August 28,
2008
SOFT TISSUE
MANIPULATION©
A combined
article by Lyn Paul Taylor and Timothy Hui
(Editing Assistant
and Computer Consultant: Joanna Soon, B.S.)
SOFT TISSUE
MANIPULATION
Lyn Paul Taylor,
A.A., B.A., M.A., R.P.T.
Adhesions
generally form as a result of the body's nonspecific attempt to
heal a soft tissue injury with a prolonged inflammation process.
When soft tissues are exposed to the “burning” effects of prostaglandins
(an integral part of the inflammation process) for too long, the body
floods the area with collagen, in the form
or collagen fibrils, to “heal the burn” by forming a scar matrix.
Since there is no real burn to heal and no scar matrix to form, the
little collagen fibrils start “sticking” tissue layers together
instead (a process sometimes termed fibrosis). This becomes a
problem because the tissue layers that are supposed to be able to slide
past one another and no longer can. The tissues then “pull”
against one another causing further stress and pain, extending and possibly
spreading the inflammation process.
Indeed, this
is the source of most of the chronic painful conditions seen in the
physical medicine, orthopedic, chiropractic,
and rheumatological fields. These conditions become chronic because
most are unaware of the existence of the adhesion problem and, quite
understandably, fail to effectively treat the condition. These
fields continue to successfully treat many of the attending symptoms,
often providing temporary relief (especially with pain), but until the
adhesions are broken, no real “cure” will be produced. This
makes soft tissue manipulation a valuable technique. Once adhesions
are broken the tissues have a chance to return to normal, especially
if the inflammation process has also been simultaneously relieved, thus
preventing the reformation of the adhesions and ending the vicious cycle.
Soft
tissue manipulation is defined as
the manual manipulation of the soft tissues of the body for the purposes
of breaking adhesions.
There are two
basic types of adhesion breaking techniques:
- Probing and shearing
- Rolling
In
the first technique an intense deeply probing pressure
should be used. The point of contact varies in width, depending
on which fingers are used and how many. The probing
is performed by forcefully inserting the finger or fingers into the
patient's subsurface tissues and then “shoveling” with the fingertips,
creating a shearing force that will break the adhesions
by separating the tissues from one another.
This
technique is often painful because of the high degree of pressure required
to break the adhesion formations, and because
the manipulated tissues have generally been sensitized by the inflammation
process (an effect of the bradykinins). To minimize the pain,
somewhat, pressures should be increased gradually and contact with the
skin's surface should be kept as broad as possible.
Rolling,
the second technique, involves lifting the tissues between the fingertips
and thumb, forming a dome of tissue. The dome should then be rolled
between the thumb and fingers forcing the dome to a point or ridge,
thereby producing a subdermal shearing force sufficient to break the
adhesions. Initially, the shearing force is exerted one to three
cm. below the apex of the tissue-roll dome and travels toward the apex
of the dome as it is minimized. When successfully applied, the
practitioner should feel a “popping” or “crunching” sensation
with the fingertips as the adhesions break.
Sometimes the “popping” or “crunching” may actually be audible
and quite loud (these effects also occur when the probing technique is utilized).
These techniques must be adapted and modified
as the types of tissues vary.
Fingertip “probing”
to break adhesions within the
Carpal Tunnel using the Probing and Shearing Technique
Adhesions,
which form within the larger structure of the musculature, exist between
the fascial layers surrounding each muscle fiber bundle. These
adhesions interfere with the natural expansion
of the muscle as it contracts, sometimes prohibiting full contraction
and producing pain. The focus of treatment should be on separating
the fascial layers surrounding the involved muscles. This is accomplished
by inserting the fingers between the muscle bundles (as much as is feasible)
and using deep transverse friction to broaden the muscle and force the
muscle bundles apart, thus allowing free movement of individual muscle
bundles.
Ligaments
typically link two bones and allow hinged motion of the joint they cross.
Therefore, they too possess a range of motion over the bone at right
angles to the long axis. This range of motion may be lost if posttraumatic
adhesions have formed. To regain this
motion, the ligaments should be manually moved over the involved bone
or joint, both following the pathway of its normal movement and at right
angles to it. Likewise, the skin over the ligament must be probed,
and any adhesions broken, to restore normal motion and eliminate the
pain common to this condition.
Superficial
adhesions occurring between the skin, muscle
and tendon layers and are associated with prolonged inflammation
of deeper tissues. They may be found by lifting the skin in a broad
pinch. When pinched, the skin over the adhesion site will be difficult
to pick up and separate from underlying muscle layers.
Rolling
to break sub dermal adhesions in the forearm as a
partial treatment of Tennis Elbow
Likewise,
when a broad pinch is finally achieved, the affected skin is generally
thickened and will produce a snapping or crinkling sensation under the
manipulating fingertips when rolled. It should be noted that abnormal
thickening of the skin may exist simply as a collagen build up, without
appreciable adhesion to other structures, as in the “dowager hump.”
These conditions can be successfully treated with soft tissue manipulation
and greatly reduced, especially in combination with ultrasound, at the
appropriate amplitude.
In
areas that are normally difficult to "pinch", especially over
the backbone, shin, foot and palm of the hand, a technique similar to
that used for fascial adhesions between muscle bundles, described above,
should be used (refer to Soft Tissue Manipulation in Tight Areas).
Simply
lifting the dermal layers in a broad pinch and rolling the tissues between
the fingers until free from the muscle layers or well softened may relieve
most superficial adhesions. This procedure
should continue until the snapping and crinkling has disappeared.
It may be initially painful, but the pain lessens as the adhesions break
up. It should be noted that some adhesions between the skin and
muscle layers may be so well developed that they will not break. In
such cases, one must resort to stretching to restore some mobility.
Tendons
that may be affected by adhesions are most
commonly (though not always) those that have synovial sheaths associated
with them. When an adhesion forms, it is usually said to be between
the inner surface of the synovial sheath
and the tendon itself, inhibiting the free movement of the tendon and
possibly creating a considerable amount of pain. Such adhesion
formations are generally thought to occur
as a result of tenosynovitis (inflammation of the synovial sheath).
Putting
the tendon on stretch creates an immobile base against which the fingers
can move the tendon sheath. This may
be useful for relieving tendinous adhesions. The tendon should
be massaged by rolling the tendon sheath back and forth transversely
against the tendon; this serves to smooth the gliding surfaces.
To manipulate areas without a synovial sheath, a back and forth transverse
deep tissue friction should be applied to the tendon with sufficient
force to move the tendon across its bony pathway. Relief of tendon
adhesions can (in many cases) generate almost immediate pain relief
and restoration of function.
Precautions:
Soft
tissue manipulation is contraindicated over
the site of acute phlebitis, thrombophlebitis,
or phlebothrombosis. Soft tissue manipulation over such a site may cause
the dislodgment of a blood clot or embolus,
which may proceed to lodge in various organs, including the lungs, arteries
of the heart, or brain, causing ischemia or infarction.
Soft
tissue manipulation is also contraindicated
for patients suffering from acute inflammatory diseases of the skin
or other soft tissues, including joints or surface layers of the bone.
Such conditions may be complicated or exacerbated by soft tissue manipulation.
Skin suffering from furuncles, ulcerations,
or open wounds should not be manipulated.
Finally,
soft tissue manipulation is contraindicated
over areas of soft tissue calcification,
traumatic arthritis of knee, or over joints that suffer from infective
arthritis.
SOFT TISSUE
MANIPULATION IN TIGHT AREAS
Timothy Hui,
B.S., D.C.
As stated earlier, soft tissue manipulation
is defined as the manual manipulation of the soft tissues of the body
for therapeutic purposes. For most areas in the body, the techniques
described above are effective. However, their usefulness is greatest
in large open soft tissue areas, and diminished in areas restricted
by bones and joints, such as between vertebral transverse processes,
around the AC joint, and in the joints of
the elbow. Therefore, to break adhesions
in these tight areas, a modification of techniques must be applied.
The
key is to use the probing and shearing technique
directly within the bony groove while holding the soft tissues in tension.
However, getting the tissues into the correct tension can be a bit tricky,
since tension must be maintained in all three dimensions.
Technique
First, lay your finger (in this case
the middle finger) near the area to be manipulated (in this case the
radial channel). Press down to gain superior to inferior (S-I)
tissue slack. Note that the starting point is actually away from
the radial channel.
Next,
holding the S-I tissue slack, move your finger medially to gain medial
to lateral tissue slack (M-L)
Then move your
finger distal to proximal to gain tissue slack perpendicular to your
first movement.
Next,
I have found that by rotating your finger, you can both add tension
along the outside of the finger and hold the tension well. (fourth
finger side of the middle finger in the picture below)
Then
finally, after all the tissue slack has been taken, and the finger is
within the area to be manipulated, simply drive proximal to distal along
the area to break adhesions.
Really,
the exact steps taken can be interchanged as long as slack is taken
in all three dimensions like the figure below.
Remember
that once all the slack is taken up, the ending position will be away
from the starting position, so start away from the area to be manipulated.
This technique can be used on any tight bony area. The exact angles
and slack will differ by area, as well as from patient to patient, but
the principle remains the same.
In summary
–
- Take up tissue slack.
- Maintain tension
in all three dimensions.
- A short drive will
break adhesions if tissue slack is maintained.
- Adjust angles to
break adhesions along other planes.
References:
J.V. Basmajian,
Manipulation, Traction and Massage, Williams & Wilkins, Baltimore,
Md., 1985. Pp. 211-280
G.B. Finnerty
and T. Corbitt, Hydrotherapy, Frederick Ungar Publishing
Co., New York, N.Y., 1967.
G.A. Logan
and R.F. Logan, Techniques of Athletic Training, Franklin- Adams
Press, Pasadena, Ca., 1967. Pp. 110-111
F.B. Moor,
S.C. Peterson, E.M. Manwell, M.F. Noble and G. Muech, Manual of Hydrotherapy
and Massage, Pacific Press Publishing Association, Mountain View,
Ca., 1964. Pp. 129-160
B.V. Reed,
J.M. Held, "Effects of Sequential Connective Tissue Massage on
Autonomic Nervous System of Middle-Aged and Elderly Adults,"
Physical Therapy, 68:8, August 1988. Pp. 1231-1234
S.J. Sullivan,
L.R.T. Williams, D.E. Seaborne, M. Morelli, "Effects of Massage
on Alpha Motoneuron Excitability," Physical Therapy, 71:8,
August 1991. Pp. 555-560
F.M. Tappan,
Healing Massage Techniques: Holistic, Classic, and Emerging Methods,
Appleton & Lange, Norwalk, CT, 1988.
J.G. Travell
and D.G. Simons, Myofascial Pain and Dysfunction, The Trigger Point
Manual, Williams & Wilkins, Baltimore, Md., 1983. Pp. 26, 88-89
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