Soft Tissue Examination and Intervention Part I

100th monkey effect

- an analogy of how manual therapy techniques become part of clinical practice

clinical reasoning model

- hypothesis

- biopsychosocial model

- ICF model of disablement

- best research evidence

the impact of language in musculoskeletal rehabilitation

- the words clinician use can either heal or cause devastating lasting harm

- the worry associated with medical problems can lead to a perpetual search for answers in web searching, physician hopping, etc.

- mounting evidence that psychological factors are more accurate predictors of pain and disability than are pathoanatomic factors

sticks and stones main ideas

- clinicians needs to be conscious about how their words are interpreted by the patient

- there are no do overs, once you say it, you can't take it back

- clinicians can liberate patients from unnecessary worry and disability

- some patients are predisposed to see the negative rather than the positive

- use different metaphors

- you don't need to impress patients with latin words

motivational interviewing

- use open ended questions

- affirmations

- reflections

- summary

fascia

- continuous 3-dimensional web like network of fibers and fibrils, extending from the surface of the skin to the periosteum

- fascia extends from the inner aspects of the skull down to the soles of the feet

- largest interconnected system in the body

what does fascia do

- surrounds, protects, supports, and communicates with every structure of the human body

- fascia makes up the shape and form of the body itself

multi fibrillar system

- fascia is made up of a network of fibrils with variable lengths and thicknesses, giving a disordered and chaotic appearance

- made up of collagen Type I (70%), III, IV (10%) and elastin (20%)

collagen

- an insoluble fibrous protein made up of amino acids that give the fibers strength and resilience

- wave like "crimping" pattern that provides some degree of stretch

elastin

- a protein made up of smaller amino acids that lends elasticity and flexibility to tissue

- absorb tensional forces up to the limit of collagen fibers

- think spandex: a synthetic fiber that is woven into other fabrics to provide elasticity to garments

fibrils

- can lengthen, slide along one another, and divide into two or three separate fibers while still maintaining tissue continuity

- allows for absorption and dispersion of energy

ground substance

- a highly hydrated viscous proteoglycan gel that embeds the fibers

- lubricates the fibers and maintains critical inter fiber distance, assists with absorbing and distributing forces throughout the body

contents of ground substance

- proteoglycans

- glycosaminoglycan chains

proteoglycans

- consist of a core protein with one or more attached glycosaminoglycan chains (GAG)

GAG chains

- hydrophillic

- they attract and absorb water into the multi fibrillar system

viscous colloid

- a solid material suspended in fluid

- ex: ground substance

- colloids are not compressible and respond to pressure in a distinct way

- idea of thixotropy

thixotropy

- less/low and slow pressure results in a greater response (less viscous ground substance)

- a firmer and quicker response results in resistance (more viscous)

myofascial release

- a low load, long duration stretch of soft tissue

- its effectiveness is thought to be related to improving motility of ground substance (changing the viscosity)

improvement in flexibility via foam rolling is

- more likely the result of changes in viscosity vs. lengthening the tissue

temperature affect on ground susbtance

- ground substance is more fluid at higher temperatures (heat up tissue before you lengthen)

- more firm at lower temperatures

how can bodywork improve mobility

- more likely to influence fluid dynamics than to loosen tissue

- however, there is some degree of lengthening by freeing up bound fascial elements

composition of fascia

- the specific composition is dependent on its function

- tensional and compressional demands influence the fiber arrangement, length, and density

- most fascia allows for free and easy movement in multiple directions, however some fascia is denser and providers greater stability

tensegrity

- term coined by Buckminster Fuller

- american architect who introduced the element of tension into construction rather than using traditional brick and mortar

- he used steel beams and cables to create tensional forces that share the loading across the entire structure

biotensegrity

-in the human body tensegrity is referred to as biotensegrity

- bones are the steel beams, and the fascia is the cables

- fascia shares loading across the entire form to provide stability

- allow for upright posture and dynamic movement

hookes law of elasticity

- states stress in a material is directly proportional to the strain as long as the elastic limit has not been reached

- explains how the network of fiber and fibrils adapt to internal and external stress

- in stretch: ground substance is squeezed out

- release strentch: fluid goes back into tissue

what does a cell consist of

- cell membrane

- nucleus

- separated by cytoplasm

- the cell membrane separates the extracellular matrix/fascia from the material inside the cell, intracellular

what does the cell membrane maintain

- it maintains the integrity of the cell

- controls the passage of material into and out of the cell

what is the extracellular matrix

- the hydrated multifibrillar fascial network

what is inside the extracellular matrix

- groups of cells with specific, specialized functions

- cells are found in large clusters along micro-capillaries

- macrophages: derived from monocytes, phagocytic type cells that move throughout the body

- fibroblasts: responsible for making the structural framework that supports and connects other tissues and organs

- mast cells: found within the tissues

integrins

- transmembrane adhesion proteins that link the extracellular matrix to the cells cytoskeleton

mechanotransduction

- as the structural form of the cell alters in response to the applied load, processes are triggered involving chemical signaling that influences cellular activity

- cells are mechanically dependent on the fibers to which they are attached

- the process by which cells convert physical, mechanical stimuli into biochemical acivity

how does tension alter cellular activity

- tension along a fiber that connects to an integrin changes the orientation, position, and shape of the cells influencing cellular activity

- this is called mechanotransduction, whereby a mechanical stimulus is converted into biomechanical activity

how does manual therapy work with mechanotransduction

- it not only modifies tissue structure but also can influence cell function through force transmission

- the fascial system is responsible for maintaining metabolic homeostasis and restrictions in the fascia can influence a multitude of systems and malfunction

- this may be the reason why patients feel relief from a wide variety of systems after body work

what happens during normal movement of the fascial system

- blood vessels and nerves are protected by the fibrillar network

- before each fiber reaches its maximal stretching point, it recruits the adjacent fiber to disperse the force

- fibers can also slide along a node or divide into two or three fibers

what happens when fascia is damaged

- damaged tissue will be repaired, but not always the exact former state

- the greater the tissue damage, the less successful the repair

- the repair process is the same for dermis, muscle, tendon, ligaments, every structure in the human body

purpose of a scar and healing

- a scar does not have any functional use, its sole purpose is to PLUG the gap in damaged tissue

- the repair process is very non-specific

- where adhesions form, the fibers are wider and bunched tightly together, void of blood vessels

- thickened Type I collagen arrange haphazardly like a patch

- suppleness and flexibility is replaced by stiffness and loss of intrinsic mobility

inflammatory phase

- begins immediately, lasts 24-48 hours

- histamine and heparin are released and blood flow increases (heat, redness, swelling)

- prostaglandins produce pain (warning body to protect itself from further damage)

granulation phase

- macrophages, leukocytes and neutrophils debride the area and prepare the wound for healing, capillary budding begins

fibroblastic phase

- rebuilding of tissue

- collagen is synthesized in a disorganized manner

- cross linking allows for early movement without disruption of the wound (immobilization)

-high metabolic tissue (muscle, skin, etc) 5-8 days

- low metabolic tissue (ligaments, tendons, etc) 3-5 wks

what can lack of movement cuase

- lack of movement due to immobilization or prolonged postures can lead to loss of ground substance and inter-fiber cross linking

maturation phase

- remodeling, 3 weeks to 12 months, involves remodeling of collagen in response to normal stress produced with functional movement

- unfortunately, depending on the degree of damage and the amount or lack of early movement, mobility may never return to normal, and the body may be left with some level of impairment

how does inflammation affect fascia

- low grade irritation caused by joint dysfunction, poor posture, overuse, habitual patterns, or movement imbalances

- no clear-cut stages like wound healing, homogenous processes, cyclic, effects the entire fabric of the connective tissue

what do macrophages & fibroblasts do during inflammation

- are activated to clean and debride the area of inflammatory exudates and microdamaged collagen

- fibroblasts repair damaged collagen

- haphazard laying down of collagen

- loss of ground substance and water, fibers stick to one another, creating progressive stiffness and loss of intrinsic flexibility

myofibroblasts

- appear and anchor to adjacent collagen fibers and contract

- this shrinks the tissue (frozen shoulder)

- tissue shrinkage results in further dysfunctional movement

- viscous cycle

inflammation cycle of fascia

- chronic irritant

- macrophages activated

- increased vascularity

- increased fibroblastic activity

- increased production of connective tissue (fibrosis)

- increased myofibroblastic activity

- shrinkage of connective tissue

- abnormal movement (biomechanics)

- repeat

how does manual therapy effect fascia

- gentle massage can be performed during the inflammatory phase to increase circulation, improve lymphatics, guide orientation of collagen fibers, and modulate pain

- more mechanical techniques (myofascial release) can be used during ground tissue remodeling to increase ground substance and break collagen cross links and adhesions to restore mobility and felixibility