SOFT TISSUE MANIPULATION

Dr. Hiral Pandya

DEFINITION
Any technique be it manual or mechanical, which
imparts mechanical energy to soft tissue of the body
through the skin without producing any change in the
position of the joint, in order to elicit certain
physiological and psychological effect which can be
utilized for therapeutic, restorative or preventive purposes
either on a sick or healthy individual.
CLASSIFICATION
Massage is classified based on :-
⚫ Character of Techniques

⚫ Depth of tissue approached

⚫ Part of body massaged

⚫ Means of application of pressure

⚫ Character of Techniques –

⚫ Stroking

⚫ Pressure

⚫ Percussion / Tapotment

⚫ Vibration
• Depth of Tissue Approached –

– Light Massage
– Deep Massage

• Part of Body Massaged –

– General massage
– Local massage

• Means of Application Of Pressure –

– Manual Massage
– Mechanical Massage
Stroking Technique :-
⚫ Superficial Stroking
⚫ Deep Stroking / Effleurage

This technique consists of linear movement of relaxed

hand along whole length of segment which cover one
aspect of the segment at a time. It is repeated in a
rhythmical way.
Superficial Stroking – Rhythmical linear movement of
hand over skin in either direction i.e. Proximal to Distal or
Distal to Proximal without any pressure.

Effleurage – Linear movement of hand over skin in

direction of venous or lymphatic flow with moderate
pressure.
Pressure Technique :-
In this technique, the hand of therapist and skin of the
patient move together as a one and deep localized pressure
is applied.

Subdivided into –
⚫ Kneading

⚫ Petrissage

⚫ Friction
Kneading –
In this technique, the tissue are pressed down to
underlying structures in circular direction and parallel to
long axis of bone.

The contact between therapist’s hand and patient’s skin is

never interrupted.

Different techniques in this groups –

⚫ Digital Kneading
⚫ Palmar Kneading
⚫ Reinforced Kneading / Ironing
Petrissage :-
In this technique, the tissues are grasped and lifted away
from underlying structures and pressure is applied to
tissue in the direction that is perpendicular to long axis of
bone.

Different techniques in this group –

⚫ Picking up
⚫ Wringing
⚫ Skin Rolling
Friction :-
In this technique, tissue are subjected to small range of to
and fro movement performed with constant deep pressure
of finger or thumb.

Different techniques of this group are –

⚫ Circular friction
⚫ Transverse friction
Vibratory Techniques :-
In this technique, Mechanical energy is transmitted to the
body by vibrations of distal part of upper limb i.e. hand
and/or fingers. They are in constant contact with patient’s
skin using body weight and co-contraction of upper limb
muscles.

Different techniques in this group are –

⚫ Vibration
⚫ Shaking
Percussion / Tapotment techniques :-
In this technique, soft, gentle blows are applied over the
body, which produce characteristic sound. The hands are
not in constant contact with the skin and strike the body
part at regular intervals.

Different techniques in this group are –

⚫ Clapping
⚫ Hacking
⚫ Beating
⚫ Tapping
⚫ Pounding
BASED ON DEPTH OF TISSUE APPROACHED –

Light Massage :- Force applied during the maneuver are

light, so effect of massage is only to superficial tissue. E.g.
Stroking, Tapping, etc.

Deep Massage :- Force applied during the maneuver are

deep, so effect of massage is upto deep tissue. E.g.
Friction, Kneading , etc.
BASED ON THE PART MASSAGED –

General massage:- Massage applied to whole body. E.g.

In persons following prolonged recumbency and athletes
after exhaustive physical work.

Local Massage :- Massage applied in a particular area of

the body segment. E.g. Friction over ankle after sprain.
BASED ON MEANS OF ADMINISTRATION OF
TECHNIQUE –

Manual Massage :- Massage applied by hand or any other

body part of the therapist is called manual massage. E.g.
Techniques of massage, etc.

Mechanical Massage :- When mechanical devices

administer mechanical energy to the patient’s body, to
manipulate soft tissues is mechanical massage. E.g.
Vibration, etc
PHYSIOLOGICAL EFFECTS
The magnitude, duration and the direction of application of
a particular technique determines the effects produced by
the technique on the body.
Effects on Circulatory system
⚫ On venous and lymphatic flow
⚫ On arterial flow
⚫ Effects on Blood
⚫ Effects on the exchange of nutritive elements
⚫ Effects on Nervous system

⚫ On sensory nervous system

⚫ On motor nervous system

⚫ On autonomic nervous system

⚫ Effects on Mobility of soft tissues

⚫ Effects on Respiratory system

⚫ Effects on Skin

⚫ Psychological effects
Effects on Circulatory System
Effects on Circulatory System
▣ On venous and lymphatic flow :-
Massage facilitates forward movement of venous
blood and lymph. This reduces chances of stagnation of
the blood and the lymph in the tissue space.

The flow of venous and lymphatic channels from

extremities depends on the activity of the smooth
muscles present in the walls of the vessels.
 The contraction of these
muscles along with valves
present in the vessels acts
as a strong pumping action
which keeps tissue space
clear.
 Contraction of skeletal muscles

Compresses blood vessels and exerts pressure on

the fluid inside

Stimulates contraction of smooth muscles present

in walls of vessels

Further increases pressure inside the vessels

Valves open up and fluid moves onto the next segments

Valves provide only unidirectional flow so the fluid
cannot come back to the empty segments.
When the muscles relax, the segment is refilled by the
fluid from the distal segments.
So, this way, venous and lymphatic fluids are allowed to
move only in one direction.
The mechanical effect of massage resembles with normal
muscular contraction. So, it drains blood and lymph
from the massaged segment / part.
⚫ On Arterial Flow :-
Massage improves the blood supply of the area being
treated.
Due to –
⚫ Release of Vasodilators

⚫ Activation of Axon Reflex

⚫ Decrease of venous congestion

Effects on Blood
⚫ Increases RBCs and Haemoglobin.

⚫ Increases Platelet count.

⚫ Increases Neutrophil count.

Effects on Exchange of Metabolites
Massage promotes rapid disposal of waste products
and the replenishment of the nutritive elements.
Effects on the Nervous System
⚫ Sensory System :-
Massage has a sedative effect on CNS if applied
monotonously and with slow rhythm.
Massage helps in relieving pain by stimulating sensory
receptors such as of touch and pressure which is
carried by Aβ fibers, which play an important role in
inhibition of perception of pain which are carried by
Aδ and C fibers.
 The stimulation of low threshold
mechanoreceptor blocks the pathway of
pain sensation by presynaptic inhibition at
the level of substansia gelatinosa of spinal
cord. So by this mechanism light massage
could reduce pain.
Some massage manoeuvers also facilitate
secreation of anti pain substances such as
β endorphin and enchephalin at level of
midbrain. These substances descend down
to dorsal horn of spinal cord and suppress
release of substance P. thus it blocks
transmission of pain.
 This effect is otherwise known as counter-irritant
effect. So this may be one of the mechanism by which
heavy pressure massage such as kneading, friction, etc
relieves pain.
⚫ Motor System :-
Facilitatory effects of Massage :-
Massage can facilitate muscle by stimulation of skin
receptor or stretch to muscle spindle. Superficial stroking,
Taping, Hacking , etc are used for these purpose.

Muscle spindle contains intrafusal fibers supplied by

gamma motoneurons and extrafusal fibers supplied by
alpha motoneurons.

Any stretch to muscle spindle activates gamma

motoneuron and activates reflex arc.
 The impulse travel via afferent nerve fibers and
propagates toward spinal cord. Some impulses are
monosynaptically transmitted to alpha motoneuron of the
same muscle. The activation of alpha motoneuron causes
contraction of extrafusal fibers.
Inhibitory Effects of Massage :-
It is said that massage can exert inhibitory effect on
motoneuron. It is due to activation of Golgi Tendon
Organ, which has a inhibitory effect on stretch
mechanism.

Various massage maneouvers such as petrissage,

kneading , etc could be used for it.
⚫ Autonomic Nervous System :-
Massage increases skin temperature, activates sweat
glands and increases skin conductance.
Effects on Soft Tissues
Massage maintains and restores the mobility of soft
tissues.

It prevents adhesion formation, joint stiffness,

contracture, etc.
Effect on Respiratory System
Percussion and Vibration techniques of massage assist in
removal of secretion from larger airways.
 Effects on Skin

⚫ Massage improves nutritive status of skin.

⚫ It makes skin soft and supple.

⚫ The dead cells are removed after constant contact of

hand with skin.

⚫ The sweat gland, hair follicles and sebaceous glands

function more effectively after massage.
⚫ By activating sweat glands there is increase in perspiration
so heat dissipation is increased.

⚫ It also facilitates sebaceous secretions from glands of skin

and thus improves lubrication and appearance of skin.
Psychological Effects
⚫ Decreases Anxiety and Tension
⚫ Induces Relaxation
THERAPEUTIC USES
⚫ To improve mobility of the soft tissues.
⚫ To reduce muscle spasm and pain under abnormal
conditions.
⚫ To reduce oedema.
⚫ To increase circulation.
⚫ To mobilize secretions in the lungs.
⚫ To induce local and general relaxation.
▣ Mobility of Soft Tissues :-
The skin, fat, fascia, muscles and ligaments are the
soft tissues of the body.

Any inflammation or injury to these structures leads

to adhesion formation which decreases their mobility
and causes pain.

After inflammation, the new granulation tissue form

during process of healing is usually edematous.(due to
presence of protein rich fluid which leaks into the tissue
space from the capillaries) Oedema is in soft tissues
persists long after inflammatory process is over.
 It consolidates and binds the newly laid collagen
fibers to each other and to surrounding structures. This
causes adhesion formation, extensive scarring, soft tissue
tightness and contracture.;which causes pain and
disfunction.
The to and fro movement of massage mechanically
breaks down the adhesion and facilitates free movement of
adherent structures.
It increases scar mobility.
⚫ Tendinitis
⚫ Tenosynovitis
⚫ Fibrositis
⚫ Muscular injury
⚫ Ligament sprain
⚫ Post surgical scar
⚫ Post burns contracture
⚫ Pre and post operative cases of plastic surgery
▣ Muscle Spasm and Pain :-
Spasm is a protective mechanism which prevent
further injury by restricting the movement. It is
associated with pain.

In presence of spasm there occurs capillary

constriction which reduces blood flow to that part. It
results in limitation of flow of nutrients and oxygen to
the area and accumulation of waste products.

This further results in pain. Thus a vicous cycle is

established i.e pain – spasm – pain [Link] vicious
cycle can be broken by massage
 Pain is reduced following massage by
⚫ Stimulation of Aβ fibers thus blocking the pain.
⚫ Stretches individual fibers of soft tissues and thus reduces
the tension.
⚫ Removal of metabolic waste products.
⚫ Increased blood flow to the part.
⚫ Reduction of Oedema :-
Oedema is accumulation of tissue fluid in extracellular
space.
Massage reduces oedema by mechanical effect of
forcing the fluid into the drainage channels.
When oedema is due to muscle inactivity, valve
insufficiency, lymph node blockage various massage
techniques are used to reduce oedema.
⚫ Enhancement of Circulation :-
Massage causes vasodilatation and thus increases
temperature of the part being treated. So it can be used in
case of cold extremity.
Maintains the trophic conditions of paralysed part
utilizing circulatory effects of massage.
Massage can be used when body part cannot be
moved by several reasons such as severe exhaustion
following intense work, prolonged recumbency,
paralysis.
 It uses the pumping mechanism in these cases it
improves lymphatic and venous drainage. Also reduces
stagnation.
The improved arterial circulation is helpful in
exchange of nutritive elements into paralysed parts. Thus,
nourishment is provided.
The increased circulation is also helpful in sports
such as preactivity massage brings more blood and oxygen
to massaged part and warms up the muscles. Postactivity
massage helps in removal of waste products thus
preventing muscle soreness.
▣ Mobilize secretions in Lungs :-
Various massage techniques could be used in cases of
respiratory disorders. In these diseases, there are
increased and vicid secretions which accumulates,
stagnates, dries up and block the small respiratory
pathways.

The gas exchange of the part distal to block becomes

restricted and gradually the segment of lung collapses .

Similarly, there is increased sputum production after

operation of cardiothoracic or abdominal region.
 Massage transmits the mechanical energy to the lung
tissue through the chest walls which leads to loosening up
of viscid secretions and moves it up in bronchial tree.
drainage of sputum is facilitated by postural
drainage then removed by coughing.
⚫ General and Local Relaxation :-

Massage is helpful in reducing tension and anxiety.

Massage enhances feeling of well being and relaxation.

CONTRAINDICATIONS
GENERAL CONTRAINDICATIONS :-
⚫ High Fever
⚫ Severe renal and cardiac disease
⚫ Deep X-ray therapy
⚫ Osteoporosis
⚫ Severe Spasticity
⚫ Very hairy skin
⚫ Patient’s Preference
LOCAL CONTRAINDICATION :-
⚫ Acute inflammation
⚫ Skin Diseases
⚫ Recent Fractures
⚫ Severe Varicose Veins
⚫ Atherosclerosis
⚫ Thrombosis
⚫ Myositis Ossificans
⚫ Malignancy
⚫ Open Wound
GENERAL CONTRAINDICATIONS :-
Fever –
Fever is generalised rise in body temperature. There is
increase rate of all metabolic functions.
The application of massage in presence of fever should
be judged properly and if at all administered should be
done carefully so that it does not compromise tissue
function.
⚫ Severe Renal and Cardiac Diseases –
In renal and cardiac conditions, there is presence of
oedema but the cause for it is different so massage is not
helpful.
Many patients may also suffer from thrombosis,
artherrosclerosis, etc. where massage cannot be applied as
it may be fatal.
Many positions are not suitable for these patients
such as prone lying, etc.
⚫ Osteoporosis –
Osteoporosis is a bone disease where there is decrease in
bone density.

Bone becomes weak and fragile. So may not tolerate

pressure of forces applied. Even if applied it may lead to
fractures.

So massage must be applied very cautiously in case of

osteoporosis.
⚫ Severe Spasticity –
Spasticity is abnormal increase in tone of muscles due to
upper motor neuron lesion. Massage should not be given
in this conditions.

Muscle tone is maintained by muscle spindle. In upper

motor neuron lesion, activity is increased and therefore the
threshold of intrafusal fibers to stretch is decreased. So
even a minimal amount of stretch may activates the reflex.

As massage increases the tone of muscles it should not

be used in cases of spasticity.
⚫ Very Hairy Skin:
Rubbing the hairy skin,especially opposite to the
direction of the hair follicle,is painful.
Usually massage is not apply to a very hairy
skin,either it can be shaved off or heavy oil lubrication of
the area prior to massage can reduce the chance of hair
pulling.
⚫ Patients Preference –
If patient is not willing to take massage don’t apply it.
 LOCAL CONTRAINDICATIONS :-
Acute Inflammation –
❑ Massage increases vascular changes taking place during
inflammatory [Link] blood flow &
vasodilatation

❑ Granulation tissue (formed 48 to 72 hours after injury) has

a very delicate blood supply which can easily be damaged
by movements of massage. This interferes with repair
process and delays healing.
⚫ Skin Diseases –
Because infection can spread to other part, therapist can
get cross infection, massage may be painful to patient.
⚫ Recent Fractures –
Massage should not be given as it disturbs the healing
process. Massage may disturb the organisation of callus
formation. Even it is painful if massage is applied in initial
stages of fracture.
It can be applied to area proximal to fracture site but
not over the fracture site.
⚫ Varicose Veins –
In this condition veins become dilated. It results in
venous congestion and walls of vein becomes thin. So
massage to that part may lead to haemorrhage in that part.
⚫ Thrombosis and Arteriosclerosis –
This condition is characterised by formation of fatty
plaque in arterial lumen. Massage should not be given in
such cases as it may dislodge and block the circulation of
vital organs.
⚫ Myositis Ossificans –
In this condition there is callus formation in soft tissues.
Joint capsule and periosteum is stripped from bone with
violent trauma. Blood collects under stripped soft tissue
forming haematoma. This haematoma is invaded by
osteoblasts and become ossified. This gives pain and
limitation of movement.
Further stretching of soft tissues may increase
bleeding and exaggerate the condition. E.g. elbow joint
⚫ Malignancy –
Metastasis(spread of tumour cells from one area to the
other)is the essential feature of all malignant tumours.
Tumor cells through lymphatic and blood pathway spread to
other areas. So massage should not be used in such cases.
⚫ Open wound –
Massage if applied over open wound would cause more
pain and further damage healing tissues.
Practical Aspects Of Massage
⚫ Positioning
⚫ Drapping
⚫ Stance of Therapist
⚫ Attitude of Therapist
⚫ Appearance of Therapist
⚫ Contact and Continuity
⚫ Selection of Technique
⚫ Lubricant
⚫ Accessories
Positioning
The aim of positioning are –

⚫ The part to be treated should be fully supported to ensure

relaxation and gain confidence of patient.

⚫ The body part should be easily approachable to the

therapist for proper administration of techniques.

⚫ It should not hamper the continuity of techniques.

 Following are the positions used –
⚫ Prone Lying :- For back and Posterior aspect of lower
limb.

⚫ Supine Lying :- For anterior aspect of lower limb, upper

limb and face.

⚫ Half Lying :- For upper limb, lower limb and chest.

⚫ Side Lying :- For upper limb, lower limb and chest.

⚫ Sitting :- For Upper limb, upper back and chest.

 Prone Lying –
▣ Pillows are placed for positioning.
▣ One pillow under abdomen to flatten back and to
relax extensor muscles of spine.

▣ Pillows under lower legs to support lower legs

and to maintain knee in flexion. To reduce pressure over
anterior aspect of ankle and to keep toes free.

▣ Pillow under crossed hands of patients at forehead

to support neck in neutral position, minimize tension on
posterior neck muscles and to facilitate easy breathing.
This position is no used in patients with cardiac or
respiratory diseases.
 Supine Lying –
Pillows are placed under the knees to keep hip and knee
slightly flexed to relieve tension on hamstrings, rectus
femoris and iliofemoral ligament. To tilt pelvis posteriorly
to avoid back hollowing and relax back extensors.

A small pillow under neck to support cervical lordosis,

maintain neck in neutral position and relax muscles
around neck.
This position may be unsuitable for patients suffering from
respiratory and cardiac disorders.
Half Lying –
Position is suitable for elderly, cardiac and respiratory
patients as breathing becomes easier.

In this position trunk is about 45º angle in relation to

lower limbs with pillows under both knees.
Side Lying –
Pillow under head to maintain alignment of neck in neutral
position.

2-3 pillows under uppermost lower limb ; one under thigh

and two under legs to completely support hip in line with
trunk.
Sitting –
For upper limb massage, limb has to be placed on plinth
on prearranged pillows to maintain 90º of flexion and
abduction at shoulder with elbow extended and wrist and
fingers supported.

For massage of upper back or posterior aspect of neck,

patient sits with facing plinth and supporting forehead by
crossing hands on plinth or pillows on the plinth.
Drapping
The part to be massaged must be fully exposed so that
therapist can look the part and rule out the
contraindications. Also any adverse effects during
manipulation can be noticed.
For Back –
Exposed part is from occiput to PSIS.
Drapped part is lower limbs and upper limbs.
For Lower limb –
Exposed part is from toe to groin.
Drapped part is contralateral lower limb and trunk.
For Upper Limb –
Exposed part is Tip of finger upto axilla.
Drapped part is Contralateral upper limb and trunk.
Stance of Therapist
The therapist should adopt the position which can provide –
⚫ Wide base to ensure proper stability during manipulation.
⚫ Free body movement to have rhythm and continuity of
massage
⚫ Effective used of body weight while applying pressure.

Flexion attitude of spine during massage strains back and

cause discomfort so should be avoided.
Following are the positions of therapists –
⚫ Stride standing
⚫ Walk standing
⚫ Fall – out standing
Attitude of Therapist
⚫ Therapist should be completely relaxed.

⚫ His/her manners should be pleasant and courteous.

⚫ He/she should be confident.

⚫ Should give instruction to the patient in an effective

manner.
⚫ His/her voice should be clear, low pitched and soothing.

⚫ He/she should avoid conversations and discussions during

the session.

⚫ Instructions should be given in the language that is

understood by the patient.

⚫ Instructions should be simple, short and self explanatory.

Appearance of Patient
⚫ Nails of therapists should be short and clean.

⚫ Therapist should remove all rings, bangles, watches, etc.

⚫ Hairs of therapist should be short or properly arranged.

⚫ Sleeves of apron should be half or folded upto the arm.

⚫ Hands should be washed and dried up before and after
application of massage.

⚫ Therapists should not touch patient’s skin with cold hands.

Contact and Continuity

Selection of Technique
Lubricants
Purpose of using lubricant –
⚫ Makes skin soft and smooth
⚫ Reduce friction between therapist’s hand and patient’s skin

Indications for using lubricant –

⚫ Presence of excessive sweating
⚫ Poor condition of skin

Commonly used lubricants are –

Powder, Oils and Creams.
⚫ Powder is used in presence of profused sweating as it
readily absorbs moisture.

⚫ Oils are helpful when skin is dry and scaly as it provide

smooth gliding.

⚫ Creams such as lanolin or lanolin based creams are used

for mobilisation of scar due to burns or surgical trauma.
Accessories
⚫ Low stool or without arm support chair
⚫ Couch
⚫ Bedsheet
⚫ Towels
⚫ Pillows
⚫ Small kidney tray
⚫ Soap
Flowchart of Massage Treatment
 Prepare the treatment area
Arrange all Accessories
Examine the Patient
Ask the complain
See the medical reports
Rule out general contraindications
Expose the part to be treated
Look for local contraindications

Contraindications No present contraindications

present

Do not administer massage

 No contraindications present

Position the patient

Drape the patient

Select the technique

Administer massage

Terminate the treatment

(Inspect the area and rearrange all
accessories)