1. Soft Tissue Techniques Therese Obioha OMS V Sarah Watson OMSV 21 June 2013

2. Overview of Lab Review of Screen, Scan, Segmental Definition Overview of Soft Tissue Techniques Types of Soft Tissue Treatments Practice Time Use of Soft Tissue Treatment 2

3. Review of Screen, Scan, Segmental Definition 1. Screen ◦ Is there a problem? ◦ Look, listen, feel 2. Scan ◦ Where is the problem? ◦ One tissue scan + one confirmatory motion scan  Tiebreaker scan if needed 3. Segmental Definition ◦ What is the problem? ◦ Naming the dysfunction (in ease) 4. Diagnosis  Treatment 3

4. Screen... Scan... Segmental Definition...

5. Find Somatic Dysfunction on Your Partner Write down areas and remember the areas for later 5

6. Screen—Palpation  Axial Spine: Comparing Above with Below  Ask the question, “Is there a difference in tissue resistance?”

7. Screen—Gross Regional Motion  Cervical rotation  Apply a slight rotary force to the left/right  Cervical sidebending  Tell patient to let the head fall to the left/right

8. Screen—Gross Regional Motion  Thoracic rotation  Apply a slight rotary force to the left/right Feel for that initial resistance to motion.  Thoracic sidebending  Apply a slight downward force using your body weight as leverage

9. Screen-Gross Regional Motion  Lumbar lordosis  Patient *actively* flexes (bends over)  Lordosis should flatten out  Lumbar rotation  A notable prominence of left or right paraspinal tissues is abnormal This test can be combined with the previous one.

10. Overview of Soft Tissue Treatments 10

11. Overview of Soft Tissue Treatments: Causes of Dysfunction? Irritation (somatic dysfunction) Psychogenic factors overuse trauma Infectious agents Inactivity Visceral Disease 11 - Adapted from Dr. Eland

12. Soft Tissue – Circle of Irritation 12 - Adapted from Dr. Eland

13. Overview of Soft Tissue Techniques When to use soft tissue techniques: 1. Relax Tight Muscles 2. Stretch the fascia around tight muscles 3. Increase circulation to the fascia and muscles 4. Improve local tissue nutrition, oxygenation, and removal of waste via lymphatics 13

14. Overview of Soft Tissue Techniques Defined as: Direct treatments that address the muscular and fascial structures of the body and the associated neural and vascular elements. Direct method technique: A technique engaging the restrictive barrier and then carrying the dysfunctional segment into the restrictive barrier 14

15. Overview of Soft Tissue Techniques Defined as: Direct treatments that address the muscular and fascial structures of the body and the associated neural and vascular elements. Direct method technique: A technique to engage the restrictive barrier (of a muscle or group of muscles) …and then focused on carrying the dysfunctional segment TOWARDS the restrictive barrier 15

16. Overview of Soft Tissue Techniques When to use soft tissue techniques (cont.) 5. Identify areas of somatic dysfunction 6. Improve local and systemic immune response 7. Provide a general state of relaxation for the patient (from Foundations of Osteopathic Medicine, pg. 819) 16

17. Overview of Soft Tissue Techniques A Side Note! Tissue Response and Treatment While you are doing these techniques, you will feel changes in the tissues with your hands Ex. Relaxation of muscles Increased temperature of tissue (due to increased blood flow) A pulsation under your fingers Related to Circulation and other natural body rhythms. 17

18. Types of Soft Tissue Treatment 18

19. Types of Soft Tissue Treatment: Lateral stretching Linear stretching Deep pressure (Inhibition) Others: ◦ Tapotement, Effleurage, Petrissage 19

20. Types of Soft Tissue Treatments Kneading (Lateral Stretching) o Force applied perpendicular to the long axis of the muscle o The rhythmic lateral stretching the muscle and fascia o The origin and insertion are held stationary 20 Force

21. Types of Soft Tissue Treatments Inhibition o Steady pressure applied to muscle to increase relaxation via intrinsic muscular reflexes 21 Force

22. Types of Soft Tissue Treatments Traction ( Linear Stretching) o A linear force to draw structures apart o The origin and insertion the muscle are pulled away from each 22

23. Types of Soft Tissue Treatments Effleurage o Light pressure to the skin to compress the underlying subcutaneous tissues o This helps to move fluid along lymphatic channels 23

24. Types of Soft Tissue Treatments Petrissage o Deep kneading or squeezing action to remove swelling; more pressure than effleurage. o This helps to break up adhesive bands from the skin to the deeper tissues o Important to know WHERE you are directing this fluid o Anatomy of lymph nodes and lymphatic flow 24

25. Types of Soft Tissue Treatments Tapotment o Striking the belly of a muscle with the hypothenar edge of the open hand in rapid succession o Increased blood flow o Breaks up fatty nodules 25

26. Types of Soft Tissue Treatments Deep Friction o The application deep strokes of the thumb, knuckles, or elbow to small paraspinal muscles o Helps to break up fibrotic changes in small paraspinal muscles o Can also help to increase local circulation through release of local chemical mediators 26

27. Summary of Treatment Types Most Commonly Used Kneading, Inhibition, Traction To remove swelling Effleurage/Petrissage To Increase Circulation Tapotement, Deep Friction 27

28. Time to Practice! 28

29. Paraspinal Muscle Dysfunction A. Kneading 1. Pt prone 2. Physician stands opposite of tight muscle 3. Doc places heel of one hand along erector spinae muscles and reinforces with heel of other hand 4. Force is applied anteriorly and laterally to scoop muscle laterally 29

30. Paraspinal Muscle Treatment A. Inhibition 1. Pt prone 2. Physician stands opposite of tight muscle 3. Doctor places pad of thumb over tight muscles and reinforces with the heel of the other hand 4. Continued force is applied until relaxation of muscle is achieved 30

31. Suboccipital Muscle Dysfunction A. Kneading and stretching 1. Pt supine 2. Physician contacts medial aspect of suboccipital muscles with pads of fingers of both hands 3. Fingers are drawn superiorly (stretching) and laterally (kneading) 4. Use enough force to feel the muscles relax, but not to cause discomfort 5. Force is slowly relaxed, fingers repositioned, and kneading and stretching repeated 6. Recheck 31

32. Cervical Paraspinal Muscle Dysfunction A. Bilateral stretch 1. Pt supine 2. Physician’s forearms crossed under patient’s neck and hands are placed on anterior aspect of patient’s shoulders 3. Physician lifts pt’s head until the muscular restrictive barrier met 4. Force slowly relaxed 5. Stretching may be repeated 6. Recheck 32

33. Lumbar Paraspinal Muscle Dysfunction A. Kneading and stretching 1. Pt is prone 2. Physician places heel of one hand along the medial aspect of the erector spinae muscles 3. The other hand cups the ASIS on the side of the tight muscles and lifts to provide a stretch 4. Anterior and lateral force is applied through the hand on the erector spinae 5. A rhythm is developed between the two hands B. Inhibition 33

34. Upper Extremity Lymphatic Congestion A. Effleurage 1. Pt supine 2. Physician lifts patient’s arm vertically and grasps patient’s fingertip with one hand 3. Physician applies enough pressure to compress skin against the deep fascia and strokes the lateral side of finger from distal to proximal 4. Physician then applies enough pressure around the arm to compress skin against the deep fascia and strokes the arm from distal to proximal at various points on the circumference until the entire arm has been treated 34

35. Conclusion – Student Response Types of soft tissue treatments When to use soft tissue Why would we use soft tissue treatments 35

36. (Some examples of) Clinical Application of Soft Tissue Techniques 1. Ankle Sprain 2. Low Back Pain 3. Overuse 1. Acute 2. Chronic 4. Tension Headache 5. Other?

37. Next Lab! Putting all the pieces together OMM Applications for Headaches Dx, Tx, and Follow-Up Care… 37

38. Resources DiGiovanna E, Shiowitz S, Dowling D. An Osteopathic Approach to Diagnosis and Treatment. 3 rd ed. 2005: Philadelphia, PA. Lippincott Williams & Wilkins: 80-83 Ward, et al. Foundations of Osteopathic Medicine. 2 nd ed. :glossary Kimberly PE. Outline of Osteopathic Manipulative Procedure: The Kimberly Manual. Millenium ed. 2000; Marceline, MO. Walsworth Publishing Co: 37-59 38