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Intro to STM Lecture Flashcards

1
Q

Manual Therapy: Still

A

Osteopathy, abnormal structure

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2
Q

Manual Therapy: Cyriax

A

Musculoskeletal diagnosis

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3
Q

Manual Therapy: Mennell

A

Joint mobilization and massage

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4
Q

Manual Therapy: Katenborn and Maitland

A

joint mobilization

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5
Q

Bodywork & Massage

A 
Traditional Swedish Massage
Connective Tissue Massage
Structural Integration (Rolf)
Manual and movement 
- trigger paint therapy (travell)
- shiatsu (acupuncture points)
- reflexology 
- trager (oscillations)
- therapeutic "touch" and Reiki
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6
Q

Connective Tissue Cells

A
  • fibroblasts and fibrocytes
  • epithelial cells
  • macrophages, neutrophils
  • mast cells (release histamines)
  • plasma cell proteins
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7
Q

Connective Tissue Extracellular Matrix

A 
Fibers
- collagen (type I): loose and dense
- elastin
- reticulin
Ground substance
- viscous gel-like medium 
- H20
-GAGs
- suspends collagen fibers
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8
Q

Name 3 types of connective tissue

A

dense regular
dense irregular
loose irregular

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9
Q

Which type of connective tissue is most difficult to redirect? how can it be done?

A

dense regular connective tissue.

perpendicular friction to break up unwanted fibers

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10
Q

How soon can you start soft tissue mobilization to produce normal collagen remolding?

A

Not day 1 –> P.R.I.C.E.

On day 2-4 –> proliferation stage may have begun

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11
Q

What type of connective tissue are ligaments and tendon? What are its characteristics?

A

Dense Regular

Dense parallel collagen fibers
Proportionally less ground substance
Not highly vascular.

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12
Q

What type of connective tissue are joint capsules, dermis, aponeuroses, high-stress fascial sheaths (ie lumbodorsal fascia?) What are its characteristics?

A

Dense Irregular

Multidirectional collagen fibers
Resists multidirectional stressers

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13
Q

What type of connective tissue is superficial fascia, muscle and nerve sheaths, internal supportive network?What are its characteristics?

A

Loos Irregular

Sparse, multidirectional fibers
more elastin and ground substance
viscoelastic properties
most likely affected by external forces

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14
Q

What is fibrosis?

What causes fibrosis?

A
  • excessive connective tissue formation (cross linking)
  • stimulated by low-grade irritation (overuse/postural stress/ movement dysfunction)
    -involves a larger tissue than mere adhesions
    (ie restriction in abdomen can restrict shoulder flexion)
  • impedes structure and function of healing and neighboring tissue
  • progresses with time immobilized
  • fibrosis can spread to neighboring tissues
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15
Q

What is Stage I of connective tissue repair?
Time frame?
Events?
Relevance to STM?

A

Inflammation

0-48 hours +

Events:
homeostasis
inflammation
phagocytosis and leukocytosis

Relevance:
STM may disrupt homeostasis

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16
Q

What is Stage II of connective tissue repair?

A

Proliferation

2-4 days - 2 to 3 weeks.

Events:
Re-epithelialization
Granulatoin and vascularization
Collagen synthesis and fibroplasia
Contraction of the defect/wound

Relevance:
STM may disrupt contracture and stimulate increased collagen synthesis

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17
Q

What is Stage III of connective tissue repair?

A

Remodeling
3 weeks to 12 months

Events:
collagen lysis and synthesis
fiber reorientation
scar maturation continues >1 year

Relevance:
Tensile forces affect new fiber orientation
Adhesions inhibit fiber reorientation
Scar is weaker than skin

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18
Q

Effects of Immobilizatoin on connective tissue?

A
  • adhesions, fibrous infiltrate, and fibrous development
  • loss of ground substance
  • decrease mobility (longer immobilization, longer recovery time)
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19
Q

Effects of immobilization on muscle?

A
  • sarcomere loss (not likely to cause adaptive shortening)
  • fatty intrusion and fibrosis
  • cross bridge adhesion (more likely to be the cause)
  • affects neighbor muscles in parallel and series
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20
Q

Parasympathetic response to STM

A
  • reduce depression and anxiety
  • reduce related measures: BP, HR, RR, lactates, pain

Evidence:

  • decreased depression in 17 RTCs
  • RTC reflexology decreases anxiety in CA pts
  • RTC DECREASES SHORT TERM ANXIETY IN POST-OP PATIENTS
  • decreases anxiety, HR, cortisol in psych in-pts
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21
Q

What are the physiological effects of STM?

A

1) increase circulation, decrease edema & lymphedema
2) parasympathetic response, promote relaxation, decrease anxiety
3) analgesia, decrease pain and discomfort
4) metabolism
5) increase connective tissue mobility or length; prevent fibrosis
6) function

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22
Q

What’s a measurable outcome for increase circulation, decrease edema & lymphedema?

A

increased blood flow, skin temp, tcO2; decreased girth

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23
Q

What’s a measurable outcome for parasympathetic response, promote relaxation, decrease anxiety?

A

decreased HR, BP, RR, anxiety medication

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24
Q

What’s a measurable outcome for analgesia, decrease pain and discomfor?

A

VAS, pain scales, pressure tolerance, analgesic use

25
What's a measurable outcome for metabolism?
serum levels, cell counts, spO2
26
What's a measurable outcome for increase connective tissue mobility of length; prevent fibrosis?
increased ROM (joint, muscle, fascial mobility), other related functions
27
What's ameasurable outcome for function?
functional scales (ie oswestry, FIM, DASH)
28
Evidence for Analgesic Outcomes
pain relief and/or increased function after massage vs placebo or control - LBP: decreased LBP after massage vs STM/posture/exercise/placebo and increased function after massage therapy/ STM/posture/exercise vs placebo - Neck pain: increased function and decreased pain at 4-10 weeks BUT NO CHANGE AT 6 MONTHS VS CONTROL - Cancer: decreased pain and anxiety IN SHORT TERM AFTER MASSAGE
29
Evidence for Circulatory Effects
Normal response: reactive hyperemia (capillary dilation) Increase blood flow vs skin temperature: - petrissage increases both (cohort) - petrissage increased temperature but not blood flow (cohort) - acupressure increases LE and trunk blood flow (case control) Decrease Edema: - RETROGRADE MASSAGE and finger wrapping decrease volume - decreased post exercise swelling - decrease ankle and pain May assist increase in lymph motility: - only support is case study and opinion
30
Evidence for Analgesic Effects
Proposed processes: - decreased edema thus pressure on nerve endings (cohort) - parasympathetic nervous system response (cohort) - substance P- a CNS neurotransmitter mediating pain (with shiatsu decreased pain and sub P in fibromyalgia) - Gate control (not really applicable n clinical setting) - pain and muscle spasm: the pain-spasm cycle - chemical mediators
31
Biomechanical Effects
Endorphins (increase in pts with myalgia after CTM) Serotonin and dopamine: - increase with decreased pain and depression in LBP pts - increases with decreased pain in breast CA pts Cortisol associated with pain and anxiety: - no change in cortisol in CA - decreased cortisol in psych in-pts *cognitive thought can affect cortisol levels
32
Visceral Effects
May stimulate reflex peristalsis Cupping (Chest PT) to increase lung secretion Acupuncture meridians: - acupuncture increased LE and trunk blood flow in PVD Head Zones: Reflexology (decrease pain and anxiety in CA pts)
33
Immunologic & Metabolic Effects
lymphocyte protection and immune response : - decreased lymphocyte/helper T loss in HIV+ peds - increased lymphocyte/helper T in breast CA Insulin: - increased insulin/IGF and wt in preterm neonates Creatine Kinase: - decreases CK and post exercise soreness but NO INCREASE IN MUSCLE FUNCTION IN NORMALS
34
Muscle and Connective Tissue Effects of Massage
Theories: 1) Thixotropy: fluid stiffness affects movmeent (like ketchup bottle) 2) Viscoelastic tissue elongation due to stretch: - no effect on birth perineal trauma * takes 30 minues to change length of connective tissue. we dont actually do that in the clinic. 3) Neuromuscular relaxation effect - massage reduces EMG activity AFTER EXERCISE 4) increased fibroblast activity 5) surgical scar reduction?
35
Gene Expression Effects
Altered expression of fibrin related gene immediately after massage Altered expression of inflammation-related gene during recovery hours later - may attenuate inflammatory process and speed healing (1RTC)
36
Connective Tissue Effects of Myofascial Manipulation
Theories Fibrous and cross bridge adhesion reduction - collagen reorientaton (skin thickness changes. decreased adipose) - bundle orientation (ligaments TFM) - MAY free neighbor muscles to function
37
Muscle and Connective Tissue Effects of STM: outcomes and selected evidence
Increased ROM, joint motion; decreased stiffness: - increased ROM and function in knee OA - petrissage decreases stiffness in bikers - increases shoulder ROM and functon Increase in strength: - increased grip in CTS - strength associated with pain - with friction, decreased fatigue effect on grip strength
38
Adverse effects?
- muscle soreness - goose bumps or clamminess (abnormal sympathetic nervous system response) - unexpected neurological signs (paraesthesia) ==> reposition and continue - speech or mental status changes - nausea and/or vomiting - significant or sudden vital signs changes - chest, abdominal, or other unexpected pain
39
Sports Outcomes
- for pitcher's forearm neuropathy in return to sport | - PRE-SPRINT SPORTS MASSAGE HAD NO POSITIVE EFFECT
40
PT Indications for STM
- pain - edema - impaired ROM - impaired strength - postural malalignment - impaired movement/function
41
Outcomes in Pediatrics
- reduced pain and itching in pediatric burn patients | - higher mental development scores after massage in low birth weight neonates vs kangaroo carry
42
Contraindications to STM: general principles
- monitor patient's respose - treatment area: general vs regional - technique: deep/vigorous vs superficial/gentle - endangerment sites: ie Anterior neck, femoral triangle - MUST TAKE VITALS AT EVAL
43
Types of Contraindications
- Acute Inflammation - Areas of Lost integrity - communicating pathologies - cardiac/circulatory disorders - clotting disorders and anticoagulants - area of altered sensation - impaired cognition/communication
44
Area; depth/technique limited by: | inflamation
regional; all
45
Area; depth/technique limited by: | areas of lost integrity
regional; deep and or superficial
46
Area; depth/technique limited by: | communicating pathologies
general or regional; all
47
Area; depth/technique limited by: | cardiac/circulatory disorders
regional; deep
48
Area; depth/technique limited by: | area of altered sensation
regional; deep
49
Area; depth/technique limited by: | impaired cognition/ communication
general or regional; all
50
What technique to palpate following layers? 1) superficial: epithelium & subcutaneous tissue 2) middle: subcutaneous tissue extensibility 3) deep: muscle, tendon, deep fascia
1) light touch, temperature, shear 2) skin rolling, superficial mobility 3) compression, muscle play
51
Traditional Massage
* static contact (possibly away from area of pain) - to prepare patient * Effleurage - stroking * Petrissage - kneading and compression * Precussion * Vibration
52
Direction of Strokes
* direction of force optimized by body mechanics - generally in line with forearm - generally comes with weight shift * parallel to muscle fibers (stroking, stripping) to lengthen * perpendicular to muscle (strumming, bending) to break up adhesions * circular * distal to proximal. massage begins at proximal segment to assure venous flow. - retrograde massage for edema reduction
53
Sequence of Strokes
- relaxing to start - superficial to deep - proximal segement before distal segments - how to end depends on whats next in plan of care.
54
Pressure and Depth Varies
- palpated tissue - body surfaces - tissue type and person - direction: proximal deep, distal light - vary during massage: (start superficial > progressively deeper> end superficial) - vary with stroke: effleurage, petrissage, friction - moderate pressure essential for SNS effects
55
Duration
Local: - impairment-outcome based: - soft tissue release: 5-90seconds - edema reduction: 5-30 minutes - transverse friction massage 60-90sec total General: - 30-45 minutes or more
56
Effleurage
- slow stroking - performed with: molded hands, finger/thumbs, knuckles, forearm, first webspace (2 hand, shingle, tree branches) - purpose and expected outcomes?
57
Stroke Rate and Speed
* Vary with purpose: - fast to invigorate (pre-sport) - slow to relax or assess soft tissue * Vary with stroke: - effleurage 15/min - petrissage 30-90/min - friction 90-150/min * Vary with direction - slow for initial proximal stroke - faster distal return * Rhythmic to relax and communicate
58
Petrissage
(for edema reduction and muscle relaxation, increase circulation, decrease pain, decrease swelling) - kneading, wringing, and rolling - performed with: 2 hand, 1 hand, web spaces, pinch grasp, thumb (direct compression, 1-hand extremity kneading, J strokes)

STM (2 decks)

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