Ernest Eckford Tucker
Soft Tissue Treatment
Lesion in the Osteopathic sense is the original
or responsible cause of disease. Unless otherwise specified, it refers
to bony or mechanical disorder or strain.
It is rarely that disease arises from one cause only.
Nor is it possible to choose among the many causes and say which is primary
and which secondary, except in time. All causes acting at one time
are responsible causes, “procuring causes” as the legal phrase is.
Mechanical lesions are, however, always fundamental and determinable.
Analysis of mechanical factors in disease so far
as at present understood shows that they may be divided into several classes
The reason for so dividing them is that they need
to be separately studied, since they require different forms of treatment.
Osteopathic lesions, much the most important, will
be discussed last.
Myopathic lesions are those in which contracture
of muscles is the cause of further disorder, is the mechanical factor that
needs to be removed. These may be themselves secondary, or may be
merely a part of the whole abnormal condition; that seems to make no difference
in the effect. The removal of this part does in fact relieve, or
tend to relieve, the whole, and to react on the primary condition from
which it arose. The discussion of that fact is a matter for the subject
of principles. We are here concerned with the technic for removing
(The word contraction is used to indicate normal
contraction; contracture is used to refer to the pathological continuance
or exaggeration of contraction.)
With myopathic lesions should be included contracture
of areolar tissue (which being briefer will be considered first).
This proves to be very widespread, though rarely very acute, but is important
as a cause of disease. The same irritation that causes contracture
of muscle may overflow into areolar tissue and cause contracture of that
also. The more sluggish and less controlled areolar tissue may then
remain in contractured state much longer than the muscular tissue.
All living tissue is contractile. The contraction
of areolar tissue ;may be at times surprisingly vigorous. Under the
irritation of shock, as from a blow or cold, etc., it shows itself.
It may remain long after the cause has been removed. In that state
it becomes a cause of trouble in nerves and in venous and lympathic drainage.
This humble and ignored kitchen-drudge tissue of the body has some highly
important functions. Normally it is in a state of slight contraction.
It holds the skin in position so that it does not drag and stretch by its
own weight. It holds the skin against the under-lying structures
so that it prevents accumulation of lymph, etc.; it guides the lymph along
to the opening of the lympathic ducts and aids it to enter. It adapts
itself to variations in atmospheric pressure and in position. In
inflammation, it contracts vigorously around the inflamed area, being sufficient
to seal up the part and prevent the diffusing of the inflammatory exudates;
so that it acts to circumscribe inflammation; and in so doing converts
the part into erectile tissue; whence the swelling. In wounds it
prevents the escape of lymph and helps to close up injured blood vessels.
When so occurring it is likely to remain almost indefinitely,
as though it lacked the power of spontaneously relaxing. It is when
thus remaining contractured that it becomes a source of mischief.
The effects of its contraction are in line with its
function. It overdoes that which is normally its work. It has
in normal tissue the effect it should have only in wounds, etc. It
checks the lymph, retards the blood, numbs the nerve terminals, prevents
the easy adjustment of part to part and so causes friction, etc.
There are certain areas of the body where this tissue
is especially abundant, where such disorders are of greater relative frequency,
which should be mapped out and studied; as for instance the back of the
The relaxation of such tissue is best accomplished
by manipulation beginning gently and increasing gradually, so as not to
rupture the delicate fibres. A sense of coldness and of resistance
may be noted, and a distinct though vague sense of comfort like that from
removing tight clothes is noted by the patient. Around bruises or
boils, etc., there is an area more or less wide-spread of such contracture.
By beginning far enough away and gently enough and approaching gradually
nearer the injured part, one may often in a few minutes handle it with
ease and practically without pain, and greatly improve lympathic and venous
drainage and nerve tone. After fractures, sprains, etc., it has been
found that such relaxation of areolar tissue hastens recovery markedly.
Hot applications may be used to numb the nerves if necessary, after which
manipulation will be found to give much less pain.
The treatment is of course contraindicated in focal
infections and bleeding wounds.
Muscular contractures are almost invariably associated
with disease. Disease is always a matter of excess. This excess
takes the shape of nerve overflow, and causes contractures around the nerve
centers of the parts affected, at the spine, or in areas supplied from
the same segment. Relaxation of such muscles does in fact have a
beneficial effect on the disease; the reason for which pertains to the
subject of principles.
For the relaxation of contracted muscle there are
three mechanical methods: manipulation (rhythmic stretching with
the hand) stretching (by passive movements of the body) and inhibition
(pressure with the hand, on the muscle or its nerves). To this may
be added exercise, to promote functional relaxation.
Five minutes of massage will exhaust temporarily
any normal muscle. From one to two minutes is all that is usually
required to relax single muscles in contractured states. The time
that it takes to get this relaxation is a rough measure of the depth of
the pathological excitation.
The difference between these methods is not very
great, and the one that should be used is more a matter of the convenience
of the operator and the patient than that of pathological indication.
Probably the best method is a combination of the
three. Placing the patient in a comfortable and relaxed position
such that the contractured muscles are extended but not to their fullest
extent, apply pressure to the muscle while extending it further, for three
or four seconds, then release for a second or two, and repeat, until the
muscle is found to relax.
Students should practice with a dynamometer at their
side until they can gauge the amount of pressure they are applying.
In no other way can they criticize or standardize their own work or successfully
compare it with that of others. Rarely as much as ten pounds need
be used on the neck, in adults; more in the back, still more in the lumbar
Where muscles are found to be sore, manipulation
should be gentler at first, increasing in weight; should be farther away,
approaching nearer the focus of disorder, as the pain diminishes under
the manipulation. The pain should disappear under the treatment,
or shortly after. The reaction time of the sensory nerves measures
the reaction time of the nerves involved in the pathological condition,
so that when the change has occurred in the one, it will be found to have
occurred to some degree at least in the other also.
Failure to secure results in such treatments is due
first to failure to secure perfect relaxation. It should not
be prolonged beyond the point of relaxation, but should not be left until
at least some relaxation is secured. Dr. Tyndall states that “We
often miss the whole effect of a treatment because w do not make it a point
to secure perfect relaxation at the segment treated.”
Failure may be due also to ignoring of the deep muscles
of any given segment. These are apparently the ones most affected
and closest to the nerve centers involved. When the more superficial
muscles have relaxed, the examining finger should pursue the investigation
to the deeper tissues, until the whole palpable area of the segment has
been outlined and relaxed—short always of overfatigue of the nerves.
The normal uncontracted muscle should be almost unpalpable—as soft as the
cheek. In very thin persons the tendons of spinal muscles will often
be mistaken for contractured muscle fibres. Often after treating
a certain area a short time and leaving it for some other point and then
returning, the first point will be found to have become relaxed.
It is best always to return to make sure.
In severe conditions heat may be used to aid in relaxing.
Heat tends to produce a paretic condition of blood vessels, cold to produce
a spastic condition of them; and the effect on muscles is of the same kind.
Knowledge of specific centers is very valuable in
soft tissue treatment. The treatment should be begun and carried
to a finish first at the specific centers for the organs affected.
Other contractures may if necessary be ignored for the time.
Frequency of treatment is a matter of the severity
of the condition and the character of the disease. Contractures will
recur if the irritation from which they arise remains. In pneumonia
these recur sometimes in a few minutes or half an hour. Short of
causing unfavorable reaction from the treatment itself the tissues may
be relaxed as soon as contraction recurs. This is not always possible.
In pneumonia every hour is not too frequent, and some physicians treat
as often as every twenty minutes. In the exanthemata the usual
practice is three times a day except in more dangerous states, when it
may be more frequent, graded according to the strength of the patient.
In the average chronic condition the frequency of treatment is determined
by mechanical conditions of the framework. Twice to three times a
week is the average. In asthma, once in a week or ten days is best,
more frequent is regarded as hazardous.
Relaxation as a preparation for reduction of bony
lesions is by some regarded as essential. In general it is advisable
especially if the sensibilities of the patient need to be considered; but
it is not always mechanically necessary.
Have patient lie on right side on table; right leg
extended straight with the body; left leg drawn up and forward, knee resting
on table in front of right knee. Draw shoulders well back; left shoulder
slightly in advance so that chest slopes slightly toward table; head resting
on a pillow high enough to keep neck up, straight with spine.
The longer muscles of the right side—erector spinae
mass—will be found to be on tension; those on the left side relaxed.
The deep muscles of the left side may sometimes be stretched, according
to the position of the patient. Contractured muscles may be easily
noted on the left side.
The bodies of the lumbar vertebrae have sunk toward
the table farther than the spine thereof (rotated). It will be noted
that the axes of rotation of lumbar vertebrae are posterior to the tips
of the spines in general. The articular surfaces on the left side
are telescoped into each other, those of the right extended; the costal
processes are approximated on the left, separated on the right.
Standing behind the patient place one or both thumbs
on the top or left side of the spinous processes and slide them forward
following the contour of the bone, keeping the muscular mass in front of
them, until they meet the resistance of the contractured muscle; then press
them against the mass, swinging the lumbar spine forward with the pressure,
and release and repeat, slowly and with graduated pressure, until the contractures
are overcome. This pressure and motion tends to separate the costal
processes from each other on the left side, swinging the bodies still farther
toward the table, and to stretch the muscles. Having relaxed the
larger and more superficial muscles, carry the exploration deep into the
tissue between the vertebrae.
This is effective as far up as the eighth or ninth
To increase its effectiveness in the lower dorsal
and to carry it up into the mid dorsals, grasp the patient’s shoulder with
the right hand, drawing back or merely holding, while the slow rhythmic
pressure is applied with the left thumb.
To make it effective in the upper dorsals, place
the patient’s left elbow in contact with the table fairly close to the
body and hold it there with the left hand while applying rhythmic pressure
with the right thumb.
In dorsal vertebrae, this pressure does not cause
further extension with stretching. Stretching is here produced by
side-bending, the shoulders being carried upward. Pressure against
one side of a vertebra tends to carry it forward, but that movement is
slight. There is always enough elastic “give” to ligament, cartilage,
and even bone, to insure some motion and some stretching of contractured
muscle, by this alone. But this motion is opposed by several
factors in the chest. The articular surfaces are flat against it.
The ribs also, sustained by the pectoral muscles and the intercostals continuation
of them, do not yield and so prevent rotation of the vertebra. Lastly
is the fact that the center of rotation of a dorsal vertebra is in front
of the body, so that it can rotate only by carrying the rib with it.
To produce further stretching in this position the shoulder must be used
to produce side-bending.
If, however, the operator puts the fingers of his
left hand on the corresponding rib at about the center and presses down
and forward so as to carry the rib away from the spine, this together with
the thumb pressure at the spine rotates the vertebra to the limit of its
capacity; and aids in relaxing the deep muscles of that segment.
If instead of holding the shoulder the operator carries
it up so as to stretch the pectoral muscles and elevate the ribs and then
applies pressure to the left side of the dorsal vertebrae, he produces
side-bending with stretching, especially when the patient inhales.
As the patient exhales this may be changed into a primary rotation, with
rotation downward of the rib on transverse process and between vertebral
In the upper dorsals and ribs there is very little
real motion. A slight flexion and extension; a slighter unilateral
flexion and extension or side-bending; a still slighter rotation, are all
that are found in the average person. (For these reasons the articular
surfaces are irregular as shown in the analysis of that subject made at
When, however, the head is drawn back and the face
turned toward the table, pressure on the left side of the vertebrae here
causes the transverse processes to be separated to the full limit of their
possible motion on the left side, with corresponding motion at
all other parts, and with stretching of the muscles.
Pressure technic is little used for the neck; caution
must be exercised on account of the possible pain to the patient.
It is not necessary to press hard enough to produce
motion in all cases. The pressure alone will ultimately relax all
of the muscles that it reaches. It is not necessary to make the pressure
greater as the contraction is greater. We are dealing with not mechanical
but vital structures; gentle pressure will be pretty sure to win in the
end. Prolonging the pressure is better than increasing the force
Have the patient lie on right side on table; operator
stands in front. Anchor patient’s knees against operator’s abdomen
(on innominate bone, or fix with right hand). Reach with left hand
(or both hands) across body and place fingers in contact with left (upper)
side of spine of limbar vertebrae; slide them forward following contour
of bones and drawing muscular mass before them (caution—the finger tips
should not be used, as the clawing so produced may cause pain); use the
balls of the fingers. Draw with rhythmic motion until muscles relax.
The position of the knees has no effect on the position
of the lumbar vertebrae or the tension of lumbar muscles unless they be
carried high enough to produce extension of the vertebrae and tension of
hip muscles; in which case it is the larger superficial muscles (erector
spinae mass) that are tensed, and not the deeper and more important ones.
The effect of the drawing on the muscles is slight
as to relations of the vertebrae, producing some slight rotation and flexion
of those whose muscles are drawn upon. The chief effect is on the
To make this treatment effective in the lower dorsals,
hold knees as before, and place hand on patient’s shoulder to hold or to
push while drawing forward and upward on the muscles of this area.
The effect of this, beside stretching of the muscles
to which tension is directly applied, is to cause unilateral extension
(side-bending) of the vertebrae at the focus of the tension, with rotation
downward of the ribs unless this is offset by sufficient pressure on the
shoulder to tense pectoral and intercostals muscles.
The sasme technic applied to the ribs causes rotation
downward or upward according to the tension on the pectorals and intercostals,
and with respiratory movements, stretching of muscles and ligaments below
the rib, and with side-bending of the vertebrae to which they are attached;
(rotation if the traction is low enough with less pressure on shoulder).
To make this technic effective for mid and upper
dorsals, anchor the patient’s elbow against operator’s abdomen or by means
of left hand, while applying tension to spinal muscles with right hand.
Or, with operator’s left hand on patient’s left shoulder, patient’s arm
thrown over operator’s arm, the arm may be carried up toward patient’s
face until tension is produced on pectoral and intercostal muscles, with
similar traction. The student should explore the various effects
of different positions and tensions of patient’s arm and shoulder on vertebral
and rib movements, while applying traction to muscles and ribs.
To make this technic effective in upper dorsal and
lower cervical areas, carry the patient’s head slightly back with left
hand, and press his shoulder slightly back and down with right wrist while
right hand is applied to muscles of upper dorsal or lower cervical areas.
For the neck, however, this technic is best applied
with patient supine, operator’s left hand on patient’s forehead, rotating
it in direction opposite to traction, his right hand passing across the
neck to the left side of the spinous processes, applied to the muscles
of the neck. The effect of traction in this position, beside the
tension on the muscles, is to cause complicated movement of the cervical
vertebrae. The traction alone would cause the head to roll to the
right with approximation of articular surfaces on right, extension on left.
The rotation by the forehead alone would cause first rotation of the atlas-axis
joint then extension of the right articular surfaces and approximation
of those on the left. The combination of the two causes extreme rotation
of the atlas on the axis to the left, rotation side-bending of the lower
cervical vertebrae to the right, and extreme lateral motion of the
vertebrae over which tension is applied (a sort of combination of many
motions) to the left. The picture varies with the kind and degree
of tension and rotation applied. The student should try to form a
moving picture of the actual movements of the different parts of the neck.
There is an endless variety of ways in which the pressure
technic and the traction technic may be applied to the relaxation of muscles,
according to the convenience and stature of the operator and the conditions
in the patient’s body.