Essential Requirements for Soft Tissue Manipulation

Chapter 3 Essential Requirements for Soft Tissue Manipulation

The professional practice of soft tissue manipulation (including massage) requires consideration of a number of essential requirements. Important ethical considerations are clearly relevant to the practice of this medical art, and the basic issues are outlined in this chapter. The technical requirements for the administration of soft tissue manipulation include the type of equipment to be used, methods of positioning the patient, and various lubricants, to mention just a few. All of these issues are considered in this chapter, so as to separate them from the descriptions of the basic massage strokes in the following chapter. Each of the issues discussed in this chapter is relevant to the material discussed in most of the remainder of the text.

This chapter does not explore the many types of mechanical device claimed to be useful for massage treatment. A discussion of these devices has been deliberately omitted because in most cases they do not deliver a true massage treatment. These devices usually impart a simple vibration wave to the tissues, typically at a frequency from 50 to 60 Hz. Although a mechanical stimulus of this type will certainly have an effect on the tissues, it is not, nor can it be, the same kind of stimulus as that given by trained human hands.


All health professionals involved in direct patient care are expected to, and are honor bound, to adhere to high levels of ethical practice. This is especially the case when it comes to the practice of soft tissue manipulation (including massage), because massage requires direct contact with the patient’s skin and the patient will necessarily be undressed for treatment. Therefore, every therapist should conduct him- or herself with the highest standard of professionalism during massage treatments, indeed, in the same manner as they would to deliver any other treatment modality (Mykietiuch, 1991; Norton, 1995). In addition, by observing the usual high standards of personal hygiene and cleanliness, the therapist leaves the patient feeling confident of an effective and professional treatment. Because massage treatment involves the exposure of the body part to be treated and direct touching of the patient by the therapist, inappropriate touching and unnecessary exposure are to be avoided at all times. Many of these ethical issues will be addressed in the chapters that follow.

All of the major professional associations in which massage is practiced have extensive codes of ethics. These codes are excellent sources of information on the various issues related to the ethical practice of massage. Although much has been written on these issues, the various codes of practice are an excellent starting place for the reader to find more detailed information in this area. The web sites of professional associations such as the American Physical Therapy Association (APTA), the American Massage Therapy Association (AMTA), the American Nursing Association (ANA), the American Occupational Therapy Association (AOTA), the Australian Physiotherapy Association (APA), the Canadian Physiotherapy Association (CPA), and the Chartered Society of Physiotherapy (CSP) are listed at the end of the chapter for easy reference. There are, of course, many other professional associations that could be added to this list, but to include all of the appropriate associations is beyond the scope of this chapter. The intent is only to list a few examples.

The therapist should be relaxed in his or her manner and movements, which allows the therapist to concentrate on the treatment. As in all treatments, an adequate explanation to the patient is an essential prerequisite. There is considerable risk of scratching the patient if the therapist wears jewelry, such as watches and rings (with large stones and settings), on the wrists or fingers. In this respect, therapists are advised to work without such jewelry. In addition, any jewelry that the patient may be wearing should be removed from the part of the body to be treated.

It is essential for the therapist to maintain the confidentiality of each patient’s health-related information. A discussion of one patient’s situation with another patient is an obvious breech of confidence and an ethical violation. Indeed, in some instances this behavior may be against the applicable law.

Undressing and appropriately draping the patient are important aspects of all massage treatments. Instructing the patient on what to wear for treatment is helpful because it can greatly facilitate the treatment. It will also reduce embarrassment for both therapist and patient. Explaining the procedures and the need for undressing and draping are important steps in gaining the patient’s confidence and verbal consent to treatment. In this regard, a male therapist needs to be especially diligent when treating a female patient. In this case, it may even be helpful to have a female assistant present during the draping and positioning of the patient. Examining the patient, both before and after treatment, is another essential component of modern rehabilitation practice. Obviously this involves undressing, draping, touching, and often moving the patient. All of these procedures require the same high standards of ethical practice. Unnecessary touching and exposure must be avoided.


The effective use of soft tissue manipulation techniques requires a thorough knowledge and practical application of surface anatomy. Because the therapist’s hands are moving over the patient’s tissues, it is essential that the therapist be able to recognize the anatomical structures involved, especially when performing techniques that are designed to affect specific structures, such as a tendon or part of a muscle. Obviously, if a technique is performed to the wrong structure, treatment is unlikely to be successful. Clearly, there can be no substitute for thorough preparation in surface and gross anatomy. Although it is not the primary intention of this text to review surface anatomy in detail, the therapist must be familiar with a number of important structures. These structures are listed in Boxes 3-1, 3-2, 3-3, and 3-4 and have been covered in Chapter 2. In addition, most of these landmarks are identified on the accompanying DVD. They are listed here as a record of the major landmarks and structures that can be regarded as essential knowledge for the effective use of soft tissue manipulation. From time to time anatomical terms change, and this can be confusing when deciding what to call a particular structure. Whenever possible, the latest and most widely accepted anatomical nomenclature has been used. Where appropriate, former names have been included in parentheses, if it seemed this would be helpful.


Because soft tissue manipulation is performed with the hands, the condition of the hands is extremely important to both therapist and patient. The therapist’s hands must be clean and well groomed yet strong and flexible. The nails should be kept reasonably short and the tips rounded so that they do not injure the patient during any of the strokes. The ideal hands for massage are well padded, warm, supple, and dry. They should express sensitivity and gentleness and yet have firmness and strength. Beginning massage practitioners may increase the suppleness of their hands by partaking in various hand exercises. Some individuals have naturally flexible hands and are able to move them rhythmically, and they seem to be able to learn the techniques of massage more readily than others. Nonetheless, with appropriate guidance, anyone who conscientiously spends sufficient time in practice will eventually acquire good technique.

Hands that have cuts, open sores, warts, or other skin lesions are not suitable for massage treatments. It is important for therapists to take exceptional care of their hands if they are to be effective with the use of massage. Simple household, automotive, or garden work can be damaging to the hands. A few minutes spent raking leaves or sweeping a yard can easily cause a blister to appear. Adequate protection with suitable gloves is therefore essential. The use of a high-quality hand or skin conditioner helps to keep hands in good condition.

The hands must be thoroughly washed before and after treatment and should always be scrupulously clean. The use of a high-quality nailbrush is essential in order to remove dirt from under the edge of the nails. To be effective, hands should be washed for at least 30 seconds to a minute. Antibacterial soap may also be helpful. Careful drying with disposable paper towels is also highly recommended (see DVD Chapter 3-7).

Areas of hard, dry skin (callus) can be removed by gently rubbing a very mild abrasive, such as raw, granulated sugar, into the hands. A small amount of olive oil should be combined with the sugar to produce a paste that is then rubbed into rough areas of skin. This technique can be repeated several times each day until the areas of hard skin soften. Granulated sugar does not completely dissolve in olive oil and therefore retains its mildly abrasive texture when it is rubbed into the skin. The olive oil also helps to soften the skin. Care must be taken with clean-up following this technique because the sticky mixture of oil and sugar is difficult to remove if allowed to get onto the treatment linens or clothing. It is best to use paper towels to remove the oil and sugar from the hands before washing with soap and hot water (see DVD Chapter 3-8).

During massage treatments, the hands fulfill two main roles: they move the skin, subcutaneous tissues, muscles, and other structures, and at the same time they acquire information about the condition of those tissues. In this respect, the hands may be viewed as mobile sensors, relaying information to the therapist concerning the condition of the tissues being massaged. Moist, perspiring hands are a great disadvantage to the therapist and may be uncomfortable for the patient. Therapists may minimize this condition by frequently washing and drying their hands, possibly with some evaporating spirits.

It is important for the therapist to be relaxed during the application of massage, as most of the strokes are performed not with the hands alone but by using body weight and moving the body to different positions. Effective massage can be physically demanding, and the therapist who has strong, flexible hands and good upper body strength will likely find massage treatments much less tiring than those who are not as fit. Various exercises that strengthen and mobilize the hands and upper limbs in general will be of considerable benefit and should be seen as good preventive maintenance for the therapist.

In the great majority of both ancient and modern cultures, massage has been performed using one or both hands. Other body parts have been used, such as the feet and elbows, but they are not considered in the present text. Many different parts of the hand can be used for massage, including the palms, fingertips/pads, thumb tips/pads, ulnar border, knuckles, and all areas on the palmar surface of the hand. Figure 3-1 and Box 3-5 show several areas of the hand that can be used in massage. The same areas are shown on the accompanying DVD (see DVD Chapter 3-2).


If the therapist has warm, soft, dry hands, use of a lubricant may be unnecessary; however, most massage situations require the use of a lubricant to facilitate movement of the hands over the patient’s body tissues. This is largely because perspiration on the skin surface (both on the therapist’s hands and the patient’s skin) produces a sticky situation that may well be uncomfortable for the patient. In addition, it will make it difficult for the therapist to perform the various strokes properly. Several types of lubricant are in common use. Although massage is generally regarded as a very safe treatment, minor problems can arise with the use of various types of lubricant. Some therapists develop an allergic reaction, as may the patient, and this will probably necessitate the use of a different medium (Bruze, 1999; Frosh, 1996; Sanchez-Perez & Garcia-Diez, 1999; Held, 2001; Lis-Balchin, 1999).

Jun 4, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Essential Requirements for Soft Tissue Manipulation

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