Principles of Massage And Soft

Tissue Manipulation

By Dr Nikhat Fatma
Sports Physiotherapist
 SLOs
Students will know the Principles of soft tissue
manipulation at the end of the session.
Principles of Soft tissue
manipulation
 1)Position of the therapist-
 When starting to perform and practise massage check that you
can:
 Reach all parts.
 Stand in walk or lunge standing to do so.

Stance of the therapist-

 The therapist, should adopt a position which can provide.
 Wide base to ensure proper stability during manipulations
 Free body movement to have rhythm and maintain the
continuity of massage.
 Effective use of the body weight to minimise muscle
work while applying pressure.
Flexion attitude of spine during massage strains
the back muscles and adds to the discomfort of
therapist. Therefore, it should be avoided as far as
possible.

Generally, the therapists during the practice of

massage adopt the following modification of
standing.
 Stride standing
 Walk standing
 Fall-out standing.
 2)Self Preparation or Appearance of
the therapist
Long hair must be restrained so that it cannot come into
contact with the subject and, equally, necklaces or other
jewellery which can dangle should be discarded, as
should a wristwatch.

Attention to personal appearance, hygiene are all

important.

Rings should be removed as they can cause discomfort

to the practitioner when performing some manipulations
and to the patient during most manipulations
Well - cared - for hands which are smooth with short,
clean nails are essential.

Cleanliness is important to avoid cross infection so

wash your hands before and after each treatment.

Other ornaments like long ear rings.necklace etc

either remove or arrange properly.
• Washed your hand and dried up before and after
massage.

• Therapist should avoid any sort of perfumes as

they can have a nauseating effect on some patient
due to allergy.
 3)Attitude of the therapist.
Therapist should be pleasant and courteous.

Therapist must give necessary instruction to the

patient in an affective manner.

Therapist voice should be clear , low and smooth.

Avoid conversation during the session.

The instruction should be simple short and self

explanatory.
 Relaxation –
Relaxation of your hands is very important so that you
always use your hands in full contact with your patient, and
moulded to the shape of the body you are touching, with
awareness of the tissues and of their state.

Relaxed hand contact is one in which the hand conforms to

the contour of the part.

In addition you will need to be able to relax your whole

arm to perform some manipulations. You should practise a
method of relaxation yourself prior to learning massage.
4)The environment
The treatment area should be quiet, with discreet
colours, well heated and well ventilated but not
draughty.
Contact mediums
Lubricants- like powder , oils , cream etc.

Purpose of using lubricants are-

 To make skin soft and smooth
 Reduce friction between therapist’s hand and
patient’s skin.
 Gain the placebo effect.
 5)Positioning of the patient
Depending upon the age, sex, condition and the part to be
treated, patient should be placed in a suitable and comfortable
position. The aim of this positioning is to ensure the
following:

1. The part to be treated should be fully supported to ensure

relaxation and to gain the confidence of patient.

2. The body part should be easily approachable to the therapist

so that he does not face any difficulty in proper
administration of the techniques.

3. It should not hamper the continuity of massage.

 6)Drapping
The part to be massaged must be fully exposed so that
therapist can thoroughly look over the part and rule out the
contraindications.

Any adverse effects produced during manipulation can also be

noticed immediately. However, any undesired exposure of the
body parts must be avoided.

The other parts of body must be drapped properly using

appropriate drapping material such as bed sheets, towel, etc.
This drapping or covering up of the patient helps.
 to honour the modesty and privacy of the patient
 to keep the patient warm (in winter
7)Selection of the technique of
massage
8)Contact and continuity
9)ACESSORIES

Following accessories are essential in the practice of

massage

 Low Stool or Without Arm Support Chair-It is used in

positioning of patient in sitting, during the massage of
the face and upper limb and the upper neck.
 Couch-It should be well-padded. The top of couch
should be covered with washable plastic or rexine , to
facilitate cleaning and disinfection. Height of the couch
should be adequate so that the therapist need not stoop
(when the couch is too low) or reach up (when the couch
is too high) to perform the manoeuvres. It should be
wide enough to allow the patient to turn sides.
 A couch of 6½ feet long, 2½ feet wide and 2½ -3 feet
height is adequate for the most therapists of average
height.

Wider couch will have a disadvantage that each time

patient turns the therapist has to bring him closer
towards the edge. Ideally, the couch should have shelves
incorporated into it where linen, pillows, lubricants, etc.
can be stored. Alternatively a movable trolley can be
used to keep the accessories near the couch.
Bed sheet-Six to seven, easily washable large bed
sheets are required to drape the patient. One bed sheet
should be placed over the plastic surface of couch to
facilitate patient’s comfort. This also absorbs the
perspiration. In winter, the use of one or two large
light blanket over the couch will add to the comfort of
the patient.
 Towel-Three to four, large size, and 3-4 small size
towels are required to drape and provide support to
the patient. The small towels can be used to remove
the extra lubricants from the patient’s skin.

Pillows-Seven to eight soft pillows with washable

covers are essential for positioning the patient
Small Kidney Tray or Bowl-It is used to keep
lubricants.

Soap-A non perfumed soap should be used to wash

the hands of therapist before and after massage.

Water Tap-Therapist should have access to a

running water tap to wash the hands. Alternatively
water can be kept in a small plastic container
 Sequence of the massage
Upper limb
 Superficial Stroking: From shoulder to fingers 4 to 5
strokes covering all aspects of the upper limb.

 Effleurage: Performed with only one hand the other

hand holds the patient’s hand and changes the position
of patient’s forearm. Consist of 4 to 5 strokes each ends
at axilla. Strokes are performed in following order:
Forearm Pronated
 I. Starts from posterolateral border of hand→Ulnar
border of forearm→medial,surface of arm→axilla

 II. Dorsum of hand→posterior surface of

forearm→posterior aspect of arm→ axilla.
Forearm Mid Pronated
I. Lateral border of hand including, thumb→radial
border of Forearm→lateral surface of arm→axilla.

Forearm Supinated
 I. Palm of hand→anterior surface of
forearm→anterior aspect of arm→axilla
 II. Antero-medial border of hand→antero-medial
aspect of forearm→medial surface of arm→axilla.
Kneading
a. Double handed finger kneading—around shoulder
joint
b. Single handed finger kneading over deltoid
c. Alternated handed palmar kneading over—biceps
and triceps
d. Palmar kneading—to upper part of forearm
e. Finger tip kneading—on the interosseous space
f. Thumb kneading—over thenar and hypothenar
eminences.
Picking up
 To deltoid—triceps—biceps brachii—flexors of
forearm and brachioradialis.
Hacking
 It is performed first on one aspect of the upper limb
then the position of forearm altered and other aspect
is approached.
i. Forearm pronated: Start from posterior wall of
axilla→posterior deltoid→triceps→forearm
extensors.
ii. Forearm supinated: Start from anterior wall of
axilla→anterior deltoid→biceps— forearm flexors
—palm (all bony prominences should be avoided)
during hacking.

Effleurage to whole upper limb again (distal to

proximal ending at axilla).
Lower Limb

 Superficial stroking: From the thigh to toe 3 to 6

strokes, covering all the aspects of the lower limb.

 Effleurage: Performed with both the hands

alternatively or simultaneously, consists of 3 to 6
strokes each starting from toe and ending at the
inguinal lymph nodes (femoral triangle).
Over Thigh

 Effleurage: Consist of 3 to 6 strokes covering all

aspects of thigh. Stroke ends at inguinal lymph
nodes.

 Kneading: Double handed palmar kneading to:

i. Anteroposterior aspect together
ii. Mediolateral aspect together
Picking up: On quadriceps, adductors and
hamstrings.
 Hacking
 Beating
 Effleurage.
Over Knee
Effleurage: Performed by crossing both the hands
above patella, stroke ends at the popliteal fossa.
Thumb kneading: Around margin of patella
Finger kneading: Around medial and lateral,
collateral ligaments of knee joint.
Effleurage.
 Over Leg
Effleurage: Starts from toe or ankle; stroke ends at
popliteal fossa. Rotate the limb into lateral rotation to
approach the posteromedial aspect of leg.

 Over Calf Muscles

Palmar kneading on the upper calf/thumb or finger
kneading on the lower calf
Picking up
Hacking.
Rotate the leg into medial rotation to approach the
posterolateral aspect of leg.
 Over Tibial and Peroneal Muscles
 Palmar kneading on the upper half/thumb or finger
kneading on the lower half
 Picking up
 Hacking
Over Foot

Effleurage: Stroke ends at ankle

Fingertip kneading: On the interosseous space and
over extensor digitorum brevis
Effleurage to whole lower limb.
 Back

The back can be divided into 3 areas—thoracolumbar,

gluteal region and the neck. Massage may be performed
in the following sequences in the respective areas.

Thoracolumbar Region
1. Superficial stroking: From proximal to distal.
2. Effleurage: Performed with both the hands working
together, it consists of 3 strokes executed in the following
order.
I. Starts from the most lateral lumbar region—goes
upto axilla.
II. Central lumbar region—up to axilla.
III. From posterosuperior iliac spine→midline of
back→neck →supraclavicular nodes.

Ironing: Over the entire back therapist should change

his side while
approaching the opposite side.
Finger kneading: Over paravertebra
 Simultaneously preferably starting from lower back and
proceeding gradually toward upper back.
Hacking: Entire back leaving the spinus processes and
scapulae.
Beating or pounding.
Skin rolling.
a. From side to midline or vice versa
b. In midline from distal to proximal.
For beginner, respiratory massage techniques, i.e. clapping,
vibration and shaking can be included in massage of upper
thoracic region for the sake of mastering the techniques.
Gluteal Region
Effleurage: Consists of 3 curved strokes performed with one
hand, each stroke ends at the groin. Direction of strokes is
from PSIS to iliac crest upward and from iliac crest to groin
obliquely downward in order to terminate at inguinal lymph
nodes.
Palmar kneading: Over gluteal muscles.
Ironing
Finger kneading: Over the margin of iliac crest
Picking up
Wringing
Hacking
Effleurage.
 Neck
Effleurage: Performed with palmar aspect of adducted
fingers. It consists of 3 strokes in the following order.
The direction of stroke is from upper to lower neck
i. Side of neck→supraclavicular area
ii. Back of neck→supraclavicular area
iii. Midline→side of neck→scapular muscle→axilla
Finger pulp kneading to–occiput, upper trapezius–
midscapular muscles.
Picking up–to upper fibre of trapezius
Hacking
Effleurage
Face
•Effleurage: Consists of 4 strokes directed from midline of face
to the submandibular lymph nodes performed in following
order.
i. Starts from midline of forehead→downward→below the ear
ii. From nose→cheeks→submandibular nodes
iii.From above and below mouth→submandibular gland
iv. From under chin→submandibular gland.
Finger kneading: In the same line of the stroke of
effleurage
Wringing: Performed with pulp of index finger and thumb
over the entire face
Skin rolling
Tapping
Vibration and kneading with one finger over the exit of
trigeminal nerve, i.e. supraorbital submental and
infraorbital foramina and facial nerve, i.e. stylomastoid
foramina
Effleurage.