Manual and IASTM Treatment featuring the FAKTR Concept

Transcription

1 Manual and IASTM Treatment featuring the FAKTR Concept Tom Hyde, DC, DACBSP, FRCCSS (Hon), ICSSP, FAKTR, ART, GT, CRTP, CKTP, CSTI, FICC, Adjunct Faculty UWS Cyriax Friction Massage Simple yet effective Can be time consuming Requires a functional exam Tender area is not necessarily the source of pain Hammer WI, Functional soft tissue examination and treatment by manual methods: the extremities, Aspen 1

2 Cyriax Because friction massage involves pressure and movement directed across the scar tissue, most of the theories as to why friction works are based on theories concerning the effect of motion on healing tissue. Hammer Cyriax mentioned transverse motion across the involved tissue and the resultant traumatic hyperemia as the chief healing factors of friction massage. Hammer 2

3 Cyriax Felt moving across the fibers at a right angle would not injure the normal healing tissue but would prevent the formation of or break down abnormal scar tissue. Hammer Cyriax In the acute phase, only necessary to use a light force In the chronic stages a deep, stronger friction is necessary. Hammer 3

4 Cyriax Light friction used to aid promotion of normal orientation of collagen, maintain mobility and prevent future adhesions. Recommends immediate treatment of ligament lesions to prevent adhesions. Hammer Cyriax treatment Frictioning begins lightly until a level of anesthesia begins; then the pressure is increased until a deeper level of anesthesia is reached. With this method it should be possible to arrive at the deepest tissue level within a few visits. Hammer 4

5 Cyriax treatment time A minimum of 10 minutes is usually required Depending on the thickness of the scar and the length of time the problem has existed, up to 20 minutes might be required Hammer Pin & Stretch Technique (ART ): Hands-on soft-tissue technique applied to repetitive strains, adhesions, tissue hypoxia (decreased oxygen supply), and joint dysfunction Frequently used in the treatment of Cumulative trauma disorders 5

6 How does P&S work? Used in the treatment of fascial restrictions Breaks down adhesions running perpendicular to tendon, ligament, muscle and neural tissue Allows for proper glide of adjacent soft tissue structures P&S Treatment: Utilizes passive and whenever possible active motions with a specific hand contact Passive motions are used when muscle guarding prevents proper treatment when performed actively Active motions are used whenever possible Patient has greater control over treatment Simulates normal motions between adjacent soft tissues and the neurological feed back that controls motion Modifies pain impulses via the lateral spinal-thalamic tract via movement patterns 6

7 P&S Treatment: Frequently symptoms are reproduced during treatment Treated tissue function should improve following treatment in most cases, but tissue remodeling and stabilization can take much longer Pin & Stretch Technique (ART ): A broad-based contact is taken on the area to be treated in a shorten position. Treatment can be initiated by having the clinician move the area from a shortened position to a lengthened position with a broad based contact (thumb) or the patient can actively move from the concentric to the eccentric position. 7

8 FAKTR Concepts Functional begin to think about treating patients during function, not simply in a static posture determine if the patient s condition is worse with load or no load and if with load, treat with load Kinetic look at the kinetic chain when assessing for any soft tissue injury FAKTR Concepts Treatment use your own choice of soft tissue treatment, P&S, MRT, Nimmo, PNF, Mattes - AIS, Mulligan, IASTM, Cyriax, Muscle Energy, PIR, etc Rehab why not consider using low tech rehab equipment during the treatment process in addition to post treatment 8

9 FAKTR Concepts Provocation place the patient into a position of provocation, i.e., if back pain is present when seated, treat the patient seated Motion evaluate the patient to determine if the pain is worse with or without motion, if with motion, treat with motion FAKTR Concepts Once you determine all components of FAKTR, you begin your treatment protocol Before initiating any form of treatment, a complete history and physical examination must be performed that leads you to the determination that your patient will benefit from whatever type of care you plan to utilize always remembering that your treatment MUST beat the natural history of that disorder 9

10 Bringing Soft Tissue and Exercise Rehabilitation together Rehab / proprioceptive techniques Functional movement patterns utilizing the kinetic chain Movements and/or positions of provocative to recreate symptoms, referral patterns, imbalances, instabilities, weaknesses, functional loss or injuries. Why Dynamic activities during soft tissue treatments? Through the use of active motions, functional positioning, and exercise rehabilitation during the soft tissue treatment it is possible to immediately initiate proper alignment of collagen synthesis and soft tissue remodeling through fibroblastic activity 10

11 Why Dynamic activities during soft tissue treatments? Dynamic activities force fascial planes to move against each other If there is an adhesion preventing proper fascial, muscle, ligament, soft tissue function why would we ever treat statically We can use dynamic activities to assist us in the manner in which new fibroblasts are laid down with our soft tissue treatment INSTRUMENT-ASSISTED CROSS FIBER MASSAGE ACCELERATES KNEE LIGAMENT HEALING: Dept of anatomy and cell biology, Indiana University. Loghmani, MT et al., 2006 Controlled study: 20 rats underwent surgical bilateral transection of the MCL. 7 days postoperatively GT was used on the left MCL for one minute 3x per week for 3 weeks. Results: Ligaments treated with IACFM were found to be 31% stronger and 34% stiffer than untreated ligaments. Article will appear in JOSPT. 11

12 M. TERRI LOGHMANI, PT, MS.PT, PhD. Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing july 2009 volume 39 number 7 journal of orthopaedic & sports physical therapy 12

13 Effect of IASTM on Ligamentous Healing 20R wk untreated 20R PH2 Before Treatment: Irregularly oriented and diminished amount of fibroblasts 20L wk treated 20L PH2 4wk treated The treated appears to have increased cellularity and more regularly oriented, elongated fibroblasts. 13

14 Robert Schleip states that Fascia forms a continuous tensional network throughout the human body, covering and connecting every single organ, every muscle, and even every nerve or tiny muscle. 14

15 Muscles hardly ever transmit their full force directly via tendons into the skeleton but rather distribute a large portion of their contractile or tensional forces onto fascial sheets. In turn, these fascial sheets transmit there forces to both synergistic as well as antagonistic muscles when means they stiffen not only the respective joint, but may even affect regions several joints further away. Schleip Fascia is densely innervated with many sensory nerve endings including mechanoreceptors and nociceptors, which can become the source for acute myofascial pain. Fascia also has the ability to contract. Fascia has a blood supply in addition to a nerve supply and lymphatics. These coupled with it s ability to contract raises the possibility for classification as an organ. Schleip 15

16 With the FAKTR-PM concept, we place focus on areas or regions rather than on origins and insertions. We look at regions and how these regions overlap or interconnect, rather than treating isolated, individual muscles. One important aspect of what we stress is how groups of muscles and fascia work together. Example: The shoulder. FAKTR Protocols and other manual and IASTM methods: Following a complete history and examination, if appropriate, initiate FAKTR Treat Re-evaluate Re-treat up to 3 times 16

17 Caveat: If you treat a patient with FAKTR and they exhibit excellent results but those results are short lived (1-2 days), and this scenario is repeated for 2-3 treatments, there is a strong possibility that the patient does not have a MSK disorder but some non-msk. Please reassess, send for a second opinion or consider diagnostic workups. Treatment is initiated as follows: 1. Site of pain: 1. Pain that is local or distal to what is perceived to be the involved structure 2. Loss of ROM 3. Loss of function 4. Tightness: Felt by clinician and patient On evaluation, tissue does not feel normal to either the patient or the clinician 17

18 Eccentric Training for Tendiopathies Research has shown that treating tendinopathies in the eccentric phase can be effective. Studies exist currently on the following body parts: Achilles tendon Patellar tendon Proximal lateral elbow Rotator cuff Eccentric Training for Treatment of Tendiopathies, Murtaugh, Bryan and Ihm, Joseph M. Training, Prevention, and Rehabilitation: Current Sports Medicine Reports, 2013 Am College of Sports Med; X/1203/ Literature Review Medial collateral ligament (MCL) -most commonly injured knee ligament Mechanism of a lateral to medial force causing excessive valgus displacement Athletes involved in contact sports have a higher incidence of this injury (Dressendorfer 2014). Management of injuries is under debate Surgical intervention to conservative management. Conservative treatment shows beneficial return to pre-injury levels over long-term measurement (Brotzman 2011). 18

19 Case Review Player injured Oct 18 Player fell into lateral leg, forcing valgus collapse Initial assessment by University med staff Grade 2; possible 3 8 to 10 week RTP Season over Presents Oct 19, non-weight bearing on left knee 18-Y.O. Soccer player with MCL Tear 7/10 pain (L knee) Mild, medial joint effusion Significant medial pain with palpation (-) Lachman s (-) Post. Drawer (+) Valgus Stress 10 deviation MRI report indicates severe Grade 2 Possibly Grade 3 Other knee ligaments intact, including meniscus 19

20 Intervention Goal was to return player to competition in 4 weeks for NCAA tournament Pending clearance by the university s team physician. Primary treatment method was IASTM utilizing FAKTR-brand instruments and FAKTR protocol Following assessment, initiation of the FAKTR Concepts was initiated The athlete was having difficulty going up and down stairs secondary to loss of ROM and pain Gait on flat surface was also significantly reduced and painful with loss or ROM Treatment was first given in the position of provocation 20

21 Length of each treatment was approximately seconds Following each treatment, the athlete was returned to a neutral, non-painful position, then asked to assume a position of provocation once more This process continued and included having the athlete attempt to flex or extend the knee as far as possible, while also receiving treatment with motion, in and out of flexion and extension Various low tech items were used during treatment such as: Therabands, BOSU, stability pad, ijoyboard The 5 Concepts indluded: Static - valgus, flexion, extension Motion - in and out of valgus, flexion and extension, climbing and descending stairs, medial and lateral movements so simulate a kick with zero resistance and very slowly Resistance with elastic bands attached with athlete attempting to kick a ball with the medial and lateral side of foot Function squatting, kneeling, walking, climbing and descending stairs Proprioception BOSU, Stability pad, ijoyboard, single leg stance 21

22 Treatment was both manual and with Instrument Assisted Soft Tissue Mobilization (IASTM) FAKTR Instruments were used with an emollient to reduce friction Cross Fiber Friction described by Cyriax was performed except friction was given in all directions, not just 90 degrees to the fiber Pin and Stretch or Myofascial Release also given Kinesiology tape was utilized in an attempt to offer a feeling of stability, aid in ROM and reduce pain. Intervention Weeks One & Two IASTM with active, provocative movement (daily) Class IV laser therapy (daily) Aquatic therapy (2x daily) Myofascial release (as needed) Note: No bracing was used during rehab (taping only) 8 treatments in office 3/10 pain, normal gait, body weight squat, single leg stance 22

23 Intervention Weeks One & Two IASTM with active, provocative movement (daily) Class IV laser therapy (daily) Aquatic therapy (2x daily) Myofascial release (as needed) Note: No bracing was used during rehab (taping only) 8 treatments in office 3/10 pain, normal gait, body weight squat, single leg stance Intervention Weeks One & Two IASTM with active, provocative movement (daily) Class IV laser therapy (daily) Aquatic therapy (2x daily) Myofascial release (as needed) Note: No bracing was used during rehab (taping only) 8 treatments in office 3/10 pain, normal gait, body weight squat, single leg stance 23

24 Intervention Weeks 3 & 4 Rehabilitation focusing on: Functional strength Sprinting Cutting Kicking Plyometrics RTP IASTM used with provocative exercise as needed Laser used as needed 8 treatments in office Outcomes Return to play assessment Nov 16 0/10 pain All provocative testing normal Agility, strength, sprinting & sportspecific skills normal with no pain Referred back to team MD Cleared by MD Nov days total Competed in 2 games of NCAA tourney No complaints or injury 24

25 Lateral Ankle Sprain Ankle Anatomy Ankle Joints Talocrural (ankle Mortice) Subtalar Distal Tib/Fib Ligaments Peroneals Tibialis Anterior Ext Hallucis Longus Ext Digitorum Gastroc/Soleus Flex Hallucis Flex Digitorum Tibialis Posterior 25

26 Talocrural Joint Dome of the talus Medial Malleolus Lateral Malleolus Distal Tibia Transmits torque from the lower leg to the foot Internal and external rotation at leg Pronation and Supination at foot Joint Capsule Anterior talofibular ligament Lateral malleolus to talus Prevents anterior displacement, resists inversion and internal rotation Demonstrates the lowest maximal load and energy failure Calcaneofibular Ligament Lateral malleolus to calcaneus Resists supination, internal rotation, inversion (most taut with these motions and dorsiflexion) Posterior Talofibular ligament Lateral malleolus to talus Resists inversion and internal rotation Deltoid Ligament Ligaments of Talocrural Joint 26

27 Subtalar joint Anterior Subtalar Calcaneus (sustentaculum tali) Talus Navicular Posterior Calcaneus Talus Converts torque from leg to foot Ligaments of Subtalar Joint Deep Ligaments Cervical Anterior cruciate Resists supination Interosseous Posterior cruciate Resists pronation and supination Extensor Retinacula Lateral root (within sinus tarsi) Interosseous Ligament Cervical Ligament 27

28 Ligaments of Subtalar Joint Calcaneofibular Ligament Resists inversion and internal rotation Lateral talocalcaneal ligament Resists supination Fibulotalocalcaneal ligament Resists supination LTCL Distal Tibiofibular Joint Syndesmosis Accessory gliding high ankle sprain 28

29 Ligaments of Distal Tib/Fib Joint Interosseous Membrane Anterior Inferior Tibulofibular ligament Injured in supination and external rotation High ankle sprain Weaker of the two Posterior Inferior Tibulofibular ligament Injured in pronation and external rotation Muscular Anatomy Lateral Compartment Peroneus longus Peroneus Brevis Anterior Compartment Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum Superficial Posterior Compartment Gastroc Soleus Deep Posterior Compartment Tibialis Posterior Flexor Hallucis Longus Flexor Digitorum 29

30 Lateral Compartment Peroneus Longus Attachments Lateral Head of Fibula and shaft Base of First Metatarsal and lateral border of medial cuneiform Nerve Supply Superficial Peroneal Nerve (L5,S1) Action Plantar Flexion and Eversion Lateral Compartment Peroneus Brevis Attachments Distal 2/3 Fibular shaft Base of 5th Metatarsal (styloid process) Nerve Supply Superficial Peroneal Nerve (L5,S1) Action Plantar Flexion and Eversion 30

31 Anterior Compartment Tibialis Anterior Attachments Inferior Lateral Tibial Condyle, Lateral 2/3 tibial shaft Medial surface of Medial Cuneiform and medial base of 1 st Metatarsal Nerve Supply Deep Peroneal (L4,5) Action Dorsiflexion and Inversion Anterior Compartment Extensor Hallucis Longus Attachments Middle 2/4 th of the Fibular shaft Dorsal surface of the distal phalanx of the hallux Nerve Supply Deep Peroneal (L5,S1) Action Dorsiflexion of Hallux and foot 31

32 Anterior Compartment Extensor Digitorum Attachments Lateral Tibial Condyle, Upper 3/4 th of the Fibular shaft Dorsal surface of the middle and distal phalanx of the lateral 4 toes Nerve Supply Deep Peroneal (L4,5,S1) Action Extension of lateral 4 toes and foot and assist in Dorsiflexion of foot Mechanism of Injury Acute Chronic Mechanical Instability Pathologic Laxity Arthrokinematic Impairments Synovial and Degenerative Changes Function Instability Impaired proprioception and sensation Impaired Neuromuscular Firing Patterns Postural Impairments Strength Deficits 32

33 Acute Ankle Sprain Excessive supination of the rear foot about an externally rotated lower leg after initial contact of the rear foot during gait or landing from a jump ATFL first and most commonly injured of the lateral ligaments CFL 2 nd most commonly injured PTFL only sprained in severe injuries (often accompanied by fractures &/or dislocations Grading of Ankle Sprains Grade I: Decreased ROM, strength WNL, mild swelling, tenderness over ATFL, slight antalagia, negative Anterior Drawer test Usually mild injury to ATFL Grade II: Decreased ROM with painful ROM, pain on MMT of everters, mild to moderate swelling, tenderness over ATFL & CFL, antalgic gait, positive Anterior Drawer test Involvement of ATFL and CFL Grade III: Moderate to severe swelling, tenderness over ATFL, CFL, PTFL, antalgic gait, positive anterior drawer test and talar tilt test, instability Involvement of ATFL, CFL, PTFL, associated with fractures and/or dislocation 33

34 Pathological Laxity Result of ligamentous damage Chronic ligamentous injury results in joint instability during functional activities resulting in eventual injury to the joint structures Most often at the talocrural and subtalar joints ATFL ligament injury the talus is able to excessively supinate Arthrokinematic Impairments Fibular head displacement Mulligan reports with chronic ankle instability the fibular head displaces anteriorly and inferiorly With this positioning, the talus can go through a greater range of supination before the ATFL becomes taut Decreased ankle Dorsiflexion Prevents the talocrural joint from reaching its closedpack position allowing for greater internal and inversion motions Increases pronation at the subtalar joint Posterior mobilization of the talus on the tibia recover dorsiflexion more quickly after a sprain 34

35 Impaired Neuromuscular-Firing Patterns Decreased reflexive response times of the peroneal muscles to inversion or supination Impaired proprioception Slowed nerve-conduction velocity Central impairments in neuromuscular-recruitment strategies Deficits in Bilateral Gluteus medius recruitment with severe unilateral ankle sprain Impaired Postural Control Impaired single leg stance demonstrated after both acute and those with a history of repetitive ankle sprains Combination of impaired proprioception and neuromuscular control 35

36 Impaired Postural Control Ankle Strategy Foot pronates and supinates to maintain body s center of gravity during single leg stance Those with chronic instability demonstrate hip strategy Less efficient Due to changes in central neural control in presence of ankle dysfunction Strength Deficits Demonstrated in both eversion and inversion Debate as to reason Weakness due to muscle damage or impaired neuromuscular recruitment 36

37 PHYSICAL EXAMINATION Range of Motion Passive and Active Range of Motions Flexion Extension Inversion Eversion Internal Rotation External Rotation 37

38 A-P Drawer ATFL sprain/tear Pain Laxity Inversion Stress Test CFL sprain/tear Pain Laxity 38

39 Eversion Stress Test Deltoid Ligament sprain/tear Pain laxity Internal Rotation Stress Test Posterior Deltoid Ligament and ATFL Pain, Laxity 39

40 External Rotation Stress Test PTFL and Anterior Deltoid Ligament Pain, laxity Stresses Distal Tib/Fib Syndesmosis 40

41 41

42 42

43 43

44 44

45 Bibliography (text books) Evans RC. Illustrated essentials in orthopedic physical assessment. Mosby; Hyde TE, Gengenbach MS. Conservative management of sports injury. Williams and Wilkins; Hammer WI. Functional Soft Tissue Examination and Treatment by Manual Methods. Aspen; Bibliography (ankle sprain) Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training. Dec 2002;37(4): Osborne MD, et al. The effect of ankle disk training on muscle reaction time in subjects with a history of ankle sprain. Amer Jour Sports Medicine. Sept 2001;29(5):627 Green T, et al. Randomized controlled trial of passive accessory joint mobilization of acute ankle inversion sprains. Physical Therapy. April 2001;81(4):984 Bassewitz HL, et al. Persistent pain after ankle sprain: targeting the causes. The Physician and Sportsmedicine. Dec 1997;25(12):48 45

46 Bibliography (ankle sprain) Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training. Dec 2002;37(4): Osborne MD, et al. The effect of ankle disk training on muscle reaction time in subjects with a history of ankle sprain. Amer Jour Sports Medicine. Sept 2001;29(5):627 Green T, et al. Randomized controlled trial of passive accessory joint mobilization of acute ankle inversion sprains. Physical Therapy. April 2001;81(4):984 Bassewitz HL, et al. Persistent pain after ankle sprain: targeting the causes. The Physician and Sportsmedicine. Dec 1997;25(12):48 46