Clinical Procedures

Front 1

Manual Massage
(Beard, 1952)

Back 1

Certain manipulations of the soft tissues of the body which are most effectively performed by the hands for the purpose of producing effects on the nervous, muscular, respiratory, and venous systems.

Front 2

Basic Massage Movements
Effleurage

Back 2

To skim over, stroke, glide
-Light (superficial) effleurage
-Deep Effleurage
-Horizontal stroking (Fulling)
**other techniques- knuckling, shingles, bilateral tree, 3-count stroking**

Front 3

Basic Massage Movements
Petrissage

Back 3

To Knead
-2-hand technique
-1-hand technique
-Alternating 1-hand petrissage
**also skin rolling and wringing**

Front 4

Basic Massage Movements
Friction

Back 4

To rub one surface over another
-Cross fiber
-parallel
-circular
-cyriax technique

Front 5

Basic Massage Movements
Tapotement

Back 5

To strike; percussion
-Hacking
-cupping/clapping
-slapping
-beating/pounding
-tapping
-pincement

Front 6

Basic Massage Movements
Vibration

Back 6

Fine, tremulous movements made by hand or fingers
-Shaking

Front 7

Deep Sedative Manual Massage

Back 7

Light effleurage
Deep Effleurage
Petrissage
Friction (modified)
Petrissage
Deep Effleurage
Light Effleurage

Front 8

Components of Massage

Back 8

Direction
Pressure
Rate and Rhythm
Duration
Frequency
Medium
Position

Front 9

Direction

Back 9

Usually towards the heart

Front 10

Pressure

Back 10

Varies on the patient (acute=light) (chronic=deep)

Front 11

Rate and Rhythm

Back 11

Relaxing/sedative

Front 12

Duration

Back 12

Mostly based on 15 min increments due to billing. Maybe shorter and more often throughout the day

Front 13

Frequency

Back 13

As often as necessary and as long as you are getting results

Front 14

Medium

Back 14

Kinds of lotions, gels, etc (reduces friction)

Front 15

Positions

Back 15

Comfortable for you and your patient

Front 16

Effects of Massage

Back 16

Mechanical
Physiological
Psychological

Front 17

Mechanical

Back 17

Direct effect of touch, pressure, and stretching

Front 18

Physiological

Back 18

Secondary to mechanical
Can be direct or Indirect
(Indirect alter of the heart rate, breathing rate, etc)

Front 19

Physiological
-Skin and subcutaneous tissue

Back 19

Stimulates sweat and oil glands (direct)
improving texture and appearance of skin (from mediums or increased blood flow)
Can soften or loosen up scar tissue (direct)
can toughen skin (??)(desensitize)

Front 20

Physiological
-Blood and Lymph Flow

Back 20

Arterial circulation in consistent effects (direct)
Increased venous return (elevation, compression, pressure)(direct)
Increased lymph flow (elevation, very light pressure)(direct)

Front 21

Physiological
-Muscle tissue

Back 21

Does not directly increase strength
Does not increase muscle tone
Does not prevent muscle atrophy in denervated muscle
Muscle fatigue maybe more quickly relieved by massage and rest then by rest alone

Front 22

Physiological
Other systems/tissues

Back 22

Does not decrease adipose tissue
No direct signifigant effect on bone
No effect on nerve regeneration
No proven effects on viscera
May contribute to movement of lung secretions when used with postural drainage

Front 23

Physiological
Pain

Back 23

May control pain through "gate control"
May induce a general relaxation
May interrupt pain-spasm cycle
May rid area of "pain metabolites"

Front 24

Psychological
Positive

Back 24

Relaxation, decrease stress, social aspect (interaction with therapist)

Front 25

Psychological
Negative

Back 25

Exposure, Anxious, cultural, gender

Front 26

General Indications

Back 26

Pain
Edema
Lymphedema
Adhesions ans scars

Front 27

General Contraindication
-in area to be treated

Back 27

Open wounds
Neoplasms
infection
Hyperesthesia-hypersensitive
sever blood disorders (sickle-cell)
Severe skin conditions (psoriasis)
Acute, inflammatory conditions
Edema from CHF or kidney disease (can result in generalized Edema)

Front 28

Other types of Massage

Back 28

Internal
Mechanical
Other

Front 29

Internal Massages

Back 29

Thiele's Massage (treatment for coccyxidemia) (pain in the coccyx)
Mouth/Jaw (TMJ problems)

Front 30

Mechanical

Back 30

Acupressure- trigger point, superficial nerves, helps modulate pain (pins dropped and twist at specific spots)

Front 31

Other

Back 31

Auriculotherapy- ear points, related to different parts of the body
Rreflexology- different parts of the bottom of the foot related to different parts of the body
Rolfing-very vigorous, could take hours
Myofascial Release- basically stretching muscle from both ends
Manuel Lymphatic Drainage (MLD)- very light massage
Therapeutic Touch- more like non touch, move the energy (kind of like Rheiki)

Front 32

Myofascial Trigger Points
Travell and Simmons, 1983

Back 32

A myofascial TP is a hyper-irritable spot usually within a taut band of skeletal muscle's fascia, that is painful on compression and that can give rise to characteristic pain, tenderness, and autonomic phenomena

Front 33

Incidents

Back 33

Latent TP may show all the diagnostic features of and active TP except that it causes pain when the TP is examined by palpation

Front 34

Active TP

Back 34

can have pain at rest and movement

Front 35

Latent TP

Back 35

Causes pain only with palpation

Front 36

Characteristics of Trigger Points

Back 36

-Exquisite local tenderness
-Referred pain
-palpable band with restricted stretch range
-Local twitch response (LTR)
-Metabolic Distress
-Favorable Response to stretch
Weakness and fatigue

Front 37

TP Evaluation

Back 37

Range on Motion (ROM): goniometer, restricted and painful with active TP
Strength: weakness in affected muscles, manual muscle test
-Palpation: taut band jump sing (LTR)
-Pain: Hypersensitivity, pain scale, algometer [in a referred pattern (for a specific muscle)]
Symptoms: can reproduce with palpation

Front 38

Treatment Goal

Back 38

Deactivate TP

Front 39

Treatment Techniques

Back 39

-Stretch and spray
-Relaxation
-Injections
-Massage (ischemic compression)
-Ultra sound
-E-stim
-Cryotherapy- ice over the area, it can block pain

Front 40

Trigger Point Treatment

Back 40

Goal is to deactivate active and latent TP

Front 41

TP Treatment
Massage Techniques

Back 41

Ischemic Compression
Deep stroking (stripping)
Deep friction
Vibration

Front 42

Ischemic Compression Techniques
Description

Back 42

Methods to compress tissues at site of a trigger point that will cause blanching with hypoxia followed by a reactive hyperemia
Ischemic compression can be created with sustained digital pressure, a tool, or pincer technique

Front 43

Ischemic Compression Techniques
Procedure

Back 43

-Locate trigger point with palpation
-use thumbs, fingertips, elbows (for large or deep areas), or hand tools (too protect small joints of the hands) to apply sustained pressure to the trigger point
-Apply gradually increasing pressure to the TP as sensitivity decreases and tension in taut band fades
-Apply pressure until tension subsides to when the trigger point is no longer tender to pressure (usually 20-60 seconds)
-Follow ischemic compression with stretching

Front 44

Deep Friction Massage
Description

Back 44

Involves deep massage directly to the site of a lesion in a direction perpendicular to the normal collagen fiber orientation

Front 45

Deep Friction Massage
Purpose and Effects

Back 45

Used to normalize soft tissue remodeling in the post-acute phase of injury and is most commonly performed on tendons and ligaments. Transverse pressure is applied in order not to strain tissue longitudinally which could weaken healing tissue. The therapeutic effects include:
-maintenance/restoration of soft tissue mobility (prevent excessive molecular cross-linking)
-prevention of adherent scars
-increased circulation

Front 46

Deep Friction Massage
Indications

Back 46

Tendinitis (e.g. supraspinatus tendinitis, lateral or medial epicondylitis, deQuervain's syndrome)
-Ligamentous sprains (e.g. ant. talofibular ligament, collateral knee ligaments)

Front 47

Deep Friction Massage
Contraindications

Back 47

Acutely inflamed tissue
Hematomas
Calcifications

Front 48

Deep Friction Massage
Instructions

Back 48

-Identify precise location of lesion
-Place part in a position that promotes neutral tension on tendon/ligament
-Place pad of finger or thumb directly on site of lesion (do not use lubricant)
-Initially, use light transverse pressure with small amplitude. (the patient may initially c/o mild to moderate tenderness, which is ok)
-Continue light massage for 1-2 minutes
-If tolerated, increase pressure for 1-2 minutes
-Continue to increase pressure for 1-2 minutes as tolerated
Repeat cycles for less than or equal too 15 minutes. (initial treatment is usually shorter; ~5 min)

Front 49

Deep Friction Massage
Frequency

Back 49

2-3 x/week for 6-8 treatments

Front 50

Stages of Inflammation

Back 50

-Inflammation Reaction
-Proliferative of Fibroblastic Phase (Repair and Healing)
-Maturation and Remodeling

Front 51

Inflammatory Reaction
Characteristics

Back 51

-Clot Formation
-Vascular Changes
-Exudation of cells and Chemicals
-Phagocyctosis
-Chemical Mediators

Front 52

Clot Formation

Back 52

If blood vessel ruptures:
-blood escapes into surrounding tissue (hemorrhage)
-Platelets aggregate at site and form a platelet plug to stop bleeding (Hemostasis)
-Fibrinogen converted into fibrin plug

Front 53

Vascular Changes

Back 53

Brief vasoconstriction followed by more prolonged vasodilation

Front 54

Exudation of Cells and Chemicals

Back 54

-Blood flow slows (during vasoconstriction)
-Vessel walls become "sticky"
-WBCs (leukocytes) marginate (adhere) to vessel walls (clean up cells-phagocyte)
-With vasodilation, vessels become permeable (leaky)(fluid goes out first)
-Transudate-initially plasma serum (H2O&electrolytes) passes into tissues spaces
-Exudate- as vessels become more permeable, leukocytes pass into the tissue (interstitial) spaces. Exudate looks a little bit cloudy and yellow.
**Transudate and Exudate = Edema**

Front 55

Phagocytosis

Back 55

*Big clean up phase in wound healing*
-Early Phagocytosis: Polymorphonuclear leukocytes go out first. They are small multinucleated WBC. Early phagocytosis of tissue debris
-Prolonged Phagocytosis: Mononuclear leukocytes (AKA macrophages) Are larger single nucleated WBC. Macrophages continue the phagocytic process and trigger the fibroblastic phase of tissue healing

Front 56

Chemical Mediators

Back 56

*Many cells release a variety of chemical mediators in response to trauma or injury
*The following list is a partial list of chemicals which are active during the inflammation phase
-Norepinephrine- Causes Brief vasoconstriction
-Histamine-produces vasodilation
-Prostaglandins- causes vasodialtion and pain

Front 57

Clinical Signs of Inflammation

Back 57

Red-increased blood flow
Hot- increased blood flow
Swollen-increased interstitial fluids
Painful-from pressure on nerve endings and release of certain chemical mediators

Front 58

Physical Therapy

Back 58

Control Effects of Inflammation
-PRICE-pressure, rest, ice, compression, elevation; to decrease redness, heat and edema
-Cryotherapy- to reduce pain and limit edema

Front 59

Physical Therapy

Back 59

Promote Early Healing and Prevent Deleterious Effects of Rest:
-Cautious gentle movement
-massage and muscle setting

Front 60

Repair and Healing (proliferative of fibroblastic phase)
Characteristics

Back 60

Growth of Capillary Beds into area
Collagen formation
Granulation Tissue
Very Fragile

Front 61

Growth of Capillary Beds into Area

Back 61

*Neovascularization or Angiogenesis*
-Endothelial buds develop from intact capillaries in the area
-These buds grow into the damaged area and establish new vascular network
-This new blood supply is essential for healing

Front 62

Collagen Formation

Back 62

*Fibroblasia*
Fibroblasts from dermis migrate into wounded area along strands of fibrin
-they secrete collagen to replace damaged tissue

Front 63

Granulation Tissue

Back 63

This early scar tissue with its new vascular supply is referred to as granulation tissue
Granulation tissue is very fragile and very easily injured

Front 64

Very Fragile

Back 64

Very fragile, easily injured tissue

Front 65

Clinical Signs

Back 65

Decreasing Inflammation- less redness, less heat, decreased edema

Front 66

Clinical Signs

Back 66

Pain synchronous with tissue resistance

Front 67

Physical Therapy
(promote healing: develop mobile scar)
MILD HEAT

Back 67

May facilitate the healing process by causing mild increase in blood flow
But may cause more inflammation if applied too hot &/or too long

Front 68

Physical Therapy
MILD COLD

Back 68

May decrease pain and inflammation
But may increase stiffness and slow the healing process if applied too cold &/or too long

Front 69

Physical Therapy
NONDESTRUCTIVE EXERCISE

Back 69

Active, restrictive, and endurance exercise
Progress carefully in intensity and range

Front 70

Maturation and Remodeling
Characteristics

Back 70

Maturation of connective tissue: as scar matures, it becomes stronger but is never as strong as the original tissue that is replaced

Front 71

Characteristics

Back 71

Contraction (not contracture) of scar tissue: pulling in from margin facilitate healing by making wound smaller

Front 72

Characteristics

Back 72

Remodeling of new scar tissue occurs so that collagen and fibers become more aligned and organized

Front 73

Characteristics

Back 73

Collagen aligns to applied stress

Front 74

Clinical Signs

Back 74

-Absence of inflammation (shouldn't be much)
-Pain after tissue resistance

Front 75

Physical Therapy

Back 75

Increase strength and alignment of scar; improve function:
-If contractures or adhesions present: use heat, stretch, massage (friction)
-If Pain persists: Use heat, cold, or ES

Front 76

Inflammatory Reaction
(summary)

Back 76

Clot formation
Transient vasoconstriction
Margination of leukocytes
Vasodilation
Increased vascular permeability
Fluid and leukocyte infiltration
Phagocytosis

Front 77

Proliferative Phase
(summary)

Back 77

Neovasularization
Fibroplasia
Granulation tissue

Front 78

Maturations Phase

Back 78

Remodeling and maturation of scar tissue