Soft Tissue Mobilization

Bisakha Bajracharya
Definition

A soft tissue mobilization is a form of manual physical therapy that uses hands-on
techniques on your muscles and ligaments to heal scar tissue that sometimes forms after a
soft tissue injury.
• Sustained pressure – pushing directly on the restricted tissue and holding.

• Unlocking spiral – pushing on the restricted tissue in alternating clockwise and

counterclockwise rotating motions.

• Direct oscillations – rhythmic pushing on the restricted tissue

• Perpendicular mobilization – pushing on the myofascial tissue at right angles.

• Parallel mobilization – pushing along the seams of muscles.

• Perpendicular strumming – rhythmic pushing along muscle border, followed by rubber of

top of muscle.

• Friction Massage – pushing across the grain of the muscles, tendons and ligaments.
Massage

• Massage is the scientific mode of curing certain forms of disease by systematic

manipulations. – Murrel

• Massage signifies a group of procedures, which are usually done with hand on
the external tissue of the body in a variety of ways either with a curative,
palliative or hygienic point in view. – Graham
Features

• Technique should apply mechanical force to the soft tissue of the body.

• These forces must not produce any change in the position of the joint.

• The technique must evoke some physiological and/or psychological effect which
serve to achieve the therapeutic, restorative or, the preventive goal.
Effects of Massage
1. Effects on the circulatory system 6. Effects on the mobility of the
• On the venous and the lymphatic flow
soft tissue
• On the arterial flow.
2. Effects on blood
7. Effects on the respiratory system
3. Effects on the exchange of nutritive 8. Effects on the skin
elements
9. Effects on the adipose tissue
4. Effects on metabolism
5. Effects on the nervous system 10. Psychological effects
• On sensory nervous system
11. Effects on immune system.
• On motor nervous system
• On autonomic nervous system.
Therapeutic uses

Massage is used for the following purposes:

• To improve the mobility of the soft tissues

• To reduce muscle spasm and pain

• To reduce oedema

• To increase circulation

• To mobilise secretions in the lung

• To induce local and general relaxations

Contraindication

• General contraindications • Local contraindications

- Acute inflammation
- High fever
- Skin diseases
- Severe renal or cardiac diseases - Recent fractures
- Deep X-ray therapy - Severe varicose veins
- Osteoporosis - Atherosclerosis
- Thrombosis
- Severe spasticity
- Myositis ossificans
- Very hairy skin
- Malignancy
- Patients preference - Open wound
- Poisonous foci
Patient groups where the use of massage should be
performed with caution
• Older people.
• Those with fragile skin.
• Those with circulation disorders of the blood or lymph.
• Those with early stage osteoporosis.
• People recovering from skin infections or bone fractures.
• Children.
• Adults with learning disabilities.
• Adults with physical disabilities not previously described but which may impact
on the quality experience of receiving massage therapy.
Steps of massage
Patient preparation
• For treatment of the upper limb, unclothe from the neck to finger tips and especially
remove all straps.

• For treatment of the lower limb, unclothe from the groin to the toe – remove trousers, do
not pull them up.

• For treatment of the back, unclothe from the head to the buttocks. Pants/briefs can remain
on, but must be pulled down to leave the area above the gluteal cleft exposed.

• For treatment of the neck, unclothe from the head to the level of the lowest point of origin
of trapezius, i.e. 12th thoracic vertebra.

• For treatment of the face, unclothe from the hairline to just below the clavicle.
Positioning of the patient
• Depending upon the age, sex, condition and the part to be treated, patient should be
placed in a suitable and comfortable position. The aim of this positioning is to ensure the
following:

1. The part to be treated should be fully supported to ensure relaxation and to gain the
confidence of patient.

2. The body part should be easily approachable to the therapist so that he does not face
any difficulty in proper administration of the techniques.

3. It should not hamper the continuity of massage.

• 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 lower limb, upper limb and chest.

• Side lying : for upper limb, chest and lower limb.

• Sitting : for upper limb, upper back and face.

Prone lying
Supine lying
Half lying
Side lying
Sitting
• When used for upper limb massage the limb has to be placed on the plinth over
prearranged pillows to maintain about 90° angle of flexion and abduction at shoulder
joint, with elbow extended and wrist and fingers supported. This is the position of the
ease which also elevates the arm so that gravity assists the drainage.
• When used for the posterior aspect of neck and the upper back, the patient should face
the plinth and support is given to the forehead in one of the following way.
i. Placing the forehead over the dorsum of both hands which are crossed and kept over the
plinth.
ii. Placing the forehead on pillows or (rolled towel) placed over the plinth (if the shoulder
mobility is restricted).
• For facial massage, the posterior neck can be supported on the head rest. The face is thus
exposed for the therapist to carry out the procedure
Drapping

• This drapping or covering up of the patient helps.

- to honour the modesty and privacy of the patient

- to keep the patient warm (in winter).

Self preparation
• Nails of therapist should be short and clean, as long nails may scratch the body and
creates discomfort during treatment.

• Therapist should also remove all the rings, bangles, watches, etc. for the similar reason.

• Hair of therapist should be preferably short or it should be properly arranged so that it

does not dangle over the patient’s body and irritate him.

• For the same reason, ornament like necklace, long ear rings, etc. either should be
removed or arranged properly.

• The sleeves of therapist’s apron should be either half or folded upto arms in order to
increase the efficient use of the hand.
• In order to avoid any chance cross infection, the hands should be washed and dried up
before and after massage. If this is done before the patient, it helps to win the
confidence.

• When the climate is cold, therapist’s hands must be warm.

• Therapist should not touch the patient’s skin with cold hands. He should make them
warm by rubbing against each other. This is essential to avoid the unnecessary
stimulation of cold receptors which may produce discomfort and increase the muscle
tension of the patient.

• Therapist should avoid any sort of perfumes as they can have a nauseating effect on
some patients due to allergy.
• The range of movements of all the joints of your forearm and hands should be full. If you
have stiff hands, do a series of stretching exercises aimed at increasing your range of
movement. The most important large range movements are:

- Full abduction/extension of the thumb to give a wide grasp – an octave.

- Full flexion and extension of the wrists or at least 80° of each movement.

- Full pronation and supination of the radioulnar joints.

• Hand exercises

1. Touch the index finger tip of one hand with the index finger tip of the other and at the
same time put your thumbs together. Press fingers and thumbs so they extend backwards.
Do this with middle, ring and little fingers, together with the thumbs as before.

2. Push the fist of one hand between two adjacent fingers of the other hand so that they are
separated into wider abduction. Keep your fingers in the same plane. Repeat for each space.
3. Place your hands together as in prayer and with your thumbs resting on your chest
push your wrists downwards to extend them without separating the heels of your hands.

4. Reverse your hands, placing the backs together and push your elbows downwards thus
flexing your wrists.

5. Place your hands in the prayer position and, keeping them together, turn them down
and up. Try to touch your abdomen and chest alternately at each rotation. When you can
hold with your hands just very slightly separated practice the rotation of your two hands,
not touching, but simultaneously. Next move your two hands alternately so that they
pass one another at mid-point . Observe that the finger tips of each hand will now strike
your abdomen at precisely the same point
• Relaxation

Relaxation of your hands is very important so that you always use your hands in full contact
with your patient, and moulded to the shape of the body you are touching, with awareness
of the tissues and of their state.
• The environment

- The treatment area should be quiet, with discreet colours, well heated and well ventilated
but not draughty. The padded, adjustable treatment couch or chair should have a washable
undercover and towels to cover the areas not being treated. At least two pillows should be
available and a disposable paper sheet should cover both pillows and bedding.
Contact mediums
• Purpose

- Make skin soft and smooth

- Reduce friction between therapists hand and patients skin

- Gain placebo effect

• Indication

- Presence of excessive sweating either with the patient or with the therapist

- Poor condition of the skin. For example dry, rough, scaly and fragile skin
• Powder

Talcum powder. It should be non-perfumed if possible, or baby powder may be selected.

Corn starch BP, which is sterilisable, is a heavy powder which absorbs sweat very readily
and should be used in the presence of profound sweating by either the patient or the
practitioner. Ensure it is not inhaled by the therapist or patient and that the patient is
agreeable to its use.
• Oils

Pure lanolin. This has a ‘drag’ effect on skin due to its thick and heavy texture and is used to
obtain a slight pull on the skin. Lanolin cream which is a water-based cream is used when
less ‘drag’ is required.

• Liquid oils

The most commonly used liquid oil is probably vegetable oil.

Liquid paraffin is sometimes used.

Baby oil may also be used to provide a ‘gliding’ effect and to lubricate the skin.
• Creams

These are commercial preparations using a variety of ingredients.

• Water-based lubricants

The water-based lubricant most commonly used is ung. eucerin. This light cream is used to
give moderate lubrication and, as it absorbs rapidly, is mainly of value as an introduction to
deeper work. Ensure the medium is at skin temperature before use and is put into the
therapist’s palm before transfer to the patient with gentle strokes.
• Soap and water

Soap and hot water, with or without the addition of oil, is used for scaly skins which may
be caused by prolonged immobilization in a cast or by use of some medications which
promote and increase skin healing but which may cause the skin to become dry and scaly.

• Allergic reactions

Some contact mediums can cause mild to severe allergies. Nut and wheat content in a
contact medium is contraindicated totally for patients who have allergies to these
substances. Always check allergic responses of a medium before use
Stance of the therapist
• Wide base to ensure proper stability during manipulations

• Free body movement to have rhythm and maintain the continuity of massage

• Effective use of the body weight to minimise muscle work while applying pressure.

• Generally, the therapists during the practice of massage adopt the following modification
of standing.

- Stride standing

- Walk standing

- Fall-out standing.
Stride standing stance Walk standing stance
Fallout standing stance
Attitude of the therapist
• Therapist should be completely relaxed.

• His/her manners should be pleasant and courteous.

• He/she should be confident and give necessary instructions to the patient in an effective
manner.

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

• As far as possible he/she should avoid conversations/discussions during the session.

• The instructions should be given in language which patient can understand.

• These instructions should be simple short and self-explanatory.

Accessories
• Couch

• Bedsheets

• Towels

• Pillows

• Small kidney tray or bowl

• Soap

• Water tap

• Low stool
Classification of massage

BASIS OF CLASSIFICATION OF MASSAGE

ON THE BASIS OF CHARACTER OF TECHNIQUES
Stroking manipulations
• The technique of this group consists of linear movements of relaxed hand along the whole
length of segment known as “Strokes”, which usually cover one aspect of the entire
segment of the body at a time. An even pressure is applied throughout the strokes, which
are repeated in rhythmical way. According to the amount and direction of applied pressure,
it is divided into two techniques.

1. Superficial stroking: It is the rhythmical linear movement of hand or a part thereof over
the skin in either direction, i.e. proximal to distal or vice versa, without any pressure.

2. Deep stroking or Effleurage: It is the linear movement of hand, over the external surface of
body in the direction of venous and lymphatic drainage, with moderate pressure.
Pressure manipulations

• In this group of techniques, the hand of the therapist and skin of the patient move together as
one and fairly deep localised pressure is applied to the body. The techniques are directed
towards the deeper tissue. The aim is to achieve the maximal mechanical movement of different
fibres with the application of that maximum pressure, which a patient/subject can tolerate
comfortably.

• 3 major subgroups

- Kneading

- Petrissage

- Friction
• Kneading: In this group of techniques, the tissues are pressed down on to the underlying- firm-

structure and intermittent pressure is applied in circular direction, parallel to the long axis of bone.

The applied pressure increases and decreases in a gradual manner but the contact of the therapist’s

hand(s) with the patients body is never interrupted. Different techniques of this group are:

— Digital kneading: Pressure is applied with the fingers (finger kneading) or thumb (thumb

kneading).

— Palmar kneading: Pressure is applied with the palm.

— Reinforced kneading/ironing: Both the hands, placed over one another, are used to apply

pressure. The lower hand, which is in contact with the patient’s skin, receives reinforcement from the

other hand.
• Petrissage: In this category of massage, the tissues are grasped and lifted away from the
underlying structures and intermittent pressure is applied to the tissue in the direction
that is perpendicular to the long axis of bone. Different techniques of this group are:

i. Picking up: Tissues are lifted away from underlying structures, squeezed and then
released using one or both the hands.

ii. Wringing: Using both the hands, tissues are lifted away from the underlying structures,
squeezed, twisted and then released.

iii. Skin rolling: The skin and fascia are lifted up with both the hands and moved over the
subcutaneous tissues by keeping a roll of lifted tissue continuously ahead of the moving
thumb.
• Friction: In this group of technique the tissue are subjected to small range of to and fro
movement performed with constant deep pressure of the finger or thumb. Different
techniques of this group are:

— Circular friction: Direction of movement is circular.

— Transverse friction to and fro movement is performed across the length of structure. It is
also called cross-fibre massage.
Vibratory manipulations
• In this group of techniques, the mechanical energy is transmitted to the body by the
vibrations of the distal part of upper limb, i.e. hand and/or fingers, which are in constant
contact with the subjects skin, using the body weight and generalized co-contraction of
the upper limb muscles. This technique is mainly directed towards the lung and other
hollow cavities.

Vibration: In this technique, the fine vibrations are produced, which tend to produce fine
movement of hand in upwards and downward direction.

Shaking: In this technique, coarse vibrations are produced, which tend to produce fine
movement of hand in sideway direction.
Percussion/tapotement manipulations
• In this group of techniques, a succession of soft, gentle blows are applied over the body,
which produce a characteristic sound. The striking hands are not in constant contact with
the skin and strike the body part at regular interval. This results in the application of an
intermittent touch and pressure to the body during these manipulations.
ON THE BASIS OF DEPTH OF TISSUE APPROACHED

• Light Massage Techniques

The force applied during the maneuver are light, so that the effect of massage is confined
to the superficial tissue only. e.g. stroking, tapping, etc.

• Deep Massage Techniques

The forces applied during the massage are moderate to deep so that the effect of massage
reaches to the deeper tissues like muscle. e.g. friction, kneading, etc.
ON THE BASIS OF REGION MASSAGED
• General Massage

Massage applied to the entire body is usually termed as general massage. However,
massage administered to a large body segment like the back, lower limb, etc. can
also be included in this category.

• Local Massage

When massage is administered in a particular area of the body segment it is

termed as local massage. This is used in the treatment of the local pathological
conditions. For example, massage of wrist in tenosynovitis, friction to lateral
ligament of ankle following sprain, etc. can be considered as local massage.
ON THE BASIS OF MEANS OF ADMINISTRATION OF
TECHNIQUE
• Manual Massage

The word “manual” refers to the ‘lying on’ of hand over the subject’s body. The massage
administered with the hand or other body part of the therapist is called manual massage.
e.g. technique of classical massage, connective tissue massage, trigger point massage,
accupressure massage, etc.

• Mechanical Massage

When the mechanical devices based on the principles of massage, administer the
mechanical energy to the patient’s body, in order to manipulate soft tissue, it may be
termed as mechanical massage. e.g. vibrator, compression devices, pneumatic massage, etc.
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