GO Competency Lab Manual Therapy: Soft Tissue Mobilization (STM) 1. Basic Considerations of Manual Therapy

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1 Manual Therapy: Soft Tissue Mobilization (STM) 1 Upon completion of this lab, clinicians will be able to: 1. Demonstrate the ability to assess soft tissue relative to an orthopedic patient 2. Understand the ability to differentiate normal from abnormal joint end feel related to pain, stiffness, and abnormal movement patterns as a result of soft tissue restriction 3. Asses and appropriately establish a manual therapy treatment plan designed specifically for STM and each identifiable problem that at a minimum utilizes passive stretch techniques 4. Discuss the importance of including these findings in the overall treatment plan Note: It is recognized that mastery of soft tissue mobilization techniques can involve a significant investment of time. We also recognize the value of shared practice experience. This lab is meant to be an overview and a guide to stimulate discussion, demonstration and sharing of ideas and techniques related to soft tissue mobilization and treatment strategies. The strategies you choose to demonstrate as a group should be guided by the practice experience, knowledge and formal training. All clinicians should recognize their own limitations and practice within the scope of their skill level Basic Considerations of Manual Therapy Two primary types of Manual Therapy 1. Soft tissue mobilization (STM) o Myofascial restrictions o Scar tissue (fibrosis) o Capsuloligamentous tightness o Musculotendinous adaptive shortening 2. Joint mobilization (JM) o Hypomobilty o Hypermobility Consider STM first soft tissues and joints work in collaboration Healthy tissues are happy tissues o Tissue integrity depends upon nutrition, hydration, and function Manual therapy techniques can be combined eclectically based on the needs of the patient, treatment progression, or skill of the clinical associate Two barriers to consider o Physiological barriers Soft tissue tension limits further voluntary ROM, but additional ROM can be introduced by external means o Anatomic barriers This serves as the final barrier of ROM; movement beyond this point may cause tissue damage Less is more begin gradually with continual reassessment Hand placement or patient contact o One hand or point of contact will typically stabilize while the other hand or point of contact performs the movement or treatment Consider precautions or contraindications (not all inclusive) o Fracture, infectious arthritis, tumors, osteoporosis, joint ankylosis, acute inflammatory disorders, technical skill of clinical associate Cardinal Rule: Treatment interventions must never be forcibly passed through protective spasm

2 Manual Therapy: Soft Tissue Mobilization (STM) 2 Elements and Principles of Assessment Approaches Observation, Inspection and general appearance Involved versus uninvolved side and overall functionality Morphology (ecto, meso or endo) and/or obesity Muscular changes (disuse atrophy, overuse hypertrophy) Preferred positioning, contracture, adaptation, guarding, alignment, etc Integumentary status - skin color changes should be noted when appropriate (i.e. erythema, pallor, cyanosis, ecchymosis), new or old surgical wounds, wound status, etc Soft Tissue Palpation and Assessment Skills Light touch Temperature, texture, moisture, tension (skin mobility, ligamentous assessment) Deep touch Tenderness, compression, or shear forces Observation Integumentary status - skin color changes should be noted when appropriate (i.e. erythema, pallor, cyanosis, ecchymosis), edema, new or old surgical wounds and status, etc Special Considerations Do not apply excessive pressure or movement of the hands Joint Play Assessment Skills Glide and/or separate the joint surfaces without angular movement to a given joint Joint play is greatest in the maximal loose-packed position 1. Loose packed position is defined as the position in which the joint capsule is most relaxed and the greatest amount of joint play is possible 2. Closed packed position is when the joint capsule and ligaments are maximally tight. Maximal contact of the convex and concave surfaces is achieved. While in the closed-packed position, mobilization cannot be performed. Avoid joint compression during assessment of end feel Joint End Feel Evaluation Normal End Feel 1. Soft Soft tissue approximation and/or stretching 2. Firm Capsuloligamentous stretching 3. Hard Bone-to-bone stop Abnormal End Feel 1. Less elastic Scar tissue or due to adaptive shortening 2. More elastic Increased tone or shortened muscles 3. Springy block Internal derangement when rebound is seen and felt 4. Empty Severe pain limits movement and no appreciable physical stop is felt 5. Premature Occurs before a normal stop due to contracted tissues, spasm, or other joint anomaly Elements of Treatment Approaches Passive o Patient takes no active role in the treatment process Active o Patient and clinical associate are guided by continuous interaction throughout the treatment process Direct o Typically the starting position of treatment begins at the first point of resistance or barrier. Movement and force are in the direction of motion restriction

3 Manual Therapy: Soft Tissue Mobilization (STM) 3 Indirect o The joint is positioned into its most free motion, away from resistance or barrier to motion. (struck drawer analogy) o Movement and force are away from direction of motion restriction General o Single treatment is provided to multiple areas or joints at the same time Specific o Single treatment is localized to one area or joint o Hand placement to accomplish proximal stability and distal mobility o Joint traction or distraction techniques may be used STM can be an integral part of treatment aiding in decreasing pain while improving ROM, strength and overall functional ability. Specific purposes of STM include, but not limited to: Relaxation of contractile and improved mobility of non-contractile tissues Decrease pain Increase circulation, promote healing and tissue nutrition Improve venous or lymphatic drainage in turn deceasing localized swelling and edema Improve structural balance Considerations for Treatment The patient should be in a position of comfort and both patient/clinician should be relaxed Use proper body mechanics while treating Gradual implementation of techniques ensuring no significant increase in pain Avoid friction with hand positions and use leverage when applicable Muscle stretch should be perpendicular to the muscle origin, thereby elongating the parallel fibers Compression may be used to reach deeper tissues Remember, less is more Soft tissues have a memory. Sustained, low repetition and frequent ROM activities throughout the day encourage tissue elongation and promote end ROM sustainability Inhibitory techniques may aid in treatment and muscle relaxation, such as (but not limited to): 1. Heat (to relax tissues) 2. Firm pressure 3. Vibration 4. Cold (to inhibit neuronal conduction) Clinicians should consider what the patient s normal ROM is and how age and lifestyle related changes may have a direct impact on ROM and expected functional ability. Defer to the patient to determine the comparable or concordant sign. The goal is to determine which movement or position reproduces, or with some techniques decreases familiar pain or loss of function to the patient. This will assist the clinical associate in developing an appropriate care plan. Consider PROM with overpressure to differentiate between soft tissue and joint restrictions. Consider joint crepitus. 1. Crepitus is best appreciated on AROM testing, however can be detected throughout the examination process with ROM. It may be indicative of articular changes either of interfacing tissues or directly to the joint surface itself.

4 Manual Therapy: Soft Tissue Mobilization (STM) 4 Consider soft tissue restrictions and how that can impact normal joint play and arthrokinematics. Consider the age of the patient, prior level of function and patient specific goals prior to implementing a treatment plan. Skin texture and moisture changes can often be associated with complex regional pain syndrome (CRPS). Commonly associated symptoms/characteristics include: hyperhidrosis, smooth and/or shiny skin appearance, cyanosis, atrophy of the skin, increased hair growth, and dry/scaly skin. Consider soft tissue restrictions and/or adaptations involving the kinematic chain when assessing gait. For example, excessive pronation can be the result of compensatory changes or the malalignment of proximal structures such tibiofemoral internal rotation, genu valgum, etc. Adaptive changes can result in both positive and negative results as part of the patients overall structure. Principles of Treatment Approaches (specifics to be covered in additional lab sessions) Strain/Counterstrain 1. Gentle technique in which tender points or located in soft tissues and the involved structure is placed in a shortened position, approximating the origin and insertion of the involved tissue. 2. This position is defined as the position of ease, or position of greatest comfort. 3. The position relieves the specific tenderness and is held for approximately 90 seconds and then the structure is slowly returned to a resting position. Muscle Energy 1. This method involves a muscle contraction by the patient followed by relaxation and stretch of the agonist or antagonist. 2. The involved structure is placed at the first point of resistance or barrier of motion. For example, the patient is positioned at the barrier, and then gently pushes (moderate to maximal contractions for STM and minimal to moderate for JM)) in the opposite direction away from the barrier for up to 7 seconds and then relaxes. 3. After a 5 second or more rest, the clinical associate moves the structure further into the new barrier and the process is repeated up to 5 times. 4. The clinical associate may then employ an active indirect technique to the antagonists followed by a passive stretch performed by the clinical associate at end range to facilitate further ROM into the barrier. Positional Release 1. The area or structure to be treated is placed in a loose-packed position. An external force, such as compression or torsion, is introduced and then the area or structure is placed into a shortened position or region of free motion. 2. Continual feedback from the patient allows for fine tuning of the position. Articulatory 1. The involved structure is guided gently through its full or available ROM while gently engaging resistance or barriers of motion (jiggle the stuck drawer) Grades of mobilization (I II for pain inhibition, III IV for increasing ROM) 1. Grade I slow, small-amplitude movements performed at beginning of the range 2. Grade II slow, large-amplitude movements short of resistance 3. Grade III slow, large amplitude movements performed to the limit of the range 4. Grade IV slow, small amplitude movements performed at the limit of the range

5 Manual Therapy: Soft Tissue Mobilization (STM) 5 Stretching 1. The involved structure is guided to end ROM by active, active-assist, or passive means. 2. Once the barrier is engaged, an optimal sustained stretch is provided to the involved structure for a minimum of seconds. 3. Repeat up to 4 times per patient tolerance. 4. The clinical associate may also choose to apply a prolonged stretch while performing rhythmic oscillations of small amplitude at end range. This in turn, may decrease discomfort and/or pain while increasing the extensibility of the tissues. Acupressure 1. The irritable tissue or trigger point is placed under sustained pressure for as long as it takes to feel a softening of involved tissue. Trigger points are best described as areas of hypersensitivity of selective tissues which refer pain to the central nervous system. Scar and periarticular surgical incisional massage 1. Tissue mobility is promoted with STM techniques local to the surgical incision and surrounding tissues 2. Tissues mobility is encouraged perpendicular to the incision, but should be mobilized in all planes of motion 3. Treatment time depends on tissue integrity, pliability, and patient response Contractile tissue extensibility can be contributed to prolonged mild tension remodeling as related to the creep phenomenon. Determine which soft tissue technique may be of benefit to the patient either by clinician experience or training combined with ongoing feedback from the patient. It is important to remember to ask for feedback from the patient prior to, during and post treatment. In addition, the clinician should assess the effects of each treatment at the subsequent visit, to include subjective feedback and appropriately adjust the treatment interventions. Postural Adaptation, Disuse and Aging; as well as conditional and post-procedure related changes may present an orthopedic patient with common problem areas. The following areas are a starting point when considering common muscular tissues/groups and prime movers involved in adaptive SHORTENING. Lower Extremity 1. Hip Flexors (iliopsoas) 2. Hip External Rotators (piriformis) 3. Hip Adductors (adductor magnus/longus/brevis and gracilis) 4. Hip Abductors (gluteus med/min, tensor fasciae latae, piriformis) 5. Knee Flexors (hamstrings) 6. Knee Extensors (quads, i.e rectus femoris) 7. Ankle Plantar Flexors (gastrocnemius, soleus) and isolation Upper Extremity 1. Shoulder Adductors and Internal Rotators (pectoralis major/minor, latissimus dorsi, teres major) o Latissimus dorsi and teres major isolation o Subscapularis isolation

6 Manual Therapy: Soft Tissue Mobilization (STM) 6 ** Lab Competency: Treatment rationale, patient and clinician position related to STM for each of the areas above are demonstrated over the following pages. Alternative positions are acceptable as long as the targeted tissues are addressed. This lab should focus on at least four or more specific areas or techniques with clinicians demonstrating appropriate skill levels. Additional manual therapy techniques demonstrated and practiced by clinicians should be based on experience and need of the group. Hip Flexors Treatment rationale: adaptive shortening of the hip flexors, restricted capsular mobility, anterior hip and groin pain, decreased hip extension ROM, etc Patient position: patient should be in sidelying with the involved side up. Ensure the patient is stabilized and comfortable maintaining a neutral spine. Clinician position: stand behind the patient and stabilize the pelvis. The clinician should also provide support to the distal lower extremity throughout the course of treatment. (passive stretching) passively extend the hip into extension until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. Hip External Rotators Treatment rationale: adaptive shortening of the external rotators, restricted capsular mobility, anterior hip and groin pain, decreased hip internal rotation ROM, etc Patient position: patient should be resting comfortably in supine. Clinician position: stand to the side of the patient on the involved side. Flex the involved hip to above 90 and stabilize the contralateral side of the pelvis via the ileum. The clinical associate should also provide support to the distal lower extremity throughout the course of treatment. (passive stretching) passively adduct and slightly flex the hip until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. This position may also be performed below 90 of hip flexion based upon select tissue testing and target tissues.

7 Manual Therapy: Soft Tissue Mobilization (STM) 7 Hip ADDuctors and Internal Rotators Treatment rationale: adaptive shortening of the hip adductors and internal rotators, restricted anterior capsular mobility, anterior hip and groin pain, decreased hip extension and external rotation ROM, etc Patient position: patient should be resting comfortably in supine. Clinician position: stand to the side of the patient on the involved side. Flex the involved hip to 45 and place the lateral malleolus above the contralateral patella. Stabilize the pelvis via the ileum. (passive stretching) passively abduct and externally rotate the hip until a ROM barrier is experienced. The therapist will hold this position for seconds. Repeat up to 3 times. Hip ABDuctors Treatment rationale: adaptive shortening of the hip abductors, iliotibial band (ITB), lateral retinacular and fasical tissues, restricted capsular mobility, decreased hip adduction ROM, etc Patient position: patient should be in sidelying with the involved side up near the edge of the supportive surface. Ensure the patient is stabilized and comfortable maintaining a neutral spine. Clinician position: stand behind the patient and stabilize the pelvis. The clinician should also provide support to the distal lower extremity throughout the course of treatment. (passive stretching) passively extend and adduct the hip until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. This position may also be performed with 90 degrees of knee flexion based upon select tissue testing and target tissues. Knee Flexors Treatment rationale: adaptive shortening of the knee flexors (hamstrings), restricted posterior knee joint and/or capsular mobility, sciatic nerve pain, etc Patient position: patient should be resting comfortably in supine. Clinician position: kneel to the side of the patient on the involved side. Flex the involved hip to 90 and place the distal

8 Manual Therapy: Soft Tissue Mobilization (STM) 8 lower extremity on your shoulder. Provide firm contact with both hands on the distal thigh superior to the patella to prevent patellar compression. (passive stretching) passively extend the lower extremity via downward pressure on the distal thigh or by applying upward pressure through the distal lower extremity until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. Knee Extensors Treatment rationale: adaptive shortening of the knee extensors (quads), peripatellar tissues, restricted capsular mobility, ROM, etc Patient position: patient should be in supine with the involved side up near the edge of the supportive surface. Ensure the patient is stabilized and comfortable maintaining a neutral spine. Clinician position: stand to the side of the patient on the involved side. The clinical associate should stabilize the proximal lower extremity while introducing further ROM and support to the distal lower extremity throughout the course of treatment. (passive stretching) passively flex the knee until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. This stretch may be performed in many varying positions, but an attempt should be made to isolate the involved tissues based upon selective tissue testing or goals of treatment. Ankle Plantarflexors Treatment rationale: adaptive shortening of the ankle plantarflexors (gastrocsoleus), restricted posterior ankle joint and/or capsular mobility, sciatic nerve pain, etc Patient position: patient should be resting comfortably in prone or supine. Clinician position: stand to the side of the patient on the involved side. Stabilize the distal lower extremity. Support the plantar and calcaneal regions with the treating hand and forearm. (passive stretching) passively dorsiflex the ankle until a ROM barrier is experienced while maintaining available knee extension ROM. Hold this position for seconds. Repeat up to 3 times.

9 Manual Therapy: Soft Tissue Mobilization (STM) 9 soleus isolation Treatment rationale: adaptive shortening of the ankle plantarflexors (soleus), restricted posterior ankle joint and/or capsular mobility, sciatic nerve pain, etc Patient position: patient should be resting comfortably in prone or supine. Clinician position: stand to the side of the patient on the involved side. Stabilize the distal lower extremity. Support the calcaneal and plantar regions with the treating hand and forearm. (passive stretching) with the involved extremity and knee bent to 90, passively dorsiflex the ankle until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. Shoulder ADDuctors and Internal Rotators Treatment rationale: adaptive shortening of the shoulder adductors (pectorals, latissimus dorsi, teres major and subscapularis), restricted capsular mobility, ROM, etc Patient position: patient should be in supine with the involved side(s) in shoulder flexion, abduction and external rotation. Clinician position: stand to the involved side or cephalic region of the patient. During treatment, the clinical associate should ensure the patient is not compensating in the lumbar region with excessive or exaggerated lordosis. (passive stretching) passively flex, abduct and externally rotate the shoulder in scapular plane until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. This stretch may be performed in many varying positions but attempts should be made to isolate the involved tissues based upon selective tissue testing and/or goals of treatment. lattisimus dorsi and teres major isolation Treatment rationale: adaptive shortening of the shoulder adductors and internal rotators (latissimus dorsi, teres major), restricted capsular mobility, ROM, etc Patient position: patient should be in supine with the involved side(s) in shoulder flexion, abduction and external rotation. Clinician position: stand to the involved side or cephalic region of the patient. During treatment, the clinician should ensure the patient is not compensating in the lumbar region with excessive or exaggerated lordosis.

10 Manual Therapy: Soft Tissue Mobilization (STM) 10 (passive stretching) passively flex and externally rotate the shoulder while stabilizing the lateral border of the scapula. Progress PROM until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. subscapularis isolation Treatment rationale: adaptive shortening of the shoulder internal rotators, restricted capsular mobility, ROM, etc Patient position: patient should be in supine with the involved side in neutral adduction. Clinician position: stand to the involved side or cephalic region of the patient. Treatment hand should be same side as involved side of patient. Stabilize via the scapula. (Passive stretching) with the involved side and elbow bent to 90, passively externally rotate the shoulder until a ROM barrier is experienced. Hold this position for seconds. Repeat up to 3 times. This stretch may be performed in many varying positions of abduction, but an attempt should be made to isolate the involved tissues based upon selective tissue testing and/or goals of treatment.