SSTM MT1 Flashcards
(102 cards)
1
Q
Local tissue dimension
A
this decribes what happens with the tissue that is manipulated/ treated by the therapist and also how the tissue reacts
this system includes soft tissue structures such as: skin, muscles, ligaments, tendons, joint structures and the different fluid systems
structures can be influenced by manipulation in the following three ways:
1. during the healing process after injury, e.g decreases swelling/ improve tensile strenght
2. changes in the phy and mech characteristics of tissues, thus the bio mech structure e.g improve ROM
3. Local changes in the dynamics of fluids e.g decrease swelling/ improve oxygenation
2
Q
Neurological dimension
A
manual effects have an effect on 3 areas:
motor system and neuro-muscular response
altered pain sensation
reflexive autonomous changes
the manual technique/ event has the following effects:
stimulates proprioceptors
cognition
voluntary movement
manual techniques can influence different neurological and neuro-muscular conditions such as:
post musculoskeletal injury (with resulting neuro-muscular impairment)
rehab after central nervous system injury
re-education of posture and movement
management of pain
3
Q
psycho-physiologic dimension
A
the effects of touch and manipulation on the patient’s emotions and thoughts are examined here
the manual event / touch may lead to psychological processes
emotions result in a somatic response, e.g changes in muscle tone
4
Q
Importance of movement after soft tissue injury:
A
blood and lymphatic flow are stimulated
normal connective tissues homeostasis is achieved
improves healing process and health of tissue
normal vascular regeneration
correct alignment of collagen
improves/ prevents excessive cross linkages and adhesions
hence: movement/ mobilisation: grading depending on the phase of healing is of utmost importance for:
normal structural and functional characteristics of muscles and collagen tissue
this tissue can function better during daily functional activities
5
Q
Fluid dynamics: Intro
A
there are a number of fluid systems in the body.:
blood
interstitial fluid
lymph
synovial fluid
cerebrospinal fluid (CSF)
flow of these systems is dependent on the pressure gradient within and between the various fluids
while manual techniques affect a number of fluid systems, only blood, lymphatic fluid and synovial fluid
6
Q
manual techniques are used to improve the flow in the following instances:
A
inflammation after trauma/ injury
oedema
effusion of joints
ischaemic conditions (compartment syndrome)
7
Q
manual techniques are used to improve the flow in the following instances:
in detail
A
- manual techniques also remove obstructions in tissue which in turn improves normal flow of fluids
- normal flow in the fluid systems regenerates via:
heart pump
muscle pump
resp pump
movement - hydrostatic pressure: pressure of fluid within tissue
- hydrokinetic transport: movement of fluid as a result of pressure gradient, assisted by mechanical forces
8
Q
factors influencing flow within the fluid systems:
A
intrinsic factors:
-refers to factors within tissue itself
-e.g during the inflammatory process; increased fluid pressure in muscles after exercise
extrinsic factors:
-refers to the effect from adjacent tissue or structures obstructing blood or lymph supply and drainage
-e.g local structural abnormalities e.g
musculoskeletal and myofascial abnormalities
9
Q
effect of manual techniques on blood flow
A
blood flow in muscles is influences by intrinsic and extrinsic forces such as muscle contractions and intermittent compression
manipulation techniques which influence blood flow are:
-active pumping techniques”
muscle’s own fluid pumping mech activated
indication: muscles that are ischaemic or swollen, or during inflammation.
results in deeper drainage
method: muscle in shortened position, intermittent contraction and relaxation, sub maximal contraction
passive pumping techniques:
external compression improves flow in a relaxed muscle
two methods: intermittent external compression and static and rhythmic stretch (i.e physiological joint movements)
effect on flow is influences by: speed, force, frequency and direction of forces applied
10
Q
effect of manual techniques on lymphatic flow
A
lymphatic formation and flow are influences by intermittent tissue compression and passive and active movements
increased lymphatic flow indicates increased diffusion and filtration between blood/ interstitial and lymph components
increased lymphatic flow within and around a damaged area facilitates the healing process and assists in decreasing pain
11
Q
physical effect of manual techniques on tissue
A
tension forces compression rotation bending shearing forces combined forces
12
Q
tension forces
A
lengthening force, extension, longitudinal stretch
results in increased collection of collagen; thus the tissue has better quality and strength
minimal effect on flow of fluid
13
Q
compression
A
shortening and broadening of tissue
increased pressure within tissue
good pumping effect and improves flow of fluid
14
Q
rotation
A
complex mechanical effect on tissue
combination of compression and progressive lengthening of fibres furthest from rotation axis
more articulation techniques
15
Q
bending
A
anatomically refers to: F, E, SF
compression on concave aspect and lengthening at convex aspect
aim: use as tension force in order to lengthen and also stimulate flow of fluid
16
Q
shearing forces
A
especially with joint articulation
combination of tension and compression forces
17
Q
combined forces
A
simultaneous application of a number of forces e.g F and rot
with every force being applied there is a build-up of tension on the tissue
may be more effective that 1 movement
18
Q
what are examples of manual stretches?
A
- passive stretch
2. active muscle stretches
19
Q
passive stretch:
A
the patient is entirely relaxed while the muscle in being stretched
method: stretch or lengthen the muscle passively (in direction opposite to the action of the muscle, and including all joints in the path/ course of that muscle) using an external force (PT)
20
Q
passive muscle stretches influenced by:
A
- speed of stretch
- power/ force of stretch
- duration of stretch
- method of stretch/ type of stretch
- cyclical stretch
- oscillatory stretch
21
Q
speed of stretch:
A
slowly and evenly applied in order to allow for viscous changes in the tissue
give sufficient time for muscle to lengthen
what are the dangers of fast stretches
22
Q
power/ force of stretch:
A
depends on phase of healing when stretch is applied
inflammation: weak tensile strength in tissue; regenerating tissue can easily be disrupted. minimal or no stretches
during regeneration/ remodelling phase: slow decrease of tensile strength of tissue
the amplitude and strength of the applied stretch depends on:
a) amount of discomfort experienced by the patient
b) level of tissue damage (e.g manner of injury, clinical signs and symptoms)
c) “acuteness” of injury (dependent of healing process)
23
Q
duration of stretch:
A
influenced by: force applied breadth and length of muscle level/amount of tissue damage inflammation formation of scar tissue
suggested time for stretch of muscle-tendon unit: 30-60 sec
BUT: duration of stretch depends on palpation and the feeling of change in length of the tissue
24
Q
method of stretch/ type of stretch:
A
as a result of the complec anatomical organisation of connective tissue and muscle-tendon junction
apply different forces in order to achieve desired stretch, e.g lengthen together with SF
25
cyclical stretch
smaller force applied: 1st 4 cycles only to 10% past the muscles length at rest
has a building-up effect on tissue
26
oscillatory stretch
decreased discomfort during stretch
| small oscillatory stretches added at the end of ROM
27
2. active muscle stretches
the pt uses muscle contraction in order to stretch a muscle
method:
stretch/ lengthen the muscular-tendinous unit by using patient's own muscle power
stretch/ lengthen the muscle passively to full length
request that the patient isometrically contracts muscle in the lengthened position- no pain
contraction up to 15 sec for creep effect
pt relax muscle and takes/ lengthens muscle into further ROM
contract- relax phases to be repeated 3-4 times while gradually lengthening muscle
active stretch is based on visco-elasticity of the tissue. thus: active stretches are only effective in muscular structures
could also use combination forces in order to stretch all compartments
28
contra-indications for active muscle stretched
no active stretches within 1st few days after injury (inflammatory stage)
forceful contraction and stretches only during late regeneration- and remodelling phase
29
why does a person experience/ feel pain?
pain is usually caused by tissue injury of inflammation, the damaged or inflamed tissue directly exiting the nerve membranes
this local occurence activates a range of reactions in the spinal cord and higher brain centres which in turn regulate and modulate the experience of pain. the experience is dependent on various factors
30
how do manual techniques achieve pain reduction?
pain is not a system by itself but rather connected to the healing- and behavioural processes of the body and individual.
3 dimensions:
local tissue level by direct stimulation of the damaged area
the neurological dimension by acticvation of the 'gating mech
the psycho-physiological/ psychological dimension by psycho-dynamic and emotional effects of touch
31
pain gate theory (level of spinal cord)
suppression of nociceptive input at dorsal horn (spinal cord), also known as "sensory gating"
simultaneous add of other stimuli e.g. active or passive movement as well as vibration, stimulate mechano-receptors (i.e sensory stimulation of e.g cutaneous/ skin, myofacial and articular receptors) which block nociceptive unput by closing the pain gate on spinal cord level
thus pt experience less or no pain. this block occurs on pre and post synaptic level
manual techniques thus bring relief by activating the spinal component of pain gate mech.
modulation of this afferent act however happens on different levels in the CNS (e.g higher centres)
32
on higher levels -stimulation of endogenous anti-nociceptive systems
endogenous opoids are released by the brain (higher centres) during passive movements (PMs) of a joint and during any pleasurable activities.
these endogenous opiods (the body's own pain suppression) also includes the pain gate mech and thus the experience of pain is reduced or blocked
33
effect of blocking conduction
there is a progressive reduction of firing of small and large diameter normal joint afferents after one or two mins of sustained or repeated joint movements
+- 30 sec of repeated mechanical stimuli lead to fast and complete conduction block of desensitised nociceptors
this research hence suggests that PM's may decrease pain perception momentarily
34
hysteresis effect on neural firing
repeated or sustained movements and movements at end of range stretch peri-articular soft tissues and thus increase ROM. the increase in range can be attributed to creep deformation.
after creep derormation there is significant decrease/ total arrest of firing occurs in the large or small diameter joint afferents, as well as in the desensitised nociceptors
35
changes in axoplasmic flow and transport
axoplasma is responsible for the nutriment and optimal function of neural structures.
it is also responsible for the transference of nerve growth factor which in turn is responsible for the regulation and production of neuro peptides (e.g substance P and somatostatin)
according to Butler PM's can restore faulty axoplasmic flow by e.g:
dec the sensitivity of the target tissue (energy demands form target tissue thus dec and less energy is demanded from the axoplasma)
improved intraneural circulation
36
inhibition of reflex muscle spasm
a lesion of the joint may result in hyperactivity of the surrounding muscle
fusimotor firing and thus intrafusal firing is maintained at a high frequency resulting in a shortened position.
muscle fibres then become hyper-sensitive to incoming stimuli and as a result of the sustained contraction the joint structures are firmly compressed
this in turn impedes movement
PMs may improve the range and decreases perception of pain as they inhibit the reflex spasm
the move created mech impulsed which decrease fusimotor neuron firing
stretching of the muscle (by movement) leads to tension in the tendon itself
the golgi tendon inhibits fusimotor neural firing and thus relaxes the intra- and extrafusal fibres.
another hypothesis suggests that type III mechanoreceptors have a reflex inhibitory effect on the associated muscles of the joint
37
what is the somatopsyche sequence?
refers to the body as a source of the sensory experience and its psychological influences
MT can have effects on local tissue physiology and repait, but is also patterned somatic responses and psychological changes.
38
what are the psychological changes post MT?
mood changes
changes in perception of body image
behavioural changes
39
what are patterned somatic responses?
```
general changes in muscle tone
increase pain tolerance
altered autonomic and visceral act
facilitation of healing processes
facilitation of self-regulation
```
40
manipulation as a sensory experience
| proprioceptors:
main receptor influenced by MT
found in muscles, tendons, joint capsules, ligaments and skin
function: convey information about the mechanical state of the body, length of muscles, force of muscle contraction, velocity of movement etc
41
proprioception can be divided into 2 anatomical levels:
1. superficial proprioception
sensations arising from the level of the skin, i.e the body's envelope
affected by MT techniques: soft tissue techniques, massage, effleurage and static hold techniques
2. deep proprioception
sensations arising from receptors in muscles and joint complexes i.e the bodies interior
can be affected techniques using joint movement, active muscle contraction, stretches, and deep soft tissue massage techniques
42
touch as interpersonal communication
touch is used as interpersonal communication (tactile communication) in cases such as a handshake, pat of the shoulder, gentle stroke and embrace
```
tactile communication can be used as part of the therapeutic process, when treating:
patients' suffering from depression
psychological wards
maternity wards
terminally sick patients
```
a pt might experience therapist touch as distressing, if the patient has had previous negative touch exp
factors influencing interpret of touch (C,SB,PE,F,NoPTR,BI,AT,SB)
touch is perceived as a positive experience when:
approp
not impose
not commun
what messages does a positive and neg touch convey?
the patients response to touch can be observed by:
43
what are the factors that will influence the interpretation of touch in the therapeutic setting are:
```
culture
social backround
previous experiences
feelings
nature of patient-therapist relationship
body image
areas of taboo
symbolism in the body
```
44
touch is perceived as a positive experience when:
appropriate to the situation
not imposing greater intimacy that the subject desires
not communicating a negative message
45
what message does positive and negative touch convey?
positive touch: conveys support, personal acknowledgement, intimacy and reassurance
negative touch: conveys aggressive and sexual messages
46
the patient's response to touch can be observed by:
their facial expression
body language
muscle tone
skin temp
47
pleasure and pain in MT
pleasure and pain have different effects on the body
48
pleasure
promotes expansion and integration
| encourages normal movement and autonomic motility for normal healing and well-being
49
pain
causes muscle contraction and withdrawal
fragmentation of the body-self
abrupt jerky movements
altered autonomic functions (i.e breath holding, increased heart rate and nauseous feelings)
50
what is a common side effect of MT
physical pleasure
51
two forms of pleasure can be derived from MT:
tactile pleasure
| return to health, well-being and normal functioning of a part/ all of the body
52
internal pleasure can be achieved by:
stimulation of deep proprioceptors e.g
active techniques/ muscle contraction or effort
passive techniques- full joint range of motion
stretches: muscle and joint stretches
physical activities: playing, sport, yoga, ADL
53
therapeutic / pleasurable pain:
when the patient wants the manipulation or manual therapy to be forceful, deep and painful.
they derive pleasure form being physical hurt.
possible reasons why the patient may want therapeutic pain during treatment:
1. the close anatomical organization of the punishment and pleasure centres in the brain
2. psychological and social origins: sacrifices for the ultimate goal of being pain-free; pt will endure pain die to the end-result. pleasure; believe not pain; no gain; shows that the therapist has found the source of all evils and is about to expel it from the body
3, masochistic tendencies (early tactile relationship of parents with child)
54
when is negative therapeutic pain experienced?
pt complains of sharp, bruising hot or tearing pain
55
MT painful?
can be painful, but should be pleasurable pain. it should not be painful just for the purpose of non-therapeutic pain. it should not cause excessive pain and thus further tissue damage.
56
What are taboo areas?
areas of the body with greater sexual symbolism and carry greater emotional weight
are:
ventral; flexor areas are more emotive/ intimate than extensor areas
genitals, breasts, mouth, ears, eyes, nostrils and head
57
how can the problem of taboo areas be overcome by MT?
1. initially, with the evaluation of the pt, putting a pt-therapist contract in place, which entails setting of boundaries
2. ask permission to apply hands to certain area/ using hands
3. explain what will be done, where and how
4. give reasons, therapeutic purpose / use/ intent
5. presence of a 3rd party
58
how will you obtain success with MT?
the therapeutic intent should match the pt's condition
59
what are the two forms of therapeutic intent?
1. instrumental manipulation:
aims mechanically to cure or prevent progression of the pt's condition. used in mechanical conditions (physical elements of technique)
2. expressive manipulation:
accepting the pt as a whole (body and mind) with the aim of curing or preventing the progression of pt's condition as a whole-person (supportive, relaxation, empathy) the therapist's intent. used in psychsomatic conditions e.g emotional stress
60
what is the difference between the 2 forms of manipulation?
```
instrumental
local, focal
brief
high-medium force
may be painful
investigative, prodding
mechanistic
uninvolved
corrective
expressive
broad, integrative
maintain contact
low to medium force
pleasurable pain
touching the whole person
non-mechanistic
empathy, compassion
communicative
```
61
touch fulfills different roles in MT:
1. touch is a sensory experience
2. touch serves as a stimulus for the development of self-regulation
3. it can be used as interpersonal communication
4. touch can have an effect on body-self, body image, body space and symbolism
5. it can be source of pleasure or therapeutic pain or erotic
6. the therapeutic intent of touch determines the effect of treatment
62
oedema?
increase of fluid in the tissue spaces due to disturbance in the process of fluid exchange between capillary blood vessels and the tissues
can be accumulation of fluid beneath the skin or in body cavitities, e.g pleural effusion, ascites (fluid in the abdominal cavity) or pericardial effusion (fluid in the pericardium)
63
local oedema
limited to small skin area (e.g allergic rash or over an area of inflammation) and is caused by increased permeability of the blood vessels.
the area is itchy (allergy) or painful (inflammation)
can be limited to a limb (e.g the arm) if the lymph nodes were removed due to cancer. the lymph vessels transport protein and fluid to the lymph nodes and eventually to the bid blood vessels in the chest. when lymph nodes are removed and the blood vessels thus interrupted, accumulation of lymph develops in the involved limb. another cause of limb oedema is ligament , tendon, muscle injuries or bone fractures.
with oedema in lower leg in bedridden immobile patient, venous thrombosis can be the cause.
64
general oedema (no message)
3 diseases that are especially characterised by widespread oedema with accompanying pleural effusion and ascites:
nefritis- with nefritis/ nefrosis a lot of protein is lost through the urine. an NB fn of blood protein is to keep water inside the body vessel through osmotic suctions force. if the protein in blood dec, more fluid is forced out and accumulates around the blood vessels. oedema is first noticed in areas where the skin is loose like around eyes and posterior aspect of hands and later spreads to rest of body
liver cirrhosis
the liver is not capable to produce protein and together with increased blood pressure it leads to fluid being forced from the blood vessels. ascites usually appears first and later general oedema
heart failure
the blood protein is most normal with heart failure, but the inability of the heart to pump blood back to heart causes higher pressure in the veins. in the upright position this pressure is highest at ankles and oedema is thus first observed at feet. bedridden pt= sacrum
65
aims of oedema massage:
```
removal of excess fluid from tissues
promotion of circulation
prevention of adhesions/ fibrosis due to oedema becoming chronic (congestive oedema)
decrease of pain in swollen limbs
increase range at joints
```
66
prep for edema massage:
1. the limb is measured beforehand
2. the limb should be elevated for 15-30 mins, 45 degrees above level of the heart prior to commencing the massage
3. breathing exercises to promote venous circulation
4. pump movements- 10x each joint from proximal to distal
5. static contractions of muscle groups, keep contraction for 10 sec and repeat 10x
67
massage technique
devide the limb into areas or zones of 8-10 cm each and work proximally to distally to ensure that all zones are "oedema free" before you start working distally.
best results achieved id trunk massage is performed direction of the lymph nodes to " make space" for oedema from the limbs.
68
what are the different massage techniques?
1. intermittent pressure: work from proximally to distally to make "space" for the oedema. this technique must be performed lightly and slowly.
2. effleurage:
short strokes of hand-over hand from 8-10cm. always work in the directiona and end in the area of the lymph nodes. as oedema decreases, work can be done more distally. the whole circumference of the limb must be treated. the stroke must be regular, slow and performed lightly and always work in the directions of the lymph nodes.
3. petrissage:
if the oedema is fairly large (fibrotic/ congested), semi-circular movements especially with the fingertips must be performed. with larger areas the thumb or palm of the hand can also be used. again start proximally and the work distally. petrissage must always be alternated with effleurage techniques in the direction of the lymph nodes.
69
message techniques considerations:
as oedema decreases other handgrips can also be used during effleurage and pertissage, but always work from distally to proximally in the directions of the lmphatic and or venous drainage.
after massage, the patient can again perform pump movements , now distally to proximally. lastly measurements are done on the same areas for re-evaluation.
record the measurements
always work as light as possible during the first couple of treatments performed too hard and deep can cause severse pain and lead to more swelling. if the patient experiences pain during massage, you must work lighter.
70
what is time needed to spend with massage?
40-90 mins can be spent on massage on a daily basis. more than half of the time can be spent on the trunk because it gives better results than when you only work on the limb.
the patient must be seen daily for 7-10 days and thereafter followed up for another 3-4 x per week for 4 weeks.
71
what is the effect of oedema massage:
oxygenation of skin inc as oedema is removed
if skin discolouring and hair loss is present, it should recover completely. the skin gets thinner and more supple and because the serum glands are functioning better, the skin is not as dry. other symptoms like pain, stiffness and immobility around joints, as well as pins and needles should also disappear.
72
what is home advice following oedema massage:
patient must be able to lift the limb as much a possibe during the day.
do pump/ circulatory exercises (from proximally to distally) and static contraction exercises with arm or leg at least 3 times per day with limb elevated.
do not soak the arm or leg in the bath for too long, rather take a shower
oedema of the arm:
do not carry heavy objects
limit ADL that can worsen swelling in the arm as far as possible
oedema of the lower leg:
do not stand still in one place for longer than 2-3 mins
avoid walking long distances
rather give the patient elbow crutches/ one elbow crutch to walk with during the acute phase of the injury (for the first 6 days.
always sleep with the limb in 20-45 degrees of elevation
73
what is a trigger point?
is a focus of hyper-irritability in skeletal muscle or muscle tissue. should pressure be applied on the TP it results in local tenderness. when this focus/ point is sufficiently hyper-sensitive it may lead to referred pain and tenderness and sometimes also referred autonomous signs such as erythema, sweat response, temperature changes and propriocptive impairments.
myofacial trigger points can also result in myofascial pain syndromes with sensory. motor and autonomous symptoms. sensory changes may include dysaesthesia, hyperalgesia and referred pain.
74
what are the characteristics of TP's (differentiate from Fibromyalgia):
"taut band" in the muscle in which the TP is found
a local "twitch" response (LTP): brisk contraction of the muscle fibre in and around the taut band. this response can be evoked by firm (snapping) palpation ogn teh TP or quick insertion of a needle.
the patient's referred pain can be evoked using mech stimulation (esp compresion) of the TP
the referred pain occurs in a specific pattern of referrak
ROM is decreased with increased sensitivity to stretch the muscle
the impaired muscle must be weakened as a result of pain, with no muscle atrophy.
the patient's description of begin and cause of the pain may also be indicated a TP
75
what are types of TP:
myofacial, cutaneous, fascia, ligament, periosteal
TP's can be active or latent. in latent TP tenderness can be found during evaluation without the person having any symptoms
an active TP has symptoms locally or in a referral area
active TP's may lead to shortened or weakened muscle
76
aetiology/ patho-physiology of TP's
TP's often develop after an initial injury of the muscles fibres. this injury may be a specific traumatic event or repeated injuries with micro trauma of the muscle.
'injury pool theory': TP's develop after and initial injury to the muscle, the TP causes pain and stress in the muscle fibres. as stress/tension inc the muscle tires and is more susceptible to forming extra TP's. the presence of predisposing factors together with specific incident leads to sensitive locus, nociceptors and an active locus (motor end plate) cross, a TP is formed. the senstitive locus is the point in teh tense muscle band where the local twitch response is found. while the sensitive loci can be found throughout the muscle they are concentrated in the area of the TP.
77
evaluation of TP's?
pt with possible TP's nececities a thorough interview during which history of the patient's symptoms should be assessed in detail.
information gathered during the interview must correspond with the physical findings.
during the physical evaluation the areas of symptoms and the referral areas should be carefully noted on a body chart
78
what are the three ways of palpation and ID of TP:
flat palpation with the tips of the fingers over the fibres of the affected muscle
"snapping" palpation may be used in order to ID the specific TP. 'pincer' palpation is a method when the muscle is firmly grasped and rolled between the thumb and index finger
deep palpation is used when the TP is covered by a layer of superficial tissue. for deep palpation one finger tip is used over the area where the TP is suspected to be. reproduction of the pt's symptoms localises the TP.
79
management of TP's
non-invasive
spray and stretch: passive stretching of the muscle after application of a cooling spray. the TP must initially be precisely localised. spray is applied over the area ot TP as well as area of referral
ultrasound
TENS
massage: different techniques can be used in order to achieve relaxation and lengthening of the affected muscle
physiotheraoy: ID underlying, predisposing and excacerbating factors. e.g muscle imbalances, joint stiffness, poor of faulty techniques, ergonomics, etc
physiotherapy managment should include a holistic and thorough evaluation which allows for ID of all the factors. management includes all five pillars of health care delivery, i.e promotion, prevention, cure, rehab and referral
invasive:
injection of the TP: local pain relief, corticosteroidsm botulinum toxin
dry needling
acupuncture
80
ST
soft tissues:
ligaments, muscle, tendon, other connective tissue (e.g. nerve sheath), reacts to injury in a relatively predictable manner.
the healing process is similar in all ST, although there is some variation between tissues (e.g bone), age, lifestyle, systematic factors (e.g alcohol abuse, smoking, diabetes mellitus, nutrition, general health) and local factors (e.g extent of injury, mech stress, blood supply, oedema or infection) also all have influence on healing and regeneration
81
how can ST be injured?
trauma
over-use (esp repetitive)
illness
chemical agents such as inflammatory processes
the body's soft tissues must withstand the force of tension which lengthens the tissues.
after injury the tensile strength of the tissues is decreased and the main focus of the healing process is to re-establish the tensile strength of the healing tissue
82
soft tissue has 3 different types of fibres:
collagen fibres are long, straight, rigid and strong and give soft tissues its tension strength
reticular fibres consist of reticulin which are interwoven with collagen fibres and adds elasticity to the rigid qualities of collagen
elastic fibres, consisting of elastin, are stretchable and give the tissue a degree of elasticity.
83
what is the function of connective tissue?
supports and protects, but should be mobile
- strong= capable to withstand the mech forces which the tissue normally encounters
- should be long / can be lengthened= able to lengthen sufficiently in order to allow for necessary movement
- mobile/loose: separate from surrounding tissue
84
what are the causes of ST injury?
1. direct or indirect causes
2. underlying pathology
3. stress or exhaustion
cause affects the assessment and management
85
direct or indirect causes of ST injury?
e.g strike against the arm resulting in painful deltoid muscle
an indirect cause is a secondary occurence, e.g subluxation of a joint leading to extensive stretch of the ligaments and capsule surrounding the joint
86
underlying pathology
a number of illness processes are known for involving collagen fibres, e.g RA which in turn leads to tears of the upper cervical ligaments
known that age affects tendons and ligaments making them susceptible to damage under mechanical strain.
87
stress or exhaustion
this is over-use factor commonly seen is sport injuries or people who does repetitive movements, such as operating a key board.
RSI = long term overuse problem
88
acute injuries
these types of injuries are characterised by an orderly and timely healing process leading to sustainainable restoration of the anatomical and functional integrity
sudden incident/ crisis is followed by predictable resolution
89
chronic injuries
either did not undergo an orderly and timely process to restore anatomical and physiological integrity or went through a healing process without achieving an anatomical and functional result
often represent an inability of the cell matrix to adapt to the exposure of loading
90
what are the functional characteristics of a scar?
determined by the ability of collagen fibres to:
1. develop along the same stress lines as those it replaces. the max strength of the collagen will be in the direction of the forces it is exposed to during the remodelling phase of healing.
2. be as long as the tissue it replaces
3. allow independent movement between the tissue itself and the surrounding layers of tissue
4. be of sufficient quantity and quality to withstand the forces of stretching/ distraction it is exposed to.
91
Acute inflammatory (lag) phase
prevent further injury -> protect and support
allow normal inflammatory process
control swelling
pain relief
the tension force of the injured tissue is dependent on a weak fibrous connection
the tension force does not increase during this period
tension applied to the area during this time will disrupt / re-tear the fibrin network leading to more scar tissue formation.
92
regeneration/ proliferation phase
very weak collagen needing careful mobilisation
longitudinal forces in order to increase tensile strength.
the tension force increases as a result of collagen formation
the tension force if the are will depend on the orientaion and amount collagen fibres
careful and graded tension applied to the area will influence the amount and direction of the collagen fibres
careful tension of the healing tissue will increase collagen synthesism, facilitate functional collagen alignment and increase cross linkages in order to make it more stable.
effect: bigger increase of the tissues tensile strength.
93
remodelling/ maturation phase
longitudinal and transverse forces to align, lengthen and mobilise scar tissue
the tension strength of the area still increases but slower than during the regeneration phase.
intre- en extra-molecular linkages and scar tissue contracture occur in this period.
tension applied to the area will continue to re-orientate the collagen fibres and prevent scar tissue contracture
SSTM changes the mechanical properties of the connective tissue in terms of the visco-elastic response to loading, based on the principles of hysteresis, "creep' and plastic deformation
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what are the effects of soft tissue therapy
improves effective scar tissue formation in post-acute healing ST lesions.
decrease excessive adhesions and scar tissue formation in chronic ST lesions
decrease focal area of intra-muscular tissue thickening
decrease excessive fascia thickening in areas of abnormal cross linkages between collagen fibres
facilitates injured tissue to regain strength as soon as possible
decrease spasm secondary to pain
decrease pain by:
decreasing excessive tissue tension which is associated with an activated mechanical nociceptor
removing chemical substances which activates the chemical nociceptors found in tissue.
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motivation for specific soft tissue mobilisation (SSTM) techniques:
tension is applied to the scar in order to:
stimulate collagen synthesis
facilitate the healing process by aligning the collagen fibres parallel to the direction of force- faster than in tissue not exposed to tension.
have functional scar as end result
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What is a large component of management of ST dysfunction?
the promotion of ST adaptation in order to restore the tissue's ability to handle functional loading
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SSTM uses:
specific
graded
progressive application of force by using physiological, accessory or combined techniques
facilitate collagen synthesis, orientation and binding in the early stage of the healing process
or to facilitate changes in the visco-elastic response of the tissue during later stages of healing
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SSTM
standardised method of using manual therapy to treat benign soft tissue pathology and enables a more sensitive and specific approach that the traditional used deep transverse frictions.
use graded and progressive application of force, as close to the stage of healing process as possible
to imprve the tensile strength of the tissue and restore the functional biomechanical properties of soft tissue.
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ID of the etiology of the injury and any exacerbating factors in relation to ST dysfunction:
ST dysfunction takes place when:
the load is excessive in relation to the mechanical properties of the tissue
the biomechanical properties of the tissue have decreased in relation to a 'normal' load
all the above
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ID of area of tissue dysfunction and application of treatment in order to restore the biophysical properties in relation to specific functional demands:
Once ID , progressive tension is necessary in order to restore the mechanical properties
phy tests in determining the area of dysfinction:
observation
evaluation of functionall activities\APM
isometric muscle test
assessment of muscle length
assesment of muscle power and control
changes in mech properties of ST by SSTM; creep, plastic deformation and hysterisis-> change the visco-elastic response and tissue architecture
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degenerative pathology
many of 'inflammatory lesions' e.g achilles tendontitis and patellar tendonitis, in some circumstances, be degenerative rather than inflammatory.
absence of inflammation means that there is no stimulus for the normal healing process, and application of SSTM may in this instane result in inflammatory response, initiated healing
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specific progressive rehab programme in order to ensure sufficient control of the affected area in order to decrease the risk of repeated injury
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specific and progressive rehab program should go hand in hand with SSTM to restore:
muscle control
proprioception
co-ordination
fitness
psycho-social factors
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