3/23/2016

1

Tom Hyde, DC, DACBSP, FRCCSS (Hon), ICSSP,

FAKTR®, ART®, GT, CRTP, CKTP, CSTI, FICC,

Adjunct Faculty UWS

Manual and IASTM Treatment featuring the FAKTR Concept

Cyriax – Friction Massage

Simple yet effective

Can be time consuming

Requires a functional exam

Tender area is not necessarily the source of pain

Hammer WI, Functional soft tissue examination and treatment by manual methods: the extremities, Aspen

3/23/2016

2

Cyriax

Because friction massage involves pressure and movement directed across the scar tissue, most of the theories as to why friction works are based on theories concerning the effect of motion on healing tissue. Hammer

Cyriax

…mentioned transverse motion across the involved tissue and the resultant traumatic hyperemia as the chief healing factors of friction massage.

Hammer

3/23/2016

3

Cyriax

Felt moving across the fibers at a right angle would not injure the normal healing tissue but would prevent the formation of or break down abnormal scar tissue.

Hammer

Cyriax

In the acute phase, only necessary to use a light force

In the chronic stages a deep, stronger friction is necessary.

Hammer

3/23/2016

4

Cyriax

Light friction used to aid promotion of normal orientation of collagen, maintain mobility and prevent future adhesions.

Recommends immediate treatment of ligament lesions to prevent adhesions.

Hammer

Cyriax treatment

Frictioning begins lightly until a level of anesthesia begins; then the pressure is increased until a deeper level of anesthesia is reached. With this method it should be possible to arrive at the deepest tissue level within a few visits. Hammer

3/23/2016

5

Cyriax treatment time

A minimum of 10 minutes is usually required

Depending on the thickness of the scar and the length of time the problem has existed, up to 20 minutes might be required

Hammer

Pin & Stretch Technique (ART®):

Hands-on soft-tissue technique applied to repetitive strains, adhesions, tissue hypoxia (decreased oxygen supply), and joint dysfunction

Frequently used in the treatment of Cumulative trauma disorders

3/23/2016

6

How does P&S work?

Used in the treatment of fascial restrictions

Breaks down adhesions running perpendicular to tendon, ligament, muscle and neural tissue

Allows for proper glide of adjacent soft tissue structures

P&S Treatment:

Utilizes passive and whenever possible active motions with a specific hand contact

Passive motions are used when muscle guarding prevents proper treatment when performed actively

Active motions are used whenever possible– Patient has greater control over treatment

– Simulates normal motions between adjacent soft tissues and the neurological feed back that controls motion

– Modifies pain impulses via the lateral spinal-thalamic tract via movement patterns

3/23/2016

7

P&S Treatment:

Frequently symptoms are reproduced during treatment

Treated tissue function should improve following treatment in most cases, but tissue remodeling and stabilization can take much longer

Pin & Stretch Technique (ART®):

A broad-based contact is taken on the area to be treated in a shorten position. Treatment can be initiated by having the clinician move the area from a shortened position to a lengthened position with a broad based contact (thumb) or the patient can actively move from the concentric to the eccentric position.

3/23/2016

8

FAKTR Concepts

Functional – begin to think about treating patients during function, not simply in a static posture – determine if the patient’s condition is worse with load or no load and if with load, treat with load

Kinetic – look at the kinetic chain when assessing for any soft tissue injury

FAKTR Concepts

Treatment – use your own choice of soft tissue treatment, P&S, MRT, Nimmo, PNF, Mattes - AIS, Mulligan, IASTM, Cyriax, Muscle Energy, PIR, etc

Rehab – why not consider using low tech rehab equipment during the treatment process in addition to post treatment

3/23/2016

9

FAKTR Concepts

Provocation – place the patient into a position of provocation, i.e., if back pain is present when seated, treat the patient seated

Motion – evaluate the patient to determine if the pain is worse with or without motion, if with motion, treat with motion

FAKTR Concepts

Once you determine all components of FAKTR, you begin your treatment protocol

Before initiating any form of treatment, a complete history and physical examination must be performed that leads you to the determination that your patient will benefit from whatever type of care you plan to utilize always remembering that your treatment MUST beat the natural history of that disorder

3/23/2016

10

Bringing Soft Tissue and Exercise Rehabilitation together

Rehab / proprioceptive techniques

Functional movement patterns utilizing the kinetic chain

Movements and/or positions of provocative to recreate symptoms, referral patterns, imbalances, instabilities, weaknesses, functional loss or injuries.

Why Dynamic activities during soft tissue treatments?

Through the use of active motions, functional positioning, and exercise rehabilitation during the soft tissue treatment it is possible to immediately initiate proper alignment of collagen synthesis and soft tissue remodeling through fibroblastic activity

3/23/2016

11

Why Dynamic activities during soft tissue treatments?

Dynamic activities force fascial planes to move against each other

If there is an adhesion preventing proper fascial, muscle, ligament, soft tissue function why would we ever treat statically

We can use dynamic activities to assist us in the manner in which new fibroblasts are laid down with our soft tissue treatment

INSTRUMENT-ASSISTED CROSS FIBER MASSAGE ACCELERATES KNEE LIGAMENT HEALING: Dept of

anatomy and cell biology, Indiana University. Loghmani, MT et al., 2006

Controlled study: 20 rats underwent surgical bilateral transection of the MCL.

7 days postoperatively GT was used on the left MCL for one minute 3x per week for 3 weeks.

Results: “Ligaments treated with IACFM were found to be 31% stronger and 34% stiffer than untreated ligaments.”

Article will appear in JOSPT.

3/23/2016

12

M. TERRI LOGHMANI, PT, MS.PT, PhD.Instrument-Assisted Cross-Fiber MassageAccelerates Knee Ligament Healing

506-514 | july 2009 | volume 39 | number 7 | journal of orthopaedic & sports physical therapy

3/23/2016

13

Before Treatment: Irregularly

oriented and diminished amount of

fibroblasts

20L 506004 4wk treated 20L PH2 4wk

treated 20R 506004 4wk untreated 20R PH2

The treated appears to have increased

cellularity and more regularly oriented,

elongated fibroblasts.

Effect of IASTM on Ligamentous Healing

3/23/2016

14

Robert Schleip states that “Fascia forms a continuous tensional network throughout the human body, covering and connecting every single organ, every muscle, and even every nerve or tiny muscle.”

3/23/2016

15

Muscles hardly ever transmit their full force directly via tendons into the skeleton but rather distribute a large portion of their contractile or tensional forces onto fascialsheets. In turn, these fascial sheets transmit there forces to both synergistic as well as antagonistic muscles when means they stiffen not only the respective joint, but may even affect regions several joints further away.

Schleip

Fascia is densely innervated with many sensory nerve endings including mechanoreceptors and nociceptors, which can become the source for acute myofascialpain. Fascia also has the ability to contract. Fascia has a blood supply in addition to a nerve supply and lymphatics. These coupled with it’s ability to contract raises the possibility for classification as an “organ.”

Schleip

3/23/2016

16

With the FAKTR-PM concept, we place focus on areas or regions rather than on origins and insertions. We look at regions and how these regions overlap or interconnect, rather than treating isolated, individual muscles. One important aspect of what we stress is how groups of muscles and fascia work together.

Example: The shoulder.

FAKTR Protocols and other manual and IASTM methods:

Following a complete history and examination, if appropriate, initiate FAKTR

Treat

Re-evaluate

Re-treat up to 3 times

3/23/2016

17

Caveat:

If you treat a patient with FAKTR and they exhibit excellent results but those results are short lived (1-2 days), and this scenario is repeated for 2-3 treatments, there is a strong possibility that the patient does not have a MSK disorder but some non-MSK. Please reassess, send for a second opinion or consider diagnostic workups.

Treatment is initiated as follows:

1. Site of pain:1. Pain that is local or distal to what is perceived to be

the involved structure

2. Loss of ROM

3. Loss of function

4. Tightness:Felt by clinician and patient

On evaluation, tissue does not feel “normal” to either the patient or the clinician

3/23/2016

18

Eccentric Training for Tendiopathies

Eccentric Training for Treatment of Tendiopathies, Murtaugh, Bryan and Ihm, Joseph M. Training, Prevention, and Rehabilitation: Current Sports Medicine Reports, 2013 Am College of Sports Med; 1537-890X/1203/175-182

Research has shown that treating tendinopathies in the eccentric phase can be effective.

Studies exist currently on the following body parts:Achilles tendonPatellar tendonProximal lateral elbowRotator cuff

Literature Review

• Medial collateral ligament (MCL) -most commonly injured knee ligament – Mechanism of a lateral to medial force causing

excessive valgus displacement

• Athletes involved in contact sports have a higher incidence of this injury (Dressendorfer 2014).

• Management of injuries is under debate – Surgical intervention to conservative management.

• Conservative treatment shows beneficial return to pre-injury levels over long-term measurement (Brotzman 2011).

3/23/2016

19

Case Review

• Player injured Oct 18

• Player fell into lateral leg, forcing valgus collapse

• Initial assessment by University med staff– Grade 2; possible 3

– 8 to 10 week RTP

– Season over

• Presents Oct 19, non-weight bearing on left knee

18-Y.O. Soccer player with MCL Tear

• 7/10 pain (L knee)• Mild, medial joint effusion• Significant medial pain with

palpation• (-) Lachman’s• (-) Post. Drawer• (+) Valgus Stress

– 10◦ deviation• MRI report indicates severe

Grade 2– Possibly Grade 3

• Other knee ligaments intact, including meniscus

3/23/2016

20

Intervention

• Goal was to return player to competition in 4 weeks for NCAA tournament

– Pending clearance by the university’s team physician.

• Primary treatment method was IASTM utilizing FAKTR-brand instruments and FAKTR protocol

Following assessment, initiation of the FAKTR Concepts was initiated

The athlete was having difficulty going up and down stairs secondary to loss of ROM and pain

Gait on flat surface was also significantly reduced and painful with loss or ROM

Treatment was first given in the position of provocation

3/23/2016

21

Length of each treatment was approximately 30-45 seconds

Following each treatment, the athlete was returned to a neutral, non-painful position, then asked to assume a position of provocation once more

This process continued and included having the athlete attempt to flex or extend the knee as far as possible, while also receiving treatment with motion, in and out of flexion and extension

Various low tech items were used during treatment such as:Therabands, BOSU, stability pad, iJoyBoard

The 5 Concepts indluded:

Static - valgus, flexion, extension

Motion - in and out of valgus, flexion and extension, climbing and descending stairs, medial and lateral movements so simulate a kick with zero resistance and very slowly

Resistance – with elastic bands attached with athlete attempting to kick a ball with the medial and lateral side of foot

Function – squatting, kneeling, walking, climbing and descending stairs

Proprioception – BOSU, Stability pad, iJoyBoard, single leg stance

3/23/2016

22

Treatment was both manual and with Instrument Assisted Soft Tissue Mobilization (IASTM)

FAKTR Instruments were used with an emollient to reduce friction

Cross Fiber Friction described by Cyriax was performed except friction was given in all directions, not just 90 degrees to the fiber

Pin and Stretch or Myofascial Release also given

Kinesiology tape was utilized in an attempt to offer a feeling of stability, aid in ROM and reduce pain.

Intervention• Weeks One & Two

– IASTM with active, provocative movement (daily)

– Class IV laser therapy (daily)

– Aquatic therapy (2x daily)

– Myofascial release (as needed)

• Note:

– No bracing was used during rehab (taping only)

– 8 treatments in office

– 3/10 pain, normal gait, body weight squat, single leg stance

3/23/2016

23

Intervention

Weeks One & Two

IASTM with active, provocative movement (daily)

Class IV laser therapy (daily)

Aquatic therapy (2x daily)

Myofascial release (as needed)

Note:

No bracing was used during rehab (taping only)

8 treatments in office

3/10 pain, normal gait, body weight squat, single leg stance

Intervention• Weeks One & Two

– IASTM with active, provocative movement (daily)

– Class IV laser therapy (daily)

– Aquatic therapy (2x daily)

– Myofascial release (as needed)

• Note:

– No bracing was used during rehab (taping only)

– 8 treatments in office

– 3/10 pain, normal gait, body weight squat, single leg stance

3/23/2016

24

Intervention• Weeks 3 & 4

– Rehabilitation focusing on:• Functional strength• Sprinting• Cutting• Kicking• Plyometrics• RTP

• IASTM used with provocative exercise as needed

• Laser used as needed• 8 treatments in office

Outcomes

• Return to play assessment Nov 16– 0/10 pain– All provocative testing normal– Agility, strength, sprinting & sport-

specific skills normal with no pain– Referred back to team MD

• Cleared by MD Nov 17

– 35 days total

• Competed in 2 games of NCAA tourney– No complaints or injury

3/23/2016

25

Lateral Ankle Sprain

Ankle Anatomy

Ankle Joints– Talocrural (ankle Mortice)– Subtalar– Distal Tib/Fib

Ligaments Peroneals Tibialis Anterior Ext Hallucis Longus Ext Digitorum Gastroc/Soleus Flex Hallucis Flex Digitorum Tibialis Posterior

3/23/2016

26

Talocrural Joint

Dome of the talus Medial Malleolus Lateral Malleolus Distal Tibia

Transmits torque from the lower leg to the foot– Internal and external

rotation at leg– Pronation and Supination

at foot

Ligaments of Talocrural Joint

Joint Capsule Anterior talofibular ligament

– Lateral malleolus to talus– Prevents anterior displacement,

resists inversion and internal rotation

– Demonstrates the lowest maximal load and energy failure

Calcaneofibular Ligament– Lateral malleolus to calcaneus– Resists supination, internal

rotation, inversion (most taut with these motions and dorsiflexion)

Posterior Talofibular ligament– Lateral malleolus to talus– Resists inversion and internal

rotation

Deltoid Ligament

3/23/2016

27

Subtalar joint

Anterior Subtalar– Calcaneus (sustentaculum

tali)

– Talus

– Navicular

Posterior– Calcaneus

– Talus

Converts torque from leg to foot

Ligaments ofSubtalar Joint

Deep Ligaments Cervical Anterior “cruciate”

Resists supination

Interosseous Posterior “cruciate”

Resists pronation and supination

Extensor Retinacula Lateral root (within

sinus tarsi)

Cervical Ligament

Interosseous Ligament

3/23/2016

28

Ligaments ofSubtalar Joint

Calcaneofibular Ligament– Resists inversion and

internal rotation

Lateral talocalcaneal ligament– Resists supination

Fibulotalocalcaneal ligament– Resists supination

LTCL

Distal Tibiofibular Joint

Syndesmosis

Accessory gliding

“high ankle sprain”

3/23/2016

29

Ligaments of Distal Tib/Fib Joint

Interosseous Membrane

Anterior Inferior Tibulofibular ligament– Injured in supination and

external rotation

– High ankle sprain

– Weaker of the two

Posterior Inferior Tibulofibular ligament– Injured in pronation and

external rotation

Muscular Anatomy

Lateral Compartment– Peroneus longus– Peroneus Brevis

Anterior Compartment– Tibialis Anterior– Extensor Hallucis Longus– Extensor Digitorum

Superficial Posterior Compartment– Gastroc– Soleus

Deep Posterior Compartment– Tibialis Posterior– Flexor Hallucis Longus– Flexor Digitorum

3/23/2016

30

Lateral Compartment

Peroneus Longus– Attachments

Lateral Head of Fibula and shaft

Base of First Metatarsal and lateral border of medial cuneiform

– Nerve Supply Superficial Peroneal

Nerve (L5,S1)

– Action Plantar Flexion and

Eversion

Lateral Compartment

Peroneus Brevis– Attachments

Distal 2/3 Fibular shaft

Base of 5th Metatarsal (styloid process)

– Nerve Supply Superficial Peroneal

Nerve (L5,S1)

– Action Plantar Flexion and

Eversion

3/23/2016

31

Anterior Compartment

Tibialis Anterior

– Attachments Inferior Lateral Tibial Condyle,

Lateral 2/3 tibial shaft

Medial surface of Medial Cuneiform and medial base of 1st Metatarsal

– Nerve SupplyDeep Peroneal (L4,5)

– ActionDorsiflexion and Inversion

Anterior Compartment

Extensor Hallucis Longus

Attachments Middle 2/4th of the Fibular shaft

Dorsal surface of the distal phalanx of the hallux

Nerve Supply Deep Peroneal (L5,S1)

Action Dorsiflexion of Hallux and foot

3/23/2016

32

Anterior Compartment

Extensor Digitorum– Attachments

Lateral Tibial Condyle, Upper 3/4th of the Fibular shaft

Dorsal surface of the middle and distal phalanx of the lateral 4 toes

– Nerve SupplyDeep Peroneal (L4,5,S1)

– Action Extension of lateral 4 toes and

foot and assist in Dorsiflexionof foot

Mechanism of Injury

Acute

Chronic

– Mechanical Instability Pathologic Laxity

Arthrokinematic Impairments

Synovial and Degenerative Changes

– Function Instability Impaired proprioception and sensation

Impaired Neuromuscular Firing Patterns

Postural Impairments

Strength Deficits

3/23/2016

33

Acute Ankle Sprain

Excessive supination of the rear foot about an externally rotated lower leg after initial contact of the rear foot during gait or landing from a jump

ATFL first and most commonly injured of the lateral ligaments

CFL 2nd most commonly injured

PTFL only sprained in severe injuries (often accompanied by fractures &/or dislocations

Grading of Ankle Sprains

Grade I:– Decreased ROM, strength WNL, mild swelling, tenderness over ATFL, slight

antalagia, negative Anterior Drawer test– Usually mild injury to ATFL

Grade II:– Decreased ROM with painful ROM, pain on MMT of everters, mild to

moderate swelling, tenderness over ATFL & CFL, antalgic gait, positive Anterior Drawer test

– Involvement of ATFL and CFL

Grade III:– Moderate to severe swelling, tenderness over ATFL, CFL, PTFL, antalgic gait,

positive anterior drawer test and talar tilt test, instability – Involvement of ATFL, CFL, PTFL, associated with fractures and/or dislocation

3/23/2016

34

Pathological Laxity

Result of ligamentous damage

Chronic ligamentous injury results in joint instability during functional activities resulting in eventual injury to the joint structures– Most often at the talocrural and subtalar joints

– ATFL ligament injury the talus is able to excessively supinate

Arthrokinematic Impairments

Fibular head displacement– Mulligan reports with chronic ankle instability the

fibular head displaces anteriorly and inferiorlyWith this positioning, the talus can go through a greater

range of supination before the ATFL becomes taut

Decreased ankle Dorsiflexion– Prevents the talocrural joint from reaching its closed-

pack position allowing for greater internal and inversion motions

– Increases pronation at the subtalar joint– Posterior mobilization of the talus on the tibia

recover dorsiflexion more quickly after a sprain

3/23/2016

35

Impaired Neuromuscular-Firing Patterns

Decreased reflexive response times of the peroneal muscles to inversion or supination

– Impaired proprioception

– Slowed nerve-conduction velocity

– Central impairments in neuromuscular-recruitment strategies

Deficits in Bilateral Gluteus medius recruitment with severe unilateral ankle sprain

Impaired Postural Control

Impaired single leg stance demonstrated after both acute and those with a history of repetitive ankle sprains

Combination of impaired proprioception and neuromuscular control

3/23/2016

36

Impaired Postural Control

Ankle Strategy– Foot pronates and supinates to maintain body’s

center of gravity during single leg stance

– Those with chronic instability demonstrate hip strategyLess efficient

Due to changes in central neural control in presence of ankle dysfunction

Strength Deficits

Demonstrated in both eversion and inversion

Debate as to reason

– Weakness due to muscle damage or impaired neuromuscular recruitment

3/23/2016

37

PHYSICAL EXAMINATION

Range of Motion

Passive and Active Range of Motions

– Flexion

– Extension

– Inversion

– Eversion

– Internal Rotation

– External Rotation

3/23/2016

38

A-P Drawer

ATFL sprain/tear

– Pain

– Laxity

Inversion Stress Test

CFL sprain/tear

– Pain

– Laxity

3/23/2016

39

Eversion Stress Test

Deltoid Ligament sprain/tear

– Pain

– laxity

Internal Rotation Stress Test

Posterior Deltoid Ligament and ATFL

– Pain, Laxity

3/23/2016

40

External Rotation Stress Test

PTFL and Anterior Deltoid Ligament

– Pain, laxity

Stresses Distal Tib/Fib Syndesmosis

3/23/2016

41

3/23/2016

42

3/23/2016

43

3/23/2016

44

3/23/2016

45

Bibliography (text books)

Evans RC. Illustrated essentials in orthopedic physical assessment. Mosby; 1994.

Hyde TE, Gengenbach MS. Conservative management of sports injury. Williams and Wilkins; 1997.

Hammer WI. Functional Soft Tissue Examination and Treatment by Manual Methods. Aspen; 1999.

Bibliography (ankle sprain)

Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training. Dec 2002;37(4):364-375

Osborne MD, et al. The effect of ankle disk training on muscle reaction time in subjects with a history of ankle sprain. Amer Jour Sports Medicine. Sept 2001;29(5):627

Green T, et al. Randomized controlled trial of passive accessory joint mobilization of acute ankle inversion sprains. Physical Therapy. April 2001;81(4):984

Bassewitz HL, et al. Persistent pain after ankle sprain: targeting the causes. The Physician and Sportsmedicine. Dec 1997;25(12):48

3/23/2016

46

Bibliography (ankle sprain)

Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training. Dec 2002;37(4):364-375

Osborne MD, et al. The effect of ankle disk training on muscle reaction time in subjects with a history of ankle sprain. Amer Jour Sports Medicine. Sept 2001;29(5):627

Green T, et al. Randomized controlled trial of passive accessory joint mobilization of acute ankle inversion sprains. Physical Therapy. April 2001;81(4):984

Bassewitz HL, et al. Persistent pain after ankle sprain: targeting the causes. The Physician and Sportsmedicine. Dec 1997;25(12):48