STM Lecture 1 - Current Theories

Soft Tissue

Tissues that connect, support, or surround other structures and organs

- Tissues in body that are not bones/organs

Soft Tissue Examples

- Muscles

- Tendons

- Ligaments

- Fascia

- Nerves

- Fibrous Tissues

- Blood Vessels

- Synovial Membranes

Other Tissue

Bones + Organs

- For STM, help to identify muscles using bony landmarks

- To avoid during percussion therapy

Fascia

Continuous 3D matrix of structural support; SENSORY ORGAN

- Forms perfect profile of everything in system

- Dynamic sensory network

FASCIA FIRST !!!

Fascia Characteristics

Soft tissue component of connective tissue system

- Supports everything in body

- Deep and superficial layer

- All muscles have fascial connections

Muscle Spindles

Activate when we move; Stimulated when fascia is stretched

- Inform CNS of changes in tone and elasticity

Muscle Spindles - Location

Layers of epimysium and perimysium

Why are sensory receptors in fascia important?

Allow for smooth and safe movement

Superficial Fascia

Houses nerves, blood, and lymph

- Superficial vessels

Superficial Fascia - STM Effects

Techniques done here affect:

1. Lymph flow

2. Ability of skin to glide on superficial fascia unrestricted

Deep Fascia

Envelops all muscles in body

- 2 Types (Aponeurotic + Epimysial)

Deep Fascia - Main Function

Transmit muscular forces at a distance

- Biotensegrity

Types of Deep Fascia

1. Aponeurotic

2. Epimysial

Aponeurotic Fascia

Binds muscles together or connects muscles to bone

- Sheet-like, pearly white fibrous membrane

Epimysial Fascia

Surrounds entire muscle belly + helps separate muscles

- Fibrous connective tissue sheath

- Thin and tough

Perimysium

Sheath surrounding bundles of muscle fibers

Endomysium

Sheath surrounding individual muscle fibers

Extracellular Matrix (ECM)

Fiber network of proteins + substances that provide structure to connective tissues

- Made up of / suspended by ground substance

Ground Substance

Hydrated gel-like substance that holds all other necessary cells for biological function

- Prevents adhesions

- Homeostasis of it is crucial

What does ECM supply fascia?

1. Viscosity

2. Elasticity

3. Ability to send movement

Cells in ECM

- Ground substance

- Lymphocytes

- Macrophages

- Fat Cells

- Melanocytes

- Mast Cells

- Elastic Fibers

- Collagen Fibers

- Reticular Fibers

Collagen

Provides tensile strength

Elastin

Provides recoil / elasticity

What does ground substance provide?

Glide

What stimulates ground substance?

Movement

- Maintains hydration + viscosity of tissues

- Prevents adhesions

Normal Phase of Healing

Point of injury --> Point of repair

Fibrosis

Point of repair --> Excess Repair

- TOO MUCH HEALING!

Fibrosis - Characteristics

Excessive buildup of collagen + extracellular matrix during healing

- Biological process

- When normal repair process becomes overactive/prolonged

- Limit mobility, elasticity, normal force transmission

Normal Healing Upon Injury/Trauma

1. Local Response

2. Decreased Mobility due to space reduction

3. Linear with distinct end point

Local Response

- Inflammation

- Fibroblast formation

- Maturation

Inflammation

Starting point of normal healing

- Reduces space and mobility

Fibroblasts

Lay down collagen and extracellular matrix

Is healing linear?

YES

- Has a distinct end point

Early movement

Helps maintain space, hydration, and alignment of collagen

- Gentle movement

Effects of Immobilization

1. Loss of Ground Substance

2. Fibrofatty Infilatrates

- Both contribute to microadhesions

Loss of Ground Substance

Decreases critical inter-fiber distance and lubrication

- Tissues dry up, have less glide

- Disorganizes fibers

Fibrofatty Infiltrates

Normal muscle fibers are replaced by fat

- Inflammatory signals

- Larger amounts = Macroadhesions (PLAY)

Immobilization Examples

- Casting

- Sling

- Bracing

- Splinting

- Protocols post-op

- Sedentary

- Fear/Avoidance of movement

Macroadhesions

Large areas of restricted tissue under conditions of immobility

- With or without injury/trauma

Macroadhesions - Characteristics

1. Decrease play

2. Limits ROM

3. Shortens involved tissues

- Mechanical process

Microadhesions

Small areas of "stickiness" or "gum" in tissues w/ decreased ground substance + fatty fibroinfiltrates

- Smaller

What contributes to microadhesions (gum)?

Loss of ground substance + fibrofatty infiltration

Microadhesions vs Macroadhesions

Same process, only difference is magnitude

Shrinking

Homogenous change in entire fabric

- Larger area involved

Cyclical

Continues if irritant is present

Tissue Fiber Organization - Disruptions

Disorganized = Lose elasticity + Force transmission

- Controlled loading helps realign fibers

Fascia - Training Principles

Elastic Loading + Counter-movement

- Preloading tissue

- Dynamic stretching

- Hydration

- Consistency

Fibrosis Cycle

CYCLE REPEATS AS LONG AS IRRITANT IS PRESENT

- Cycle occurs due to immobility

1. Trauma/Injury

2. Macrophages activated

3. Increased blood flow (vascularity)

4. Increased fibroblasts

5. Increased connective tissue production

6. Increased myofibril activity

7. Shrinking of connective tissue (FIBROSIS)

8. Abnormal movement dysfunction

Fascial Adhesions

Interfere with proper coordinated movement!

- Restrict tissue glide

- Impair sensory input

- Change CNS control of movement

How do address fascial adhesions

MOVEMENT = MOST IMPORTANT!

- With STM

Fascial Adhesions - STM Management

- Promote circulation

- Ward off microadhesions from becoming macroadhesions

- Promote normal tissue repair

- Slow scar tissue formation

- Neuromodulatuion of pain + tone

3 Models to cause soft tissue changes

All three play a role in outcome

1. Mechanical Model

2. Neurological Model

3. Myofascial Meridians

- Biotensegrity

Mechanical Model

Soft tissue work forms viscoelastic tissue

- Tissue Deformation

- Changes to hyaluronic acid --> Decrease ground substance

- Decreases in extracellular matrix space

- Fibroblast response to shearing forces (inflammation)

- Dense facial layers

- Compensations

Hyaluronic Acid

Component of ground substance

- Hydration

- Lubrication

- Viscoelasticity

What region has the highest hyaluronic acid concentration?

Under deep fascia

Mechanical Model - Limitation

Forces from hand are too small to actually change tissues

Mechanical Model - Interventions

Influence tissue glide, treat fascia

- Cupping

- Skin rolling

Neurological Model (Dermoneuromodulation)

Changes in soft tissue are primarily due to NS

- NS MODULATION!

- Not due to mechanical reshaping

- Neurological Reset

Neurological Model - CHaracteristics

We change brain perception via skin

- Mechanical input stimulates receptors

- Brain elevates safety of sensory input

- Allows for movement once deemed safe -- More ROM

What mechanoreceptors are present within fascia network?

- GTOs

- Ruffini Endings

- Pascinian Corpuscles

What fascia has the most mechanoreceptors in the body?

Thoracolumbar Fascia

Neurological Reset

Reset occurs to downregulate muscle tone

- Overwhelming amount of info!

- NS can be reset with diaphragmatic breathing

Neurological Reset - Steps

1. Muscle stimulated (stretch/tension)

2. Mechanoreceptors activate

3. Info to CNS via sensory neurons

4. New instructions carried by motor neurons --> mm fibers

5. Muscles relax and lengthen

Diaphragmatic Breathing

Can reset nervous system

Mechanical Model - Overall Summary

TISSUE DEFORMATION

Neurological Model - Overall Summary

NERVOUS SYSTEM MODULATION

Tensegrity

Tensional integrity; Describes how structure is stabilized

- Continuous tension + Discontinuous compression

- Takes shearing, bending moments, levers into account

- Self-organized, hierarchal, load distributing

- Low energy consuming

How do bone and fascia contribute to Tensegrity?

Pulling one apart impacts entire structure

- Forces distribute EVERYWHERE

- BONE = Anchor

- FASCIA = Fabric between bone

Pec Minor - Tensegrity Example

By working on pec minor, you are impacting system to help shoulder ROM

- Coracoid Process and Ribs = Anchors

- Pec Minor = Cable between ribs and coracoid process

Biotensegrity

Body's integrity is maintained by balance of continuous tension and discontinuous compression

- Body is a connected network

- Tensegrity applied to anatomy

- Change in tension ANYWHERE within system is instantly signaled everywhere else in body

Biotensegrity - Components

Continuous tension = fascia + muscles

Continuous compression = bones and joints

Biotensegrity - Fascia + Muscles

Fascia distributes force --> Muscles dynamically adjust

- Continuous tension

Biotensegrity - Spine

Acts as central tensegrity tower integrated with entire system

Total Body Modeling

1. Viscoelastic bony segments

- Limbs

2. Viscoelastic connectors

- Cartilage

- Joint capusles

- Ligaments

3. Viscoelastic active motor system

- Muscle

- Tendons

- Connective tissue

4. Visceral Organs

Kinetic Chain

Functional, sequential movement of joints and muscles

- If joint doesn't move, muscle won't move it

Myofascial Meridians (Anatomy Trains)

Mapped fascial lines; Tension in one area influences another

- Like highways

- Longitudinal connections between muscle + fascia

- Muscles do not act in isolation

- Continuous fascial sheaths

- Global force transmission

Anatomical Slings / Myofascial Chains / Myofascial Slings

Cross-body force transmission system; Movement engines

- Can manipulate one area to influence another

- i.e. Posterior oblique sling, lateral sling, anterior oblique sling

Myofascial Meridians vs. Anatomical Slings

Myofascial meridians = Map entire body's connectivity

Anatomical slings = Part of Myofascial meridian system

- Specifically identified units within map

ICHARTS

I = Intake Forms

- PT order

C = Chief Complaint

- Why are they here

H = History

- Goals, medical hx, lifestyle

A = Asymmetries

- Rule out areas that are not problem, start hypothesizing

R = ROM

- Active/Passive

T = Tissues

- Play/Tone

S = Special tests

- Neurodynamics/Ortho

- Do at end to avoid provocating patient (annoying)

Strumming

Used to assess tone

Perpendicular Deformation

Used to assess play

Clinical Practice Guidelines (CPG)

Evidence-based recommendations that drive clinical decisions

- A-F; What works for whom and which situation?

- Reduce variability in care

CPG - A thru C

CAN PRIORITIZE

CPG - A

Strong Evident (Should Do)

- Hip OA

- Lateral ankle sptain

- Heel pain / Plantar Fascitis

CPG - B

Moderately Evident (May Do)

- Acute LBP (<3 months)

- Chronic neck pain

- PFPS (taping)

CPG - C

Weak Evidence (Can Do)

- Carpal tunnel syndrome

- Sub-acute neck pain to T/S + C/S

CPG - D thru F

Should NOT be part of treatment

CPG - D

Conflicting Evidence

CPG - E

Theoretical

CPG - F

Opinion (SHOULD NOT PRIORITIZE)

- STM not mentioned in multiple CPGs

Does it mean a technique does not work if it is not in a CPG?

NO -- Further evidence is just needed

Evidence Based Practice

1. Best Evidence

2. Clinical Expertise

3. Patient Values

STM - Indications

- Loss of ROM

- Scar tissue and adhesions

- Play/Tone disruptions

- Poor quality of movement

STM Contraindications

- Open Wound / Broken Skin

- Hematoma

- Fracture

- Active infection (CAN SPREAD)

- Cancer

- Acute circulatory disorders (Embolism risk)

- Skin conditions

- Advanced diabetes

- Anti-coagulant medications

- Systemic infection (cellulitis)

- Obstructive Edema (Can worsen swelling)

- Acute RA (CAN CAUSE FLARE UP)

STM Precautions

Keep STM to minimum, focus more on integration of movement

- Psychosocial factors (Anxiety, pain, fear avoidane)

- Pregnant

- Hypersensitivity

- Hyper/Hypotension

- Acute/Inflammatory stage of healing