Chapter 1: Specific Interventions

• Aid in reduction of of metabolites from muscle
• Reactivating a muscle that has not been functioning secondary to guarding and ischemia
• Revascularization of muscle
• Decrease guarding in a muscle

Stimulation of skin and superficial fascia to facilitate decrease in muscle tension

• Movement of skin, fascia, and muscle causes histological and mechanical changes to occur in soft tissues
• Produces improved mobility and function

• Decrease pain, edema and muscle spasm
• Increase metabolism and cutaneous temperature
• Stretch tight muscles and other soft tissues
• Improve circulation
• Strengthen weak muscles
• Mobilize joint restrictions

Patients withs oft tissue and joint restriction that result in pain and limit ADL's

• Absolute: soft tissue breakdown, infection, cellulitis, inflammation, and/or neoplasm
• Relative: hypermobility and sensitivity

• Effleurage
• Petrissage
• Functional massage
• Transverse friction massage
• Movement approaches

• Three techniques used to assist in reactivation of debilitated muscle and/or to increase vascularity to a muscle
•  
• 1) Soft tissue without motion
• 2) Soft tissue with passive pumping
• 3) Soft tissue with active pumping

• Traditional technique 
• Hands do not slide over skin -- stay in contact with skin while hands and skin move together over muscle
• Direction of force is parallel to muscle fibers 
• Total stroke time should be 5-7 seconds

• Place muscle in shortened position and one hand place tension on muscle parallel to muscle fibers 
• Other hand passively lengthens muscle and simultaneously gradually releases tension of hand in contact with muscle

• Place muscle in lengthened position 
• With one hand, place tension on muscle perpendicular to muscle fibers
• Other hand guides limb as pt actively shortens muscle
• As muscle shortens, gradually release tension of hand in contact with muscle

• Used to initiate an acute inflammatory response for a tissue that is in metabolic stasis (i.e. tendonosis)
• Involved tendon is briskly massaged in transverse fashion (perpendicular to direction of fibers)
• Performed for 5-10 minutes and tends to be very uncomfortable for the pt

Require the patient to actively participate in treatment

• Examples include:
• 1) Feldenkrais
• 2) MET
• 3) PNF Hold-Relax-Contract Technique

• Facilitates development of normal movement patterns
• Practitioner uses skillful, supportive gentle hands to create sense of safety, maintain supportive contact, while introducing new movement possibilities in small, easily available increments

• Include voluntary contraction in a precisely controlled direction, at varying levels of intensity, against an applied counterforce from clinician
• Purpose is to gain motion that is limited by restrictions of neuromuscular system
• Modification of PNF technique

Antagonist of shortened muscle is contracted to achieve reciprocal inhibition and increased range

• Inhibit pain and/or muscle guarding
• Lubricate joint surfaces
• Provide nutrition to joint structures
• Maitland suggests that grades III and IV oscillations are beneficial to stretch tight connective tissues

• Grade I: small amplitude, at beginning of range of joint play
• Grade II: large amplitude, midrange of joint play
• Grade III: large amplitude, at ends range of joint play
• Grade IV: small amplitude at end range of joint play
• Grade V: manipulation of high velocity and low amplitude to anatomical endpoint of a joint (technically not an oscillation, since it is a single movement rather than a repetitive one)

• Grades I and II: improve joint lubrication and nutrition, decrease pain and muscle guarding
• Grades III and IV: stretch tight muscles, capsules, and ligaments
• Grade V: regain normal joint mechanics as well as decrease pain and muscle guarding

• Joint ankylosis
• Malignancy involving bone
• Disease that affect integrity of ligaments (RA and Downs)
• Arterial insufficiency
• Active inflammatory and/or infective process

• Arthrosis (DJD)
• Metabolic bone disease (osteoporosis, Paget's disease, and tuberculosis)
• Hypermobility
• Total joint replacement
• Pregnancy
• Spondylolisthesis
• Use of steroids
• Radicular symptoms

To stretch/lengthen/deform collagen and normalize arthrokinematic glide (as described by Kaltenborn

• Grade I:
• "Loosening" translatoric glide
• Small amplitude traction force
• Relieve pain and/or decompress joint during joint glides

• Grade II:
• "Tightening" translatoric glide
• Movement takes up slack in tissues surrounding joint
• Used to alleviate pain, assess joint play, and/or reduce muscle guarding

• Grade III:
• "Stretching" translatoric glide
• Movement stretches tissues crossing the joint 
• Used to assess end-feel or to increase movement (stretch tissue)

• Mechanical, manual, and self or auto traction
• Vertebral bodies separating
• Distraction and gliding of facet joints
• Tensing of ligamentous structures of the spinal segment
• Intervertebral foramen widening
• Spinal muscles stretching

• Inhibit pain and/or muscle guarding
• Improve translatoric glide in cases of joint dysfunction due restriction
• Health care practitioners who perform include PTs, osteopaths, chiropractors, and medical doctors

• Generalized: 
• Fairly forceful
• Long lever techniques intended to include as many vertebral segments as possible
• More commonly performed by chiropractic practitioners 

• Specific:
• Aimed at having an effect on either a specific segment or only a few vertebral segments
• Minimal force with sort lever arm
• Often includes "locking" techniques based on biomechanics to ensure that a specific vertebral segment receives the manipulative thrust
• More commonly performed by PTs

• Mid-Range:
• Very gentle, short lever arm techniques
• Barrier created in mid-range by specific positioning of patient as well as creating tautness in surrounding soft tissues
• More commonly performed by osteopathic practitioners

• Not communicating clearly with pt regarding the technique
• Taking too long to properly position the pt
• Not performing "trial" thrust prior to actual thrust
• Not allowing person to bottom out with breath prior to performing thrust
• Taking up slack while pt exhales and then letting off with pressure prior to thrust
• Velocity too slow
• Amplitude too great 
• Headaches in cervical region are common indication for thrusts but also a contraindication (ask about birth control combined with smoking since this may be a cause for a vascular accident - HA frequently precede CVA)
• Consider performing thoracic thrusts to attain result that was sought after for cervical thrust 
• Perform vertebrobasilar testing when performing manipulations to cervical segments

• Movement of neural structures to regain normal mobility
• Tension tests for upper and lower extremities (i.e. dural stretch tests) = movement of soft tissues that may be restricting neural structures (i.e. cross friction massage for adhesions of radial nerve to humerus at fracture site) 
• Perform assessment with neurotension testing
• Determine whether managing irritated or non irritated neurological tissue (irritated - grade II mobs (Maitland) - should be non painful; non irritated - grade III mobs (Maitland) to engage barrier but remain non painful)
• Postural reeducation: to open up interverebtral foramen and decrease tension to tissues

• Indications: used for pts who have some type of restriction in neural mobility (anywhere along course of nerve)
• Contraindications: extreme pain and/or increase in abnormal neurological signs

• Decrease muscle guarding
• Decrease pain
• Increase vascularity of tissue
• Promote regeneration and/or speed up recovery of connective tissues (cartilage, tendons, ligaments, capsules, and intervertebral discs)
• Mobilize restricted tissue to increase flexibility
• Increase endurance of muscle
• Increase coordination of muscle
• Increase strength of muscle
• Sensitize muscle to minimize joints going into excessive range (in cases of hyper mobility)
• Develop dynamic stability and functional movement patterns, allowing for optimal function within the environment

• Pt's home program will consist of exercises to reinforce clinical program
• Necessary to perform enough reps for desired physiological effete on appropriate tissues as well as develop coordination and endurance to promote dynamic stability within functional patterns

• A.K.A. Intramuscular Manual Therapy (IMT)
• Utilized to break up TPs in myofascial pain syndrome 
• Solid filiform needle is inserted into trigger point (within the muscle)