Summary

Specialized manual skills are used extensively in both evaluating and treating the canine patient. Manual techniques are used in an assessment to identify soft tissue abnormalities, muscle length tightness, limitations in passive range of motion (PROM), and restrictions in arthrokinematic motion. Soft tissue palpation requires the ability to distinguish between normal and pathological tissue characteristics. Flexibility is assessed with particular sensitivity to multijoint muscles. PROM provides information regarding quality and quantity of joint range of motion (ROM) with the use of end-feels and goniometry. Joint play is used to assess accessory joint motion. Identification and interpretation of abnormal findings will direct the therapist in determining the most appropriate and most efficient treatment techniques. Manual treatment involves a variety of soft tissue techniques, specific stretching techniques, PROM with overpressure, and joint mobilization, including glides and traction. Soft tissue techniques are designed to address a specific tissue type and pathology. Techniques used to increase circulation are different from techniques used to reduce adhesions or eliminate trigger points. Decreased flexibility is treated with direct and nondirect stretching techniques designed to optimize patient tolerance and effectiveness. Treatment of limited PROM depends on information gathered from end-feel assessment. Motion limited by a firm, elastic end-feel will require treatment techniques different from motion that is limited by a boggy end-feel. Finally, joint mobilization consists of glides and traction. Different grades and techniques of mobilization are used to treat pain versus hypomobility.

Manual skills are critical to successful evaluation and treatment of the canine rehabilitation patient. Manual techniques are used in assessment and treatment of soft tissue abnormalities, osteokinematic and arthrokinematic dysfunction, and pain. In this chapter, manual skills are divided into four categories: soft tissue mobilization (STM), passive range of motion (PROM), stretching, and joint mobilization.

STM

Soft tissue mobilization (STM), or massage, is the systematic application of manual pressure and movement of soft tissues, including skin, tendons, ligaments, fascia, and muscle. Soft tissue treatment techniques have been used for medical conditions since the 1800s; however, STM has been a source of some controversy, as its value has not been well documented (Hertling & Kessler, 1990). One must be diligent in determining the rationale for its use. Treatment techniques must be based on an accepted physiologic basis. Each technique must clearly support the specific treatment objectives as well as the predetermined goals and plan for resolving the pathologic state.

When pressure is applied to soft tissues, the tissue layer interfaces glide and separate, creating physiological effects. STM is presumed to create circulatory effects that drive fluid from the interstitial space to the vessels with movement toward the lymph nodes and heart (Millis et al., 2004). Mobilization of connective tissue is used to increase the extensibility of the tissue and to prevent or reduce adhesion formation. Soft tissue techniques can be used to increase range of motion (ROM) (Sefton et al., 2011), promote healing (Zusman, 2011), and reduce pain (van den Dolder et al., 2010; Sefton et al., 2011).

Soft Tissue Assessment

To determine the appropriateness of STM as a treatment, a careful evaluation of the soft tissues must be performed. A thorough soft tissue assessment will identify the presence of soft tissue pathology, swelling, and pain. With this information, the most effective soft tissue treatment technique can be chosen.

Soft tissues are evaluated by palpation of specific tissues and structures. A variety of techniques are used to assess soft tissue depending on tissue type. For example, fascial restrictions are evaluated using techniques quite different from those used for muscle or tendon. It is important to be cognizant of the properties of each type of tissue, understanding that normal muscle feels different from normal tendon, ligament, or fascia. The contralateral side is used for comparison. Documentation includes a description of the tissue that can be characterized by texture, shape, tone, and density. Abnormal soft tissue can be described as thick, soft/firm, boggy, tight, tender, in spasm, warm/cold/clammy, or as having crepitus.

Assessing Swelling

The terms edema and swelling are often used interchangeably. In the strict sense, however, swelling does not include pitting. Swelling is the abnormal build up of fluid in tissues (intracellular, extracellular, intracapsular, and extracapsular). When pressure is applied to a swollen area and an indentation remains once the pressure is removed, it is referred to as pitting edema (Table 6.1).

Table 6.1 Characteristics of swelling

Type of swelling	Characteristic
Fluid swelling	Soft and mobile
Edematous synovial swelling	Boggy
Pitting edema	Thick and slow moving

Resolution of swelling is a common treatment goal, as swelling will retard the recovery process. Swelling can result in pain, loss of ROM and reflex inhibition of the surrounding muscles, leading to atrophy and weakness. Swelling can be measured with a Gulick girthometer and documented in centimeters (Figure 6.1) or it can be palpated and documented as minimal, moderate, or severe.

Figure 6.1 Measurement of stifle joint swelling using a Gulick girthometer and documented in centimeters.

Soft Tissue Treatment

Varying physiologic states are treated using different STM techniques. For example, effusion is most effectively treated with longitudinal strokes of moderate pressure, whereas a muscle spasm will respond better to ischemic compression. Once the goal of your soft tissue treatment is established, the most appropriate technique(s) can be applied.

Treatment Goals:

Treatment goals would include the following:

Increase circulation
Decrease swelling
Increase tissue extensibility
Reduce adhesions
Increase scar mobility
Eliminate trigger points or tender points
Promote tendon and ligament healing
Increase ROM
Decrease pain
Decrease muscle spasm
Facilitate or inhibit neuromuscular activity.

Techniques

The choice of technique for a particular condition will depend upon the goal of treatment; the size and shape of the muscle, tendon, ligament, or fascia; and the pathological state of the tissue.

Effleurage consists of long slow strokes, generally light to moderate pressure, usually parallel to the direction of the muscle fibers (Figure 6.2).

Petrissage involves short, brisk strokes, moderate to deep pressure, parallel, perpendicular, or diagonally across the direction of the muscle fibers. It may include kneading, wringing, or skin rolling (Figure 6.3).

Tapotement is rhythmic, brisk percussion often administered with the tips of the fingers, primarily used as a stimulating stroke to facilitate a weak muscle (Figure 6.4).

Cross-friction massage involves applying moderate pressure perpendicularly across the desired tissue (Figure 6.5). Pressure is maintained in such a way that the finger does not slide across the skin, but rather takes the skin with it. In so doing, the force is transmitted directly to deeper tissues. Cross-friction massage is commonly used on tendons, ligaments, and well-healed scars to realign noncontractile fibers. Cross-friction massage was made popular by one of the foremost specialists in the diagnosis and treatment of musculoskeletal injury and pain syndromes, British physician James Cyriax. He believed that proper remodeling could be stimulated by manually manipulating the tissues to both break down the scar tissue and promote circulation.

Ischemic compression is performed by applying sustained moderate to deep pressure to an area of localized hyperactivity. It is a therapeutic technique in which blood flow to a local area is intentionally blocked. It is believed that a resurgence of local blood flow will occur upon release. Once discomfort is reduced, increased pressure is applied. Ischemic compression is thought to restore circulation, inhibit the muscle, reduce muscular tension, and promote healing.

Trigger point pressure release involves applying gentle digital pressure to a trigger point. It is based on the extensive work of Janet Travell, MD, and colleagues. Travell defined a trigger point (TrP) 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” (McPartland, 2004). In 1999, Travell and Simons recommended treating trigger points with gentle digital pressure rather than the previously proposed ischemic compression. They named their new technique “trigger point pressure release” (Simons et al., 1999), identified common trigger point locations and linked them to specific referral patterns. Deactivation of these points can be achieved by manual trigger point release, spray and stretch, dry needling, or injection (McPartland, 2004). Treatment is designed to alleviate referred sensations as well as localized pain.

Positional Release Therapy/Strain-Counterstrain (SCS) is a technique based on the identification and resolution of tender points. A tender point is distinguished from a trigger point in that it elicits local pain only. The patient is placed in a position in which the origin and insertion of the hypertonic muscle are brought close to one another. This position is held for 90 seconds (3 minutes for the neurological patient). The process is completed by slowly and passively returning the patient to an anatomically neutral position without firing of the muscle spindle.

Figure 6.2 Effleurage to the gluteal muscles.

Figure 6.3 Petrissage (skin rolling) of the paravertebral muscles.

Figure 6.4 Tapotement to the triceps muscle.

Figure 6.5 Cross-friction massage of the supraspinatus tendon.

The technique is based on SCS techniques developed by Lawrence Jones, DO, in the 1950s. He believed that SCS inhibited the muscle spindle activation, thereby decreasing the amount of afferent impulses to the brain and thus, efferent impulses to the same muscle. By interrupting this pathway, the patient’s muscle is allowed to relax and assume a normal resting tone (Kuchera, 2008).

Additional manual techniques that are outside the scope of this text but merit acknowledgement are as follows:

Myofascial release (MFR) addresses myofascial connective tissue restriction with the intention of eliminating pain and restoring motion. Elongation of restricted fascial tissue is achieved by applying a slow, low load (gentle pressure) to the target viscoelastic medium (fascia). The load is applied in three planes of motion using either direct or indirect techniques. This technique requires advanced training from a therapist specializing in MFR.

Acupressure is based on the ancient healing art of acupuncture. Using the same pressure points and meridians, acupressure employs finger pressure rather than needles to specific points on the body.

Manual lymphatic drainage (MLD) therapy focuses on specific lymph nodes and the natural flow of the lymphatic system. Given that the lymphatic system does not have its own pumping mechanism, lymphatic drainage therapy (LDT) is intended to promote free flowing lymphatic drainage. The technique uses specific rhythmic hand strokes taught by an MLD therapist.

Treatment Design

With knowledge of the above treatment techniques, one can determine which technique(s) will most effectively address the patient’s issues (Table 6.2). It is important that the underlying cause of the soft tissue abnormality be addressed for long-standing resolution of the problem to occur.

Table 6.2 Treatment guidelines by goal

Goals	Techniques
Increase circulation	Effleurage, petrissage, tapotement
Decrease swelling	Effleurage; lymphatic drainage
Increase soft tissue extensibility	Effleurage, petrissage, cross-friction massage, positional release, trigger point release, MFR
Reduce adhesions	Cross-friction massage
Increase scar mobility	Cross-friction massage, MFR
Eliminate trigger or tender points	Trigger point release, positional release, ischemic compression
Promote tendon and ligament healing	Cross-friction massage
Increase ROM	All of the above
Decrease pain	Effleurage, petrissage, cross-fiber massage, trigger point release, MFR, ischemic compression
Decrease muscle spasm	Ischemic compression, effleurage, petrissage, tapotement

For example, upper trapezius or scalene muscle pain is a common complaint in human medicine. Upon evaluation, trigger points, tenderness, and decreased flexibility are noted. Soft tissue techniques will likely provide temporary relief at best. The underlying cause of the overused muscles must be determined to fully resolve the issue. A possible cause may be poor posture while working on the computer. Thus, complete resolution will require changing the gravitational effect on this muscle with postural correction and exercise. A similar canine example would be the patient with an iliopsoas strain secondary to lumbosacral instability. The muscle can be treated with manual therapy, creating a temporary improvement in the patient’s status, but symptoms will reoccur until the lumbosacral instability is addressed.

There are a few contraindications to STM. Patients with mast cell tumors, phlebitis, or infectious/parasitic dermatitis in the affected area should not be treated with this technique. With these precautions in mind, the therapist can determine the best techniques to apply to the patient, based upon the indicated treatment goals.

Case Study 6.1 Manual Therapy for Postoperative FHO

Signalment:

9 y.o. M/N Brittany Spaniel

Presenting Complaint:

1 month postoperative L FHO with decreased ROM, weight bearing, and weakness

Evaluation:

Physical exam WNL except:

Gait: (Walk) PWB LR, decreased L stride length and stance time, compensatory spinal side bend

Palpation: Decreased STM, trigger point and tenderness at L psoas

PROM: Hip extension L 125, R 150

Flexibility: L psoas moderately tight; R NL

Atrophy: Moderate+ at L gluteals, moderate at L hamstrings, and quadriceps

Strength: 3-leg strength test: fair (3/5); diagonal limb strength test: poor (<3/5)

Assessment:

1 month postoperative L FHO with expected limitation in ROM, flexibility, and strength

Problem List:

Limited L hip extension

Tight L psoas
RH weakness
Inadequate weight bearing
Altered gait.

Goals:

Symmetrical walking gait in 6 weeks

Symmetrical sit-to-stand transfers in 6 weeks
Ability to walk on stairs without difficulty in 8 weeks
Return to 1-hour hikes in 10 weeks.

Treatment:

Modalities: Laser to L iliopsoas

Manual Therapy: Passive stretch of L iliopsoas with STM trigger point release L iliopsoas

PROM: Hip extension with STM of sartorius, rectus femoris, iliopsoas

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Tags: Canine Sports Medicine and Rehabilitation

Jul 9, 2017 | Posted by admin in EQUINE MEDICINE | Comments Off

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