Front Matter

Chapter 6 Manual Therapy 121

Soft tissue mobilization

Soft tissue mobilization (STM) or massage is
the systematic application of manual pres­
sure and movement of soft tissues, including
skin, tendons, ligaments, fascia, and muscle.
Soft tissue treatment techniques have been
used for medical conditions since the 1800s;
however, these techniques are a source of
some controversy, as their value has not been
well documented (Hertling & Kessler, 1990;
Crawford et al., 2016).
Some authors suggest that STM has positive
effects on the circulatory, muscular, lymphatic,
and endocrine systems (Fritz & Grosenbach,
2009; Salvo, 2012). More specifically, STM
is  presumed to create circulatory effects
that  drive fluid from the interstitial space
to  the vessels with movement toward the
lymph  nodes and heart (Millis et al., 2004).
Mobilization of connective tissue is used to
increase the extensibility of the tissue and to
prevent or reduce adhesion formation. Soft tis­
sue techniques have been shown to increase
ROM (Sefton et al., 2011), promote healing
(Zusman, 2011) and reduce pain (van den
Dolder et al., 2010; Sefton et al., 2011). Sefton
and colleagues (2011) demonstrated that soft
tissue mobilization decreased the motor unit
activity of the muscle, increased tissue extensi­
bility, and increased range of motion. Abbott
and colleagues (2015) demonstrated that STM
combined with therapeutic exercise is more
effective than exercise alone in the treatment of
osteoarthritis, particularly if the treatments are
spread out over an 11‐month period of time.
However, Bervoets and colleagues (2015) found
no additional benefit when adding STM to
a therapeutic exercise treatment. As a stand‐
alone treatment, however, STM was effective
in increasing function and decreasing pain.
STM has been compared to therapeutic ultra­
sound (US) in its effect on range of motion
(ROM) and pain with upper extremity neuro­
dynamics (nerve tension testing) in humans.
This study demonstrated greater improve­
ments in mobility with STM than with US
(Costello et al., 2016). STM is frequently used to
enhance post‐exercise recovery. However, a
recent meta‐analytical review suggests that the
effects are unclear and provide unimpressive,
temporary effects (Poppendieck et al., 2016).

Soft tissue assessment

To determine the appropriateness of STM as a

treatment, an evaluation of the soft tissues must

be performed. A thorough soft tissue assess­

ment will identify the presence of soft tissue

pathology, swelling, and pain. With this infor­

mation, the most effective soft tissue treatment

technique(s) can be chosen.

Soft tissues are evaluated by palpation of

specific tissues and structures. A variety of

techniques are used to assess soft tissue depend­

ing on tissue type. For example, fascial restric­

tions are evaluated using techniques quite

different from those used for muscle or tendon.

It is important to be cognizant of the properties

of each type of tissue, understanding that nor­

mal muscle feels different than normal tendon,

ligament, or fascia. The contralateral side is

used for comparison. Documentation includes

a description of the tissue that can be character­

ized by texture, shape, tone, and density.

Abnormal soft tissue can be described as thick,

soft/firm, boggy, tight, tender, in spasm,

warm/cold/clammy, or as having crepitus.

Assessing swelling

The terms edema and swelling are often used

interchangeably. In the strict sense, however,

swelling does not include pitting. Swelling is

the abnormal build‐up of fluid in tissues (intra­

cellular, extracellular, intracapsular, and extraca­

psular). When pressure is applied to a swollen

area and an indentation remains once the pres­

sure is removed, it is referred to as pitting edema.

Table 6.1 lists several characteristics of swelling.

Resolution of swelling is a common treatment

goal, as swelling will retard the recovery pro­

cess. Swelling can result in pain, loss of ROM,

and reflex inhibition of the surrounding mus­

cles, leading to atrophy and weakness. Swelling

Table 6.1 Characteristics of swelling

Type of swelling Characteristic

Fluid swelling Soft and mobile

Edematous synovial

swelling

Boggy

Pitting edema Thick and slow moving