Connective Tissue Massage

1. Connective Tissue Massage

2. C.T.M. • CTM is a specific manipulative technique applied to the CT close to the body surface. • The technique is applied via the PT ‘s middle & ring fingers to the epidermis & through this to the deeper CT which suffer a tensile strain placed upon them.

3. C.T. Zones • Using the principle that (All CT is continuous). So • Changes in tension & mobility of CT in one area will be reflected in the CT at some other points. • An example is in the obvious reduction of function which can be produced by the shortening of CT seen in: • Contracture • Scarring • Often this CT change ‘ll be reflected in the skin CT by a change in normal mobility, PT should detect it on assessment.

4. Effects of C.T.M. Physical: 1. Stretching CT. 2. Mobilizing CT. Reflex: • Circulation. 2. Pain.

5. Uses of C.T.M • Diagnosis of internal organs. • Treatment of internal organs. by the application of CTM strokes to specific skin areas.

6. Technique of Application • Technique of CTM can be applied to any body area. *Treatment only to the back & neck will be considered now. • With any manual skill demonstration, practice & correction are the essential components of developing the ability to apply it & to evaluate its efficiency. • This is especially true for CTM as the stroke itself is complex & its direction needs to be felt more than drawn on a diagram. • Tissue tension can only be interrupted by the perceptive sensation of the PT’s fingers.

7. Position of the Patient • To treat the back or neck, the pt is positioned as for the assessment : • sitting on a plinth with legs over the side. • hips & knees at 90°. • Hands resting on thighs. This is the optimum position for treatment, but - Side lying may be used if sitting is difficult.

8. Position of the PT Fingers • The essential feature of CTM is !: • Tensile strain is applied to CT to produce: • Physical effect. • Reflex “ . • To achieve this effect: • Middle finger is supported by ring finger. Thumb is supported on pt. • These fingers make an angle with skin of 40-60°. • Strokes is always a pull with the wrist leading the mov. • Tension must be developed between finger pads & pt’s skin. So lubricants aren’t used • Sufficient pressure is used to achieve adherence. • PT nails must avoid the skin. • Angle altering → vary stroke depth or speed of pull. • To have superficial effect: a. ↓angle. b. ↓ speed • The reverse is true.

9. Assessment Technique Prior to C.T.M. • In order to detect changes in the tension of CT caused either by: • Physical shortening &/or • Alteration in fluid content. • PT begins the examination by: • Observation • Palpation

10. a. Observations • Pt is seated with thighs supported • Hips & knees at 90° • Feet supported • Hands resting on thighs • Back exposed as low as the gluteal cleft • Back is observed to note changes in: • Surface contour between the 2 sides • Changes in symmetry produced by m. spasm • In the absence of spasm, • ↑ or ↓ amounts of fluid in the CT → • Alteration in fluid viscosity, could be the cause.

11. b. Palpation 1.General palpation is undertaken when the skin is moved against the deep fascia by small symmetrical pushes using the middle 3 fingertips of slightly flexed fingers. 2. Mov. produced should be the same on both sides, (&in all directions) a difference in mobility indicating ! * ↑ tension. 3. These small movs. are started at the sacrum & symmetrically progressed upwards over the whole back.

12. Types of Strokes 1. Short 2. Long • Short strokes: depending upon 1. Pt size 2. Area under ttt 3. Tension of CT. 4. Strokes are up to 3 cm long Sequence of events: - Achieve adequate adherence of the pads of 3rd & 4th fingers to the skin. - With the wrist leading the mov, a slack is taken up in the superficial skin tissue & tension then applied to the deeper CT. - This should be done without a sliding mov bet. skin & finger pads. - Sensation experienced by the pt may be cutting or scratching, but not be unduly uncomfortable. - Short strokes are usually applied in a sequence (repeated consequentlly) - Number of repetitions depends on: 1. The effect achieved 2. Pt. reaction

13. 2. Long Strokes • Differ from short strokes in that: Mov is allowed between finger pads & skin. • Again appropriate slack of sup. tissue taken up. • Fingers are drawn along surface with constant pressure & speed in a direction → apply appropriate tension to CT. • A mobile fold of tissue should precede the stroking fingers. • The effect of both short &long strokes will be: • Physical as the CT is stretched • Reflex by the effect on the NS. 5. Repetition: Each set of strokes may be repeated up to 3 times.

14. Techniques of Treatment • Portions of the body to which CTM is applied are called sections. • A specific set of CTM is applied to each section. • Principle that all CT is connected requires all ttt strokes start at the sacrum & Work up along the trunk to the neck. • Treatment may then process out along the limbs if appropriate.

15. The Role of CTM in the management ofLesions of the Back & neck • CTM techs are applied to lumbar, thoracic & cervical. • Time taken can be considerable when compared to that of other manipulative techs, but provided an appropriate assessment of S&S has been carried out. • PT may consider that CT of this region require specific attention. • CTM is a tech places the PT in close contact with potentially pain producing tissuesin the regions ofthe spine.

16. Effects of CTM • Circulatory A. Local circulatory effect: • As a result of tensile stress placed on CT by the stroke applied. • Strokes are sufficiently traumatic → mast cell → release histamine-like substances → vasodilation. (triple response) • A local axon reflex may occur whereby sensory stimulation produced in the skin by CTM → arteriolar dilation in the area. • Subsequent ↑ capillary pressure → translation of fluid into the tissues. • Benefits of local ↑in circulation → affect fluid level within the matrix of the CT & help restore normal tension & sensitivity. • In presence of inflammation, the circ ↑ → resolution & remove pain-producing chemicals. (in chronic inflam only, not acute)

17. B. General circulatory effect: • CTM → stimulate ANS → reflex effects on circulation in specific areas. • These areas may be superficial or deep & the technique affect circ on both. • Dicke on doing CTM on her sacral area →↑foot peripheral circulation. • However, general circulatory effects can be detrimental & →↓ ABP → fainting in certain sensitive individuals .

18. 2. Physical effects of CTM a.CT strokes (short & long) → affect CT mobility. In↓ mobility: - 1stshort strokes of a hook-on nature→release & stretch the CT. - 2nd Once this achieved, long strokes now are applied to make CT move in a physiological way. b. Restoration of normal CT mobility mean that tissues ‘ll be allowed to move through a normal excursion without: 1. enchroaching on the function of other adjacent tissues 2. producing painful stress. *Stretching exs may sometimes be appropriate when this stage is reached.

19. 3. Reduction of Pain 1.CT is a sufficiently strong physical stim→produce tissue trauma & release histamine, bradykinin → stim CT nociceptors & mechanoceptors. 2. Large diameter f. of mechanoceptors in CT→ effect at synapses in Substantia Gelatinosa (SG)& Nucleus Proprius at post horn cell (PHC) →↓transmission in small C diameter pain f. 3. The gate of Melzack is closed. 4. CTM stroke itself is considered as painful stim→ carried by large A delta f. → PHC, cross synapses at level of SG & ascend → cortex (where sense of cutting or scratching is felt)

20. 5. As this impulse passes through mid-brain, may interact with periaqueductal area of grey matter (PAG) & Raphe Nucleus. 6. This interaction → descending pain suppression system → release body’s own opiate-like substances (Encephalin) → block forward transmission in nociceptive synapses of post. horn. 7. The circulatory effect also → ↓ pain level by removing chemicals which cause nociceptive stimulation. 8. By restoring the normal tension in tissues & reducing stress (of pain stimuli) on nociceptive endings → their threshold may be returned to a more normal level.

21. Summary of Mechanism of Release of Opiate through CTM • Stimulation of mechanoreceptors with large A delta f. → override small c. pain f. • These impulses passes through midbrain. • Descending pain suppression → release body’s own opiate-like substances (encephalin) → block forward transmission in nociceptive synapses of post. horn cells. • By restoring the normal tension in tissues & reducing stress on nociceptive endings → their threshold may be returned to a more normal level.

22. Summary of pain reduction mechanism • Stim of mechanoreceptors with large A delta f → override small C f. of pain. • ↑ circulation → drain waste products causing pain. ↑ secretion of histamine substance. • ↑ secretion of encephalin →↓ pain. • Pain due to CTM tensile strain → dissociates the original pain sensation.

23. Diagnosis with CTM • S & S of the main pathology relative to organ include (heart, lung, stomach, liver) which indicate metabolic problem or organic pathology. • If no associated S & S of disease, this means that the problem is locally in skin ,CT & ms as spasm, scar, contractures(tightness), etc.,…

24. Observe for the Skin • Dark areas, with shiny adjacent (scar) areas. • Hair overlying skin in specific diseases. • Contracted (shrinking skin) at areas of spasm with dark color due to grooving of skin. • Scar areas are shiny, hard, contracted & pale in color.

25. Signs of Good Strokes • Hyperemia over skin (pink color) (due to improved circulation). • Feeling of relief after few minutes of the session.

26. Signs of Bad Strokes • Redness, with or without swelling. • Hotness (signs of inflammation). • ↑ Pt discomfort. • Injury orscratching or laceration of skin. • Intractable pain.

27. Session Duration & Frequency • Every other day or daily. • Twice /day, upon pt tolerance. • Session duration may reach 20 min. • Strokes to be repeated till: 1. Erythema, 2. Effect & Pt feel relief. A. Administer 15 session, B. Then rest for 3 weeks to: • Give chance to body tissue reacting with each other & • See how CT will close again or retain its gained flexibility.

28. Indications • Revascularization of sports injurye.g.(chronic: contusion, strain &sprain). • Torticollis. • M. cramp, contractures &skin scar.. • LBP. • Cervical pain. • Arthritis & jt pain. • Circulatory system (intermittent claudications). • Myocardial problems. • Respiratory problems (to↑ chest expansion).

29. Contraindications • TB (bone &chest). • Mental diseases. • Wounds &cuts. • Fresh infections. • Fresh burns. • Acute inflammations.