Tulsa Soft Tissue Eval and Intervention · •Maitland training primarily involves the joint tissues ... fluids, but primarily referring to bony structures and more precisely to the

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Soft Tissue Evaluation and Treatment

Steven W. Forbush, PT, PhD, OCS, OMTC

Why Soft Tissue?

• Maitland training primarily involves the joint tissues

• McKenzie does not mention soft tissue as an issue to address in most classifications

• However!• Massage has been a part of intervention since at least

3,000BC (started in Egypt and China)• Soft tissue is gaining popularity in the PT community

through the training and use of dry needling…but only for trigger points?

So…

• What do we need to treat?• What does evaluation of soft tissue add to a PT

diagnosis?• When is soft tissue the primary pain complaint

and when is it a secondary or resultant issue?• Is soft tissue/muscle pain always because a muscle needs

treatment?

• Is palpation even inter-tester reliable in studies?

Structure and Function: Are They Inseparable?

• Structure determines function and vice versa• Anything causing structure to change should

cause function to be modified and soft tissue is one of the things which must change in length, strength, and action

• As practitioners, we should be able to assess with vision, touch, and communicate these changes in function and structure– A tissue that is changed will have a palpatory

change in relation to the same tissue on the other side or similar tissues assessed before

Interdependence of Structure and Function

• Shortened or fibrosed muscle can’t function normally

• Habitual poor posture in static or dynamic status will impair normal function and will lead to injury

• Skin changes might relate to autonomic stress

• Overuse, Misuse, or Abuse = STRESS and functional changes

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Why and How We Perceive

• We are neurologically capable of receiving input and then discerning this input as an objective criteria

• The mechanisms of palpation and discernment are complex, and not fully understood

Sensors: What is in the Research• Light touch:

Mechanoreceptors • Heat and cold: Thermo-

receptors or nociceptors• Degree of tactile

sensitivity in any area is in direct proportion to the number of sensory units present and active in that area.

• Fingers, tongue, and lips are the most sensitive in tactile ability

Receptor Adaptation• Receptors turn off if

constantly stimulated (receptors fire less frequently)

• A baby’s butt versus your fanny is a good example of difference and adaptation

• Tip of the second finger or palm are less abused than the tip of the first or the thumb

Reverse Central Sensitivity

• Tissues will be ignored more when there is constant stimulus from the area

• Brain realizes it doesn’t need to attend as much with the constant stimulation

• The homunculus changes through plasticity

Objective Palpatory Literacy• “Practitioners who use

hands to manipulate structures should be able to feel, assess, and judge the state of a wide range of physiological and pathological conditions and parameters, relating not only to the tissues with which they are in touch but others associated with these, perhaps lying at greater depth.”

Chaitow L. 2003, 2nd ed.

Palpatory Literacy: Areas We Assess Regularly

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Tissue Restrictions• Global areas sometimes feel different in quality of

tissue motion compared to others or compared to tissue within the same individual.

• Tissue motion is not gradable in the way that joints are gradable.

• Experience is the key to the feel of these tissues• “The first step in the process of palpation is

detection, the second is amplification, and the third step must therefore be interpretation. The interpretation of the observations made by palpation is the key which makes the study of the structure and function of tissues meaningful…”

Viola Frymann, 1963

Palpation Information

• “Palpation is anything but an end to itself”Lewit K. 1987

Describing What is Felt

• Need to have common terminology

• Density, turgidity, compressibility, tensile state and elasticity might be areas of discussion

How would you describe this tone?

Palpation Objectives: Greenman, Principles of Manual Medicine, 2009

• Detect abnormal tissue tone and texture

• Evaluate symmetry in the position of structures

• Detect and assess variations in range and quality of movement during the range and at the end range of available motion

• Sense the position in space of yourself and the person being palpated

• Detect and evaluate change in the palpated findings over time and intervention

Muscle Palpation

• We will start and concentrate on muscle palpation

• 3 types of muscle in the body:1. Skeletal muscle2. Smooth muscle3. Heart muscle• Can’t palpate anything other than skeletal

muscle

Skeletal Muscle• Anchored to bone either directly or

through a tendon• When the muscle contracts, the

structure moves• If the muscle has too much neural

stimulation, too little nutrient, or chemical changes due to accumulation of waste products or inflammatory changes, the tone of skeletal muscle is changed (enhanced) and less controlled

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Palpatory Findings in Clinic

• How many of you have palpated some non-normal muscle reaction or tone in a spinal area in a clinical setting?

• What did this abnormality of function impart to you?• What did you do about this?

• How do you find the side you wish to treat in a patient? Which is the side that is worse?

• How many times do you bill for soft tissue mobilization in a week?

Let’s Use Terminology

• Describe abnormal soft tissue findings• Swollen, hot, tender, firm, increased tone,

“tight”, in spasm, protecting, different, or

So, What is Found in the Literature About Abnormal Tone?

Types of Abnormal Muscle Tone in Literature

• There are scant articles in literature concerning soft tissue findings and description of tone

• Articles and original description of Maitland and other therapists of the word spasm

• Articles on guarding • Discussion on facilitation from a neurological basis• Articles on muscle reflexes• Lots of articles and description of trigger points or

Travell points• Much literature on neurologic-based spasticity

Spasm• Defined in the manipulative literature as “an

abnormal muscle reaction or tone” that is found through palpation of tissues surrounding a joint.

• Other definitions also exist:– From Ian Brown: A muscle spasm is a convulsive

contraction in a muscle. It may be present as a sustained contraction (tonic) or as an alternating contraction and relaxation (clonic). A muscle spasm, known as reflex muscle guarding, occurs in response to a painful stimulus

– Muscle spasms are spontaneous, often painful muscle contractions related to traumatic, chemical, or neurological based irritation (Wikipedia)

Guarding• A protective response in muscle that results from pain or fear of

movement

• A muscular response to position or postural change or correction

• A phenomenon in which muscles react to an injury to a joint, bone or ligament by contracting in order to form a protective splint

• A sign detected during physical pain whereby the patient involuntarily contracts muscles second to pain

• (In some literature guarding is considered and equal term to spasm)

Hollmann, et al. Musculoskelet Sci Prac, 2018 Vol 37: 64-68.

Salvatori, et al. Journal of Orthopaedic & Sports Physical Therapy, 2014 Volume 44: 440–449

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Janda: The Original Muscle Descriptions

• Janda proposed a concept of muscle dysfunction that involved the development of muscle hypertonicity in a predictable fashion as a result of pain, overuse, repetitive motion, stress, injury, fatigue, poor posture, or deconditioning of the neuro-motor system.

• Classification differentiated between postural and phasic muscles

Janda Vladimir. Muscle spasm: a proposed procedure for differential diagnosis. J Man Med. 1991;6:136-139

Janda• Central nervous system control is

evident by having increased reactivity in faulty systems

• Hypertonic muscles have a tendency to inhibit their antagonist through the theory of Sherrington’s law of reciprocal inhibition (Sherrington, 1906) and a muscle imbalance can occur– Hyperactive muscles with hypertonicity

have been described as a muscle GUARDING.

Facilitation• An automatic, impulsive stimulation of a particular

muscle to contract through neural stimulus (Janda)• Obviously used as a term to discuss methods to

enhance neural stimulation or response in the neurological treatment realm

• Can this term be used for the responses to neural nociceptive segmental reflexes? Will discuss this more later

Glajdosic, et al. Clinical Biomechanics, 2001. Volume 16, (2): 87-101Nansel, et al. J Manip Physio Ther, 1993. Volume 16, (2): 61-65

When Were First Mentions of Tone• Tone in orthopedics started with the

description of the “osteopathic lesion” by Andrew Taylor Still in the early part of the 20th century (Now know as a Somatic Dysfunction)

• This original orthopedic abnormal tone was described as the muscular response to a segmental irritation– Nociceptors were known to produce

muscular guarding reactions, as well as autonomic activation, when musculoskeletal or visceral tissue is stressed or damaged

– These reactions might further limit motion and could change posture and mobility that develop as compensation to the original restriction

Still’s Osteopathic Lesion• The musculoskeletal restrictions of the somatic

dysfunction were generally considered “segmental” or following common embryological innervation (myotomes, dermatomes, or other)

• One of three mechanisms are listed as the initial and perpetrating factor, including changes in:

1. Circulation and extracellular fluid distribution2. Connective tissues

3. Neural mechanisms controlling muscles and autonomics

Osteopathic Lesion (Somatic Dysfunction)

• Showed hyper-excitability of paravertebral muscles innervated by nerves from a spinal segment in which the vertebra was altered in motion

• The spinal cord segment involved in a somatic dysfunction acted as a “neurologic lens” focusing activity on the affected spinal segment (Denslowand Korr)

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Model of Nociceptive Segmental Reflex

Nociceptive Spinal Reflex (Buskirk)

• Based on connections between the nociceptor and the spinal interneurons with continuations to the brain and brainstem

• Peripheral nociceptor axons travel with both somatic and visceral nerves and all have their cell bodies in the dorsal root ganglia

• Many nociceptors terminate within the spinal segment of entry, but others may travel several spinal segments cephalad or caudad in Lissauer’s tract before finally synapsing in the dorsal horn

• There are musculoskeletal responses to these stimuli aimed at decreasing the noxious stimulus reflexively

Still and the Osteopathic Lesion

Andrew Taylor Still, MD, DO, coined the original idea of lesion based on the obstruction of flow of body fluids, but primarily referring to bony structures and more precisely to the spine. Throughout the 20th century, this idea was shaped and developed into the concept of somatic dysfunction, a term that is familiar to both US-trained osteopathic physicians and foreign-trained osteopaths and has been an essential cornerstone of osteopathic practice and teaching.

Somatic Dysfunction

DEFINITION:Somatic Dysfunction is a Restriction in joints

muscles, or fascia that may affects blood supply, lymph flow, and nervous function.

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Somatic DysfunctionDiagnostic Criteria:

–Tenderness: tenderness in area of tone

–Asymmetry: difference in symmetry

–Restriction: moves different than surrounding

–Tissue Texture Changes

Somatic Dysfunction

Tissue Texture Changes

Tissues affected by the segmental influences with have a abnormally high tone compared to the tissues

not affected. These tissues will have a different texture and a different response to pressure.

Should We Treat This Muscle

• Any attempt to stretch the muscle affected by the “osteopathic lesion” to a normal position as found in an inactive state will re-stress the original nociceptors and trigger activity in any others with lowered thresholds

Application• Think of a mother taking children to the

mall to shop• The mother will be mildly protective

and watch over the children when necessary

• If a threat enters the environment (stranger talking to kids) the mother will go into a higher protective state

• If someone tries to pull the mother away at this time, she will react strongly and will not be removed

• If the stress is removed, the mother will relax and will function normally again

The Osteopathic Model or MTrPs

• Lately, there is very little literature on somatic dysfunction and much mention of myofascial trigger points

• Debate will continue on whether these are the same entity or separate muscle issues

• Here is the evidence on MTrPs

Trigger Points (MTrPs)• Simons, Travell, and Simons defined the

myofascial trigger point as “…a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is tender when pressed, and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena…”

• The hypothesis involves:1. Local myofascial tissues2. The central nervous system3. Systemic biomechanical factors

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MTrP Continued• A MTrP will be found at the area of most sensitivity in

a taut muscle• A snapping palpation will create a twitch response• Sustained palpation pressure on a MTrP usually

reproduces the referred pain pattern for which it is responsible

Motor End Plate• Simons implicated the motor end plate as the central

etiology of MTrP• MTrPs have a motor component, whereas tender

points found in patients with fibromyalgia do not.– They are found on biopsy to have contraction knots– MTrPs are pain-producing transmitted by A-delta fibers

and C fiber afferent sensory neurons to the neural system

Characteristics of MTrPs

• So:– Palpable taut band(s) within a muscle running in parallel

with the fibers which are tender• Two authors find moderate inter-rater reliability in finding these

bands (McEvoy and Huijbregts, 2011; Bron et al, 2011)

– There is a twitch response when the band is stimulated with palpation or strumming

– There is a referred pain response when the band is palpated with direct pressure (could take a few seconds)

Why Do They Occur?

• Many reasons are suggested:– Low level muscle contractions (Haag, 1988)

– direct trauma (Dommerholt et al, 2005)

– unequal pressure in the muscle (Otten, 1988)

– too much eccentric contraction (Gerwin et al, 2004)

– sub-maximal to maximal concentric contractions • NOTE: muscles rarely tear in concentric contraction

and primarily tear in eccentric activity!

Where Do They Occur?

• Most occur in the central belly of the muscle• 85% of trigger points are suggested to be in

the central motor point area• Some trigger points are suggested to be

found at the musculoskeletal junction at insertion sites.–MORE ON THIS LATER

Active vs. Latent Trigger Points

• Active trigger points:Produces referred pain and the symptoms produced are familiar to the patient

• Latent trigger point (theory)In contrast, latent trigger points (LTrPs) are foci of hyperirritability in a taut band of muscle, which are clinically associated with a local twitch response, tenderness and/or referred pain upon manual examination.It is suggested that latent trigger points can become active and are therefore treated as a preventative intervention

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Primary vs. Secondary Trigger Points

• Primary trigger points are the point of initiation of the problem in the soft tissue. Treatment of this area should ease the patient’s pain and results in decrease of the taut band

• Secondary trigger points or satellite TrPs arise in response to the tone created by the existing central trigger points and occur in the surrounding muscles (theory)– if not addressed can create a reoccurrence of the

primary area problem

Latent and Secondary MTrP

• No consistent research is found to suggest that diagnosis of latent and secondary trigger points has inter-tester reliability

• Research strongly supports the inter-tester reliability of finding primary active trigger points.

Trigger vs. Tender Points

• Many patients have tender soft tissue structures…not usually the same as MTrPs– Tender muscles from stress/strain or slight injury– Just tender in many muscular areas (consistent

with fibromyalgia or peripheral/central sensitivities)

– Tender in a muscular area over a joint that is inflamed or irritated

Fibromyalgia

• 11 of 18 tender points present• Widespread pain in all four quadrants of their body

for a minimum of three months. • Fatigue, irritable bowel syndrome, sleep disorders,

chronic headaches, jaw pain, cognitive or memory impairment, muscle pain or morning stiffness, painful menstruation, numbness and tingling in the extremities, dizziness or light headedness, skin and chemical sensitivities

Fibromyalgia Tender Points Tender Points vs Trigger Points

• Strongly suggested by many authors that these two types of muscular tenderness are not equal!

• A tender point is not necessarily a trigger point but a trigger points will, by definition, be tender

• How can we decide which is which?

http://www.fibromyalgia-symptoms.org/fibromyalgia_widespread_pain.html

http://www.fibromyalgia-symptoms.org/fibromyalgia_fatigue.html

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MTrP Treatment Methods Suggested

• Spray and stretch• Manual techniques• Injection therapy• Dry needling

Manual Treatment of MTrPs• Deep digital pressure was

hypothesized to cause ischemia and this is no longer suggested

• Gentle digital pressure is still suggested– Suggests this separates myosin

from actin (no proof)

• If MTrPs cross a joint, action on the joint is indicated to reduce stimulus to the MTrP

Dry Needling• Needling (dry needling) is suggested as

necessary to inactivate MTrPs– Elicits a local twitch response if successful

• Dry needling is an invasive procedure where a acupuncture needle is inserted into the skin and muscle in the area of a trigger point or other tension area in a muscle in order to relax the tissue and reverse the tension or abnormal tone in the muscle

• In the US, a survey of programs noted that only sparce DPT programs offer practice intervention with trigger point dry needling as a part of the curriculum (Georgia State University)

Legality

• In scope of PT to dry needle in Canada, Spain, Ireland, South Africa, Australia, Netherlands, and Switzerland

• In USA, dry needling for PT allowed in New Hampshire, Maryland, Virginia, South Carolina, Georgia, Kentucky, New Mexico, Colorado, Alabama, Oregon, Texas, and Ohio and many other states it is not mentioned as something specific that can be done but is considered part of the scope of practice.

• Absolutely disallowed in Florida, Tennessee, and Hawaii (PTs can’t penetrate the intact skin)

Dry Needling Effect

• Lewit (1979) found immediate analgesia in 87% of needle placement sites (only 31% had long relief)

• Effectiveness of Dry Needling for UQ MF Pain: A systematic Review and Meta-Analysis

Kietrys et al, 2013, JOSPT• Recommend TrDN for decreasing pain for up to 4 weeks• Lidocaine injection may be more effective; no comparison to

other rx.

Why Does Dry Needling Work?

1. Subjects with active MTPs in the trapezius muscle have a

biochemical milieu of selected inflammatory mediators, neuropeptides, cytokines, and catecholamines different

from subjects with latent or absent MTPs

Shah, et al. Arch Phys Med Rehabil. 2008 Jan;89(1):16-23

– After dry needling the milieu immediately is eliminated

• Suggested that this is caused by damaging the neuromuscular motor point

2. Potentially effects the meridian lines and the sympathetic

function responses

– Increase in vertical jump after dry needling of calf musculature

Bandy, et al. Int J Sports Phys Ther. 2017 Oct;12(5):747-751

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So What!What do we have so far?• Literature suggests we have EMG active

musculature in total and calls this spasm• Literature suggests we have shortened

muscle and calls this tightness• Literature suggests we have myofascial

tissue changes and lists many of these as different labels within myofascial trigger points

Soft Tissue Definitions

• Some of what we will describe in more detail now:– Tissue tone and findings

• Spasm• Guarding• Tightness• Facilitation• MTrPs• Spasticity• “Oma”

Let’s Consider Each of These Areas with EMG Data (preliminary data/Forbush)

Spasm: (How would you define a person in spasm?)– The typical person with a spasm response is very irritable

in the muscle. An example would be the person s/p trauma like a whiplash where the next day the muscle is reactive to any stretch or contraction and responds with strong nociceptive response

– Pain response is usually high during any stress on the tissue and muscle relaxants are typically given by the physician of record

– Preliminary EMG finding on a muscle that responds like this shows high motor activity with spike waves present during any motion or stress. The pattern shows the high irritability one would expect

Spasm

• A contraction of the muscle, when maintained, will cause a chemical change in the muscle and resultant uncontrolled reactivity and pain with rest and motion

• EMG of this type of tone shows repeated spike waves within a strong activity cycle

Guarding

• Remember, this word is interchanged often with spasm in the literature. It is important to define it so that it can be unique. The best definitions of guarding are based on the criteria of Janda in1991– Hypertonicity occurs with reactivity to position modulated from

central nervous system input– Example would be the protection of a position in standing involving

postural muscles. They do not allow the body to move freely– Typically this description is not painful unless the contraction is

prolonged without rest– This shows on EMG as steady muscle activity in protected position

and when the person changes position, the tone reduces dramatically

Guarding

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Tightness• Adapted and shortened muscles are labeled as tight. • Janda and others considered this a response to perpetual and

chronic positioning in a shortened position, sometimes due to abnormal tone (think guarding or spasm over time)– Could also explain some of the trigger point findings, tightness in a

section of a muscle oriented in line with the fibers • Hammer, in his Functional Soft Tissue book, describes tightness

as a condition involving tone, but also states:– Reasons for shortening include postural overload, sedentary

lifestyles, poor work positions, or previous hypertonicity• Obviously, if a muscle is adaptively shortened, this happens to

reduce need for contraction and the EMG shows an inactive, or minimally active, muscular tissue

MTrP

• We have already described this in detail• Active EMG findings are different in latent

and active trigger points (see below)

Facilitation (via Forbush)• Probably an effect of an irritation or dysfunction in a

movement segment• Though this term is rarely used in orthopedics, it would

signify there is an enhancement of tone from another source– In this case the tone is enhances through the neuro-segmental

spinal reflex described earlier or the Osteopathic Lesion– The segment of irritation will feed nociceptive information to

the dorsal horn in one or several segments. The body will feed this information to interneurons and some stimulation will go to the ventral horn areas and to the respective segmental muscles as a means of protection

– In EMG, this type of response shows only segmental increased electrical activity but is similar to guarding

REVIEW OF TONE AND TISSUE DESCRIPTIONS

Time for review

Spasm: Through Functional Definition

• Continues with change in position

• Reactive to touch or motion• Involves the entire muscle in

area of problem• Can be the end result or the

initial problem• Example: Immediate post

whiplash or hamstring immediately after strain

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Tightness: Adaptive Shortening

• Does not change with change in position• Usually should not be tender• Involves the entire muscle (origin to

insertion)• Usually the end result of a problem• Example: Hamstring tightness

Scar and Adhesions

Guarding

• Does change with a change in position or loading of the affected area

• Not usually tender to touch or pressure• Involves the entire muscle or problem area• Usually is a protective response to another

problem

• Example: Lumbar extensor guarding, gluteal guarding, or postural activity in the upper trapezius

MTrPs

• Continues with a change in position• Reactive with a twitch response to

strumming the taut fiber• Involves only a portion of the muscle• Usually tender by definition• Don’t know the reason for existence• Can be treated directly

Facilitation

• Guarding of a specific area or segment– The osteopathic lesion?

• Usually only changes in character with change in motion of segment it protects

• Can be tender or minimally tender• Usually a secondary problem not a primary

problem• Example: Segmental band in thoracic area or

response of trapezius to C4/C5 irritation

TISSUE TYPE ALL OR PARTCHANGE IN POSITION TENDERNESS

TREATABLE DIRECTLY

Tightness All No No Yes

Spasm All No Yes Yes

Guarding All Yes No No

MTrP Part No Yes Yes

Facilitation PartYes

(offending) Maybe No

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Other Findings in Evaluation of the Orthopedic Client

• Spasticity:– Hoffman’s sign or clonus present with spinal

stenosis of cervical or thoracic– Always denotes an UMN lesion

• Well defined in neurological literature• A true objective sign of neurological injury

– Can’t be said of orthopedic tone types

“Omas”

• A lump in the tissue from other than an orthopedic type of injury or response.

• Lipoma, hematoma, any number of benign or malignant tumors that can be found in tissues

• Possibility of Neurofibromatosis or other disease processes.

• To be noted and treated around

Omas

Treatment of Soft Tissue Problems

Treatment of Soft Tissue Findings• Treatment depends on the type of tissue tone you are

treating– If tightness, need to treat the tissue to break adhesions, bundles, or

increase length– If spasm, the tissue will not respond well to any intervention as it is

chemically irritated and highly reactive to stretch or activity. However, the therapist must change this chemical congestion and calm the input system

– In guarding, the reason for the protection needs to be addressed and the muscle tissue is not the prime focus of intervention

– In MTrPs, need to work on taut muscle and create twitch response in care

– In facilitation, the segmental reason for the protection and feedback needs to be addressed primarily and the tissue will normalize

Treatment of Tightness• Stretching:

– Bandy et al: 30 seconds for under 35; 45 seconds for over with static

– Dynamic stretching is more popular in literature recently• Deep soft tissue work:

– Move the fibers and fibrils on each other to reduce adhesions and improve intrinsic slide and glide in the muscle and increase blood flow

• Contract/Win/Relax/Stretch:– Explain

• Graston techniques:– Tools or no tools. Advantages and disadvantages

Documents/Hoffman%20Sign.MOV

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Tightness Myofascial Tightness and Release

• A poorly supported treatment methodology• Use techniques to stretch fascial restrictions• Autonomic causes are common

Treatment of Scar

• Do not want to shear the scar within itself– May cause blistering or lesion to tissue

• Want to separate scar from 3-D connections– Separate from underlying tissues

• Can longitudinally influence the scar

• Need to work in all compass directions

Scar Treatment

• Use of tactifying agent (something with rosin)

• Adhere to tissue• Shear tissue in a direction of restriction• Hold for 30-60 seconds• Go into other direction and repeat

Treatment of Spasm• Need to change chemical milieu in the tissue and neural irritability• Electrical stimulation to increase fluid exchange and improve

blood flow to the tissues• Icing to decrease neural input to the tissues• Protective positioning to allow rest of the protective tissues• Eventually find the reason for the initiation of the tone and treat

the cause

Treatment of Facilitation• Remember that facilitated muscle tissue is

neurologically reactive to the segmental irritation and nociceptive input (osteopathic lesion)

• Can’t treat the tissue…must treat the segment– Oscillatory graded mobilization for hypomobile– HVLA to segment if hypomobile– Low level oscillation if hypermobile– Stabilization if hypermobile with segmental

strengthening– DO NOT TREAT MUSCLE…TREAT REFLEX AND REASON!

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Treatment of Facilitation

• Important to note whether hypermobile or hypomobile– If hyper…stabilization, positional correction or

surgery– If hypo…mobilization or HVLA thrust

techniques, MET

Manipulation

• A necessary tool for use on many patients with facilitation and with MTrP

• Patients have changed in muscle tone with these techniques

• Results are immediate

Treatment of MTrPs

• Expected to treat with manual technique in literature:– Press and lift the tissue and then palpate

the tissue with digital pressure– Light pressure into the bundle to release– Spray and stretch somewhat effective

• Dry needling:– Proper technique and instruction– Awareness of the contraindications and

precautions– Push for the twitch response

Other Treatment

• Soft tissue massage– Circulatory enhancement– Increases sliding of fibers

within the muscle

– Can change fluid dynamics

Friction Massage

• Friction over a highly scarred area or over a chronic tendon issue (Brosseau et al, 2009; Cochrane Review)– Purpose is to increase blood flow to

an inherently low blood supply area– Make sure the therapist does not

damage the tissue during treatment– Decreases sensitivity and pain– More effective in UE than LE in

research

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Graston Techniques• Guided tools to improve

tissue extensibility and improve blood supply

• Why use a tool instead of hands?

• Pressure distribution• Strength• Depth

• Why use hands instead of a tool?

• Feel• Responsiveness of the tissues• Temperature and turgidity

Stretching

• Shown to be effective in persons with MTrPsand in persons with adaptively shortened musculature

• Not effective on guarding, spasm, or facilitation. WHY?

Conclusions

• Palpation should be critical part of a comprehensive evaluation

• Palpation skill is inherent in all humans, but may be more developed in some

• Palpation skills can also be more developed through practice and training

• The tissue must be exposed to allow full visual and palpatory access

Cases

• 5 cases to consider: (will probably not have enough time to cover all in this lecture)– Jose (carpenter with LBP)– Jack (wakes with “crick in the neck”)– Carl (thoracic wrap around pain and irritation)– Monique (radicular pain s/p lumbar laminectomy)– Bill (executive with upper trap pain and shoulder

issues on right)

Case #1: Jose

• 34 y/o carpenter• 5’6” and 200#• Prominent abdomen, lordotic in standing• Pain pattern:– Hurts in LB area at end of work day– All pain (ache) in low back area

– Some stiffness in the morning which resolves quickly

Structural and Soft Tissue Evaluation

• Standing with excessive tone in lumbar• Improves with end range extension and flexion• Quadrant test is negative• Thomas test mildly positive B• LLD negative• Seated flexion with minimal tone

– Comfortable with flexion, extension, and rotation in sitting

• Palpation is not tender in most areas

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Questions

• What kind of tone is this?• What are the three things you found to come to

this conclusion?• Would you work on the soft tissue on this

patient as a primary action to improve his pain?– If so, what would you do to/with the soft tissue?

• What would be your primary focus of therapy?

Case #2: Jack

• 27 year old doctoral student• 6’2”, 185# and very lean• Plays soccer regularly in competitive

environment• Jack woke this morning with severe pain in his

R lateral neck. Unable to move without pain. Has no abated today since he woke up. Wearing his brother’s soft cervical collar.

Structural and Soft Tissue Exam

• Stands with neck protected in midline and slightly side bent to the R

• Unable to actively move in rotation to the L or SB to the L without severe lateral/posterior neck pain

• Worse with flexion than extension but still painful in lateral musculature and some posterior

Additional Information

• Very tender at C4 posterior pillar on the R>L• Tender and reactive SCM and scalenes R>L• Limited PROM in the mid-cervical segments• Vertebral artery test unable to be tested• No signs of UE involvement

Questions





Case #3 Carl

• Carl is a worker in a factory and works with moderately heavy product in loading pallets throughout most days

• He is 31 years old, 5’10”, and weighs 182#• He has pain in the central to R-sided thoracic

area pain (dull ache) in the T6 area. The pain will get worse during the day and radiates toward the anterior chest area along the rib. It improves with ibuprofen and with decreased rotational activities

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• Thoracic with mild kyphosis and mild scoliosis (<15 degrees in standing)

• He has LLD with the R > L at approximately ½”• There is a band of muscle that is prominent (almost

looks like swelling) and this area is mildly tender with palpation. It gradually refers to a larger area a bit more lateral with continued pressure. The band goes bilaterally from the lateral paraspinals on the opposite side


• Restrictions were found in the rib and facet at T5-T7 R greater than the L

• Breathing was unrestricted and there was no reactive tone with motion

• Pain was worsened with compression/flexion combination in this area and with end range rotation to the R

Questions





Case #4: Monique• This is a 25 year old aerobics, zumba, and core

exercise instructor and is a certified personal trainer. • In the midst of making a boxing workout video, she

had a bout of LBP on the R.• This pain has remained consistent for 2 weeks• She had a lumbar laminectomy without fusion with

open technique at the age of 20 because of LE neural symptoms and a diagnosed disc

• She is 5’6” and 125 pounds

Structure and Soft Tissue Exam

• Monique stands with a slightly accentuated lordosis and has massive gluteal musculature

• She runs 3-4 miles daily beyond her dance and training regime

• She is level at the base and has good posture• There is a consistent prominence of the lumbar

musculature B in standing which reduces in sitting• She hurts mostly with quadrant testing B and

repeated forward flexion


• PIVM of the lumbar has only mild restriction at L3/L4 on the L. All else moves relatively well

• There is increased tone bilaterally in the lumbar paraspinals and the multifidi (over the sacrum)

• Hips have 50 degrees of IR bilaterally• There is no pain below the knee• She continues to work out through the pain• Scar tissue line is 4” and is reddened

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Lumbar and Fascial Scarring Questions





Case #5: Bill

• Bill is a 56 year old executive working with Honeywell systems

• He is 5’8” and weighs 220# and has a prominent abdomen

• He is complaining of L upper trap pain and some pain with function of the shoulder on this same L side. The pain is worse with activity and he feels “tight” all the time


• Pt. states he has had a disc problem for years (15) and he has managed with a retraction program which makes him slightly better

• Mild OA changes found with end range testing in the cervical spine and he had an boggy type end feel

• He has moderate FHP and increased upper T-spine kyphosis in standing and sitting


• Bill has mild to minimal restriction is the C4-C6 areas of bilateral cervical

• Palpation of the upper trap reveals some lumpy areas in the line of the muscle outside the motor point

• Palpation of these “ropey” areas causes a pain into his lateral deltoid and into the side of his face

Other Data

• Infraspinatus is weaker in the L than in the R UE by at least a half grade but it is painful

• Painful nodules were found in the infraspinatus fossa in line with the fibers

• No thoracic restrictions were found• What kind of response are you looking for?• He also has a slight Dowager’s hump in the C-T

junction

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Questions

• What type of soft tissue problem would this be to you?

• Can you treat the tissue or do you need to treat the underlying structure?

• What options do you have for treatment and how would you go through this treatment regime?

• What is the prognosis?• Does he have a “chronic” disc problem?

Final Statements• We have become practitioners that have removed

ourselves from the simple therapeutic touch which is a vital component not only of connecting to the patient but to the true assessment of patient condition and involvement

• If we can assess the tissue and through this assessment, define the tissue tone type, we will be more effective at appropriate treatment

• Need to treat tightness, MTrP, and spasm directly and need to treat guarding and facilitation indirectly

Questions?