Chapter 47 Soft Tissue Manipulation
An Overview of Diagnostics and Therapies*
Introduction
The term “soft tissue” is a ubiquitous and, at times, vague term. Every profession that deals with the mobility, stability, and dynamic function of the neuromusculoskeletal system must embrace diagnostic and therapeutic soft tissue procedures. Medical and therapeutic systems such as those used by naturopaths, chiropractors, osteopaths, allopaths, physical therapists, massage therapists, and body-centered psychotherapists all have their own procedures for identifying and treating a variety of soft tissue dysfunction. Despite their differences, terms used, or the theories advocated by each profession, they all agree to some degree that soft tissue dysfunction can cause and/or indicate disease, injury, aberrant reflex activity, and aberrant movement patterns, the results of which can have minor or profound effects on the health of the individual. In addition, most professionals that diagnose and treat soft tissue dysfunction seem to refer to a common phenomenon: distinct, palpable, usually sensitive areas of soft tissue aberrations or lesions that are either directly or reflexively related to local or organ dysfunction and/or disease.1,2
The thoughts, ideas, and theories that are foundational to physical medicine are evolving; so too are the thoughts, ideas, and theories foundational to soft tissue diagnostics and therapeutics. One clinically relevant and interesting note is that many systems of health care delivery are moving to more encompassing and holistic ideas about the interrelation of many cells, tissues, organs, and systems to obtain and maintain optimal health and wellness. Functional or lifestyle medicine practitioners look at the various systems of the body in hierarchical fashion. Treating systems “upstream” or higher up on a hierarchical list of systems allows the practitioner to optimize the health of the individual without chasing down symptoms.3 Movement therapists and doctors who help to improve and stabilize movement are looking at movement patterns instead of single or even dual-planar movement. The idea that movement only transmits from muscle origin to insertion is long gone, clinically incomplete, and inferior to the recent, more functional theories.4–6 Soft tissue diagnostic and therapeutic procedures are currently evolving; this evolution is occurring as a result of clinical treatment and trials and other empirical methods.
Although the working definition of soft tissue has always included muscles, ligaments, tendons, fascia, and more, each individual tissue was looked at and often treated as a separate entity, not as functional units. There has been a recent push to look at functional groups of soft tissues. Ideas like myofascial “chains,” “trains,” and units are taking the soft tissue world by storm and proving to be clinically superior to some of the incomplete, older, more reductionist ideas.7–9 Tension relationships are now ideas that permeate soft tissue diagnosis and therapies. Muscle coordination and perception are looked at as functions of these relationships rather than the work of a group of muscles and their respective myoneural units.7–11
Soft tissue therapy may be used to accomplish the following:
• Normalize soft tissue dysfunction in preparation for joint manipulation.12–14
• Restore postural or functional integrity; this has been one of the primary uses of soft tissue therapies for ages, and now many are thinking about this more in terms of restoring healthy tension relationships throughout all of the integrated soft tissue structures of the body.7–915
• Function as part of a comprehensive approach to health care in which tension relationships and subsequent reflex activity, manifested in soft tissues, are used diagnostically and therapeutically.16
Of final note, professions that classically have not viewed soft tissue as the primary avenue for their treatment benefits have been evolving their paradigm. Acupuncturists specifically have been viewing soft tissue, more specifically fascia, as part of their diagnostic and treatment foundation. Various authors in the acupuncture world have noted that acupuncture points and connective tissue and soft tissue planes have a very intimate relationship and, at times, are indistinguishable.17–19
Health Implications of Soft Tissue Manipulation: The Big Picture
Immune System
Clinically, many who practice soft tissue manipulation have noted various immune responses from patients and clients. The evidence for these effects have been elucidated, mostly through studies of massage therapy. Because the immune system receives messages and is controlled by the nervous and endocrine systems, the effects of soft tissue manipulation regarding the immune system are neuroendocrine in nature.20
Emotional
Soft tissue manipulation has been shown to help the emotional status of individuals experiencing depression, eating disorders, excessive anger, rage, rejection, and fear. Using soft tissue manipulation as an adjunct therapy when treating individuals with emotional distress can have widespread systemic effects that may prove to be necessary.21–26
Endocrine
Inappropriate amounts of hormones will cause a breakdown in this important system of control. Most notable, especially with regard to soft tissue manipulation, is excess cortisol. Soft tissue manipulation has been found to decrease inappropriately elevated levels of cortisol. The effects of chronically high cortisol levels occur at the hypothalamic-pituitary-axis level and can disrupt and create aberrations in neuroendocrine function. In addition, soft tissue manipulation has also been shown to raise low levels of dopamine and serotonin; this effect has implications in treating addictions, eating disorders, depression, and more.27–31
Definition: Functional Soft Tissue
As noted in the introduction, thoughts, ideas and theories surrounding soft tissue diagnosis and manipulation are evolving. The phrase “functional soft tissue” has been utilized by this author and others. The idea that muscles, bones, tendons, fascia, and ligaments are separate entities is an idea that, although true in a histologic sense, is not the whole truth in a functional sense. A more clinically useful idea is that all of these structures transmit tension. Some of them contract, others resist tension, others give way to tension; the bottom line is they all respond and transmit tension. What many consider the apex of the soft tissue evolution is that soft tissue pathologies exist when the transmission of this tension is altered. As a result, various authors have developed ideas that link all connective and soft tissues together functionally. Myers developed the “Anatomy Trains” idea, and Stecco developed ideas that link soft tissues together functionally through fascial motor units, centers of coordination, centers of perception, and centers of fusion. Ida Rolf was on the cutting edge of these ideas and looked at the physical body as a transmitter of tension.7,8,9,32
Taking the idea of functional soft tissues one step further–the fitness and performance professions are evolving closely with the clinical soft tissue manipulation professions to develop very integrative and useful movement therapies. These movement therapies bridge the gap between more passive soft tissue manipulative techniques and exercise. Many effective soft tissue manipulative techniques include active movement and mobilization on the patient’s and/or client’s part. These therapeutic procedures, combined with more passive soft tissue interventions, are proving to be more effective than passive techniques alone.33
Soft Tissue Pathologies
Researchers and clinicians have used differing terminology to describe similar phenomena, resulting in confusion of what is essentially an uncomplicated pattern. In the musculature and connective tissues of the body, often in the regions of the origins and insertions of the muscles, soft tissue points are often commonly found at motor points and in the muscle belly. The commonality, despite differing opinions on diagnostic criteria and the manner in which they are assessed, is palpable, sensitive areas of altered structure resulting from injury, anoxia, irritation, stress, aberrant reflex activity, and/or aberrant movement patterns. Another commonality to these points is their size, which ranges from 0.5 to 1.0 cm across, and their feel, which is described either as harder or firmer than surrounding normal tissue, or as having an “edematous,” “boggy,” “fibrous,” or “stringy” feel.34
It is often noted that these localized areas of altered structure and function occur in bands of stressed fibers, both fascial and muscular. In all cases, such localized areas are, to a greater or lesser degree, sensitive or tender out of proportion to the amount of pressure exerted.35 All these points are potential “trigger points,” but only those that, upon pressure, are noted to refer pain or other symptoms to a distant (target) area, and that are recognizable as “familiar” to the individual, are classified as such points.36, 37
Methods of Identification
Despite all of the advances in imaging, the most widely used clinical procedure to identify soft tissue pathology is a combination of movement, special (orthopedic) tests, and skilled palpation. The diagnostic use of movement patterns will be discussed in the next section; they too can be used to locate focal soft tissue lesions and points.16,38–40
• Traditional massage methods—mainly palpatory awareness during various massage strokes like effleurage, petrissage, tapotement, and vibration.
• Specific palpation techniques—such as those developed by massage, naturopathic, chiropractic, physical therapy, and osteopathic schools. The common thread is the development of fine motor skills and palpatory awareness, the foundation of which is a solid knowledge of structural and functional anatomy.
• Neuromuscular technique—a method of combined assessment and therapy developed in the 1930s by Stanley Lief, an American-trained naturopathic and chiropractic physician working in Europe.
Aberrant Movement Patterns
As noted in the introduction, soft tissue diagnostics and therapeutics are evolving into a more functional paradigm; with this evolution comes a journey into the idea that movement patterns will help clinicians elucidate soft tissue dysfunction and focal lesions.4–9,11,36
Methods of Identification
Simple, single planar movement patterns have been assessed by many.6,11 These are often easier to assess, but their relevance has been questioned over the last 10 years. Multiplanar movement patterns have been purportedly better, more accurate, and more clinically relevant in the assessment of soft tissue and other neuromusculoskeletal structures.4–936 There is no definitive proof as to which strategy and which motions are the most clinically relevant. Clinicians have begun to use patterns described as “primitive” by Gray Cook and Kyle Kiesel.4,5 The aforementioned clinicians and authors designed a succinct and concise assessment of seven movements. These movements range from deep squats, to toe touches, to lunges, to push-ups, and to active straight leg raises. The assessment of these motions has been given a 3 point system: 0 means there is pain with the movement pattern; 1 is difficulty performing it even after some compensatory correction; 2 is difficulty performing it without said compensation but having the ability to perform it with said compensation; and 3 is full ability and stability while performing each pattern. The relevance of each pattern is speculative and debatable. Gray36 designed a complex assessment of movement patterns through triplanar movements. Although the theory behind his assessments is similar to Cook’s and others, his procedures are unique. This is not a concise and neatly packaged technique, but many clinicians are seeing great results with their patients using Gray’s theories and applications.
Soft Tissue Manipulation Techniques
Therapeutic efforts and techniques may be directed toward the diagnosis and treatment of the mechanical aspects of dysfunction (trauma, strain, aberrant movement patterns, etc.) and toward the use of the available information from such reflex areas in a more wide-ranging, holistic approach to the health of the patient.37
General, rhythmic techniques are often employed on the soft tissues to relieve local dysfunction and/or to prepare for subsequent adjustment of osseous structure. There are common threads to each technique; many use rocking and other rhythmic movements, compression and ischemic compression, and a variety of contacts (hands, digital pressure, elbows, and various devices). In all of the available soft tissue techniques, the objectives are improvement of circulation and drainage; release of contracture, fibrosis, and/or adhesion; greater range of movement; decreased pain and improved movement; and stability. Most soft tissue methods can be applied in a stimulatory as well as a relaxing or inhibitory manner, but care should be taken to prevent stimulation from becoming irritation. Table 47-1 represents a survey of various soft tissue techniques and a brief description of each.
| TECHNIQUE | DESCRIPTION |
|---|---|
| Articulation | Repetitive passive movements employing leverage through variable ranges of the arc |
| Effleurage | Superficial drainage technique derived from massage therapy |
| Inhibition/ischemic compression | Describes an objective rather than a method; consists of pressure applied for lengthy periods, slowly applied and slowly released, using thumb contact as a rule |
| Kneading | Deep or superficial rhythmical pressure, usually applied by thenar or hypothenar eminence |
| Positional release methods | Approaches that, instead of acting directly on restricted or shortened structures, aim to position them in a state of “ease” by moving away from restriction barriers, allowing a spontaneous normalization to occur, involving neural (muscle spindle) resetting and circulatory enhancement These methods include what is known as strain/counterstrain as well as much craniosacral work |
| Rhythmic traction | Repetitive attempts to separate articulations to stretch interarticular and periarticular structures |
| Springing | Repetitive, usually slowly applied, pressure of a gradual nature, often used diagnostically |
| Stretching | Short and long amplitude attempts at separation of muscular attachments and stretching of ligaments, fascia, and membranes |
| Vibration | Rapid oscillatory pressure or movement |
The Potential of Soft Tissue Manipulation
The professions that utilize manual medicine are experiencing a resurgence in the tradition of “hands-on” assessment, treatments, and therapies. The musculoskeletal system is both the greatest energy consumer and the largest organ of sensory input in the body. This primary machinery of life has long been unappreciated in therapeutic terms. The development of methods such as strain/counterstrain, muscle energy technique, fascial manipulation, trigger point therapy, and neuromuscular technique and research, as well as other reflex systems, ensures that the diagnostic and therapeutic potential of the soft tissues are increasingly being recognized and utilized.
“Any factor that causes derangement of transport mechanism in the axon or that chronically alters the quality or quantity of the axonally transported substances could cause the trophic influences to become detrimental. This alteration in turn would produce aberrations of structure, function and metabolism, thereby contributing to dysfunction and disease. Almost certainly to be included among these harmful factors are the deformation of nerves and roots, such as compression, stretching, angulation and torsion that are known to occur all too commonly in the human being and that are likely to disturb the interaxonal transport mechanisms, intraneural microcirculation and the blood-nerve barrier. Neural structures are especially vulnerable in their passage over highly mobile joints, through bony canals, intervertebral foramina, fascial layers and tonically contracted muscles. Many of these biomechanically induced deformations are of course subject to manipulative amelioration and correction.”41
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