Manual therapy can be performed for many reasons. One goal is often general wellness or relaxation. Another might be to address a specific pathologic myofascial condition. When massage is done for the latter, there are many terms used to describe it, including medical, therapeutic, rehabilitative, remedial, clinical, and orthopedic massage. I prefer the term clinical orthopedic manual therapy (COMT), using the word manual instead of massage to recognize and encompass all manual therapy treatment techniques a therapist can employ—massage, as well as stretching and joint mobilization.
There are two major factors that usually define COMT work. One is that instead of being applied broadly across the body, the modalities are targeted at the specific structure or structures that are the underlying causative mechanism for the pain and/or
dysfunction the client is experiencing. The other is the depth of the work, in other words, the force of the pressure that is being generated into the client’s tissues. For this article, I would like to explore how the depth of COMT is applied. In effect, what does it mean to generate the force needed to challenge tissue tension and find the optimal therapy zone?
COMT massage is generally performed with deeper pressure. Deep pressure is not always indicated or preferable to lighter work, but it’s often the key to remedying the cause of the client’s condition. So, the question might be: How do we determine when deeper work is needed? The quick answer is: when the condition is a mechanical one that is located in deeper tissues. In these cases, lighter work simply can’t reach and address the underlying cause.
With nearly every myofascial condition, unhealthy baseline muscle tone is involved. Most often, the resting baseline tone is overly contracted. This musculature can be described as “hypertonic,” “overly facilitated,” “locked short,” “locked long,” or, in layman’s terms, “tight.” The other factor that is usually involved, especially with more chronic conditions, is fascial adhesions. Between tight musculature and fascial adhesions, perhaps the best way to describe this is tissue densification.
Tissue densification can be divided into two categories based on the size of the area affected: a broad global area versus a focal localized area. Global densification occurs when the entire muscle, or a large portion of it, is tight. Contrasting this, focal localized densification can be caused by a myofascial trigger point (TrP) and/or fascial adhesions.
The underlying cause of global muscle tightness is not a mechanical issue in the tissue itself; rather, it lies in the nervous system’s control of baseline muscle tone. Baseline muscle tone is controlled by muscle spindle activity, which is itself controlled subconsciously by gamma motor neurons, ultimately in the brain (Image 1). With this type of tightness, even though manual treatment might be applied to the local myofascial tissue where the client is experiencing discomfort, it is ultimately directed at influencing the central nervous system.
When working on a client with global tightness, depth of pressure does not necessarily need to be deep. Rather, it can vary greatly from light to deep based on the depth of work that would best convince the client’s subconscious nervous system to down-regulate their muscle tone, and this varies from client to client, as well as from one area of their body to another (see Tissue Densification Table).
Local densification can involve two mechanisms—myofascial TrPs and fascial adhesions. Unlike global tightness, whose root cause is in the nervous system, both TrPs and fascial adhesions are local mechanical issues situated in the myofascial tissue itself; they are not directly mediated/regulated by the central nervous system. Therefore, for manual therapy to affect these local issues, it must reach them. This means that if the target tissue is deep, the pressure must be deep. Working lightly in the area can’t cause the mechanical change needed to help resolve the condition. Let’s explore myofascial TrPs and fascial adhesions, and what role depth-of-pressure massage must play in improving each of these conditions.
Myofascial Trigger Points: A myofascial TrP is a focal area of hypertonicity within myofascial tissue, most often within muscular tissue (Image 2).
The proposed and generally accepted primary causative mechanism is termed the energy crisis hypothesis. This posits that a lack of energy (energy crisis) is responsible for the formation and perpetuation of the TrP. To understand this, we need to understand the structure of muscle tissue.
So where does the energy (and energy crisis) enter this equation? The energy for this mechanism comes from adenosine triphosphate (ATP) molecules, formed in the mitochondria by the burning of glucose in the presence of oxygen. The ATP is required during two steps in the mechanism. It is necessary to reabsorb the calcium back into the sarcoplasmic reticulum; if the calcium is not reabsorbed, then the active sites will forever remain exposed, and the myosin heads will forever stay attached, perpetuating contraction. The second place that ATP is needed is to release the myosin-actin cross-bridge; therefore, without the ATP energy, the muscle contraction cannot release. This might seem counterintuitive, but it takes energy to release a muscle contraction; a good example of this is rigor mortis (see “Rigor Mortis”).
The point of this discussion is to explain that if a muscle loses its ability to create ATP, it has a crisis of energy and a TrP forms. Once formed, it self-perpetuates. Why might muscle tissue lose its ability to generate ATP in the first place? The most likely reason is ischemia, a loss of arterial blood supply to the muscle tissue. This most likely occurs due to prolonged contraction in the muscle tissue, which hardens/densifies the tissue, thereby compressing the arteries in the area and cutting off their ability to deliver the oxygen and glucose needed by the mitochondria to create the ATP. Once the densification of the TrP occurs, it creates a vicious cycle: It cuts off its own arterial supply (ischemia), which then creates the condition wherein the TrP contraction forms, which perpetuates the ischemia, which perpetuates the TrP, etc.
Trigger Point Massage Therapy: Although there is no universal agreement on how massage therapy treatment helps treat a mysofascial TrP, and most causes of a myofascial condition are multifactorial, I believe the principal mechanism involved is promoting blood flow to the ischemic tissue of the TrP. This is essentially a mechanical problem, so it requires a mechanical solution (although neural facilitation via the nervous system can contribute, so the central nervous system can be an additional factor). The mechanical solution is generating pressure into the tissue to, in essence, milk arterial blood supply into the tissue. And now, to bring this full circle, if the TrP is located deep in the tissue, the pressure must be deep to reach it!3
We are now at the crux of this article . . . the concept of challenging the tissue-tension mechanical barrier of densified tissue. When we first generate massage pressure into the client’s myofascial tissue, the tissue yields to our pressure, and we sink in unimpeded. But as we continue to slowly and gradually increase our pressure (Note: slowly and gradually!), we start to feel the tissue resist (Image 9).
This is the point where the tissue has yielded as much as it can without us causing a change in its state. It’s at this tissue-tension barrier that we can now begin to effect a change and be therapeutic. So, for COMT to be effective, we must be able to feel this tissue-tension barrier. Next is our ability to challenge the barrier. This requires us to increase our pressure (Image 10). How much? Well, the more you challenge, the more effective the treatment is, until you reach a point where your increased pressure can cause harm.
Working in this zone of challenging tissue tension effectively but not excessively is learning how to work within what is called the optimal therapy zone. To do this, we must constantly be present and mindful. This is a kinesthetic palpatory skill, so although it does help to intellectually understand the mechanism involved (it’s amazing how the hands follow what the mind envisions), this is a skill that’s refined with physical practice and experience. So, until we have confidence in our ability to modulate our force for the optimal pressure to challenge tissue tension, it’s always safer to stay on the relatively lighter side.
Having said this, if we continually work lighter to be safer, we will not become maximally efficient at creating the healing change needed when addressing deeper tissues. So, please endeavor to learn how to deliver deep pressure comfortably (for you and the client), safely, and effectively.
Similar to a TrP, fascial adhesions are a local mechanical state of the tissue, not nervous-system mediated/controlled (Image 11).
Fascial adhesion densification can occur for a number of reasons, including lack of motion or injury to the tissue. Regardless of the cause, once fascial adhesions have formed, they can restrict motion in the area, causing hypomobile tissue dysfunction. To treat fascial adhesions, they must be mechanically worked with massage pressure. Whether we describe this as “melting the adhesions” or “breaking up the pattern of the adhesions,” the pressure we generate must reach the target tissue to be effective. Therefore, if the adhesions are deep in the tissue, the pressure must be commensurately deep to reach them.
Stretching might be an even clearer example of how COMT work must challenge tissue tension to be effective. When the range of motion (ROM) at a joint is decreased, we need to stretch the client by challenging the joint to move further to increase the joint’s ROM.
Let’s illustrate this idea with the following example: A client comes in with restricted ROM, say abduction of their arm at the glenohumeral joint is limited to 90 degrees. To increase their ROM, we need to stretch them by asking their arm to move beyond 90 degrees of abduction. During this stretch, as we move their arm up to 90 degrees, there is no resistance. At 90 degrees, we have reached tissue tension and start to feel that their tissue will resist any further movement. However, if we now stop at 90 degrees, we don’t ask for a change; consequently, we don’t improve their function because we don’t increase their ROM (we maintain the ROM, but we don’t increase it).
To be therapeutic, we need to challenge the tissue-tension mechanical barrier by moving them past 90 degrees, perhaps somewhere between 91 and 95 degrees of abduction (Image 12). We challenge tissue tension, mindful of staying within the optimal therapy zone.
I like to say that to be an excellent COMT practitioner, we need only three skill sets. The first is that we need to know anatomy. The second is that we need to be able to critically reason to figure out how to effectively treat the client (knowing anatomy and being able to think critically allow us to figure out physiology, pathophysiology, assessment, etc.). And the third skill is to be able to feel tissue-tension barriers in our client’s tissues. Being able to feel and challenge tissue-tension barriers allows us to comfortably, safely, and effectively deliver the hands-on treatment techniques needed to help treat our clients.
Grade IV slow oscillation joint mobilization is legal and ethical for massage therapists in most states.1 Essentially, it’s a form of specific pin-and-stretch with the target tissue usually being the intrinsic fascial (ligamentous/joint capsular) tissue of the joint.
As a stretch, we would employ the same biomechanics as we do with regular stretching (regular stretching is technically defined as “Grade III joint mobilization”). We bring the client to the end of their ROM (i.e., their tissue-tension barrier). We then ask for a little more motion by challenging that barrier. And, as in massage and stretching, we are mindful to stay within the optimal therapy zone.
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