Week 9: Soft Tissue Mobilization

What is soft tissue mobilization (STM)?

A manual therapy technique used by PTs to treat soft tissues through various hands-on interventions

What interventions fall under manual therapy according to the APTA Guide to Practice?

• Lymphatic drainage

• Manual traction

• Massage

• Joint mobilization/manipulation

• Neural tissue mobilization

• Passive ROM

• Dry needling

Are terms like massage, STM, and soft tissue manipulation used interchangeably?

Yes, though STM is used broadly to include various techniques

What are the main goals of STM?

• Decrease pain

• Improve mobility

• Circulation

• Flexibility

• Coordination

• Joint mobility

• Motor firing

• Remove lactic acid

How does STM help decrease pain?

By increasing the pain threshold via stimulation of cutaneous nerve receptors

How does STM improve mobility?

It allows soft tissues to slide and glide freely by reducing restrictions from posture, pain, or pathology

How does STM promote healing?

It improves vascular flow and nutrient absorption

What neuromuscular effect does STM have?

It decreases excitability and normalizes neural firing patterns

What knowledge must a therapist have before performing STM?

• Anatomy

• Physiology

• Pathology

• Tissue healing timelines

• Technique knowledge

Why is clinical rapport important?

Comfort with touch can be affected by trauma, culture, or religion

What are risks to check for before STM?

• Allergies

• Contraindications

• Patient’s comfort or history with STM

What must be explained before treatment?

• Purpose

• What the patient will feel

• The importance of feedback

Why is feedback important?

To ensure comfort and safety;

the patient should be an active participant

What are key preparation steps before STM?

• Clear contraindications

• Check for allergies

• Position and drape properly

• Assess the skin

What direction are STM strokes typically performed?

Parallel to muscle fibers,

distal to proximal (toward the heart)

What is the proper progression during STM?

Warm-up → deeper treatment → cool-down

What is effleurage?

Light gliding stroke to:

• Warm up tissue

• Improve blood flow

• Assess tenderness

What is petrissage?

Kneading and lifting tissue to address adhesions and improve circulation

What is knuckling used for?

Deep stroking using knuckles to improve fascial mobility

What is stripping?

Deep, focal stroking using thumb or pisiform to reduce fascial adhesions

What is fascial stretching?

Gripping and stretching fascia to improve mobility

What is skin rolling?

Lifting and rolling skin to improve circulation and tissue mobility

What is strain-counterstrain?

Moving to a position of comfort for 90 seconds to reduce muscle irritability

What is positional release?

Similar to strain-counterstrain but adds light acupressure

What is trigger point massage?

Circular pressure on trigger points for 1–5 minutes to reduce symptoms

What is trigger point acupressure?

Static pressure for 60–90 seconds on a trigger point

What is active release?

Holding pressure while the patient actively moves for 3–5 reps

What is cross-friction massage used for?

Tendinopathies and scar tissue; involves deep perpendicular strokes

Name absolute contraindications for STM?

• Malignant tumors

• Skin conditions

• Open wounds

• Acute inflammation

• Impaired sensation or communication

Name precautions for STM?

• Circulatory dysfunction

• Joint effusion

• Neurological symptoms

• Osteoporosis

• Pregnancy

• Dizziness

• Steroid or anticoagulant use

What spine position is ideal during STM?

Neutral spine

How long may a patient be positioned for STM?

10–30 minutes

What is important for draping?

Maintain modesty while providing access to treatment area

What is an example of prone positioning setup?

Neutral cervical spine, pillows under chest and abdomen, bolster under ankles

What are typical treatment goals for STM?

• Increase blood flow

• Improve mobility

• Relax muscles

• Improve ROM

• Reduce pain sensitivity

Why must anatomy and pathology be understood?

To guide appropriate technique and load based on tissue healing

What is key for therapist body mechanics?

• Wide base of support

• Neutral spine

• Proper table height

Why is therapist mindset important?

Patients can sense therapist’s energy;

focus ensures safety and effectiveness

Why is patient communication critical?

To protect both patient and therapist and avoid misunderstandings

What nonverbal cues should be monitored?

• Guarding

• Facial expressions

• Fidgeting

• Positional shifts

What hygiene practices are required?

Wash and sanitize hands before and after;

only intended body parts touch patient

How should nails and hands be maintained?

Nails short and clean;

hands soft and sanitized

How can lotion contamination be prevented?

Use single-serve amounts;

avoid double-dipping into containers

When should emollients be used?

For techniques like effleurage or petrissage;

avoid for techniques needing grip

What is the typical treatment flow?

Warm-up → deeper techniques → cool-down

What determines combination and pressure of techniques?

• Clinical reasoning

• Patient goals

• Tissue response

What is mechanotransduction?

The process by which the body converts mechanical forces into a cellular response that leads to structural change

Why is mechanotransduction considered corrective in PT?

It directly addresses the underlying pathology by promoting structural healing

What are the three phases of mechanotransduction?

1. Mechanocoupling

2. Cellular communication

3. Response

What happens during mechanocoupling in a tibia fracture?

Appropriate weight-bearing is applied after the non-weight-bearing phase

What happens during cellular communication in a tibia fracture?

Weight-bearing stimulates osteocytes

What is the response in a tibia fracture?

Osteoblast activity increases, leading to greater bone density

What is tendon dysrepair?

A reversible stage of tendon pathology involving degradation of the extracellular matrix

What is degenerative tendinosis?

A progression of dysrepair when the tendon is not properly loaded or the source of pathology remains

How is tendon pathology corrected through PT?

By using activities that promote mechanotransduction, such as cross-friction massage and heavy eccentric training

What is mechanocoupling in tendons?

Eccentric overload physically deforms the tendon cell, or tenocyte

What happens during cellular communication in tendons?

Deformation stimulates integrins, which send signals through the cytoskeleton to the nucleus

What is the final response in tendon mechanotransduction?

DNA upregulation, leading to mRNA transcription and protein synthesis

How do tendon cells communicate with each other?

Through gap junctions and chemical messengers

What is the typical structural response in tendons?

Collagen synthesis

What training method best promotes collagen synthesis?

Eccentric overload training

Why must the eccentric phase be loaded more than the concentric phase?

Because the eccentric phase is more efficient at stimulating adaptation

Give an example of an eccentric exercise for tendons

Seated hamstring curl: use both legs to curl, lower with one leg

What is the recommended dosage for eccentric loading?

3 sets of 15 reps,

1–2 times per day

What protein that limits muscle growth is inhibited by overload?

Myostatin

What growth factor increases with eccentric overload?

IGF-1Ec, also known as MGF

How does eccentric overload affect neovascularization in tendons?

It destroys abnormal vascular ingrowth and the pain-causing nerves associated with it

What is Instrument Assisted Soft Tissue Mobilization (IASTM)?

IASTM involves using specially designed tools to achieve the benefits of soft tissue mobilization

What are the tools used for in IASTM?

They help clinicians detect and treat soft tissue dysfunction and amplify the feel of tissue restrictions

What materials are IASTM tools typically made of?

Stainless steel or plastic

What are some popular IASTM systems?

• Graston

• Hawk Grips

• ASTYM

What are the main theories behind the effects of IASTM?

Breaking cross-links, mechanotransduction, desensitization of pain fibers, improved fluid dynamics, and improved nerve metabolism

How does IASTM promote mechanotransduction?

By activating fibroblasts, promoting Type I collagen production, and helping restart stalled healing processes

How does IASTM desensitize pain fibers?

Through the Gate Theory of pain modulation

How does IASTM improve fluid dynamics?

By promoting redistribution of interstitial fluid and improving circulation

How can IASTM affect nerve metabolism?

It may enhance nerve metabolism and improve conduction efficiency

Why use a tool instead of hands in soft tissue mobilization?

Tools offer precision, amplify tissue feel, reduce therapist fatigue, and increase efficiency while still requiring hand guidance

What is the advantage of tool contact area compared to fingers?

Tools have a smaller, more precise contact area than fingers

How do tools help reduce therapist fatigue?

They lessen strain on the therapist’s hands and joints during treatment

What are common indications for IASTM?

• Tendinopathies

• Fascial syndromes

• Myofascial pain syndromes

• Trigger points

• Ligament pain syndromes

• Scar tissue adhesions

• Edema

• Entrapment syndromes

What are examples of tendinopathies treated with IASTM?

• Epicondylalgia

• Achilles pain

• Patellar tendinopathy

What are examples of fascial syndromes treated with IASTM?

• Plantar fasciitis

• ITB syndrome

• Trigger finger

What are examples of ligament pain syndromes treated with IASTM?

MCL, LCL, AC ligament, and UCL pain syndromes

What are examples of entrapment syndromes treated with IASTM?

• Carpal tunnel syndrome

• Ulnar entrapment

• Thoracic outlet syndrome

What is the first step of an IASTM treatment protocol?

Warm up the target area

What are some ways to warm up tissue before IASTM?

• Walking on a treadmill

• Using a recumbent bike or arm ergometer

How long should an IASTM session last per area?

<10 min

Less than 10 minutes per area

How long should a single lesion be treated during IASTM?

30–60 seconds,

up to 90 seconds maximum

What is the guiding principle for initial IASTM treatments?

Less is more

What should be done after performing IASTM?

Exercise the treated area

What type of exercises are recommended post-IASTM for acute conditions?

Low-load, high-repetition resistive exercises

What type of exercises are recommended post-IASTM for chronic injuries?

Eccentric exercises

What is recommended for cooling down after IASTM?

Apply ice if the patient is sore or bruised

What should patients be educated about before or after IASTM?

They may experience mild to moderate pain, soreness, or bruising that resolves in 1–3 days

What outcomes are expected after IASTM?

• Improved ROM and flexibility

• Decreased pain during movement

What are signs of regression after IASTM?

Increased pain or bruising beyond normal tolerance

Educate the patient, decrease dosage, or discontinue if intolerance continues

What factors determine tool selection for IASTM?

The size of the treatment area

What is the typical bevel position for most IASTM strokes?

Bevel UP

What angle should the tool be held during IASTM?

30–60 degrees for most strokes,

90 degrees for specific techniques