minutes of walking immediately after treatment. This allows the patient to start coordinating the neuromuscular system and gives the patient a chance to experience movement in a dysfunction-free state. Spray and stretch technique Vapocoolant spray is a coolant liquid contained in a pressurized canister is used to achieve brief and rapid cutaneous cooling Vapocoolant sprays are used for temporary pain relief before stretching muscles with active trigger points or muscles with local spasm. Types of vapocoolant sprays: 1. Ethyl chloride is a highly flammable and explosive pressurized liquid, possibly toxic to the environment and if inhaled. 2. Fluori-Methane, in contrast, is nonflammable, nonexplosive, and nontoxic, but because it is made of chlorofluorocarbons, it represents a danger to the environment—destruction of the ozone layer. 3. Third-generation vapocoolant spray: Spray and Stretch and Instant Ice (both a blend of 1,1,1, 3,3-pentafluoropropane and 1,1,1,2-tetrafluoroethane) is non–ozone depleting and nonflammable, liquid aerosol skin refrigerants that are bottled under pressure.  The cold sensation serves as a counterirritant stimulus to the thermal afferents that overlie the target muscle, causing a reflexive reduction in motor neuron activity and allowing stretch to occur more easily. 44 Ass.Prof. Dr. Fatma Alfeky Application procedure: 1.Inform the patient that he or she should feel brief and vigorous cold sensations during therapy, as well as mechanical muscle stretch. 2.Ensure comfortable body positioning and the muscle containing the trigger point is placed on slight passive stretch (e.g. in right upper trapezius: cervical flexion, left lateral flexion, right rotation). 3.Cover the patient’s eyes, nose, and the mouth by towel if spraying near the face, to minimize the patient’s inhalation of the spray. 4.Hold the vapocoolant can about 30-46 cm from the skin and angled so that the spray hits the skin at about 30 or 90 degrees. 5.Apply two to five unidirectional parallel sweeps over the trigger point and along the related tight muscles with speed of 10 cm per second. 6.Immediately after cooling, have the patient take a deep breath and then perform a gentle passive stretch while exhaling. 7.Following this procedure, the skin should be rewarmed with moist heat, and the muscles should be moved through their full active range of motion 45 Ass.Prof. Dr. Fatma Alfeky  Scar tissue release Superficial wounds heal without scar tissue formation by simply regenerating the damaged epithelium. The healing of deeper wounds is an organized and predictable process consisting of three overlapping phases: inflammation, proliferation and maturation/remodeling 1) Inflammatory or reaction Phase: After injury to 72 hours and managed by:  Compression, elevation, cold, and gentle active movement.  Gentle massage techniques to stimulate the lymphatic system proximal to the injured area may be used.  No tissue barriers should be engaged or stretched and a touch grading of 3 should not be exceeded. 2) Proliferation or Fibroplasia or Rebuilding Phase: From 3 to 20 days 1. Epithelialization 2. Revascularization (angiogenesis) 3. Collagen synthesis (collagenization) 4. Wound contraction Proliferative stage is managed by:  Lymphatic massage and other techniques that stimulate an intact lymphatic system should be the focus of the therapy program.  Gentle techniques engaging the subcutaneous layers together with active motion and tendon gliding exercises to minimize adhesions between the developing scar and surrounding tissue. 3) Remodeling or Maturation Phase: From 3 weeks to 6 months and managed by scar tissue release 46 Ass.Prof. Dr. Fatma Alfeky  A scar is the fibrous tissue that replaces normal tissues which a burn, wound, surgery, radiation or disease has destroyed For open wounds (including surgical wounds) and severe internal tears (ruptured tendon or ligament), wound closure and tissue strength are critical and a certain amount of scarring is necessary and inevitable.  When scar tissue fills defects in loose, flexible tissue, it will change to duplicate the same tissue characteristics as far as possible in the final stages of healing.  Impaired mobility within loose, flexible tissue may contribute to chronic pain and tissue stiffness as well as abnormal movement patterns within the musculoskeletal system Hypertrophic scarring is due to the overproduction of immature collagen during the proliferative and remodeling phases of wound healing.  This is more likely to occur in wounds that cross the lines of tension in the skin, in wounds with a prolonged inflammatory phase (large or infected wounds) or in burns because of their lengthy proliferative phase 47 Ass.Prof. Dr. Fatma Alfeky  A contracture is the pathological shortening of scar tissue resulting in deformity.  The term ‘contracture’ is usually used to indicate a loss of joint range of movement as a result of connective tissue and muscle shortening.  Underlying contracture formation are adhesions or excessive cross-links. Adhesions are related to the scarring process and develop secondary to the normal healing process. It is the process of adhering or uniting two surfaces or parts, especially the union of the opposing surfaces of a wound. Fibrosis is defined as the thickening and scarring of connective tissue. Fibrosis, as a process, is less linear than scarring, which typically occurs step by step in sequence.  Fibrosis usually involves the connective tissues and structures of an entire region. Scar Tissue Release Therapy It is a gentle technique used to decrease discomfort, fascial adhesions, dark coloring and congestion of scar tissue. The primary aim is the maximizing of function without disruption of the wound healing, repair and maturing processes. The goal of treatment is to loosen the collagen fiber linkages that have developed within the scar and the adherences between it and its surrounding tissues. Principles of Scar Tissue Release: 1. Treatment is directed at the mechanical restriction identified through evaluation. 2. The goal is to move the tissue barrier towards a normal end-feel and amplitude. 3. It applies direct pressure to specific points and directions of resistance, i.e. concentrating effective force on local areas. 48 Ass.Prof. Dr. Fatma Alfeky  4. Treatment is approached in a layered fashion from superficial to deep; clearing one layer or compartment of restrictions before moving to a deeper or adjacent layer. 5. Techniques are performed at or just before the palpable tissue barrier at varying angles to the restriction. 6. Gentle touch grading is used during the early stages. For mature, chronically adhered scars more forceful treatment at higher touch grading may be necessary. 7. For effective, concentrated force application, the therapist’s fingers or hand should not glide over the skin’s surface. 8. No, or very little, lubrication should therefore be used. Precautions for immature scars: 1. Take extreme care with radiated tissues, as the skin is delicate and can break easily. 2. Stop if techniques cause pain or increase tissue redness. 3. Never perform massage on any open lesions. Scar tissue release techniques: 1. Gross stretch 2. Gentle circles 3. Upside-down ‘J’ 4. Vertical lifts 5. Skin rolling 6. Wringing or ‘S’ bends 49 Ass.Prof. Dr. Fatma Alfeky  Kinesio-Taping Kinesiology taping can assist body healing mechanism. Basic functions and effects of Kinesio-Taping 1. Skin function:  Sensory stimuli to mechanical receptors  Decrease inflammation and pressure on chemical receptors  Pain reduction: Gate Control Theory 2. Muscle function  It improves muscle contraction of a weakened muscle (decreased nociception)  Reduces muscle fatigue  Relieves pain  Increases range of motion  Restores tone and improves proprioception 3. Joint function  Adjusts misalignment caused by spasms and shortened muscle  Normalizes muscle tone and abnormality of fascia involved  Improves range of motion  Relieves pain 4. Lymphatic function:  Lifts the skin, causing convolutions which provide space and decrease pressure 51 Ass.Prof. Dr. Fatma Alfeky   With lifting of the skin, filaments which attach skin to endothelial cells are opened allowing for lymph obligatory load to fill in lymphatic capillaries  Creates areas of decreased pressure, under the Kinesio tape, which allows areas of higher pressure to migrate to areas of lower pressure Advantages of Kinesio-Taping 1. It works with the body allowing full ROM 2. No latex in the product making it skin sensitive and safe to use from pediatric to geriatric populations 3. It allows comfortable wear over a 3-5 day period 4. Water resistant fabric that wicks away the moisture as well as giving the patient the ability to bathe as normal Clinical application and Removal of the Tape 1. The skin must be dry and oil-free. 2. Each of the corners of the tape strips should be rounded with scissor 3. The strips may be cut as I-, Y- , or X-tapes, or, fan-shaped (in lymphatic therapy) 51 Ass.Prof. Dr. Fatma Alfeky 4. During its manufacture, the K-Tape is applied with a slight stretch of 10% to the backing paper. This stretch should be retained during the application of the tape strips. 5. The tape is removed in the direction of hair growth. 1. Muscle applications They are used for increased or reduced resting muscle tone, as well as for injuries to the musculature, and bring about a normalization of the resting muscle tone, reduction in pain, and improvement in resilience, which facilitate more rapid healing.  For Tonus increasing (facilitation effect): the application is affixed from the muscle of origin to the muscle of insertion  For Tonus decreasing (relaxation effect): the application is affixed in the opposite direction, from muscle insertion to muscle origin The muscle application is affixed with 10% tape stretch. The patient is placed with the muscle in the elongated position. I- and Y-tapes are predominantly used. 2. Ligament applications They are used for injuries and overloading of ligaments and tendons. They can be used to treat pain points, trigger points, or spinal segments. 1. Ligament applications:  The tape application for ligaments (ligament application) is affixed with maximum stretch.  The joint is positioned so that the ligaments are under tension.  Exclusively I-tapes are used. 52 Ass.Prof. Dr. Fatma Alfeky 2. Ligament Applications for Tendons  The ligament application for tendons is affixed with maximum tension from insertion to muscle-tendon junction.  The patient is in the elongated muscle position.  Exclusively I-tapes are used. 3. Spacetape  It describes an application that is affixed over a point in a cross or star shape using tapes of the same length.  Each tape is affixed with maximum tension.  The body is in the elongated muscle position.  Exclusively I-tapes are used.  In general, four strips are used for a star. After affixing the first tape strip, the second is affixed at an angle of 90° to form a cross. Strips 3 and 4 are applied at 45° angles to the cross.  This application is used for pain points and trigger points, spinal segments, and the iliosacral joint. 3. Corrective applications They are divided into functional correction and fascia correction. 1. Functional correction is used for osseous misalignments, e.g., patella misalignment, and brings about a position shift of the osseous structure. 53 Ass.Prof. Dr. Fatma Alfeky   Anchor the base and skin displacement firmly.  The application is carried out with maximum tape tension.  The correction via the tape strips runs towards the base.  Y-tapes are predominantly used for functional correction, but I-tapes are also possible. 2. Fascia corrections are used for adhesions in muscle fibers and bring about a loosening of the fascia as well as pain reduction. 1. Brain coordinates movement not muscles 2. Taping movement patterns helps to prime the sensorimotor system via cutaneous afferent stimulation 3. Improve performance via improved fascial continuity  The patient is in the resting position.  Affix the base below the pain point.  Rhythmically pull the tail strips up to the threshold state Thereby displacing the base  The correction runs in the direction of tension of the tape strips.  Y-tape is used for the corrective fascia application.  Functional correction is also possible using I-tape. 54 Ass.Prof. Dr. Fatma Alfeky  4. Lymphatic applications  They are used in disorders of lymphatic drainage.  The lymphatic application brings about lifting of the skin. The space between the skin and subcutaneous tissue is thus increased, thereby stimulating the lymphatic collectors to resume their function.  The lymphatic application is affixed with 25% tension in the tape.  The patient is in the pre-stretched position.  Exclusively fan tapes are used. Contraindications of Kinesio-taping 1. Open wounds 2. Unhealed scars 3. Infection 4. Cancer 5. Deep venous thrombosis 6. Skin allergy Limitations of Kinesio-taping 1. Body hair may need to be clipped or shaved 2. Apply approx. 45 minutes before activity 3. Application during activity, may require the use of a tape adherent 4. Patient understanding and willingness to wear tape for multiple days, or in public (TMJ, SCM) 55 Ass.Prof. Dr. Fatma Alfeky  Traditional Chinese Medicine Traditional Chinese Medicine 1. Acupuncture: is one of the primary treatments under the umbrella of Chinese and East Asian medicine. The treatment itself involves the insertion of hair-thin needles at specific points on the body to promote balance and healing.  Ear acupuncture, also called auriculotherapy: Detailed map of the ear that included 43 points, each corresponding to a specific organ or area of the body.  Electroacupuncture: is the electrical stimulation of needles in acupuncture points to strengthen the needling effect.  Dry needling (trigger point acupunture): Dry needling is a functional anatomical locoregional needling technique for the treatment of myofascial syndrome. The aim of dry needling is to trigger the local muscle twitch reaction. 2. Acupressure is a technique in which pressure is manually applied to an acupuncture point on the body using the fingers, palms, hands, and even elbows. Manually stimulating these points can gently help move the vital substances Qi and Blood.  Acupressure techniques are often recommended to use at home for self-treatment of headaches, nausea, and motion sickness.  The general rule is to apply moderate pressure on the point using small circular motions for 60 to 90 seconds. 3. Reflexology stimulates particular points on the surface of the body, which in turn affects other areas or organs of the body. 4. Cupping: is a therapy in which heated glass cups or vacuum-pumped plastic cups are applied to an area of the body, usually the back or legs, creating suction to clear stagnations and encourage the movement of the vital substances Qi and Blood. Indicated for pain in the locomotor system (e.g. on mTrPs) or as a segmental treatment for visceral pain 56 Ass.Prof. Dr. Fatma Alfeky  Fundamentals of Acupuncture 1. Acupuncture Meridian Theory A. The 12 major meridians or channels exist on both sides of the body, and each of them contains a series of acupuncture points that are used to manipulate the Qi flowing through them. Qi—a very important concept in acupuncture—is the life force that regulates all of the body’s processes.  They circulate Qi and Blood through the body and create a network that links all the organs and substances.  Disorders of an organ can affect areas of the body linked by that organ’s meridian; similarly, blockages in a meridian can affect that meridian’s master organ.  The twelve main meridians are: Gallbladder, Liver, Lung, Large intestine, Stomach, Spleen, Heart, Small Intestine, Bladder, Kidney, Pericardium and San Jiao. B. There are two additional major meridians not associated with the organs: The Du (governing) meridian, and the Ren (conception) meridian. These meridians run up and down the midline of the body. 2. Yin and Yang Theory In Chinese medicine, health depends on a delicate balance of Yin and Yang in the body. Yin and Yang become imbalanced when the flow of Qi becomes interrupted or blocked.  Any interruption or blockage in the flow of Qi in one of the 12 organs or its corresponding meridian can cause an imbalance of Yin and Yang and lead to illness.  This balance of Yin and Yang relates very closely to the Western idea of homeostasis—the delicate balance of all of the body’s systems, which is essential to maintaining health. Yin organs create and regulate the Qi, Blood, and Body Fluids, and are each associated with a dominant emotion. Each Yin organ is paired with a complementary Yang organ that receives, processes, and absorbs food and/or promotes the transformation of fluids and substances. They also 57 Ass.Prof. Dr. Fatma Alfeky help move and excrete food particles that are not used by the body. Yin and Yang organs work in pairs to ensure that Qi and Blood circulate through the entire body.  There are six Yin organs, and they are generally thought of as more important than their Yang partners. They are the Heart, Lungs, Spleen, Liver, Kidneys, and Pericardium.  The six Yang organs are the Gallbladder, Stomach, Small Intestine, Large Intestine, Bladder, and Triple Burner. Acupuncture mechanisms: 1. Peripheral: release vasodilatory neuropeptides into the muscle and skin. 2. Spinal effects or segmental effects: The gate-control theory of pain. The theory states that through the needle, nerves can be stimulated to block ‘trigger’ impulses of pain. 3. Supraspinal effects: Diffuse noxious inhibitory controls (DNIC) and beta-endorphin mediated descending pain inhibitory pathways from the hypothalamus. Indications of Acupuncture For acute and chronic myofascial pain and limited motion with myofascial involvement as in:  Migraines, arthritis, premenstrual syndrome, neuralgia, carpal tunnel syndrome, epicondylopathy , impingement syndrome, functional visceral pain syndrome intolerance, tension headaches, fibromyalgia, Facial pain, Temporomandibular syndrome, Periarthropathies, Tendinopathies, , Post-traumatic pain, Piriformis syndrome, chondropathia patellae, cervical and low back pain. Contraindications of acupuncture: 1.Clinically manifest clotting disorder for deep needling 58 Ass.Prof. Dr. Fatma Alfeky  2.Life-threatening diseases 3.Epilepsy 4.Psychosis Undesirable effects of acupuncture: 1. Haematoma 2. Prolonged local pain 3. Hypotensive circulatory reaction (needle collapse) 4. Increase in pain 5. Nerve lesion 6. Causing an epileptic attack in epileptics 7. Infection (especially dangerous with long-term needles) 8. Pneumothorax (the most common serious adverse event) Application of Acupuncture: 1. Needle insertion: hold the needle with the first three fingers and place the other hand, thumb or second and third fingers next to the acupuncture point, pressing gently and lightly supporting the needling hand (ulnar border of the hand, little finger); insert the needle quickly to the subcutaneous level and probe deeper with light right–left rotational movements (depending on the tissue and the point) and cause the de Qi needle sensation 2. Number of needles and duration of treatment  On average, between 4 and 24 needles are used.  Treatment lasts between 20 and 45 min. 59 Ass.Prof. Dr. Fatma Alfeky  Trigger point therapy 1. Ischemic compression (IC): part of integrated neuromuscular inhibition technique (INIT) 2. Strain-counter strain (SCS): Part of integrated neuromuscular inhibition technique (INIT) 3. Muscle energy technique: part of integrated neuromuscular inhibition technique (INIT) 4. Massage Techniques: Transverse (cross-fiber) friction, deep touch, J stroking 5. Spray and stretch technique 6. Dry needling 7. Kinesio-Tape: Ligament application (spacetape) 8. Electrostimulation acupuncture 9. Acupressure 10. Cupping 11. Electrophysical agents: LASER, ultrasonic, Shockwave, TENS, iontophoresis 12. LASER acupuncture 13. Cryostretch. 14. Injection (saline, anesthetics, steroids) 15. Exercise: Stretching, Strengthening, Postural correction 16. Psychotherapy 17. Hydrotherapy 18. Assess the dysfunction: Myofascial release, Manual Lymphatic Drainage Techniques (MLD) and Scar tissue release. 61 Ass.Prof. Dr. Fatma Alfeky