Br J Sp Med 1994; 28(3)

Review

Massage - the scientific basis of an ancient art:

part 1. The techniques
Geoffrey C. Goats PhD MCSP
School of Occupational Therapy and Physiotherapy, University of East Anglia, Norwich, UK

Manual massage is a long established and effective compression and the introduction in 1939 of ultra-
therapy used for the relief of pain, swelling, muscle spasm sound therapy, now widely used in sports physio-
and restricted movement. Latterly, various mechanical therapy.
methods have appeared to complement the traditional
manual techniques. Both manual and mechanical techni-
ques are desscribed systematically, together with a review The techniques of massage
of indications for use in sports medicine.
Tradition defines massage as 'hand motions practised
Keywords: Massage, history, techniques, applications on the surface of the living body with a therapeutic
The manipulative techniques traditionally classified
goal12. The resurgence of therapeutic massage began
in France and much of the nomenclature is in that
as massage consist primarily of palpation, rubbing language. The techniques, both manual and mecha-
and kneading. These arose from the natural, intuitive nical, are described below together with specific
desire to rub a painful injury. Massage is widely used indications for their use. Contraindications to mas-
in sports medicine and has much to offer the injured sage are few, but include malignancy, infection of
athlete. The therapeutic effects are diverse and body fluid and unusually fragile skin.
include control of swelling, increased blood flow, and
relief of pain and muscle spasm. Massage accelerates
inflammatory processes and mobilizes contracted Manual techniques
fibrous tissue. Massage will also affect muscle tone Effleurage
and cause general relaxation. These slow rhythmic stroking hand movements,
moulded to the shape of the skin, frequently begin
History and end a treatment session (Figure 1). The strokes
pass from distal to proximal and parallel to the long
The first mention of massage appears in the Nei axis of the tissue. Gradual compression reduces
Ching, the oldest existing medical work, written muscle tone and induces a general state of relaxation
before the death of the Chinese Emperor Huang Ti in that relieves muscle spasm and prepares the patient
2598 BC1. Ancient Indian and Greek texts, including for more vigorous treatment. Firm pressure acceler-
the work of Hippocrates, describe massage as an ates blood and lymph flow, improves tissue drainage
effective therapy, especially for treating sports or war and thus reduces recent swelling. Rapid strokes have
injuries, and the practice spread widely within the the opposite effect. These will increase muscle tone
Roman Empire. The social decadence of the late and may be useful during the final preparation for
Roman period tarnished the reputation of massage competition.
for more than a thousand years and the merits of this
manual therapy remained hidden until the Renaiss-
2
ance .
The era of modem massage began in 1863 with the
publication of a treatise systematically classifying
each technique according to the bodily system
affected3. This stimulated scientific research and, as
instrumentation improved, modern massage techni-
ques developed rapidly. These are described fully
elsewhere4-11. Some innovations were technological,
such as pneumatic systems producing rhythmical

Address for correspondence: Dr G. C. Goats, School of

Occupational Therapy and Physiotherapy, University of East
Anglia, Norwich, NR4 7TJ, UK
(© 1994 Butterworth-Heinemann Ltd
0306-3674/94/030149-04 Figure 1. Effleurage

Br J Sp Med 1994; 28(3) 149

Massage techniques: G. C. Goats
Kneading The firm pressure needed for frictions is transmit-
Kneading consists of slow circular compression of ted through the index finger reinforced by the middle
soft tissues against underlying bone. The greatest finger. Larger areas are treated using the index,
pressure is applied as the hands move proximally, middle and ring fingers of one hand supported by
although contact is continuous. Small areas are those of the other. Friction massage begins with
usually treated using the fingertips alone. Kneading initial gentle transverse movements that gradually
promotes the flow of tissue fluid and causes reflex bear more deeply into the tissue and continue for
vasodilation and marked hyperaemia. This reduces 5-15min. Frictions do not attempt to soothe, but
swelling and helps resolve inflammation. Vigorous instead cause mild tissue destruction, a marked local
kneading decreases muscle spasm and can stretch hyperaemia and an inflammatory reaction.
tissues shortened by injury. Frictions are very useful in sports therapy, esp-
ecially for the treatment of adherent or contracted
Petrissage connective tissue. Contracted tissue often signifi-
Skin rolling is a forceful technique that can only be cantly reduces athletic performance. The localized
applied to fleshy regions of the body. A fold of skin, stretching and degradation of collagen caused by
subcutaneous tissue and muscle is squeezed, lifted frictions can restore fibres to a more normal
and rolled against the underlying tissues in a alignment during the remodelling phase of healing13.
continuous circular motion. With each cycle, the Function often improves greatly provided that
hands progress on to adjacent tissue, taking care not healing is accompanied by correct joint positioning
to drag uncomfortably on the skin. Petrissage is and gentle exercise.
particularly useful for stretching contracted or adhe- This massage technique will also temporarily
rent fibrous tissue and will relieve muscle spasm. reduce pain by activating the 'pain gate' mechan-
Acting more deeply than kneading, petrissage also ism1' 1
promotes the flow of body fluids and can resolve
long-standing swelling. Tapotement
'Wringing' evolved from the simple rolling petris- Tapotement is the name given to percussive massage
sage described above; superficial tissues are grasped techniques. The purpose of these vigorous applica-
in both hands and twisted in opposite directions. tions, often misunderstood, is to vibrate tissues,
'Picking up' involves lifting and stretching soft trigger cutaneous reflexes and cause vasodilation.
tissues away from underlying tissues. These variants Thus muscle tone increases and retained interstitial
of the original technique represent a more localized fluid resulting from injury and inflammation is
application and allow treatment of injuries in delicate dispersed. Swelling reduces and healing is acceler-
soft tissue lying over superficial bone, such as an ated.
anterior tibial muscle strain. Several tapotement techniques exist, the simplest
being 'clapping'. The therapist cups the hands and
Frictions strikes the patient's skin smartly with the concave
Frictions are an accurately delivered penetrating palmar surface. On impact the hollow space traps an
pressure applied through the fingertips. The move- air cushion next to the skin which reduces the
ment is mainly circular or transverse relative to the stinging sensation and disperses the shock more
alignment of the underlying structures (Figure 2) with evenly through the tissues. Modifications of this basic
minimal lateral movement. Frictions are aimed technique, which have the same therapeutic effects,
directly at the site of damage. Tendons and ligaments include 'hacking' along the long axis of tissue using
are treated under slight tension, while muscles are the ulnar border of the hand, 'beating' the skin with
best manipulated in a relaxed position, thus avoiding loosely flexed fingers and 'pounding' with tightly
excessive damage to the muscle cells. closed fists.

Vibrations and shaking

This type of massage produces yet coarser and more
energetic vibration of tissue. 'Vibrations' are deli-
vered by trembling both hands held firmly in contact
with the skin. Unlike effleurage, this method
compresses swollen tissue and can reduce oedema
with less risk of infection spreading within natural
channels in the body.
'Vibrations' are also used in chest physiotherapy to
disperse mucus from the smaller elements of the
respiratory tree and improve respiratory function.
:.. ...
The performance of an athlete suffering the after
i
;. effects of a mild chest infection might thus be
improved. The pleural membrane should damp such
vibration efficiently, but the demonstrable effective-
ness of this technique indicates that the physical
Figure 2. Frictions principles involved require further research16.

150 Br J Sp Med 1994; 28(3)

 Massage techniques: G. C. Goats
'Shaking' is a yet more vigorous treatment in which Holland). Some pneumatic systems inflate and
muscle of the chest wall is grasped and shaken deflate a series of cuffs sequentially. The resulting
forcefully. A physiological effect similar to that of pressure wave can be directed in either direction and
'vibrations' is produced and the treatment can at any desired speed. Sequential compression re-
improve thoracic mobility and assist ventilation. duces claudication pain and improves skin condition
Secretions are expelled directly or ejected by trigger- impaired by vascular disease'8 19.
ing a cough reflex. These mechanical systems can speed up the early
stages of recovery from sports injury by reducing
venous congestion and improving blood supply. This
Equipment techniques quickens the inflammatory process and subsequent
Devices increasing pressure healing. The taut sleeve triggers mechanoreceptors in
Massage using hand-held rollers was widespread the skin and, by activating the pain gate mechanism,
after 1880 and is once again popular in fitness centres. reduces pain and facilitates early mobilization and
There is scant evidence that the technique does more exercise.
than soothe, an effect likely to depend more upon the
masseur than upon the equipment itself. Rollers are Devices causing vibration
the least sophisticated example of a family of devices
that compress tissue. The first vibration therapy, advocated by several
Rhythmically alternating external pressure, applied famous figures, consisted of a fast ride on horseback.
using warm flowing water, is the basis for many Mechanical devices now offer a safer and more
traditional hydrotherapy massage treatments now localized vibration treatment. The therapeutic prin-
rarely available within the UK National Health ciples involved are similar to those described for
Service. These include 'undercurrent massage' with a tapotement.
powerful underwater jet applied to the skin, 'needle The usefulness of coarse vibration devices, often
showers' of fine but forceful jets of water directed on promoted by beauty salons as a way of removing fat,
to a standing patient and, of course, the whirlpool is highly questionable'7. Similarly, the various hand
bath or jacuzzi17. Hydromassage is often available in held devices sold to the public frequently produce
fitness clinics and plays an important role in sports minimal vibration yet often appear useful for treating
rehabilitation, particularly in Southern and Eastern musculoskeletal pain. A powerful placebo effect
Europe. Hydromassage can cause deep relaxation, would appear to be at work.
soften and debride scarred or hardened skin, and Therapeutic ultrasound operating at frequencies
induce generalized vasodilation that accelerates heal- between 1-3 MHz is also a type of vibratory massage.
ing of superficial tissues. The physiological and therapeutic effects mimic those
Pneumatic external compression, applied using an of conventional massage techniques. This therapeutic
air-filled cuff or sleeve has a successful history for modality is used widely in sports medicine and the
treating swollen limbs. Modem systems such as interested reader is referred20-22
to specialized reviews for
'Flowtron' (Huntleigh Technology, Luton, UK) use a more detailed discussion
an air compressor to inflate and deflate rhythmically a
plastic sleeve wrapped around the limb (Figure 3).
Pulsed pressure changes, within predetermined Summary
limits, alternately empty superficial veins and lymph Massage has for many years played an important role
channels into the deep circulation, and then allow in athletic rehabilitation and is enjoying a justified
refilling. Valves within the deep vessels ensure this resurgence of interest. Sports therapy can now draw
unilateral flow. upon an extensive body of research documenting the
Some devices encase the limb in a rigid chamber diverse physiological and therapeutic effects of
that can be both evacuated as well as pressurized manual therapy. These will be explored fully in a
(e.g. Vasotrain; B.V. Enraf-Nonius Delft, Delft, subsequent article and will be instrumental in
establishing massage as a treatment of choice for a
wide range of sporting injuries.

References
1 Huang Ti. The Yellow Emperor's Classic of Internal Medicine
(Translated by Veith I). Baltimore, USA: Williams and
Wilkins, 1949.
2 Celsus AC. De Medicina. Leiden, Netherlands, 1665.
Fiur3Pnumtic|, copeso 3 Estradere JDJ. Du Massage. Paris, France: Ecole De Medecine,
1863.
4 Beard G, Wood EC. Massage: Principles and Technique.
Philadelphia, Pennsylvania, USA: Saunders, 1964.
5 Bell AJ. Massage and the physiotherapist. Physiotherapy 1964;
50: 406-8.
6 Francon F. Massage technique. In: Massage, Manipulation and
Traction. Licht 5, ed. Huntington, New York, USA: RE.
Krieger, 1976: Chapter 3.
7 Hofer J. Total Massage. New York, USA: Grosset and Dunlop,
1976.
Massage techniques: G. C. Goats
8 Hollis M. Massage For Therapists. Oxford, UK: Blackwell 16 Selsby DS. Chest physiotherapy. May be harmful in some
Scientific Publications, 1987. patients. BMJ 1989; 298: 541-2.
9 Mennell JB. Physical Treatment by Movement, Manipulation and 17 Licht S. Mechanical massage techniques. In: Massage,
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10 Reiter S, Garrett TR, Erickson DJ. Current trends in the use of York, USA: RE. Krieger 1976: Chapter 5.
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11 Tidy NM. Massage and Remedial Exercises in Medical and Surgical treatment of peripheral vascular disease. JAMA 1937; 109:
Conditions. (Revised by Wale JO). 11th ed. Baltimore, USA: 2125.
Williams and Wilkins, 1968. 19 Wakim KG, Martin GM, Krusen FH. Influence of centripetal
12 Boigey MAJ. Manuel De Massage. Paris, France: Masson, 1950. rhythmic compression on localized edema of an extremity.
13 Cyriax JH. Clinical applications of massage. In Massage, Archives of Physical Medicine 1955; 36: 98-103.
Manipulation and Traction. (Licht S, ed.). Huntington, New 20 Dyson M. Mechanisms involved in therapeutic ultrasound.
York, USA: RE. Krieger, Chapter 8, 1976. Physiotherapy 73: 116-19.
14 Melzack R, Wall PD. Pain mechanisms: a new theory. Science 21 Kitchen SS, Partridge CJ. A review of therapeutic ultrasound.
1965; 150: 971-9. Physiotherapy 1990; 76: 593-600.
15 Watson J. Pain mechanisms: a review. 1. Characteristics of the 22 Maxwell L. Therapeutic ultrasound: its effects on the cellular
peripheral receptors. Australian Journal of Physiotherapy 1981; and molecular mechanisms of inflammation and repair.
27: 135-43. Physiotherapy 1992; 78: 421-6.

-.~ .~ ~ . . . .
THE 13th CONGRESS OF SPORTS MEDICINE of the A.Z. SINT-JAN
International Congress Organized by:
VZW BRUCOSPORT in cooperation with THE DUTCH SOCIETY of SPORTS MEDICINE
BRUGGE (Belgium), 14 & 15 October 1994

SESSIONS
Cardiology and Sports (DSSM) - G Schep, A Hoogeveen and J Hoogsteen (NL)
Ethics and Sports (DSSM) - F Faro, R A A Bots and E M Vrijman (NL)
Swimming Sports - H Toussaint, P Hollander (ML), W McMaster (US) and U Persyn (B)
Arthrosis and Sports (DSSM) - M P Heijboer, H G W Vermeer, C N Van Dijk H Sala and S Lim (NL)
The Hand and Sports - G Foucher (F), N Barton (UK), L De Smet (B) and R Leach (US)

KEYNOTE LECTURES
H Mielants (B) Inflammatory locomotor symptoms in sportsmen
J Lonsdorfer (F) Unfitness after heart, lung or kidney transplantation and ways for exercise retraining
W Pffirringer (D) Change of sports traumatology in a changing world
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.-. -. L.:.:.:--.
:

For further informtiont concerning te"Congres pleaseo

cnact:,.'
Sekretariaat SPORTGENEESKUNDIGE DAGEN ..
Attn. CaneDe ..yc
A.Z. Sint-Jan, Ruddershove 10,134000 BRUGGE (Belgium)
.Te
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Fax: r(2) (0J50)M4512234 2% -..-.-
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152 Br J Sp Med 1994; 28(3)