instrument-assisted soft tissue mobilization to …

1

INSTRUMENT-ASSISTED SOFT TISSUE MOBILIZATION TO THE

UPPER QUARTER

Robert McCabe, DPT, MTC, OCS, CSCS

Provider Disclaimer• Allied Health Education and the presenter of this

webinar do not have any financial or other

associations with the manufacturers of any products or

suppliers of commercial services that may be

discussed or displayed in this presentation.

• There was no commercial support for this

presentation.• The views expressed in this presentation are the views

and opinions of the presenter.• Participants must use discretion when using the

information contained in this presentation.

» Sheet or band of connective tissue that

attaches to and separates skeletal muscles or internal organs

» 3 dimensional collagen matrix that is attached

to all of the biological structures which assists the body systems to operate in an integrated

manner

Zugel, BJSM, 2018

2

» Mechanical Support - chains, slings or lines

• Local and Regional

• Impacts posture

» Movement

• Detects, Transmits, and modifies forces

• “ Cellular crosstalk” among sensory receptors

» Visceral function

Chaitow, 2012 , Lee & Lee 2013, Myers 2011

» Tensegrity-Transfer of tension through network of mechanoreceptors

• Deep fasciae• Superficial fasciae

• Aponeurosis• Epineurium• Visceral fasciae

• Endomysium• Tendons

• Epimysium

• Joint Capsule

• Meninges

• Ligaments

• Retinacula

• Tendon

• Intermuscular septa

• Dermis

• Perimysium

3

Fluid levels/ hydration

Trauma ( injury / surgery)

Disease ( ex: diabetes)

Aging

Activity level

Nutrition

4

Acute

Necessary response for tissue healing / regeneration

Applic : Long-term use of NSAIDS may inhibitmuscle growth

Chronic

Excessive response Fibrosis (collagen)Tethering/ compression

of soft tissues pain“Spillover” of

inflammatory cytokines into bloodstream

Central nociceptor stim.Fatty infiltration / mm

atrophy (ex : Disc injury Applic: Strength gains

in elderly

Tissue regeneration

Muscle growth

Neuromuscular

performance

• Ex- Power generation

Chronic MSK pain

5

13

B

From Anatomy Trains – Thomas Myers

Supraspinatus

Levator Scap

TricepsInfraspinatusPost GH

Capsule“Rhombo-

Serratus”

Inf. GH

CapsuleTeres MajorTeres Minor

15

From Anatomy Trains – Thomas Myers

Medial IM

Septum

Pec Major

Lat Dorsi

Teres Major

Neurovascular

BundlePec Minor

Carpal

TunnelUCL

Wrist

Flexors

Biceps

6

Epicranial fascia Erector /

sacrolumbarfascia Sacrotuberous

ligament Hamstrings

Gastrocnemius

Achilles Tendon Plantar fascia

Splenius Capitis

Sternocleidomastoid

External/ internal

intercostals

Gluteus Maximus

Tensor Fasciae

Iliotibial tract

Lateral compartment

Peroneal muscles

Splenius capitis /cervicis Rhomboid Major / Minor

Serratus Anterior External/Internal Oblique

TFL/ ITB Tibialis Anterior

Biceps femoris

SacrotuberousLiagament

Sacrolumb fascia/ Erector Spinae

7

SternocleidomastoidRectus Abdominis

Quadriceps TendonAnterior Compartment

Tibialis Anterior

Latissimus DorsiThoraco-lumbar Fascia

Sacral FasciaGluteus Maximus

Vastus Lateralis

Quadriceps Tendon

8

Trigger Point vs. Fibrosis

» Fibrosis - ▲ Muscle hardness

Collagen deposition / chemical ’s

» Trigger Point - ▲ Muscle hardness

Symptomatic

Pressure elicits symptoms

Muscle

GH Capsule

Fibrosis

9

Arterial perfusion

Fascial sliding

Neuromodulation

Pain

Muscle activity

Reabsorption of fibrosis

“ Break up” adhesions ?

Prevent overuse/ chronic - induced fibrosis

Recovery from muscle soreness

Short-term flexibility

May Chronic musculoskeletal pain

Stress on hands

CMC joint

Barrier

Specificity of targeted tissue

10

» Trigger points/ MFP

» Chronic tendinopathies

» Adhesions / fibrosis /excessive scar

» Neuromuscular imbalances

» Scapula Dyskinesis

» Postural Dysfunction

» Ligament sprains (i.e. UCL)

» Nerve entrapments (CTS, TOS)

Movement

Disorder

» Inflammatory or infectious skin conditions

- Psoriasis, dermatitis, eczema, cellulitis,

shingles, Athlete’s foot, foot- mouth disease

» Impaired skin integrity

Open Wound / non- closed wound margins

» Directly over surgical incision

Fibroblastic stage 0-12 weeks

» Directly over ecchymosis/effusion

» Directly over acutely traumatized tissue

» Directly over unstable fractures

» Hematoma/ myositis ossificans

» Osteomyelitis

» Varicose veins

» Cancer

» Body art

» CRPS

» Polyneuropathies

» Unhealed, closed non- complicated fractures

» Autoimmune disorders

» Diabetes

11

» Rheumatoid arthritis

» Ankylosing spondylitis

» Adjacent to pacemakers, insulin pumps

» Post- injection ( i.e. PRP )

» Lymphedema

» Central sensitization / hypersensitivity

• Massage cream

• Moisturizing lotion

Ex : Albolene TM

• Ultrasound gel

Medical Grade Disinfectant / Cleaner

After every use !

MRSA

Ex : ProtexTM

12

KELLEY MJ. JOSPT, 2013: 43(5)

Synthesis of

studies ► ► ►Recommendations

KELLEY MJ. JOSPT, 2013: 43(5)

» Several case reports /case series

» Some basic science studies

» Recent RCT’s & Systematic Reviews

Protocols/ approaches based on Level 5 evidence (expert opinion)

13

• Nielsen 07’ - ↑ in surface circulation ↓ pain locally and distal.

• Lambert, M. Phys. Ther. Reviews. 2017

- Systematic review

- Significant short-term ( < 3 mos.) in pain and/or

ROM vs. control and/ or other tx. groups

• Moon, JH. J. Phys Ther Sci.

- RCT

- IASTM superior to static hamstring stretches

on immediate hamstring flexibility on pts. w

non-specific LBP

• Gulick, D. J. Bodyworks & Movement Ther. 2017 -

- RCT – 3 groups of pts w UT trigger points

- IASTM – 3 techniques applied 6x over 3 weeks

- UT PPT in all 3 groups

• Miller, S - JOSPT 2018

- RCT – 3 groups of pts w UT trigger points

- IASTM vs. static stretching vs. self STM (Theracane)

- Significantly greater improvements in cervical

ROM and PPT in IASTM group

Increase career longevity

• 68 % of PT experience thumb pain.

• Of these, 25% will retire or change professions

• Based on 1102 Australian Physiotherapists

McMahon- Australian J of PT 06’

14

● Buffalo Horn

● Jade Stone

● Stainless Steel

Scanning vs. mobilizing tissue

Clinician technique

Tissue depth of application

Frequency

Duration

Treatment objective

Tissue Reactivity

Treatment Sequence

15

» Scanning = Assessing the tissue

Parallel to muscle/ Both directions

Superficial Deep

Assess for resistance

- “Bump” - Trigger point

- Grainy or gritty feel- Fascial

» Treatment Multiple angles

Superficial Deep

» Clinician Technique

Two hand technique

- Tissue is on slack Deep effect

One hand technique

- Take up soft tissue slack with non-

instrument hand Superficial effect

Application angle : 30° to 60°

» Tissue Depth = Pressure

Variables affecting tissue depth

A. Degree of tissue tension / slack

B. Degree of force

C. Angle of application

Angle Deeper effect

B. Tool surface

Concave vs. convex

Large vs. small surface

Sharp vs. dull surface area

More Superficial effect

16

Superficial ( Fasciae)

Larger surface area

Sharp/ thinner edges

Concave edges

Deep Structures ( Muscle)

Smaller surface area

Dull/ thicker edges

Convex edges

» Frequency

2-3 x’s / week ( 2- 3 days in between)

» Duration

Per session: 8-10 min

Per structure / muscle : 3-10 minutes

- Knee MCL - 2 min

- ITB - 8-10 min

- PIGH shoulder capsule - 4 to 5 min

» Treatment objective

Pain /edema (Acute)

- Non- aggressive

ROM / Disrupt fibrotic tissue

- More aggressive

- Ecchymosis is normal

- STOP if petechiae is produced

- Bruising is not necessary

» Tissue Reactivity

- Must adjust parameters !

17

» Treatment SequencePre - Treatment : Warm Up Tissue Active ( i.e. UBE, Bike, Elliptical or T- Mill )

Passive ( Modalities- Heat, lazer US, Paraffin)

» Post – Treatment Therex. / Neuromuscular re-education Soft tissue / joint mobilizations

Cryotherapy Not indicated if goal is to incite an

inflammatory response ( i.e. tendinopathy

or ligament sprain)

STROKES

1. Sweep - Basic stroke

Tool edge- 30-60° angle to body surface

2. J - Stroke

Pencil grip

Tool edge- 30-60° angle

3. Strum

Deep stroke

Tool edge- 60-90° angle

18

STROKES

4. Scoop Tool edge - 90° angle

Deep tissue

5. Brushing/ Framing

Light/ De- sensitizing strokes

Bony prominences ( ex: scapula, patella)

6. Fanning

Hold one end of tool stationary

Move other end- fan like pattern

BASIC TECHNIQUES

» Structures

Splenius capitis

Oblique capitis superior

Lateral, spiral and superficial back fascial

lines

» Common indications Occipital and retro-orbital (“behind eye”)

headaches

Forward head posture

19

Suboccipital- Lateral •

» Structures

Semispinalis capitis

Rectus capitis posterior minor/major

Spiral fascial line/ superficial back line

» Common indications Occipital and retro-orbital (“behind eye”)

headaches


Suboccipital- Medial•

20

» Common indications

Cervical ROM

Scapula dyskinesis


LS trigger point

Cervical radiculopathy

Levator Scapulae


Cervical ROM

Scapula dyskinesis

Cervical pain

UT trigger point

LS trigger point

21

Upper Trapezius 1

Upper Trapezius 2

Upper Trapezius 3

22


Shoulder ROM

Functional reach behind back

Scapula dyskinesis

Sp trigger point

Supraspinatus


Shoulder ROM

IR

Horizontal adduction

Scapula dyskinesis

Posterior/ internal impingement

SLAP tears

Ip trigger point

PIGH – Posterior- Inferior Glenohumeral

23

Infraspinatus- PIGH Capsule

Infraspinatus Tendon


Cervical ROM

Scapula dyskinesis

Thoracic mobility

Periscapular trigger point

24

Scapula Framing 1

Scapula Framing 2

Rhomboids 1

25


Shoulder ROM

Abduction

Scapula dyskinesis

Posterior/ internal impingement

SLAP tears

TM trigger point

PIGH – Posterior - Inferior Glenohumeral

Teres Major


Promote LT muscle activation

Scapula dyskinesis

LT trigger point

Subacromial/ coracoid impingement

Forward shoulder posture

26

Lower Trapezius 1



SA trigger point

Scapula dyskinesis

Serratus Anterior

27

Posterior- Lateral Deltoid



Costal chondritis

PM trigger point

Shoulder ROM

ER (90°) abduction

Pectoralis Major

28

» Common indications Forward shoulder posture Median nerve dysfunction

- CTS

- Cervical radiculopathy- Thoracic outlet syndrome

P. Minor trigger point Shoulder ROM

ER (90°) abduction

Pectoralis Major/ Front Arm Line

Biceps 1

29


Lateral epicondylalgia

Radial nerve entrapment

Elbow ROM

Wrist flexion

Lateral Elbow 1

Lateral Elbow 2 - Wrist Extensors

30


Medial epicondylalgia

CTS

Pronator teres nerve entrapment

Elbow ROM

Wrist extension

Medial Elbow- Wrist Flexors

Wrist –Extensor Retinaculum

31

Palm - 1

Palm - 2

Hand - Digits – Flexor Surface

32

Hand - Digits – Extensor Surface

ADVANCED TECHNIQUES

Upper Trapezius 1

33

Upper Trapezius 2

Scalenes1

Scalenes 2

34

Supraspinatus 2

PIGH Capsule- Teres Major 1

PIGH Capsule- Teres Major 2

35

IGH Capsule- Teres Major

Triceps - Teres Major 1

Lower Trapezius

36

Front Arm Line – Median Nerve

Biceps

Lateral Elbow – Wrist extensor tendon

37

Medial Elbow – Wrist flexor tendon

• Mike is a 40 year old cross fit athlete

• Former Division III

baseball player

• Beach volleyball in off-season

Current ComplaintsReason for seeking treatment

Chief c/o right shoulder pain (P1)

• Pain location - Supero - posterior shoulder

Secondary c/o “dull ache”/ tingling in right UE (P2)

• Symptom location – Antebrachium, hand and 2nd-5th digits

• Tertiary c/o “tightness” in right cervical / UT (P3)

38

Observation/ Inspection –Key Findings » Slouched posture

» Thoracic kyphosis

» Scapulae

Anterior tilted abducted and internal rotation

Right > Left

» Bilateral upper trapezius muscle guarding

» Lower right shoulder

Functional Tests » Functional Asterisks

• Functional reach 1 (ER/Ab)-Reproduced P1

• Functional reach 2 (IR/Add/Ext) – Slight reproduction of P1

» Slouched sitting

• Reproduced P2 ( tingling / ache/ heaviness)

» Active cervical ROM – Left lat flex

• Reproduced P3

Special tests

• (-) Spurling’s Maneuver • + Roos Test – Reproduces P2

• + ULTT (Median Nerve Bias) Partially reproduced P2

• - ULTT ( Ulnar nerve Bias)

Palpation• (+) Tenderness / soft tissue hardness at mid- upper

trapezius

• Trigger pain referral pattern with deep pressure to UT

• Low Pain Pressure Threshold (PPT)

39

AROM/ PROM • IR

Joint Mobility • posterior and Inferior (GH) glide

Special Tests• Inconclusive SLAP

• + SA test cluster

• (+) Posterior impingement sign

» Diagnosis

• Thoracic Outlet Syndrome ( median nerve sub-type)

• Posterior impingement / possible SLAP tear

• Cervical radiculopathy

» Key Impairments• Cervical AROM

• Shoulder AROM (IR)

• Poor posture

» PIGH• Re-assess functional asterisk (P1)

» Front arm line • Re-assess functional asterisk / (P2)

» UT/ LS / cervical spine

• Re-assess functional asterisk / (P2)

40

Course Completion

You have completed the course

•

THANK YOU.

[email protected]

Instrument – Assisted Soft Tissue

Mobilizations to the Upper Quarter

instrument-assisted soft tissue mobilization to …

Documents