Clinical Skills 3

• Soft tissue mobilization

  Mechanical and rhythmical manipulation of soft tissue by use of the hands
• Application of soft tissue mobilization

  Application of pressure, tension, motion, or vibration to soft tissues of the body to achieve a beneficial response
• Examples of soft tissue mobilization techniques

  • Pressure with hands, knuckles, or elbow
  • Tension
  • Vibration
• Therapeutic effects of soft tissue mobilization

  • Reducing pain
  • Reducing swelling
  • Reducing muscle spasm
  • Increasing tissue extensibility
  • Reducing muscle tension
  • Increasing scar mobility
  • Increasing local circulation
  • Aiding post-exercise recovery
  • Promoting tissue remodeling
  • Promoting lymphatic drainage
  • Facilitation relaxation
  • Promoting well-being
  • Reducing stress
  • Increasing body awareness
• Systems affected by soft tissue mobilization

  • Circulatory
  • Lymphatic
  • Connective tissue
  • Musculoskeletal
  • Metabolic
  • Immune
  • Neurological
  • Psychological
• Soft tissue mobilization

  • Reduces pressure differences to allow fluid movement from high to low pressure areas
  • Has a "milking effect" to move fluid
• Soft tissue mobilization can impact shortened tissue and reduce soreness, as well as increase muscle spindle awareness
• Static touch

  Simplest and oldest form of soft tissue mobilization, motionless constant of therapist's hands with the patient's body with minimal force
• Effleurage

  Smooth, continuous motion - gliding or sliding across the skin with light to deep pressure

  proximal to distal or distal to proximal
• Petrissage

  Techniques that repetitively compress, shear, and release soft tissue, applied with various amounts of lifting, wringing, squeezing
• Specific compression

  Non-gliding technique of compression and release, perpendicular to surface of body, often sustained 5-30 seconds
• Intervention sequence for soft tissue mobilization

  1. Effleurage

  2. Petrissage

  3. Specific compression

  4. Petrissage

  5. Effleurage

  6. Passive stretch

  7. AROM using target muscle
• Indications for soft tissue mobilization

  • Adhesions/scarring
  • Impaired connective tissue integrity
  • Decreased mobility of skin
  • Impaired mobility
  • Muscle strains and tears
  • Tendinopathies
  • Trigger points
• Indications for STM

  • Adhesions/scarring
  • Impaired connective tissue integrity
  • Decreased mobility of skin
  • Impaired mobility
  • Muscle strains and tears
  • Tendinopathies
  • Trigger points
  • Impaired muscle performance
  • Muscle spasm
  • Posture
  • Pain
  • Swelling/edema/lymphedema
  • Abnormal tone
• Tendonapathy

  Subacute/chronic - increase blood flow, promote healing
• Tendinitis

  Acute inflammation
• Contraindications

  • Acute inflammation (know PMH)
  • acute flare of chronic local or systemic inflammation
  • Acute neuritis or peripheral neuropathy
  • Areas of impaired sensation
  • Skin conditions
  • Hemophilia or hemorrhage
  • Cardiac arrhythmia, unstable hypertension
  • Inadequate circulation
  • DVT
  • Liver/kidney failure
  • Fever > 100* F
  • Acute ligament, tendon, muscle tear
  • Unhealed fracture (locally)
  • Malignancy
• Contraindications require patient education, compression, and elevation
• Cardinal signs of inflammation

  • Pain level
  • ROM (local)
  • Swelling
  • Redness
  • Heat
• Contraindications depend on the number of days out from injury and the severity of the cardinal signs of inflammation
• Peripheral neuropathy

  Loss of sensation, limited feeling
• Contraindications for skin conditions include inspecting for lesions and assessing skin integrity
• Contraindications for bleeding disorders include asking about history and inspecting for bruises/ecchymosis
• Contraindications for cardiac arrhythmia and unstable hypertension include asking about blood pressure and heart palpitations
• Contraindications for inadequate circulation include asking about history and inspecting for changes in skin color and pooling
• Contraindications for DVT include asking about history and assessing for swelling and tenderness of the calf (Homan sign) using the Wells criteria
• Contraindications for liver/kidney failure include asking about history and inspecting for jaundice, as well as assessing vitals
• Contraindications for fever over 100*F include assessing temperature
• Contraindications for acute ligament, tendon, muscle tear include inquiring about the history of present illness
• Contraindications for unhealed fracture include inquiring about the history of present illness
• Contraindications for malignancy include the signs listed on slide 22
• Precautions

  • Chronic arthritic conditions
  • Fracture while casted or immediately after removal
  • Joint instability/hypermobility
  • Medications for anticoagulation
  • Atherosclerosis
  • CHF or emphysema
  • Medications that alter neuro, cardiac, or kidney function
  • Epilepsy or uncontrolled seizures
  • Immunosuppression (HIV+, RA meds)
  • MS
  • Osteoporosis
  • Post CVA
  • Post MI
  • Pregnancy
  • Spasticity/rigidity
  • Fragile skin
• No STM should be performed within 48 hours after open heart surgery
• Absolute contraindications for STM with malignant disease

  • Undiagnosed cancer
  • Night pain at consistent time
  • Malaise
  • Unexplained weight loss
  • Fever/chills
  • Any undiagnosed lump
• STM can be used with precaution and outstanding communication with the care team in the early stages of cancer or when the emphasis is on comfort rather than cure, such as in hospice/palliative care
• Endangerment sites

  • Anterior neck
  • Axilla
  • Thoracic cage
  • Umbilicus
  • Elbow
  • Femoral triangle
  • Popliteal fossa
• Endangerment sites require working with awareness, monitoring patient response, adjusting pressure, and not taking chances
• Intervention sequence for patient education

  • Teach pressure points/STM or active therapies for self-management
  • Teach ROM
  • Teach what to do for redness/bruising
  • Teach postural reeducation
  • Teach about delayed soreness and activity modifications
  • Teach hydration
• Documentation

  • Area
  • Position
  • Techniques used
  • Patient's response
  • Functional gains
  • Pain reduction
• Documentation should include asterisk signs before and after the intervention