Chapter 47 Soft Tissue Manipulation
An Overview of Diagnostics and Therapies*
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
• 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
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
For every therapeutic intervention, we must first determine how best to utilize the technique and/or intervention. For soft tissue manipulation, there are localized responses that will be addressed later in this chapter; this section is devoted to how soft tissue manipulation affects overall health.
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
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
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
What this author is referring to in this subsection is the effect that soft tissue manipulation has on our ability to maintain homeostasis or homeodynamics after the introduction of a stressful stimulus. According to Selye and proponents of the General Adaptation Syndrome line of thought, our physical, biochemical, and emotional being can withstand a certain amount of stress. Everyone has a different threshold, and soft tissue manipulation allows the practitioner the opportunity to remove layers of stress so we can adapt and thrive.
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