LIVE ONLINE TEACHING

Subject: EXERCISE THERAPY

Topic : SOFT TISSUE MANIPULATION
Year : II YEAR BPT

Faculty Name : BIJISH KUMAR B

Designation : VICE PRINCIPAL (PESCOP)
Department : PHYSIOTHERAPY

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LEARNING OBJECTIVES
At the end of the lesson, students will be able to:

 Define soft tissue manipulation (massage) and discuss a brief history

of massage
 Discuss the preparation methods for a physiotherapist and patient
before massage procedure
 List out the requirements of the treatment area and equipment
required for massage
 List the Classification of massage techniques
 Method of performance and effects and uses of different massage
techniques
 Demonstrate various body massage sequences.

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DEFINITION OF MASSAGE
Definition:
“Massage is the scientific manipulation of soft tissues.”
• Derived from two sources
 Arabic : mass : to press
 Greek word : Massien : to knead

• Manipulation is skillful handling.

• The manipulation of soft tissues with hands is performed
in order to produce effects on the nerves, muscular and
circulatory systems, which will help to restore or improve
function.
• Massage requires skilled use of hands and brain, and this
only comes with practice.
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HISTORY OF MASSAGE THERAPY

Brief History:
 One of the oldest of the sciences and has been used for
curative purpose from the earliest times. The Chinese
applied friction to the soft tissues of the body, thousands
of years BC.
 Two hundred years ago the theory was scientifically
worked out by the Scandinavians and Germans which is
now known as the Massage Therapy.
 Sweden : early 19th century, Peter Ling (acknowledged
founder of curative gymnastics) appears to be founder of
modern day massage techniques, incorporated with
French massage techniques
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Treatment considerations & Guidelines

• Need to know the underlying pathology

• Need to know basic principles (manual dexterity, co-
ordination and concentration). Must also exhibit patience
and courteousness
• Hands must be clean, warm dry & soft. Nails must be
short and smooth.
• Maintain correct positioning
• Maintain good posture to prevent fatigue and backache
• Good position required to allow for correct application of
pressure and rhythmic strokes during the procedure

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 Points of consideration
• Pressure regulation should be determined by the type and amount of
tissue present. Pressure is governed by the condition and which
tissues are affected
• Each stroke must have equal pressure and time
• Duration depends on pathology, size of area
• If swelling present in an exterimity, treatment should be given
proximally
• Massage should never be painful, except for friction massage. Should
not cause ecchymosis
• Direction of forces in direction of muscle fibers
• Each procedure should start and end with effleurage
• Make sure patient is warm and comfortable, relaxed position
• Body part elevated if necessary, should begin with superficial stroking
• Pressure should be in line with venous flow
• Bony prominences and painful joints to be avoided
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Preparation
• Treatment room:
• Comfortable temperature, necessary privacy
• Couch :
• Adjustable, towels, pillow, blanket
• Self preparation
• Stance : lunge or walk standing
• Clothing : loose enough to allow unrestricted movement, should be
Looking neat and Professional.
• Female therapist: Nails should be short with smooth edge, long hair
should be tied back.
• Hands : should be clean, smooth and soft. Ornaments to be
removed
• Exercises and Practice Rhythm, Strokes, Palpation

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Preparation

Patient :
• Explanation to patient
• Consent
• Draping
• Never expose treatment area without the permission.
• Chaperone can be allowed with consent
• Coupling media : oil, cream, gel, powder

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Indications

• Mobilization of intertissue fluids

• Reduction of modification of edema
• Increase in local blood flow
• Decrease muscle soreness
• Pain reduction
• Facilitation of relaxation
• Prevention and elemination of adhesions

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 Contra Indications

General Local

• High fever • Acute inflammation

• Severe renal or cardiac • Skin diseases
disease • Recent fractures
• Deep X-ray therapy • Severe varicose veins
• Osteoporosis • Atherosclerosis
• Severe spasticity • Thrombosis
• Hairy skin • Myositis ossificans
• Malignancy
• Open wound
• Others

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Therapeutic uses

• Improves mobility of soft tissues

• Reduce muscle spasm, soreness
• Reduce edema
• Increase circulation
• Mobilize secretions in lungs
• Induce local and general relaxation

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 Physiological effects
• Excretory system : increases output, reduces fluid retention, stimulates
digestive system
• Circulatory system : improves peripheral circulation, nutrients, oxygen,
release of vasodilators, decrease venous congestion
• Nervous system : facilitatory effect on motor system, sedative effect on
CNS, release of endorphin reduces pain and muscle tension
• Muscular system : relieves tightness, reduce soreness, increases
circulation
• Metabolic system : the removal of waste products increases. Increasing
the removal of waste products helps to remove lactic acid more
efficiently and so decreasing muscular fatigue and pain.
• Respiratory system : percussion and vibration techniques helps in
removal of secretions
• Integumentary system : improves nutritive status of skin, soft, supple
and finer
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Classification Of Techniques

1. Stroking Manipulations

2. Pressure Manipulations

3. Percussion Manipulations

4. Shaking Manipulations

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 Stroking
Technique:
 The stroking manipulation can follow any direction and needs contact
and continuity throughout, with proper support and relaxation. Applied
by using pads of finger, thumb or alternating hands.

Effects And Uses:

• Gets the patient used to touch
• Allows assessment of the state of skin and tissues of the area
• Improves sensory analgesia
• Slow stroking will relax and sedate and decrease muscle tone
• Faster strokes will stimulate superficial blood flow, accelerate lymph
drainage
• Used to start and end session

Contraindications:
 When the patient is intolerant to it.

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 Effleurage
 Deeper stroking, this is always performed in a centripetal direction, ie
From distal to proximal and ending in a group of lymphatic glands.
 Grade I : influence the flow in superficial vessels
 Grade II : affects deeper vessels
 Grade III : applies to reinforced effleurage with one hand on top of the
other

Technique:
 The limb to be treated is completely supported. Operators hand to be
molded to the part. Both aspect of the hand to be treated.
 Strict contact to be maintained. Both hands used together or
alternately. The upward stroke must be firmly and evenly applied. the
down ward stroke very light, only to maintain contact.

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Effects And Uses:
• Assists lymphatic and venous system
• Assists interchange of tissue fluid
• Assists removal of waste product and chemical irritants
• Passively stretches muscle fibers
• Restores mobility at tissue interfaces
• Light strokes decrease muscle tone
• Deep strokes increase muscle tone
• Used at start end and in between other manipulations

Contra Indications:
 Contraindicated in cystic swellings and in cases of varicose veins.
 Precautions to be taken in the following cases: Gross edema, infantile
paralysis.

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 Pressure Manipulations or Petrissage
Kneading
Grade I : is sufficient to influence superficial vessels and compress
superficial tissues on underlying structures
Grade II : affects deeper tissue drainage and will compress deep tissue
on underlying structures
Grade III : applied to superimposed or reinforced strokes and may be as
much as can be tolerated by the patient without producing tissue
damage
Technique
 Squeezing kneading: The whole surface of one or both hands is
used. The muscles are gently squeezed, pressed down to the
underlying structures and relaxed.
 Circular kneading: The palmar surface of the hand and fingers placed
on the part to be treated and pressure applied to the tissue.
 Finger kneading: This is a circular movement performed with the
thumb or fingers on small areas such as the face, palm or sole and
pressure applied to the muscles in circular direction. It is similar to
friction but applied to muscles.
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Effects And Uses:
 Stimulates venous and lymphatic flow

 Increases mobility of fibrous tissues

 Helps interchange of tissue fluids

 Helps prepare soft tissue for exercise

 Helps removal of waste products

 Increases length and strength of connective tissues

 Provokes somato-visceral reflex effects

 Restores mobility between tissue interfaces

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Ironing
Technique:
 Performed mainly on the back and the gluteal region. One hand
reinforces the other and the body weight is used to get the
maximum depth and to move the thick structures over the
underlying bone.

Effects And Uses:

 Chronic lumbago, sacroiliac strain. It produces heat and helps in
removing waste product, loosens and stretching of tightened
structures

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 Petrrissage

Picking Up
TECHNIQUE:
 The part to be treated is palpated first , then the muscle is
pressed against the bone lifted, squeezed and relaxed.
For large muscle groups both the hands are used, V or c
shape

EFFECTS AND USES:

 Same as kneading.

 Particularly good for mobilizing soft tissues

 Use after effleurage and kneading

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 Petrrissage

Wringing
Grade I : usually applied to finger strokes
Grade II : using whole hand
Grade III : painful to tolerate (No grade III)
Technique:
 Fingers and thumb are used in wringing tissues being compressed.
Tissues are then lifted and pulled towards with one and away with
other.

Effects And Uses:

 Particularly good for separating superficial and deep adherent tissue

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Rolling
Technique
 A manipulation where the therapist lifts up the skin and subcutaneous
fascia with both hands then moves keeping a roll of skin raised
continuously ahead of the moving thumbs.
 Performed most frequently on the back, where it can be done either
longitudinally parallel to the spine or transversely across the back
from the spine working laterally.

Effects And Uses

 Same as kneading
 Also mobilizes scar tissue
 When performed slowly it has stretch effect on the tissues being
manipulated

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Friction
Technique:
 These are small or large, deep, penetrating movements performed in
a circular direction over small areas or joints with the padded
surface of finger tips. the pressure varies in depth according to the
structure to be treated.

Effects And Uses:

 Inflammatory exudates around the joint is softened and broken down
and adhesion prevented. Scar tissue is stretched and loosened by
frictions and prevent adhering to the underlying surface

Contraindications:
 Recently healed scars, sensitive areas, swollen joints in recent injury
like dislocations and joints with inflammatory changes.

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Percussion or Tapotement Manipulations

Tapotement
This technique of Swedish massage, as the name suggests
consists of rhythmic tapping that uses a fist, a cupped hand,
ulnar board of the hand, or your fingertips. This helps to
loosen and relax the muscles being manipulated but also
helps stimulate them neurologically.

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 Percussion or Tapotement Manipulations
Hacking
Technique:
 Arms are adducted elbows flexed and the wrist extended. The movement
consists of pronation and supination of the forearm producing succession
of short and sharp blows with the ulnar border of the medial three fingers.
The little finger is to be the first to strike the part treated.
Effects And Uses:
 Stimulates local circulation and muscle tone
 Gives generalised feeling of stimulation
 Provokes muscle and tendon reflexes
 Light stroke effects superficial tissues
 Deeper strokes aid the evacuation of the lungs
Contraindications:
 Subcutaneous areas, cases of hyperaesthesia, hypotonic muscles etc.

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Clapping
Grade I : very superficial, called skin clapping
Grade II : deeper, slower and firmer
Grade III : clapping is very firm and may involve elbow and wrist

Technique:
 Used for limb back and chest. The hands are held loosely cupped and
the area is struck by the palmar aspect of the hands and fingers. The
action is produced by alternate flexing and extending the wrists
Effects And Uses:
 Same as hacking with exception of provoking tendon or muscle reflex
 Increase lung activity when performed on chest.
Contraindication:
 In cases of tuberculous lung disease.
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Beating
Form of Tapotement
Grade I : performed at faster rate, with fairly light contact
Grade II : slower with firmer contact
Grade III : very deep and rate can be varied as required

Technique:
 Involves the use of lightly clenched fists to hit the area. The action
involved is wrist flexion and extension with the finger/palmar area
making contact with the treatment area

Effects And Uses:

 Same as clapping

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Pounding
Grade I : stroke applies faster rate, light contact
Grade II : slower rate with firmer contact
Grade III : deeper with varying rates

Technique:
 The hands are held in lightly clasped fists with the thumb resting
against the first finger. The action is to pronate and supinate the
radio-ulnar joints and make contact with the patient using the ulnar
border of hand.

Effects And Uses:

 Same as clapping

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Shaking Manipulations
Vibrations
Grade I :
Grade II : firmer and slower with more tissue movement
Grade III : firm pressure as can be tolerated and in a very slow action
Technique:
 Tissues are pressed and moved up and down or away from and
towards manipulator and released. Small oscillations of whole arm
produce trembling effect. Single or both hands, slightly flexed.
Effects And Uses:
 Stimulates muscle tone and local circulation
 Provides feeling of well being
 Aids Peristalsis

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Shaking
Technique
 Placing the hand larger surface area and circular movements with
hand fixed on area.

Effects And Uses

 Stimulates the circulation
 Increases tissue mobility
 Assists breaking adhesions
 Prepare soft tissue to stretch and exercise

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Procedure
• Receiving the patient
• Introduction
• Prepare the treatment area
• Examine the patient
• Contraindications
• If no
• Position the patient
• Drape the patient
• Select techniques
• Administer techniques
• Terminate treatment
• Inspect the area treated
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Lower Limb [Leg] Massage

Positioning : lying or half lying

o Stroking
o Picking up
o Wringing
o Hacking
o Friction
o Effleurage
The Effleurage manipulation is
performed in between the
massage sequence.
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Upper Limb [Arm] Massage

Positioning : Sitting (back on

chair) or lying. Shoulder
abducted to some extent
elbow flexed to 90 degree with
wrist and hand supported.
Massage manipulation
sequence:-
 Stroking
 Effleurage
 Kneading
 Picking up
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Upper Limb [Arm] Massage

 Stroking
 Hacking
 Friction
 Effleurage

The Effleurage manipulation is

performed in between the
massage sequence.

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Back Massage
Prone lying with pillow under lower legs to flex knees; pillow under
abdomen (if needed) to flatten the back. No pillow under head.

Massage manipulation sequence:-

 Stroking  Beating
 Effleurage  Hacking
 Clapping
 Kneading
 Pounding
 Ironing
 Friction
 Rolling
 Effleurage
 Wringing
The Effleurage manipulation is performed in between the massage
sequence.
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Facial Massage
Positioning : Supine Lying
Massage Manipulation
Sequence:-
 Stroking
 Hacking
 Kneading
 Friction
 Effleurage
The Effleurage manipulation
is performed in between the
massage sequence.
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Gluteal region

Positioning : prone lying, side lying.

Massage Manipulation Sequence:-

 Kneading ( Soft and Deep tissue)

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Chest Physiotherapy

Positioning : Half lying or supine lying position with

pillows under the back and lower legs.

Massage Manipulation Sequence:-

Clapping
Shaking
Vibration
[Note-clapping manipulation is performed
with towel.]
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REFERENCES:

Hammer, WI.(2005). Functional soft tissue examination and

treatment by manual methods. Jones and Bartlett

Frits, S. (2005). Sports & Exercise Massage. Elsevier Mosby.

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THANK YOU

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