Lecture 5 - Soft Tissue Mobilization

Soft Tissue Mobilization (STM)

Assessment, Treatment, and Management of soft tissue injury/pain/dysfunction

- Primarily of neuromusculoskeletal system

- Therapeutic manipulation + deformation of soft tissue

STM Goal

Affect movement either directly or indirectly

- Increase mobility/flexibility

- Reduce pain

Massage vs STM

Massage = Increase blood flow, remove metabolic waste from muscle

- Relieve physical + emotional stress

STM = Addresses soft tissue restrictions

STM Framework

1. Increase circulation

2. Deliberate microtrauma

- introduce healing cycle

3. Release of adhesions

4. Neuromodulation of pain and tone

Skin + Fascial Layers

From superficial to deep...

1. Skin

2. Superficial fascia

3. Deep fascia

4. Epimysium

5. Muscle

Skin Color Assessment

Can help identify cause of dysfunction

Red skin

Fever, allergy, infection, inflammation, heat, embarassment

- Relates to DVT, blood clots

Black and Blue skin

Bruises -- Blood clots under skin

Yellowish skin

Accumulation bile pigments

- Sometimes cirrhosis

Pallor or blanching skin

- Anemia

- Emotional or physical stress

- Decreased arterial blood flow

Hypertrophic scar

Raised at site of original wound, but maintains borders

- Reddish, sometimes itchy

- Caused by too much stress on scar early on

- Body makes more scar tissue, but nowhere to go but up

Keloid Scar

Also raised, but grow past the site of the wound

- Overtaking normal, healthy tissue

- BEYOND borders of wound!

Deep cut healing time

Appropriate stress is key!

- After 2 years is typical for return to normal

- i.e. Incision after hip replacement surgery

STM and Skin

Assesses mobility, relation to underlying tissue

- Asseses scar mobility relating to superficial/deep fascial connections

Fascia

Sheet/band of connective tissue found throughout the body

Fascia characteristics

1. Interdependent layers with several depths

- Ranging from skin to bone

2. Attaches, encloses, & separates muscle/organs

3. Nerves, vessels, muscle, adj. tissue move within compartments

4. Innervated by sensory tissue

Fascia and Muscle

Fascia is ANATOMICALLY inseparable from muscle!

- Sensory receptors in fascia help signal pain

Fascial Slings

Working one part can impact another part of sling via fascia

Connective Tissue Nature

Visco-elastic!

Connective Tissue: Viscosity

If deformation of tissue is sustained/repeated, it will stay deformed

- Slow recovery to baseline

Connective Tissue: Elasticity

When lengthened, will return to its original length when force is removed

Immobilization of Connective Tissue

1. Loss of ground substance

2. Fibro-fatty infiltrates

3. Macro-adhesions

Ground Substance

Maintains space between collagen fibers

- Improves ability of tissue to move freely

Loss of ground substance

- Decreased distance between adjacent fibers

- Increased fiber contact --> Micro-adhesions

- Random fiber orientation due to no stress from immobilization

Fibrofatty Infiltrates

Change in structure/organization of collagen in joint capsules and ligaments after 2 weeks immobilization

- Due to no stress

- Rapid degeneration with DENSE fibrofatty conn. tissue

Fibrofatty infiltrates

White = Increased Fat Deposits

Macro-adhesions

Unwanted connections between neighboring tissues

- Larger fibrofatty infiltrates adhering adj. tissues together

Bonds that you DONT want to occur!

Normal Healing

- Local Response

- Decreased Mobility

- Linear w/ distinct end point

Local Healing Response

1. Inflammatory

2. Fibroblast formation

3. Maturation / Remodeling

Fibrotic Tissue

Fibrotic tissue formation is normal for healing process when controlled

Fibrosis

Formation of excessive fibrotic tissue

- Occurs when normal tissue is immobile

- Scarring continues to happen beyond normal timeframe

Abnormal result = Scarring after prolonged immobilization

Fibrosis Characteristics

- Traumatic

- Immobilization

- Change in structure (larger area)

- Cyclic (progresses if no intervention)

Fibrotic Tissue Characteristics

No give to it -- All force goes to joint!

- Hard & Fibrous

- Inflexible

- Less functional

- Increased joint load

Healthy Tissue Characteristics

- Soft/Supple

- Flexible

- Highly functional

- Decreased joint load

Fibrotic Tissue Treatment Goal

Decrease load of the joint

Muscle adhesion

Band of fibrous tissue that holds structures together abnormally

- Things won't move as smoothly/efficiently

- Rupture more likely for shortened muscles

STM: Connective Tissue

Reducing adhesions by releasing bonds

- Early intervention = Most beneficial response

- Rarely done as sole treatment

- ROM, Flexibility, Muscle Activation

Inflammatory Process: 4 Main Elements

1. Changes in blood circulation

2. Changes in vessel wall permeability

3. WBC response

4. Release of inflammatory mediators

Inflammatory Process

1. Injury occurs

- Initial vasoconstriction for only a few seconds

- Quick sympathetic response (few seconds)

2. Vasodilation

- Increasing blood flow/plasma

3. Edema (swelling)

WBC Response to injury

1. Open wound --> Bacteria --> Increased WBCs

- WBC presence leads to inflammatory release

2. Increasing blood vessel permeability

3. Localized inflammatory response

5 Signs of inflammatory response

1. Heat

2. Redness

3. Edema (swelling)

4. Pain

5. Loss of function

Heat & Redness (inflammatory response)

Tissue cells are damaged

- Vasodilation --> Increased blood volume

- WBCs to injury site

Edema, Pain, LOF (inflammatory response)

Increased swelling + pain --> Loss of function

- Fluid leaks out of vessels into surrounding tissue (swelling)

- Pressure activates pain receptors

Stages of Healing

1. Acute - Inflammatory

2. Subacute - Repair/Healing

3. Maturation and Remodeling

Acute Inflammatory Stage: Characteristics

- Vascular changes

- Inflammatory exudates

- Clot formation

- Early fibroblastic activity

Acute Inflammatory Stage: Clinical Signs

- Inflammation

- Pain BEFORE tissue resistance

Acute Inflammatory Stage: STM Intervention

Protection

- Promote healing and prevent compensatory patterns

- Passive movement in pain-free range

- STM to assist w/ inflammatory exudate absorption

- i.e. Hypertrophic scar

Subacute Inflammatory Stage: Characteristics

- Growth of capillary beds

- Collagen formation -- Granulation tissue

- Fragile, easily injured tissue

Subacute Inflammatory Stage: Clinical Signs

- Diminishing inflammation

- Pain DURING tissue resistance

- Patient in pain AT end-feel

Subacute Inflammatory Stage: STM Interventions

Controlled Motion

- Promote scar mobility

- Controlled STM of scar tissue toward injury

- Improve connections, sliding skin around scar!

Maturate/Remodeling Stage: Characteristics

- Scar remodeling

- Collagen aligns along lines of stress forces

- Improved tissue strength and organiztion

Maturate/Remodeling Stage: Clinical Signs

Absense of inflammation!

- Pain AFTER tissue resistance (overpressure)

Maturate/Remodeling Stage: STM Interventions

Return to normal function!

- Increase strength + alignment of scar tissue

- Cross-fiber friction massage

- Progressive stretching + ROM

- More aggressive, encourage motion

Analgesic Effect

Reduces pain

STM: Pain Management

Has analgesic effect

- Improves blood flow, reduces inflammation (systemic)

- Removes pressure on pain receptors

- Temporarily reduce muscle spasm

Light touch (STM)

Reduces nociceptive signaling

Acupressure points

Helps release endogenous opioids to assist with pain recovery

Median Nerve

Must elongate 20% to be functional

Carpal Tunnel Syndrome

Transverse carpal ligament thickens

- Lessens space for median nerve

- Impacts hand

Tarsal Tunnel Syndrome

Tibial nerve becomes compressed in tarsal tunnel

- Similar to carpal tunnel, impacts foot

Nerve adhesion (vertebrae)

- Increased ant. tilt, angled lower back

- Facet joint closed

- Scar forms where nerve adheres to tissue

Myofascial Release (MFR)

Techniques for moving fascia + soft tissue of hypomobile areas

- Typically done from superficial to deep

- Skin shearing --> muscular deformation --> TrP release

MFR Treatment Progression

Depth:

Superficial --> Deep

Force:

Direction: Start Parallel --> Perpendicular

Intensity: Less force --> Greater force

Length of involved tissue:

Shortened --> Lengthened

- Lengthened = Less tolerable

STM Contraindications

- Malignancy

- Inflammatory skin condition

- Unstable fx

- Hemorrhage

- Localized infection

STM Precautions

- Circulatory/Cardiovascular disorders

- Abnormal sensation

- Immunocompromised

- Scar healing

Superficial Fascia/Skin Shearing: Contraindications

- Recent incision

- Burn graft

- Psoriasis

Bony Contours: Contraindications

- Osteoporosis

- Fracture

Body Mechanics

- Flexed fingers

- Force thru top hand

- Straight line

STM Clinical Application

Purposeful, supplemented with other intervention

- Patient is not here for "massage"

Layers of Palpation

1. Skin / Superficial Fascia

2. Muscle

3. Tendon

4. Ligament / Joint Capsule

5. Bone

Normal Skin Quality

Smooth & Pliable

- Hair growth sometimes present

Normal Skin Temperature

Uniform body temp

Normal Skin Consistency

Soft and very elastic

- Skin becomes firmer with more tension placed on it