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Massage Today
May, 2014, Vol. 14, Issue 05

A Practical Application of the Tissue Density Grading Scale

By Linda LePelley, RN, NMT

The Tissue Density Grading Scale (TDGS) was developed to reliably represent the condition of musculoskeletal tissues at all stages of treatment or progression. By comparing pre-treatment assessments that include the TDGS with a post-treatment follow-up assessment, the effectiveness of any massage therapy treatment can be objectively depicted and documented.

While the following example makes reference to the use of Tissue Density Restoration (TDR) massage, it is important to understand that the TDGS is representative of the state of musculoskeletal tissues regardless of any type of treatment, or what treatment that may be. TDR massage is just the modality I happen to use, but any other type of massage may be evaluated in the same manner, whether it is Trigger Point Therapy, Myofascial Release, CST, Bowen, etc.

The basic TDGS follows. A more complete explanation of the scale may be found in the March 2014 issue of Massage Today.

Tissue Density Grading Scale

  • Grade 0 (Yellow) = Tissue is flaccid, hangs from attachments and has little to no resistance to gravity.
  • Grade 1 (Green) = Tissue is toned yet easily malleable.
  • Grade 2 (Blue) = Tissue is firm, tender if pressed into; muscles may appear and feel as if they are bound together as one.
  • Grade 3 (Red) = Tissye is tight, rubbery and is strongly resistant to mobilization.
  • Grade 4 (Brown) = Tissue is hardened, rigid and immobile.

A Case Study

tissue density - Copyright – Stock Photo / Register Mark A 54-year-old male client presented complaining of moderate to severe pain in his left shoulder stating, "It hurts all around, it's stiff, I have trouble lifting my arm and turning my head to look back is difficult." He attributed it to a 20-year-old auto collision, combined with age and a recent drop in the temperature seemed to have made it worse. He was not able to raise his left arm to shoulder height. He stated that he didn't want to go to a doctor because he didn't want pain medication or muscle relaxers, which were all he'd been offered on previous visits to complain about the same symptoms.

Having the client right side-lying, I gently grasped the glenohumoral joint and attempted to mobilize it. I found the entire region was resistant to movement, resulting in rocking the client's entire upper left quadrant and head. The scapula's medial border seemed to be firmly engulfed within the tissues above and below it; they felt rubbery and solidified. The client's right side, by comparison, was found to be very mobile, with normal range of motion.

I explained to my client that, because I could feel and demonstrate to him the elevated density in the affected tissues, I believed I could help relieve his pain and improve his range of motion. I suggested several treatments, with the first ones given as closely together as possible.

The basic guidelines for Tissue Density Restoration (TDR) massage are:

  • Focus on the location of the pain.
  • Stay at or below a number 3 on the 1-10 Pain Scale.
  • Work in a warm location and keep the tissues warm.
  • Keep the area you are working on moving continually. This will usually require working on areas no larger than the span of your two hands at a time.
  • Continue the treatment until you can feel a softening and smoothing change in the density of the target area, at which time the client will also state that it feels better.

Treatment Protocol

I started the assessment/treatment with the client on a warm table, using a heat transferring device, similar to a hot stone. I began to feel areas that were notably firmer than their surroundings. As the tissues became a little more malleable, I asked my client to identify the areas that hurt the worst. He directed me to spots just above the superior border and superior angle of the left scapula; the top lateral edge of his humerus; and near the base of the deltoids. We also found a large, hardened area between the upper medial aspect of the scapula and the spine. Its location and density prevented the scapula from being able to adduct. I explained to my client that while it didn't belong there, it probably consisted of multiple layers of tissues that do belong – they have simply adhered to each other and conglomerated. The good news, however, is that no matter how uncomfortable and disruptive the structure may be, it can be restored to normal density and proper functioning.

The first hour of my client's initial two hour visit was spent determining the areas that were causing the greatest amount of pain and dysfunction. These target areas were determined to be:

  1. An oblong, oval shaped lump, approx. 8cm long and 2.5cm in diameter; nestled in the left scapular notch. Engulfs Medial Supraspinatus. Density Grade 3 within a Grade 2+ area. Lump is firmly attached to deeper tissues. Attempt to palpate or mobilize, results in pain over 3.
  2. Patch of dense tissue between medial border of Scapula and the spine, approx. 9cm by 5cm in diameter. Density Grade 3+, approx. 1½cm in thickness, within area of Grade 2 tissues. It prevents scapular adduction, attempts to mobilize, results in pain over 3.
  3. Area of hardened tissue, approx. 4cm in diameter with slight 2cm diameter concavity visible at center involving the cartilaginous tissue at the head of the left humerus. Density Grade 3 at borders, 4 in center. Attempt to mobilize results in pain over 3.
  4. Thickened patch of dense tissue approx. 2cm by ½cm at the insertion of the left pectoralis major to the humerus. Density Grade 3 within large area of Grade 2 surrounding. Attempt to mobilize results in pain greater than 3.

The remainder of the session was spent using TDR massage techniques. By the end of the massage, the borders of the identified areas were more pronounced and easier to locate, due to softening of the surrounding tissues, as well as some improvement in the target areas. The results of the post-treatment assessment were:

  1. Lump is smoother, length and diameter reduced approx. ½cm uniformly, am able to slightly mobilize surrounding tissues without exceeding a 3 on the 1–10 pain scale. TD Grade of lump remains a 3, within a grade 2 area. Does not feel as securely anchored to deep tissues. Client expresses some relief.
  2. Area of this patch of elevated TD remains the same, but thickness feels approx. ½cm smaller. Area is softer and much more easily mobilized. Still unable to palpate or adduct medial border of scapula. Client states that it feels, "much better."
  3. Tissues in this affected area are fully malleable, with no ridges or other palpable abnormalities. Overall TD Grade at this area is a 1+. The client states there is no more pain at this location.
  4. This patch has reduced by approx. 1½ cm in size, and the TD Grade is now 2 within an area Grade of 1+. Client states that it only hurts when pressed into with moderate pressure.

This client received four treatments in the first week, followed by six more weekly treatments. The client states he is very happy with the results, he feels as if he is 75% to 80% improved. He claims he is able to turn his head easily when backing up in his car; and he has a full range of motion in his arm and shoulder. At this point the TDGS is:

  • Lump is gone, this area is fully mobile and pain free. TD Grade at this location is 1+.
  • Medial border of scapula is palpable; scapula has greater range of motion. Adduction improved 80% or greater. Dense area still approx. 9 by 5cm in area, but thickness feels approx. ¼cm. TD Grade is 2. Client states it will start to feel tight when he has been working for several hours, but has had no recent pain.
  • This area remains pain free, overall TD Grade is 1.
  • This area is pain free, with an overall TD Grade of 1.

I hope this example of how I use the TDGS portrays the value and usefulness of this tool. You may have noted that a color is associated with each grade. By color coordinating the numerical grade, one may provide a more comprehensive illustration of the size, location and condition of affected tissues on any anatomical diagram. The TDGS is easily adapted into whatever documentation form you prefer, whether it be written, drawn or both.

Click here for previous articles by Linda LePelley, RN, NMT.


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