SOFT TISSUE MANIPULATION

INTRODUCTION:
Manipulation is a passive technique performed by a therapist which has small amplitude but high velocity and cannot be controlled by the patient. On the other hand mobilization is large amplitude, small velocity movement under the control of patient. Soft tissue manipulation may be utilized to: normalize dysfunction preparatory to manipulation of osseous structures. restore postural or functional integrity achieving what osseous adjustments can seldom achieve: actual alterations in structural position of musculoskeletal segments. function as part of a comprehensive approach to health care in which the reflex activity, as manifested in surface structures, is used diagnostically and therapeutically.

Soft tissue stressors Congenital factors, such as short leg, small hemipelvis. Birth trauma, such as cranial trauma from forceps delivery which distorts the internal cranial fascia tentorium cerebelli and falx cerebri which, because of body-wide fascial continuity, can cause distortions elsewhere.

Biochemical changes resulting from nutritional, toxic, endocrine, infectious and other influences.

Overuse, misuse or abuse of the musculoskeletal system in work or recreational settings.

Habitual postural stress. Habitual upper chest breathing pattern . Trauma either repetitive minor forms or major incidents. Reflexive factors, including myofascial trigger points and viscerosomatic influences. Chronic somatization influences generated by negative psychosomatic factors and emotional coping traits, including fear, anger, anxiety, depression, etc. Biochemical changes resulting from nutritional, toxic, endocrine, infectious and other influences.

Progressive adaptive changes to soft tissue stressors : An initial alarm response will occur in which tissues become hypertonic. If not short term, localized oxygen deficit is probable, together with retention of metabolic waste products, both of which result in discomfort or pain and the likelihood of an increased hypertonic response. The constant activity of the neural reporting stations of these tissues leads to increased sensitization and the development of a tendency to hyperreactivity (known in osteopathic medicine as facilitation. Macrophages become activated along with increased vascularity, fibroblast action and connective tissue production leading to cross-linkage and shortening of tissues.

Changes in the muscles as a result of hypertonicity which, if sustained, results in progressive fibrotic modification. Sustained hypertonicity leads to drag on tendinous attachment to the periosteum, and the likelihood of pain and dysfunction in these tissues. If such stressed tendons or muscles cross joints, they become crowded and their function is modified. The antagonists of chronically hypertonic muscles will be reciprocally inhibited and, as a result, normal firing sequences of muscles may alter e.g. where excessive activity of synergist muscles occur in order to take on the tasks of weakened (inhibited) prime movers, or synergists. Chronically shortened hypertonic structures have a sustained inhibitory effect on their antagonists an example would be short, tight, erector spinae muscles and weakened (inhibited) abdominal muscles seen in the typical slouching, pot-bellied, sway-back, posture; another example would be the inhibition of deep neck flexors associated with short tight neck extensor muscles, seen in the typical chin-poke, head position. Chain reactions of such dysfunction can occur resulting from the shortening over time of postural muscles (type 1 fibers) and the inhibition and weakening (without shortening) of phasic muscles (type 2 fibers). Localized areas of hyperreactivity (facilitation) may evolve paraspinally, or in particular stress-prone regions of any myofascial structures trigger points and other reflexively related changes. These triggers themselves commonly become sources pain and of further dysfunction. Postural and functional changes will become apparent throughout the body, e.g. in relation to breathing pattern dysfunction (upper chest breathing),

which can result from (for example) poor, slumped posture, and which cannot be easily normalized until the structural changes which encourage it are corrected. Therapeutic input in response to such changes needs to address the multiple changes which have occurred to reduce hypertonicity, resolve fibrotic changes, lengthen shortened structures, tone weakened/inhibited structures, mobilize joints, deactivate trigger points as well as removal of habitual patterns of use which have added to, or caused, the dysfunctional patterns, including postural and respiratory re-education.

The musculoskeletal changes described above may have components which include biomechanical, biochemical and psychological components, all of which need to be understood and, where possible, modified or removed.

SOFT TISSUE POINTS:

A degree of reductionist thinking is necessary to understand the nature and value of the reflex areas, points, and zones that have been described by the many systems of soft tissue manipulation. In general, these points can be divided into sensitive soft tissue alterations that result from physical strain or trauma (including the soft tissue effects of emotional stress) and alterations which are the result of reflex activity (e.g. viscerosomatic reflexes). These changes can be considered as adaptive responses to patterns of stress as outlined above. Methods of identification There are a variety of methods by which soft tissue changes may be located through palpation. These include: Traditional massage methods Specific palpation techniques, such as those developed by osteopathic and other schools.

 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) Skin distraction techniques evolved by the German connective tissue massage (Bindesgewebsmassage) practitioners. All of these, and other methods of palpation, may be utilized in order to identify areas of local soft tissue dysfunction which may be sources of, or results of, reflex activity or other local adaptive responses. The analysis of the available information present in localized areas of the soft tissues requires consideration of a variety of classifications and systems. It is necessary to examine some of the systems which have described the same tissue changes in different ways, in order to compare the similarities and differences in the descriptions of points (discrete, usually sensitive, areas of altered structure and function in the soft tissue) and the diagnostic and therapeutic significance ascribed to them.

GENERAL SOFT TISSUE MANIPULATIVE TECHNIQUES:

Therapeutic effort may be directed toward the diagnosis and correction of the mechanical aspects of dysfunction (trauma, strain, etc.) or toward the use of the available information from such reflex areas in a more wide-ranging, holistic approach to the health of the patient. General, rhythmic techniques are often employed on the soft tissues to relieve local dysfunction and/or to prepare for subsequent adjustment of osseous structure.

In all of these variations, the objectives are the improvement of circulation and drainage, release of con-tracture, and increased range of movement. Inhibition implies a degree of pressure sufficient to achieve reduction in hepertonia or neurological activity. All of these may be applied in a

stimulatory as well as a relaxing manner, but care should be taken to prevent stimulation from becoming irritation.

DISCRETE PALPABLE POINTS RELATED TO TRAUMA OR STRAIN:

In the musculature and connective tissues of the body, often in the regions of the origins and insertions of the muscles, there are palpable, sensitive areas of altered structure resulting from injury, irritation, stress, etc. These have been described as tender points, trigger points,1Ah Shi points in traditional acupuncture (literally spontaneously tender points), and indurated points, among other descriptions. Common to these points is their size, which ranges from 0.5 to 1.0cm across, and their feel, which is described as harder or firmer than surrounding normal tissue, or as having an edematous or stringy feel. It is often noted that these localized areas of altered structure and function occur in bands of stressed fibers, both fascial and muscular. All these points are potential trigger points, but only those which, upon pressure, are noted to refer pain or other symptoms, to a distant (target) area, that are recognizable as familiar to the individual, are so classified.

Identification of these points as areas of localized dysfunction is dependent upon palpatory literacy The ability of the examiner to readily distinguish between the texture and other characteristics of normal and abnormal tissues. Development of such a degree of sensitivity is a matter of practice and is readily acquired by any practitioner willing to spend but a little time touching, feeling, assessing, comparing, and judging what it is that is being felt. In most, but not all, cases, these altered areas of structure and function are found to lie in shortened muscle tissue or fascia.

Bossy notes that the common structures found under all acupuncture points include neurovascular structures, connective tissues, and subcutaneous fatty tissues. The connective tissues are thought to be vital in producing the acupuncture sensation noted as being essential to effective therapy. These structures impart the gripping of the needle, and the manipulation of the needle affects, through localized tissue traction, minute neural reporting stations, such as Meissner corpuscles, muscle spindles, and Golgi tendon organs. There are other features of connective tissue that are capable of resulting in either excessively increased general tone, or in localized areas of soft tissue distress and dysfunction.

THE POTENTIAL OF SOFT TISSUE MANIPULATION:

The professions within medicine which utilize manual therapy, such as physiotherapy, have tended to discard the tradition of hands on treatment in favor of a more technological approach, leaving the soft tissues to massage therapists and sports therapists. Osteopathy (as practiced in Europe where it is not a part of a general medical practice, as it is in the US, but rather a system which addresses structural and functional dysfunction via manipulative methodsand chiropractic, which are conceived as being largely concerned with the joints and osseous component of the musculoskeletal system, have in recent years come to recognize the vast importance of the soft tissues in both diagnostic and therapeutic roles. The musculoskeletal system is both the greatest energy consumer of the body and its largest organ of sensory input. While this primary machinery of life has long been unappreciated, in therapeutic terms, the development of methods such as strain/counterstrain, muscle energy technique, and neuromuscular technique and the vast amount of information derived from acupuncture tradition and research, and other reflex systems ensure that the diagnostic and therapeutic potential of the soft tissues are now being recognized.

The premier osteopathic researcher of the past three decades, summarizes another vital implication of soft tissue dysfunction interference with axonal transport mechanisms thus: 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 bloodnerve 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. This survey has touched on some of the many ways in which soft tissue dysfunction may impinge upon the economy of the body as a whole. Soft tissue manipulation is an important diagnostic and treatment modality and should be considered an integral part of the practice of any physician or practitioner whose intent is to care for the whole person. (Those interested in studying this topic in more depth will find references 28 and 81 very helpful. These thoroughly cover the topics surveyed here and provide useful tables, charts and diagrams and pictures of the various techniques as they are applied to a patient.