Manual Strategies: Optimizing Patient Outcomes in the Clinic $0.00

Manual Strategies: Optimizing Patient Outcomes in the Clinic

By: Paula Donahue, PT, DPT, MBA, CLT-LANA | Mar 25, 2019
Manual Strategies: Optimizing Patient Outcomes in the Clinic

When addressing soft tissue dysfunction (STD) or correcting musculoskeletal (MSK) impairments, clinicians are keen to incorporate the most impactful treatment strategies to address their patients’ impairments. The primary goals are to reduce impairments and maximize function and performance within the shortest time possible. Ideally, patients also become self-sufficient in their long-term self-care to keep or even exceed the gains made during their rehabilitation. Of course, obtaining these positive outcomes also directly relates to increased patient satisfaction. Incorporating a skilled hands-on approach is essential to achieve such expedited and more optimal therapy results. Why? Hands-on tissue mobilization techniques stimulate connective tissue remodeling and breakdown scar tissue and fascial adhesions[1] allowing for a mechanism of more thorough tissue repair and improved pain and range of motion. Research suggests that targeted mobilization of tissue assists with faster healing times[2, 3]. Furthermore, hands-on professional care is essential in providing longer-lasting and more impactful relief from symptoms than stretches or exercises alone[3, 4].

Tools To Aid the Hands Can Be Useful


It is important to note that hands-on techniques do not necessarily refer to hands only, rather oftentimes pairing manual skills with manual tools can lead to even stronger outcomes. Instrumented Assisted Soft Tissue Mobilization (IASTM) is a common intervention with use of ergonomically designed tools to assist with the remodeling of damaged tissue encouraging collagen formation and organization[5]. Tools that aid in trigger point relief, such as knobbers and theracanes, and myofascial releases, such as wedges and belts, help to assist the provider in the application of these hands-on techniques by increasing the power and duration of the release as well as physically alleviating strain on the clinician. The stimulation of tissue turnover allows for regeneration of soft tissues, reduced tissue fibrosis and increased muscle fiber recruitment potential. Oftentimes with STD and MSK impairments comes maladaptive postures, tissue shortening and weakness along with pain and impaired movement patterns that further feed into a negative cycle exacerbating local, regional or systemic symptoms. Not only does a hands-on approach help to expedite treatment outcomes, but also ideally the approach teaches patients how self-mobilization of tissue can further help them advance their treatment outcomes in between therapy visits and after discharge.



Why Is A Hands-On Approach Important?


Even the inclusion of exercises, kinesiology tape, topical agents, and posture retraining to name a few, initially benefit from hands-on training by the expert to ensure that proper technique and understanding is gained by the learners. So, if research supports tissue mobilization with expedited and more impactful patient-reported outcomes, why are hands-on approaches not consistently utilized in the clinic? The most common concerns for using hands-on approaches are patient dependency and disempowerment utilizing a patient-passive intervention. Alleviating such concerns is done by consistently empowering the patient on his/her personal role and giving the patient control over the techniques s/he can immediately start to implement in between rehab visits. This further reinforces the patient’s transition to becoming independent with self-management from the start of care while also promoting the clinician to continuously tailor the patient’s home program and hands-on approach at every visit. A win-win-win situation since the third-party payor is also interested in reduced therapy visits and fewer future medical care needs.

Additionally, quality therapy sessions consist of skilled techniques that a patient could not otherwise do at home. This enhances the patients’ perceived value of the care being provided, yet should not detract from empowering the patients toward their own independent self-care. Hands-on tissue mobilization is done and reinforced in such a way during clinic visits to expedite patient goals and support their self-management strategies.

Negative Pressure Adding Value to Tissue Mobilization


There are a variety of tools to aid the hands when mobilizing tissue, some of which are previously mentioned. Tools can provide physical assistance and protect the therapist’s own body from repetitive trauma as well as some can provide what is not possible with physical touch alone such as through negative pressure. Cupping is a common example of negative pressure, though the intensity of pull exerted on the tissue is not easily controlled and less ideal for hypersensitive areas or tissue where bruising and swelling may result in greater harm than good. Alternatively, graded negative pressure through devices like LymphaTouch® provide an opportunity for therapists to control the amount of pull on the superficial tissues to achieve tissue stretches and mobilization in an opposite direction than what is possible from hands or tools that are used to apply a downward pressure on the tissue. Why can this add value to tissue mobilization?



With tissue mobilization, it is most ideal to assist with a 3D mobilization of tissue remodeling to minimize adhesions in all potential directions and repair the tissue toward its pre-injured state permitting ease of movement in all directions. Use of graded negative pressure essentially mobilizes the upper half of the sphere of movement while manual techniques utilizing downward pressure on the tissue assists with the lower half of the sphere of tissue movement. In both situations, the clinician can add to the tissue mobilization through rotational and diagonal movement techniques. An additional feature when using graded negative pressure is the ability for the therapist to document the quantified amount of tissue pull tolerated by the patient from 20-250mmHg. For example, a patient with chronic knee pain following a total knee replacement may initially only tolerate graded negative pressure tissue mobilization of 50-60mmHg, but following a few minutes of treatment, that same tissue location may begin to tolerate 70mmHg and then progress to a pull of 150mmHg within 1 to 2 visits. This provides objective documentation of the tolerable changes occurring for the patient in the mobilization of the tissue. Simultaneously, the patients oftentimes experience increased joint movement and reduced pain or tenderness to touch.

Using graded pressure allows the clinician to reduce the intensity of the pull on the tissue to stay within the patient’s tolerance to treatment. The device also has the feature of adjusting the working and resting phase from 0.5 to 5seconds. During the resting phase, the therapist can continuously adjust the exact location of treatment further ensuring no trauma to the tissue. Graded negative pressure application is easy to use and intuitive using touchscreen features to adjust compression and length of work and rest phases. Four treatment head sizes allow for convenient fit from smaller body regions (i.e. hands, feet, and angulations of face) to larger body sizes of the back and thigh. The key is to use the largest treatment head size possible while still obtaining full skin contact for adequate suction

A subtler technique to achieve a slight tissue stretch away from the body is through the application of kinesiology tape, a complementary modality to many MSK treatments. Though kinesiology tape does not provide an opportunity for intense tissue mobilization, it works continuously while in place and is a good adjunctive support to tissue mobilization for patients who are not allergic or contraindicated to the use of the adhesive.



Variety of Patient Populations Benefitting From Complete Tissue Mobilization


There are a variety of patient populations benefiting from complete tissue mobilization that use hands-on techniques for 3D tissue mobilization to address soft tissue dysfunction. Such patients are those who have degenerative tissue impairments like degenerative tendinopathy. Additionally, tissue mobilization is essential for those with a build-up of scar tissue from surgeries, acute or chronic trauma, or even overuse injuries resulting in repetitive microtrauma. For example, the understanding of scar mobilization is well known by therapists who treat patients with chronic pain as the intensity and severity of scar adhesions can be quite devastating to patients. Most commonly, scars that cross joint lines are well understood to impact the joint’s range of motion such as with total knee replacement, Achilles tendon repair and shoulder arthroplasty. It is also important to utilize 3D tissue mobilization over non-joint scars including abdominal procedures given the impact the scar adhesions have on breathing, posture, torso mobility and internal organ functionality. Tissue remodeling and repair of damaged collagenous tissues are essential to also reduce nerve impingement and restore neurodynamics such as with carpal tunnel or lateral epicondylitis repairs. To recover shorted tissue and impaired muscle functioning, tissue mobilization is necessary to correct muscle and tendon injuries such as hamstring tendon repair and plantar fasciitis. Furthermore, cancer surgeries involving radiation and lymph node removal frequently leave patients with chronic pain and impaired joint movement where unfortunately these patients are told too often to embrace their new norms. Cording associated with the disruption of the lymphatic system, such as axillary cording following axillary lymph node removal, is frequently left undertreated with simple arm stretches and postural correction. However, proper and thorough tissue mobilization can make life altering improvements to the pain and movement gained by the patient who would otherwise be left with chronic pain managed by pain medications and the encouragement to move through the restrictions. Even if movement alone could eventually resolve the symptoms, it seems most beneficial to patients to recover as quickly as possible especially before compensatory postures and movements set-in that will result in further movement dysfunctions.

About the Author



Paula Donahue, PT, DPT, MBA, CLT-LANA

Physical Therapist, Vanderbilt Dayani Center for Health and Wellness

Assistant Professor, Department of Physical Medicine and Rehabilitation

Vanderbilt University Medical Center

paula.m.donahue@vumc.org

Paula Donahue works as a physical therapist at the Vanderbilt Dayani Center for Health and Wellness, and has been a physical therapist since 2000 with experience in acute, outpatient and home care therapy. She is also an Assistant Professor in the Department of Physical Medicine and Rehabilitation at Vanderbilt University Medical Center. She received her training at Duke University (BS), Northwestern University Physical Therapy and Human Movement Sciences (DPT), The Johns Hopkins Carey Business School (MBA), and The Academy of Lymphatic Studies (CLT). She has administrative and clinical experience primarily addressing orthopedic, neurologic and oncologic conditions and has specialized training in lymphedema and lipedema management. She enjoys helping people achieve their physical goals and maintain healthy lifestyles to ultimately improve their abilities and quality of life.


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