STM Exam Review

Soft Tissue

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

- Muscles + Tendons + Ligaments + Fascia

- Nerves, fibrous tissues, blood vessels, synovial membrames

Microadhesions

Small areas of restriction in tissues w/ decreased ground substance + presence of fatty fibro-infiltrates

Macroadhesions

Larger areas of restricted tissue under conditions of long/large amounts of immobility

- With or Without injury/trauma

What causes microadhesions?

Decrease of ground substance + presence of fatty fibroinfiltrates

What causes macroadhesions?

Long / large amounts of immobility, with or without injury/trauma

What does ground substance provide

Tissue glide

Microtrauma

From repetitive, low-force stressors over time

- Leading to chronic overuse injuries

Macrotrauma

Single, high-force event causing immediate acute injury

Fascia

Soft tissue, continuous 3D matrix of structural support

- Dynamic sensory network

- Supports everything in body

- Superficial + Deep

Superficial Fascia

Houses superficial vessels (blood, nerves, lymph)

Deep Fascia

Envelops all muscle in body

- Fxn is to transmit muscular forces at a distance

What does fascia transmit/transfer?

FORCE

Does fascia have a sensory component?

YES -- DYNAMIC SENSORY NETWORK

- Muscle spindles activate when fascia is stretched --> Inform CNS

- Allows smooth and safe movement

Normal Healing

LINEAR WITH DISTINCT END POINT

- Local response (inflammation, fibroblasts, maturation)

- Decreased mobility due to space reduction

Effects of Immobilization

1. Loss of ground subtance

2. Fibrofatty infiltrates --> MACROADHESIONS

Both contribute to microadhesions

Injury/Trauma + Immobilization

- Macroadhesions (shortens tissues, decreases play, restricts ROM)

- Homogenous change in entire fabric (shrinking)

Cyclical --> Continues if irritant is present

Fibrosis

Too much healing --> Limits mobility, elasticity, force transmission

STM Mechanical Model

Tissue deformation changes soft tissue

- Changes to hyaluronic acid --> Decreased ground substance

- Decrease ECM space

- Inflammation response

- Compensations

STM Neurological Model (Dermoneuromodulation)

Changes in soft tissue are primarily due to NS

- NOT from reshaping tissue

- Stimulation of muscle spindles + GTOs --> NS Modulation

- Reduction in activation (relax)

STM Biotensegrity Model

Change in tension anywhere is instantly signaled everywhere in body

- Muscles dynamically adjust as fascia distributes force

- Spine = Tensegrity tower --> Integrates w/ system

Current thought as to why STM is effective

ALL THREE MODELS PLAY A ROLE

How to assess tissue play

Perpendicular Formation

How to assess tone

Strumming

FABQ

Fear Avoidance Beliefs Questionnaire

What is the importance of outcome measures such as FABQ?

Yellow flags can influence outcome of PT, must address!

CPG - Category A

Strong Evidence that STM is beneficial for:

1. Hip OA

2. Lateral Ankle Sprain (recurrent)

3. Plantar Fasciitis

CPG - Category B

Moderate Evidence that STM is beneficial for:

1. Acute LBP (< 3 months)

2. Chronic Neck Pain

3. Patellofemormal Pain Syndrome

STM Indications

- Loss of mobility and ROM

- Scar tissue + tissue adhesions

- Play and Tone distruptions

- Poor quality of movement

STM Contraindications

- Active infection

- Acute circulatory disorders

- Systemic infection (cellulitis)

- Obstructive edema

- Acute RA

- Broken skin / open wound

- Hematoma

- Healing fx

- Cancer

- Skin conditions

- Anti-coagulants

STM Precautions

- Psycosocial yellow flags (anxiety, pain catastrophizing, fear)

- Pregnant

- Hypersensitive

- Hyper/hypotension

- Acute/inflammatory stage of healing

Trigger Point

Localized area of increased sensitivity in tight area

- Taut, local pain, restricted ROM

Active Trigger Point

Spontaneously painful, pain at rest

- Specific referred pain patterns

Latent Trigger Point

Pain only on compression

Trigger Point - Signs + Symptoms

- Tightness

- Local pain

- Asymmetries

- Decreased ROM

- Muscle weakness

What is the most effective treatment for trigger points?

Sustained Pressure ~ 10-100 seconds

- Aim for intensity of 4-7, start gentle

Trigger Point Treatment - Technique Options

ALL IN COMBO WITH EXERCISE / STRETCHING

- Sustained pressure

- Small kneading strokes (friction)

- Parallel strokes (know direction of fibers)

- Pinching compression

- Dry needling

Trigger Point Treatment - Duration

10 - 100 seconds

Trigger Point Treatment - Intensity

4-7 on pain scale

- Start gentle

- Augmentation techniques to make less aggressive

Upper Trap - Muscle Referral Pattern

RAM'S HORN

Psoas - Muscle Referral Pattern

LBP

- L3 dermatomal pattern

Visceral Referral Pain - Characteristics

- BP changes

- Nausea

- Sweating

- Deep/inside pain (not superficial)

Fibromyalgia

Chronic Pain Syndrome; Differential dx for myofascial pain syndrome

- Sleep disturbance

- Systemic

- Psychosocial factors

- Fatigue

- dx with 18 specific points, 11/18 painful for dx

Myofascial Pain Syndrome

Chronic pain disorder affecting muscles and fascia

- Treatment goal = reduce TP irritability

- Restricted ROM + Muscle weakness

- Feeling of "knots"

How soon can you mobilize a scar?

As early as 2 weeks

- Once surgical incision is closed

How late can you mobilize a scar?

Up to 2 years

- Can still make some impact after

Acute Scar Treatment

Approximation

Scar Treatment > 2 Weeks / once scar is closed

Half circles using 2 fingers

- WITHOUT SEPARATING INCISION

- Periwound area first, then over length of scar

- Lateral pulls perpendicular to scar

Scar Treatment > 4 Weeks

Cross friction

- Perpendicular to line of scar

Scars - Superficial STM Interventions

- MFR (shearing + torsion)

- Skin rolling

- Cupping

Scar Mobilization - Goals

1. Put beneficial stress through new tissue

2. Improve Sensations (sensitivity, itchiness)

3. Improve Circulation

Scar - Phases of Healing

1. Inflammatory Phase (1-10 days)

- GOAL = Protect fragile tissues

2. Proliferative Phase (3-21 days)

- Collagen guides alignment

- Capillaries bud + granulation tissue fills wound

3. Maturation Phase (7 days - 2 years)

- Remodeling! Fiber reorganization + scar contraction

- Load progressively

- Pale, flat, pliable

What do you pair with self myofasical release (MFR)?

Stretching

Theragun Surface Area

Smaller = MORE INTENSE

Larger = LESS INTENSE

Myofascial Meridians - Treatment Benefits

Can impact a sensitive area by manipulating elsewhere

Regional Interdependence

Point of restriction may be away from point of pain

How do you put tension on the superficial back line?

Downward Dog position

What physical activity loads the functional line?

Cross-body rotational movements

- Throwing

Deep Frontal Line - Function

Myofascial Core; Provides stability + Position changes to core structure

- Lifts inner arch of foot

- Stabilizes legs, pelvic floor, chest

- Supports lumbar spine from front

- Balances neck and head

Deep Frontal Line Dysfunction

Causes fxnl restriction over time which may appear elsewhere

- NOT acute change, but chronic

Proximal stability = Distal mobility

MFR Progression

External to internal

1. Manual application

2. Myofascial Rebounding

3. Myofascial Unwinding

What happens when you increase the instrument angle during IASTM?

Increased angle = Increased intensity

IASTM - Indications

- Limited motion

- Pain during motion

- Motor dysfunction (poor patterns)

- Lack of tissue glide

Wet vs Dry cupping

Wet = Incisions and blood

Dry = No incisions / blood

What cupping technique is used when working with a new patient?

Stationary Cupping

What cupping technique can be stimulating?

Fast moving cupping

Cupping - Treatment Time

3-5 minutes

Cupping - Treatment Intensity

< 7/10

- Start with 1-2 pumps

Cupping - Indications

- Decreased ROM / flexibility

- Inflammation

- Pain

- Headaches

- TPs

- Poor scar healing

Cupping - Goals

- Improve circulation

- Alleviate adhesions

- Clear congestion + stagnation

- Lift, rehydrate, manipulate fascia

- Neovascularization

- Reduce pain by alleviating pressure on sensory organs

Cupping - Contraindications

- Dry / Cracked skin

- Contagious skin condition

- Open wound

- Compromised joints

- Over umbilicus

- Bleeding disorders

- Anemia

- Muscle dystrophy

- Excessive swelling

- DVT

- Varicose veins

- NEW tattoos

Lymphedema - What happens to transport capacity?

Transport Capacity is REDUCED

- Lymph load remains normal

What happens to osmotic pressure with increased altitude?

INCREASES

- Pushes fluid out --> EDEMA

- Wear compression on airplane

What causes dynamic insufficiency (edema)?

- CHF

- Chronic venous insufficiency

- Immobility

- Pregnancy

- Pressure from tight jewlery, bandages, garments (tourniquet effect)

What is strictly contraindicated with edema caused by cardiac insufficiency?

Compression therapy and manual lymphatic drainage

Lymphedema - Exam Findings

- Chronic swelling

- Localized pain / "heaviness"

- Atrophic skin changes

- Secondary Infections (cellulitis, lymphangitis, erysipelas)

Cellulitis

Acute infection of skin and deep tissues

- May be life threatening

Lymphangitis

Infection of lymphatic vessels

- Often results from cellulitis

- May be life threatening

Erysipelas

Acute dermal infection impacting skin + subq tissues

- Includes lymph vessels + nodes

What typically causes primary lymphedema?

Congenital malformations

- Hypoplasia (most common; less lymph vessels)

- Hyperplasia (larger than normal lymph vessels)

- Aplasia (absence of lymph vessels

Lymphedema - Stages

Stage 0 (Latency) = No Signs/Symptoms, cannot see or measure

- Patient education

- Automatic after surgery

Stage 1 (Reversible) = Edema only, visible swelling

- Soft + pitting

- Reduce w/ elevation overnight

Stage 2 (Spontaneously Irreversible) = Fibrosis

- Constant pressurw to break up fibrotic tissue over time

- Must wear garments, complete decongestive therapy

- Positive stemmer's sign

Stage 3 = Lymphostatic Elephantiasis = Skin Changes + Increased Vol.

- Papillomas

- Positive stemmer's

- Frequent infections

What dictates lymphedema stage?

Tissue quality, NOT size

Lymphedema Diagnosis - Gold Standard

Lymphoscintigraphy (LAS)

- Maps lymphatic system

Stage 0 Lymphedema - Priority

Patient education

Stage 1 Lymphedema - Priority

Reverse to latency stage via elevation overnight

Stage 2 Lymphedema - Priority

Constant pressure to break up fibrotic tissue over time

Stage 3 Lymphedema - Priority

Prevent further infection, reduce size + tissue hardening

When do you see a positive stemmer's sign?

Lymphedema Stages 2 + 3

- Skin cannot be lifted on dorsum of toe

What procedure is recommended for measuring a lymphedema pt's limb?

Circumferential

- Taken in intervals of 4-6 cm along extremity

- Summing measurements

- Volumetric is more cumbersome

Lymphedema - Augmentation Techniques

- Deep abdominal technique

- Diaphragmatic breathing (at least 10x am and 10x pm)

- Decongestive exercises

Short Stretch Bandaging

Used to manage lymphedema

- Maintain decongestive affect achieved from MLD session

- Prevent re-accumulation of fluid into tissues

Exercise for patients in complete decongestive therapy (CDT)

Light exercise progressing appropriately

- Encourages movement of lymph fluid out of limb

Where is the highest density region for lymph nodes in the body?

Abdominal Region

Which kinesiotaping application is used for lymph correction / swelling?

"Fan" Strip, channeling technique

- Lifting effect on skin, decreasing pressure + facilitating fluid flow

- 10-15% tape stretch

What info does muscle play assessment give?

- Functional strength

- Flexibility

- Imbalances

- Neuromuscular control

What info does muscle tone assessment give?

Muscle's underlying tension + resting resistance to passive movement

Kinesiotaping - Proposed Effects

SKIN

- Decrease painful, abnormal sensations

MUSCLE

- Assists or inhibits function

JOINT

- Improves alignment + proprioception

LYMPHATIC

- Facilitates local circulation + lymphatic flow