Ch.4 Client examination for Outcome-Based Massage

Objectives

1. Distinguish "Outcome based massage" vs "Wellness massage"

2. Identify elements of the client interview that are relevant to the assessment of soft tissue dysfunction

3. Identify the components of the objective examination for massage including MSK, psychoneuroimmunologic, multisystem, neurologic, cardiopulmonary, and functional components

4. Discuss how to perform palpation and identify the impairments that can be assessed using palpation

5. Describe a variety of nonpalpatory approaches to assessing the impairments that are relevant to massage

FOCUS OF THE CLIENT EXAMINATION FOR 

OUTCOME-BASED MASSAGE

Medical Massage 

(We don't really call it "Medical massage." However, the book is trying to say "Impairment focused massage" by Yukes)

• Identification of soft tissue dysfunction released to the client's clinical condition
• Identification of other primary and secondary impairment that therapists can treat with massage techniques if appropriate
• Identification of the client's activity and participation limitations that are associated with soft tissue dysfunction

Wellness Massage

• Identification of the body structures and function in the client's wellness goals that therapists can treat with massage techniques
• There should not be any soft tissue dysfunction. Otherwise it is not "Wellness Massage"

Performing the Subjective Examination

Purpose is to identify soft tissue dysfunction.

• Any long-standing MSK condition that may result in chronic soft tissue tightening
•  Hx of prolonged infection near the affected site
• Change in pain over the time from initially specific, localized pain to more diffuse, generalized pain
• Hx of chronic pain
• Hx of pain combined with anxiety, stress or emotional trauma
• Idiopathic pain with complex Hx of multiple injuries
• Multiple surgeries that might predispose the client to scarring
• Hx of multiple conflicting assessment and ineffective Tx from multiple providers
• Postural change over the time
• Hx of SXS relief from massage or stretching
• Client uses the words such as “tight, hard, wired” to their SXS
• Hx of bony changes such as leg length discrepancy, scoliosis, or dental malocclusion

Performing the Objective Examination

This will vary with the client's presenting issue and the purpose of treatment.

Therapist may use their experience and discretion in determining the order in which they perform the objective examination

Using Palpation in Client Examination

Basic Principle of Palpation

• What is the structure or quality?
• How does this finding differ from other structures or qualities that I have palpated?
• How does this finding relate to the client's history?
• How does this structure reflect the clients' demonstrated and reported function?

Objects of Palpation

• Abnormal connective tissue density
• Abnormal level of resting muscle tension
• Abnormal neuromuscular tone
• Adhesion
• Impaired extensibility of contractile and noncontractile tissue
• Impaired integrity of contractile and non contractile tissues
• Decreased rib cage mobility
• Fascial restriction
• Muscle spasm
• Pain
• Scarring
• Swelling: edema, effusion, lymphedema
• Trigger Points

Force of Palpation

• Therapist should use the minimum pressure required to contact the chosen tissue or structure
• Lighter force to greater force

Musculoskeletal Examination

Postural malalignment

Abnormal joint alignment or deformity within a bone

Development of neuromuscular and musculoskeletal dysfunction

Direct or as a result of the compensatory motions or postures that can accompany postural malalignment

Joint Integrity

• Capsular restriction
• Capsular Laxity
• Capsulitis and Synovitis
• Ligament Insufficiecy
• Ligament Laxity
• Nonmyofascial Trigger Point

Joint Mobility

• Joint ROM
• PROM
• AROM
• Accessory Joint Motion
• End Feel

Muscle Integrity

• Muscle integrity
• Muscle extensibility
• Contracture
• Muscle strain or tear
• Tendinitis
• Tendinosis
• Myofascial Trigger Point

Muscle Performance

• Muscle performance
• Muscle strength
• Muscle power
• Muscle endurance

Resting Muscle Tension

• Resting muscle tension
• Muscle spasm

Adhesion and Scarring

• Scar
• Adhesions

Connective Tissue Integrity

• Fascial restrictions
• Abnormal connective tissue density

Psychoneuroimmunologic Examination

• Chronic Stress
• Stress Response
• Cognitive Transactional Model of Stress
• Physiologic Model of Stress
• Life Events Model of Stress

Multisystem Examination

Acute pain

Provoked by noxious stimulation from injury, surgery and/or disease 

Chronic Pain

Persists beyond the normal healing time and includes aspects of peripheral and central sensitization and physiological components

Somatic pain

It is caused by a stimulus to tissue in a person with an intact nervous system 

• Inflammatory pain
• Caused by tissue response to an injury or irritant and should resolve when the irritant ceases with healing
• Nociceptive pain
• Caused by noxious stimuli of nociceptive receptors in the skin or muscles: touch, pressure, temperature
• It is the sensitization of peripheral nociceptors as a result of injury that causes an increased release of neurotransmitters in the dorsal horn of the spinal cord
• The sensitized dorsal horn neutrons demonstrate an increased background activity, an increased receptive field size, and increased responses to peripherally applied stimuli

Neuropathic pain
It is caucused by an injury, dysfunction, or change within the sensory nervous system

• Central pain syndrome
• Caused by a lesion in the CNS that affects the pain regulation system in the spinal co and brain such as injury, CVA, tumor, or disease
• Thalamic lesions are the most common and present on the contralateral side in the non Derma Tomar distribution
• Complex regional pain syndrome
• Previously known as Reflex sympathetic dystrophy
• This affect oth sensory and motor parts of CNS
• Fibromyalgia
• Sensitization of the sensory nerves within the muscles causing central sensitization
• Usually associated with depression and poor sleep
• Phantom Pain
• Involves central changes prior to loss of oh part that cause subsequent incongruity of sensory and motor input
• Client will perceive pain in body parts that are no longer present
• Radiculopathy
• Pathological condition caused by blockage or pressure on nerve root (s) that results in sensory abnormalities, pain and motor loss within the nerve root distribution
• Symptoms are usually within nerve root distributions: Dermatomes for sensory function and myotomes for muscle function 
• Radiculopathy pain
• Pain caused by stimulation of novice Pt I’ve afforestation fibres in spinal nerves, nerve roots, or ganglia
• It is caused by spontaneous ectopic nerve discharge and is different from Radiculopathy, although both are often present at the same time
• Referred pain
• Pain that patient perceives as coming from an are away from the source because of the proximity of different suffering sensory nerves
• Example: Visceral pain, TrP pain
• Visceral pain
• Pain from Oran’s innervated by the autonomic nervous system, which is both a sensory and motor system
• Pain is usually a combination of notice Pt I’ve and neuropathic pain
• Organ pain refers to Somali pain fields because of lack of separate visceral sensory pathways and the low number of visceral afforestation fibres
• Example: Cardiac ischemia associated with pain in the left arm, neck an face
• Dermatomal pain
• Area of skin supplied by one dorsal nerve root
• Injury of a dorsal root can result in sensory loss in the skin or can be experienced by the client as a burning or electric pain
• Myotomal pain
• Pain in a myotome, a group of muscles supplied by the nerve root
• This could also result in weakness in specific muscles
• Sclerotomal pain
• Pain in a sclerotome, an area of one or fascia innervated by one segmental nerve root
• Example: Hip pain can be referred to the groin, SI joint, L/S, knee, or ankle
• Referred TrP pain
• Pattern of referred pain relates to its site of origin
• Untreated TrP can be associated with pain symptoms that include, but are not limited to, radiculopathy, tennis elbow, tension headache, occipital headache, and frozen shoulder

Physiological pain

• Chronic pain syndrome
• Recurring multiple, clinically significant pain complaints that can cause social and occupational dysfunction
• Pain disorders
• Pain causing distress and/or functional impairment, where psychological factors play an important part in its onset, severity, and continuation
• This is not conscious or intentional. Hypochondriasis, serious disease that is often caused by misinterpretation of boy symptoms, falls within this category

Impaired sensation secondary to entrapment neuropathy

Swelling: Abnormal enlargement of a segment of the body

• Edema
• Accumulation of fluid in cells, tissues or serous cavities
• 4 main causes
1. Increased permeability of capillaries
2. Decreased plasma protein osmotic pressure
3. Increased pressure in capillaries and volumes
4. Lymphatic flow obstruction
• Effusion
• Excessive fluid in that joint capsule, indicating irritation or inflammation off the synovium
• Most common in Knee
• Lymphedema
• cumulative of abnormal amount of lymph flui an associated swelling of subcutaneous tissues that result from the obstruction, destruction or hyperplasia of lymph vessels
• Dependent edema
• An increase in extracellular fluid volume that is localized in a dependent area such as a limb
• This edema can be associated with swelling or pitting
• Pitting edema
• Pitting edema is edema that retains the indentation produced by the pressure of palpation
• CONTRAINDICATIONS for Massage therapy
• Solid edema
• Infiltration of subcutaneous tissue by mucous material

Neurologic Examination

Neuromuscular Tone

• Postural tone
• The development of muscle in skeletal muscles that participate in maintaining the position of different parts of the skeleton
• Hypertonia
• General term used to refer to muscle tone that is above normal resting levels
• Hypotonia or Flaccidity
• General term used to refer to muscle tone that is below normal resting levels
• Spasticity
• Increased muscular tone that is a result of an upper motor neurone lesion that may or may not be associated with reflex hyperexcitability
• Rigidity: Increased muscular tone that occurs as a result of brain stem or basal ganglia lesions
• Decocrticte rigidity
• Result of brain stem lesions
• Sustained contraction and posturing of the trunk and lower limbs in extension and upper limbs in flexion
• Decerebrate rigidity
• Result of brain stem lesions
• Sustained contraction nad posturing of the trunk and lower limbs extension
• Parkinsonian rigidity 
• Result of basal ganglia liesions
• Tight contraction of both agonist and antagonist muscles throughout the movement
• Clonus 
• Cyclical, spasmodic hyperactivity of antagonistic muscles that occurs at a regular frequency in response to a quick stretch stimulus

Cardiopulmonary Examination

• Dyspnea aka SOB
• Indication of inadequate ventilation or insufficient amount of oxygen in the circulating blood
• Rib Cage Mobility
• The capacity of the rib cage to move within the available anatomical range of motion during respiration, based on the arthrokinematics of the joints of the rib cage and the thoracic spine, and the ability of the associated soft tissue to respond to the movement
• Airway Clearance: Ability to move pulmonary secretions effectively through the use of normal mechanisms of cough and the mucociliary escalator
• COPD aka Chronic Obstructive Pulmonary Disease
• Presence of increase airway resistance
• Associated with increased sputum production and cough that can predispose the individual to recurrent bronchial infection
• Example: Emphysema, chronic bronchitis, asthma
• Chronic Restrictive Pulmonary Disease
• Pulmonary disorder characterized by the restriction off lung expansion, such as interstitial fibrosis 

Functional Examination

• Self-Care Activities: Daily tasks that an individual needs to perform in order to be independent
• Health-Related Quality of Life: Client’s perception of the impact that his clinical condition is having on his quality of life

Scientific Basis of Soft Tissue Examination

• Soft tissue Layers: Therapist can differentiate between characteristics of three layers, such as hardness, density, texture, and mobility, to distinguish between tissue layers
• Epithelium
• Connective tissues
• Contractile tissue
• Superficial fascia
• It houses fast and water, provides a path for nerves and vessels, and sometimes contains thin strains of striated muscle that can control the movement of the skin
• Deep fascia 
• It is dense connective tissue that lies between the superficial fascia and muscle
• The investing layer of the deep fascia is dense connective tissue that lies between the superficial fascia and muscle
• Soft Tissue Mobility and Restrictive Barriers
• Normal soft tissue ROM
• Within normal ROM, normal soft tissue has 3 barriers or resistance that can limit movement.
1. Physiologic barrier: It determines ROM that is available under normal condition
2. Elastic barrier: The resistance that therapist feel at the end of the passive ROM when they have taken the “slack” out of  or are “engaging” the tissue
3. Anatomical barrier: Final resistance to normal ROM that the bone, ligament, or soft tissue can provide. Motion beyond the anatomical barrier results in tissue damage
• Restrictive barriers
• It may occur in skin, fascia, muscle, ligament, joint capsule, or a combination of these tissues when soft tissue dysfunction is present
• It can limit the available ROM anywhere within the tissues
• Presence of a restrictive barrier will change the quality of end-feel
• Barrier release phenomenon
• If the therapist sustain the pressure on the tissue barrier, a “release” may occur after the latency period that will vary with the nature of the tissue and its state of health
• Example: Connective tissue si most responsive to sustained pressure and will demonstrate a slow, palpable stretch of tissue called creep or viscoelastic creep
• “This sounds like a PNF stretch” says Yukes

• Resting Muscle Tension
• Some words such as “hard,” “tight,” “soft,” and “ropy” directly describe  the texture of the muscle at rest
• Description like “body,” ”dry,” or ”leathery” have unspoken implications about tissue health
• Terms like “taut band” or “facilitated segment” describes complex theories about pathology of muscle or other tissue
• Contribution of low-level actomyosin myofibril cycling to passive resting tension
• Active tone: aka Hypertonicity 
• Unnecessary or extraneous muscle tension: Muscle tension that is potentially under voluntary control
• Trigger point: Myofibril shortening and activity, possibly as a result of calcium leakage at dysfunctional motor end plates. The contraction knots and taut bands of TrP frequently cause elevated resting tension in the surrounding muscle fibres
• Spasm: Involuntary contractile activity that is associated with motor neurone and EMG-monitored activity.  Spasm is a common result of orthopaedic injuries
• Spasm produces pain in one of three ways
1. Overloading parts of the muscle
2. Subjecting nociceptors between active and non active parts of the muscle to shearing forces
3. Through ischemia

Conclusion

Palpation provides an important means of assessing a variety of aspects of soft tissue function that can suggest the presence of impairment such as temperature, tissue mobility, fluid status, tissue texture, and tissue consistency

Therapists can also extend their interpretation of the findings from standard musculoskeletal, neurological, cardioplmonary, and psychological tests and measures to include an analysis of the contribution of soft tissue dysfunction