Introduction. Clinical Massage for Sports and Rehabilitation. Review of Tissue Types. Why Learn Clinical Massage?

Transcription

1 Chapter 26 Clinical Massage for Sports and Rehabilitation Susan G. Salvo Michael A. Breaux Introduction A massage therapist often works as part of a client s health care team Insurers are recognizing massage as effective and worthy of reimbursement Uses of clinical massage protocols: Stand-alone treatment in a clinical setting Full-body sports massage for athletes Focused segment as part of a massage session Why Learn Clinical Massage? Reasons to learn and use targeted clinical techniques: Healing time often swifter with deep-tissue techniques Effectiveness of treatment stronger with deeptissue techniques Clients request clinical massage techniques because they need more than relaxation massage for their aches and pains Review of Tissue Types Fascia can change states: Sol state is flexible and elastic Gel state is thicker and can restrict movement Muscle Anatomy: origin, insertion, fiber direction Physiology: action, synergists, antagonists, eccentric and concentric contraction Introduction Spasms are neuromuscular events General or localized muscle contraction Also known as tender points Stress of an injury reduces threshold (strength of stimuli require to generate nerve impulse) Increased neurological activity may lead to summation Spasms may produce knots or rigid zones in part of all of a muscle Introduction Trigger points are neurochemical events Like spasms, trigger points also produce knots and rigid zones in muscles Unlike spasms, trigger points cause muscle fibers to stick together Found in muscles, tendons, fascia, ligaments, and periosteum 1

2 Causes Fine-motor movements Gross-motor movements Posture Stress and fatigue Direct trauma Periods of inactivity Disease and disorders Location and Palpation Look for the following: Changes in tissue thickness (lumps, strings) Immobility or resistance to gliding strokes Muscle shortening with weakness Edema Pain or tenderness Hypertonicity Temperature changes Ischemia Location and Palpation Location and Palpation Slide the skin over the underlying tissue in a figure 8 or compass pattern until the spot of most tenderness is located Maps Maps 2

3 Maps Maps Classification of Trigger Points: Active and Latent Active trigger points Cause pain even at rest and when no external physical stimulation takes place Often refers pain in specific patterns Pain may be constant or episodic Latent trigger points Cause pain only when pressure is applied Remain hidden until activated Often found only during palpation Classification of Trigger Points: Central and Attachment Central trigger points Develop almost directly in center of a muscle Respond well to heat and compression Attachment trigger points Located at musculotendinous junctions Caused by unrelieved tension from central trigger point s taut band Respond well to cross-fiber friction and ice Classification of Trigger Points: Key and Satellite Key trigger points Active or latent trigger points that refer pain to secondary (satellite) trigger points Sustained shortening can weaken a muscle, shifting burden to nearby muscles Satellite trigger points Arise in referral zones of key trigger points Arise in synergist/agonist muscles adjacent to muscles with trigger points Trigger Point Symptoms: Referred Pain Referred pain phenomena: the tendency of some trigger points to produce sensation distal to that of the trigger point when compressed Most pain refers distally (73% occurrence) Some pain is experienced directly beneath trigger point (27% occurrence) Pattern of pain referral is fairly consistent among people 3

4 Other Trigger Point Symptoms When compressed, trigger points can also cause two other symptoms Twitch response: reflexive impulse that cause affected muscle or adjacent muscle to fire spontaneously Jump sign: client s spontaneous reaction of wincing, jumping, or verbalizing Muscle Soreness: Types Immediate muscle soreness: Experienced during or shortly after activity Disappears after normal blood flow returns Delayed-onset muscle soreness (DOMS) Begins 8 to 14 hours after activity Peaks 48 hours after activity Muscle Soreness: Types Muscle fatigue: exhaustion or weakness Not same process as muscle soreness Prolonged contractions during exercise use glucose During exercise, muscles don t receive adequate oxygen to remove all of the byproducts of glucose use (lactic acid) Lactic acid builds up in the muscles, causing temporary weakness Muscle Soreness: Theories of DOMS Inflammation theory Prolonged periods of work cause microscopic muscle tears DOMS pain is inflammatory process that accompanies tissue repair Connective tissue damage theory Hydroxyproline (OHP) is released into blood when connective tissues are damaged OHP levels peak when soreness peaks Muscle Soreness: DOMS Does not result in long-term damage Not felt at rest Usually follows excessive or difficult exercise or any uncustomary activity Most DOMS pain is caused by eccentric muscle contraction Injury Injury: occurrence that causes tissue damage Usually from violence or an accident Lesion: tissue that deviates from normal tissue Can be acute or chronic 4

5 Injury Classifications Acute injury Begins abruptly from recognizable cause Symptoms: severe, including pain, swelling, and loss of function Management: PRICE (protection, rest, ice, compression, elevation) Injury Classifications Chronic injury Develop slowly and persist for long periods May be associated with multiple acute episodes, or may recur because of incomplete recovery from an acute injury Symptoms: same as acute, but experienced to a lesser degree Management: rehabilitation, including massage, stretching, physical conditioning, and avoiding reinjury Typical Causes of Sports Injury Improper warm-up Lack of flexibility Unsuitable equipment Ill-fitting, worn out, wrong size, wrong position Overtraining Working too hard or insufficient rest Symptoms include irritability, fatigue, depression, sleeplessness, weakened immune system, and DOMS Inflammation Inflammation is protective response to traumatic tissue damage Functions of inflammation Stabilize area Contain infection Prepare for repair Intensity of response is proportional to damage Inflammation Inflammation Inflammation process Blood vessels expand and white blood cells migrate to injury site Injured tissues release histamines and kinins, which make capillary walls more permeable and allow plasma to pass through Blood plasma fills interstitial spaces, increasing tissue pressure and causing pain Pain, swelling, and muscle splinting limit range of motion 5

6 Resolution Resolution replaces aged or mildly damaged tissue Resolution only possible if cellular membrane and nuclear contents are unharmed Example: mild sunburn Regeneration Regeneration repairs moderately damaged tissue Occurs when damaged tissue is replaced with new tissue of same type No loss of tissue function occurs Example: skinned knee Fibrosis Fibrosis repairs severe wounds by replacing original tissue with scar tissue Occurs when not enough tissue is left for repair by regeneration Fibroblasts are mobilized to injury site to create scar tissue Fibrotic scar creates strong bond, but does not provide function of tissue it replaces Example: surgical scar, postsurgical adhesions Remodeling (Scar Maturation) Remodeling (or scar maturation) is secondary phase of fibrosis and makes scars in elastic tissues more pliable Scar tissue is restructured by simultaneous destruction and creation of collagen fibers Occurs with muscle contraction and relaxation Keloids: irregular, thick elevated scars resulting from excess collagen production Adhesions: bands of scar tissue binding tissues that are normally separate Recovery Time Factors Age Wound condition Health and habits of the patient Nutrition Circulation Recovery Time Factors Type of tissue involved Epithelial Muscle Bone Adipose Ligaments and tendons Cartilage Nervous 6

7 Rehabilitation Rehabilitation: process of restoration to maximal self-sufficiency and function after an injury Also called recovery Begins after the acute phase of an injury (usually day 4) Stages of Rehabilitation 1. Evaluation Eliminate spasm and trigger-point activity Address faulty body mechanics 2. Conditioning Restore flexibility and strength Rebuild endurance 3. Maintenance Tailor conditioning activities to lifestyle Support health and well-being Rehabilitation Stage 1: Evaluation Use massage to address spasms and trigger points Relieves ischemia by local increase in circulation Relieves neurovascular entrapment by relaxing taut muscles and fascia May reduce intrajoint pressure Correct faulty body mechanics (e.g., posture, gait) Rehabilitation Stage 2: Conditioning Stretching Weight training and aerobic exercise begin 1-2 weeks after stretching Usually supervised by a physician or other qualified professional Prevent repeated injury by strengthening all involved muscles and joints Swimming, walking, running, and biking good choices for building endurance Rehabilitation Stage 3: Maintenance Continuation of conditioning tailored to client s lifestyle Lifestyle modifications to support health and well-being: Diet Stress reduction Massage therapy maintenance plan Rehabilitation: Working with Athletes Athletes snap back faster from minor muscular injuries, but not from ligament or tendon injuries Can be counterproductive for athletes to stop training to allow healing Athletes are often highly motivated, so they must be cautioned not to overwork 7

8 Observation Observation is initial component of all assessments Watch facial expressions while conversing Note any swelling, redness, bruising, lacerations, deforming, and general demeanor Palpation Anomalies Client reaction Edema Twitching Moisture Temperature Superficial fascia Posture Body s position in space (sitting, standing, lying down) Standing position is baseline for balance and alignment Misalignment is often source of chronic pain, spasms, and trigger points Evaluate in several planes using horizontal and vertical landmarks Posture Horizontal landmarks: note deviations in symmetry or distance from ground Anterior midsagittal plane Posterior midsagittal plane Posture Vertical landmarks: note deviations to left or right of the plane Midsagittal plane Coronal plane Gait A person s walking pattern Two phases Stance: when the heel of one foot strikes the ground until the toe of that foot lifts off Swing: from toe-off until heel-strike 8

9 Range of Motion (ROM) Movement around a joint or set of joints Assess ROM to determine which muscles to target with massage Measure both passive and active ROM Active: uses voluntary muscles Passive: measure movement by therapist while patient relaxes Range of Motion (ROM) End-feel: limitation from bone or muscle felt at the end point of passive ROM Hard end-feel: abrupt end of motion from an anatomical stop (e.g., bone) Soft end-feel: springy, spongy end of motion Clinical Massage Techniques Address pain at its source Compression Sustained pressure Friction Myofascial release Use slightly more aggressive pressure than that used for relaxation massage May cause mild discomfort No more discomfort than 6 to 7 on scale of 10 Clinical Massage Techniques: Compression Rhythmic pumping on the muscle Pushes blood out of areas, followed by flush of blood when pressure is released Broadens muscles, inducing relaxation Used on muscled areas Variations: One-handed: palmar, hand-over-hand, or fist Two-handed: fulling/broadening Twist: baby jar lids Clinical Massage Techniques: Sustained Pressure Held pressure applied to trigger points and spasms for 3-7 seconds Relieves pain and discomfort Also called ischemic compression because skin blanches under pressure Clinical Massage Techniques: Friction Rubbing one surface over another Reduces adhesions between tissue layers Minimizes the size of keloids Encourages scar maturation Variations: Cross-fiber (deep-transverse) friction Chucking (parallel) friction Circular 9

10 Clinical Massage Techniques: Myofascial Release (MFR) Group of manual techniques used to reduce fascial restrictions Deep glide (variation: pin and stretch) Torquing Skin rolling Clinical Massage Techniques: Myofascial Release (MFR) Skin rolling involves lifting and compressing skin and superficial fascia Essential part of Bindegewebsmassage No downward force, so can be used over bony areas Can be uncomfortable Roll with thumb and forefinger or use two thumbs in S-curve Treatment Overview Allow 72 hours after injury before beginning treatment Locate tender spots based on client s complaint and common trigger point areas Use a combination of techniques and appropriate amount of pressure Release central trigger points and their attachment trigger points before stretching muscles Common Mistakes Overworking Working too deep Working too long Experience is the best teacher for judging pressure, tissue density, and tissue resistance Aftercare Aftercare Treatment of injuries may increase local sensation of discomfort and referred pain Education helps clients understand what to expect after treatment In most cases, body becomes acclimated to a treatment after 4-6 sessions Aftercare suggestions Stretches Self-massage Stress-reduction techniques Changing sleeping Nutrition adjustments Ergonomic adjustments Regular exercise Salt and soda bath Ice and heat 10

11 Sports Massage Event massage Pre-event: quick with moderate pressure to increase circulation and flexibility Inter-event: short and light to address problem areas and facilitate rapid return to homeostasis Post-event: promote rest, relaxation, and blood flow by moving wastes out of muscles and spreading muscle fibers Sports Massage Maintenance massage Supports athlete s needs and goals Emphasizes prevention Promotes healthy tissue by addressing common tension patterns, spasms, adhesions, and trigger points Rehabilitative massage Enhances recovery of soft-tissue injuries by increasing circulation Target Areas in the Athlete Running athletes: joints and muscles of entire lower extremity Racquet sports: ankle and calf, lower back, shoulders, elbows, and knees Cycling sports: neck, shoulders, forearms, hands, lower back, and entire lower extremity Swimming sports: neck, shoulders, upper arms, and entire lower extremity Target Areas in the Athlete Contact sports: hands and shoulders, and entire lower extremity Jumping sports: shoulders and entire lower extremity Baseball and softball: neck, shoulders, chest, upper/lower back, and abdomen Golf: wrists, elbows, neck, shoulders, chest, upper/lower back, and abdomen Common Treatment Areas Neck and head Cranial base release Shoulders Unroll upper traps Low back and hip Summary Massage therapists who work on clients with injuries and conditions need knowledge and skill in the following areas: Spasms, trigger points, and muscle soreness Injury types, tissue healing, and rehabilitation Clinical massage techniques Treatment for specific body areas Sports massage, if working with athletes 11