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The Pressure Gradient System (PGS) was created in order to refine student massage therapy skills in relationship to soft tissue manipulation and to form a framework for therapist to therapist communication.


September 9, 2009
By Ian Dolmage RMT professor

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The Pressure Gradient System (PGS) was created in order to refine student massage therapy skills in relationship to soft tissue manipulation and to form a framework for therapist to therapist communication.

This has been a work in progress since 1999 and has changed in its structure a number of times. In 2000, the first formation of the PGS, which referred to depth of pressure, was published in the Journal of Soft Tissue Manipulation. At that time, four pressure gradients (P1 to P4) were used. Each one challenged deeper layers of soft tissue.

The PGS is an effective tool for teaching students how to deliver consistent pressure. This system helps the student develop what has been coined “Intelligent Touch.” Students who learn and use this system have a better awareness and frame of reference with regard to soft tissue manipulation and can communicate what pressure gradients are appropriate for the individuals they are treating.

Massage therapists will often use words like “that client can take a lot of pressure” or “this client likes light pressure.” However, words like “a lot of pressure”
or “likes light pressure” become ambiguous to therapists when treating clients because these terms have no standard frame of reference to pressure levels or depth. 

In a lab class in the mid-’80s, our instructor used a weigh scale to show how much pressure we could apply with our hands. This raised the question “how well can we reproduce a constant and repeatable pressure using thumbs, fingers and elbows.”

The contact of palms, and forearms would be too broad and would not be specific enough. It was necessary to demonstrate that a therapist could repeat a particular pressure within a range. It would not be possible for a therapist to repeat a consistent pressure of 10 pounds, 10 times in a row.

Therefore, the PGS system was created for flexibility and uses a 5 pound range of pressure. One of the hypotheses was that a massage therapist could repeat a consistent thumb pressure of 5 to10 pounds, 10 times in a row. If it could be demonstrated that a therapist could consistently show that his/her average pressure varied between 5 to 10 pounds, then it would be highly possible that the majority of therapists could do the same.

If so, this could be used to create a new therapist to therapist communication tool regarding soft tissue manipulation pressures.

In order to quantify this system, (to create measurable accuracy among therapists), mean, mode, range and standard deviation were used. From a mathematical/research perspective one could use an alternate method of the PGS, which would be to use 5 pound ranges of pressure and then do the above math to calculate the standard deviation for repeated attempts of applying a pressure of 5, 10, 15 pounds, etc. Because of the many variables involved when manipulating soft tissue,  using range to relay pressure information is preferable in communication between therapists.

The Pressure Gradient Levels
This system has 12 different pressure gradient areas. This again is based on using the thumbs, fingertips and elbow. The following are the pressure gradient areas in abbreviated form.

Pressure gradient 1 PG 0 to 5 lbs  Pressure gradient 2 PG 5 to 10 lbs 
Pressure gradient 3 PG 10 to 15 lbs Pressure gradient 4 PG 15 to 20 lbs 
Pressure gradient 5 PG 20 to 25 lbs Pressure gradient 6 PG 25 to 30 lbs 
Pressure gradient 7 PG 30 to 35 lbs Pressure gradient 8 PG 35 to 40 lbs
Pressure gradient 9 PG 40 to 45 lbs Pressure gradient 10 PG 45 to 50 lbs
Pressure gradient 11 PG 50 to 55 lbs Pressure gradient 12 PG 55 to X lbs

An every day bathroom weigh scale with a silicone mouse pad was used to create a realistic feel. The therapist must calibrate his/her pressure by looking at the scale while applying fingeror thumb stripping and/or sustained digital pressure on the scale.

During this process, a sense or feel of what amount of force reproduced the target pressure is developed. A range between 5 to 10 pounds of digital pressure was attempted. This process took only about 10 to 15 minutes.

After several trials without looking at the scale, a pressure that averaged between 5 to 10 pounds was achieved ten times in a row. The resulting average pressure was 7.3 pounds.

Repeating the process using 10 to 15 pounds of digital pressure resulted in an average of 13.5 pounds. This experiment was continued using thumb and fingertip pressure up to 30 to 35 pounds. In this range, accuracy suffered when attempting to repeat consistent pressures. Using elbows required more trials to achieve a satisfactory degree of accuracy.

In the face of some skepticism, the system was demonstrated to a group of colleagues. After 15 to 20 minutes they reached the desired accuracy. This created more confidence in teaching the students the Pressure Gradient System.

I gave the students a framework of theory information that related to tissue barriers, the stress/strain curve, mathematics, terminology and hypo/hyper mobile connective tissue characteristics.

After the theory of the PGS was explained in lecture format, the students were put into groups of two. They used weight scales with silicon pads. They would feel and see on the scales what 0 to 5 pounds of pressure felt like then 5 to 10 and so on up to 20 to 25 pounds.

After feeling the different pressure gradients, they went back to 0 to 5 pounds and felt it again. At this point they were asked to repeat a pressure between 0 to 5 pounds 10 times without looking at the scale.

Their partners were instructed to record each attempt. The students’ partners were also told not to make any comments as to how well the student was doing during the test.

This was repeated up to 20 to 25 pounds. At the end of this experiment the students did the mathematic calculations and found they were accurate up to 20 to 25 pounds.

After the experiment, class discussion ensued on how they felt about the system. The students all agreed that they had a much better sense or feel for the amount of force it took to reproduce different pressure gradients.

The students were asked if they understood what it meant to say that the client felt most comfortable with 10 to 15 pounds of thumb or fingertip pressure. All students agreed that this system gave them a clear frame of reference when communicating with colleagues about soft tissue manipulation forces.

My 18 years of working in the field of massage therapy has resulted in recognizing the importance of treating myofascial trigger points. Treating trigger points with finger and thumb stripping or sustained pressure (for me) has been quite successful.

Using the PGS during the last seven years has shown that 5 to 20 pound of digital pressure for the upper back and neck muscles (for most clients) is the appropriate range of pressure for treating trigger points. The interesting thing is that you can activate or treat the same TP at 10, 15, 20 or 25 pounds of pressure. Experience has demonstrated that, the less pressure the better. This is the case for two main reasons; to minimize pain to the client, and increase longevity of the therapist.

If it takes only 10 pounds of digital pressure to treat a TP, then that’s what the therapist should be using. Generally, the more experienced the therapist is, the less force she/he uses. Novice therapists will hammer on a TP and cause post muscle inflammation and pain.

This is due to lack of experience and confidence in treating TPs. Therefore, the less compression and shearing forces used to treat TPs, the better.

When teaching students to treat myofascial trigger points, students are given a sense of what Pressure Gradient is appropriate for activating or treating trigger points. Creating this framework is vital in the learning process. Once the student has a frame of reference for adequate pressure for treating TPs she/he will more quickly achieve the skill set needed to treat TPs effectively. During the assessment phase, students are taught to record or note what amount of digital pressure it takes to show irritation or pain with soft tissue palpation. This information can be used to measure progress or change in the  tissue over a series or treatments.

It would be beneficial to both the student therapist and client to research and collect general information about what amount of digital pressure it takes to release myofascial trigger points of the upper back and neck region.

Anecdotally, the students found that they were releasing TPs with a pressure gradient that ranged between 5 to 20 pounds of digital pressure. To do this, the therapist must periodically test and retrain him/herself to retain the necessary accuracy in range of pressure.

One way of furthering research in this area is through case studies. One could gather together 4 to 6 experienced therapists who are well versed in TP release and train them on the PGS. The therapist would calibrate themselves once a day for 3 to 5 minutes before treating clients’ TPs. Then, after one month have a debriefing of what they discovered.

Another potential research area is the use of PGS to measure the amount of time and pressure needed to elongate connective tissue. This research could be done in relationship to increasing ROM of the hamstrings, cervical spine, etc.

Time and connective tissue characteristics are a big factor in calculating the compression, tension and shearing forces that will produce creep. This is not really new information. Most experienced massage therapists know that some clients have stronger connective tissue characteristics than others.

Another aspect that is important is using this system when communicating to insurance companies. Therapists could include information about the assessment of soft tissue related to digital palpation pressures. Over a number or treatments using the PGS, it should be demonstrated that as the pressure gradients increase, so does ROM.

However, pain levels related to digital pressure should decrease. There should be a direct correlation between increased physical function and an increase of treatment pressure (up to a point) over a period of time.

There has been much research done by physiotherapists and other health care professionals showing pressure algometers reliability related to myofascial trigger point location, sensitivity and pain thresholds. Most of these studies show good intra and inter reliability with these devices. 

I have provided a list of articles that speak to pressure algometers and connective tissue characteristics. They are listed in the references section of this article. To my knowledge there are no articles or research on palpated or manual pressure measurements.

In conclusion, you can contact this author if you are interested in learning more about the PGS. Assistance in implementing this system into an educational or professional environment would be available.

ABOUT IAN DOLMAGE
Ian Dolmage has been a massage therapist since 1989 and worked in private practice for 9 years. In 1995, he initiated the massage therapy program at Algonquin College of Applied Arts and Technology and in 1998 became a full time professor at Algonquin College. During this time, he created a clinical manual known as Student’s Guide to PNF Stretching and co-authored MIRL’s Guide to Joint Mobilization, both published text books. As a massage therapy educator, his main teaching areas include assessment and treatment theory and the integration of these areas into lab and clinical practice. In Dec. 2006 Ian was elected in district three as a professional council member for the College of massage Therapist of Ontario. He has also published articles in The Body Politic and The Journal of Soft Tissue Manipulation. These articles include “Pressure Gradients,” “Gaining Ownership,” which addresses chronic clinical weakness in the massage profession and “Universal Terminology” which address the confusion around the multiple PNF stretching terminologies. • I would like to thank Paul Clifford and Trish Dryden for recommending editing modifications and research information.  – Ian Dolmage, RMT Professor

References:
1. C,K Andrade, P Clifford: Outcome-Based Massage: Lippincott Williams& Wilkins Philadelphia 2001: 65-66.
2. Latour M, Dolmage I, et.al.: Student’s Guide to Clinical PNF Stretching 2nd edition: Ottawa: Algonquin College Publishing Center; 2004: 15-17.
3. Kisner C, Colby C: Therapeutic Exercise Foundations and Techniques 5th edition. Philadelphia: F.A. Davis; 2002:73-76.
4. M Brown: Making Sense of Research: Curties-Overzet 2003: 84-91
5. Cornwall, MW: Biomechanics of non-contractile tissue: a review. Phys Ther 64:1869, 1984
6. Threlkeld, AJ: The effects of manual therapy on connective tissue. Phys Ther 72:893, 1992
7. Sciotti VM, Mittak VL, DiMarco L, Ford LM, Plezbert J, Santipadri E, Wigglesworth J, Ball K. Clinical precision of myofascial trigger point location in the trapezius muscle. Pain. 2001 Sep; 93(3):259-66.  New York Chiropractic College, Seneca Falls, NY 13148, USA.
8. Reeves JL, Jaeger B, Graff-Radford SB. Reliability of the pressure algometer as a measure of myofascial trigger point sensitivity.1986 Mar; 24(3):313-21.
9. Antonaci F, Sand T, Lucas GA. Pressure algometry in healthy subjects: inter-examiner variability. Scand J Rehabil Med. 1998 Mar; 30(1):3-8.
Antonaci F, Bovim G, Fasano ML, Bonamico L, Shen JM. Pain threshold in humans. A study with the pressure algometer.
Funct Neurol. 1992 Jul-Aug; 7(4):283-8.


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