Massage and Soft Tissue Mobilization (STM) Study Guide Notes

Massage/Soft Tissue Mobilization (STM) Study Guide

Reasons for Seeking Massage Services

  • People seek massage services for various reasons:
    • Medical purposes
    • Relaxation and stress relief
    • Pampering

CPT Codes: Massage vs. Manual Therapy

  • Massage and manual therapy have different CPT codes and represent different types of interventions.
  • Some clinics may cover manual therapy but not massage.
    • Soft tissue mobilization (myofascial release, IASTM, cupping) falls under manual therapy interventions.

Effects of Immobilization and Trauma

Connective Tissue
  • Permanent loss of Glycosaminoglycans (GAGs) and water (H2OH_2O).
  • Collagen synthesis degradation.
  • Irregular collagen deposition and cross-linking.
  • Weakening of ligaments, tendons, and joint capsules.
  • Altered sensory input.
Muscle Tissue
  • Loss of sarcomeres and muscle weight.
  • Decreased protein, mitochondria, and enzymes.
  • Increased fibrosis at the musculotendinous junction during healing.
  • Muscle contusions heal with dense irregular connective tissue (scar tissue).
  • Decreased muscle extensibility.

Effects/Benefits of Massage/STM

General
  • Movement maintains balance between collagen synthesis and degradation.
  • Movement activates the alignment of fibroblasts and myofibroblasts in the direction of stress.
  • Facilitates GAG production, maintaining inter-fiber distance and lubrication.
  • Restores gliding between tissue layers.
  • Provides neurophysiological benefits due to the rich proprioceptive content of fascia.
Biomechanical Effects
  • Movement of:
    • Venous and lymphatic flow via a mechanical fluid pump.
    • Hematoma.
    • Lung secretions.
    • Intestinal contents.
  • Mobilization of:
    • Muscle fibers.
    • Tendons and tendons in sheath.
    • Skin and subcutaneous tissue.
    • Scar tissue.
    • Adhesions.
  • Stretches connective tissue (tensile loads).
  • Muscle Effects:
    • Stretches a muscle.
    • Elongates fascia.
    • Mobilizes soft-tissue adhesions or restrictions.
  • Skin Effects:
    • Increases skin temperature.
    • Increases sweating.
    • Decreases resistance to electrical current.
    • Toughens yet softens the skin.
    • Removes dead cells.
    • Stretches/breaks down fibrous tissue within the skin.
Physiological Effects
  • Increases skin temperature.
  • Increases skin and muscle blood flow.
  • Increases flow of nutrients and removal of wastes.
  • Stimulates or inhibits healing process.
  • Increases parasympathetic activity.
  • Increases relaxation hormones.
  • Decreases stress hormones.
  • Decreases anxiety.
  • Releases endorphins in the brain.
  • Patient gains confidence in clinician (1-on-1 treatment).
  • Light slow stroking evokes systemic relaxation.
  • Fast, deep strokes increase blood flow to the area.
  • Cardiovascular Changes:
    • Decreases heart rate, breathing rate, and blood pressure.
    • Mechanical vibratory massage increases blood pressure and stroke volume but there is no change to heart rate.
  • Edema reduces by increasing venous & lymphatic flow.
Neurological Effects
  • Decreases neuromuscular excitability.
  • Decreases pain via removal of edema and waste.
    • Reduces mechanical pain by decreasing pressure from swelling.
    • Reduces chemical pain by increasing blood flow and encouraging waste removal.
  • Decreases pain via sensory stimulation by stimulating T cells (transmission cells).
  • Decreases muscle spasm or tension.
Psychological Effects
  • Increases parasympathetic drive.
  • Endorphin release.

Stages of Healing for Manual Therapy

  • Manual therapy is most effective/beneficial in certain stages of healing.

Regional Interdependence and the Fascial System

  • Tensegrity = Tension + Integrity
    • Isolated structures don’t exist; the whole body is affected.

Considerations in Massage/STM

Patient Demographics
  • Age, gender, beliefs, preferences.
Patient History
  • Past medical history/Medications (PMHx).
  • Prior STM purpose/response.
  • Allergies.
Precautions/Contraindications
  • Consider precautions and contraindications.
Evidence
  • Evidence to support use.

Contraindications/Precautions of Massage/STM

Contraindications
  • Malignancy.
  • Inflammatory skin conditions.
  • Acute fracture.
  • Hemorrhage sites.
  • Obstructive edema.
  • Heart failure.
  • Clotting or bleeding disorders.
  • Acute rheumatic conditions.
  • Localized infection.
  • Suspected thrombophlebitis.
  • DVT (deep vein thrombosis).
  • Severe varicose veins.
  • Abdomen during pregnancy.
  • 24 hours after scuba diving.
Precautions
  • Intoxication or drug use.
  • Severe psychosis.
  • Decreased sensation.
  • Hypermobile joint segments (connective tissue disorder).
  • Osteoporosis.
  • Degenerative changes.
  • Skin disorders.
  • Sensitive superficial tissues (eyes, lymph nodes, superficial nerves).

Potential Adverse Effects of Massage

  • Post massage soreness and malaise (PMSM).
  • Ecchymosis.
  • Nerve damage.
  • Rhabdomyolysis.
  • Cervical headache/vertigo.

Massage Stroke Types

Effleurage
  • Intent: encourage blood flow and stimulate the tissues.
    • Beginning: relaxes patient & indicates area to be treated.
    • End: calms down irritated areas to prepare for release of contact.
  • Direction: congruent with lymph and venous return (towards the heart).
  • Pressure: superficial, rhythmic stroking contouring the body or relates to direction of underlying muscles.
  • Rate/Rhythm: slow and rhythmic.
Petrissage
  • Intent: free adhesions by stretching and separating muscle fiber, fascia, and scar tissue & assisting with venous return and milking out waste products.
  • Direction: fingers/hands moving in the same or opposite directions.
  • Pressure: deep.
  • Rate/Rhythm: slow, lifting and kneading of the skin, subcutaneous tissue and muscles.
Tapotement
  • Intent: promotion of relaxation and desensitization or irritated nerve endings.
    • Respiratory therapy for pulmonary hygiene.
    • Sports massage to stimulate blood flow.
  • Direction: N/A.
  • Pressure: varies from gentle tapping to pounding of the skin.
  • Rate/Rhythm: fast.
Cross Friction
  • Intent: mobilize tissues (often fascia, muscle, or tendons) and separate adhesions that restrict and cause pain (facilitates local blood profusion).
  • Direction: circular or perpendicular.
  • Pressure: begin lightly and then move to firmer strokes.
  • Rate/Rhythm: slow.
Trigger Point Release/Ischemic Compression
  • Intent: release tightness in a taut band of tissue.
  • Direction: compression (down).
  • Pressure: determined by patient tolerance.
  • Rate/Rhythm: 30 seconds – 5 minutes (until tissue release).
Myofascial Release
  • Intent: obtain relaxation and elongation of tense and/or adhered tissues (ease the tension of fibrous connective tissue bands).
    • Relieve soft tissue form abnormal grip of tight fascia
  • Direction: pulling the tissues in opposite directions, stabilizing the proximal/superior position with one hand while applying a stretch with opposite hand, or using the patient’s body weight to stabilize the extremity while a longitudinal stress is applied.
  • Pressure: N/A.
  • Rate/Rhythm: N/A.

Massage Sequence for Therapeutic Massage and Edema Management

  • Elevate!
  • Begin proximal to the edematous area. If swelling is present in an extremity, treatment should begin proximally.
  • Use long, slow strokes towards the torso.
  • Move starting point slightly distal every fourth or fifth stroke.
  • When the starting point moves distal to the edema, begin working back proximal to milk the fluid toward the heart.

Function of Medium for Massage

  • Decrease friction between the patient’s skin and the clinician’s hand.
    • More medium should be used on hairy areas.
  • During friction massage lubricants may interfere with the certain results you want to obtain.
  • During petrissage some lubricants interfere with the kneading & lifting.

Patient and Therapist Positioning

Patient Positioning
  • Make sure the patient is warm, comfortable, supported, and relaxed.
  • Make sure the patient is properly draped.
  • Support filling in negative spaces.
Therapist Positioning
  • Avoid hyperextension or hyperflexion of any joints which may lead to hypermobility.
  • Must obtain good posture/neutral joint to prevent fatigue and pain.
  • Weight should be evenly distributed on both feet.
  • You must be able to fit your hand to the contour of the area being treated.

Professional Considerations for Massage/STM

Ethical Issues
  • Respect privacy and patient sensitivity.
  • Ask for consent.
  • Continuous communication.
  • Professional appearance.
  • Personal hygiene.
  • Avoid inappropriate touching and unnecessary exposure.
  • Avoid interruptions.
Care of Hands
  • Wash prior to (and after) treatment (warm water and thoroughly dried).
  • Jewelry off.
  • Nails short with no edges.
  • Contact precautions if appropriate.

Documentation of Massage/STM Interventions

  • Client position
  • Contraindications/precautions reviewed
  • Medium used denies allergies
  • Areas of massage
  • Strokes/techniques performed
  • Intensity of pressure provided
  • Duration
  • Intensity