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Soft-tissue Mobilization Techniques for the Hand Therapist
( CASE STUDY
J
Soft-tissue Mobilization Techniques for the Hand Therapist Gary S. Sutton, MS, PT, SCS, ATC Sports Program Manager, Sports and Occupational Rehabilitation Center, Richmond, Virginia
Mary R. Bartel, OT, PT, CHT Director, Hand Center at the University Suburban Health Center, Cleveland, Ohio
estoration of mobility becomes an immed iate
R treatment objective for the hand therapist when injury or disease limits the ability of the patient to perform functional activities. Dr . John Madden states, "The key to normal hand function is the ability of strong, dense connective tissue structures to glide relative to one another." 1 Factors limiting the functional mobilit y of a patient have been categorized as compensation made in the presence of physical, mental, and emotional stress. " The con sequences of these adaptations to stress can be readily observed in the "soft tissues" of the muscle and connective tissue systems. Dens e connective tissue is continuous throughout the planes of the body and functions to provide support for nerves and blood vessels. Dense connective tissue give s shape and stability to muscles, separates and supports internal organs and joints, and assists in imparting isolated movement of one bod y part on another through specialized arrangements of collagen fibers known as tendons. " Gliding of one adjacent laminated connective tissue layer on another promotes the health of those tissues by circulating body fluids that facilitate lubrication and provide for nutrition of the connective tissues." Conversely, loss of mobility between con-
Present ed in part at th e nation al meeting of th e Ameri can Occupational Therapy Association, March 23, 1987, Baltimore , Maryland . Corresponde nce and reprint requ est s to Ga ry S. Sutton, MS, PT, SCS, ATC, Sport s Program Man ager , Sports and Occupation al Rehabilitation Center, 1810 Glen sid e Drive, Richmond, VA 23226.
ABSTRACT: Soft-tissue mobili zation (sTM) is a syste m of manual techniqu es e mploying low-load , long-d u ratio n for ce s appl ied in a pproxi matio n, tra ction , and tor sion al vec to rs to improve mobil ity between overlying and adjacent co n nect ive tissue layer s througho ut th e body. The purpose o f thi s a rticle is to present th e th eory of sTM as relat ed to th e properti es of wound healing and of ada ptive sho rte ning of so ft tissu e , to describe th e gen eral principles of four sTM te chniques, a nd to det ail specific appli cation of s TM techniques in the treatme nt of a di sorder related to a lon gfinger exte ns o r digitorum co m munis laceration and its repair. J HAND THER 7 :185- 192, 1994.
nective tissue layers ma y comp romise th e well-bein g of the connective tissue at th e site of restriction and may create symptom s at a d istance from the restriction. Tethering of or pr essure on neurova scular stru ctur es may create paresthesias, or symptoms of vascular compromise, as d escribed by patients with thoracic outlet syndrome. Lon g-standing scarring between fascial planes," which mechanically restricts mobility of soft tissues and/or joints, can cause sy mptoms in adjacent structures due to "compensatory hypermobility" 4,6, 7 and can lead to "relative flexibility" 8 of adjacent muscle groups.
Loss of mobility between connective tissue layers may compromise the wellbeing of the connective tissue at the site of restriction and may create symptoms at a distance from the restrictions. Soft-tissue mobilization (STM) is a system of manual techniques employing low-load, long-duration forces applied in ap proximation, traction, and torsional vectors to improve mobility between overlying fascial planes, thus restoring balance and sy mmetry to the musculoskeletal system ." The purpose of this article is to pr esent the theory of STM, to describe the general principles of STM, and to detail specific application of STM techniques in the treatment of a disorder related to a long-finger extensor digitorum communis (EDC) laceration and its repair. July-September 1994
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PROPERTIES OF WOUND HEALING Tissue repair in response to injury typically follows an ordered sequence of events in which a collagenous scar replaces damaged tissue lost through an injury or a disease process. 10,1 1 Four phases of scar-ti ssue formation have been described: the inflammatory stage, the granulation stage, the fibroblastic stage, and the maturation stage. 12 Further evidence delineates the presence of modified fibroblasts, which appear during the maturation stage of wound healing. These fibroblasts function to synthesize new collagen fibers, but also display the contractile capabilities of smooth muscle cells . These "myofibroblasts" have been theorized to playa key role in the mechanism of contraction of granulation tissue in wound healing, but may also influence and direct the process by which pathologic soft-tissue contractures are forrned .P:'"
PROPERTIES OF ADAPTIVE SHORTENING OF SOFT TISSUE While the response of the human body to trauma has been well described as the formation of a scar with the potential for wound contracture, the mechanism of adaptive shortening of surro u nd ing soft tissue is not well understood. Adaptive shortening refers to the loss of soft-tissue extensibility of tissues investing a joint in response to the decrease in demand for joint motion.'? The critical concern in the inve stigation of adaptive shortening appears to be the stimulus by which joint motion becomes limited. Adaptive shortening of connective tissues supporting a joint has been demonstrated in the presence of joint trauma followed by cast immobilization. The mechanism of restriction describes an increase in "crosslink formation" between adjacent collagen fibers. 15 Further laboratory studies have substantiated decreased connective tissue extensibility in cast-immobilized specimens as a result of increased collagen synthesis in immobilized tissues. 16 In human specimens, prolonged external immobilization of seemingl y normal joints promotes progressive contracture of capsular and periarticular structures, resulting in encroachment of the joint space by fibrofatty connective tissue. Maintained immobility further ap-
Prolonged external immobilization of seemingly normal joints promotes progressive contracture of capsularand periarticular structures. pears to cause obliteration of the joint cavity and eventual ankylosis of the joint. 17 Muscle, when castimmobilized, demonstrates invasion by fat and connective tissue. 18 When casted in a shortened position, muscle also loses overall length due to the loss of sarcomeres. 19 Skin quickly remodels to shortened positions due to a rapid rate of collagen turnover that 186
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is almost identical to the rate of new collagen deposition observed in traumatized skin in the early stages of wound healing.P" Although trauma and rigid immobilization have been reviewed as causes of adaptive shortening of soft tissue, similar decreases in the demand for joint motion with concomitant "stiffness" may evolve from patterns of adaptation to stress." Repeated postural stresses that occur during daily activity, combined with tensions of emotional and psychologic origins, facilitate a confused pattern of tense, contracted, fatigued myofascial tissue. Manifestations of prolonged stress from postural, psychologic, or mechanical origins cultivate distinct patterns of individual adaptation, compensation, structural change, and, ultimately, pathologic change within the human body." This continuum becomes more visible in the symptoms expressed as a result of the repetitive microtrauma of the distance runner, the postural strains of the dentist, and the anxiety of the secretary hunched over a typewriter while attempting to meet a deadline.
Faulty movement patterns create muscle strengthl/ength imbalances about a joint that alter the biomechanics of the joint and eventually produce symptoms. Health care professionals concur that stress causes adaptations that may evolve into disorders ." Controversy does exist, however, regarding the cause of certain adaptations and how these adaptations are treated. One theory proposes that the human body takes a "path of least resistance" in accommodating stress. Movement is generated through joints and muscle groups that can most easily accomplish the task, often at the expense of synergistic and antagonistic elements. Consequently, faulty movement patterns create muscle strength/length imbalances about a joint that alter the biomechanics of the joint and eventually produce symptoms. Treatment from a motor-learning approach is directed at activating synergists and antagonists of the muscle group in question in an effort to restore balance and reestablish normal biomechanical motion." An example de scribes the dominance often exhibited by the shoulder internal rotators over the shoulder external rotators in acting as a force couple with the abductors to achieve elevation of the arm. Continued elevation of the arm in light of poor mechanics may lead to impingement. This muscle imbalance is corrected and the impingement is relieved by retraining the shoulder external rotators to work more forcedly in a shortened position as the arm is elevated, reinforcing proper biomechanics. An alternative theory suggests that soft tissues may become relatively immobilized in compensated postures and may undergo adaptive shortening in much the same manner as if more rigid immobilization had occurred .2 ,9 , 22 Thus, from a mechanical perspective, the adaptively shortened tissue
must be passively lengthened before normal motion can occur. In the previous example, the shoulder internal rotators must be passively stretched to achieve a balance of muscle lengths about the joint. Once this balance has been restored, the patient can then begin to select and accomplish motions and postures consistent with his or her normal mechanics.P Further study is needed to define soft-tissue adaptive shortening, thereby promoting the efficacy of treatment.
THEORY OF SOFT-TISSUE MOBILIZATION Current therapies used to control wound contracture in traumatized tissue involve biochemical control of collagen production and of myofibroblastic activity, and " p hysical means." 23 Physical measures imposed to prevent contracture include static splinting, which is presumed to counter the contractile property of the myofibroblast, and range of motion (ROM) exercises, which are performed to orient new collagen fibers that proliferate during wound healing .24 Mechanical forces utilized in ROM exercises to passively elongate restricted tissues include a lowload application maintained for extended periods.P Soft-tissue mobilization techniques require initial assessment of the pathologic limit of the affected tissue, or the "barrier."? This assessment is performed as part of the therapist's preferred orthopedic and functional evaluation. The assessment includes palpation of both the local site of symptoms as well as the adjacent and antagonistic tissues to detect abnormal "tissue tension,"? or limited tissue mobility relative to the pa tient's contralateral side. Tissue mobility is assessed by the skillful loading of the myofascia by the therapist who monitors the quality and quantity of deformation that results. The therapist stresses the tissue by loading the structure with both compressive forces and shear forces . Compression implies applying a force perpendicular to the tissue surface, whereas shear forces are developed by applying a force parallel or oblique to the tissue being assessed.P While compression and shear represent two distinct force vectors used to assess tissue mobility, the therapist skilled in STM may apply these forces together in the evaluation and treatment of affected tissue . Physical restrictions can be assessed by palpation for the patient who sustains tissue tension even when the body part is at rest, as compared with the contralateral side. Restrictions may also be palpated in the passive inability of skin or other superficial tissu es to glide over deeper structures, or in the loss of passive lateral gliding of the tissue being assessed. Restrictions can often be observed in puckering or gathering and in color changes of the skin as tension is applied . Subjectively, the patient may com~ent that there is "burning, tightness, catching, or a tight band" around the area of restriction during the course of the assessment and later as a part of the treatment. Once the barrier or restriction is located, it is engaged with a low, steady load until a "release" is perceived by the therapist. This release has been de-
A release may occur immediately, or may require maintained loading for 90 to 120 seconds, depending on the strength of the restriction. scribed clinically as a "giving way" or a "melting" of the previously perceived barrier, allowing for an increase in soft-tissue extensibility.9 Biomechanically, the perception of release may be connected to "creep," which is a condition of continuous loading of biologic tissue until a point is reached where the maintained load causes a measurable increase in tissue length." Such a release may occur immediately, or may require maintained loading for 90 to 120 seconds, depending on the strength of the restriction .F Once th e initial barrier has released, secondary barriers may be located in various planes adjacent to the original restrictions. Additional barriers are likewise engaged and released until an increase in soft-tissue extensi. bility is palpated. Patient participation in the STM technique may further enhance compliance and optimize treatment results. For example, a mobilizing force applied to the barrier in multiple vectors based on the direction of the tissue limitation can be accompanied by active muscle contractions, under the direction of the therapist. Such contractions serve to activate the agonistic myofascial unit or the antagonistic group. By actively contracting the muscle being mobilized, an auxiliary load can be applied under the control and according to the tolerance of the patient. Contraction of the antagonistic muscle group, which also applies a load under patient control, additionally creates an inhibitive effect on the muscle being stretched by reciprocal inhibition via the muscle spindle. Effects of STM may include autonomic nervous system changes involving pulse rate, blood pressure, skin color, moi sture, and temperature; altered emotional states; and sensory changes in which the patient may relate burning, tingling, stinging, and elevated temperature in the tissue being stretched ." Further, the release of soft-tissue restrictions may cause an increase in blood and lymphatic flow that would then promote wound healing and would potentially reduce edema. Conceptually, the patient a.nd the therapist notice an increased freedom of active movement in isolated motions as well as in functional patterns of the trunk and the extremities. <:=?ns~ quently, STM is indicated for decreased mobility In soft-tissue structures, including skin, fascia, neurovascular structures, ligaments, tendons, and muscles. Specifically, restrictions in tendon excursion during elongation or contraction, decreased muscletendon length, limitations in joint mobility, muscle spasms, pain syndromes, and edema can be ad dressed with STM.
Soft-tissue mobilization is indicated for decreased mobility in soft-tissue structures. July-September 1994
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fiGURE 1. The sim plest soft-tissue mobilization treatm ent techn ique-pushing or pulling into the barrier or restriction.
Presently, little scientific evidence has been produced to validate the efficacy of STM techniques with regard to the degree and the duration of lasting change they produce in human tissues . Furthermore, clinicians can only speculate about soft-tissue barriers and the mechanism of their release. Despite the lack of scientific explanations, the concept of mobility restrictions of soft tissue as a source of pain in the patient has become a topic of considerable discussion among health care practitioners. 2 ,4. 6 - 9 , 21, 22, 27 - 30 Further investigations into the efficacy of STM techniques must be conducted by health care professionals who seek to modify pain and to increase mobility for their patients. Contraindications to STM include malignancy, hypermobile joint segments, recent fractures, hemorrhage sites, recent sutures, osteoporosis, acute rheumatologic conditions, localized infection, and inflammatory conditions.? Precautions requiring the judicious use of STM include new scars (to avoid opening wounds), tendon and nerve repair (to avoid rupture), and hypersensitivity to touch at the site being treated. Although often physically appropriate, STM must be used with care in cases of reflex sym- . pathetic dystrophy (RSD). " Since the severity of RSD is made worse by pain, one should be very careful throughout its management to avoid anything that will increase the pain. " 3 1
GENERAL PRINCIPLES OF SOFT-TISSUE MOBILIZATION Some general principles regarding the application of STM are offered to benefit and to protect both the patient and the therapist. An explanation of the treatment technique being applied and a description of possible sensory experiences that may follow are vital in preparing the patient for treatment. Treatment preparation may also include applying a skin lubricant and, occasionally, shaving hair at the site to be treated to make the treatment more comfortable for the patient. Ease of access to the area to be treated often requires removing clothing and draping the area with a gown, as appropriate, exposing proximal as well as distal parts. Often one region may affect another and may need to be examined and possibly treated . As the therapist begins to think about us ing 188
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STM for a patient with limited tissue mobility, the general area to be treated is decided upon first, e.g., the wrist, then a localized area is picked to begin treatment, e.g., the dorsum of the wrist. Once changes in that localized area are observed, treatment then can proceed to another localized area. The forces used with STM are initially applied to superficial restrictions and then progress to deeper areas of limited mobility. The length of the STM treatment session varies, but it should be short initially, e.g., 3 to 5 minutes. This allows the therapist to monitor the patient's response and the tolerance of the treated tissues. Once the patient and the therapist "get a feel" for accompanying sensory changes or soreness, manual treatment time can be extended. Due to the prolonged loading of restricted tissue necessary for treating patients by using STM techniques, the therapist should endeavor to use varied manual contact points during treatment. By varying contact points among the elbow, the pad of the thumb, the hypothenar eminence, and the metacarpophalangeal (MCP) joints, for example, the therapist should be able to protect :small joints and to prevent overuse injuries. Finally, in terms of general principles, remember that STM is only a part of the total treatment regimen and it should be followed by functional activities and/or exercises that make use of the gained mobility .
An explanation of the treatment technique being applied and a description of possible sensory experiences that may follow are vital in preparing the patient for treatment. SOFT-TISSUE MOBILIZATION TECHNIQUES Specific STM techniques apply biomechanical forces to restrictions in soft tissues using various parts of the upper extremity. These manual contacts include the fingers, thumbs, knuckles, hypothenar eminence, palm, forearm, or elbow, depending on the size and configuration of the area to be treated.
,-' '- - --n...,
fiGURE 2. This soft-tissue mobilization treatment technique involves osc illating pressures directed at muscle spasms and hypertonic mu scles.
an "5" shape. This modification can be used for lateral epicondylitis, posterior interosseous nerve compression, and other conditions.
Patient involvement can enhance STM techniques.
The 'T stroke is a soft-tissue mobilization technique that uses multidirectional forces.
FIGURE 3.
Once a restricted motion is identified, the sim plest treatment technique involves pushi~g into t~e barrier or restriction? (Fig. 1). A compressIve force IS applied perpendicular to the perceived soft-tissue restriction and is held for approximately 90 seconds, or until a release is perceived. The assisting hand can either stabilize the restricted area by offering a counterpressure or assist in pushing into the rest~ic tion . Occasionally, this direct approach at stretchmg the limitation is not well received by the patient, and an indirect approach is necessary. Rather than developing a force pushing into the restriction, a path of "lesser resistance" is found by pulling away from the greatest restriction . This "push-pull" technique can be applied in multiple vectors into or away .from a scar or soft-tissue barriers. Often these techniques are effectively applied with fingertip pressure on a tight scar, or with palm pressure on an area of dense connective tissue. A second technique involves oscillating pressures directed at muscle spasms and hypertonic muscles" (Fig. 2). Instead of maintaining a low-loa~, sustained force, this technique requires low-amplitude, rhythmic mobilizations aimed at relaxing neuromuscular tone and patient guarding. This technique is applied with wide manual contacts, preferably one palm or both palms. The 'T' stroke is a third technique utilizing multidirectional forces. Force is applied with the fingertips as if making a ''1'' over and into the area of restriction'? (Fig. 3). Counterpressure from the assisting hand is necessary for the localization of the mobilizing force . This technique is effective for longitudinal scars or for patterns of tightness, such as the preoperative and postoperative treatment of lateral epicondylitis. The "Indian burn" is a fourth technique where counterpressure is developed between the two hands of the therapist in an effort to twist restricted tissue in opposite directions? (Fig. 4). This technique is effectively used for areas of generalized tightness, as well as for multidirectional restrictions, especially those occurring in the arm and the forearm. As a general treatment, this technique can be used on compartment syndromes and/or after fasciotomy . A modification of this technique is an " 5" maneuver (Fig. 5). The therapist uses both of his or her thumbs in approximating the location of the restriction and then places them in offset directions to apply pressure on this area, which ends up stretching the tissue into
Patient involvement can enhance STM techniques. Generally, the patient is asked to actively contract or lengthen a restricted muscle- tendon group while the therapist applies a specific STM technique . This mode of treatment is particularly useful in the case of flexor tendon or extensor tendon repairs where tendon gliding is restricted by scarring or by adhesion formation. For example, on evaluation, the hand therapist determines that the patient has developed a restriction in proximal and distal gliding of a flexor digitorum profundus tendon following surgical repair. In an effort to augment the. STM forc~, the patient is asked to forcefully flex hIS or her fingers while the therapist applies fingertip pressure to the area of restriction, most commonly at the incision site . This fingertip pressure is directed distally toward the patient's fingertips, offering a counterforce to the patient's attempt at finger flexion . Alte~na tively, active wrist and finger extension by the patient is countered by a proximally directed pressure by the therapist, effecting a stretch to scar tissue limiting distal glide of the repaired flexor digitorum profundus tendon. Also , contract-relax proprioceptive neuromuscular facilitation techniques can be utilized to bring about a more vigorous tendon pull through by the therapist, providing resistance to finger flexion at the distal pad with proximally directed counterpressure at the site of the scar. A e-second contraction
FIGURE 4. In the soft-tissue mobilization treatment technique known as the " Indian burn ," counterpressure is developed in an effort to twist restricted tissue in opposite directions.
FIGURE 5. This modification of the " Indian burn " technique is known as the "5" maneuver.
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is maintained in this position, followed by actively advancing the finger into further extension while maintaining the proximal counterpressure and repeating this sequence. With each of these techniques, the therapist seeks to hold the position of the skin and the connective tissues as the tendon is being moved, thus stretching restrictions that limit gliding of the muscle- tendon unit under the skin and through adjacent connective tissues. To ensure skin surface contact, a nonslip pad of a material such as Dycem (Dycem Ltd., Bristol, UK) can be a useful adjunct to treatment. Active movements initiated by the patient can aid in stretching musculotendinous restrictions, but also can assist in localizing the sites of scar restriction. By asking the patient to initiate isometric contractions through the available joint ROM, restrictions may be observed by the therapist in the form of tethering or puckering of the scar and the surrounding skin surface. Further, by performing isometric contractions at distinct intervals in shortened or lengthened positions, the patient can offer feedback regarding the range at which restrictions are perceived. Thus, the therapist may be able to corroborate observations with patient perceptions and may be able to develop an STM treatment progression based on limitations in ROM with techniques the patient will tolerate. Patient perceptions of the application of STM techniques range from pain, tingling, burning, and ripping to pulling, pressure, and warmth. Often patients report that symptoms diminish as the force is maintained over an area of restriction through the application of a single technique. The patient and the therapist frequently perceive a release or a "letting go" as the restriction lessens. Increased tissue heat and superficial reddening of the skin can often be observed for several minutes after the treatment has concluded . While this release of heat and the associated reddening of the skin have been associated with a breakdown of chemical bonds between adjacent connective tissue layers, the mechanism of this breakdown is not well understood. Another consideration in utilizing STM techniques is the application of a superficial cold pack prior to treatment for the patient with acute pain and palpation. Application of cold following STM may be a useful adjunct in limiting soreness that may ensue. Also, recognition needs to be given to the augmentation of joint mobilization techniques, of appropriate modalities, of splinting, of active and passive exercises, and of functional retraining to ensure the success of STM . The STM technique selected, the manual contacts employed, and the amount of force applied are dependent on the size of the area to be treated, the magnitude and the direction of the restriction, the stage of wound healing, the tolerance of the patient, and the skills and creativity of the therapist. Multiple variations and combinations of the techniques described can be used on various types of soft-tissue restrictions. The following report describes how STM was used in the rehabilitation of a patient after surgical repair of a lacerated extensor tendon. 190
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CASE REPORT A Zl-year-old male college student who was a heavyweight wrestler had an EDC laceration in zone 4, the dominant long finger of his right hand. The injury occurred on January 1, 1992, when he struck another person in the mouth and lacerated the tendon on a tooth . The patient underwent surgery that same day for repair of the EDC laceration, debridement, and closure of the wound. This began a 6-day stay in the hospital for intravenous antibiotics due to the origin of the wound. The patient was referred for therapy, routine extensor tendon repair rehabilitation, on January 10. At that time he had a l-cm slit over the dorsal distal metacarpal of his right hand, with slight drainage of serosanguinous fluid . Treatment consisted of routine wound care, edema control, dynamic extension splinting, active interphalangeal (lP) joint flexion, passive MCP joint extension by splinting, and joint mobilization. On initial evaluation, the patient had full passive finger extension but lacked 23 degrees of active MCP joint extension as measured according to the American Society of Hand Therapists' recommendations." During splinting he had 45 degrees of active MCP joint flexion, 55 degrees of active proximal interphalangeal (PIP) joint flexion, and 20 degrees of active distal interphalangeal (DIP) joint flexion. The patient had 50 degrees of active wrist flexion and 45 degrees of active wrist extension. The rest of his fingers had full joint mobility, as did the rest of his upper-extremity joints . When the patient was seen on January 14, 1992, his wound was closed . Scar massage was initiated and gentle pushing into and pulling away from the scar was started. Splinting and ROM treatment continued. More aggressive STM was initiated on January 21. The patient maintained full passive MCP joint extension. He had 65 degrees of active wrist flexion and 55 degrees of active wrist extension. The patient had -13 degrees of active MCP joint extension with full active IP joint extension. He had 60 degrees of active MCP joint flexion, 65 degrees of active PIP joint flexion, and 30 degrees of active DIP joint flexion. He now had full joint mobility at his IP joints . Visually, restrictions in tendon gliding could be seen at the wound site, just proximal to the head of the third metacarpal joint, with attempts at active extension and flexion. Treatment progressed to more aggressive pushing into the scar, and sustained fingertip pressure was used at those areas where the patient felt burning or pulling, or where tightness was palpated. In addition, the "S" maneuver and the '']'' stroke were introduced to apply pressure multidirectionally into the scar. In conjunction with these techniques, 3 weeks after repair, STM techniques involving active patient participation were employed . The first technique used a mobilizing force pushing distally into the restricted area (wound area) while the patient actively extended his isolated EDC. A second technique was utilized in which the therapist pulled proximally on the perceived restriction while the patient actively flexed his MCP joint. The patient often reported a pulling or burning sensation with this method, but noted a release or cessation of this as pressure was maintained. (Note that STM treatments were advanced on resolution of passive restrictions in connective tissues, and not necessarily on diminution symptoms.) The patient was encouraged to perform "self-S'TM" as part of his home exercise program .
The patient was encouraged to perform "self-STM" as part of his home exercise program.
On January 28, 1992, splin ting wa s discontinued altogether. Dycem was used with the STM techniques to maintain better skin contact when both applying pres sure to the area of restriction in all directions and pushing pro ximally and distally into the scar whil e the patient actively flexed and extended, respectively, his MCP joint. After treatment, his active ROM was still -13 degrees of MCP joint extension , but his MCP joint flexion was 70 degrees, his PIP joint flexion wa s 95 degrees, and his DIP joint flexion was 75 degrees. The patient continued his active ROM exercises, progressed with passive ROM exercises, started grip strengthening, and added Dycem to his STM at home. Four weeks after surgery , the patient wa s able to use his hand for all activities of daily living , with restrictions on heavy lifting at his part-time job at a hardware store. Also, he was instructed to buddy strap his index and long fingers together during wrestling practice. The patient was seen again on February 14, 1992. His active ROM was - 10 degrees of MCP joint extension and 73 degrees of MCP joint flexion. He had 100 degrees of active PIP joint flexion and 83 degrees of active DIP joint flexion . His active wrist flexion was 65 degrees and his active wrist extension was 60 degrees . The patient's grip strengths as measured from position 1 to position 5 of the Jamar dynamometer (Therap eutic Equipment Corp., Clifton , NJ) were 23, 57, 87, 83, and 78 lb for his right hand and 68, 140, 135, 137, and 112 lb for his left hand . He was further progress ed on his strengthening program for both flexion and extension. He also wa s instructed to con tinue with his STM techniques using the Dycem . At this time the patient wa s allowed full use of his hand . He was permitted to return to full duty at work and to wrestle competitively. The patient was last seen on February 28, 1992, two months after his injury. His active ROM was - 15 degrees of MCP joint extension and 75 degrees of MCP joint flexion, 0 to 100 de grees of PIP joint flexion, and o to 80 de grees of DIP joint flexion. His grip strengths were 83, 143, 142, 125, and 139 lb for his right hand and 73, 152, 155, 137, and 120 lb for his left hand . Functionally, he reported full use of his right hand with occasional pain whil e successfully completing his collegiate wrestling session. Although the patient did not have full active ROM, he had functional ROM and use of his hand. With time we expect him to regain full grip strength (10% greater than the grip strength of his left hand) and to maintain, or slightly increase, his MCP joint motion . Although it is difficult to know objecti vely whether this pati ent would hav e recovered as qu ickly, or as functionally, without STM, we contend that the techniques employed greatly assisted in freeing his extensor tendon of restrictions as well as in increasing his active ROM and decreasing his pain with movements. We recommend that the hand therapist consider the appropriate use of STM with both surgical and nonsurgi cal hand disorders.
CO NCLUSION Decreased upper-extremity function resulting from loss of joint motion represents a challenge to every hand therapist. While scar tissue formation is described as an integral component of wound healing, th e process necessitates modification. Strategic loading of newly forming scar tissue is necessary both to e nsure the ultimate strength of the tissue under repair and to maintain the mobility of the healing tissue from adjacent structures. Early intervention in accordance with healing constraints serves to limit both soft-tissue restrictions and adaptive postures and behaviors that can occur at a distance from the wound . Soft-tissue mobilization has been described as a system of manual techniques employing low-load, long-duration forces applied to improve mobility in restricted connective tissue . Mechanical forces applied in approximation, traction, and torsional vectors have been discussed . The application of STM is in accordance with the patient's tolerance and is monitored by the therapist's perception of the release . The details of the case report as well as the clinical experience of the authors lend support for the utilization of STM as an effective modality in the treatment for connective tissue restrictions .
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17. 18. 19.
20. 21. 22. 23. 24.
stiffness : Role of collagen sy n thesis opposed to altered molecular bond ing. Ann Surg 164:1- 11, 1966. Ennek ing WF, Horo witz M: The intra-articular effects of immobilization on th e hu man knee. J Bon e Joint Surg Am 54:973985, 1972. Cooper RR: Alterations during imm ob ilization and reg en eration of skeletal mu scle in cats. J Bone Joint Sur g Am 54:919951, 1972. Tabary Jc, Tabary C, Tardieu C, Gold spink G: Ph ysiol ogical and structural changes in th e eat' s soleus mu scle due to immobilization at differ ent len gths by pla ster casts. J Ph ysiol 224:231-244, 1972. Madden JW, Smith HC: The rate of collagen sy nthesis and deposition in dehi sced and resutured wo un ds . Surg Gyn ecol Obst et 130:487- 493, 1970. Cha itow L: Neuromuscular Technique. Welling boroug h, Northampton sh ire, Thorson s Publ ish ers Limited , 1980. Grodin A: Personal commu nication, 1982. Rudolph R: Contraction and th e control of contraction . World J Surg 4:279-287, 1980. Arem AJ, Madden JW: Effects of stress on healing wounds: Non cyclical ten sion . J Sur g Res 20:93-102, 1976.
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25.Sape ga A, Quedenfeld T, Moye r R, Butler R: Biophysical factors in range of mot ion exercise. Ph ys Spor ts Med 9(12):5765, 1981. 26. Brand PW: Clinical Mechan ics of th e Hand. SI. Loui s, C. V. Mosby, 1985. 27. Barnes J: Myofascial Release . Course not es, Harma rville Rehabilitat ion Center, 1985. 28. Rolf I: Structural inte gration : A contribution to the understanding of stress. Confinia Psychiatrica 16:69-79, 1973. 29. Travell JG, Simons DG: Myofa scial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Williams and Wilkins, 1983. 30. Upled ger J, Vrede voogd JD: Craniosacral Therapy. Sea ttle, Eastland Press, 1983. 31. Lankford LL: Reflex sy mpa thetic dystrophy. In Green DP: Op erati ve Hand Su rgery, 2nd ed ., vol. 1. New York, Churchill Livingston e, 1988. 32. Johnson GS, Saliba VL: Soft tissue mobilizati on . In White A, And erson R: Con serv ati ve Care of Low Back Pain . Baltim ore , William s and Wilkin s, 1991. 33. Adams LS, Topo ozian E, Greene LW: Ran ge of motion . In Casanova JS (ed) : Clinical Assessment Recommendations, 2nd ed . Chicago , American Society of Hand Therapists, 1992.
J
Soft-tissue Mobilization Techniques for the Hand Therapist Gary S. Sutton, MS, PT, SCS, ATC Sports Program Manager, Sports and Occupational Rehabilitation Center, Richmond, Virginia
Mary R. Bartel, OT, PT, CHT Director, Hand Center at the University Suburban Health Center, Cleveland, Ohio
estoration of mobility becomes an immed iate
R treatment objective for the hand therapist when injury or disease limits the ability of the patient to perform functional activities. Dr . John Madden states, "The key to normal hand function is the ability of strong, dense connective tissue structures to glide relative to one another." 1 Factors limiting the functional mobilit y of a patient have been categorized as compensation made in the presence of physical, mental, and emotional stress. " The con sequences of these adaptations to stress can be readily observed in the "soft tissues" of the muscle and connective tissue systems. Dens e connective tissue is continuous throughout the planes of the body and functions to provide support for nerves and blood vessels. Dense connective tissue give s shape and stability to muscles, separates and supports internal organs and joints, and assists in imparting isolated movement of one bod y part on another through specialized arrangements of collagen fibers known as tendons. " Gliding of one adjacent laminated connective tissue layer on another promotes the health of those tissues by circulating body fluids that facilitate lubrication and provide for nutrition of the connective tissues." Conversely, loss of mobility between con-
Present ed in part at th e nation al meeting of th e Ameri can Occupational Therapy Association, March 23, 1987, Baltimore , Maryland . Corresponde nce and reprint requ est s to Ga ry S. Sutton, MS, PT, SCS, ATC, Sport s Program Man ager , Sports and Occupation al Rehabilitation Center, 1810 Glen sid e Drive, Richmond, VA 23226.
ABSTRACT: Soft-tissue mobili zation (sTM) is a syste m of manual techniqu es e mploying low-load , long-d u ratio n for ce s appl ied in a pproxi matio n, tra ction , and tor sion al vec to rs to improve mobil ity between overlying and adjacent co n nect ive tissue layer s througho ut th e body. The purpose o f thi s a rticle is to present th e th eory of sTM as relat ed to th e properti es of wound healing and of ada ptive sho rte ning of so ft tissu e , to describe th e gen eral principles of four sTM te chniques, a nd to det ail specific appli cation of s TM techniques in the treatme nt of a di sorder related to a lon gfinger exte ns o r digitorum co m munis laceration and its repair. J HAND THER 7 :185- 192, 1994.
nective tissue layers ma y comp romise th e well-bein g of the connective tissue at th e site of restriction and may create symptom s at a d istance from the restriction. Tethering of or pr essure on neurova scular stru ctur es may create paresthesias, or symptoms of vascular compromise, as d escribed by patients with thoracic outlet syndrome. Lon g-standing scarring between fascial planes," which mechanically restricts mobility of soft tissues and/or joints, can cause sy mptoms in adjacent structures due to "compensatory hypermobility" 4,6, 7 and can lead to "relative flexibility" 8 of adjacent muscle groups.
Loss of mobility between connective tissue layers may compromise the wellbeing of the connective tissue at the site of restriction and may create symptoms at a distance from the restrictions. Soft-tissue mobilization (STM) is a system of manual techniques employing low-load, long-duration forces applied in ap proximation, traction, and torsional vectors to improve mobility between overlying fascial planes, thus restoring balance and sy mmetry to the musculoskeletal system ." The purpose of this article is to pr esent the theory of STM, to describe the general principles of STM, and to detail specific application of STM techniques in the treatment of a disorder related to a long-finger extensor digitorum communis (EDC) laceration and its repair. July-September 1994
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PROPERTIES OF WOUND HEALING Tissue repair in response to injury typically follows an ordered sequence of events in which a collagenous scar replaces damaged tissue lost through an injury or a disease process. 10,1 1 Four phases of scar-ti ssue formation have been described: the inflammatory stage, the granulation stage, the fibroblastic stage, and the maturation stage. 12 Further evidence delineates the presence of modified fibroblasts, which appear during the maturation stage of wound healing. These fibroblasts function to synthesize new collagen fibers, but also display the contractile capabilities of smooth muscle cells . These "myofibroblasts" have been theorized to playa key role in the mechanism of contraction of granulation tissue in wound healing, but may also influence and direct the process by which pathologic soft-tissue contractures are forrned .P:'"
PROPERTIES OF ADAPTIVE SHORTENING OF SOFT TISSUE While the response of the human body to trauma has been well described as the formation of a scar with the potential for wound contracture, the mechanism of adaptive shortening of surro u nd ing soft tissue is not well understood. Adaptive shortening refers to the loss of soft-tissue extensibility of tissues investing a joint in response to the decrease in demand for joint motion.'? The critical concern in the inve stigation of adaptive shortening appears to be the stimulus by which joint motion becomes limited. Adaptive shortening of connective tissues supporting a joint has been demonstrated in the presence of joint trauma followed by cast immobilization. The mechanism of restriction describes an increase in "crosslink formation" between adjacent collagen fibers. 15 Further laboratory studies have substantiated decreased connective tissue extensibility in cast-immobilized specimens as a result of increased collagen synthesis in immobilized tissues. 16 In human specimens, prolonged external immobilization of seemingl y normal joints promotes progressive contracture of capsular and periarticular structures, resulting in encroachment of the joint space by fibrofatty connective tissue. Maintained immobility further ap-
Prolonged external immobilization of seemingly normal joints promotes progressive contracture of capsularand periarticular structures. pears to cause obliteration of the joint cavity and eventual ankylosis of the joint. 17 Muscle, when castimmobilized, demonstrates invasion by fat and connective tissue. 18 When casted in a shortened position, muscle also loses overall length due to the loss of sarcomeres. 19 Skin quickly remodels to shortened positions due to a rapid rate of collagen turnover that 186
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is almost identical to the rate of new collagen deposition observed in traumatized skin in the early stages of wound healing.P" Although trauma and rigid immobilization have been reviewed as causes of adaptive shortening of soft tissue, similar decreases in the demand for joint motion with concomitant "stiffness" may evolve from patterns of adaptation to stress." Repeated postural stresses that occur during daily activity, combined with tensions of emotional and psychologic origins, facilitate a confused pattern of tense, contracted, fatigued myofascial tissue. Manifestations of prolonged stress from postural, psychologic, or mechanical origins cultivate distinct patterns of individual adaptation, compensation, structural change, and, ultimately, pathologic change within the human body." This continuum becomes more visible in the symptoms expressed as a result of the repetitive microtrauma of the distance runner, the postural strains of the dentist, and the anxiety of the secretary hunched over a typewriter while attempting to meet a deadline.
Faulty movement patterns create muscle strengthl/ength imbalances about a joint that alter the biomechanics of the joint and eventually produce symptoms. Health care professionals concur that stress causes adaptations that may evolve into disorders ." Controversy does exist, however, regarding the cause of certain adaptations and how these adaptations are treated. One theory proposes that the human body takes a "path of least resistance" in accommodating stress. Movement is generated through joints and muscle groups that can most easily accomplish the task, often at the expense of synergistic and antagonistic elements. Consequently, faulty movement patterns create muscle strength/length imbalances about a joint that alter the biomechanics of the joint and eventually produce symptoms. Treatment from a motor-learning approach is directed at activating synergists and antagonists of the muscle group in question in an effort to restore balance and reestablish normal biomechanical motion." An example de scribes the dominance often exhibited by the shoulder internal rotators over the shoulder external rotators in acting as a force couple with the abductors to achieve elevation of the arm. Continued elevation of the arm in light of poor mechanics may lead to impingement. This muscle imbalance is corrected and the impingement is relieved by retraining the shoulder external rotators to work more forcedly in a shortened position as the arm is elevated, reinforcing proper biomechanics. An alternative theory suggests that soft tissues may become relatively immobilized in compensated postures and may undergo adaptive shortening in much the same manner as if more rigid immobilization had occurred .2 ,9 , 22 Thus, from a mechanical perspective, the adaptively shortened tissue
must be passively lengthened before normal motion can occur. In the previous example, the shoulder internal rotators must be passively stretched to achieve a balance of muscle lengths about the joint. Once this balance has been restored, the patient can then begin to select and accomplish motions and postures consistent with his or her normal mechanics.P Further study is needed to define soft-tissue adaptive shortening, thereby promoting the efficacy of treatment.
THEORY OF SOFT-TISSUE MOBILIZATION Current therapies used to control wound contracture in traumatized tissue involve biochemical control of collagen production and of myofibroblastic activity, and " p hysical means." 23 Physical measures imposed to prevent contracture include static splinting, which is presumed to counter the contractile property of the myofibroblast, and range of motion (ROM) exercises, which are performed to orient new collagen fibers that proliferate during wound healing .24 Mechanical forces utilized in ROM exercises to passively elongate restricted tissues include a lowload application maintained for extended periods.P Soft-tissue mobilization techniques require initial assessment of the pathologic limit of the affected tissue, or the "barrier."? This assessment is performed as part of the therapist's preferred orthopedic and functional evaluation. The assessment includes palpation of both the local site of symptoms as well as the adjacent and antagonistic tissues to detect abnormal "tissue tension,"? or limited tissue mobility relative to the pa tient's contralateral side. Tissue mobility is assessed by the skillful loading of the myofascia by the therapist who monitors the quality and quantity of deformation that results. The therapist stresses the tissue by loading the structure with both compressive forces and shear forces . Compression implies applying a force perpendicular to the tissue surface, whereas shear forces are developed by applying a force parallel or oblique to the tissue being assessed.P While compression and shear represent two distinct force vectors used to assess tissue mobility, the therapist skilled in STM may apply these forces together in the evaluation and treatment of affected tissue . Physical restrictions can be assessed by palpation for the patient who sustains tissue tension even when the body part is at rest, as compared with the contralateral side. Restrictions may also be palpated in the passive inability of skin or other superficial tissu es to glide over deeper structures, or in the loss of passive lateral gliding of the tissue being assessed. Restrictions can often be observed in puckering or gathering and in color changes of the skin as tension is applied . Subjectively, the patient may com~ent that there is "burning, tightness, catching, or a tight band" around the area of restriction during the course of the assessment and later as a part of the treatment. Once the barrier or restriction is located, it is engaged with a low, steady load until a "release" is perceived by the therapist. This release has been de-
A release may occur immediately, or may require maintained loading for 90 to 120 seconds, depending on the strength of the restriction. scribed clinically as a "giving way" or a "melting" of the previously perceived barrier, allowing for an increase in soft-tissue extensibility.9 Biomechanically, the perception of release may be connected to "creep," which is a condition of continuous loading of biologic tissue until a point is reached where the maintained load causes a measurable increase in tissue length." Such a release may occur immediately, or may require maintained loading for 90 to 120 seconds, depending on the strength of the restriction .F Once th e initial barrier has released, secondary barriers may be located in various planes adjacent to the original restrictions. Additional barriers are likewise engaged and released until an increase in soft-tissue extensi. bility is palpated. Patient participation in the STM technique may further enhance compliance and optimize treatment results. For example, a mobilizing force applied to the barrier in multiple vectors based on the direction of the tissue limitation can be accompanied by active muscle contractions, under the direction of the therapist. Such contractions serve to activate the agonistic myofascial unit or the antagonistic group. By actively contracting the muscle being mobilized, an auxiliary load can be applied under the control and according to the tolerance of the patient. Contraction of the antagonistic muscle group, which also applies a load under patient control, additionally creates an inhibitive effect on the muscle being stretched by reciprocal inhibition via the muscle spindle. Effects of STM may include autonomic nervous system changes involving pulse rate, blood pressure, skin color, moi sture, and temperature; altered emotional states; and sensory changes in which the patient may relate burning, tingling, stinging, and elevated temperature in the tissue being stretched ." Further, the release of soft-tissue restrictions may cause an increase in blood and lymphatic flow that would then promote wound healing and would potentially reduce edema. Conceptually, the patient a.nd the therapist notice an increased freedom of active movement in isolated motions as well as in functional patterns of the trunk and the extremities. <:=?ns~ quently, STM is indicated for decreased mobility In soft-tissue structures, including skin, fascia, neurovascular structures, ligaments, tendons, and muscles. Specifically, restrictions in tendon excursion during elongation or contraction, decreased muscletendon length, limitations in joint mobility, muscle spasms, pain syndromes, and edema can be ad dressed with STM.
Soft-tissue mobilization is indicated for decreased mobility in soft-tissue structures. July-September 1994
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fiGURE 1. The sim plest soft-tissue mobilization treatm ent techn ique-pushing or pulling into the barrier or restriction.
Presently, little scientific evidence has been produced to validate the efficacy of STM techniques with regard to the degree and the duration of lasting change they produce in human tissues . Furthermore, clinicians can only speculate about soft-tissue barriers and the mechanism of their release. Despite the lack of scientific explanations, the concept of mobility restrictions of soft tissue as a source of pain in the patient has become a topic of considerable discussion among health care practitioners. 2 ,4. 6 - 9 , 21, 22, 27 - 30 Further investigations into the efficacy of STM techniques must be conducted by health care professionals who seek to modify pain and to increase mobility for their patients. Contraindications to STM include malignancy, hypermobile joint segments, recent fractures, hemorrhage sites, recent sutures, osteoporosis, acute rheumatologic conditions, localized infection, and inflammatory conditions.? Precautions requiring the judicious use of STM include new scars (to avoid opening wounds), tendon and nerve repair (to avoid rupture), and hypersensitivity to touch at the site being treated. Although often physically appropriate, STM must be used with care in cases of reflex sym- . pathetic dystrophy (RSD). " Since the severity of RSD is made worse by pain, one should be very careful throughout its management to avoid anything that will increase the pain. " 3 1
GENERAL PRINCIPLES OF SOFT-TISSUE MOBILIZATION Some general principles regarding the application of STM are offered to benefit and to protect both the patient and the therapist. An explanation of the treatment technique being applied and a description of possible sensory experiences that may follow are vital in preparing the patient for treatment. Treatment preparation may also include applying a skin lubricant and, occasionally, shaving hair at the site to be treated to make the treatment more comfortable for the patient. Ease of access to the area to be treated often requires removing clothing and draping the area with a gown, as appropriate, exposing proximal as well as distal parts. Often one region may affect another and may need to be examined and possibly treated . As the therapist begins to think about us ing 188
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STM for a patient with limited tissue mobility, the general area to be treated is decided upon first, e.g., the wrist, then a localized area is picked to begin treatment, e.g., the dorsum of the wrist. Once changes in that localized area are observed, treatment then can proceed to another localized area. The forces used with STM are initially applied to superficial restrictions and then progress to deeper areas of limited mobility. The length of the STM treatment session varies, but it should be short initially, e.g., 3 to 5 minutes. This allows the therapist to monitor the patient's response and the tolerance of the treated tissues. Once the patient and the therapist "get a feel" for accompanying sensory changes or soreness, manual treatment time can be extended. Due to the prolonged loading of restricted tissue necessary for treating patients by using STM techniques, the therapist should endeavor to use varied manual contact points during treatment. By varying contact points among the elbow, the pad of the thumb, the hypothenar eminence, and the metacarpophalangeal (MCP) joints, for example, the therapist should be able to protect :small joints and to prevent overuse injuries. Finally, in terms of general principles, remember that STM is only a part of the total treatment regimen and it should be followed by functional activities and/or exercises that make use of the gained mobility .
An explanation of the treatment technique being applied and a description of possible sensory experiences that may follow are vital in preparing the patient for treatment. SOFT-TISSUE MOBILIZATION TECHNIQUES Specific STM techniques apply biomechanical forces to restrictions in soft tissues using various parts of the upper extremity. These manual contacts include the fingers, thumbs, knuckles, hypothenar eminence, palm, forearm, or elbow, depending on the size and configuration of the area to be treated.
,-' '- - --n...,
fiGURE 2. This soft-tissue mobilization treatment technique involves osc illating pressures directed at muscle spasms and hypertonic mu scles.
an "5" shape. This modification can be used for lateral epicondylitis, posterior interosseous nerve compression, and other conditions.
Patient involvement can enhance STM techniques.
The 'T stroke is a soft-tissue mobilization technique that uses multidirectional forces.
FIGURE 3.
Once a restricted motion is identified, the sim plest treatment technique involves pushi~g into t~e barrier or restriction? (Fig. 1). A compressIve force IS applied perpendicular to the perceived soft-tissue restriction and is held for approximately 90 seconds, or until a release is perceived. The assisting hand can either stabilize the restricted area by offering a counterpressure or assist in pushing into the rest~ic tion . Occasionally, this direct approach at stretchmg the limitation is not well received by the patient, and an indirect approach is necessary. Rather than developing a force pushing into the restriction, a path of "lesser resistance" is found by pulling away from the greatest restriction . This "push-pull" technique can be applied in multiple vectors into or away .from a scar or soft-tissue barriers. Often these techniques are effectively applied with fingertip pressure on a tight scar, or with palm pressure on an area of dense connective tissue. A second technique involves oscillating pressures directed at muscle spasms and hypertonic muscles" (Fig. 2). Instead of maintaining a low-loa~, sustained force, this technique requires low-amplitude, rhythmic mobilizations aimed at relaxing neuromuscular tone and patient guarding. This technique is applied with wide manual contacts, preferably one palm or both palms. The 'T' stroke is a third technique utilizing multidirectional forces. Force is applied with the fingertips as if making a ''1'' over and into the area of restriction'? (Fig. 3). Counterpressure from the assisting hand is necessary for the localization of the mobilizing force . This technique is effective for longitudinal scars or for patterns of tightness, such as the preoperative and postoperative treatment of lateral epicondylitis. The "Indian burn" is a fourth technique where counterpressure is developed between the two hands of the therapist in an effort to twist restricted tissue in opposite directions? (Fig. 4). This technique is effectively used for areas of generalized tightness, as well as for multidirectional restrictions, especially those occurring in the arm and the forearm. As a general treatment, this technique can be used on compartment syndromes and/or after fasciotomy . A modification of this technique is an " 5" maneuver (Fig. 5). The therapist uses both of his or her thumbs in approximating the location of the restriction and then places them in offset directions to apply pressure on this area, which ends up stretching the tissue into
Patient involvement can enhance STM techniques. Generally, the patient is asked to actively contract or lengthen a restricted muscle- tendon group while the therapist applies a specific STM technique . This mode of treatment is particularly useful in the case of flexor tendon or extensor tendon repairs where tendon gliding is restricted by scarring or by adhesion formation. For example, on evaluation, the hand therapist determines that the patient has developed a restriction in proximal and distal gliding of a flexor digitorum profundus tendon following surgical repair. In an effort to augment the. STM forc~, the patient is asked to forcefully flex hIS or her fingers while the therapist applies fingertip pressure to the area of restriction, most commonly at the incision site . This fingertip pressure is directed distally toward the patient's fingertips, offering a counterforce to the patient's attempt at finger flexion . Alte~na tively, active wrist and finger extension by the patient is countered by a proximally directed pressure by the therapist, effecting a stretch to scar tissue limiting distal glide of the repaired flexor digitorum profundus tendon. Also , contract-relax proprioceptive neuromuscular facilitation techniques can be utilized to bring about a more vigorous tendon pull through by the therapist, providing resistance to finger flexion at the distal pad with proximally directed counterpressure at the site of the scar. A e-second contraction
FIGURE 4. In the soft-tissue mobilization treatment technique known as the " Indian burn ," counterpressure is developed in an effort to twist restricted tissue in opposite directions.
FIGURE 5. This modification of the " Indian burn " technique is known as the "5" maneuver.
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is maintained in this position, followed by actively advancing the finger into further extension while maintaining the proximal counterpressure and repeating this sequence. With each of these techniques, the therapist seeks to hold the position of the skin and the connective tissues as the tendon is being moved, thus stretching restrictions that limit gliding of the muscle- tendon unit under the skin and through adjacent connective tissues. To ensure skin surface contact, a nonslip pad of a material such as Dycem (Dycem Ltd., Bristol, UK) can be a useful adjunct to treatment. Active movements initiated by the patient can aid in stretching musculotendinous restrictions, but also can assist in localizing the sites of scar restriction. By asking the patient to initiate isometric contractions through the available joint ROM, restrictions may be observed by the therapist in the form of tethering or puckering of the scar and the surrounding skin surface. Further, by performing isometric contractions at distinct intervals in shortened or lengthened positions, the patient can offer feedback regarding the range at which restrictions are perceived. Thus, the therapist may be able to corroborate observations with patient perceptions and may be able to develop an STM treatment progression based on limitations in ROM with techniques the patient will tolerate. Patient perceptions of the application of STM techniques range from pain, tingling, burning, and ripping to pulling, pressure, and warmth. Often patients report that symptoms diminish as the force is maintained over an area of restriction through the application of a single technique. The patient and the therapist frequently perceive a release or a "letting go" as the restriction lessens. Increased tissue heat and superficial reddening of the skin can often be observed for several minutes after the treatment has concluded . While this release of heat and the associated reddening of the skin have been associated with a breakdown of chemical bonds between adjacent connective tissue layers, the mechanism of this breakdown is not well understood. Another consideration in utilizing STM techniques is the application of a superficial cold pack prior to treatment for the patient with acute pain and palpation. Application of cold following STM may be a useful adjunct in limiting soreness that may ensue. Also, recognition needs to be given to the augmentation of joint mobilization techniques, of appropriate modalities, of splinting, of active and passive exercises, and of functional retraining to ensure the success of STM . The STM technique selected, the manual contacts employed, and the amount of force applied are dependent on the size of the area to be treated, the magnitude and the direction of the restriction, the stage of wound healing, the tolerance of the patient, and the skills and creativity of the therapist. Multiple variations and combinations of the techniques described can be used on various types of soft-tissue restrictions. The following report describes how STM was used in the rehabilitation of a patient after surgical repair of a lacerated extensor tendon. 190
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CASE REPORT A Zl-year-old male college student who was a heavyweight wrestler had an EDC laceration in zone 4, the dominant long finger of his right hand. The injury occurred on January 1, 1992, when he struck another person in the mouth and lacerated the tendon on a tooth . The patient underwent surgery that same day for repair of the EDC laceration, debridement, and closure of the wound. This began a 6-day stay in the hospital for intravenous antibiotics due to the origin of the wound. The patient was referred for therapy, routine extensor tendon repair rehabilitation, on January 10. At that time he had a l-cm slit over the dorsal distal metacarpal of his right hand, with slight drainage of serosanguinous fluid . Treatment consisted of routine wound care, edema control, dynamic extension splinting, active interphalangeal (lP) joint flexion, passive MCP joint extension by splinting, and joint mobilization. On initial evaluation, the patient had full passive finger extension but lacked 23 degrees of active MCP joint extension as measured according to the American Society of Hand Therapists' recommendations." During splinting he had 45 degrees of active MCP joint flexion, 55 degrees of active proximal interphalangeal (PIP) joint flexion, and 20 degrees of active distal interphalangeal (DIP) joint flexion. The patient had 50 degrees of active wrist flexion and 45 degrees of active wrist extension. The rest of his fingers had full joint mobility, as did the rest of his upper-extremity joints . When the patient was seen on January 14, 1992, his wound was closed . Scar massage was initiated and gentle pushing into and pulling away from the scar was started. Splinting and ROM treatment continued. More aggressive STM was initiated on January 21. The patient maintained full passive MCP joint extension. He had 65 degrees of active wrist flexion and 55 degrees of active wrist extension. The patient had -13 degrees of active MCP joint extension with full active IP joint extension. He had 60 degrees of active MCP joint flexion, 65 degrees of active PIP joint flexion, and 30 degrees of active DIP joint flexion. He now had full joint mobility at his IP joints . Visually, restrictions in tendon gliding could be seen at the wound site, just proximal to the head of the third metacarpal joint, with attempts at active extension and flexion. Treatment progressed to more aggressive pushing into the scar, and sustained fingertip pressure was used at those areas where the patient felt burning or pulling, or where tightness was palpated. In addition, the "S" maneuver and the '']'' stroke were introduced to apply pressure multidirectionally into the scar. In conjunction with these techniques, 3 weeks after repair, STM techniques involving active patient participation were employed . The first technique used a mobilizing force pushing distally into the restricted area (wound area) while the patient actively extended his isolated EDC. A second technique was utilized in which the therapist pulled proximally on the perceived restriction while the patient actively flexed his MCP joint. The patient often reported a pulling or burning sensation with this method, but noted a release or cessation of this as pressure was maintained. (Note that STM treatments were advanced on resolution of passive restrictions in connective tissues, and not necessarily on diminution symptoms.) The patient was encouraged to perform "self-S'TM" as part of his home exercise program .
The patient was encouraged to perform "self-STM" as part of his home exercise program.
On January 28, 1992, splin ting wa s discontinued altogether. Dycem was used with the STM techniques to maintain better skin contact when both applying pres sure to the area of restriction in all directions and pushing pro ximally and distally into the scar whil e the patient actively flexed and extended, respectively, his MCP joint. After treatment, his active ROM was still -13 degrees of MCP joint extension , but his MCP joint flexion was 70 degrees, his PIP joint flexion wa s 95 degrees, and his DIP joint flexion was 75 degrees. The patient continued his active ROM exercises, progressed with passive ROM exercises, started grip strengthening, and added Dycem to his STM at home. Four weeks after surgery , the patient wa s able to use his hand for all activities of daily living , with restrictions on heavy lifting at his part-time job at a hardware store. Also, he was instructed to buddy strap his index and long fingers together during wrestling practice. The patient was seen again on February 14, 1992. His active ROM was - 10 degrees of MCP joint extension and 73 degrees of MCP joint flexion. He had 100 degrees of active PIP joint flexion and 83 degrees of active DIP joint flexion . His active wrist flexion was 65 degrees and his active wrist extension was 60 degrees . The patient's grip strengths as measured from position 1 to position 5 of the Jamar dynamometer (Therap eutic Equipment Corp., Clifton , NJ) were 23, 57, 87, 83, and 78 lb for his right hand and 68, 140, 135, 137, and 112 lb for his left hand . He was further progress ed on his strengthening program for both flexion and extension. He also wa s instructed to con tinue with his STM techniques using the Dycem . At this time the patient wa s allowed full use of his hand . He was permitted to return to full duty at work and to wrestle competitively. The patient was last seen on February 28, 1992, two months after his injury. His active ROM was - 15 degrees of MCP joint extension and 75 degrees of MCP joint flexion, 0 to 100 de grees of PIP joint flexion, and o to 80 de grees of DIP joint flexion. His grip strengths were 83, 143, 142, 125, and 139 lb for his right hand and 73, 152, 155, 137, and 120 lb for his left hand . Functionally, he reported full use of his right hand with occasional pain whil e successfully completing his collegiate wrestling session. Although the patient did not have full active ROM, he had functional ROM and use of his hand. With time we expect him to regain full grip strength (10% greater than the grip strength of his left hand) and to maintain, or slightly increase, his MCP joint motion . Although it is difficult to know objecti vely whether this pati ent would hav e recovered as qu ickly, or as functionally, without STM, we contend that the techniques employed greatly assisted in freeing his extensor tendon of restrictions as well as in increasing his active ROM and decreasing his pain with movements. We recommend that the hand therapist consider the appropriate use of STM with both surgical and nonsurgi cal hand disorders.
CO NCLUSION Decreased upper-extremity function resulting from loss of joint motion represents a challenge to every hand therapist. While scar tissue formation is described as an integral component of wound healing, th e process necessitates modification. Strategic loading of newly forming scar tissue is necessary both to e nsure the ultimate strength of the tissue under repair and to maintain the mobility of the healing tissue from adjacent structures. Early intervention in accordance with healing constraints serves to limit both soft-tissue restrictions and adaptive postures and behaviors that can occur at a distance from the wound . Soft-tissue mobilization has been described as a system of manual techniques employing low-load, long-duration forces applied to improve mobility in restricted connective tissue . Mechanical forces applied in approximation, traction, and torsional vectors have been discussed . The application of STM is in accordance with the patient's tolerance and is monitored by the therapist's perception of the release . The details of the case report as well as the clinical experience of the authors lend support for the utilization of STM as an effective modality in the treatment for connective tissue restrictions .
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