Nearly two hours of instructional video

FIFTH EDITION

Giovanni De Domenico
po
 About the Author

Giovanni De Domenico

Grad Dip (Physiotherapy), Dip TP, MSc, PhD, MCSP, MAPA, MCPA

Dr. Giovanni De Domenico was born in England and quali- Dr. De Domenico moved to Canada in 1989 to take up an
fied there as a physiotherapist in 1970. Following a period of appointment as Associate Professor in the School of Phys-
general experience in a variety of clinical settings, he under- iotherapy at Dalhousie University in Halifax, Nova Scotia.
took the Teacher of Physiotherapy program at the Coventry In this position, he was again responsible for teaching all
School of Physiotherapy and the North London Polytechnic, aspects of EPA and massage. In 1992 he became Profes-
completing this program in 1975. He was then appointed to sor and Director of the School of Physical Therapy and
the staff of the Royal Orthopaedic Hospital, School of Phys- Assistant Dean in the College of Medicine at the University
iotherapy, in Birmingham, United Kingdom. He then gained of Saskatchewan in Saskatoon. He relocated to the United
a Master of Science degree from the University of Aston in States in 1994 as Professor and Chairman of the Department
Birmingham, followed by an appointment to the staff of the of Physical Therapy at the University of South Alabama in
Wolverhampton School of Physiotherapy in Wolverhamp- Mobile, Alabama, where he served for seven years. His cur-
ton, United Kingdom. rent appointment took him to Texas in 2001, as Professor
Dr. De Domenico immigrated to Australia in 1978 to take and Chairman of the Department of Physical Therapy at the
up an appointment in the School of Physiotherapy, Facul- University of Texas Health Science Center at San Antonio.
ty of Health Sciences, Sydney University, in Sydney, New Once again, he teaches all aspects of EPA and massage.
South Wales. In 1984 he was appointed senior lecturer in Dr. De Domenico is a well-known author and teacher,
the School of Physiotherapy at Curtin University in Perth, having lectured extensively in Australia, New Zealand,
Western Australia. While in Australia, Dr. De Domenico was Southeast Asia, and North America. He has been an active
responsible for undergraduate and postgraduate teaching and member of the Chartered Society of Physiotherapy (CSP)
research in the broad area of electrophysical agents (EPA) in the United Kingdom, the Australian Physiotherapy Asso-
and the field of soft tissue manipulation (massage). He was ciation (APA), and the Canadian Physiotherapy Association
awarded a Doctor of Philosophy Degree in 1987 for his the- (CPA), having served on many local and national commit-
sis Kinaesthetic Acuity and Motor Control in Humans. This tees. In 2005 he served as President of the Texas Society of
work was undertaken in the School of Physiology and Phar- Allied Health Professions (TSAHP).
macology, Faculty of Medicine, at the University of New
South Wales in Sydney.
 FIFTH EDITION

BEARD’S MASSAGE

Principles and Practice

of Soft Tissue
Manipulation

Giovanni De Domenico
Grad Dip (Physiotherapy), Dip TP, MSc, PhD
MCSP, MAPA, MCPA
Professor and Chairman
Department of Physical Therapy
School of Allied Health Sciences
University of Texas Health Science Center at San Antonio
San Antonio, Texas
SAUNDERS
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BEARD’S MASSAGE: PRINCIPLES AND PRACTICE OF SOFT ISBN*°978-0-7216-0350-6

TISSUE MANIPULATION, Fifth Edition
Copyright © 2007, 1997, 1981, 1974, 1964 by Saunders, an imprint of Elsevier, Inc.
Copyright © renewed 1992 by Gertrude Beard and Elizabeth C. Wood

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 This book is dedicated to the memory of
Gertrude Beard, RN, RPT
(1887-1971)
and to all those who seek to learn the skills of this ancient art
for the benefit of others.
 Contributors

Patricia A. Brewer, BS, PhD Catherine Ortega, EdD, PT, ATC, OCS
Associate Professor, Department of Physical Therapy Assistant Professor, Department of Physical Therapy
Assistant Dean for Student Affairs School of Allied Health Sciences
School of Allied Health Sciences University of Texas Health Science Center at San Antonio
University of Texas Health Science Center at San Antonio San Antonio, Texas
San Antonio, Texas
Elizabeth C. Wood, MA, MS, RPT
Co-author of previous editions

Colleen Liston, AUA, Grad Dip (Physiotherapy), Grad

Dip Hith Sc, MSc, PhD
Contributor to the fourth edition

Rachel Fey-Larsen, PT
President, Forte Rehabilitation and Wellness Center
San Antonio, Texas
 | Foreword to the First Edition
There are some things in every man’s life that have a great Massage has often been neglected in favor of other physi-
effect upon his future success and the success of some of cal measures which can be used more easily. Massage
the people around him. One of these things happened to me requires skilled use of the hands and brain for its curative
when a physical therapist named Gertrude Beard came to effects—producing or regaining elasticity of tissues, stimu-
Chicago shortly after the First World War, after she was lating blood supply, giving the patient confidence and at the
discharged from the Army. same time giving him encouragement and psychological
Miss Beard was taken onto the staff of Wesley Hospital stimulation to use the part that is disabled—and no machine
immediately and started work on my patients, most of them can substitute. There is a psychology that goes along with
workers who had been injured at the stockyards. She worked any form of medical treatment, and if the physical therapist
in a place called the “bath department,” which consisted of is not using his or her powers of encouragement to get the
one shower, one Scotch douche, a table and a couple of patient to do what he should do, then he or she is not doing
sinks. She and the patients had to sit on stools, and no one a job in whatever is being done.
in the hospital took her appearance with any great degree In my opinion massage is one of the things that can be
of hope that she was going to do anything that had not been neglected, misused, paid for and thrown out the window
done before. At that time (1919-1920) physical therapy, in without accomplishing what it should unless it is understood
my experience, was something to do when you couldn’t and properly applied. This book presents a clear picture of
think of anything else to do to get rid of the patient. techniques and the principles upon which they are based.
Miss Beard had made a study of what was not considered The text is well written and illustrated and should be read
a very great science at that time, and went on to develop and reread by the doctor and the physical therapist to the
physical therapy techniques which have brought help to ever-lasting benefit of the patient’s recovery.
many patients who would never have recovered had it not
been for her efforts. Paul B. Magnuson, MD
In 1927 she became the technical director of Northwest- Professor of Bone and Joint Surgery,
ern University’s new school of physical therapy. She and her Emeritus, Northwestern University Medical School
teaching colleagues have taught more than five hundred Founder and Honorary Chairman,
physical therapists the techniques and principles of physical Rehabilitation Institute of Chicago
therapy since that date. The story of their work is worth Former Chief Medical Director,
noting—a story of devoted, dedicated persons who believe Veterans Administration
in what they know, and who continue to educate doctors and May 1964
patients as well as students in the benefits of physical therapy
and especially massage.
 Digitized by the Internet Archive
in 2022 with funding from
Kahle/Austin Foundation

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 : Preface
As outlined in the previous edition, the basic principles gestive Therapy for the Treatment of Lymphedema (Chapter
and techniques of soft tissue manipulation (massage) have 12), Massage in Sport (Chapter 13), Massage for the Baby
changed very little with the passage of time. Although a and Infant (Chapter 14), and Soft Tissue Manipulation in
variety of new techniques have been introduced in recent Complementary/Alternative Medicine (Chapter 16). Chapter
years, together with a few new treatment concepts, in the 17, Eastern Systems of Soft Tissue Manipulation, has been
main we continue to use and develop the time-honored prin- greatly expanded. The newest and most exciting feature is
ciples of this most ancient healing art. Since the publication a companion DVD video that complements the text and
of the fourth edition in 1997, there has been a significant photographs, providing the necessary guide to the proper
interest in the concepts of health and wellness and the techniques for each of the strokes discussed. Although still
importance of a holistic approach to the maintenance and photographs are helpful in showing hand positions, they
promotion of health in all its dimensions. This has prompted cannot show the proper timing and flow of the techniques
a change in title for the fifth edition of this classic text. as well as video. Each stroke is described and demonstrated
on several body areas. The text indicates the applicable
BACKGROUND chapter on the DVD by using the prefix DVD before the
specific chapter numbers. For example, DVD 4-/2 indicates
As a pioneer in the development of the physical therapy
video clip number 12 from Chapter 4 of the text. These
profession in the United States, Gertrude Beard played an
cross-references should be a tremendous help to students of
important role in promoting the use of soft tissue massage.
massage, because they will be able to easily find a demon-
However, she did not develop a particular system of massage
stration of each technique on the DVD that matches the
that could be called Beard’s Massage. Instead, she promoted
description and information in the text. In addition to dem-
an understanding and use of many of the classical tech-
onstrations of the basic Swedish remedial massage tech-
niques of massage. For this reason, the fifth edition has been
niques, the DVD features an important section on surface
retitled, but still includes the name of Ruth Beard as a tribute
anatomy. This section supports all of the practical chapters
to her enduring legacy in promoting the use of massage. It
of the text. The DVD also demonstrates the basic techniques
is evident from a study of the history of massage that there
of passive movement to the neck and the upper and lower
were, and still are, many different systems and schools of
limbs. In addition to these innovations, the DVD contains
massage. However, all types of massage fall under the
demonstrations of the specialized decongestive massage
general concept of soft tissue manipulation (STM), because
techniques used in the management of lymphedema, which
they are in most cases performed by the hands on a wide
is described in Chapter 12 of the text.
variety of the soft tissues of the body. The new title of this
Many of the photographs in the text are new, especially
book reflects this reality while giving the founding author
those in Chapter 4. They were taken as still shots from the
her rightful place of honor. In addition, the retention of the
video used to produce the DVD. In this way, readers of the
dedication to Gertrude Beard from the first edition’s Fore-
text will be able to see the same photographic illustration in
word by Dr. Paul B. Magnuson (1884-1968) continues to
the text as that seen on the DVD. Once again, without the
honor these two pioneers in physical therapy and rehabilita-
assistance of the models, the new photographs would not
tion over a period of some 50 years.
have turned out so well. Sincere thanks are extended to
The fourth edition marked a significant rearrangement of
Mark DeAnder, Lauren Burns, Tim Hoover, and Robert
material from previous editions and the addition of several
Culp for their important contribution to this work. Likewise,
new sections. In particular, the new photographs were a
I am very grateful to Eric Hanken and all of his staff
major feature. The fourth edition was very successful and
at Bauhaus Media Group, especially Steve Cox, who edited
was translated into Spanish, Portuguese, Italian, and Japa-
the video. Sincere thanks are also extended to Rachel
nese. The fifth edition builds on the success of its predeces-
Fey-Larsen, who in addition to her work on the video and
sor and includes an exciting new concept in the study of this
the chapter on the management of lymphedema, generously
most ancient of therapeutic arts. allowed me to use her physical therapy clinic as the venue
for the filming of the DVD.
NEW TO THIS EDITION The Swedish remedial massage tradition continues to be
The fifth edition contains many new features, including new the heart of the techniques described in the text. Each
chapters: Anatomical Landmarks for Therapeutic Massage massage stroke is described in expanded detail and is com-
(Chapter 2), Focal Massage Sequences (Chapter 9), Decon- plemented by the photographs and video. This will enable
viii PREFACE

readers to develop their own massage sequences, properly is arranged to facilitate such study, especially with the
based on knowledge of the effects of the stroke and the inclusion of the DVD demonstrating each basic technique
specific needs of each patient. As an important guide to through video. Of course, effective massage cannot be
planning sequences of massage strokes, Chapters 5 and 6 learned entirely from a textbook or a video. Only close
on general and local massage techniques continue to follow guidance from an experienced teacher will ensure that the
quite closely the methods described in the previous editions. student reaches the appropriate level of competence in what
In this regard, I wish to acknowledge the tremendous con- is, after all, a finely tuned motor skill on the part of the
tribution of the authors of the third edition, Elizabeth Wood therapist.
and Paul Becker, whose work I have continued to incorpo- As with previous editions, the current text does
rate into the present text. not pretend to be sufficient in itself, but I believe it does
In the previous edition, several new chapters considered provide the background information and concepts necessary
massage systems from a number of different traditions. to give the theoretical framework for the subject area,
These important contributions have been expanded in the along with the basic elements of the practical techniques
fifth edition. Once again, the material in these chapters for several types of soft tissue manipulation. Together
is intended to provide only an expanded outline of the with an experienced teacher and sufficient practice, the
subject areas, since a complete examination of each concept student should expect to be able to reach high levels of
is well beyond the scope and intent of the present text. I am competence. A serious study of soft tissue manipulation
therefore deeply grateful to Dr. Patricia Brewer, Rachel continues to be one of the very best ways of developing
Fey-Larsen, and Dr. Catherine Ortega for their outstanding sensitivity and competence in using the hands for therapeu-
commitment and dedication to providing this important tic purposes. In my view, significant training in massage
information. should be an essential part of the preparation of rehabilita-
tion professionals.
NOTE TO THE STUDENT
Giovanni De Domenico
The fifth edition of this classic text is once again intended San Antonio, Texas
for those pursuing a serious study of massage. The material January 2007
 Contents

PART ONE GENERAL PRINCIPLES Chapter 5 Mechanical, Physiological,

Chapter 1 Historical Perspectives, 3 Psychological, and Therapeutic
An Overview of the History of Massage, 3 Effects of Soft Tissue
Manipulation, 117
A Review of the Historical Writings on Massage, 6
Mechanical Effects, //8
Chapter 2 Anatomical Landmarks for Physiological Effects, //9
Therapeutic Massage, 37 Psychological Effects, /3/
Patricia A. Brewer
Primary Therapeutic Effects of Massage, /33
Therapeutic Uses of Massage, /33
Head and Neck, 37
Indications for Therapeutic Massage, /33
Upper Limb, 38
Contraindications to Massage, /33
Back, 4/
General Precautions, /36
Lower Limb, 42

Chapter 3 Essential Requirements for Soft PART TWO PRACTICE

Tissue Manipulation, 49
Chapter 6 Soft Tissue Manipulation
Ethical Issues, 49
Techniques as an Evaluation
Knowledge of Surface Anatomy, 50
Tool, 145
Preparation of the Hands for Massage, 50
Stroking and Effleurage, /46
Lubricants: Powders, Creams, and Oils, 52
Pressure Manipulations (Pétrissage), /46
Treatment Tables, Chairs, and Accessories, 53
Percussion and Vibration Manipulations, /46
Draping and Positioning the Patient, 55
Deep Friction Techniques, /46
Body Mechanics of the Therapist, 57
Essential Components of Massage, 6/
Chapter 7 General Massage Sequences, 149
Indications and Contraindications for the Use of
A Sequence and Technique for General
Massage, 66
Massage, /49
Chapter 4 Classification, Definitions, and Techniques for a General Massage Sequence, /50
Descriptions of the Basic Massage Specific Techniques for a General Massage
Strokes and Relaxed Passive Sequence, J52
Movements, 69
Chapter 8 Local Massage Sequences, /83
Classification of Massage Strokes, 70
The Hoffa System, /S4
Stroking Manipulations, 7/
Technique for a Local Massage Sequence, /88
Pressure Manipulations, 79
Percussive Manipulations (Tapotement), 9/ Chapter 9 Focal Massage Sequences, 2/5
Vibration and Shaking, 97
Depletive Massage, 2/5
Deep Frictions (Cyriax Frictions), 99
Chronic Edema, 2/7
Relaxed Passive Movements, /04
Hematoma, 2/7
Cutaneous Scar Tissue, 2/9
Muscle, Tendon, or Ligament Adhesion, 22/
Colon Dysfunction, 222
Muscle Dysfunction: Facilitation of Muscle
Contraction, 223
wiih a,

Chapter 10 Massage for the Patient with a Chapter 14 Massage for the Baby and
Respiratory Condition, 225 Infant, 279
Relaxation, 225 Technique for Baby or Infant Massage, 280
Airway Clearance, 226 General Whole-Body Stroking, 280
Postural Drainage, 226 Head and Face, 28/
Percussion Techniques, 227 Upper Limbs, 28/
Vibration and Shaking, 232 Chest and Abdomen, 283
Deep Breathing and Coughing, 233 Lower Limbs, 283
Passive Movements of the Lower Limbs, 233 Back, 285
Buttocks, 285
Chapter 11 Connective Tissue Massage, 235 Suckling, 286
Brief History and Theoretical Foundations, 235
Reflex Zones (Head’s Zones), 235 Chapter 15 Massage in Palliative Care, 290
Basic Diagnostic Technique for Connective Tissue Ancient versus Modern Care of the Dying, 290
Massage, 237 Massage Techniques for the Elderly Patient Who Is
Basic Treatment Technique, 239 Terminally Ill, 29/
Effects of Connective Tissue Massage, 240 Techniques, 29/
Treatment Indications, 24/
Treatment Frequency and Duration, 24/ Chapter 16 Soft Tissue Manipulation in
Contraindications, 24/ Complementary/Alternative
Medicine, 294
Chapter 12 Decongestive Therapy for the Myofascial Release Techniques, 295
Treatment of Lymphedema, 245 Trigger Point Therapy, 297
Rachel Fey-Larsen Reflexology, 301
The Lymphatic System, 245 Rolfing Structural Integration, 304
Pathophysiology, 247 Point Percussion Therapy, 304
Principles of Treatment, 247 Craniosacral Therapy, 305
Evaluation, 249
Skin and Wound Care, 250 Chapter 17 Eastern Systems of Soft Tissue
Lymph Fluid Mobilization, 250 Manipulation, 3/0
Strokes, 25/ Acupressure, 3/0
Sequences and Pathways, 252 Shiatsu, 3/4
Compression Therapy, 259 Traditional Oriental Massage, 3/6
Therapeutic Exercises, 260 Traditional Thai Massage, 3/7
Patient Education, 260 Huna Massage, 3/8

Chapter 13 Massage in Sport, 266 Appendix Closed-Chest (External) Cardiac

Catherine Ortega Massage, 321
History of Sports Massage, 267
Therapeutic Effects of Massage for an Athlete, 267 Index, 323
General Principles
 Historical Perspectives

Massage is an ancient healing art, and there is growing sci- of the hands in a rubbing and squeezing motion that is both
entific evidence of its effectiveness in the management of soothing and comforting. Indeed, many animal species,
patients in a wide variety of diseased and traumatic states. especially primates, use grooming behavior, and, although
As a medical art, it is practiced in many different ways it is not necessarily therapeutic, it is certainly part of the
among the diverse cultures around the world. This chapter behavioral repertoire of many species. In short, touching as
concentrates primarily on the historical development of an activity probably has its genesis at the earliest times in
massage as it pertains to the use of Western concepts of the development of human culture. It seems quite likely that
medical practice. In particular, the chapter concentrates on some type of manual techniques (e.g., massage) were in
the history of the place of massage in modern rehabilitation regular use then, together with the application of various
practice. medicinal compounds derived from plants, animal sources,
The modern French words masser (verb) and massage and inorganic materials.
(noun) could have derived from any of three original roots, Although such ancient cultures had little, if any,
namely the Hebrew word mashesh, the Arabic word mass, recorded history, massage techniques almost certainly were
or the Greek word massin. Although obviously French in part of their medical culture. Certainly, prehistoric humans
origin, masseur (male) and masseuse (female) are used in were capable of practicing sophisticated medicine, including
the English language to denote those who practice massage. brain surgery. The well-known prehistoric practice of
By the early 1780s, the word massage was used in India, removing small circles of bone from the skull, called tre-
and it appeared in most European cultures around 1800. phining (or trepanning), clearly shows that the practitioners
Massage is mentioned as a form of treatment in the of the day were capable of complex medical tasks (Broca,
earliest medical records, and its use has persisted through- 1876; Prunieres, 1874). Not only were they able to make
out recorded history. Writings of physicians, philosophers, holes in the skulls of their patients, but these latter-day sur-
poets, and historians show that people from the most ancient geons were able to do this more than once in a given person.
of times in cultures all around the world used some form of In addition, the findings clearly show that many people
rubbing or anointing. The history of massage is large and survived the procedure, as evidenced by the presence of
complex. This chapter presents a broad overview of its chro- healed areas of bone in the skull. One cannot help but
nology and a more detailed review of a number of the impor- believe that a culture capable of this level of surgical prac-
tant aspects of massage. tice must long before have discovered the considerable and
obvious benefits of massage-like treatments.

AN OVERVIEW OF THE HISTORY Ancient History

OF MASSAGE The use of manual massage techniques in many ancient
Prehistoric Times cultures is well documented in extensive written and picto-
Although there is little direct evidence that massage was rial records. For example, at the time of Hwang Ti, the
practiced as a healing art in prehistoric times, it seems likely Yellow Emperor (d. 2599 Bc), the great Chinese medical
that it was. There is a certain instinctive quality to the use work known as the Nei Chang was written (ca. 2760 Bc).
iai iain PART ONE GENERAL PRINCIPLES

wat Saisie
This work contains detailed descriptions of massage-like when many aspects of ancient culture and practice were
procedures and a great many details of their use (Veith, abandoned.
1949). During the Tang dynasty (AD 619-907), four primary
kinds of medical practitioners were recognized: physicians, Modern History of Medical Massage
acupuncturists, masseurs, and exorcists; however, following (European, Mainly British)
the Sung dynasty (AD 960-1279), the use of massage declined Much of ancient culture and tradition in medicine and
greatly. Massage is also described in one of ancient India’s science was-lost through the Middle Ages, and it was not
first great medical writings, the Ayur-Veda books of wisdom until the Renaissance, especially in the sixteenth century,
(about 1800 Bc). Most of the great ancient cultures of the that some of the older methods of medical practice were
world have described in some detail the uses and benefits again used. Advances in the study of anatomy and physiol-
of massage, which was often combined with other kinds of ogy enabled scientists of the time to understand more about
traditional treatment, particularly bath treatments. The the effects and uses of some of these more ancient traditions.
Egyptian, Persian, and Japanese cultures, in particular, Ambroise Paré (1518-1590), the famous French surgeon,
placed great emphasis on the use of massage and these allied was among the earliest writers to consider and discuss the
treatments. effects of massage. Paré was particularly interested in the
The ancient Greeks used massage widely to maintain use of friction and general massage movements to treat
physical health and ensure lasting beauty. Homer described patients who had dislocated a joint.
in The Odyssey how war-torn soldiers were massaged back Harvey’s discovery of the circulation of the blood in 1628
to health. Hippocrates (460-360 Bc) also wrote on the subject did much to enhance the acceptance of massage as a thera-
and described many of the uses of massage in medical peutic measure. Despite these seemingly important advances,
practice. In discussing treatment following reduction of a massage treatments did not become popular throughout
dislocated shoulder, Hippocrates said: Europe until the eighteenth century. At that time, two of the
And it is necessary to rub the shoulder gently and smoothly. more notable exponents of the treatment were Germans,
The physician must be experienced in many things, but namely Hoffmann (1660-1742) and Guthsnuths. Another
assuredly also in rubbing; for things that have the same famous physician, who claimed in the 1880s that massage
name have not the same effects. For rubbing can bind a could be a very useful treatment, particularly to the soft
Joint which is too loose and loosen a joint that is too hard. tissues following fracture, was the famous French physi-
However, a shoulder in the condition described should be cian Just Lucas-Championniére (1843-1913). In the late
rubbed with soft hands and, above all things, gently; but 1890s, Sir William Bennett was impressed with Lucas-
the joint should be moved about, not violently, but so far Championniére’s work and began what was then a revolu-
as it can be done without producing pain. (Johnson, tionary treatment using massage at St. George’s Hospital in
1866) London, England. Other authors also strongly advocated
The ancient Greeks, perhaps more than other cultures, massage for a variety of soft tissue problems, especially
are responsible for giving massage such a high level of social writer’s cramp (Robins, 1885; de Watteville, 1885a, 1885b).
acceptance. They established elaborate bathhouses where The era of modern massage is usually said to have begun
exercise, massage, and bathing were available, but the during the early 1800s, when a wide variety of authors were
patrons were lovers of luxury and questionable behaviors advocating massage and developing their own systems. A
rather than seekers of health. The bathhouses were the play- famous thesis by Estradere in 1886 was an important con-
grounds of the rich and powerful. Ordinary citizens were tribution to the developing science of massage (Estradere,
not so fortunate. 1863).
The Romans inherited much of the tradition of massage Arguably, the most famous and enduring influence on
from the Greeks, and it was widely used, especially in massage is the contribution made by Pehr Henrik Ling
conjunction with hot baths. Galen (ap 131-201), the most (1776-1839). Ling developed his own style of massage and
famous physician in the Roman Empire, wrote extensively exercises, which later gained international recognition as
on the topic of massage and described several ways in Swedish remedial massage and exercise (Benjamin, 1993;
which it could be administered. Julius Caesar (ca. 100 Bc) Ostrom, 1918). Ling was a fencing instructor, and in 1805
is said to have had himself pinched all over as a cure for he was appointed gymnastics and fencing master to the
a complaint similar to neuralgia. The influence of Galen University of Lund in Sweden. He designed a system of his
on all aspects of medical thinking cannot be overstated; own that consisted of four types of gymnastics: educational,
it is probably because of him that massage and its allied military, medical, and aesthetic. In 1813 he founded the
treatments survived long after the fall of Rome. Galen Central Institute of Gymnastics in Stockholm, and he taught
strongly recommended that in preparation for impending there until his death in 1839. Much of Ling’s work was
combat, gladiators be rubbed all over until their skin was published after his death, mainly owing to the efforts of his
red. The use of massage continued, and it was not until the students and colleagues (Kellgren, 1890). He gained inter-
early part of the Middle Ages that it fell into some decline national recognition for the terminology that bears his name,
in Europe and Asia. This era was known as the Dark Ages, and in many cases modifications of his basic concepts of
 HISTORICAL PERSPECTIVES CHAPTER 1 —
Ccieaaacccaahut
exercise have been used throughout the world. In more in its own right plays a relatively small role in modern
recent times, however, many of Ling’s original ideas faded Western medicine; however, in recent years in many coun-
from popularity, but his work remains an important influ- tries, specific massage professionals (massage therapists)
ence in the early development of the profession of physical have emerged. In this case, the treatment modality is massage
therapy (physiotherapy). itself. It is important to remember that the modern profes-
In Holland, Johann Mezger (1839-1909) also used sion of physical therapy came into existence around the turn
massage widely and developed his own style. By 1900 of the twentieth century and that massage techniques were
modern medical massage techniques were being used in established in medical practice long before that time. In fact,
most parts of the developed world and, of course, their use massage has a long tradition of use in the nursing profession
continued in the more ancient cultures. In fact, “manual (Estabrooks, 1987; Goldstone, 1999, 2000), which predates
medicine” had become an integrated part of a modern the rehabilitation professions by many centuries. In recent
approach to the treatment of trauma and disease (Harris & decades, the nursing profession has rediscovered its massage
McPartland, 1996). heritage and is once more employing the benefits of massage,
In England in 1894, a group of four dedicated women along with other newly emerging massage professions
founded the Society of Trained Masseuses with the aim of (Huebscher, 1998; Mallios, 1996; Palmer, 1992; Wright,
raising the standards of massage and the status of women 1995).
taking up the work. In 1900 the society was incorporated Massage techniques can be used to promote a general
by license to the Board of Trade and became known as the sense of relaxation and wellness. These days, thanks to the
Incorporated Society of Trained Masseuses. During World resurgence of interest in holistic medicine and popular con-
War I, membership rose, and by 1920 some 5000 members cepts of wellness, the general public still has great faith in
were practicing. In 1920 the society merged with the Insti- the “laying on of hands”; however, such forms of massage
tute of Massage and Remedial Exercises (Manchester). need to be differentiated from the medical massage tech-
These two bodies were then granted a Royal Charter and niques used in other health professions, especially physical
became known as the Chartered Society of Massage and therapy. These more general massage techniques, performed
Medical Gymnastics (CSMMG). World War II saw the on persons who are otherwise healthy, may be termed rec-
emergence of a young profession, as large numbers of sol- reational massage and should not be confused with the term
diers returned from various parts of the world, and the role therapeutic massage. These terms are defined in more detail
of physiotherapy became more important. Massage alone in Chapter 3.
became less important as other means of rehabilitation were Another technique that appears to be similar to massage
developed. For this reason, in 1943 the name of the society is known as “therapeutic touch.” This somewhat controver-
was changed to the Chartered Society of Physiotherapy sial technique needs to be clearly differentiated from thera-
(GSP): peutic massage. Essentially, although the name implies that
From similar beginnings in many other countries, the touching is involved, in its original conception therapeutic
modern profession of physical therapy as it is now known touch does not actually require the therapist to touch the
developed and branched into most parts of the world, devel- patient. The therapist’s hands simply move over the part to
oping differently in each region to accommodate particular be treated without actually making contact. Supporters
needs. Medical massage is rarely used in modern rehabilita- claim that the technique balances energy fields around the
tion practice as a treatment in its own right, but it is used as affected parts (Feltham, 1991; Ireland & Olson, 2000;
part of an overall treatment plan for some patients. It has Krieger, 1979, 1981).
largely been superseded by other, more active treatments, Because the primary effects of therapeutic massage are
but it remains one of the most important means of develop- mechanical, a technique that does not have a mechanical
ing hand skills in the therapist. In physical therapy practice, component cannot work on the same principles. Other
soft tissue massage has developed into many types of manual effects must be invoked to explain its efficacy. Although
mobilizing techniques that take the form of a wide variety therapeutic touch is a popular facet of New Age medicine,
of manipulations performed on both soft tissues and joint it is a long way from enjoying strong scientific acceptance.
structures. In effect, the skilled use of the hands is still the Paradoxically, this concept is not new. Traditional Chinese
cornerstone of the profession of physical therapy and is medicine has many techniques that are similar to so-called
likely to remain so for the foreseeable future. Although therapeutic touch.
massage is rarely used as the sole treatment in physical This text considers only the theory and practice of thera-
therapy and many other manual techniques have become peutic massage. In this regard, the major influence behind
popular, it is still an important part of the range of soft tissue the techniques described is the Swedish remedial massage
techniques that aspiring therapists should learn (Domenech, tradition (Benjamin, 1993; Ostrom, 1918). Before describing
1996). these techniques in detail, the history of various aspects of
In many older Asian cultures such as China, Japan, and medical massage must be explored. This section is self-
India, massage is still used extensively as part of the tradi- contained and may be referred to in relative isolation from
tional methods of treatment. Massage as a specific treatment the rest of the text, as many of the concepts mentioned here
 PART ONE GENERAL PRINCIPLES
sit Onl

are expanded upon throughout the remainder of the book. ized the need for a system for its use. He placed no limit on
The review focuses on a number of aspects of the practice the means of massage. At the same time, Douglas Graham
of massage rather than on a chronological history. Readers of Boston, writing from 1884 to 1918, described massage
interested in the history of soft tissue manipulation as
from these perspectives are directed to the following a term now generally accepted by European and American
sources: Beard (1952), Bohm (1918), Braverman and physicians to signify a group of procedures which are
Schulman (1999), Bucholz (1917), Cole and Stovell (1991), usually done with the hands, such as friction, kneading,
Despard (1932), Graham (1884, 1913), Henry (1884), manipulations, rolling, and percussion of the external
Johnson (1866), Kamentz (1960, 1985), Mason (1992), tissues of the body in a variety of ways, either with a cura-
Quintner (1993, 1994), and Stockton (1994). tive, palliative, or hygienic object in view.
He went much further than Murrell (in recognizing that the
term needed definition) and limited the means to the hand
A REVIEW OF THE HISTORICAL and the surfaces involved to the external tissues. Graham
WRITINGS ON MASSAGE identified the objectives as being curative, palliative, or
A review of the early literature on massage demonstrates a hygienic.
surprising lack of detailed descriptions of the massage Kleen, one of Graham’s contemporaries, limited the
strokes themselves. Even the more recent material reveals a areas involved to the soft tissues. In addition to the hand as
lack of information on the actual techniques of massage. a means of administering massage, he included ancillary
Given the great variations in massage techniques used today apparatuses. This seems contradictory given that he elimi-
and the limited scientific rationale for their use, one might nated the idea that massage is exercise. In this he differed
wonder if it is possible to draw any conclusions about their from his early compatriot, Ling.
value—or lack of it—in modern rehabilitation. The remain- Albert Hoffa (1859-1907) of Germany also limited the
der of this chapter considers the paucity of detailed informa- means of massage to the hand but embraced its broad appli-
tion on techniques and confusion about the meaning of the cation—to all the mechanical procedures that can cure
terms currently in use. It is not a complete account of the illness (Hoffa, 1897). At about the same time, another
history of massage, as only the techniques are considered German, J.B. Zabludowski (1851-1906), also limited the
and the methods compared to determine, if possible, their administration of massage to the hand but specified “skillful
influence on the development of present-day methods and hand grasps, skillfully and systematically applied to the
techniques. This account does not cover every technique body.” While limiting the movement to skillful hand
that can be found in the literature, only the most common grasps, he, like Murrell, recognized the use of systems
ones still in use. Some techniques that were once popular (Zabludowski, 1903).
are not considered here because they are no longer used to C. Herman Bucholz of the United States (Boston) and
any great degree. An excellent example is the many different Germany was as imprecise as any of his predecessors. He
types of nerve manipulation. Once quite popular, these tech- did not mention the hand or any other means of administer-
niques could involve direct stroking, friction, or stretching ing massage in his recommendations for therapeutic
of the major peripheral nerves (Jabre, 1994; Lace, 1946). It manipulation of the soft tissues. Even James B. Mennell
will be interesting to see if in the future these techniques (1880-1957), whose great contributions have made the
are rediscovered. science of massage what it is today, gave no formal defini-
tion of massage.
Definitions of Massage In 1932, John S. Coulter (1885-1949) said:
A comprehensive definition of massage cannot be found in According to the present, generally accepted meaning of the
the early medical literature. Thomas’s Medical Dictionary word, massage includes a great number of manipulations
(1886) offers the following description: “Massage, from the of the tissues and organs of the body for therapeutic
Greek, meaning to knead. Signifying the act of shampoo- purposes.
ing.” (Shampoo is from the Hindi, meaning “to press.”) In 1952, Gertrude Beard (1887-1971) wrote of massage
Throughout much of the history of medicine, massage and as
exercises are referred to simultaneously, and early writers the term used to designate certain manipulations ofthe soft
make little distinction between the two. Kleen (1847-1923) tissues of the body; these manipulations are most effectively
of Sweden, who first published a handbook of massage in performed with the hands and are administered for the
1895, claimed to be the first to show clearly that massage is purpose of producing effects on the nervous, muscular, and
not an exercise therapy (Kleen, 1906, 1921). respiratory systems and the local and general circulation
William Murrell (1853-1912) of Edinburgh and London, of the blood and lymph.
writing at about the same time, was more specific when he
defined massage as “the scientific mode of treating certain Massage Terminology
forms of a disease by systematic manipulations.” He limited A study of the literature in this area might easily lead to
massage to the amelioration of disease but evidently real- confusion over the number of different terrns used to describe
 HISTORICAL PERSPECTIVES CHAPTER 1
er re
‘Sanaa
the various techniques of massage. Despite some similari- In the early twentieth century, physicians in the United
ties, there is considerable confusion, and a comparison States contributed to the literature of massage. Graham
reveals that few writers have given the same meanings to avoided the French terms and listed “friction, kneading,
these terms. A survey of these differences seems useful if manipulation, rolling, pinching, percussion, movement,
one is to interpret correctly any reading of earlier massage pressure, squeezing” and the very early Italian term maxala-
techniques and at the same time possess a clear idea of the tion. In his 1919 book, J.H. Kellogg (1852-1943) describes
meanings as they are presently accepted and used in this different movements, in contrast to some of the English
text. Much of the background information in this area comes writers of a century earlier (e.g., John Grosvenor), who used
from the work of Graham (1884, 1913). only the term friction.
The various advocates of massage among the ancient Murrell of Scotland and England, Kleen of Sweden, Hoffa
Greeks and Romans, from the time of Homer in the eighth of Germany, Bucholz of Germany and the United States, and
century BC through the fourth and fifth centuries Ap, John K. Mitchell (1859-1917) of the United States embraced
used relatively consistent terminology. For example, the French terminology, whereas Zabludowski of Germany
these writers most frequently used the terms friction, and Mennell of England dropped it almost entirely.
rubbing, and anointing. Celsus of Rome (25 Bc-AD 50) used, Kleen, Zabludowski, Mitchell, Bucholz, and Mennell
in addition, the term unction (Cellsus, 1665). Hippocrates gave a rather simple general classification of the terminol-
used the terms anatripsis and rubbing. Galen adopted the ogy with subdivisions of the movements. Mennell’s general
term anatripsis from Hippocrates but added tripsis, trip- classification identified “stroking, compression, and percus-
sisparaskeu lasthke, and apotherapeia. Oribasius (325- sion.” McMillan (1925) used “effleurage, pétrissage, fric-
403), a Roman who followed Galen a century later, described tion, tapotement, and vibration.’ Louisa Despard (1932),
apotherapeia as bathing, friction, and inunction. Other Frances Tappan (1978, 1998), and Lace (1946) used a
terms used in this period were pommeling, squeezing, and mixture of French and English terms. Elizabeth Dicke and
pinching. associates (1978) used both German and English terms to
There is little literature on medical practice during the describe the specialized techniques used in connective
Dark Ages, but massage practitioners in many European tissue massage (CTM).
cultures during the fifteenth, sixteenth, and seventeenth cen- The chronology described in the previous paragraphs is
turies adopted the terminology used in the earlier period. presented in tabular form in Table 1-1, which presents a
Among those who strongly advocated the use of massage chronology of the terminology of massage.
were the noted French surgeon Ambroise Pare and the
famous English physician Thomas Sydenham (1624-1689), Description of Massage
who confined their terminology to friction. Alpinus (1553- Techniques (Strokes)
1617) of Italy used rubbing but added maxalation, manipu- The early literature offers little description of the individual
lation, and pressure. Frederick Hoffman (1660-1742) of massage techniques. The present analysis has been limited
Prussia adopted Galen’s term apotherapeia. Hieronymus to information available since the time of Ling and to those
Fabricius (1537-1619), an Italian, seems to be the first to used most commonly today. To understand the meaning of
have used the term kneading, and he also used rubbing. the terms used by various authors, it is helpful to analyze
In the early part of the nineteenth century, there was a several aspects of the techniques, including direction of the
definite change in terminology, evidently owing to the influ- movement, amount of pressure applied, parts of the hand
ence of Ling. Ling, who has been credited as the originator used to perform the technique, the actual motion performed,
of the Swedish system of remedial massage, traveled widely and the specific tissues of the body to which the massage is
all over Europe and incorporated into his system the French applied.
terms effleurage, pétrissage, massage a friction, and tapote- Peétrissage
ment. To these he added rolling, slapping, pinching, shaking,
Several techniques come under the general heading of
vibration, and joint movement—a specific example of a part
pétrissage (a French term meaning “kneading”). Essen-
of the present-day exercise in the classification of massage
tially, these techniques involve applying pressure to the
movements.
tissues in a kneading manner. They can be performed with
Mezger (1839-1909) of Holland used the French termi-
the whole hand, the fingers, or the thumb. They may be
nology exclusively, and William Beveridge (1774-1839) of
performed with either hand or both hands at the same time.
Scotland seems to have originated the use of the term finger
To create greater pressure to some body areas, one hand can
rubbing. Lucas-Championniére of France also used unique
reinforce the other.
terminology: his gentle massage, which he termed glucoki- To perform pétrissage strokes, Ling grasped the tissues
nesis and effrayan, influenced the massage techniques used
between the thumb and fingers, whereas Mitchell (1904),
to this day. Blundell (1864) of England used the terms inunc- Kellogg (1919), Bucholz (1917), and Mennell (1945) recom-
tion, friction, pressure, and percussion. In contrast, the mended chiefly using the palm in contact with the tissues.
islanders of Tonga in this same period used the terms toogi
toogi, mili, and fota; Hawaiians used the term lomi-lomi.
Text continued on p. 11.
Teen -Sr ey PART ONE GENERAL PRINCIPLES

lable 1-1 Terminology of Massage

inl» Y-\lee t ii
tai ands
|, |Amici 6} 2 bSaaiiinle

CIRCA 1000 Bc to ap 500*

1000 BC Homeric Age Greece Anointing
Rubbing
Circa 500 Bc Herodikus Greece Rubbing
Friction
484-425 BC Herodotus Greece Rubbing
Friction
460-380 BC Hippocrates Greece Rubbing
Anatripsis
128-56 BC Asclepiades Rome Friction
25 BC-AD 50 Celsus; Aurelius Rome Friction
Rubbing
Unction
AD 130-200 Galen; Claudius Rome Tripsis
Anatripsis
Tripsisparaskeulasthke
Apotherapeia
AD 325-403 Oribasius Rome Apotherapeia
1. Bathing
2. Friction
3. Inunction
Fifteenth, Sixteenth, and Seventeenth Centuries*
1492-1541 Paracelsus Switzerland Friction
1510-1590 Paré, Ambroise France Friction
1553-1617 Alpinus, Prospero Italy Rubbing
Maxalation
Manipulations
Pressure
1537-1619 Fabricius, Hieronymus Italy Rubbing
Kneading
1624-1689 Sydenham, Thomas England Friction
1660-1742 Hoffmann, Friedrich Prussia ; Apotherapeia
Eighteenth and Nineteenth Centuries
1731-1823 Henry, Admiral Rubbing
1742-1823 Grosvenor, John England Friction
1774-1839 Beveridge, William Scotland Finger rubbing
1776-1839 Ling, Pehr Henrik Sweden Effleurage
Pétrissage
Massage a friction
Rolling
Slapping
Pinching
Shaking
Vibration
Tapotement
Joint movement
1819 (date of Balfour, William Scotland Compression
writing) (Edinburgh) Percussion
Friction
1839-1901 Mezger, Johann Holland Effleurage
Georg (Amsterdam) Massage a friction
Pétrissage
Tapotement
1. Beating
2. Clapping
“Other terms used in this period were pummeling, squeezing, and pinching.
'Sau-Tsai-Tow-Hooe, published in Japan in the sixteenth century, shows that the Japanese used the terms pressure, percussion,
and vibration
(and rubbing) from very early periods. Cong-Fou of the Tao-Sége is the Chinese expression applied to physicians who use mechanical
therapeutics. They rubbed the entire body with the hands and gently pressed the muscles between the fingers.
 HISTORICAL PERSPECTIVES CHAPTER 1

lable 1-1 Terminology of Massage—cont’d

A
= NAY] AIVITIN©

Nineteenth and Twentieth Centuries?

1843-1913 Lucas-Championniére, France Glucokinesis
Just Marie Effrayante
1847-1923 Kleen, Emil Andreas Sweden Effleurage-stroking
Gabriel Frictions-rubbing
Pétrissage
1. Pinching
2. Rolling
3. Kneading
Tapotement
1. Slapping
. Pushing
. Beating
. Clapping
. Vibration
awh
6. Shaking
1848-1928 Graham, Douglas United States Friction
Kneading
Manipulation
Rolling
Pinching
Percussion
Movement
Maxalation
Pressure
Squeezing
1851-1906 Zabludowski, J.B. Germany Pressure
manipulations
1. Intermittent
pounding
. Slapping
. Vibration
. Hacking
WP
af . Pinching
6. Shaking
Stroking
manipulations
1. Rubbing
2. Kneading
3. Muscle rolling
4. Pressing
5. Stroking
1852-1943 Kellogg, J.H. United States Describes 37
movements including:
Touch
Stroking
Friction
Pétrissage
Kneading
1. Superficial
2. Deep
a. Palmar kneading
b. Fist kneading
c. Digital kneading
d. Rolling
e. Wringing
f. Chucking
Vibration
Percussion
Joint movement

used the term lomi-lomi.

tAt this time, the islanders of Tonga used the terms toogi-toogie, mili, and fota. Hawaiians
Continued
isisnasiai PART ONE GENERAL PRINCIPLES

lable 1-1 Terminology of Massage—cont’d

AIVILN ©

Nineteenth and Twentieth Centuries‘—cont’d

1853-1912 Murrell, William Scotland and Effleurage
England Pétrissage
Friction
Massage a friction
Tapotement
1859-1907 Hoffa, Albert Germany Effleurage
Stroking
Friction
Finger friction
Pétrissage
1. Two-hand
2. Two-finger
Vibration
Tapotement
1. Hacking
2. Slapping
1859-1917 Mitchell, John K. United States Effleurage
(Philadelphia) Pétrissage
1. Rolling
2. Fist kneading
3. Digital kneading
4. Wringing
5. Pulling
Friction
Tapotement
1874 (book Bucholz, C. Herman United States Rubbing
published in 1917) 1. Simple
2. Effleurage
3. Stroking
Kneading
1. Pétrissage
a. Deep
b. Grasping
c. Lifting
d. Wringing
e. Pressing
f. Rolling
g. Harping
2. Friction
Clapping
Shaking
Tapotement
1880-1957 Mennell, James B. England Stroking
1. Deep
2. Superficial
Compression
1. Kneading
2. Pétrissage
3. Frictions
4. Pressure
Percussion
ay. Hacking

. Clapping
. Beating
. Vibration
WPM
aor. Shaking
 HISTORICAL PERSPECTIVES CHAPTER 1

lable 1-1 _ Terminology of Massage—cont’d

Nineteenth and Twentieth Centuries‘'—cont’d

Books published in Despard, Louisa L. England Effleurage
1910 and 1932
1. Deep
2. Superficial
Stroking
Massage a friction
Pétrissage
Tapotement
1. Clapping
2. Hacking
3. Beating
4. Pounding
Vibration
Shaking
Books published in Dicke, Elizabeth Germany Stroking
1944 and 1952 1. Pulling
2. Pull and hook-on
3. Widening
Book published in Lace
1946
Book published in Cyriax, James England Deep massage
1959 Deep friction
Book published in Tappan, Frances United States Effleurage
1961 Pétrissage
Tapotement
Friction
Vibration
Book published in Ebner, Maria England Lifting
1962 Pressure
Stroking
Tensile stroke
Lifting stroke
Stretching
Book published in Wood, Elizabeth United States Stroking
1974 1. Deep
2. Superficial
Kneading
Friction

Hoffa and Mennell emphasized that the hand must fit the between the thumb of one hand and the fingers of the other.
contour of the tissues. It was Hoffa (1897) who distinguished Mezger lifted the tissues and kneaded them between the
different types of pétrissage, depending on which parts of hands. In addition to lifting the tissues for pétrissage, Despard
one or both hands were used to perform the movement. also described a type of pétrissage in which the tissues are
According to Ling and Murrell, the motion is a rolling one grasped and pressed down onto the underlying structures and
and the skin moves with the fingers, but Hoffa, Mitchell, at the same time squeezed (compression kneading). Murrell
Kellogg, Despard (1932), Bucholz, and Mennell lifted the and Hoffa stipulated firm pressure, Ling said that it varies,
mass of tissues and used a squeezing movement. In addition and Mennell prescribed that it should be gentle. Mitchell and
to the rolling, Murrell (1886) recommended that the tissues Despard alternately increased and decreased the pressure.
be pressed and squeezed, similar to squeezing out a sausage. Kellogg stated that it must not be so great as to prevent deeper
Bucholz and Mennell recommended that the hand glide over parts from gliding over still deeper structures.
the skin instead of moving the skin along with the hand. Many authors mentioned that pétrissage is applied to
Despard and Mennell alternately compressed the tissues muscle groups, individual muscles, or some part of a muscle.
 PART ONE GENERAL PRINCIPLES

Ling mentioned specifically that the skin, subcutaneous compression given transversely to the muscle fibers although
tissues, and muscles are grasped. Mitchell was not specific; the general movement was centripetal, and Bucholz stated
he mentioned only tissues. Murrell said a portion of muscle that the manipulations might be either centripetal or
or other tissue was manipulated. Most authors describe centrifugal. Table 1-2 summarizes the various descriptions
the direction as centripetal; Hoffa and Mennell described of pétrissage.

‘apie 1-2 Description of Massage Movements: Pétrissage

NAME _sDIRECTION._____
PRESSURE __ PART OF HAND __MOTION.
Ling Varying Grasped Kneading Skin,
between movements; subcutaneous,
thumb and rolled between tissue, and
fingers thumb and muscle
fingers; skin
moves with
fingers
Mezger Lifting, then Some part of
kneading muscle
between hands
Murrell Centripetal; Firm Both hand Pressed and Portion of muscle
hands move or fingers of rolled between or other tissue
simultaneously one hand; fingers and
in opposite thumb and subadjacent
directions fingers wide tissues; skin
apart must move
with hands;
similar to
squeezing out
a sausage
Kleen Rollings,
kneadings, or
pinchings
Hoffa Not with Chiefly base Lift from underlying Grasp entire
(one hand) fingertips, of thumb tissues; press bulk of
but chiefly and index out like a sponge muscle; begin
with base of finger—not at insertion
thumb and tips
index finger
(two hands) Transversely Both hands Pick up and Crosswise
to muscle squeeze out before
fibers masseur;
backward and around as
forward in much of
opposite muscle as
directions possible
(two fingers) Firm Tip of Twisting movement Muscles that
thumb, of skin spread out
index, and and cannot be
middle grasped by
finger entire hand,
particularly if
covered by
fascia
Mitchell Close— Whole palm Lifting mass a “Tissues”
alternately and parts of little; Kneading
tightening fingers skin to move
and nearest with hands
loosening of palm—not over underlying
the hold fingertips; tissues
fingers
close
together
 HISTORICAL PERSPECTIVES CHAPTER 14

asada
lable 1-2 Description of Massage Movements: Pétrissage—cont’d
isis 7 DIRECTION.
ittiapiiaes
ss PRESSURE. PART OF HAND _MOTION.__ “TISSUES
Upward Not so great As much of Tissues Individual
as to prevent palmar squeezed and muscles or
deeper parts surface as lifted from muscle
from gliding possible; bone or deeper groups
over still fingers tissues, rolled,
deeper close and stretched;
structures together and grasp released
opposing when strain is
thenar at its maximum
eminence
Despard Centripetal Intermittent One or both Grasped, raised Muscles, singly
hands from attachment or in groups
(picked up,
lifted from
underlying
tissues), then
compressed
alternately
between fingers
of one hand
and thumb of
other; move
onward or
between each
compression or
grasped; tissues
are pressed
down upon
underlying
structures and
at same time
squeezed
Bucholz Follows One or both Grasped, lifted Muscles or
outline of working as much as muscle groups
muscle; simultaneou- possible from
succession of sly; as much base, and
single of hand as kneaded or
manipulations possible wrung; glided 1
may be either held close or 2 inches,
centripetal or to skin repeated from
centrifugal one end of
muscle to the
other; if muscle
cannot be
lifted, rolled
and pressed
Mennell _ Compression Gentle Entire surface Entire muscle Muscles
lateral of hand group picked
relaxed up in hands and
squeezed,
compressing
alternately
between thumb
of one hand
and fingers of
other hand; hands
glided gently
over surface
 PART ONE GENERAL PRINCIPLES

Kneading should slip over the skin and that the entire surface of the
Only the most recent authors described kneading as a sepa- palms should be used. Grosvenor and Graham also shared
rate technique; earlier authors used the French term pétris- this view. Hoffa, Bucholz, Despard, and Mennell prescribed
sage to describe the movement, which was similar in many that the movement be done with the ball of the thumb or
respects to kneading, as we now understand it. fingers, which remain in contact with the skin and move it
Several authors described pétrissage as a kneading move- over the underlying tissues. Influenced by Ling, several
ment and made little distinction between the two. Other authors used the French term massage a friction, which is
descriptions of kneading were similar to those of pétrissage. no doubt similar to the contemporary technique of friction,
Mennell stated that they resemble each other very closely, or frictions.
the only difference being that pétrissage is a picking-up The modern proponents of friction techniques are Cyriax
movement with lateral compression, whereas in kneading (1959, 1977, 1978) and Dicke et al. (1978). Cryiax described
the compression is vertical. Kellogg’s concept is opposite to deep transverse frictions of muscles, tendons, and ligaments,
that of Mennell: he stated that the tissues are lifted in knead- the pulling strokes of Dicke and associates use dry, forceful
ing but not in pétrissage. According to Graham (1913), in friction between the fingertips and the skin.
kneading the fingers and hand slip on the skin, whereas With regard to the tissues to which friction should be
Kellogg cautioned that the surface of the hand must not be applied, Kleen, Mitchell, and Mennell used it on small
allowed to slip across the surface of the skin. areas, whereas Graham extended each stroke from joint to
McMillan (1925) used pétrissage, or kneading. Graham joint. There seem to be two distinct ideas about this move-
used kneading on the tissues beneath the skin, whereas ment. One holds that the friction occurs between the hand
Kellogg subdivided kneading as superficial for skin and and the skin surface (e.g., Dicke uses a distinct pattern of
underlying tissues as well as deep for muscles. Graham and short pulling strokes in specific areas). The other (which
Kellogg differed also on direction. Graham stated that seems currently to be more acceptable) prescribes that the
movements should be congruent with the return circulation, part of the hand being used be kept in contact with the skin
and Kellogg stated that for superficial kneading the relation and that the superficial tissues be moved over the deeper
to the veins is not important. Mennell began kneading of (underlying) ones. Table 1-4 summarizes the various des-
the limbs at the proximal portion of an area and progressed criptions of the technique of friction.
to the more distal portion. This kneading is performed with
Stroking and Effleurage
the two hands on opposite sides of the limb, the whole
palmar surface being in contact with the part. Gentle pres- Stroking and effleurage are similar in many respects and
sure is then applied, usually as the hands work in opposite can be discussed together. Like kneading and pétrissage,
directions. He stated that the pressure is gentle, alternating these French and English terms have been used almost inter-
waves of compression and relaxation are applied to a series changeably. Mennell did not include the term effleurage in
of points, and the pressure is greatest when the hand is his classification of massage movements. It is generally
engaged with the “lowest part of the circumference of the agreed that the direction of the movement is centripetal;
circle and least when at the opposite pole” (Mennell, 1945). however, Mennell and Kellogg differ. They both used the
Table 1-3 provides a summary of the various descriptions of term stroking, and Kellogg stated that the direction is with
kneading. the blood current in the arteries, though he did not mention
the amount of pressure. Mennell divided stroking into
Friction
superficial and deep manipulations. Superficial stroking
The various descriptions of friction in the literature betray may be either centripetal or centrifugal, but the pressure,
much confusion among those who used this form of massage. though firm, must be only the lightest touch possible to
Kleen (1921) and Mennell, unlike the other authors, used maintain contact. Deep stroking was given in the direction
the plural frictions, although they did not agree on pressure. of the venous and lymphatic flow.
Kleen prescribed that the pressure be quite hard, and Despard used both stroking and effleurage: the direction
Mennell said it should be light, slowly progressing to deep, of both is centripetal, but the pressure in stroking is vigor-
depending on the conditions. Hoffa asserted that the pres- ous, and Despard noted that in effleurage it should vary
sure seeks to penetrate deeply; Mitchell and Kellogg according to the condition of the patient. Other factors in
described it as moderate. the movements were similar, and she described the motion
Grosvenor (1825) and Graham stated that friction is given of effleurage as stroking, as did Ling, Mezger, Kleen, and
with long strokes, whereas most of the other authors wanted Mitchell.
it performed with small circular motions. Graham said fric- Ling said the pressure of effleurage varies from the light-
tion may be circular or rectilinear (the latter parallel or est touch to pressure of considerable force. Murrell and
horizontal to the long axis of the limb). According to Kleen said that it varies, whereas Hoffa and Bucholz used
Kellogg, the direction is from below upward, following the light pressure at the beginning of the stroke, increased it
large veins, and the motion is centripetal, centrifugal, cir- over the fleshy part of the muscle, and decreased it again at
cular, or spiral rotary. Kellogg also stated that the hands the end. Mitchell varied the pressure according to the region
 HISTORICAL PERSPECTIVES CHAPTER 1

lable 1“3 | Description of Massage Movements: Kneading

DIF e}s
ato J PLAINLD

From insertion As much as Kneading, rolling, Tissues beneath

to origin of possible of squeezing, skin
muscles, fingers and manipulatory;
with return hand; slip on circulatory
circulation skin
Kellogg Relation to Thumb and Essentially a
(superficial) veins not last two pinching Skin and
important phalanges of movement; loose cellular
first or first tissues underlying
and second skin simultaneously
fingers compressed and
lifted from
underlying bone
or muscle
(deep) Little on thin Surface of Grasped or Muscles
tissues, greater hand not compressed
on thick, firm allowed to
tissues slip along
surface of
skin
(digital) Ends of fingers Tissues rubbed
and thumbs and pressed
alone against underlying
bony surface
Mennell Centripetal; Gentle; Whole of Circular, hands Muscle mass
begin proximal alternating palmar working in
portion, wave of surface of opposite directions
advance to compression both hands
more distal; and relaxation; on opposite
compression applied series sides of limb,
vertical of points, with alternating
greatest pressure heel of hand
when hand is and then
engaged with fingers
lowest part of
circle; least
pressure
when at
opposite pole

being treated and used heavy pressure on the upward stroke, recommended that the palm be in good contact and conform
keeping the hand in contact for a return stroke, but with to the contour of the area being treated. Table 1-5 summa-
much less pressure. Bucholz also kept the hand in contact rizes the various descriptions of effleurage and stroking
for a return stroke, touching the skin very lightly. given by some of the best-known writers on massage.
Most authors agreed that stroking and effleurage are to
be given over large areas. Mennell emphasized that the Components of Massage
muscles must be relaxed, and Hoffa and Bucholz said that When applying therapeutic massage techniques, the follow-
the movement should follow the anatomical outlines of the ing factors must be considered: direction of the movement,
muscles. Nearly all authors advocated using the palm of the amount of pressure, rate and rhythm of the movements,
hand for effleurage and stroking. In addition to the palm, media (lubricants) used (including instruments other than
some used the heel of the hand, its edge, the tips of the the hand), position of the patient and therapist, and duration
fingers, the ball of the thumb, and the knuckles for effleu- and frequency of the treatment. Each of these is considered
rage and stroking. Hoffa, Bucholz, Despard, and Mennell from a historical perspective.
 PART ONE GENERAL PRINCIPLES

AY

Grosvenor One hand Palm of hand Long strokes

ascends as
other
descends
Kleen Quite hard Volar side of Rubbings Small surface
(frictions) thumb or
three middle
fingers or
sometimes
base of
hand,
occasionally
with entire
hand flat
Hoffa Circular Seeks to Tips of fingers, Index and Part placed
penetrate either thumb middle on solid
deeply or middle fingers seek support
and firm point of
support; ball
of thumb
held
Graham Circular or Upward Both hands Each stroke
rectilinear; strokes, move at same reaching
latter may be stronger time; one from joint to
vertical or returning ascends as joint
parallel to lightly, graze other
long axis of surface for descends
limb; or soothing
horizontal, influence;
transverse or heavyin
at right centripetal
angles to the direction
long axis
Mitchell Moderate— Thumb or Rubbing in Areas where
steady fingertips of small circles larger grasp
one or more of pétrissage
fingers; hand is not
to slip over possible
surface
Kellogg From below Considerable, Hand Slipping over
upward, depending on skin
following area; amount
large veins; never such
centripetal, that the hand
centrifugal, will not slip
circular, over surface
spiral rotary or so great as
to interfere
with arterial
circulation
Bucholz Circular Moving skin
over
underlying
parts
 HISTORICAL PERSPECTIVES CHAPTER 1

Table 1-4 Description of Massage Movements: Friction—cont’d

Mennell Circular or Light—slowly Usually tips Muscles

(frictions) transversely progressive of fingers or must be
to long axis to deep, tip or ball relaxed
of muscle depending on thumb
fibers condition
present

Despard Circular Palmar Moving Tissues

aspects or tissues upon
tips of fingers underlying
or ball of ones
thumb, also
dorsal aspect
of middle
phalanges of
fingers

lable 1-5 Description of Massage Movements: Effleurage and Stroking

peers
DIRECTION ale 8 wrath B

Centripetal Varying from Stroking

lightest touch
to one of
considerable
force
Mezger Centripetal Superficial and Flat Stroking
gentle
Murrell Direction of Varying Palm or
muscle knuckles
fibers,
centripetally
Kleen Centripetal Varying Large portion Stroking Large area of
with hand skin
flat, its ulnar
or radial side
or with thumb
and forefinger;
one or both
hands
Hoffa Toward the Begin lightly, then Conform to Hand Follows
heart increase and part treated conforms strictly
diminish again as broadly closely to anatomical
toward end of and closely limb; thumb structures of
stroke as possible; and fingertips muscles
whole of proceed along along
hand or part grooves grooves
of it (according between between
to extent of muscles muscles, over
part treated) veins and
flat for broad lymph
surfaces; ball channels;
of thumb; begins
fingertip; beyond
knuckle affected part,
(when part is extends over
covered by affected
thick fascia) region,
finishes in
well part

Continued
——
18 PART ONE GENERAL PRINCIPLES

ing—cont'd
‘able 1-5 Description of Massage Movements: Effleurage and Strok
a 6 PLAIN
NAIV a LJ IN a
Flat hand, Stroking
Mitchell Centripetal Depends on
region; return heel of hand,
stroke much edge of hand,
less pressure thumb, thumb
than upward and fingers
but keeping or fingertips
contact
Fits as closely Where possible, Anatomical
Bucholz Centripetal; Slight at distal
as possible lift up and outlines of
with part of muscle,
to muscle grasp around muscle
lymphatic increase over
flow fleshy part, muscle and
decrease stroke with
toward thumb and
proximal fingers; if not
part; return possible to
stroke in lift, hand
centrifugal presses
direction, muscle
touching skin against
lightly underlying
base
Despard Centripetal Vary according Whole of one Stroking
to condition or both hands
of patient of palmar
surface of
fingers and
thumb; hand
molded to fit
part
Kellogg Blood current Fingers, palm, Touch
in arteries knuckles combined
with motion
Mennell Centripetal Superficial— Flat surface; Rhythmic Extended area
(superficial) or firm but hand supple of body;
centrifugal, lightest touch to mold to muscles must
but continue contour with be relaxed
same once wide area
direction is
established
(deep) Centripetal Deep—light
with venous
and lymph
flow
Despard Centripetal Vigorous Tips of
fingers

Direction treatment. (The circulation of the blood was not described

The literature shows that until the time of Hippocrates, the until nearly 2000 years later.) Asclepiades (125-56 Bc), a
direction of massage was centrifugal (Johnson, 1866). Hip- Roman who lived a few centuries after Hippocrates, believed
pocrates’s contributions to medicine are outstanding, and he that the body was composed of regularly distributed canals
demonstrated his genius in the use of massage and in many in which nutritive fluids moved. Sickness was thought to be
other medical treatments. He favored the centripetal direc- a disturbance of the normal movement of these fluids. He
tion for massage movements. He was unusual in his empha- attempted to restore free flow of the nutritive juices by
sis on Clinical observation, and it is likely that he based his rubbing but gave no direction for the movement (Johnson,
choice of direction on clinical observations of the effects of 1866).
 HISTORICAL PERSPECTIVES CHAPTER 1

Five centuries after Hippocrates, Galen varied the direc-

medical treatment in the British Royal Navy, where it has a
tion of massage movements depending on the purpose of the
proud tradition (Stockton, 1994).
massage and its relation to exercise. At the beginning of the
Beveridge emphasized the importance of touch with
nineteenth century, Ling advocated light stroking in a cen- varying pressure and the differences in the effects produced
trifugal direction and deeper pressure with centripetal
depending on the amount of pressure. In the early part of
movements. This concept has held to the present day. In the nineteenth century he wrote, “The finger of a good
Lucas-Championniére’s superficial stroking technique, as rubber will descend upon an excited and painful nerve as
described by Mennell, the direction may be either centrifu- gently as the dew on the grass, but upon a torpid callosity
gal or centripetal but without deviation once the direction as heavily as the hoof of an elephant.”
is established (Mennell, 1945). These later writers expressed Mezger varied the pressure with the type of movement.
clearly what effects were expected from movements in the The pressure for effleurage was gentle, and that for massage
centripetal direction as compared with those in the centrifu- a friction was “with considerable force” (Berghman &
gal direction. Murrell (1886) asserted that the direction be Helleday, 1873). This force must have been considerable,
from below upward and in the direction of the muscle fibers. as Colombo, one of his contemporaries, stated that
Hoffa and Bucholz were among the first to mention that the Mezger’s patients frequently had blue spots on their bodies.
direction should be congruent with the venous and lym- Zabludowski, who was known as the king of German mas-
phatic circulation. Mennell said all deep movements of seurs, criticized the gentle massage advocated by Lucas-
massage should be performed centripetally to aid venous Championnieére for the treatment of fractures. Zabludowski
and lymphatic flow. Many authors advocated beginning the said that when massage became painless it ceased to be
movement at the proximal (rather than the distal) portion of massage and was merely treatment by suggestion; although
a segment, but with the direction of the pressure in each in a book written later (1903), Zabludowski wrote that
movement being in the direction of venous flow (centripetal) massage is not in most cases painful and that when it neces-
even though the succession of the movements is in the oppo- sarily becomes painful the pain should subside. Bucholz,
site (centrifugal) direction. writing in 1917, did not agree with Zabludowski’s early
Some massage techniques, such as deep friction and concepts. He believed all needed effects could be obtained
CTM, are specific about the direction of the movement in without such abuse of force.
the area where they are applied. About the same time, Kleen and Hoffa showed they
appreciated the finesse of technique together with knowl-
edge, and they regulated the pressure according to the bulk
Pressure of the tissues, increasing it when working on the belly of a
Consideration of pressure seems to have been important muscle and lessening it at the ends of the muscle. (In this
from the earliest description of massage movements, there is evident recognition of the early concepts of
although there was no consensus among early practitioners. Herodikus and Herodotus.) They also observed that the
The Greek authors Herodikus (ca. 500 Bc) and Herodotus proper amount can be judged only by practice.
(484-425 Bc) varied the pressure during the movement: Throughout the late nineteenth and early twentieth cen-
gentle at first, then greater, and toward the end gentle again turies, many authors gave the impression that the greater the
(Johnson, 1866). Later, Hippocrates distinguished the types pressure, the more effective the massage. They began the
of pressure, mentioning gentle, hard, soft, and moderate. He treatment, or series of treatments, with gentle pressure and
emphasized the importance of selecting the correct pressure worked up to the tolerance level of the patient. Kellogg
for a given technique to obtain the desired result, as in the stated that the patient’s tolerance is established during pro-
frequently quoted statement, “Hard rubbing binds; soft longed treatment, beginning gently and increasing pressure
rubbing loosens; much rubbing causes parts to waste; mod- gradually until almost the “whole strength of the operator
erate rubbing makes them grow.” might be employed without injuring the patient.’ Despard
Ambroise Pare, the most renowned surgeon of the six- stated that the vigor and amount of pressure should vary
teenth century, recognized a difference in the amount of according to the condition of the patient, being always gentle
pressure used (Graham, 1884) and described three kinds of at the beginning of the course of treatment and gradually
friction—gentle, medium, and vigorous—and the effects increasing as the patient improves.
of each. From the fifteenth through the beginning of the Mennell was outstanding in his rationale for the use of
eighteenth century, emphasis on heavy pressure seemed to massage. He stated that the amount of pressure depends
be growing. The extremist in this regard was Admiral Henry solely on the relaxation of the muscles. When the muscles
(1731-1823) of the British Navy, who believed that “great are relaxed throughout the treatment, even a light pressure
violence” was important (Johnson, 1866). He described must influence every structure throughout the part being
some of the manipulations as painful, “but they cease to be treated. He believed that movement can be deep without in
so if persevered in, and become even pleasant.” (Rolfing any sense being forced. He reasoned that if the muscles are
seems to some to be a modern-day application of Henry’s relaxed they offer no more resistance to the movement than
beliefs.) Eventually massage became a well-accepted part of does so much fluid, and any pressure applied on the surface
eaminetinis PART ONE GENERAL PRINCIPLES

Pili wis.
will be transmitted freely to all structures under the hand. mended effleurage be given slowly and rhythmically, and for
He said that practice with a skill born only of a delicate a stimulating effect, she suggested that the strokes be quick
sense of touch will show how very light may be the pressure and strong. She varied the rate and vigor according to the
that suffices to compress any structure to its fullest extent condition of the patient and performed all movements
and, therefore, incidentally to empty the veins and lym- rhythmically.
phatic spaces. He also said, “The delusion is deep rooted— In describing stroking movements, some authors distin-
and will die hard—that ‘stimulation’ in massage is impossible guished between the rate of the primary stroke and that of
without the expenditure of muscle energy and vigour. A the return stroke, making the return stroke more rapid,
delusion, nevertheless, it is.” which creates an uneven rhythm. Mitchell advised this and
asserted that a common fault of massage is making the
Rate and Rhythm movements too fast. Mennell identified these essentials of
Some authors mentioned briefly the rate of massage move- superficial stroking: (1) the movements must be slow, gentle,
ments, but few addressed rhythm. Others combined the two. and rhythmic, and there must be no hesitancy or irregularity
Of the early writers, Herodikus and Herodotus both consid- about it; and (2) the time between the end of the stroke and
ered pressure and rate. They advocated gentle and slow the beginning of the next should be identical with the time
movements in the beginning, rapid and heavy ones next, and of stroking throughout the movement. He believed the
slow and gentle movements to end a treatment (Kellogg, rhythm must be even to produce an even stimulus. For the
1919). Hippocrates, describing the treatment of a dislocated stroke from shoulder to hand, he prescribed 15 movements
shoulder, stated, “It is necessary to rub the shoulder gently per minute. For deep stroking, he said that there is no need
and smoothly.” None of the users of massage after Hip- for great speed, as the flow of venous blood is slow and that
pocrates made mention of rate or rhythm until the eigh- of the lymph even slower. He thought that kneading too
teenth century. Beveridge evidently considered great speed rapidly is inimical to success and that for frictions the
an advantage: he believed that flexibility of the fingers is rhythm should be slow and steady. The movements in con-
important because it permits rapid motion. Ling varied rate nective tissue massage are unhurried but not of any precise
according to the type of movement: effleurage should be rate or rhythm.
given slowly; rolling, shaking, and tapotement (percussion)
rapidly. Mezger agreed that effleurage should be given Media (Lubricant)
slowly. The stories of Homer imply that as early as 1000 Bc an oily
Graham, Kellogg, and Bucholz were specific about the medium was used for massage. According to Homer’s
rate (number of strokes per minute) but not about the dis- Odyssey, women rubbed and anointed the war-torn heroes
tance covered in each stroke; thus, the number of strokes to rest and refresh them. Herodotus advised that a “greasy
had no specific relationship to rhythm. These authors speci- mixture” should be poured over the body before rubbing,
fied different numbers of strokes. For friction, Graham and Plato (427-347 Bc) and Socrates (470-399 Bc) referred
specified 90 to 180 strokes per minute. Bucholz (1917) pre- to the benefit received from anointing with oils and rubbing
scribed that the speed should depend on the desired effect: as an “assuager of pain” (Graham, 1913). Olive oil was the
In irritable cases a slow gentle stroke may produce a preferred medium (lubricant), and it was believed that the
marked effect, while in treating an atrophic limb of an oil itself had some therapeutic value. Roman history records
otherwise healthy person, considerable speed, up to 50 to that Cicero’s health was much improved by his anointer’s
60 times a minute or more, with a good deal of pressure ministrations.
may be applied. Celsus made a distinction between rubbing and unction,
Kellogg adjusted the speed depending on the type of move- or anointing. The rubbing in of greasy substances he called
ment and stated the distance to be covered with each stroke. unction. Other authors later contended that unction could
Stroking, he thought, should not cover more than | or 2 not be performed without friction of some sort. In the days
inches per second; friction, 30 to 80 strokes per minute, of Galen, the massage following exercise used more oil than
depending on the length of the stroke; and pétrissage, a not- the one given before exercise. Galen recommended rubbing
too-rapid 30 to 90 strokes per minute (although he specified with a towel to produce redness, followed by rubbing with
that the pace could be more rapid in small parts). oil for the purpose of warming up and softening the body
Kleen varied the rate according to the area treated: he in preparation for exercise.
thought effleurage on the shoulder and back should be rapid. Henry used unique media. He also devised various
Lucas-Championniére emphasized that massage should be instruments and tools that he said prevented nerves and
slow and uniform, with rhythmic repetitions. Zabludowski tendons from falling asleep or becoming fixed. If these
stated that the area covered to some extent determines the structures were kept in constant motion, “the blood would
speed. He compared the rhythm with that of music and sug- pass quickly through the blood vessels, leaving no fur behind
gested that a metronome be used in practice but not as a it, so that ossification which so frequently terminates the
regular guide. Despard varied the rate and rhythm according human existence is prevented.” The instruments were made
to the effect desired. For a soothing effect, she recom- of wood and bone. He principally used cattle ribs, as it was
 HISTORICAL PERSPECTIVES CHAPTER 1

useful to have curved instruments. He also used a hammer suggest soapsuds as a medium, especially to help remove
with a piece of cork covered with leather as well as the dead skin from a limb following the removal of a plaster
rounded end of a glass vial (Johnson, 1866). Graham fol- cast.
lowed a similar method to a certain extent for percussion. Mennell said the selection of a medium is a personal
He suggested that the back of a brush or the sole of a slipper preference and believed the best one is the simplest, namely
could be used, but even better were India rubber balls French chalk, which might be improved by adding oil. He,
attached to steel or whalebone handles (Graham, 1913). as well as other users, recommended an oily medium, espe-
In exceptional circumstances, Murrell said, a bundle of cially when the skin is dry and scaly. Some suggested that
swan feathers, lightly tied together, could be used for tapote- it be used on children and older patients. Of the later users
ment (percussion). For reflex stroking, Kellogg used the in this group, the reason, although it was not stated, undoubt-
fingernail, the end of a lead pencil, a wooden toothpick, or edly was to avoid abrading sensitive skin. Although there
the head of a pin. On the island of Tonga in the early nine- was no credible evidence at the time to support their conten-
teenth century, Graham (1913) reported that “three or four tion, earlier writers believed that the medium itself had
little children tread under their feet the whole body of the curative power.
patient.” At about this time, the Russians and the Finns used
bundles of birch twigs for flagellation before steam baths, Position of the Patient and Therapist
and the Hawaiians gave massage while patients were sub- The early writers gave little indication of the position of the
merged in water. patient or of the therapist while performing massage.
The more recent users of massage have different opinions Nothing was written of this until about the seventeenth
concerning the various lubricants and equipment used. century. However, a bas-relief of the return of soldiers from
Some object to any sort of lubricant, and those who use a war, as described in Homer’s Odyssey, depicts massage
medium choose either an oily lubricant or a powder. Those being given to Odysseus. He is seated, and the masseuse is
who use no medium, in a technique called dry massage, crouching in a most uncomfortable position in front of him
assert that it is cleaner, gives a more certain feeling to the and is massaging his leg (Figure 1-1).
hands and steadier movements, is more stimulating, and Alpinus said the patient should be extended horizontally.
makes it unnecessary to expose the patient’s body. It seems Many of the later writers described the patient’s position in
incredible, but frequently massage has been administered detail and emphasized that the patient should be relaxed—
through the patient’s clothing. Galen records that when a this after the patient had been placed in such a position that
gymnast asked Quintas what was the value of anointing relaxation would seem to be utterly impossible. Few of them
(rubbing with oil), he replied, “It makes you take off your gave a rationale for the positions they prescribed, and they
tunic.” Some types of massage, however, do require a dry seemed to disregard entirely any effect that gravity might
technique for effective treatment (e.g., deep friction and have on venous or lymphatic flow. Ling emphasized that the
connective tissue massage). muscles must be relaxed for many movements and yet
Of those who use oil as a lubricant for massage, many described rolling and shaking the arm while the seated
different compounds, both liquid and solid, have been sug- patient held the arm horizontal with the hand on a table or
gested. The more commonly mentioned ones are olive oil, the back of a chair (Kellgren, 1890).
glycerin, coconut oil, oil of sweet almonds, and neat’s-foot
oil. Some users prefer solid lubricants because the liquid oils
are difficult to handle. The solid lubricants suggested are
wool fat, petroleum jelly, lanolin, hog’s lard, cold cream,
and cocoa butter.
Zabludowski was quite specific in his preference for
white Virginia petroleum jelly because it was odorless,
tasteless, and neutral. He said that the chief basis for the use
of any lubricant was personal preference. Those who recom-
mend oily lubricants say that they make the skin soft,
smooth, and slippery; prevent the pain of pulling hair; and
prevent acne. Some of those who are opposed to the use of
oily lubricants claim that they promote hair growth.
Others recommend powder as a lubricant, as they believe
it is more pleasant for general massage, makes deep knead-
ing possible, and improves the sense of touch. Several users Figure 1-1 An Early Record of Massage
recommend it particularly to absorb the moisture from the in Bas-Relief
patient’s skin and the therapist’s hands. Grosvenor recom- In Homer’s Odyssey, warriors on their return home from battle
mended the use of fine hair powder, and more recent writers were rubbed and kneaded to promote recovery from their battle trauma.
have suggested talcum or boric acid powder. A few writers This image depicts the return of Odysseus.
 PART ONE GENERAL PRINCIPLES

Cleoburey described Grosvenor’s position for massage of the bed with the patient's foot in his lap. Bucholz said the
the lower extremity: patient should be in a relaxing position that would also allow
The female rubber [Grosvenor always employed females] the operator to work with sufficient comfort. Bucholz also
is seated on a low stool, and taking the patient’s limb in did not favor the sitting position for massaging the legs,
her lap (which position gave her command over it) so as to although he thought it might be used for the foot and calf if
enable her to rub with extended hands. the patient was sitting on a table and the operator was in
The position of the patient is not described. One would front of the patient on a chair (Bucholz, 1917).
assume that he or she was seated in a position similar to Despard recommended that the patient be in a comfort-
the one shown in the Greek bas-relief of Odysseus (see able position with the muscles relaxed, yet for back stroking
Figure 1-1). she said the patient might stand with the hands resting
Graham said the patient should be in a comfortable posi- against a wall or other support (Despard, 1932).
tion, with joints midway between flexion and extension, and Mennell said the most important factors in performing
he warned that if the “manipulator” was too close to the all stroking movements are the position of the patient and
patient, his movements would be cramped, and if he was too of the masseur, and the relative position of one to the other.
far away, the movements would be indefinite, superficial, He gave no set rules for either’s position but said there
and lacking in energy (Graham, 1913). should be a reason for every position of the masseur and for
Kleen described a bench on which the patient was to lie the position in which the part under treatment is placed.
and which was approachable from all sides. The masseur Some of the illustrations in his text show the masseur stand-
stood or sat beside it. He gave much detail of patient posi- ing, and others show the masseur sitting. Stroking of the
tions for the treatment of various areas. For massage of the lower extremity was illustrated to point out some common
neck and throat, he had the patient sit on the bench (Kleen, faults of positioning of the patient and of the masseur
1921). (Mennell, 1945).
Hoffa recommended support to the entire length of the In discussing the effect of massage on venous flow,
part of the body that is being treated, so that the muscles Mennell considered the effect of gravity to be very impor-
are relaxed, yet he had the patient sit on a stool for massage tant. He recommended that the patient lie recumbent on the
of the head, neck, shoulders, and upper arms. For massage table, in a position that allows relaxation of abdominal
of the elbow, forearm, hand, and fingers, an illustration muscles, with the thighs supported to enhance venous and
shows the patient sitting with these parts resting on a table. lymphatic flow from the distal part of the lower extremity.
To treat the leg and foot, the patient sits on the table with To treat edema of an extremity, he recommended elevating
the foot supported in the lap of the masseur. He said that the part while giving the massage. For patients with respira-
the masseur’s position should be comfortable, not strained, tory problems, there are specific positions for postural
always beside the patient’s bed, and avoiding as much as drainage (see Chapter 10), and the therapist accommodates
possible frequent and unnecessary changes of position. For his or her position and stance accordingly.
the thigh, the masseur sits beside the reclining patient In the basic position for CTM, the patient sits with the
(Hoffa, 1897). back toward the therapist. Lighting is important when the
Zabludowski recommended a comfortable and relaxed therapist is assessing the patient's tissues. In addition to
position for the patient. The exact position depended on the the basic back section, other parts of the body can be treated
part to be treated. The patient’s glasses were to be removed with CTM, and the patient is positioned accordingly (see
and the lighting and room temperature adjusted to ensure Chapter 11).
comfort. Some work might even be done with the patient
standing, and small children might be held in the masseur’s Duration
lap if a table was not available. He emphasized the posture Galen was one of the first massage users to address the
of the masseur and said the standing position was preferred. duration of a treatment, although he advocated a trial-and-
The masseur should have a sure footing and coordinated error approach. He wrote:
movements, to ease his work and avoid too much flexing and What shall be the duration of the rubbing it is impossible
extending in many joints. Zabludowski added some quaint to declare in words; but the director, being experienced in
rules for the masseur: he should observe his watch chain so these matters, on the first day must form a conjecture,
it does not bother the patient; he should wear glasses instead which shall not be very accurate, but the next day, having
of pince-nez, which might slide off the nose if he perspired; already acquired some experience in the constitution of this
he should wear a jersey (knit) undershirt, heavy or light subject, he will reduce his conjecture continually to greater
according to the season; he should not work in street clothes, accuracy.
should remove his rings, wear short sleeves, and even remove Grosvenor gave specific directions for the duration of treat-
things from pockets that are in the way when he is sitting ment. He said that friction should at first be continued for
(Zabludowski, 1903). an hour, “observing always to rub by the watch” (Cleoburey,
Mitchell (1904) recommended that the patient be reclin- 1825; Johnson, 1866). Murrell said the entire duration of a
ing and for some areas that the operator sit on the edge of local massage should not exceed 8 to 10 minutes and that
 HISTORICAL PERSPECTIVES CHAPTER 1

other authorities thought 4 minutes was enough. Kleen venor’s. Kleen believed massage should be given at least
believed the duration of a treatment was important, but that once daily—and in some cases, for injury, several times
no hard and fast rule could be given. Local massage, he daily. Hoffa recommended daily massage. Zabludowski
thought, usually should last 15 minutes, and general massage advocated daily massage in most cases but believed that the
at least half an hour and sometimes longer. Hoffa suggested physical and psychological reactions of the patient should
10 to 20 minutes for local and 30 to 45 minutes for general determine the frequency. For quick results, he believed
massage. treatments should be given twice daily, but in cases that
Zabludowski said the duration might be 5 to 30 minutes, necessitated weaning from massage, the frequency of treat-
depending on the size of the affected area, the patient’s age, ments should be lessened gradually to two or three per
the duration of the illness, and the patient’s constitution and week.
habits. With regard to the time frame over which treatments Graham recognized the frequency of treatment as part of
should continue, he said it depends on the condition to be the dosage of massage, which should be regulated according
treated, the prognosis, and so forth, but is usually 2 to 3 to the patient’s condition. He associated force with the fre-
weeks. According to Graham, the patient’s condition and the quency and duration of treatment, local massage being done
effect of the massage should determine the duration of the frequently and general massage at least once daily. In con-
treatment. Bucholz said the duration of the treatment should trast to Zabludowski’s weaning from massage, Graham said
depend on the desired effect. For a fresh injury, he stated the frequency could be increased after four or five treat-
that 5 to 10 minutes may be adequate, whereas a general ments. Bucholz said that the frequency of treatment depends
massage should last 40 to 50 minutes. Despard prescribed largely on the patient’s social condition but advised twice-
a definite period of time for massaging each area of the body daily massage in many surgical cases. He believed it wise
and said the duration of the treatment should increase as the to begin with short sessions and to increase according to the
patient’s condition improves. patient’s reaction. Table 1-6 compares the various compo-
Mennell believed it necessary to consider the age of the nents of massage treatments according to some of the best-
patient when administering massage. If the sole aim is to known exponents of the technique.
secure a reflex effect, in very young and aged persons,
Mennell believed that the duration of treatment should be
lessened. For treatment of neurasthenia, Mennell said the
maximum duration is 75 minutes, which may be attained in SUMMARY
comparatively few cases (and never during the earlier stages Historically, many pioneers of soft tissue massage treatment
of treatment). At first, 20 minutes is often sufficient and the seemed to have no physiological basis for their techniques,
treatments may be gradually increased in duration and, particularly in relation to pressure, rate of movements, and
toward the end, should be decreased in a similar manner. In positioning of the patient. The heavy pressure advocated in
cases of injury, however, he emphasized the danger of pro- the fifteenth through the early eighteenth centuries was sup-
longing the series of the massage treatments in lieu of active planted by more gentle massage, as introduced by Lucas-
exercise as the patient improves. Championniere and Mennell in the early twentieth century.
Amazingly, Hippocrates, who certainly did not have access
Frequency to the scientific and physiological data available today, came
Celsus, a noted medical author although not a physician, to the same conclusion. At the beginning of the twentieth
wrote merely as an encyclopedist in his De Medicina (1665), century Bucholz and Hoffa began to show some rational
presenting ideas that appealed to him and were drawn from application of massage technique based on knowledge of
the available literature. It may be assumed, therefore, that physiology, but in this respect Mennell is outstanding.
his writings express some of the ideas that were popular at Clearly, then, opinions differ widely on most aspects of
that time. He gave some details of massage technique and the various techniques described in the literature as medical
appreciated the value of correct dosage. He stated: massage. Over the centuries, some aspects of the techniques
We should pay no attention to those who define numerically have received considerable attention at the expense of others.
how often anyone is to be rubbed; for this must be gathered As aresult, it is difficult to identify well-reasoned rationales
from the individual; and if he is very feeble, 50 times may for most of the techniques used in massage. In this respect,
he enough; if more robust, it may be requisite to rub 200 of course, massage treatments were no different from other
times, and between both limits according to the strength. so-called medical treatments of the same era. Medical treat-
He also believed treatments should be done less frequently ments were often based on anecdotal information. Except
for women, children, and elders than for men (Celsus, 1665; for the fact that they appeared to help many patients and
Johnson, 1866). seemed worth continuing, medical understanding of the effi-
Grosvenor advised daily treatment (more or less as the cacy of massage owed little to science. Certainly the focus
case would permit), gradually increased to three times daily. was on the art of massage rather than its scientific basis in
Murrell also believed in frequent treatment (three or four medical practice.
times daily), but each treatment was much briefer than Gros-
Text continued on p. 34
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 PART ONE GENERAL PRINCIPLES

This text is mindful of the heritage and rich tradition of Graham D: Practical treatise on massage, New York, 1884, Wm.
Wood.
massage treatments and continues to seek a more reasoned
Graham D: Massage: manual treatment and remedial movements,
approach to the practice of this ancient art. To this end, a Philadelphia, 1913, Lippincott.
classification system is described, which pulls from several Graham D: Writer’s cramp and allied affections: their treatment by
earlier traditions and uses a consistent and well-reasoned massage and kinesitherapy, Edin Med J 19:23i-239, 1917.
Grosvenor J: A full account of the system of friction adopted and
methodology. Each of the various massage strokes is care-
pursued with the greatest success in cases of contracted joints and
fully described, and, where appropriate, the clinical and lameness from various causes, Oxford, 1925.
scientific rationale for their use is considered. It is hoped Harris JD, McPartland JM: Historical perspectives of manual
that this approach will dispel much of the confusion appar- medicine, Phys Med Rehabil Clin N Am 7(4):679-692,
1996.
ent in the early writings on massage.
Henry L: Massage, Aust Med J 6:337-347, 1884.
Hoffa A: Tecknik der massage, Stuttgart, 1897, Ferdinand Ernke.
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Benjamin PJ: Massage therapy in the 1940’s and the College of Swedish 9(4):197-199, 1998.
Massage in Chicago, Massage Ther J (Fall):57-62, 1993. Ireland M, Olson M: Massage therapy and therapeutic touch in
Berghman G, Helleday U: Anteckningar om massage, Nord Med Arkin children: state of the science, Alt Ther Health Med 6(5):54-63,
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Blundell JWF: The muscles and their story from the earliest times, Jabre J: “Nerve rubbing” in the symptomatic treatment of ulnar nerve
London, 1864, Chapman & Hall. paresthesiae, Nerve Muscle October:1237, 1994.
Bohm M: Massage: its principles and technic, Philadelphia, 1918, Johnson W: The anatriptic art, London, 1866, Simpkin Marshall.
Saunders. Kamenetz HL: History of massage. In Licht S, editor: Massage,
Braverman D, Schulman R: Massage techniques in rehabilitation manipulation and traction, New Haven, Conn, 1960, Elizabeth
medicine, Phys Med Rehabil Clin N Am 10(3):631-649, Licht.
1999, Kamenetz HL: History of massage. In Basmajian JV, editor: Manipula-
Broca P: Sur l’age des sujets a la trépanation chirurgicale néolithique, tion, traction and massage, ed 3, Baltimore, 1985, Williams &
Bull Soc Anthrop de Paris xi:572, 1876. Wilkins.
Bucholz CH: Therapeutic exercise and massage, Philadelphia, 1917, Kellgren A: The technic of Ling’s system of manual treatment,
Lea & Febiger. Edinburgh and London, 1890, Young J Pentland.
Celsus AC: De medicina, 1665, Leiden, Netherlands. Kellogg JH: The art of massage, ed 12, revised, Battle Creek, Mich,
Cleoburey W: System offriction, ed 3, London, 1825, Munday & 1919, Modern Medical.
Slatter. Kleen EAG: Handbook i massage och sjukgymnastik, Stockholm, 1906,
Cole J, Stovell E: Exercise and massage in health care through the ages. Nordin & Josephson.
In Winterton P, Gurry D, editors: The impact of the past upon the Kleen EAG: Massage and medical gymnastics, ed 2, New York, 1921,
present: Second National Conference of the Australian Society of the William Wood.
History of Medicine, Perth, Australia, 1991, Hawthorn Press. Krieger D: Therapeutic touch: how to use your hands to help or to
Cyriax J: Treatment by massage and manipulation, New York, 1959, heal, Englewood Cliffs, NJ, 1979, Prentice Hall.
Paul Hoeber. Krieger D: Foundations of holistic health nursing practices: the
Cyriax J: Textbook of orthopedic medicine, ed 7, vol 1, New York, 1978, renaissance nurse, Philadelphia, 1981, Lippincott.
Macmillan. Lace MV: Massage and medical gymnastics, London, 1946, J&A
Cyriax J, Russell G: Textbook of orthopedic medicine, ed 9, vol 2, Churchill.
Baltimore, 1977, Williams & Wilkins. Mallios JB: Massage: an ancient healing therapy rediscovered in the
Despard L: Textbook of massage and remedial gymnastics, ed 3, New 1990s, Home Health Care Manage Prac 8(2):15-20, 1996.
York, 1932, Oxford University Press. Mason A: Rub, rub, rubbish: massage in the nineteenth century,
de Watteville A: The cure of writer’s cramp, Br Med J 1:323-324,
Physiotherapy, JCSP 78(9):666, 1992.
1885a. McMillan M: Massage and therapeutic exercise, Philadelphia,
de Watteville A: Further observations on the cure of writer’s cramp, 1925,
Saunders.
Lancet i:790-792, 1885b. Mennell JB: Physical treatment, ed 5, Philadelphia, 1945, Blakiston.
Dicke E et al: A manual of reflexive therapy of the connective tissue:
Mitchell JK: Massage and exercise in system of physiologic therapeu-
Bindegewebs-massage (connective tissue massage), Scarsdale, NY,
tics, Philadelphia, 1904, Blakiston.
1978, Simon. Murrell W: Massage as a therapeutic agent, Br Med J 1:926-927
Domenech MA: Massage education and clinical use in the United , 1886a.
Murrell W: Massage as a mode of treatment, London, 1886b,
States, J Phys Ther Ed 10(2):68-71, 1996. Lewis.
Ostrom KW: Massage and the original Swedish movement
Estabrooks CA: Touch in nursing practice: a historical perspective, Am s, their
application to various diseases of the body, Philadelphia,
J Nurs 2(2):34-48, 1987. 1918,
Blakiston.
Estradere J: Du massage, Pans, France, 1863, Ecole de Medecine.
Palmer D: The next three decades of massage, Massage
Feltham E: Therapeutic touch and massage, Nurs Standard 5(45):26-2 Therapy J Fall:
8, 27-31, 1992.
1991.
Prunieres A: Sur les cranes artificiellement perforés et
Galen: Hygiene, Springfield, Ill, 1951, Charles les rondelles
C Thomas (Translated by craniennes a l’époque des dolmens, Bull Soc Anthrop de
RM Green). Paris 9:185,
1874.
Goldstone L: From orthodox to complementary: the fall and rise of
Quintner J: Apropos rub, rub, rubbish: massage in the
massage, with specific reference to orthopaedic and rheumatol nineteenth
ogy century, Physiotherapy, JCSP 79(1):32, 1993.
nursing, J Orthopaedic Nurs 3(3):152-159, 1999.
Quintner J: Aye, there’s the rub, down under, Physiot
Goldstone LA: Massage as an orthodox medical treatment past and herapy, JCSP
80(8):519-520, 1994,
future, Complement Ther Nurs Midwifery 6(4):169-175,
Robins RP: On writer’s cramp. In Braithwaite J, editor:
2000. The retrospect
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.
 HISTORICAL PERSPECTIVES CHAPTER 1

Stockton J: The history of massage and physiotherapy in the Royal Thomas's medical dictionary, Philadelphia, 1886, Lippincott.
Navy, Physiotherapy, JCSP 80(1):40-42, 1994. Veith I: Huang Ti: the yellow emperor’s classic of internal medicine,
Tappan FM: Healing massage techniques: a study of eastern and Baltimore, 1949, Williams & Wilkins.
western methods, Reston, Va, 1978, Reston. Wright CK: Massage by nurses in the United States and the People’s
Tappan FM, Benjamin P: Tappen’s handbook of healing massage Republic of China: a comparison, J Transcultural Nurs 7(1):24-27,
techniques: classic, holistic, and emerging methods, ed 3, Norwalk, 1995.
Conn, 1998, Appleton & Lange. Zabludowski JB: Technique of massage, Leipzig, 1903, Thieme.
 Anatomical Landmarks for
Therapeutic Massage

Knowledge of anatomy, especially that which is on the bony prominence is the external occipital protuberance (or
surface or creates superficial landmarks, is essential for inion), found on the occipital bone (Figure 2-1). Extending
performing therapeutic massage. It is important to know in caudally from the external occipital protuberance and the
which direction muscles run, where they attach to bone or posterior border of the foramen magnum, there is a superfi-
cartilage, their relationships with blood vessels and nerves, cial ligament of significance, the ligamentum nuche (or
and whether these structures are deep or superficial. Bony nuchal ligament). This structure extends from the external
structures visible or palpable from the surface are key ele- occipital protuberance along the spinous processes of the
ments to identifying these soft tissue structures. Arteries cervical vertebrae. This ligament helps to provide a site for
and nerves are delicate and easily damaged, so it is vital to muscle attachments.
be aware of their position when performing soft tissue Laterally, another structure of significance in the head is
massage. Also, deep friction massage can be done to specific the transverse process (TP) of the second cervical vertebra
tendons and ligaments, so knowledge of their position is (C2). This landmark is identified by first locating the angle
important. of the mandible. The TP of C2 is found between the angle
When describing or defining the position of structures of of the mandible and the mastoid process. An important
the body, it is important to always maintain relationships muscle landmark in the neck, just posterior to the TP of C2,
with respect to the anatomical position. The anatomical is the sternocleidomastoid muscle (Figure 2-2), best viewed
position is defined as the body standing erect, head facing with the neck extended against resistance. This muscle orig-
forward, trunk straight, and upper limbs extended with the inates from the manubrium of the sternum and the clavicle
palms upward. All structures are related to one another with and inserts onto the mastoid process of the temporal bone
the body in this position. and the superior nuchal line of the occipital bone.

Neck
HEAD AND NECK Posterior to the sternocleidomastoid muscle is a large muscle
Therapeutic massage of the head and neck region must be of the neck, the trapezius. When the patient’s shoulders are
done carefully. Several important nerves and blood vessels elevated, this muscle is easily visible. This muscle extends
travel through this area, often superficially. Knowledge of from the skull and the ligamentum nuchae, along the spinous
these structures is important to avoid causing damage, either processes of cervical and thoracic vertebrae, to insert onto
temporary or permanent. the clavicle as well as both the spine and acromion of the
scapula.
Head Deep to the trapezius muscle are the splenius muscles
Bony prominences of the head and neck provide a frame of (cervicis and capitis). These muscles reflect the meaning of
reference for location of important structures. The mastoid the word splenion, meaning bandage, and extend from the
process is a prominent bony process of the temporal bone spinous processes of cervical and thoracic vertebrae to the
and is found posterior to the ear. It is important as the inser- transverse processes of the cervical vertebrae and the skull.
tion for the sternocleidomastoid muscle. Another significant In the posterior neck, this muscle is found in a space bounded
 PART ONE GENERAL PRINCIPLES

Figure 2-1 External occipital Figure. 2-3 Acromion process

protuberance

ments and thereby protected. Massage to the upper limb is

commonly needed in athletes, repetitive injury rehabilita-
tion patients, or breast cancer patients.

Shoulder
Bony landmarks of significance in the shoulder are focused
on the scapula and the clavicle. The clavicle is palpated on
the anterior and superior aspect of the chest. Inferior to the
clavicle is the space occupied by the subclavian artery, from
which a pulse can be felt.
The scapula is a prominent flat bone on the dorsal aspect
Sje-leslelel=ilelelsri-tice)ic of the shoulder, between ribs 2 and 7. It articulates with the
Muscle clavicle anteriorly and the humerus laterally. The medial
border of the scapula can be pulled away from the back,
Figure 2-2 Sternocleidomastoid muscle along with the inferior border (at T8). The anterior border
of the scapula is palpated best from the axilla. The most
prominent posterior portion of the scapula is the spine (at
T3), which provides a surface landmark to divide the pos-
by the trapezius muscle posteriorly, the levator scapulae terior aspect of the scapula into supraspinous and infraspi-
inferiorly, and the sternocleidomastoid muscle anteriorly. nous portions. The lateral end of the spine widens to form
Anterior to the splenius muscles are three pairs of scalene the acromion (Figure 2-3). At the angle of the acromion,
muscles: anterior, middle, and posterior. These muscles are where it changes direction, the deltoid muscle originates to
involved in respiration and are important landmarks in the form a cap over the shoulder. An additional important bony
neck for locating the roots of the brachial plexus. The ante- prominence on the scapula is the coracoid process. This
rior and middle scalenes attach to the first rib, whereas the process is medial to the head of the humerus as well as the
posterior scalene attaches to the second rib. All three acromion and is inferior to the clavicle. Several important
muscles originate from the transverse processes of the fourth muscles attach here (pectoralis minor, coracobrachialis,
through sixth cervical vertebrae. At this origin, all three short head of the biceps).
muscles can be palpated as one muscle mass, posterior to The head of the humerus articulates with the scapula to
the sternocleidomastoid muscle. The roots of the brachial form the shoulder, or glenohumeral joint. Just distal to the
plexus are found in the neck between the anterior and middle head of the humerus are the greater and lesser tubercles. By
scalenes. gripping the clavicle and the acromion and rotating the
shoulder, the therapist can feel the head of the humerus as
UPPER LIMB it rotates and can also feel the greater and lesser tubercles.
The deltoid muscle caps the shoulder. It has anterior,
Massage to the upper limb most often involves the superfi- intermediate, and posterior portions. With the upper extrem-
cial muscle groups present. Although nerves and vessels are ity in the anatomical position, the anterior portion is visible
present in the upper limb, most are deep to muscle compart- when the patient flexes the shoulder against resistance. The
 P .
ANATOMICAL LANDMARKS FOR THERAPEUTIC MASSAGE CHAPTER 2 we

intermediate portion is visible when the patient abducts the carpi ulnaris, and flexor digitorum superficialis), as well as
arm against resistance. With the shoulder in extension, the the landmark for locating the ulnar nerve as it passes pos-
posterior portion of the deltoid is visible at the shoulder. terior to the medial epicondyle. The ulnar nerve is very
superficial, running in a groove posterior to the medial epi-
Arm condyle of the humerus. It can be palpated both proximal
The arm, or brachium, is separated into anterior and poste- and distal to this point, as a tight cord. The medial epicon-
rior compartments. The most superficial, visible muscle of dyle feels sharp and is more prominent than the lateral epi-
the anterior compartment is the biceps brachii muscle. It condyle. It provides a point of attachment for many of the
has, as the name implies, two heads of origin. The short forearm extensor muscles (extensor carpi radialis brevis,
head takes its origin from the coracoid process of the extensor digitorum, extensor digiti minimi, extensor carpl
scapula, whereas the long head originates from the supragle- ulnaris, and supinator).
noid tubercle within the shoulder joint. Both heads are Medial and lateral thickenings of the fibrous capsule of
observed with the arm in the anatomical position. With the the elbow are the radial collateral (lateral) and ulnar collat-
patient’s shoulder flexed and forearm supinated, the thera- eral (medial) ligaments. The radial collateral ligament is fan
pist can easily see the belly of the long head along its entire shaped and runs from the lateral epicondyle of the humerus
length until it disappears under the anterior portion of the to blend with the annular ligament of the radius. The ulnar
deltoid. The insertion of the biceps, the biceps tendon, can collateral ligament extends from the medial epicondyle to
be palpated as it attaches to the radius. The biceps muscle the coronoid and olecranon processes of the ulna. It is com-
also ends as an aponeurosis (Figure 2-4), or broadened flat posed of three bands, although these are not distinguishable
tendon, inserting into the ulna. This bicipital aponeurosis on palpation.
forms the roof of the cubital fossa and protects the brachial An important anatomical space on the anterior upper
artery and the median nerve. limb is the cubital fossa. This space is found anteriorly at
The triceps muscle, with three heads of origin, is the the transition from the arm to the forearm. The cubital fossa
major muscle of the posterior compartment of the arm. The is defined superiorly by a line connecting the medial and
lateral head is located on the lateral aspect of the arm, lateral epicondyles of the humerus. The inferior medial
the long head is medial and proximal, and the short head is border is the pronator teres muscle, and the inferior lateral
distal. border is the brachioradialis. The cubital fossa is an impor-
The olecranon process is an easily palpated proximal tant region because of the presence of several structures.
posterior prominence of the ulna. It can be felt with the Superficially, the median cubital vein is the most common
upper limb in extension, and, even more pronounced, with site for venipuncture. Found deep in the cubital fossa, the
the elbow in flexion. The olecranon fossa, a depression in brachial artery and median nerve are protected by the bicipi-
the distal humerus, can be palpated with the elbow in flexion. tal aponeurosis.
It is the site where the olecranon process of the ulna rests
when the elbow is extended. Forearm
The medial and lateral epicondyles are bony prominences The ulna is the medial bone of the forearm and serves to
at the distal end of the humerus. The medial epicondyle is stabilize this area. The posterior border of the ulna can be
the site of attachment for many of the flexors of the forearm palpated, extending from the olecranon process to the wrist.
(pronator teres, flexor carpi radialis, palmaris longus, flexor The distal end ofthe ulna is the styloid process (Figure 2-5).

a
Bicipital Styloid Process
Cur Osis of the Ulna

Figere 2-4 Bicipital aponeurosis Figure 2-5 Styloid process of the ulna
 40 PART ONE GENERAL PRINCIPLES

ee ee

This superficial bony eminence can be seen and palpated Flexor carpi radialis tendon
easily with the wrist in both extension and flexion.
Palmaris longus tendon
The radius is the lateral bone of the forearm. It is shorter
than the ulna. The head of the radius is a proximal structure
found just distal to the lateral epicondyle. It is best palpated
with the subject’s elbow flexed. Ask the subject to alter-
nately supinate and pronate the forearm, and you will
feel the radial head rotate as it articulates with the
humeral capitulum. The groove felt between the radial head
and the trochlea of the humerus during this rotation indi-
cates the humero-radial joint line (HRJ). The radius ends
Flexor carpi ulnaris
distally as the styloid process. This process can be felt later-
ally, proximal to the thumb. The dorsal tubercle of the radius Figure 2-6
(Lister’s tubercle) can be palpated medial and posterior to This figure illustrates the important relationships at the wrist of tendons,
the styloid process and separates the tendons of the extensor arteries, and nerves. (Modified from Drake RL, Vogl L, Mitchel AWM:
digitorum, extensor indicis, and extensor pollicis longus Gray’s anatomy for students, Philadelphia, 2005, Elsevier.)
muscles from those of the extensor carpi radialis longus and
brevis.
The wrist extensors are found in the posterior compart-
ment of the forearm, and most originate as the common Once the boundaries of the snuffbox have been estab-
extensor tendon from the lateral epicondyle of the humerus. lished, the pulse of the radial artery can be easily palpated
One prominent posterior compartment muscle, which is not at the wrist, proximal to the snuffbox and lateral to the
a forearm extensor, is the brachioradialis muscle. The bra- tendon of the flexor carpi radialis muscle.
chioradialis muscle is most obvious when the subject flexes The ulnar artery is also found superficially at the wrist,
the forearm against resistance, keeping the forearm in the just lateral to the ulnar nerve, which can be felt close to the
neutral position. Once the brachioradialis muscle is identi- ulnar artery, just lateral to the tendon of the flexor carpi
fied, the rest of the superficial posterior compartment ulnaris muscle. The ulnar artery pulse can be taken at this
muscles can be determined. The extensor carpi radialis location, just proximal to the pisiform bone, especially if the
longus and brevis, extensor digitorum, and the extensor wrist is in extension (Figure 2-6).
carpi ulnaris comprise the muscles in this compartment, The radial carpal (wrist) joint line correlates with the first
from lateral to medial, relating to the brachioradialis. The crease of skin on the ventral surface of the wrist. This line
tendons of these muscles, found on the dorsum of the wrist, is located at the base of the thenar eminence and indicates
are held in place during extension by the extensor retinacu- the articulation of the distal radius with the first row of
lum. The tendons of the extensor digitorum muscle are carpal bones.
clearly visible on the dorsal surface of the hand, when the
wrist is hyperextended. Hand
Most of the forearm flexors originate from the medial The proximal, or first, row of carpal bones consists of the
epicondyle as the common flexor tendon. These muscles scaphoid, Junate, triquetrum, and pisiform, listed from
include the pronator teres, flexor carpi radialis, palmaris lateral to medial. To palpate the scaphoid, locate the ana-
longus, flexor carpi ulnaris, and flexor digitorum superficia- tomical snuffbox and slide your finger to the base of this
lis. Placing your hand on the medial epicondyle and asking depression. The scaphoid is located here, just distal to the
the subject to flex and ulnar deviate the wrist will cause the radial styloid process. On the anterior, palmar, surface
of
muscles originating here to be felt. the hand, with the wrist extended, the scaphoid is felt as
a
bulge proximal to the thenar eminence. The lunate, which
Wrist
is medial to the scaphoid, appears as a slight bulge on
The anatomical snuffbox is an important landmark near the the
dorsal surface when the wrist is flexed. The triquetrum
wrist for localization of carpal bones, muscles, and the can
be found by flexing the wrist with the forearm in supinati
course of the radial artery. The boundaries of the snuffbox on,
just distal to the styloid process of the ulna. To
are tendons of the abductor pollicus longus, extensor polli- find the
pisiform, a small round carpal bone, find the flexor
cus brevis (both together at the anterior surface and often carpi
ulnaris. This muscle inserts onto the pisiform,
together in a sheath and therefore hard to distinguish as two which is
located at the base of the hypothenar eminence.
separate muscles), and extensor pollicus longus (the pos- The pisi-
form projects as a small bump on the palmar surface
terior border of the snuffbox). These muscles become of the
more hand.
visible if the subject abducts the thumb. The floor of this
The distal, or second, row of carpal bones consists
triangular area is the scaphoid bone proximally and the of the
trapezium, trapezoid, capitate, and hamate, listed
trapezium distally. from
lateral to medial. The trapezium, the most lateral
bone of
 ANATOMICAL LANDMARKS FOR THERAPEUTIC MASSAGE CHAPTER 2 Aten
lb i cai
the distal row, can be found between the scaphoid and the With the subject seated and spine flexed, the spinous
base of the first metacarpal, using the snuffbox as a guide. processes of all vertebrae become visible. The most promi-
The trapezoid is best felt with the wrist in flexion. Palpate nent spinous process is that of the seventh cervical vertebra
the proximal end of the second metacarpal to a slight depres- (C7), a significant superficial bony landmark also known as
sion. The trapezoid is a small prominence proximal to that the vertebra prominens (Figure 2-7). With the subject seated
depression. The capitate is the largest of all the carpal bones. and neck flexed, this process is readily visible in the midline
It is large enough to articulate with the second, third, and of the neck as a single tubercle. When the subject’s head is
fourth metacarpals. The capitate is found in a depression in the neutral position and rotated from side to side, the
just proximal to the base of the third metacarpal. The final vertebra prominens will move slightly while the spinous
carpal bone, the hamate, is medial to the capitate, proximal process of the first thoracic vertebra (T1), below it, will not.
to the base of the fifth metacarpal. On the palmar surface The six cervical vertebrae above this can be counted, as can
of the hand, the hamate has a hook, which can be palpated the 12 thoracic vertebrae below. The spinous process of T]
just distal to the pisiform. The hook of the hamate and the is located about a finger’s breadth above the superior angle
pisiform bone are important landmarks because of the close of the scapula. The spinous process of the third thoracic
relationship they share with the ulnar nerve. This nerve can vertebra (T3) 1s at the level of the medial part of the scapular
be easily trapped in the tunnel between these two bones or spine. The spinous process of the seventh thoracic vertebra
can be damaged if massage is too vigorous. (T7) is about a finger’s breadth below the inferior angle of
The five metacarpal bones articulate proximally with the the scapula. The five lumbar vertebrae can be seen inferior
carpals (at the base of the metacarpal) and distally with the to the twelfth thoracic vertebra (T12). With hands placed on
phalanges (at the head of the metacarpal). The base of the iliac crest and thumbs pointing toward the spine, thumbs
the first metacarpal, which articulates only with the trape- will be at the L4/LS5 disc space.
zium, can be seen at the distal end of the snuffbox. The head The trapezius muscle is a major superficial muscle of the
of the first metacarpal articulates with the base of the proxi- posterior neck and shoulder. It connects the pectoral girdle
mal phalanx. The other four metacarpal bases can be pal- to the trunk, extending from the skull, and the cervical and
pated at their respective articulations with the second row thoracic spinous processes to the clavicle, acromion, and
of carpal bones. With the digits flexed, the heads of the spine of the scapula. Elevating the shoulders will allow the
second through fourth metacarpals are visible on the dorsum therapist to visualize this muscle.
of the hand. The metacarpophalangeal joints (MCP joints) The rhomboid muscles, major and minor, are found deep
are the articulations of the metacarpal heads and the proxi- to the trapezius muscle, between the scapulae and the spine.
mal phalanges. Ask the subject to flex and extend at these They originate from the spinous processes of the vertebrae
joints to appreciate the movement. and insert on the medial border of the scapula.
There are 14 phalanges in each hand, 3 (proximal, middle, Deep to the trapezius muscle at the shoulder are
and distal) in digits 2 through 4 and 2 (proximal and distal) muscles that comprise the rotator cuff. This is a group of four
in the thumb, or first digit. Ask the subject to alternately flex muscles (supraspinatus, infraspinatus, subscapularis, and
and extend at each of these joints to appreciate their flexion teres minor), which reinforces and stabilizes the shoulder
and extension. joint. The supraspinatus muscle is found deep to the trape-
The thenar eminence is the raised area visible on the zius, above the spine of the scapula, nestled in the supraspi-
palmar surface of the hand, at the base of the thumb. It is nous fossa. The main function of this muscle is to initiate
formed by three muscles, the abductor pollicis brevis, flexor
pollicis brevis, and opponens pollicis. The hypothenar emi-
nence is a comparable structure, at the base of the fifth digit,
and it has three muscles: the abductor digiti minimi, flexor
digiti minimi, and opponens digiti minim1i.
The median nerve, the main innervation of the intrinsic
muscles of the hand, runs deep through the cubital fossa. It
becomes superficial in the distal third of the forearm. It
continues its course through the forearm to pass into the
palmar surface of the hand at the wrist. It can be localized
at the wrist just medial to the tendon of the palmaris
longus.

BACK
The back is probably the most commonly requested area for
massage. Knowledge of the bony landmarks and muscle
Figure 2-7 Vertebra prominens (C7)
groups of the back is essential for effective treatment.
 PART ONE GENERAL PRINCIPLES

abduction of the shoulder. Asking the subject to perform this LOWER LIMB
action will isolate this muscle. The infraspinatus is found
Muscle groups and bony landmarks of the lower limb are
deep to the trapezius and below the spine of the scapula.
generally larger and more prominent than those of the upper
These two rotator cuff muscles can be distinguished at their
limb. It is often necessary to massage the lower limb of
origin, but their insertions blend to form the rotator cuff
athletes and rehabilitation patients.
tendon as it inserts on the greater tubercle of the humerus.
As the name implies, the serratus anterior muscle has a Hip
separated, or serrated, insertion into several ribs as it forms The lower limb is attached to the trunk at the hip. The hip
the lateral wall of the thorax. This can be viewed anteriorly bone is actually composed of three bones, each distinct
if the upper limb is slightly extended at the shoulder. during embryonic development but fused in the adult. These
The latissimus dorsi is the largest superficial muscle of three bones are the ilium, ishium, and pubis. The iliac crest
the back (Figure 2-8). The anterolateral border of the muscle is a major surface landmark of the ilium in the region of the
is most prominent, but this large muscle can also be seen as hip. The anterior portion of the crest is more easily palpated
it originates from the thoracic and lumbar processes, sacrum, than the posterior. The crest can be followed from front to
and the iliac crest. back, as well as its medial and lateral borders. The most
The erector spinae are a deep group of muscles that run superior border of the iliac crests lies at level with the L4/L5
longitudinally alongside the spine. They extend from the intervertebral disc. This is an important landmark for the
cervical region to the sacrum. If the subject is prone and site of a lumbar spinal puncture.
extends the trunk, the erector spinae will be seen as a mus- The anterior superior iliac spine (ASIS) and the anterior
cular mass on either side of the spinous processes of the inferior iliac spine (AIIS) are prominent landmarks associ-
vertebrae. ated with the iliac crest. If the iliac crest is followed to its
The quadratus lumborum is a deep posterior muscle of opposite posterior end, the posterior superior iliac spine
the lower back. It is found laterally in the lumbar quadrangle (PSIS) is also visible and palpable. The PSIS can be seen
between the iliac crest and the twelfth rib. It is involved in on the posterior aspect of the subject, visible as a small
lateral bending of the back. dimple. A line connecting the PSIS lies at the level of S2,
There are twelve pairs of ribs. Superior to the quadratus passing through the sacroiliac (SI) joints.
lumborum and inferior to the latissimus dorsi, the inferior The second bone of the pelvis, and the most posterior, is
border of the tenth rib can be palpated. These 10 ribs are the ischium. A prominent large oval ischial tuberosity can
attached, either directly or indirectly, via costal cartilages
be palpated in the gluteal region.
to the sternum. The last two pairs, 11 and 12, are not attached A hand’s width inferior to the umbilicus on the anterior
anteriorly to the sternum. For this reason, they are called abdomen are the pubic bones. The symphysis pubis is found
“floating” ribs. It is possible to grasp rib 11 by standing in the midline, but it is often covered with soft tissue, making
behind the subject, placing both hands on the inferior border it difficult to palpate. Found a thumb’s width to either side
of the costal arch (formed by the cartilage connecting ribs of the symphysis pubis are the pubic tubercles. These bony
8 through 10 to the sternum), and moving the hands antero-
prominences provide a landmark for identifying the location
laterally on the abdomen, toward the iliac crest. The elev- of the superficial inguinal ring, a common site of herniation
enth rib will have a free anterior border. After locating the of abdominal contents into the lower limb.
eleventh rib, move the hand down and back toward the iliac
crest to find the shorter twelfth rib. Anterior Structures: Thigh
A prominent landmark separating the hip from the lower
limb is the inguinal ligament (Figure 2-9). This soft tissue
structure is the inferior margin of the external oblique
muscle and aponeurosis. It extends between the ASIS
and
the pubic tubercle.
The anterior compartment of the thigh contains the quad-
riceps femoris muscle group. This group of muscles
consists
of the rectus femoris, the vastus medialis, vastus
lateralis,
and vastus intermedius. These muscles all flex the
hip and
extend the knee. All of these muscles insert by a
common
tendon onto the tibial tuberosity. This structure
is known as
the quadriceps tendon superior to the patella and
the patel-
lar ligament (or tendon) inferior to the patella
. The tendon
contains a sesamoid bone, the patella. With
the knee in
flexion, it is clearly visible anteriorly. To see
this tendon/
ligament, flex or extend the knee. It runs slightl
Figure 2-8 Latissimus dorsi y obliquely
and laterally, inferior to the patella.
 ANATOMICAL LANDMARKS FOR THERAPEUTIC MASSAGE CHAPTER 2 43

ere
fe ee
Figure <=5
a A, Femoral triangle. B, This figure illustrates the boundaries and con-
aE are] e! 4 tents of the femoral triangle in the anterior thigh. (B, modified from Drake
P RL, VoglL, Mitchel AWM: Gray's anatomy for students, Philadelphia, 2005,
Elsevier.)

An important area on the anterior thigh is the femoral

triangle (see Figure 2-9). The superficial boundaries of the
femoral triangle are visible and palpable. The most lateral
boundary is the sartorius muscle. This muscle originates
from the ASIS and extends distally at a 45-degree angle
through the anterior thigh, where it inserts medially as part
of the pes anserinus onto the tibia. The medial boundary of
the femoral triangle is the adductor longus muscle. Another
structure related to the femoral triangle is the superior
Anterior superior iliac spine border, defined by a line extending from the ASIS to the
pubic tubercle. The pectineus muscle forms the floor of this
Inguinal ligament triangle. The inferior apex of the triangle is called Scarpa’s
triangle, where the sartorius and the adductor longus muscles
meet. Running perpendicular through the femoral triangle
Femoral nerve
are its contents. The femoral artery is in the middle of the
Femoral artery
Femoral vein
triangle, and one can feel the pulse of this artery if the leg
is in extension. To locate the femoral nerve, move laterally
Lymphatics passing in the femoral triangle from the femoral artery. The nerve
through femoral canal ries ;
will feel like a cord.
Pubic tubercle A prominent superficial bony landmark of the thigh is
the greater trochanter of the femur. With the patient supine,
Medial margin of
sartorius muscle as the hip is rotated, the greater trochanter of the femur can
be palpated in the lateral hip region, inferior to the iliac
Pubic symphysis crest. A line passing through the greater trochanters is at the
level of the pubic tubercles and the center of the femoral
heads.
The iliotibial tract or band (IT band) is a long, flat tendon
running from the hip through the thigh to insert on the tibia
Medial margin of
at Gerdy’s tubercle. The tensor of the fascia lata (TFL) is a
adductor longus
muscle small muscle found proximally in the IT band. The IT band
also serves as the tendon of insertion for the gluteus maximus
muscle.

Anterior Structures: Knee

With the knee in full flexion, you can observe two external
ligaments of the knee. The lateral collateral ligament (LCL,
or peroneal/fibular collateral ligament) extends from the
lateral tuberosity of the femur to the head ofthe fibula. This
ligament feels like a thin cord. The medial collateral liga-
ment (MCL, or tibial collateral ligament) is a broad, flat
band that runs from the medial epicondyle of the femur to
the medial condyle of the tibia.
The pes anserinus, or goose’s foot, is the insertion of the
sartorius, gracilis, and semitendinosus muscles into the
medial aspect of the tibia. All three muscles are internal
rotators of the leg.
The medial and lateral femoral condyles are superficial
and easy to palpate when the knee is flexed. The condyles
iii PART ONE GENERAL PRINCIPLES

Medial
Tuberosity t=) 9410) ¢-1|
Condyle

Figure 2-10 Tibial tuberosity Figure '2-11 Lateral and medial femoral
condyle

are the distal expansions ofthe femur. The flattened superior tibial tuberosity, posterior and distal to Gerdy’s tubercle.
surfaces of the tibia, which articulate with the distal femur, The neck of the fibula is found just distal to the head. The
are the tibial plateaus. With the knee flexed, these plateaus most distal prominence of the fibula is the lateral malleolus,
can be palpated. The horizontal groove at the level of the providing a site of insertion for many ligaments of the ankle.
tibial plateaus constitutes the knee joint line. Finding With the foot in plantar flexion, it can be seen and palpated
this line allows palpation medially and laterally to locate easily. The tendons of the fibularis longus and fibularis
the medial and lateral collateral ligaments of the knee. brevis muscles pass posterior to this landmark. The lateral
The adductor tubercle of the femur is a small prominence malleolus extends more distally than does the medial mal-
of bone on the superior aspect of the medial femoral leolus and is sharper.
condyle, best palpated with the knee in flexion. Slightly
above each femoral condyle is an epicondyle. The medial
epicondyle and the lateral epicondyle are prominent bony
Anterior Structures: Ankle and Foot
ridges on the femur. The lateral epicondyle is above the
insertion point of the LCL (peroneal/fibular collateral liga- With the subject extending the great toe against resistance,
ment) of the knee. the tendon of the extensor hallucis longus muscle is visible
The tibial tuberosity is an elevation on the anterior surface near its insertion on the base of the distal phalanx, as well
of the tibia (Figure 2-10). This is the point of attachment for as along its proximal course at the ankle as it enters the
the patellar tendon, the insertion for all of the muscles of dorsum of the foot. The tendon of the tibialis anterior muscle
the quadriceps femoris group. Distal to the tibial tuberosity, is located medially to the proximal part of the extensor hal-
the anterior border of the tibia (Figure 2-11) can be palpated. lucis longus tendon as it passes to insert on the medial
This bone is superficial and directly palpable beneath the cuneiform and the first metatarsal. This tendon is the most
skin. When the knee is flexed, the tibial condyles can be medial of the tendons on the dorsum of the foot and lies
just
palpated on either side of the tibial tuberosity. Gerdy’s tuber- anterior to the medial malleolus. By resisting extensio
n of
cle, or the tubercle of the lateral condyle of the tibia, is a the other toes, the tendon of the extensor digitorum longus
structure found on the anterior aspect of the tibia. can be found laterally to the proximal part of the
extensor
hallucis tendon and splits to insert on the middle and
distal
phalanges of the lateral four digits.
Anterior Structures: Leg
The fibularis muscles (longus, brevis, and tertius) are
The distal termination of the tibia, the medial malleolus, is
found laterally in the leg and foot. (These muscle
easily seen when the ankle is inverted. It serves as the point s were
previously known as _peroneal muscles.) With
of insertion for medial ligaments of the ankle. Posterior leg the foot
everted and dorsiflexed, the tendon of the fibularis
muscles (posterior tibialis, flexor digitorum longus, and longus is
visible passing posterior to the lateral malleolus
flexor hallucis longus) pass directly posterior to the medial as it inserts
on the medial cuneiform and the first metatarsal.
malleolus. Between the flexor digitorum longus and flexor The fibu-
laris brevis muscle is deep to the tendon of
hallucis longus muscles lie the posterior tibial artery and the fibularis
longus. The fibularis brevis tendon courses lateral
vein, as well as the tibial nerve (Figure 2-12). ly across
the ankle into the foot to insert into the
The lateral bone of the leg, the fibula, is small and thin. tuberosity of
the fifth metatarsal. The fibularis tertius, an inconsistent
The head of the fibula can be palpated at the level of the
muscle that comes off the extensor digitorum
longus, passes
 ANATOMICAL LANDMARKS FOR THERAPEUTIC MASSAGE CHAPTER 2

Tibialis posterior tendon

Flexor digitorum longus tendon
Flexor hallucis longus tendon
Medial malleolus
Posterior tibial artery
Tibial nerve
Tarsal tunnel

Flexor retinaculum

Calcaneus

Figure 2-12
This figure demonstrates the relationships of the tendons, vessels, and nerves that pass posterior to the
medial malleolus. (Modified from Drake RL, Vogl L, Mitchel AWM: Gray's anatomy for students, Philadelphia,
2005, Elsevier.)

anterior to the lateral malleolus to insert on the fifth meta-

tarsal (Figure 2-13).
The lateral collateral ligament (LCL) and the medial
collateral ligament (MCL or deltoid ligament) of the ankle
reinforce the fibrous capsule of the ankle. The MCL is larger
and stronger than the LCL. Both ligaments are found infe-
rior to their respective malleoli.
An important superficial vascular landmark on the ante- Tibialis anterior
tendon
rior ankle is the dorsalis pedis artery (or dorsal artery of the
foot). This is the main source of blood supply to the toes
and is the direct continuation of the anterior tibial artery. It
Extensor
is an important site for taking the pulse, especially if circu-
digitorum
lation in the upper limb 1s compromised. It is found midway longus tendons Extensor hallucis
between the lateral and medial malleoli. longus tendon
The foot is composed of the tarsal bones. These tarsal
bones include the talus, calcaneus, navicular, cuboid, and
three cuneiforms. The talus, which forms the ankle joint
with the distal tibia, has a talar head, which can be palpated
distal to the malleoli. The calcaneus is the largest tarsal
bone. It articulates with the talus and forms the heel of the
foot. A significant structure of the calcaneus is the susten-
taculum tali. This shelflike structure is located on the medial
aspect of the calcaneus, a finger’s breadth inferior to the Figure 2-13
medial malleolus of the tibia, and helps to support the talus. This figure shows the relationships between the tendons of the tibialis
A small lateral extension of the calcaneus, the fibular (pero- anterior, extensor hallucis longus, and extensor digitorum longus on the
neal) trochlea is palpated just anterior to the lateral malleo- dorsum of the foot. (Modified from Drake RL, Vogl L, Mitchel AWM: Gray's
lus. The navicular bone has a prominence called the anatomy for students, Philadelphia, 2005, Elsevier.)
navicular tuberosity. This is found just distal to the talar
head on the medial side of the foot. The heads of all five
metatarsals can be seen if the toes are plantarflexed, together
or separately. The first metatarsal is the shortest and broad-
 PART ONE GENERAL PRINCIPLES

est of the metatarsals. The second metatarsal is the longest. nerves can be distinguished from one another at the level of
A plantar view of the heads of the metatarsals is possible if the popliteal fossa. When the subject is supine, with hip and
the toes are dorsiflexed. The tuberosity, or styloid process knee flexed, the tibial nerve is visible in the posterior aspect
of the fifth metatarsal, provides for the insertion of the pero- of the popliteal fossa. The popliteal artery is found just
neus brevis. This bony landmark can be found by following medial to this nerve. The pulse from this vessel can be taken
the fifth metatarsal from its head, proximally, until it articu- at this location, even though the artery is deep in the popli-
lates with the cuboid. The cuboid, found proximally to the teal fossa. This relationship renders this artery subject to
fifth metatarsal, can be palpated if the peroneus brevis injury with a posterior dislocation of the knee joint. The
muscle is relaxed by inverting the foot. direct continuation of the popliteal artery into the posterior
leg is the posterior tibial artery. This artery lies deep to the
gastrocnemius and soleus muscles and provides the primary
Posterior Structures: Thigh and Leg blood supply to the foot. It becomes more superficial at the
The gluteal group of muscles is considered to be the lateral ankle, running behind the medial malleolus. Lateral to the
compartment of the thigh but is found posteriorly at the tibial nerve, running at a 45-degree angle, is the common
region of the hip. This group of three muscles—maximus, fibular nerve. This nerve is superficial and vulnerable to
medius, and minimus—is found in the area bounded by the injury as it winds around the head of the fibula.
iliac crest, the gluteal fold, the coccyx, the ischial tuberosity, The posterior compartment of the thigh contains the
and a lateral border extending from the ASIS to the greater hamstring muscles. These muscles (biceps femoris, semi-
trochanter. The most superficial muscle of the group is the membranosus, semitendinosus) can all be palpated together
gluteus maximus. as they arise from the ischial tuberosity. These muscles
The large and important nerve of the lower extremity that also comprise the borders of the anatomical space at the
passes through the gluteal region is the sciatic nerve (Figure posterior aspect of the knee, known as the popliteal fossa
2-14). It innervates no musculature in the gluteal region but (Figure 2-15).
serves as the innervation for the muscles of the thigh, leg, The popliteal fossa is defined superiorly by the biceps
and foot. The sciatic nerve bifurcates to form the tibial and femoris (lateral) and the semimembranosus and semitendi-
common fibular nerves, usually at midthigh level. These nosus (medial). It is defined inferiorly by the medial and

Vertical line
Highest point on iliac crest

Safe injection region

Horizontal line

.— Greater trochanter
Sciatic nerve Sciatic nerve

Ischial tuberosity

Ischial tuberosity

Gluteal fold

Figure 2-14
This figure illustrates the course of the sciatic nerve through
the gluteal region. (Modified from Drake RL
Vogl L, Mitchel AWM. Gray's anatomy for students, Philadelphia, 2005,
Elsevier.)
 ANATOMICAL LANDMARKS FOR THERAPEUTIC MASSAGE CHAPTER 2

Common fibular nerve

Semimembranosus
muscle
Popliteal fossa
Popliteal vein
Popliteal artery
Biceps femoris muscle
Tibial nerve
and tendon
Semitendinosus tendon

Head of fibula
Medial head of
gastrocnemius muscle

Penetrates deep fascia

Lateral head of
gastrocnemius muscle
Small saphenous vein

Figure 2-15
This figure shows the boundaries of the popliteal fossa, as well as the course of the common fibular nerve
as it winds around the fibula. (Modified from Drake RL, Vogl L, Mitchel AWM: Gray's anatomy for students,
Philadelphia, 2005, Elsevier.)

lateral heads of the gastrocnemius. With the subject lying REFERENCES

prone, the belly of the gastrocnemius muscle is seen in the
Drake RL, Vogl L, Mitchel AWM: Gray’s anatomy
for students,
posterior compartment of the leg, halfway between the knee Philadelphia, 2005, Elsevier.
and the ankle. This muscle has two heads of origin, and the Moore KL, Dalley AF: Clinically oriented anatomy, ed 5, Baltimore,
medial head is more prominent than the lateral head. The 2005, Lippincott Williams and Wilkins.
Moses KP, Banks JC, Nava PB et al: Atlas of clinical gross anatomy,
calcaneal or Achilles tendon for this muscle continues dis-
Philadelphia, 2005, Elsevier.
tally to insert on the calcaneus. This tendon is easily and Tixa F: Atlas of palpatory anatomy of limbs and trunk, Teterboro, NJ,
palpated at the heel. 2003, Icon Learning Systems.
 Essential Requirements for
soft Tissue Manipulation

The professional practice of soft tissue manipulation they would to deliver any other treatment modality (Myki-
(including massage) requires consideration of a number of etiuch, 1991; Norton, 1995). In addition, by observing the
essential requirements. Important ethical considerations are usual high standards of personal hygiene and cleanliness,
clearly relevant to the practice of this medical art, and the the therapist leaves the patient feeling confident of an effec-
basic issues are outlined in this chapter. The technical tive and professional treatment. Because massage treatment
requirements for the administration of soft tissue manipula- involves the exposure of the body part to be treated and
tion include the type of equipment to be used, methods of direct touching of the patient by the therapist, inappropriate
positioning the patient, and various lubricants, to mention touching and unnecessary exposure are to be avoided at all
just a few. All of these issues are considered in this chapter, times. Many of these ethical issues will be addressed in the
so as to separate them from the descriptions of the basic chapters that follow.
massage strokes in the following chapter. Each of the issues All of the major professional associations in which
discussed in this chapter is relevant to the material discussed massage is practiced have extensive codes of ethics. These
in most of the remainder of the text. codes are excellent sources of information on the various
This chapter does not explore the many types of mechan- issues related to the ethical practice of massage. Although
ical device claimed to be useful for massage treatment. A much has been written on these issues, the various codes of
discussion of these devices has been deliberately omitted practice are an excellent starting place for the reader to find
because in most cases they do not deliver a true massage more detailed information in this area. The web sites of
treatment. These devices usually impart a simple vibration professional associations such as the American Physical
wave to the tissues, typically at a frequency from 50 to Therapy Association (APTA), the American Massage
60 Hz. Although a mechanical stimulus of this type will Therapy Association (AMTA), the American Nursing Asso-
certainly have an effect on the tissues, it is not, nor can it ciation (ANA), the American Occupational Therapy Asso-
be, the same kind of stimulus as that given by trained human ciation (AOTA), the Australian Physiotherapy Association
hands. (APA), the Canadian Physiotherapy Association (CPA), and
the Chartered Society of Physiotherapy (CSP) are listed at
the end of the chapter for easy reference. There are, of
ETHICAL ISSUES course, many other professional associations that could be
All health professionals involved in direct patient care are added to this list, but to include all of the appropriate asso-
expected to, and are honor bound, to adhere to high levels ciations is beyond the scope of this chapter. The intent is
of ethical practice. This is especially the case when it comes only to list a few examples.
to the practice of soft tissue manipulation (including The therapist should be relaxed in his or her manner and
massage), because massage requires direct contact with the movements, which allows the therapist to concentrate on the
patient’s skin and the patient will necessarily be undressed treatment. As in all treatments, an adequate explanation to
for treatment. Therefore, every therapist should conduct the patient is an essential prerequisite. There is considerable
him- or herself with the highest standard of professionalism risk of scratching the patient if the therapist wears jewelry,
during massage treatments, indeed, in the same manner as such as watches and rings (with large stones and settings),
ne PART ONE GENERAL PRINCIPLES

on the wrists or fingers. In this respect, therapists are advised

to work without such jewelry. In addition, any jewelry that BONeE MI Head and Neck
the patient may be wearing should be removed from the part
Bony Landmarks Soft Tissue Structures
of the body to be treated. Mandible Ligamenium nuche (nuchal
It is essential for the therapist to maintain the confiden- Angle of the mandible ligament)
tiality of each patient’s health-related information. A discus- Nasal bones Splenius capitus
sion of one patient’s situation with another patient is an Frontal bones Scalene muscles
obvious breech of confidence and an ethical violation. Temporal bones Supraclavicular lymph
Indeed, in some instances this behavior may be against the Occiput nodes
External occipital Jugular veins
applicable law.
protuberance Carotid artery and pulse
Undressing and appropriately draping the patient are Mastoid process External auditory canal
important aspects of all massage treatments. Instructing the Supraorbital ridge Pinna of the ear
patient on what to wear for treatment is helpful because it Infraorbital ridge Facial muscles
can greatly facilitate the treatment. It will also reduce Zygomatic arch Muscles of mastication
embarrassment for both therapist and patient. Explaining Transverse process of C2
the procedures and the need for undressing and draping Spinous process of C2,
3, 4, 5, 6, 7
are important steps in gaining the patient’s confidence
and verbal consent to treatment. In this regard, a male thera-
pist needs to be especially diligent when treating a female
patient. In this case, it may even be helpful to have a female
assistant present during the draping and positioning of
310) "2, Trunk and Pelvis
the patient. Examining the patient, both before and after
treatment, is another essential component of modern Bony Landmarks Soft Tissue Structures
rehabilitation practice. Obviously this involves undressing, Acromion Rhomboids
draping, touching, and often moving the patient. All of Angle of the acromion Supraspinatus
these procedures require the same high standards of ethical Scapular borders Infraspinatus
practice. Unnecessary touching and exposure must be Spine of the scapula (T3 level) Serratus anterior
Inferior angle (T8 level) Latissimus dorsi
avoided.
Spinous processes (all levels) Erector spinae
“Floating” ribs Quadratus lumborum
KNOWLEDGE Symphysis pubis Gluteal muscles
OF SURFACE ANATOMY lliac crest Inguinal ligament
The effective use of soft tissue manipulation techniques Anterior superior iliac spine
requires a thorough knowledge and practical application of (ASIS)
surface anatomy. Because the therapist’s hands are moving Posterior superior iliac spine
(PSIS)
over the patient’s tissues, it is essential that the therapist be
Sacroiliac joints
able to recognize the anatomical structures involved, espe- Sacral borders
cially when performing techniques that are designed to Ischial tuberosity
affect specific structures, such as a tendon or part of a
muscle. Obviously, if a technique is performed to the wrong
structure, treatment is unlikely to be successful. Clearly,
there can be no substitute for thorough preparation in surface PREPARATION OF THE HANDS
and gross anatomy. Although it is not the primary intention FOR MASSAGE
of this text to review surface anatomy in detail, the therapist Because soft tissue manipulation is performed with the
must be familiar with a number of important structures. hands, the condition of the hands is extremely important
These structures are listed in Boxes 3-1, 3-2, 3-3, and 3-4 to
both therapist and patient. The therapist’s hands must
and have been covered in Chapter 2. In addition, most of be
clean and well groomed yet strong and flexible. The nails
these landmarks are identified on the accompanying DVD. should be kept reasonably short and the tips rounded so
They are listed here as a record of the major landmarks and that
they do not injure the patient during any of the strokes.
structures that can be regarded as essential knowledge for The
ideal hands for massage are well padded, warm, supple,
the effective use of soft tissue manipulation. From time to and
dry. They should express sensitivity and gentleness
time anatomical terms change, and this can be confusing and yet
have firmness and strength. Beginning massage practiti
when deciding what to call a particular structure. Whenever o-
ners may increase the suppleness of their hands by
possible, the latest and most widely accepted anatomical partaking
in various hand exercises. Some individuals have
nomenclature has been used. Where appropriate, former naturally
flexible hands and are able to move them
names have been included in parentheses, if it seemed this rhythmically, and
they seem to be able to learn the techniques
would be helpful. of massage
more readily than others. Nonetheless, with
appropriate
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3

guidance, anyone who conscientiously spends sufficient

30) o 8 Upper Limb
time in practice will eventually acquire good technique.
Bony Landmarks Soft Tissue Structures Hands that have cuts, open sores, warts, or other skin
| Acromion Subacromial bursa lesions are not suitable for massage treatments. It is important
| Coracoid process Rotator cuff for therapists to take exceptional care of their hands if they
| Greater and lesser Deltoid are to be effective with the use of massage. Simple household,
tuberosities/tubercles Biceps automotive, or garden work can be damaging to the hands. A
Bicipital groove Triceps
| Olecranon few minutes spent raking leaves or sweeping a yard can easily
Ulnar nerve
Olecranon fossa Wrist extensors
cause a blister to appear. Adequate protection with suitable
Medial and lateral Common extensor gloves is therefore essential. The use of a high-quality hand
epicondyles origin/tendon or skin conditioner helps to keep hands in good condition.
Radial head Common flexororigin/ The hands must be thoroughly washed before and after
Humero-radial joint (HRJ) tendon treatment and should always be scrupulously clean. The use
line Radial collateral ligament of a high-quality nailbrush is essential in order to remove
Radial styloid process (lateral)
dirt from under the edge of the nails. To be effective, hands
Posterior border of the Ulnar collateral ligament
ulna (medial) should be washed for at least 30 seconds to a minute. Anti-
Ulnar styloid process Cubital fossa bacterial soap may also be helpful. Careful drying with
Radial carpal (wrist) Anatomical snuffbox disposable paper towels is also highly recommended (see
joint line Radial artery DVD Chapter 3-7).
Dorsal tubercle of the Flexor tendons Areas of hard, dry skin (callus) can be removed by gently
radius (Lister’s) Ulnar artery rubbing a very mild abrasive, such as raw, granulated sugar,
Carpal bones Extensor tendons
into the hands. A small amount of olive oil should be com-
| Metacarpal bones Thenar and hypothenar
Metacarpophalangeal eminences
bined with the sugar to produce a paste that is then rubbed
(MCP) joints into rough areas of skin. This technique can be repeated
Phalanges several times each day until the areas of hard skin soften.
Granulated sugar does not completely dissolve in olive oil
and therefore retains its mildly abrasive texture when it is
rubbed into the skin. The olive oil also helps to soften the
B1@) ae ~Lower Limb skin. Care must be taken with clean-up following this tech-
nique because the sticky mixture of oil and sugar is difficult
Bony Landmarks Soft Tissue Structures to remove if allowed to get onto the treatment linens or
Greater trochanter Femoral triangle clothing. It is best to use paper towels to remove the oil and
| Borders of the patella Femoral nerve, artery, and sugar from the hands before washing with soap and hot
Adductor tubercle vein
water (see DVD Chapter 3-8).
Medial and lateral Trochanteric bursa
During massage treatments, the hands fulfill two main
femoral condyles Sciatic nerve
Medial and lateral Sartorius muscle roles: they move the skin, subcutaneous tissues, muscles,
femoral epicondyles Quadriceps femoris muscle and other structures, and at the same time they acquire
Tibial plateaus and Infrapatellar tendon information about the condition of those tissues. In this
knee joint line Hamstring muscles respect, the hands may be viewed as mobile sensors, relay-
Tibial tubercle/tuberosity Tensor of the fascia lata ing information to the therapist concerning the condition of
Head and neck of the lliotibial tract (IT band) the tissues being massaged. Moist, perspiring hands are a
fibula Pes anserinus
great disadvantage to the therapist and may be uncomfort-
| Lateral malleolus MCL and LCL of the knee
Anterior border of the Common peroneal
able for the patient. Therapists may minimize this condition
tibia : (fibular) nerve by frequently washing and drying their hands, possibly with
Medial malleolus Popliteal artery some evaporating spirits.
| Calcaneus Popliteal fossa It is important for the therapist to be relaxed during the
| Fibular (peroneal) Gastrocnemius muscles application of massage, as most of the strokes are performed
tubercle/trochlea Posterior tibial artery not with the hands alone but by using body weight and
Metatarsals Anterior tendons (T, H, D) mn |
moving the body to different positions. Effective massage
Styloid process Dorsalis pedis pulse
can be physically demanding, and the therapist who has
(tuberosity) of 5th MT Fibularis (peroneal) tendons |
Medial collateral ligament strong, flexible hands and good upper body strength will
Cuboid
Navicular tubercle/ (MCL-deltoid) likely find massage treatments much less tiring than those
tuberosity Lateral collateral ligament who are not as fit. Various exercises that strengthen and
Sustentaculum tali (LCL) of the ankle lateral | mobilize the hands and upper limbs in general will be of
Sesamoid bones in the Ligament of the ankle considerable benefit and should be seen as good preventive
foot Achilles (calcaneal) tendon
maintenance for the therapist.
 52 GENERAL PRINCIPLES

In the great majority of both ancient and modern cul- may well be uncomfortable for the patient. In addition, it
tures, massage has been performed using one or both hands. will make it difficult for the therapist to perform the various
Other body parts have been used, such as the feet and strokes properly. Several types of lubricant are in common
elbows, but they are not considered in the present text. Many use. Although massage is generally regarded as a very safe
different parts of the hand can be used for massage, includ- treatment, minor problems can arise with the use of various
ing the palms, fingertips/pads, thumb tips/pads, ulnar types of lubricant. Some therapists develop an allergic
border, knuckles, and all areas on the palmar surface of the reaction, as may the patient, and this will probably necessi-
hand. Figure 3-1 and Box 3-5 show several areas of the hand tate the use of a different medium (Bruze, 1999; Frosh,
that can be used in massage. The same areas are shown on 1996; Sanchez-Perez & Garcia-Diez, 1999; Held, 2001;
the accompanying DVD (see DVD Chapter 3-2). Lis-Balchin, 1999).

Poavsrdar
~-OWOCI

Traditionally, the most common type of lubricant in this

class is a finely powdered French chalk mixture or a mixture
If the therapist has warm, soft, dry hands, use of a lubricant of starch, boracic, and chalk. In current practice, an
may be unnecessary; however, most massage situations unscented baby powder is probably the most suitable powder
require the use of a lubricant to facilitate movement of the for massage. Heavily scented powders should be avoided, as
hands over the patient’s body tissues. This is largely because many people find them offensive and a few are actually
perspiration on the skin surface (both on the therapist’s allergic to them. Powder has a great advantage over various
hands and the patient’s skin) produces a sticky situation that oils and lotions as it allows the therapist to manipulate deep
tissues without the risk of the hands slipping on an oily
surface. Powder facilitates the movement of the hand over
the skin surface, but when pressure is applied, the hand and
skin move together on the deep structures. This effect may
be impossible to achieve when oils are used as a lubricant.
Although powder is an effective lubricant, it must be used
with care. The powder will tend to get on the entire treat-
ment area if the therapist shakes the container too vigor-
ously. Apart from the obvious mess that requires clean-up,
this can create a dangerous situation. Powder on the floor
can produce a slippery surface that may cause the patient or
the therapist to slip and fall. It is also important to avoid
breathing the powder, as it is a serious contaminant if
inhaled into the lungs (see DVD Chapter 3-3).

Creams
Various kinds of cream may be used; for example, lanolin,
vitamin E, or cold cream. For general use, a good-quality
moisturizing cream may be preferable to liquid oils because
Figure | in
of the convenience of application. A significant problem
with the use of some creams concerns their absorption by
Several areas of the hand can be used for massage. The circumscribed
the skin during the massage, leaving a sticky skin surface.
areas include the fingertips and finger pads, the thumb pad, the entire
palmar surface, and the ulnar border of the hypothenar eminence. The
This stickiness can make the massage difficult for the
“knuckle” region can also be used for massage, as can the back of the therapist to perform, and it may be uncomfortable for the
fingers. patient.
Creams have similar problems to the oils with their use
in massage. The cream should be a type that is absorbe
d
slightly by the skin but is not so oily that a large amount
Areas of the Hands Used in Massage
remains on the skin surface during the massage.
(DVD Chapter 3-2) Only an
amount sufficient to allow the hands to glide smooth
ly over
_ The entire palmar surface of either or both hands the skin should be used, as too much lubricant
The ulnar border of the hypothenar eminence prevents a
firm grasp of the tissues and leaves an excessive amount
| One or more fingertips on
the patient’s skin. The right amount depends on the
| One or more finger pads dryness
of the patient’s skin and of the therapist’s hands. Experi
| Either or both thumb pads ence
| The knuckle region will enable the therapist to choose the correct
amount. The
proper amount of lubricant for one area should
be put on
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3 cueisiiaiiin
sp “

both palms and applied to the area with the first stroking have been used as the lubricant, it is important to carefully
jay Movement (see DVD Chapter 3-4). remove them from the patient’s skin with paper towels and
then to wash and dry the skin.
Oils
Many types of oils can be used for massage. They are par-
ticularly useful for treating the skin and subcutaneous TREATMENT TABLES, CHAIRS,
tissues, especially scars, dry skin, and poorly nourished AND ACCESSORIES
areas. However, many deep massage strokes cannot be The most important equipment for successful massage
effectively applied when oil is used as a lubricant. This is treatment is a pair of well-trained and experienced hands
because the therapist’s hand cannot grip the superficial directed by an intelligent mind. Other equipment is impor-
tissues properly and move them on the deeper structures. tant, however, as massage treatments should be practiced with
Commonly used high-quality natural oils are olive, almond, the patient in well-supported and comfortable positions. In
and palm oil; however, many types of vegetable oil can also most cases, the patient lies or sits on some type of treatment
be used. Many types of baby oil are readily available and table (plinth). Ideally, the table height should be adjustable to
are a good alternative to the natural oils. a position that is comfortable for the therapist. A proper posi-
When applying the oil, it is best to pour a small amount tion reduces the overall stress and strain to the therapist’s
into the hands and then apply it to the skin. This reduces back by minimizing the need to bend over the patient.
the tendency for the oil to run over the patient’s skin onto Adequate support for the patient’s head, shoulders, and
the linens. Oil of any type is difficult to remove from the other body parts is extremely important, especially when a
patient’s clothing or the treatment linens. For this reason, patient is lying facedown (prone lying). A wide variety of
care should be exercised when applying any type of oil. adjustable tables are available that greatly facilitate the prac-
Sufficient paper towels under the body part being massaged tice of massage (Figure 3-2).
will help to eliminate problems related to oil spillage (see The adjustable features of these plinths help to ensure
yey DVD Chapter 3-5). that the patient and the therapist are optimally positioned,
and they significantly enhance the efficiency and overall
Soap and Hot Water comfort of the treatment for both patient and therapist.
Soap and hot water may be used for the dirty or dry, scaly Other treatment table designs are available; Figure 3-3 pres-
skin that is commonly encountered when a plaster cast has ents one example.
been removed from a limb/body part. Liquid soap, sufficient These electrically powered types of tables are usually
in quantity to produce large amounts of soapsuds, is required made of steel and are hydraulically operated. The retract-
to make this technique effective. It is directed toward able wheels allow them to be moved easily. In addition, they
affecting the skin and subcutaneous tissues and is particu- may have a variety of adjustable sections, which allow for
larly suitable for removing dead, dry skin where the tissues the separate positioning of body parts; for example, when
are somewhat undernourished. A medicated or antibacte- lying facedown, the patient’s forearms can be supported on
rial soap may be helpful when using this technique. A individually adjustable sections (Box 3-6).
modification of the basic technique of stroking is likely to Massage can also be given while the patient sits. Small,
be the most useful stroke. If possible, the therapist should wooden massage tables traditionally have been used for this
immerse the limb in the hot water and soapsuds mixture. purpose, although in recent times a variety of seating devices
The temperature of the hot water must be carefully con- have been designed for treatment. Figure 3-4 illustrates such
trolled and should be similar to that used for a comfortable a device. These chairs can be made of wood or metal and
hot bath. may be folded/collapsed for easy transportation. They can
Following massage treatment, any lubricant left on the also be individually adjusted for the comfort of each patient.
skin surface should be removed, unless it is supposed to These chairs can be helpful for a patient who cannot lie
remain on the skin (e.g., lanolin or some other emollient). facedown on a treatment table.
The lubricant should be applied sparingly to the therapist’s In addition to the equipment already described, two other
hands rather than directly to the patient. If the patient is devices are useful in massage treatments and are worthy of
powdered or “flooded” with lubricants, the skin pores may mention. The first is the so-called prone pillow. This device
become clogged, an effect that tends to defeat some of the is laid flat on the treatment table and is designed to support
aims of massage. When powder is used as the lubricant, m the patient’s head and shoulders when the patient lies face-
most cases it is not necessary to wash and dry the patient’s down. It has the advantage of allowing a patient to be rea-
skin following massage. However, if excessive powder sonably comfortable on a table that has no built-in face hole.
remains on the skin, much of it can be removed by simply Facial tissues should be used on the edges of the face hole
wiping the skin surface with a damp paper towel. The skin to make the treatment more comfortable and hygienic for
surface can then be dried with a paper towel. It is good the patient. Some patients may find these pillows a little
practice to encourage patients to shower or wash the skin uncomfortable if their upper cervical joints are held in an
surface properly at their earliest convenience. When oils extended position. Minor adjustments to the head position
iene iintias PART ONE GENERAL PRINCIPLES

Figure 3-2 Treatment Tables Suitable for Massage

Treatment tables are generaily constructed of wood or metal, with padded, vinyl-covered tops. The tabletop
may have a face hole and several sections, which may be independently adjustable. Some tables are of
fixed height, whereas others are electrically operated and hydraulically adjustable.

Components of an Ideal Treatment

= _————————n BOX 3-6
Table (i.e., One That Provides the
Greatest Flexibility and Ease in
Its Use)
Electrically operated and hydraulically adjustable in height
Equipped with a face/nose hole
Made in at least three sections, of which the two end
Figure 3-3 An Electrically Operated, portions can be adjusted to different angles
Hydraulic Treatment Table Adjustable forearm rests
Note that the table is constructed of metal and operated hydraulically Smooth rolling, retractable casters with a locking
by an electric motor. It has adjustable forearm supports and a face hole mechanism
in one end, and the other end can also be adjusted. Although the table
is usually made of metal, similar features can be found on wooden
plinths, although the height of these tables is not so easily adjustable
(see Figure 3-2, A). The table should not be too wide, because having supporting structure. These devices can convert a nonadjust-
to lean over the patient places undue stress on the therapist. able flat treatment table into an effective plinth. The wedge
can be turned around and laid flat on the plinth and used to
support the patient’s lower limbs. Figure 3-6 illustrates these
using small folded towels placed under the shoulders can uses.
usually fix any such problems (Figure 3-5). Other simple devices can also help support the patient.
Another useful device is a wedge or bolster, a support For example, sandbags, sheets, towels, and small pillows
usually placed so that the patient can lean against it. For this can
all be used to support specific areas of the patient’s body
reason, the devices must be placed against a wall or other when massage is part of a treatment plan. Certainly, it
is
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3

Figure 3-4 A Typical Massage Chair Useful for Treating the

Upper Back and Posterior Neck and Shoulder
Regions
The heights of the seat, headrest, and forearm rest are adjustable, making it easy to ensure the patient’s
comfort. These chairs are useful in the treatment of the head and posterior neck/shoulder region, both for
massage and other rehabilitation techniques such as ultrasonic and electrical stimulation treatments.

DRAPING AND POSITIONING

—_
THE PATIENT
For massage treatments to be effective, it is critical that the
patient be comfortably positioned and well supported. An
uncomfortable patient will not be able to relax, and this will
seriously interfere with the effect of the massage. Enough
pillows are required to support all parts of the patient’s body
to maximize relaxation. The patient should be kept warm
throughout the treatment, and any body parts that are not
being massaged should be covered, when possible, with
blankets, sheeting, or a similar drape. To relax the patient,
the room should be warm and preferably quiet, and when
Figure 3-5 A Prone Pillow Used to possible the patient should be treated in private. It is very
Support the Head, Neck, and important to preserve the patient’s modesty, and to that end
Shoulders the patient should be adequately covered at all times. At the
same time, the body parts being massaged must be fully
The pillow is placed under the patient’s head and shoulders, allowing
the face to be supported in the face hole. Most people find these pillows
exposed and accessible. The actual position for massage will
quite comfortable when lying facedown. The pillows can be very helpful vary for each patient and each condition. The main criterion
when used with a treatment table that does not have a face hole. Paper is that the patient be well supported and the part to be mas-
towels should be used-to cover the areas where the patient’s face saged readily accessible. The therapist should stand so that
touches the edges of the hole. he or she can reach the patient comfortably without having
to bend or stoop over the patient. For the therapist, most
massage strokes consist of a combination of total body
important for patients to be supported comfortably during movements plus hand movements in contact with the patient’s
treatment; otherwise they may not be able to relax, afid body. As much as possible, therapists should avoid flamboy-
treatment may be less effective than it otherwise would be. ant gestures, and the massage should be performed slowly
Of course, between patient visits it is important to thor- and in a manner that is comfortable for the patient. Box 3-7
oughly clean all surfaces of the treatment table, chair, prone lists the basic patient positions for massage treatments.
pillow, bolster, and other equipment. Several spray cleaners The patient may be draped with any of a number of
are readily available for this purpose; however, it is impor- materials. The most versatile one is probably a clean, folded
tant to use one that will disinfect the equipment surfaces. sheet. Sheets offer an effective method of draping a patient
 PART ONE GENERAL PRINCIPLES

ee ee

B
Figure 3-6 A Movable Wedge or Bolster to Support the
Patient While Sitting or Lying
A, The wedge is used as a back support for a patient sitting upright on the treatment table. Note that
for
the wedge to be effective, some sort of support must be placed behind it. B, The wedge is used under
the
patient's lower limbs to elevate them (e.g., in cases of chronic edema in the legs). These
devices are
extremely useful with a basic flat treatment table (i.e., one where the ends cannot be lifted)

Basic Patient Positions for the knee in order to treat the calf. In therapeutic massage,
EAA Massage Treatment the patient is always draped so that only the parts to be
treated are exposed and the circulation is not impeded in
Lying supine (facing the ceiling)
_ Lying prone (facing the floor) any way. There is no situation that requires the patient to be
| Sitting upright on a plinth with both legs supported (“long completely naked and exposed. Indeed, sound ethical prac-
sitting”) tice demands that the patient be adequately draped and not
Sitting upright on a stool or chair with the upper limb
unnecessarily exposed.
supported on a small table, the end of a plinth, or a
Many techniques can be used to drape the patient. Con-
pillow on the patient’s lap
Sitting upright on a stool facing a plinth, with the upper
sideration needs to be given ahead of time to the patient’s
limbs and head supported on pillows final position and what draping will be required. For
Sitting in a forward-leaning position on a specialized example, wrapping a folded sheet around a patient so that
massage chair the loose end is in front is not a good idea if the patient
will
be lying facedown because the patient and the therapist
will
have to struggle to expose the back. A much more effectiv
for treatment to any desired body parts. If possible, the e
technique is to place a folded sheet around the front
patient’s own clothing should not be used for draping, as it of the
patient so that both of the loose ends are at the back
is very likely that some massage lubricant will end up on of the
patient. This may be called a “back Opening” drape.
the clothing. In addition, the patient’s clothing may impede When
the patient then lies facedown on the treatment table,
the circulation; for example, if the trousers are rolled up to it will
be a simple matter to open the sheets to expose the
back.
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3 cee

Other typical drapes can be called “front opening” and “side BODY MECHANICS OF THE THERAPIST
opening.” In each case, the drape must be performed
in such
a Way as to cover the patient without risk of exposure during Soft tissue manipulation can be strenuous work, especially if
treatment. Additional sheets and towels can be used to cover the patient is large or has muscular tissues. The heranist must
those areas not receiving treatment. Figures 3-7 through 3- use care and precision of movement, which are essential to
11 illustrate the basic patient positions and some typical reduce occupational stress, risks of back injury, and strain to
draping techniques. other vulnerable regions, especially the wrists and hands.

Figure 3-7 Lying Supine (Facing the Ceiling)

A, The patient is draped for treatment to the abdomen. A rolled towel or small pillow can be used to support
the neck, and a pillow or rolled towel should also be placed under both knees. B, The patient is draped
for treatment to the lower limb. Rolled towels or small pillows can be used to support both the knee of the
limb to be treated and the other knee. A larger pillow tends to get in the way of the treatment and is best
avoided. C, The patient is draped for treatment to the upper limb. A small rolled towel placed under the
neck affords easy access to the shoulder and neck region and may be preferable to a regular-sized pillow.
Note that the upper limb can be treated with the patient in several different positions, depending on the
available equipment and the range of motion present in the patient’s shoulder region.
58 GENERAL PRINCIPLES

B
Figure 3-8 Lying Prone (Facina the Floor)
A, The patient is draped and positioned for massage to the back region. Several
methods can be used to
support the patient in this position, but in all cases a pillow should be placed
under the shin region of both
legs. This allows some knee flexion, taking the stress off the sciatic
nerve and its branches. In addition, a
pillow should be placed under the abdomen so that the lower edge of the
pillow is in line with both anterior
Superior iliac spines (ASISs). In this position, the lumbar spine remains
flat and well supported. If the pillow
is placed underneath the patient’s hips, it causes too much hip flexion
and related lumbar extension. The
Shoulders can be supported by a pillow or by two rolled towels placed
at right angles to each clavicle. The
patient can rest the head in a face hole in the treatment table or on
a folded towel. Requiring the patient
to turn his or her head to one side may be uncomfortable for
some patients, depending on how much
restriction to neck rotation is present. For this reason, it may
be best to encourage the patient to rest his
or her forehead on folded towels with the head and neck in
the midline position. B, The patient is draped
and positioned for treatment of the posterior aspect of the lower
limb. The method of supporting the patient
is similar to that shown in A, but the draping allows the lower
limb to be fully exposed.
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3

Figure 3-9 Sitting Upright on a Plinth with Both Legs Extended

(Long Sitting)
This position is particularly suitable for treatment to the anterior aspect of the lower limb. The treated limb
is best supported at the knee with a small rolled towel, as this allows the therapist’s hands to work easily
around the knee and calf region. A rolled towel or small pillow can also be used to support the other knee.
It is important not to let the patient wear trousers or shorts where the legs are rolled up above the knee,
if this constricts the blood flow to the leg. Because the lower limb is the part being treated, it is quite proper
for the patient to wear his or her own clothing on the upper part of the body. If necessary, however, full
draping is a simple procedure.

Controlled relaxation of the hands can be achieved only weight of the therapist’s body to regulate the amount of
if the therapist’s posture permits such relaxation. When the pressure applied. This allows the therapist’s body weight to
patient is lying on a treatment table, the so-called standing be evenly distributed and makes it possible for him or her
fall-out (walk standing) position is usually the most efficient to move over a large area without bending the back. This is
stance. Backward and forward swaying with the knees and an important issue, especially because massage can be
ankles bent then permits the therapist’s arms and hands to strenuous work. Figure 3-12 illustrates the basic concept of
be used over a large area with comparatively little movement good body mechanics in moving along the lower limb of a
at the hips and spine. Both feet should remain in contact patient while reducing the need for bending.
with the floor at all times to maintain balance. This swaying The therapist’s right foot is aligned with the patient’s feet
motion makes it possible for the therapist to perform long, and points toward them. The therapist’s left foot points
stroking movements rhythmically and smoothly, allows toward the patient’s head and is aligned with the patient’s
proper relaxation of arms and hands, and avoids the unnec- knee. This wide stance allows the transfer of body weight
essary fatigue associated with performing massage when between the two feet, thereby allowing the therapist’s hands
standing in a strained, stooped position. It also uses the to move easily along the limb, without bending the knee or
PART ONE GENERAL PRINCIPLES

Figure 3-10 Sitting on a Stool or Chair with the Upper Limb

Supported on a Small Table, the End of a Plinth,
or a Pillow on the Patient’s Lap
These positions are suitable for treatment of the upper limb or a part thereof.
A, The patient sits at the
end of a plinth with the arm supported on a pillow resting on the table. The
draping allows easy access to
the shoulder region while maintaining the patient’s modesty. B, The patient
is in a similar position, but the
upper limb is supported on a small table. C, The patient’s arm is supported
on a pillow resting on the
patient’s lap. This is particularly useful for the patient who has a stiff or painful
shoulder. In all three posi-
tions, the therapist may stand or sit to perform the massage.
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3 |
iam—_
ee

over the patient. Shorter therapists can remedy the situation

by standing on a low platform. In any event, each individual
therapist should make an effort to adjust the treatment table
to a height that is most suitable for his or her body. In most
cases, the treatment table will be at a suitable height when
itis level with the greater trochanter of the therapist’s femur.
When the patient is seated on an ordinary chair, it is quite
permissible for the therapist to sit on a chair facing the
patient, especially if the therapist is particularly tall in
stature. If the patient is seated in a special massage chair, a
tall therapist may sit on a chair behind but facing the
patient.
Because therapeutic massage is performed with the
hands, the posture of the upper limbs is also important. If
joint strain is to be minimized, excessive wrist flexion and
hyperextension of the fingers must be avoided. Good body
mechanics are essential for preventing injury to the thera-
pist. Although the adjustable treatment tables are good for
controlling the overall height of the patient, they often
produce a significant problem for the therapist. This is seen
during massage to the back region, especially on those treat-
ment tables that have a face hole. In this case, the patient
lies in the middle on the table with his or her face positioned
in the hole. When the therapist stands by the side of the
patient in order to massage the patient’s back, the therapist
has to twist his or her back into a most uncomfortable and
stressful position. By positioning the patient at a slight angle
across the plinth, the therapist is able to maintain good
Figure 3-11 Sitting Upright on a Stool,
spinal posture, thereby significantly reducing mechanical
Facing a Plinth, with the
stress on the spine. If necessary (when the patient is rather
Upper Limbs and Head Sup-
tall), the patient’s feet can be supported on a_ pillow
ported on Pillows
resting on the back of a chair placed alongside the plinth.
This position is especially well suited for treatment of the posterior neck
Figure 3-13 illustrates this concept.
and shoulder region. In this example, the patient holds a large pillow
close to his chest so that his chin rests on the upper edge of the pillow.
The patient then leans into the edge of the plinth and places his fore- ESSENTIAL COMPONENTS OF MASSAGE
arms on the pillows stacked in front of him. Note that the top pillow is
folded in half and the patient rests his forehead on it. Even though the All massage strokes have unique characteristics; however,
pillow supports the patient’s head and face, there is plenty of room for there are several components of massage that are common
him to breathe. Sufficient pillows should be used so that the patient sits to all techniques. Each of these is considered briefly here
upright and the head leans forward only slightly. This leaves the neck and elaborated on in the relevant description in Chapter 4.
in a comfortable, well-supported position. The patient’s chin is sup- Careful attention to these components is necessary for the
ported on the pillow wedged between the table and his chest. This pillow intelligent application of each massage stroke. Box 3-8 lists
also keeps the draping sheet in its proper position when the arms are the essential components of good technique.
lifted up onto the plinth. A similar position can be achieved by the use
of a specially designed massage chair (see Figure 3-4). Comfort and Support
The patient must be positioned comfortably with adequate
changing foot position. This facilitates a smooth and relaxed support so that he or she can relax in the required position.
technique for the therapist and greatly contributes to the Pillows are usually used to provide support, but they can
effectiveness of the treatment. i sometimes get in the way of effective massage. A suitable
The height of the treatment table is important for reduc- alternative is rolled-up or folded toweling placed under the
ing the risk of back strain for the therapist. The use of an body part, perhaps the neck, shoulder, or knee. A patient
adjustable-height treatment table is a significant asset in this who is in significant pain may not be able to keep still for
regard. The height of the table should be such that the thera- long, and this makes a comfortable and well-supported posi-
pist can reach the body part in question while keeping his tion all the more important. Folded sheets or blankets can
or her back upright. Fixed-height tables are a real problem be used to drape the patient and also to keep the patient
for very tall therapists, as they have no option but to bend warm, especially if the patient is sensitive to cold. This can
PART ONE GENERAL PRINCIPLES

A, The therapist's back is held as straight as possible. B, C, Movement

along the limb is achieved primarily
by shifting the body weight forward. Such positions minimize the risk
of back injury among therapists.
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3 sie Bidniliamets

Figure 3-13 Good Body Mechanics for a Therapist Treating

the Back Region
A, The therapist’s spine has poor posture (Scoliosis) during treatment of the patient’s back region because
the patientis positioned in the middle of the treatment table. B, By positioning the patient at a slight angle
across the plinth, the therapist is able to maintain good spinal posture, thereby significantly reducing
mechanical stress on the therapist’s spine. If necessary, the pillow supporting the patient’s feet can rest
on the top of a chair placed alongside the plinth.

BOX 3-8 Essential Components of Good

310)<"E Factors That Tend to Inhibit Relaxation
Technique in All Massage Treatments
Comfortable and well-supported positioning of patients _ Psychological factors such as a fear of hospitals or |
so they can be as relaxed as possible during treatment treatment clinics and the presence of domestic/
Flexibility of the therapist’s hands so they fit the contours personal problems
Fear of unknown treatments |
of the body part being massaged
Strange or new surroundings
Using the correct rate of movement
Untidy or dirty surroundings
Maintaining the proper rhythm
Unpleasant odors associated with hospitals/clinics
Regulating pressure and direction according to the stroke
being performed, the type of tissues being treated, and Excessive noise
Bright lights or total darkness
the purpose of the stroke
Cold, drafty rooms
Maintaining proper postural stance and good body
Pain or fear of pain
mechanics
Breathing difficulty
Fear of undressing
Inadequate or uncomfortable support, draping, or
be a surprising problem during summertime if an air-
positioning
conditioning system is keeping the room temperature too
low.
relaxation. General relaxation describes the overall state of
Relaxation the entire person; local relaxation reters to a specific body
An important component of all soft tissue manipulation part. In each case, the therapist helps the patient to relax by
relates to the level of relaxation present in the patient at the eliminating as many of the factors that inhibit relaxation as
time of treatment. Massage is likely to be much more effec- possible. At the same time, the therapist encourages relax-
tive if the patient is as relaxed as possible, especially when ation by paying special attention to factors that can promote
techniques to treat muscle tissue are concerned. Relaxation it. Boxes 3-9 and 3-10, respectively, list the factors that tend
may be thought of on two levels: general relaxation and local to inhibit or promote relaxation.
 PART ONE GENERAL PRINCIPLES

BOX 3-10 Environmental Factors That A Typical Sequence of Contractions

Promote Relaxation 2@)¢%418) Used in the Contrast Method
of Relaxation _
A quiet environment
Soft lighting | 1. Tense left foot and calf muscles (with toes pointing
A pleasant-smelling treatment room | down and calf muscles contracting), then immediately
Moderate room temperature relax the same muscles.
| A draft-free treatment area 2. Tensé left quadriceps, then immediately relax the
A comfortable and well-supported position same muscles.
| Aclean and tidy treatment area 3. Tense right foot and calf muscles (with toes pointing
down and calf muscles contracting), then immediately
relax the same muscles.
| 4. Tense right quadriceps, then immediately relax the
same muscles.
Specific relaxation techniques may be used to help a 5. Contract muscles of both buttocks and hamstring
tense patient to relax. Two common methods are the contrast muscles, then immediately relax the same muscles.
and the induction techniques. In each case, the patient must 6. Contract back extensors, pressing the head and
be supported comfortably (1.e., with enough pillows to fully shoulders into the plinth, then immediately relax the
support the whole body or a part of it). same muscles.
7. Contract abdominal muscles, tensing the anterior
Contrast Method of Relaxation abdominal wall, then immediately relax the same
muscles.
The principle of this technique is to facilitate relaxation by 8. Contract pectoral muscles to roll the upper arms
teaching the patient to become aware of the difference (the inward toward the midline, then immediately relax the
contrast) between strong muscle contraction and relaxation. same muscles.
The technique calls for the patient to contract groups of 9. Clench the left hand and tense the forearm and upper
muscles as intensely as he or she can for about 3 to 5 arm muscles, then immediately relax the same
seconds. The patient is then instructed to “relax” and “feel” muscles.
10. Clench the right hand and tense the forearm and
the difference between the two states. As each body part is
upper arm muscles, then immediately relax the same
alternately tensed and relaxed in this manner, the patient muscles.
gradually achieves a level of general relaxation. Although 11. Contract facial muscles (eyes shut tightly and teeth
the contrast technique is often used to promote general clenched), then immediately relax the same muscles.
relaxation, the principle can also be applied to facilitate
local relaxation. The physiological rationale for the tech-
nique is that a muscle relaxes easily immediately after a
strong contraction. A suitable sequence for the contrast As the therapist tries to talk the patient into relaxation, a
method is explained in Box 3-11. basic strategy is to first concentrate on the general environ-
mental factors. For example, when using the ocean beach
Induction Method of Relaxation
theme, the therapist might say:
As its name implies, with the induction method of relaxation Imagine you are lying on the warm sand by the ocean. You
the therapist induces the patient into a relaxed state, usually are in Hawaii. It’s warm but not too hot. The sun is baking
by talking to him or her. Careful attention to the patient’s the sand but, a cool breeze is blowing from the sea. You can
comfort and support is necessary, and suitable background hear the seagulls and the surf. You feel relaxed and tired,
music often helps. The patient closes his or her eyes and tries very tired.
to imagine scenes described by the therapist or suggested The aim of this phase of the technique is to set the stage
by music (perhaps the sound of a flowing stream or falling and induce a level of general relaxation in the patient. In the
rain). Mental imagery, an important part of this concept, next phase, the therapist focuses the patient’s attention to
distracts the patient’s attention from his or her physical specific body segments, usually beginning with the feet and
body. Muscle contraction is thus greatly reduced and relax- working toward the head. In this case, the therapist might
ation promoted. It is important not to use music that has a say:
recognizable tune or melody because this may distract the Now think about your feet. Think about the warm sun
patient in an undesirable direction. In this regard, the sounds shining on them. Think about how good the breeze feels as
of nature can be especially helpful. It may also be helpful it blows through your toes. Now think about your legs.
to ask the patient about his or her preference in terms of a Imagine they feel heavy, very heavy, so heavy you can
particularly relaxing situation. For example, one patient may hardly move them, even if you wanted to. Now think about
like the sounds of an ocean beach, whereas another may your hips. Again, they seem so heavy. All you want to do is
prefer those of the rain forest. In any case, it is important
relax into the warm sand.
that the chosen sounds evoke pleasant memories or imagi- In a similar manner, the therapist directs the patient to think
nary experiences for the patient. about the rest of his or her body, all the while encoura
ging
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3
scien
cll
him or her to relax. Obviously, the therapist speaks with a strong stimulation and increase tension and pain, whereas
quiet, rather slow and unexpressive voice. If the patient falls lighter pressure may produce mild stimulation, induce relax-
asleep, he or she may be allowed to rest for a short while (10 ation, and diminish pain. The reaction to external stimula-
minutes) and then is gently woken before continuing with tion varies among individuals and with the nature of the
treatment. Following such techniques, the patient will be lesions under treatment. The therapist must be able to vary
very relaxed and his or her blood pressure is likely to be the pressure exerted with any stroke so that it is well within
rather low. In this case, the patient should sit up slowly and the patient’s tolerance. There is a significant difference in
sit with his or her legs over the edge of the table for | minute the amount of pressure that needs to be exerted in order to
or more before standing. A patient who rises too quickly into be effective when treating a young man who is large (78
the vertical position may faint, so great care is needed to inches tall and 250 pounds) and muscular compared with
prevent this occurring. In fact, all patients who are recum- an 80-year-old female who weighs 90 pounds and is very
bent during massage treatments should take time and care in thin, possibly osteoporotic. The pressure used with any
getting up off the table into the standing position, because stroke always needs to be appropriate for the individual
their blood pressure is likely to be low after treatment (see patient being treated. Specific descriptions of the pressure
Chapter 5, on the effects of massage, for more details). required for each stroke are given in Chapter 4.

Direction of the Stroke Rate and Rhythm of the Stroke

Massage strokes can be performed in many different direc- The rate (speed) at which each massage stroke is performed
tions, but the chosen position depends largely on the purpose again depends on the particular function of the stroke. In
of the individual stroke. The directions include centripetal most cases, massage strokes are performed relatively slowly,
(toward the heart, in the direction of venous and lymphatic although some, such as hacking and clapping, are performed
flow), centrifugal (away from the heart, in the direction rapidly. As a general rule, most massage techniques (except
of the arterial flow), and in other specific anatomical percussion) should be slow, gentle, and rhythmic. A suitable
directions. rate occurs when the hand, or hands, move over the tissues
In most cases, the direction of a massage stroke is related at approximately 6 to 7 inches per second. At such a speed,
to some anatomical structure. For example, effleurage is the desired effects, both mechanical and reflex, can be
given in a centripetal direction because it is designed to obtained. Obviously, this rate is applicable to those strokes
promote venous and lymphatic flow in the normal direction where the hands glide over the surface of the tissues. For
of the circulation. In contrast, deep frictions are performed strokes that move in a circular fashion, the rate will vary
at right angles to the target fibers (muscle, tendon, or liga- depending on which part of the hand is performing the
ment) in order to mobilize them. Therefore each stroke must stroke. For example, during thumb pad kneading, it would
be performed in the correct direction in order for the stroke not be possible for the thumbs to cover 6 to 7 inches of tissue
to be effective. The specific direction for each stroke is per second and at the same time perform the stroke
described in Chapter 4. properly.
Generally speaking, strokes that are performed slowly
Pressure of the Stroke tend to be more relaxing, whereas rapid strokes are more
The pressure exerted with each individual stroke varies, stimulating. In all cases, it is important to perform the stroke
depending on the specific purpose of the stroke and the with the correct rhythm, usually one that 1s as constant as
patient’s physical problem. The pressure is sometimes con- possible. Continuity of treatment is important, and this is
stant but in other strokes variable. The choice of pressure achieved by ensuring an appropriate rhythm to the particu-
depends largely on the function of the stroke. A good lar massage technique. Chapter 4 indicates the appropriate
example is effleurage. In this technique, the pressure gradu- rhythm and rate at which each stroke is to be performed. In
ally increases throughout each individual stroke to be addition, the massage strokes demonstrated on the accom-
maximal at the end of the stroke. It always finishes in, or panying DVD give a clear example of the relative speed at
near, a group of superficial lymph nodes. The therapist which the various strokes should be given.
might imagine pushing the venous blood and lymph in the
superficial vessels in the direction of the circulation. As the Duration and Frequency of Treatment
volume of fluids increases, gradually increasing pressure is Massage treatment can be performed for many different
needed, and a definite pause is required at the end of the purposes. It can be a general treatment for the whole body,
stroke to allow the valves in the vessels to close. In contrast, using any number of combinations of strokes; alternatively,
other strokes are extremely light, involving just the weight techniques can be chosen to achieve a specific effect in a
of the hand moving across the skin. specific structure. For example, the therapist might well use
It is difficult to evaluate accurately the amount of pres- several massage techniques to treat an adherent scar on the
sure that is actually used, but the effect obtained depends hand. The purpose of the massage, therefore, determines
to a great extent on the regulation of the pressure and the how long the treatment is to be given and for how many
stimulation that it produces. Deep pressure may produce a sessions, depending on the specific goals of treatment.
iia PART ONE GENERAL PRINCIPLES

Most commonly, therapeutic massage is performed as too little treatment. This emphasizes the need for constant
part of a total treatment plan. Thus, specific techniques and intelligent observation of the patient and the response
might be integrated with other methods of treatment such to the treatment. It also emphasizes the need to continually
as exercise therapy, electrophysical modalities, and home reevaluate the patient in light of the specific treatment
programs. When performed in these circumstances, each goals.
massage technique 1s practiced for several minutes at a time.
Numerous repetitions of each stroke are given, depending Changés in Signs and Symptoms
on the desired result. For example, if the goal of treatment
As the condition of the treated tissue changes, it may
is to mobilize chronic swelling around the ankle region,
become necessary to alter the duration of treatment or the
appropriate massage strokes might be performed until the
techniques being used. Keeping in mind that massage is a
therapist observes a significant reduction in the swelling.
means to an end, the duration of the treatment may be short-
This might take 10 to 15 minutes or possibly longer. In
ened gradually as it accomplishes the desired results. If
contrast, a full-body massage takes much longer to perform,
massage has not accomplished the desired results, the treat-
around 45 minutes or longer in duration. Full-body massage
ment duration may have been too brief or perhaps too long.
is rarely used in modern rehabilitation but is popular in
The therapist should observe the patient closely if he or she
recreational massage.
is to appreciate the need to change the duration or mode of
Massage treatments can be given daily, if necessary, or
treatment. The duration of any massage treatment should
even several times per day. This schedule may be impracti-
therefore vary according to the lesion being treated and the
cal, however, and in practice many different treatment regi-
size of the area, the rate of the movements, the age of the
mens are in common use. Massage, like many other
patient, and any change in signs and symptoms. To obtain
rehabilitation procedures, should not be performed in a pre-
maximal benefit from any massage treatment and to avoid
scriptive manner. Unlike medications that require specific
inadequate treatment or overtreatment, it is essential
dose levels to be effective, massage treatment can be given
that therapists have a solid scientific knowledge of massage
in many different ways. It is not possible, or indeed desir-
and its physiological effects and that they apply the
able, to specify a particular number of treatments because
in rehabilitation, massage should always be given as part of massage thoughtfully and intelligently, observing its effects
carefully.
a total treatment program. It should not generally be used
in isolation. The particular goals of a treatment plan deter- It is important to remember that each patient is unique.
mine the type and number of treatments needed to reach a Even if two individuals have the same diagnosis, the problem
successful outcome, and this may not be known at the begin- will not affect them in the same manner. The same treat-
ment given to each patient will not necessarily have the
ning of treatment. It is important to remember that each
same effects. Therefore, all treatment needs to be custom-
patient is different and responds differently to treatment.
ized to meet the specific goals determined for each individ-
The duration of the treatment obviously varies according
ual patient. Careful reevaluation of the treatment and its
to the size of the area to be treated, the specific pathology,
effects will determine whether the treatment plan needs to
and the techniques chosen. Although the existing problem
be modified.
may be localized to a small area, there will undoubtedly be
physiological disturbances in adjacent areas. Therefore, the
treatment may not be limited to the diseased or injured
area. INDICATIONS AND CONTRAINDICATIONS
The size and age of the patient also affect the duration FOR THE USE OF MASSAGE
of treatment. At any given rate of massage, it takes less time Treatment using any of the various soft tissue manipulation
to treat a comparatively small person because the amount techniques is indicated when the demonstrated effects would
of tissue being manipulated is less than that of a larger be helpful to the patient. For example, if a particular tech-
person. In addition, there are some cases in which treatment nique has been shown to reduce edema, it may be appropri-
might proceed more slowly than usual; for example, if the ate for a patient who has an edematous limb. It is simply a
patient was in significant pain. question of matching the known effects of a treatment with
In discussing the dosage of massage, various medical the specific needs of the patient (as expressed in the treat-
authorities recognize the variability of application and the ment goals). All of the basic massage techniques covered in
difficulty of specifying doses. It would seem impossible to Chapter 4 are described individually, including specific
avoid either too little treatment or too much if the duration indications and contraindications.
of each treatment is specified. Mennell emphasized the Contraindications to massage treatments are a little less
importance of intelligently observing the patient during obvious and require more explanation. A contraindication is
treatment and the danger of over- or undertreating. He a demonstrated circumstance in which the use of a particu-
believed, however, that unless at some time there is evidence lar treatment technique is highly likely to result in damage
of an overdose, it is possible that the patient has been given to the patient. The probability of damaging effects will vary
 ESSENTIAL REQUIREMENTS FOR SOFT TISSUE MANIPULATION CHAPTER 3

significantly, both among treatments and for each individual

SUMMARY
patient. Nonetheless, it is possible to group a series of cir-
cumstances that are most likely to be problematic. Some are This chapter has considered the various components neces-
obvious and others are much more subtle. For example, a sary for effective massage. These components included the
patient who has a large open wound cannot receive massage background knowledge of surface anatomy, the various types
over the area of the wound. This is a common theme in of equipment used, draping and positioning of the patient,
the lists of contraindications given in Chapter 4, as are and the key factors concerned with the application of soft
many other situations. In most cases, the problem
tissue massage. Ethical issues associated with the practice of
that
contraindicates treatment exists only in the area to be massage were mentioned briefly, and readers were encour-
treated. For example, it would be perfectly acceptable to aged to investigate the various codes of ethics for those pro-
treat the right leg of a patient who had a large open wound fessions in which massage is practiced (see the list of web
on the left leg. However, in other circumstances, the patient site references). It is clear from these topics that a great deal
may have a systemic illness that might contraindicate of background information is needed, in addition to detailed
treatment with massage, although this is less likely. A patient knowledge and skill related to the individual massage strokes.
with severe congestive cardiac failure might have swollen Chapter 4 discusses these techniques in detail.
legs as a result of his or her condition. If enthusiastic attempts
are made to massage the patient’s legs and push the edema REFERENCES
back into the circulation, this may put stress on the patient’s
heart. In this case, treatment with massage is probably best Bruze M: Occupational allergic contact dermatitis from olive oil in a
masseur, J Am Acad Dermatology 41:312-315, 1999.
avoided.
Frosh R: Peanut and nut allergy: baby massage oils could be a hazard,
To assist the reader in this area, three different designa- Br Med J 313(7052):299, 1996.
tions are used to rate each of the situations that might con- Held E: Some moisturizers may cause trouble, /ntl J Dermatology
traindicate each of the techniques discussed in Chapter 4. 40(1):12-13, 2001.
Lis-Balchin M: Possible health and safety problems in the use of novel
The system used is as follows: plant essential oils and extracts in aromatherapy, J Roy Soc Health
¢ The designation A means that the use of a particular 119(4):240-243, 1999.
technique is always contraindicated and should never be Mykietiuch A: Professional conduct and boundaries. Massage Therapy J
(Winter):20-22, 1991.
performed (e.g., the presence of a melanoma in the skin
Norton L: Complementary therapies in practice: the ethical issues, J
of the areas to be treated). This designation is also Clin Nurs 4(6):343-348, 1995,
known as an absolute contraindication. Sanchez-Perez J, Gracia-Diez A: Occupational allergic contact
¢ The designation U means that the use of a particular dermatitis from Eugenol, oil of cinnamon and oil of cloves in a
physiotherapist, Contact Dermatitis 41(6):346-347, 1999.
technique is usually contraindicated and in most, but
not all, cases should not be performed. The technique
Web Site References
can be used under these circumstances, but it can only
be given with great care (e.g., a person who has marked The American Physical Therapy Association (APTA)
http://www.apta.org
varicosity of the veins). The American Massage Therapy Association (AMTA)
¢ The designation R means that the use of a particular http://www.amtamassage.org
technique is rarely contraindicated and can, in most The American Nurses Association (ANA)
http://www.nursingworld.org
cases, be performed safely and effectively. Very occa-
The American Occupational Therapy Association (AOTA)
sionally, however, an individual patient may not be able http://www.aota.org
to receive treatment using the technique (e.g., a person Australian Physiotherapy Association (APA)
who is hypersensitive when touched, perhaps because he http://apa.advsol.com.au
The Canadian Physiotherapy Association (CPA)
or she is extremely hairy or ticklish). In such a case, an
http://www.physiotherapy.ca
alternative technique (or treatment concept) may have to The Chartered Society of Physiotherapy (CSP)
be used. http://www.csp.org.uk
 Classification, Definitions, and
Descriptions of the Basic
Massage Strokes and
Relaxed Passive Movements
As the brief history of massage presented in Chapter | manipulation techniques that need to be addressed. In
revealed, there have been, and still are, many different ways general, these techniques should be used after massage and
of defining the various massage techniques. This chapter before active exercise. The basic techniques are demon-
provides specific information about each of the traditional strated on the accompanying DVD, which features a section
massage strokes that are based on the system known as on relaxed passive movements for the neck, the upper limb,
Swedish remedial massage. The definitions and descriptions and the lower limb (see DVD Chapter 4).
represent a current view of the various techniques. Of Before defining the individual massage strokes, it is
course, some of the descriptions of the strokes are at vari- helpful to start with a definition of the general concept of
ance with earlier ones. This is not surprising, given the soft tissue manipulation itself. Several terms are often used
considerable disagreement over massage terminology used interchangeably, so it may be useful to mention these here
in the past. Indeed, it is hoped that the classification and as well. Soft tissue manipulation is described as follows:
descriptions detailed in this chapter are logical, accurate, A variety of manual techniques to the soft tissues of the
and worthy of adoption. In most cases, photographic exam- body, designed to improve intertissue mobility and produce
ples are given of each of the strokes to several body parts, pain-free function.
and many of these strokes are also featured in Chapters 7 What then are the soft tissues of the body? Essentially, the
and 8, which address general and local massage soft tissue of the body comprises all structures that are not
techniques. a direct part of the skeleton. Thus, the bones, and therefore
The DVD that accompanies this text demonstrates each the joints, can be considered as the hard tissues, together
of the basic strokes to all the main regions of the body in a with articular and fibrous cartilage. In addition, the teeth,
way that cannot be replicated with still photographs. For fingernails, and toenails can be classified as hard tissue.
each technique, the DVD section is identified, making it Although there is an entire discipline of manual therapy
easy for the reader to view the technique in question. Of dedicated to mobilizing and manipulating the joints, one can
course, it is possible to pause and repeat the video section argue strongly that even these techniques are directed at the
as needed. The video provides an opportunity for viewers soft tissues rather than the bones and joints themselves. The
to understand the finer points of each technique, such as the bones and joints do not bend and stretch during or in
rate and rhythm. In addition, the surface anatomy sections response to these techniques. Instead, it is the soft tissues
of the DVD provide essential information to support the surrounding the joints (skin, capsules, ligaments, tendons,
practical techniques demonstrated in the video. etc.) that are affected, together with those muscles whose
A section on the techniques known as relaxed passive tendons span the joints being treated. A simple classification
movements or simply passive movements follows the descrip- of soft and hard tissues is shown in Table 4-1.
tions of the basic massage techniques. Although these tech- Some of the structures/tissues listed in Table 4-1 are soft
niques are not massage per se, they are important soft tissue tissue in nature but cannot be massaged because of their

pon
 PART ONE GENERAL PRINCIPLES
Bot at. pie ind

A Classification of Soft and this reason, the term therapeutic massage is used to denote
lable 4-| Hard Tissues a massage treatment intended to facilitate healing when a
SOFT TISSUES | os744 00a Sk 2 | ail
cama specific health problem exists. This text deals only with
Skin Bones
various forms of therapeutic massage.
Subcutaneous tissues Teeth There are numerous variations of technique used in rec-
Muscles Finger and toenails reational massage. Although many of these techniques cer-
Tendons Articular and fibrous cartilage tainly feel good to the client, some may have little therapeutic
Ligaments value. Other techniques seem similar to the more therapeu-
Joint capsules
tic procedures. Of course, all of these techniques have con-
Nerves
siderable psychological value. For this reason, it is helpful
Blood vessels
Lymph vessels to distinguish between recreational massage and therapeutic
Heart and lungs” massage.
Abdominal organs* Recreational massage is defined as follows:
Pelvic organs* The use of a variety of manual techniques designed to
Brain* relieve stress and promote relaxation and general wellness
Eyes*
in a person who has no definable health problem.
“These structures/tissues are soft tissue in nature but cannot be Therapeutic massage is defined as follows:
massaged because of their anatomical locations.
The use of a variety of manual techniques designed to
promote stress relief and relaxation, mobilize various
structures, relieve pain and swelling, prevent deformity,
510) Si) Types of Soft Tissue Manipulation and promote functional independence in a person who has
a specific health problem.
All systems of massage and bodywork
In addition to these major distinctions, it may be helpful
Acupressure
Shiatsu
to define three basic ways in which therapeutic massage may
Rolfing be given to a patient. A specific chapter in the text is devoted
Reflexology to each of these concepts. In each case, various techniques
Point percussion techniques are combined to form a massage sequence, and these may
Myofacial release techniques be given to the entire patient (Chapter 7), to one or more
Craniosacral techniques regions of the body (Chapter 8), or to a specific anatomical
structure (Chapter 9).
General massage is defined as follows:
anatomical locations (e.g., brain, heart, lungs). Although A combination of different massage strokes applied to all
soft tissue manipulation can affect the abdominal viscera in the major regions of the body in a single treatment session
a general way, it cannot be applied directly to a specific in order to achieve particularly desired effects.
abdominal or pelvic organ. Clearly then, soft tissue manipu- Local massage is defined as follows:
lation can have an effect on almost all tissues of the body. A combination of different massage strokes applied to an
Many of these effects are discussed in Chapter 5. There are individual region of the body in order to achieve particu-
a variety of techniques that can be considered as types of larly desired effects.
soft tissue manipulation, and these are listed in Box 4-1. Focal massage is defined as follows:
With regard to the various systems of massage and body- A combination of one or more different massage strokes
work (another common term for a type of soft tissue applied to specific anatomical structures in order to achieve
massage), this text differentiates two basic groupings: rec- particularly desired effects.
reational massage and therapeutic massage. Some of the In addition to a detailed description of each massage
specific massage strokes described in this text (or modifica- stroke, the following sections discuss the specific effects of
tions of them) can be used for both recreational and thera- each technique and the common contraindications. This
peutic massage. In this regard, it is important to clearly approach brings together all of the information pertinent to
differentiate between the two categories. each stroke.
Collins English Dictionary defines the word recreation
as “refreshment of health or spirits by relaxation and enjoy-
ment.” Other major English dictionaries use similar descrip- CLASSIFICATION OF
tions, and it is in this context that the term recreational MASSAGE STROKES
massage is intended. Individual massage strokes can be classified in a number
Dorland’s Medical Dictionary defines therapeutics as of ways. Here, they are grouped on the basis of
“the branch of medical science concerned with the treatment the way
in which each one is performed (e.g., a
of disease.” Clearly intended in this definition is the assump- pressure
stroke). Individual strokes are classified as described
tion that a health problem exists that requires healing. For in
Table 4-2.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

Mens
A Classification of Massage superficially. Deep stroking is performed slowly and super-
lable 4-2 Strokes ficial stroking more rapidly. In most cases, however, strok-
VIA
AAW
ULATION
;
MANIPULATION
1
(STF
(STROKE) , IARIATIONS ing is performed at a moderate pace, the hands moving
Stroking manipulations Stroking over the tissues at a speed of approximately 7 inches per
Effleurage second.
Pressure manipulations Kneading
(pétrissage) Picking up Depth and Pressure
Wringing The depth and pressure used for stroking techniques depend
Skin rolling
Percussion manipulations
largely on the type of stroking being used. In general, super-
Hacking
(tapotement) Clapping ficial stroking requires much less pressure than does deep
Beating stroking, where greater force is applied, thereby affecting
Pounding deeper structures.
Vibration and shaking
Deep frictions Transverse Variations
Circular Stroking is usually performed with the palmar surface of
the entire hand, in which case it is called palmar stroking.
It can also be performed with the thumb pads or fingertips,
STROKING MANIPULATIONS
in which case it is called thumb pad stroking and digital
Stroking stroking, respectively.
Definition
Superficial Stroking
Stroking is a technique that a therapist performs with the
palmar surface of either or both hands, thumbs, or fingers Superficial stroking is usually slow and gentle, but it is firm
at variable pressure and speed, moving together or alter- enough for the patient to be conscious of the passage of the
nately in any direction on the surface of the body. hands throughout the movement. When given in this manner,
the stroke is extremely relaxing for the patient.
Purpose
Deep Stroking
Stroking can be useful to begin or finish a massage sequence.
It allows the patient to become accustomed to the sensation Deep stroking is given with much greater pressure and 1s
of the therapist’s hands and, likewise, gives the therapist an usually performed slowly. Given in this manner, it tends to
opportunity to get the feel of the patient’s tissues. When stimulate the circulation to the deeper muscle tissue. For this
performed slowly, it promotes relaxation, but when per- reason, it is generally given in the direction of the venous
formed rapidly, it is very stimulating. It is also useful for and lymphatic flow.
joining sequences of other strokes. Figures 4-1, 4-2, and 4-3 show the different directions for
the technique of stroking. In addition, the DVD demon-
Basic Technique and Direction strates stroking on several body areas.
of Movement
Stroking can be given in any direction; however, the direc-
tion should be one that is convenient for the therapist and
comfortable for the patient. It usually moves in one direction STROKING
at a time. Typically, the strokes move along a line parallel
BODY PART DVD CHAPTER
to the long axis of the body (lengthwise) or across (at right Back 4-]
angles to) the long axis. Stroking can also be given at an Posterior neck and shoulders 4-13
angle to the long axis (diagonally). The movement should Posterior aspects of the lower limb 4-23
be continuous while the hand is in contact with the skin. It Anterior aspects of the lower limb 4-38
must be rhythmic; otherwise, the stimulus will be uneven. Upper limb 4-57
The beginning of each stroke must be definite but smooth.
The manipulation may be performed with one or both hands.
Both hands may be used, either alternately or simultane-
Primary Effects of Stroking
ously. When both hands are used alternately, one hand Is
Therapeutic effects are produced mainly through direct
lifted off the patient while the other makes contact. Stroking
mechanical impact on the tissues; however, there are reflex
to small areas such as the face may be performed with the
effects mediated through the sensory nervous system. The
thumbs or fingertips instead of the whole hand.
primary effects of stroking are as follows:
Rate of Movement * Significant relaxation, producing a sedative effect, that
Stroking may be performed slowly or rapidly, depending on may help relieve pain and muscle spasm (via a
the effects required. It may also be applied deeply or more pain-gating mechanism)
re GENERAL PRINCIPLES

Figure
In this example (A, B), stroking is performed ina diagonal pattern to
cover the patient’s back region. Hands
are used alternately, and the direction of the movement can be changed to
cover the area in a different direc-
tion—that is, down the back (C, D) and across the low back region
(E). See also DVD Chapter 4-2.
A-C, Stroking is performed in line with the long axis of the limb, so as
to cover the entire region. In this case, alternate hands are used and
the direction of the movement can be changed to cover the different
surfaces of the upper limb (e.g., horizontally across the limb or diago-
nally). D, E, Superficial stroking is performed in line with the long axis
of the lower limb. In this example, the hands are alternated and the
direction of the movement can be changed to cover the different sur-
faces of the limb (e.g., horizontally across the limb or diagonally). The
stroke is carried down to the knee (F) and may be extended all the way
to the foot (G), if required. See also DVD Chapters 4-24, 4-39, and
4-58.
 PART ONE GENERAL PRINCIPLES

Figure 4-3 Stroking to the Posterior Neck and

Shoulder Region
A, The stroking is performed in a vertical pattern to cover the patient’s posterior neck and shoulder region.
Hands are alternated, and the direction of the movement can be changed to cover the area in a horizontal
(B) or diagonal (C) direction. See also DVD Chapter 4-14.

* A stimulating effect (when performed rapidly) on * Join various massage manipulations (strokes) together
sensory nerve endings, resulting in a generalized, into a smooth sequence and thus give continuity to the
invigorating effect massage treatment.
* Dilation of the arterioles in the deeper tissues and in * Relieve flatulence or other intestinal movement disor-
superficial structures when slow, deep stroking is ders by mechanical direct and reflex effects on the
applied intestines.
* Promote relaxation and induce sleep in persons who
Therapeutic Uses of Stroking have insomnia.
When included in a treatment sequence, stroking can be
used to do the following: Indications for the Use of Stroking
* Increase blood and lymphatic flow in the superficial Stroking may be indicated as part of a treatment plan to
circulation. help relieve, or reduce the effects of, the following
* Relieve pain and muscle spasm, thereby promoting conditions:
relaxation. * Pain (acute or chronic)
* Help both patient and therapist become accustomed * Muscle spasm (acute or chronic)
to the feel of each other’s tissues. For the patient, it is * Superficial scar tissue (in the skin)
the sensation of the therapist’s hands. For the * Flatulence, constipation, and general abdominal
therapist, it is the contours and quality of the patient’s discomfort
tissues. ¢ Insomnia
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

Contraindications to the Use of Stroking Basic Technique and Direction

The general concept of contraindications is covered in of Movement
Chapter 3. As a technique, stroking may be contraindicated Effleurage is always given in the direction of the venous and
when any of the situations listed in Table 4-3 are present. lymphatic flow (1.e., toward the heart, in a centripetal direc-
tion). The manipulation is performed with the palmar
Effleurage
surface of one or both hands, working either alternately or
Definition simultaneously. Small areas such as the face or foot can be
Effleurage (from the French word effleurer: to skim) is a treated with the fingers or the thumb of one or both hands.
slow, stroking movement performed with increasing pres- The hand, or hands, must be relaxed and molded accu-
sure in the direction of flow in the veins and lymph vessels rately to the shape of the part being treated. The stroke
(i.e., centripetal direction). The stroke finishes with a defi- should be smooth and rhythmic and is directed toward a
nite pause and, whenever possible, in a group of superficial group of lymph glands, following the course of superficial
lymph glands. veins and lymphatics, with the therapist always working
from distal to proximal areas. At the end of each stroke, the
Purpose therapist’s hands may be allowed to gently stroke back to
Effleurage is a stroke designed to move the fluid contents of their starting position, or they may be lifted from the surface
the superficial veins and lymph vessels. It is particularly of the body and returned through the air to the starting
useful as a means of stimulating the circulation and as a position for the next stroke. Each method has advantages
stroke used between manipulations that tend to mobilize and disadvantages, so in practice, either technique is
tissue fluids. For example, after a series of deep kneading acceptable.
strokes to a muscle, effleurage given to the area will help to
move the fluids that have been mobilized by the kneading. Rate of Movement
It can also be a useful stroke to finish off a massage Effleurage is performed quite slowly (about 7 inches per
sequence. second) because the pressure exerted on the tissues is much
greater than just the weight of the therapist’s hands. Rhythm
is extrernely important with this stroke: as usual, it should
be even so that each stroke is smoothly performed through-
Main Contraindications to the out the area being treated.
Jable 4-3. Use of Stroking
Depth and Pressure
Large open areas (e.g., burns or wounds) in A To affect the contents of the superficial veins and lymphat-
the areas to be treated, especially if they ics, effleurage must be performed with significant pressure.
are infected Pressure should gradually increase throughout the stroke so
Gross edema in the areas to be treated if A
that the venous blood and lymph are pushed through the
there seems to be a possibility of splitting
veins and lymph channels. There should be a definite pause
the skin
Cancer in the skin or any other tissue in the A at the end of each stroke, at or near the appropriate group
area to be treated of superficial lymph glands. This allows the valves in the
Serious infections in the tissues to be A vessels to close, thus minimizing back flow. These changes
treated (tuberculosis, septic arthritis, etc.) in pressure during the stroke make it important to maintain
Lacerations, bruising, infections, or foreign A firm but comfortable pressure on the tissues. The greatest
bodies (e.g., glass, grit, metal) in the skin pressure is exerted at the end of the stroke when the hands
of the area to be treated
or hands are stationary.
Acute or chronic skin conditions affecting U
the areas to be treated (e.g., psoriasis,
Effleurage to a variety of body areas is depicted in
eczema, or dermatitis) Figures 4-4 through 4-6. In addition, on the DVD effleurage
Marked varicosities in the areas to be U is demonstrated to several body areas, as noted in the
treated if damage to the vein wall might following table.
result (very light stroking may be possible)
Within 3 to 6 months following radiation U
therapy in the area to be treated (skin is -
usually hypersensitive)
R
EFFLEURAGE
Areas of hyperesthesia in the areas to be
BODY PART DVD CHAPTER
treated (i.e., those who are very sensitive/
Back 4-3
ticklish to touch)
R Posterior neck and shoulders 4-15
Extremely hairy areas in the areas to be
Posterior aspects of the lower limb 4-25
reated (if stroking causes pain)
Anterior aspects of the lower limb 4-40
A, Always contraindicated; U, usually contraindicated; R, rarely Upper limb 4-59
contraindicated.
76 GENERAL PRINCIPLES

Effleurage to the Back

Effleurage is performed on the back, moving from the sacrum toward the
head. Both hands are used so
that the movements are mirror images of each other. The first stroke begins
with the fingertips on the
sacrum (A) and passes toward the head ina straight line (B). At the
upper fibers of the trapezius muscle,
the hands turn outward to pass over the muscle belly to finish in the supraclavicular
fossa, the fingers being
allowed simply to fold over (C). The second stroke begins just lateral
to the first one on the sacrum
(D) but passes more laterally up the back (E) in a similar fashion, once
again to finish in the supraclavicular
region (F). Finally, the third stroke begins with the fingertips in a position
similar to that for the previous
stroke (G). This time, however, the fingertips point outward and the
hands pass up the sides of the chest
wall (H) to finish with the ulnar border of each hand in the patient's
respective axillary regions (I). See
also DVD Chapter 4-3.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

Figure 4-4, cont’d

Primary Effects of Effleurage nism), reducing muscle spasms, and promoting

The therapeutic effects of effleurage are produced mainly relaxation.
through a direct mechanical impact on the tissues; however,
there are reflex effects mediated through the sensory nervous Therapeutic Uses of Effleurage
system. When performed properly, effleurage has the fol- When included in a treatment sequence, effleurage can be
lowing primary effects: used to do the following:
¢ An increase in the flow of venous blood in the superfi- ¢ Increase blood and lymphatic flow in the superficial and
cial and deep veins toward the heart. When pressure 1s deep circulation.
relaxed, the valves in the veins prevent backward flow. ¢ Promote the absorption of inflammatory exudates in the
¢ A stimulation of lymph flow, resulting in more rapid subacute and chronic stages of soft tissue injuries
elimination of waste products. (edema).
¢ An increased flow in the veins and lymphatic vessels ¢ Relieve pain and muscle spasm, thereby promoting
relieves the congestion in the capillaries, allowing relaxation.
vascular and lymphatic fluids to flow more readily into ¢ Follow other strokes (e.g., kneading, friction) that have
and out of the capillary beds, thereby stimulating the deeper effects and thereby encourage the absorption of
circulation and facilitating healing. si waste products into the lymphatic system.
¢ An increase in the mobility of the skin and subcutane- * Help both patient and therapist become accustomed to
ous tissues, which in turn increases range of motion in the feel of each other’s tissues. For the patient, it is the
joints and limb segments. sensation of the therapist’s hands. For the therapist, it is
* Dilation of the superficial arterioles through the axon the contours and quality of the patient’s tissues.
reflex, thereby stimulating the circulation. ¢ Join various massage manipulations (strokes) together
* Stimulation of the large-diameter mechanoreceptors in into a smooth sequence and thus give continuity to the
the skin, thereby relieving pain (pain-gating mecha- massage treatment.
78 GENERAL PRINCIPLES

Figure 4 Effleurage to the Upper Limb

In this example, effleurage is performed with the patient in a seated position,
with the forearm supported
on a pillow. The stroke is performed in line with the long axis of the
limb to coverthe region. The therapist
faces the patient and supports the patient’s hand with one hand while
using the other hand to perform the
stroke. Movement begins at the hand or wrist (A) and passes up the
lateral aspect of the forearm and arm
(B), ending by curling over the posterior fibers of the deltoid muscle
(C) to finish with the palm in the
supraclavicular fossa. The therapist then changes hands and performs
the stroke on the medial side of the
limb, beginning at the wrist and passing up the medial aspect
of the forearm (D) to finish in the axillary
lymph glands (E). See also DVD Chapter 4-59.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

Figure 4-6 Effieurage to the Posterior Neck and

Shoulder Region
The therapist stands behind the seated patient. The stroke begins with the fingertips together in the midline,
approximately at the middle to the lower border of the scapulae (A). The stroke is performed in an upward
direction (B), moving toward the base of the neck, finishing by allowing the hands to pass over the top of
each trapezius muscle (C), to end with the palms in the supraclavicular lymph nodes. See also DVD Chapter
4-15,

Indications for Effleurage PRESSURE MANIPULATIONS

Effleurage may be indicated as part of a treatment plan to Pétrissage
help relieve or reduce the effects of the following: Pressure manipulations (pétrissage, from the French word
* Chronic edema, especially in the extremities pétrir: to knead), include several different massage strokes
* Chronic pain, especially that associated with distur- that are characterized by the application of firm pressure to
bances of the circulation the tissues. In the majority of cases, these strokes aim to
* Chronic muscle spasm mobilize deep muscle and tendon tissue, including the skin
* Superficial scar tissue (in the skin) especially that and subcutaneous tissues covering them. Four distinct types
associated with trauma to a limb ¥ of stroke are discussed in this section: kneading, picking up,
wringing, and skin rolling.
Contraindications to Effleurage
The general concept of contraindications is covered in Kneading
Chapter 3. As a technique, effleurage may be contraindi- Definition
cated when any of the situations listed in Table 4-4 are Kneading is a manipulation in which the muscles and sub-
present. cutaneous tissues are alternately compressed and released.
 8 PART ONE GENERAL PRINCIPLES

Main Contraindications to the Basic Technique and Direction of Movement

ible 4-4 Use of Effleurage Kneading is a stroke in which the therapist’s hands and the
es
patient’s skin move together on the deeper structures when-
Large open areas (e.g., burns or wounds) A
ever pressure is applied to the tissues. It can be performed
in the areas to be treated, especially if with several parts of one or both hands, including the entire
they are infected palmar surface and the pads/tips of the fingers or thumbs. In
Cancer in the skin or any other tissue in A each case,<the basic direction of the movement is circular.
the area to be treated Pressure is applied during half of the circular motion and
Serious infections in the tissues to be A
released with relaxation during the other half. Although
treated (tuberculosis, septic arthritis, etc.)
kneading can be performed in a stationary manner (station-
Gross edema in the areas to be treated if A
there seems to be a possibility of splitting ary kneading), it is more usual for the hands to move across
the skin the body surface during the technique. Movement of the
Lacerations, bruising, infections, or foreign A hands is achieved during the relaxation phase of each circu-
bodies (e.g., glass, grit, metal) in the skin lar motion. The hands usually move in parallel Janes to cover
of the area to be treated the entire area to be treated. The larger the area, the more
Chronic swelling in the areas to be treated, U
lanes are needed. This type of kneading compresses the
in the lower limb associated with severe
congestive cardiac failure or any other tissues and is therefore known as palmar kneading. Several
heart condition with which lower limb variations of the technique can be used, and these will be
edema is associated considered ina later section. Figure 4-7 illustrates the concept
Acute or chronic skin conditions affecting U of circular motion and movement in parallel lanes. It is
the areas to be treated (e.g., psoriasis, common to most, but not all, types of kneading.
eczema, or dermatitis)
Rate of Movement
Marked varicosities in the areas to be U
treated if damage to the vein wall might
Kneading is performed slowly because of the pressure
result (very light stroking may be possible) exerted on the tissues. If it is performed too quickly, it is
Within 3 to 6 months following radiation U likely to be ineffective or uncomfortable for the patient. The
therapy in the area to be treated (skin is rate of movement is similar for both stationary kneading and
usually hypersensitive) the more common mobile versions. When using the whole
Areas of hyperesthesia in the areas to be R hand(s), each circular movement should take about 3 to 4
treated (i.e., those very sensitive/ticklish to seconds to complete. Obviously the rate is much lower if the
touch)
finger pads or thumb pads are used to perform the massage,
Extremely hairy areas in the areas to be R
treated (if stroking causes pain) as they are so much smaller.
Depth and Pressure
A, Always contraindicated; U, usually contraindicated; R, rarely
contraindicated. As its name implies, kneading usually requires significant
pressure on the tissues if it is to be effective. However, the
pressure must be adapted to the tissues being treated, and it
The technique produces movement in a circular direction. should be performed with much less pressure, especially on
Each circular movement is divided into two roughly equal more delicate structures such as the backs of the hands or
phases: compression and relaxation accompanied by a face. It is important for the pressure to be applied during only
sliding movement of the hands, fingers, or thumbs. During half of each circle. At such times, the hands are not moving
the pressure phase of each stroke, the therapist’s hands (or on the skin; rather, the hands and the skin move over the
fingers or thumbs) and the skin move together on the deeper deeper structures. It is not easy to quantify the actual pres-
structures. During the release (relaxation) phase, the hands sure needed during kneading, but the experienced therapist
(or fingers or thumbs) glide smoothly to an adjacent area of will be able to apply the correct amount of pressure to treat
tissue where the movement is repeated. the deep tissues effectively without harming the patient.
Purpose Variations
Because of the compressive forces applied to the tissues, Several variations of the basic kneading stroke are used, and
kneading strokes have a strong mechanical action and are these are explained in the following sections.
designed to affect deep tissue. In particular, kneading aims Palmar Kneading. When the entire palmar surface is used,
to mobilize muscle and tendon fibers and other deep struc- the technique may be called palmar kneading. The
tures, thus promoting the normal function of muscles, which basic
palmar kneading stroke is also called compression
is not only to contract to produce movements but also to knead-
ing, circular kneading, flat-handed, and whole-hand
lengthen and allow movement in the opposite direction. To knead-
ing. In this manipulation the tissues are compressed
allow this, muscle fibers and other structures must be mobile. upward
and inward in a circular motion against the underly
Kneading is also useful for mobilizing chronic swelling, ing
tissues and then released. Overlapping lanes of
especially where such swelling has become organized and circular
strokes are used to cover a large area of
is preventing normal joint and limb motion. the body, such
as the back. If the tissues are flat, such as the back
region,
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4
a
Eis a
\
\

eressure:

Relaxation
and
movement

Figure 4-7 Basic Technique and Direction of Movement for All

Circular Kneading Strokes
The basic movement in all forms of kneading is circular. Pressure is applied during half of the circle, and
relaxation with hand movement is allowed during the other half (A). The hands usually progress along the
body surface by moving in a series of parallel “lanes,” as on the back (B). The same concept is applied
to the thigh (C), except that the hands work on either side of the limb, usually beginning proximally. See
also DVD Chapters 4-4, 4-26, and 4-41.

both hands can be used on the same plane of motion (side by Squeeze Kneading. Squeeze kneading is similar to the
side). In the limbs, however, the hands usually work opposite basic kneading technique; this time, however, the tissues
to each other (on either side of the limb). This produces more are grasped and lifted upward and away from the
movement of the whole muscle masses involved. underlying tissues, squeezed gently, and then allowed
Figures 4-8 and 4-9, A, illustrate the basic two-handed to relax. The squeezing is produced by a lumbrical
technique. The techniques shown in Figure 4-9 are good action of the fingers, the tissues being squeezed between
examples of the therapist’s hands working opposite each the palm and the fingers. It is usually performed on rela-
Yay Other and out of phase. Palmar kneading, using one- and tively large muscle masses, such as those in the thigh;
two-handed techniques, is also demonstrated on the DVD. however, it can be performed on small muscles by squeezing
the tissues between the thumb and the finger pads. A varia-
tion of the technique lifts the tissues up and away from the
COMPRESSION KNEADING (WHOLE HAND) underlying bone and then passes the tissues from one hand
BODY PART DVD CHAPTER to the other while moving along the long axis of the
Back 4-4 muscle.
Posterior neck and shoulders 4-16 Finger Pad Kneading. This technique is also called digital
Posterior aspects of the lower limb 4-26 kneading, and it involves the basic palmar kneading stroke
Anterior aspects of the lower limb 4-4) performed with one or more finger pads, using one or both
Deltoid, biceps, and triceps 4-60
hands. If the therapist’s hands are placed opposite each
 Figure

The stroke usually starts at the upper fibers of the trapezius muscle and progresses along the back (A) toward
the sacrum. If required, the fingers may turn outward slightly as the hands reach the lumbar region (B). This
helps to avoid too much extension of the wrists at the sacral region. To avoid pinching the tissues, it is better
to perform the technique with the two hands working out of phase (i.e., one hand compresses moving upward
and inward, while the other relaxes moving downward and outward). See also DVD Chapter 4-4.

Figure

Two variations of the basic kneading techniques are illustrate

d. A, The hands are placed side by side on the
deltoid muscle and work out of phase, beginning at the proximal
end of the muscle and working toward its
insertion. B, The hands now move down the limb, opposite to
one another, to cover the biceps and triceps
muscles. Palmar kneading is given along both muscles in a proximal
(shoulder) to distal (elbow) direction
C, In the lower limb, the therapist’s hands work opposite
to each other. Compression is applied to the thigh
muscles but, again, the hands work out of phase with each other.
This technique works very well when it is
possible to get both hands on either side of a muscle mass.
It is easiest to start at the proximal part of the
limb (hip) and work toward the distal part (knee). See also DVD Chapters
4-26 4-41 and
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

other, for example, around the knee region, then the finger
pads usually work in phase with each other. It is quite pos- THUMB PAD KNEADING
sible, however, for the finger pads to work out of phase, and BODY PART DVD CHAPTER
this is simply a matter of preference. The technique is useful Anterior tibial muscles 4-50
for treating small- to medium-sized areas and areas of irreg- Calf muscles 4-35
ular shape (e.g., around the elbow, knee, or ankle). When Foot and toes 4-37, 4-52
both hands are used, they may work side by side in some Wrist and finger flexors 4-65
Wrist and finger extensors 4-64
situations, or opposite each other, as in Figures 4-10 and 4-
Hand 4-66
11, which illustrate finger pad kneading around the elbow
ay and knee regions, respectively. Finger pad kneading is also
demonstrated on the DVD (see DVD Chapters 4-31, 4-48,
4-51, and 4-63). Reinforced Kneading (Palmar Thumb Pad or Finger Pad). As
its name might imply, reinforced kneading is a two-handed
technique in which one hand reinforces the other. The basic
FINGER PAD KNEADING palmar kneading technique is performed with one hand on
BODY PART DVD CHAPTER top of the other, to reinforce the pressure of the stroke. It
Elbow 4-63 can be particularly useful for treating the lumbar region in
Posterior aspects of the knee 4-31 large or very muscular patients, especially when extra effort
Anterior aspects of the knee 4-48 would be required for effective treatment. This is especially
Ankle 4-51 true if the therapist is of relatively small stature and the
patient is very large. The technique is illustrated in Figure
4-13 to the lumbar region. The technique can also be viewed
Thumb Pad Kneading. The basic palmar kneading stroke at DVD Chapter 4-5.
can also be performed with the pads of one or both thumbs, Although reinforced kneading is usually performed using
usually working side by side. This technique is especially the whole palmar surface of the hand, it can also be given
useful along fusiform muscles (e.g., the flexors and exten- using the pad ofjust the thumb or using the finger pads. In
sors of the wrists and fingers or the anterior tibial muscles). these cases, reinforced thumb pad or finger pad kneading
It is also useful for the treatment of small areas in the hand, are useful techniques when extra pressure is needed in a
py foot, and face. Figure 4-12 illustrates the stroke. Thumb pad small area. In the case of the thumb, one thumb is placed
kneading is also demonstrated to various body areas on the on the tissues and the other directly on top of it. The two
DVD (see DVD Chapters 4-35, 4-37, 4-50, 4-52, and 4-64 thumbs move together to provide extra pressure when
to 4-66). needed. Similarly, one set of finger pads can be placed on
the skin and the finger pads of the other hand are simply
placed on top of them, allowing much greater pressure to be
exerted. These hand positions are useful for several tech-
niques on deep muscles (see Chapters 8 and 9).
Knuckle Kneading. Knuckle kneading is a technique for
treating small areas where greater depth of pressure is
required; for example, the sole of the foot. Pressure is
applied with the dorsal surface of the middle or proximal
phalanges, depending on the size of the area to be covered
and the preference of the therapist. The stroke is performed
with the closed fist, applying the same basic circular motions
of palmar kneading. It is usually easier for the therapist
to use a clockwise motion of the knuckles. Figure 4-14 gijyjay
illustrates the stroke, and it is also demonstrated at DVD
Chapter 4-53.

Figure 4-10 Finger Pad Kneading to the _ Picking Up

Elbow Region
Definition
In this example, the therapist’s left hand supports the medial sides of Picking up 1s a technique in which the therapist grasps and
the joint, while the finger pads of the right hand are used to perform
squeezes muscles while simultaneously lifting them away
the stroke. Alternatively, a two-handed technique can be used. In this
from the underlying tissues and then releasing them. The
case, the fingers may work either in phase or out of phase with each
grasping and releasing is performed in a circular motion,
other, depending on the therapist’s preference. The technique works
well around irregular-shaped surfaces such as the face, elbow, knee,
usually in the same direction as the muscle fibers (long
and ankle. See also DVD Chapter 4-63. AXIS).
 PART ONE GENERAL PRINCIPLES

Figure 4-11 Finger Pad Kneading around the Knee and Ankle
In these examples, the therapist uses a two-handed technique with each hand working on opposite sides
of the knee (A) and the ankle (B). The fingers may work either in phase or out of phase. In each case,
the fingers cover all aspects of the joint structures, with particular attention to the ligaments, joint capsules,
and tendons crossing the region. As an alternative, finger pad kneading may be given as a single-handed
technique. In this example (C), the stroke is given to the medial aspect of the ankle region using the
ther-
apist’s left hand. The other hand supports the lateral side of the ankle and heel. See also DVD Chapters 4-31,
4-36, 4-48, and 4-51.

Purpose movement of the digits so that the tissues are lifted away
Picking up is performed largely on muscle tissue for the from the underlying structures by a movement of wrist
purpose of mobilizing individual or groups of muscles. It extension. The tissues are then released as the hand glides
has a significant mechanical action on the muscle fibers and along the muscle belly to repeat the stroke.
is designed to increase muscle mobility, thereby facilitating A variation of the basic stroke is a two-handed technique
normal joint and limb function. in which the tissues are grasped and lifted away from under-
Basic Technique and Direction of Movement lying tissues by one hand and then passed to the other while
The usual technique is a single-handed manipulation of a still lifted away from deeper structures. The muscle is then
muscle or muscle group. The therapist grasps the tissue to released by the second hand. Progress is made along
be treated with his or her whole hand, the thumb being well a
muscle by passing the tissues from one hand to the other.
abducted. On very wide muscle groups, the hands may be
Rate of Movement
used together to give a wider grasp. The initial pressure is The movement should be slow, continuous, and rhythmic,
upward and inward in a circular motion toward the tissues. and the whole muscle belly should be treated,
The therapist grasps the tissues between the palmar surfaces generally
from origin to insertion. Care should be taken to keep
of all of the fingers and the palmar surface of the thumb. the
grasp soft and supple, thereby avoiding pinching
The intrinsic muscles of the fingers produce a lumbrical-like of the
tissues.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS 85

Figure

In this example, the therapist’s thumbs work side by side (A). The thumb pads may work either in phase
or out of phase with each other, depending on the therapist’s preference, but the out-of-phase technique
is usually more comfortable for the patient. The technique works well around small, irregular-shaped sur-
faces such as the face, hand, and foot and on long, fusiform muscle groups in the forearm (B), dorsum
(C), palm (D), and fingers (E) of the hand. In the leg, thumb pad kneading is useful on the anterior tibial
muscles (F), and the dorsum of the foot (G). Thumb pad kneading can also be given to the muscles on
the sole of the foot, either as a single-handed (H) or double-handed (1) technique. The stroke can be given
to the toes, either as a single-handed technique (J) or using two hands (K), in which case it is important
to massage alternate toes to avoid discomfort for the patient. See also DVD Chapters 4-35, 4-37, 4-50,
4-52, and 4-64 to 4-66.
 PART ONE GENERAL PRINCIPLES

Figure 4-12, cont’d

Depth and Pressure during the first half of the circular motion and released
Picking up is a pressure manipulation (pétrissage) requiring during the second half. In general, picking up is not as deep
a significant degree of pressure, especially over large a technique as palmar kneading. Figure 4-15 illustrates stan-
muscles. Sufficient pressure must be exerted to grasp and dard picking up to the biceps, triceps, thigh, and calf,
lift the muscle tissue away from the underlying structures, respectively. These techniques are demonstrated on
moving them in a circular motion. The tissues are squeezed the
DVD as described in the following table:
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS 87

Figure Figure

One hand reinforces the other in this technique. The therapist follows
the basic circular kneading technique, simply using one hand reinforced This is a modified kneading technique that is useful for applying extra pres-
by the other. The technique provides extra pressure and is useful for sure to the deep muscle layers on the sole of the foot. Itcan be used on other
deep muscle masses or large patients. See also DVD Chapter 4-5. deep muscle masses where extra pressure is required. See also DVD
Chapter 4-53.

Figure

A, The biceps muscle is picked up using a single-handed technique. B, The triceps muscles are treated
similarly. In these examples, the patient is seated comfortably at the end of a treatment table, with the
upper limb supported on a pillow. In both examples, note that one of the therapist’s hands provides coun-
terpressure to support the arm while each muscle is being treated. C, The quadriceps muscle is usually
quite large and is picked up using a two-handed technique. In this case, the thumbs are crossed, and the
muscle is lifted away from the underlying bone with a circular motion. D, A single-handed technique is
ee re an e e e S le adtann OD AD AG na .1
 88 PART ONE GENERAL PRINCIPLES

sin as

demands reasonable pressure. It is a deep stroke designed to

PICKING UP mobilize deep muscle tissue. As always, pressure must be
BODY PART DVD CHAPTER regulated so that it does not pinch the patient and cause pain.
Posterior neck muscles 4-19 This stroke requires the patient’s muscle to be completely
Upper fibers of the trapezius muscle 4-17
relaxed. If not, the technique cannot be performed properly.
Thigh muscles 4-27, 4-42
Figure 4-16 illustrates wringing to a variety of muscles, also
Calf muscles 4-33, 4-49
Biceps and triceps 4-61 demonstrated on the DVD as follows:

Wringing
WRINGING
Definition
BODY PART DVD CHAPTER
Wringing is a pressure manipulation in which the tissues are Lateral chest wall 4-6
lifted away from the underlying structures with both hands Upper fibers of the trapezius muscle 4-18
and then compressed alternately between the fingers and Posterior aspects of the lower limb 4-28, 4-34
thumb of opposite hands, while progressing along the long Anterior aspects of the lower limb 4-43
axis of the muscles in question. Biceps and triceps 4-62
Purpose
Wringing is rather similar to picking up in terms of its
purpose. It is also a technique performed largely on muscle
tissue for the purpose of mobilizing individual muscles or Skin Rolling
groups of them. It has significant mechanical action on the Definition
muscle fibers because of the twisting motion that is imparted Skin rolling is a pressure manipulation in which the thera-
to the tissues. Like picking up, it is designed to increase pist lifts the skin and subcutaneous tissues away from the
muscle mobility, thereby facilitating normal joint and limb underlying structures and then rolls them over the deeper
function. tissues.
Basic Technique and Direction of Movement Purpose
The hands are placed on the long axis of the muscle with Skin rolling is primarily designed to mobilize the skin and
the thumbs well abducted from the fingers. The tissues are subcutaneous structures. Because the skin is folded over on
grasped with both hands; lifted, using a lumbrical-like itself, it is also likely to move the contents of the superficial
action; and then twisted between the fingers and thumb of vessels and thus improve circulation to the area. Normal
opposite hands. Alternate radial and ulnar deviation of each joint and limb movements require an adequate degree of
wrist produces the classic twisting movement of the tech- extensibility in the skin and subcutaneous tissues. Skin
nique. The resulting motion is similar to that of wringing rolling is a technique specifically designed to mobilize the
out a wet towel. skin and therefore improve joint and limb function that has
The hands move alternately down the long axis of the been compromised by prolonged immobility.
muscle, working across the muscle fibers and stretching the Basic Technique and Direction of Movement
tissues. Wringing is used chiefly on large and loose groups The therapist places both hands side by side, flat on the
of muscles. The techniques can be modified, however, to patient’s skin surface, and with the thumbs stretched apart
accommodate smaller muscles. In this case, wringing may as far as possible. The extended fingers draw the tissues
need to be performed with the tips of the fingers and thumbs toward the thumbs, with a lumbrical-like action. This action
instead of the entire hands. lifts up a fold of skin between the fingers and thumbs. The
Rate of Movement thumbs then compress the tissues toward the fingers, rolling
The stroke is performed at slow to medium speed—about 4 them around the body part in a wavelike motion, away from
to 6 inches per second on a large muscle—and somewhat the therapist. The motion is repeated on the adjacent portion
more slowly on smaller muscles. This stroke requires a of skin until the entire area is covered.
particularly even rhythm if it is to feel comfortable to the
Rate of Movement
patient. If the rhythm and pressure are erratic, it will be
Skin rolling is usually performed quite slowly (about
difficult for the patient to relax and for the technique to be 4 to 6
inches per second) while taking care not to pinch the
effective. Wringing is one of the more difficult techniques tissues
and cause pain.
to master because it requires considerable dexterity and
Depth and Pressure
coordination. However, when performed correctly, it is an
Skin rolling is performed to the skin and subcut
extremely effective stroke to mobilize muscle tissue. aneous
tissues and does not require significant pressure
Depth and Pressure to be effec-
tive; however, if the skin and deeper structures are
Because the tissues are grasped and lifted from the deeper tight or
the patient has a significant layer of body fat, it may
structures during wringing, it is obviously a stroke that be dif-
ficult to lift up a roll of skin without pinching
the patient
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

= . F
Figure 4-16 Wringing to Lateral Chest Muscles and Upper and
Lower Limb Muscles
A, B, Wringing is performed to the lateral chest wall muscles. The twisting motion of the hands as they
move across the long axis of the muscle group is illustrated. Pressure is applied between the fingers of
one hand and the thumb of the other. C, D, With the patient seated and supported comfortably, wringing
to the biceps can be performed. E, F, In a similar manner, wringing to the medial thigh muscles is depicted.
See also DVD Chapters 4-6, 4-28, 4-34, 4-43, 4-62.
 PART ONE GENERAL PRINCIPLES

and causing pain. If the skin-fold thickness is more than | lesser extent. When performed properly, the pressure manip-
inch, the pressure may need to be reduced slightly to prevent ulations have the primary effects listed as follows.
pinching.
The skin and deeper structures are much more mobile in
some parts of the body than in others. This means that it Effects on the Circulation
may be difficult if not impossible to perform the technique ¢ Increased flow of venous blood in the superficial and
properly on some body parts. In any area that is naturally deep veins toward the heart (when pressure is relaxed
tight and relatively immobile (e.g., around the lower lumbar the valves in the veins prevent backward flow)
and sacral region), this technique cannot be performed well. ¢ Stimulation of lymph flow, resulting in more rapid
In addition, it may not be possible to perform this technique elimination of waste products
on patients whose skin-fold thickness is greater than 2 to 3 ¢ Increased flow in the veins and lymphatic vessels, which
inches, because it may be impossible to effectively produce relieves the congestion in the capillaries, allowing
a comfortable fold in the skin while lifting the tissues away vascular and lymphatic fluids to flow more readily into,
from deeper structures. It is much easier to perform effective and out of, the capillary beds, thereby stimulating the
skin rolling if the skin is loose. Skin rolling can be given to circulation and facilitating healing
small areas of the body, such as the dorsum of the hand or ¢ Dilation of the superficial arterioles through the axon
foot, in which case the thumb and fingertips are used to reflex, thereby stimulating the circulation
perform the technique. (NOTE: This technique is easy to
practice on an animal that has very mobile skin, such as a
cat or a dog.) Figure 4-17 illustrates skin rolling over the Effects on Muscles
posterior thoracic region. See also DVD Chapter 4-7. * Increased blood supply to superficial and deep muscles
* Increased elimination of metabolic waste products in
superficial and deep muscles
Primary Effects of Pressure * Stretching of posttraumatic scar tissue in muscle
Manipulations (Pétrissage) * Increased range of motion in muscle and a promotion of
The therapeutic effects of the pressure manipulations (pétris- normal joint and limb function
sage) are produced mainly through a direct mechanical * Reduction of muscle spasm as a result of the stimulation
impact on the tissues. In addition, there are reflex effects of the large diameter, mechanoreceptors in the skin,
mediated through the sensory nervous system, especially in thereby relieving pain (pain-gating mechanism)
the skin. These effects have been grouped into several cat- * Promotion of relaxation in superficial and deep muscle
egories, but, of course, they are all present to a greater or tissue

Figure 4-17 Skin Rolling to the Lateral Chest Wall

The hands are placed side by side, with the fingers and thumbs
stretched apart. A, A large fold of skin is
lifted up from the underlying tissues using a lumbrical action.
B, This fold of skin is then pushed/rolled
away from the therapist by moving the thumbs toward the fingers.
In this fashion, the skin is rolled around
the chest wall. The movement is then repeated on the adjacent
tissues, with the hands moving down the
back from the shoulder to the sacrum. See also DVD Chapter 4-7.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4 91

Effects on the Skin and

_ Main Contraindications to the
Subcutaneous Tissues lable 4-5 Use of Pressure Manipulations
Increased blood and lymph flow in the skin and subcu-
taneous tissues, which in turn produces a slight increase Large open areas (e.g., burns or wounds) A
in skin temperature in the areas to be treated, especially if
Stretching of posttraumatic scar tissue in muscle they are infected
Increased extensibility and mobility of the skin and Cancer in the skin or any other tissue in A
subcutaneous tissues, which in turn increases range of the area to be treated
motion in joints and limb segments, thereby promoting Serious infections in the tissues to be A
treated (tuberculosis, septic arthritis, etc.)
normal function
Gross edema in the areas to be treated if A
there seems to be a possibility of splitting
the skin
Lacerations, bruising, infections, or A
Therapeutic Uses of Pressure foreign bodies (e.g., glass, grit, metal) in
Manipulations (Pétrissage) the skin or other tissues in the area to be
treated
When included in a treatment sequence, pressure manipula-
Arterial or venous pathology (especially A
tions can be used to do the following:
thrombophlebitis and deep vein
Increase blood and lymphatic flow in the skin and in thrombosis) in the areas to be treated
superficial and deep muscles Acute muscle tears in the areas to be A
Promote the absorption of inflammatory exudates treated (especially deep intramuscular
(edema) in the subacute and chronic stages of soft tissue hematomas)
injury Hypertonic or hypotonic limbs as the areas to U
be treated (very gentle massage only)
Mobilize the skin and subcutaneous tissues
Chronic swelling in the areas to be treated, U
Mobilize contractures in the superficial and deep in the lower limb associated with severe
muscles, tendons, ligaments, joint capsules, and neuro- congestive cardiac failure or any other
vascular bundles heart condition with which lower limb
Remove the accumulation of metabolic waste products edema is associated
in superficial and deep muscles Acute or chronic skin conditions affecting U
the areas to be treated (e.g., psoriasis,
Relieve pain and muscle spasm, thereby promoting
eczema, or dermatitis)
relaxation
Marked varicosities in the areas to be U
treated if damage to the vein wall might
result
Within 3 to 6 months following radiation U
Indications for Pressure therapy in the area to be treated (skin is
Manipulations (Péetrissage) usually hypersensitive)
Pressure manipulations may be indicated as part of a treat- Areas of hyperesthesia in the areas to be R
treated (i.e., those very sensitive/ticklish
ment plan to help relieve or reduce the effects of the
to touch)
following: Extremely hairy areas in the areas to be R
Chronic edema, especially in the extremities treated (if treatment causes pain)
Chronic pain (especially that associated with distur-
A, Always contraindicated; U, usually contraindicated; R, rarely
bances of the circulation) contraindicated.
Superficial scar tissue in the skin and subcutaneous
tissue, especially that associated with trauma
Contractures in muscles, tendons, ligaments, joint
capsules, and related structures PERCUSSIVE MANIPULATIONS
(TAPOTEMENT)
Classification
Contraindications to - The percussive manipulations constitute a series of tech-
the Use of Pressure niques characterized by various parts of the hand striking
Manipulations (Petrissage) the tissues at a fairly rapid rate. Another name for this group
The general concept of contraindications is covered in of techniques is tapotement (from the French word tapoter:
Chapter 3. As a technique, pressure manipulations may be to tap). The hands usually work alternately, and the wrists
contraindicated when any of the situations listed in Table are kept flexible so that the movements are light, springy,
4-5 are present. and stimulating. In the majority of cases these strokes aim
ee PART ONE GENERAL PRINCIPLES

to stimulate the tissues, either by direct mechanical means treated. Clapping may also be performed as a one-handed
or by reflex actions. Four distinct types of percussive manip- technique, and this is quite useful for small areas, perhaps on
ulation are discussed in this section: clapping, beating, a child. A modification of the technique can even be per-
hacking, and pounding. formed on infants using rapid alternation of the finger pads
of the index and middle finger (see Chapter 10).
Clapping Rate of Movement
Definition Clapping is performed rapidly because the goal is to stimu-
Clapping is a one-handed or two-handed technique in which late the tissues. The actual rate is determined by the thera-
the cupped hands strike the skin surface rapidly, compress- pist’s ability to coordinate wrist movements, but it should
ing the air and causing a vibration wave to penetrate into be as fast as is comfortable for patient and therapist.
the tissues. Depth and Pressure
Purpose Clapping is a stroke that is usually performed rapidly but
Clapping is designed to stimulate the tissues by direct lightly. This is why it is performed with wrist movements
mechanical action. When performed over the ribs and lungs, rather than elbow flexion and extension. Pressure can be
the mechanical waves help to loosen secretions. Brisk, light increased, however, especially when treating large muscles
clapping performed over muscle tissue stimulates muscle or a patient with a large thorax.
activity by direct mechanical activation of muscle spindle Variations
afferents, together with activation of the mechanoreceptors Finger Pad Clapping. A modified clapping technique can
in the skin. be performed on the neonate, using just the finger pads of
Basic Technique and Direction of Movement the index and middle fingers. The two fingers are held
Clapping is performed with alternate movements of the straight, but fairly relaxed. The technique is one of rapid
wrists, so that the palmar surfaces of the loosely cupped alternation of flexion and extension of the metacarpophalan-
hands strike the tissues at a rapid rate. Figure 4-18 shows the geal joints, keeping the fingers straight. Only the pads of the
position of the cupped hand. Movements of the cupped hands two fingers touch the chest wall. The technique is rapid, with
are produced by alternate flexion and extension of the wrists extremely light pressure to the chest wall (see Chapter 10).
and not by flexion and extension of the elbows. It is important Figures 4-19 and 4-20 illustrate clapping to the thigh muscles
that both arms be held fairly straight but as relaxed as possi- and the posterior and lateral chest wall, respectively. These fo
ble, as this position permits rapid wrist movements. The techniques are also demonstrated on the DVD (see DVD
hands move back and forth over the muscle or area to be Chapters 4-9, 4-29, and 4-44).

B
Figure 4-18 The Cupped Hand Position Used to
Perform Clapping
A, B, Two views of the basic hand position for the Clapping stroke.
The hand is cupped by flexing the
metacarpophalangeal joints (knuckles) and extending all the other
joints in the fingers. The thumb is held
Close to the side to form part of the edge of the cup. As the hand
strikes the tissues, the air trapped in the
cup is compressed slightly, setting up a vibrating wave that travels
into the tissues (i.e., the mechanical
stimulus is transferred into the tissues). On no account should
the fingers be held stiffly, as this produces
a stinging or slapping effect. Instead, each hand is held closed
but relaxed in the cupped position. See also
DVD Chapters 4-7, 4-29, and 4-44,
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

B
Figure 4-19 Clapping to the Thigh Muscles
The therapist stands at right angles to the long axis of the muscles to be treated. With the elbows held
slightly flexed, the cupped hands alternately strike the skin surface, moving back and forth along the length
of the muscle. Note that the flexion and extension occurs at the therapist’s wrists rather than the elbow
joints. See also DVD Chapters 4-29 and 4-44.

CLAPPING
BODY PART DVD CHAPTER Depth and Pressure
Posterior thorax 4-9 Beating is a stroke that is performed rapidly and with
Lateral thorax 4-11 rather more pressure than clapping, because it is a
Posterior aspects of the inner thigh 4-29 more stimulating stroke. The pressure applied will vary
Anterior aspects of the inner thigh 4-44
according to the body part and the patient being treated.
Figure 4-21 and the DVD illustrate beating to the inner thigh
Beating muscles (see DVD Chapter 4-45).
Definition
Beating is a one-handed or two-handed technique in which Hacking
the therapist’s loosely flexed fingers and palm of each hand Definition
strike the part to be treated in rapid succession. Hacking is a one-handed or two-handed stroke in which the
Purpose lateral edges and dorsal surfaces of the fingers strike the
Beating is similar to clapping and is designed to stimulate skin surface in rapid succession to create a strong, stimulat-
the tissues by direct mechanical action. Although it is similar ing effect.
to clapping, beating is more stimulating because the hand is Purpose
closed. It can be particularly useful for stimulating the large Hacking is used to stimulate the skin and subcutaneous
muscles in the lower limbs. tissue and both deep and superficial muscle tissue.
Basic Technique and Direction of Movement Basic Technique and Direction of Movement
Beating is performed in such a way that the hand position The therapist, standing at right angles to the long axis of the
is very similar to clapping, except that the fingers are flexed muscles to be treated, flexes the elbows and abducts the
at the middle interphalangeal joints. In effect, the fingers of shoulders so that the forearms are nearly horizontal, with
the cupped hands are simply closed. This means that the the wrists near full extension (a praying position). The
dorsal aspect of the middle and distal phalanges of the movement is a rapid alternation between pronation and supi-
fingers and the heel of the hand make contact with nation of the forearms with the hands working out of phase
the tissues. Beating is usually performed by alternately with each other. It is the ulnar borders and dorsal surfaces
flexing and extending the wrists, not the elbows, while the of the third, fourth, and fifth fingers that actually strike the
rest of the arms are as relaxed as possible. The hands move skin surface. The hands move back and forth along the
along the body part being treated so as to cover the entire muscles being treated.
area involved. The most common mistake in the performance of hacking
Rate of Movement is to flex and extend the elbows rather than to rotate the
Beating is performed rapidly because it aims to stimulate. forearms. This can easily produce discomfort for the patient
The rate used should be comfortable for the patient and because the fingers strike the tissues too forcefully. During
sustainable for the therapist. the movement, the hands almost touch each other. It is
94 GENERAL PRINCIPLES

Figure
The therapist stands at right angles to the long axis of the thorax. With the elbows held slightly flexed,
the
cupped hands alternately strike the skin surface (A, B) and move back and forth across
the chest wall,
over the lungs. Again, movement is produced by flexion and extension at the wrists rather
than the elbow
joints. This technique may also be performed over a folded towel (C). This dampens the
effect of the
stroke, allowing the therapist to exert greater pressure without Causing a “slapping”
sensation on the skin
surface. The technique is used to help to loosen secretions in the lungs. See
also Chapter 10 for more
details and DVD Chapter 4-9. See also DVD Chapter 4-11 for a demonstration of
the same technique to the
lateral chest wall.

B
Figure
The basic alternating wrist action (flexion and extension)
in beating is illustrated. The stroke is performed
quite rapidly and with a little more pressure than that
used with clapping. See also DVD Chapter 4-45.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4 . : (95 eee ee

important for the fingers and hand to be relaxed during the Variations
stroke; otherwise the fingers strike the skin surface with a Ulnar Border Hacking. This variation of hacking is per-
degree of rigidity, causing an uncomfortable sensation for formed in a similar way but uses the ulnar border of the
the patient. The manipulation is performed across the muscle hand and fifth digit on large fleshy areas for a deeper effect.
fibers, and bony areas are carefully avoided. This variation is similar to pounding, except that the fingers
Hacking is usually performed with two hands, but it can are held in extension, whereas in pounding they are flexed.
be done with only one. This variation might be useful in the Point Hacking. Only the fingertips are used to carry out
treatment of small muscles, when it is difficult to fit two this technique; typically the therapist uses only a single
hands into the area. Figure 4-22 illustrates the basic hand hand, but a two-handed technique can be performed. The
positions for hacking to the anterior thigh muscles. very tips (points) of the slightly flexed fingers strike the skin
Rate of Movement surface when the wrist is alternately flexed and extended. It
This is a difficult stroke to master because it has to be per- is used mainly on the face, but it could be used on any small
formed as rapidly as possible. It requires considerable coor- area (perhaps on a child) where regular hacking was difficult
dination of effort, and it is better to perform it correctly at to perform.
slower speeds than faster but incorrectly.
Depth and Pressure Pounding
Hacking must be performed rapidly but lightly. There is no Definition
pressure other than the weight of the relaxed fingers striking Pounding is a stimulating manipulation in which the ulnar
the skin surface in rapid succession. This produces a char- borders of the loosely clenched and extended fists, alter-
acteristic sound, as each finger is clearly audible as it strikes nately and in rapid succession, strike the part to be
the surface. treated.
jay _—Hacking is demonstrated on the DVD (see DVD Chapter Purpose
4-30), and viewers can hear the characteristic sound. The Pounding is another of the stimulating strokes. It is some-
video is deliberately slowed down during part of the tech- what deeper than hacking, as the hands are lightly clenched
nique so that the hands are more visible as they strike the and the ulnar borders are used to strike the tissues. This
skin surface. pounding motion allows greater depth to the stroke.
Basic Technique and Direction of Movement
Pounding is a stroke that in many ways looks similar to
HACKING hacking. The therapist stands at right angles to the long axis
BODY PART DVD CHAPTER of the muscles to be treated, with elbows flexed and shoul-
Posterior aspects of the inner thigh 4-30
ders abducted so that the forearms are nearly horizontal.
Anterior aspects of the inner thigh 4-46
The wrists are comfortably held near full extension. The

Figure 4-22 Hacking to the Anterior Thigh Muscles

The therapist stands at right angles to the long axis of the muscles to be treated. The forearms are nearly
horizontal, and the wrists are almost fully extended. The movement is a rapid alternation between pronation
and supination of the forearms with the hands working out of phase with each other. The lateral and dorsal
a
surfaces of the third, fourth, and fifth fingers strike the skin surface one after the other, producing
characteristic sound. The hands move back and forth along the muscles to be treated. See also DVD
Chapter 4-30.
 PART ONE GENERAL PRINCIPLES

movement consists of rapid alternation of pronation and ¢ Dilation of the superficial arterioles through the axon
supination of the forearms, with the hands working out of reflex, thereby stimulating the superficial circulation
phase with each other. Unlike hacking, the fists are loosely ¢ Increased blood and lymph flow in the skin and subcu-
clenched, and it is the ulnar borders of the hands and taneous tissues, which in turn produces a slight increase
fifth digits that actually strike the skin surface. The hands in skin temperature
move back and forth along the muscles to be treated.
Figure 4-23 illustrates the hand positions for the technique
Therapeutic Uses of Percussive
of pounding.
Manipulations (Tapotement)
Rate of Movement
When included in a treatment sequence, percussive manipu-
The movement should be as rapid as the coordination of the
lations can be used to do the following:
therapist’s hands allow; however, good technique should not
be sacrificed for speed. * Increase blood and lymphatic flow in the skin and
Depth and Pressure
subcutaneous tissues
* Stimulate the circulation of the superficial and deep
Because the therapist uses the ulnar borders of his or her
muscle, thereby facilitating healing
hands to strike the surface, this can be a much deeper stroke
* Relieve pain and muscle spasm, thereby promoting
than hacking. It is therefore suitable for stimulating large,
relaxation
deep muscle masses. Pounding is also demonstrated in DVD
Chapter 4-47. * Loosen mucus in the lungs, thereby assisting with
expectoration
Primary Effects of Percussive * Facilitate muscle contraction and reeducation of
Manipulations (Tapotement) function
The therapeutic effects of the percussive manipulations * Relieve neuralgic pain following amputation, trauma, or
(tapotement) are produced mainly through a direct mechan- another pathology
ical impact on the tissues. In addition, important reflex ¢ Stimulate organ function
effects are mediated through the sensory nervous system,
especially in the skin and muscles. When performed prop- Indications for the Use of Percussive
erly, the percussion strokes have the following primary Manipulations (Tapotement)
effects: Percussive manipulations may be indicated as part of a treat-
* Stimulation of mechanoreceptors in skin, muscle, and ment plan to help relieve or reduce the effects of the follow-
tendons, which facilitates muscle contraction ing conditions:
* Stimulation of the circulation of blood and lymph in * Weak muscle contraction, or difficulty in initiating
superficial and deep muscle tissue muscle activity associated with various neurological
* Loosening of mucus in the lungs disorders
* Pain relief as a result of stimulation of mechanorecep- * Chronic pain (especially that associated with damage to
tors in the skin (pain gating) nerves or disturbances of the circulation)

Figure 4-23 Pounding to the Anterior Thigh Muscles

The basic alternating wrist action in pounding is illustrat
ed. The action is similar to hacking, except
that the fingers are loosely flexed. The stroke is perform
ed quite rapidly, moving back and forth along
the muscles being treated, with a little more pressure
than that used with Clapping. See also DVD
Chapter 4-47.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4 97
yet TEE

* Respiratory disorders associated with mucus retention,

| Main Contraindications to the
such as cystic fibrosis and bronchiectasis
lable 4-6 Use of Percussive Manipulations
Contraindications to the Use of
Percussive Manipulations (Tapotement) Large open areas (e.g., burns or wounds) in the A
areas to be treated, especially if they are
The general concept of contraindications is covered in
infected
Chapter 3. As a technique, percussive manipulations may be Severe rib fractures (flail chest); only very A
contraindicated when any of the situations listed in Table fine, gentle vibrations may be used in
4-6 are present. the presence of a rib fracture
Over the thorax in cases of acute heart failure, A
especially if coronary thrombosis or embolism
VIBRATION AND SHAKING is involved
Vibration Over the thorax in cases of acute pulmonary A
embolism
Definition
Over the thorax in cases of severe hypertension A
Vibration is a one-handed or two-handed technique in which Cancer in the skin or any other tissue in the A
a fine shaking (tremor-like) movement is conveyed to the area to be treated
tissues by the hand or fingertips. Serious infections in the tissues to be treated A
(tuberculosis, septic arthritis, etc.)
Purpose Gross edema in the areas to be treated if there A
seems to be a possibility of splitting the skin
Vibration is a stroke designed primarily to help loosen
Lacerations, bruising, infections, or foreign A
secretions in the lungs. It may also be used as a stimulating bodies (e.g., glass, grit, metal) in the skin or
technique over muscle tissue, as it can stimulate muscle other tissues in the area to be treated
afferents. Arterial or venous pathology (especially A
thrombophlebitis and deep vein thrombosis)
Basic Technique and Direction of Movement in the areas to be treated
When given over the thorax to loosen and remove lung Acute muscle tears in the areas to be treated A
secretions, the hands may be placed successively over each (especially deep intramuscular hematomas)
Hyper- or hypotonic (spastic or flaccid) limbs in U
of the various lung segments. In each case, the hands are
the areas to be treated (very gentle massage
placed lightly on the appropriate part of the thorax, with the
only)
elbows slightly flexed but relaxed. The patient is instructed Over newly formed scar tissue in the areas to be U
to breathe in, during which time the therapist gives slight treated
resistance to the inspiration. As the patient breathes out, the Chronic swelling in the lower limb in the areas to U
therapist vibrates both hands while simultaneously com- be treated, associated with severe congestive
pressing the ribs to assist expiration. The technique may also cardiac failure or any other heart condition with
which lower limb edema is associated
be performed using a single hand if appropriate, in which
Acute or chronic skin conditions affecting the U
case it is done in the same basic manner (see Chapter 10 for areas to be treated (e.g., psoriasis, eczema, or
more details). Figure 4-24 illustrates the hand positions for dermatitis)
the technique of vibrations applied to the thorax (see also Marked varicosities in the areas to be treated if U
DVD Chapters 4-10 and 4-12). damage to the vein wall might result
When vibration is used to stimulate muscle, each hand is On bony regions in the areas to be treated, in U
placed as lightly as possible on the muscle with sufficient very thin patients
Within 3 to 6 months following radiation therapy U
pressure to lightly grip the skin surface. The vibratory stim-
in the area to be treated (skin is usually
ulus is delivered with the entire hand, but the fingertips hypersensitive)
focus much of the effort to the desired muscle. The tech- Areas of hyperesthesia in the areas to be treated R
nique can be performed with either or both hands, depend- (i.e., those very sensitive/ticklish to touch)
ing on the size of the muscle to be stimulated. When the Extremely hairy areas in the areas to be treated R
technique is used to stimulate small muscles, the vibrations (if treatment causes pain)
can be applied using just the fingertips. A, Always contraindicated; U, usually contraindicated; R, rarely
contraindicated.
Rate of Movement
The vibrations are performed as rapidly as possible, and the
speed is limited by the therapist’s ability to coordinate his
expiration will vary greatly, depending on the patient’s toler-
or her hand movements.
ance and respiratory condition.
Depth and Pressure When stimulating muscles with vibration, the weight of
Vibrations are usually rather fine in quality. The hand pres- the hand provides most of the pressure applied to the
sure applied to the chest to resist inspiration and assist tissues.
ae PART ONE GENERAL PRINCIPLES

are delivered with the entire hand, with the fingertips held
straight in order to focus the effort to the desired muscle.
The technique can be performed with either or both hands,
depending on the size of the muscle to be stimulated.

Rate of Movement
Shaking is performed at a slow rate because the movement
is coarse compared with the technique of vibration. About
three to five shakes per second are typically delivered during
each stoke.

Depth and Pressure

Shaking is a more vigorous stroke than the vibration tech-
‘oe
nique.. Significantly more pressure is applied during the
Figure 4-24 Vibration to the Lateral shaking of the chest, and therefore the amplitude of each
Chest Wall movement is increased. The pressure applied is always
In this example, the patient is in the side-lying position. The therapist’s within the patient’s tolerance.
hands are placed on the lateral chest wall with the fingers spread widely This basic technique for vibration and shaking is demon- |
so that the palms of the hands are about level with the eighth rib in the
strated on the DVD (see DVD Chapters 4-10 and 4-12).
midaxillary line. Slight resistance is given as the patient breathes in, and
a fine vibratory movement is imparted only as the patient breathes out.
A similar technique to vibration is called shaking. It is performed in
exactly the same way, except that the vibrations are somewhat coarser VIBRATIONS AND SHAKING
and therefore much slower in rate. See Chapter 10 for more details and BODY PART DVD CHAPTER
DVD Chapters 4-10 and 4-12 for a demonstration of these techniques. Posterior thorax 4-10
Lateral thorax 4-12

Shaking
Definition Primary Effects of Vibration
Shaking is a one-handed or two-handed technique, similar and Shaking
to vibration but with much slower speed and greater ampli- The therapeutic effects of vibration and shaking are pro-
tude of movement conveyed to the tissues by the hand(s). duced mainly through a direct mechanical impact on the
tissues. In addition, important reflex effects are mediated
Purpose
through the sensory nervous system, especially in the skin
Shaking is a vigorous stroke designed primarily to help and muscles. When performed properly, these strokes have
loosen secretions from the lungs. It is similar to vibration the following primary effects:
but is usually performed more coarsely than vibrations. It ¢ Stimulation of mechanoreceptors in skin, muscle, and
may also be used as a stimulating technique over muscle tendons, which facilitates muscle contraction
tissue, as it can stimulate a stretch reflex. Loosening of mucus in the lungs
* Pain relief as a result of stimulation of mechanorecep-
Basic Technique and Direction of Movement
tors in the skin (pain gating)
Shaking is performed in the same basic manner as vibration, * Movement of gases when applied over the stomach and
except that it is much slower with greater amplitude of chest intestine
movement. When performed over the thorax, the therapist
places his or her hands over the appropriate lung segments. Therapeutic Uses of Vibration
In each case, the hands are placed lightly on the thorax, and Shaking
with the elbows slightly flexed but relaxed. The patient is When included in a treatment sequence, vibration and
instructed to breathe in, during which time the therapist shaking can be used to do the following:
gives slight resistance to the inspiration. As the patient * Loosen mucus in the lungs, thereby assisting with
breathes out, the therapist shakes both hands several times
expectoration
while simultaneously compressing the ribs to assist expira- Facilitate muscle contraction and reeducation of
tion. The technique may also be performed using a single
function
hand if appropriate, in which case it is done in the same * Relieve neuralgic pain following amputation, trauma,
basic manner (see Chapter 10 for more details). or
another pathology
When shaking is used to stimulate muscle, the hand is Reduce spasticity when applied longitudinally to a
placed on the muscle with sufficient pressure to lightly grip limb
while simultaneously applying traction in the long axis
the skin surface. A series of slow, fairly deep pushing strokes
* Stimulate organ function
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

¢ Relieve flatulence
Main Contraindications to the
* Resolve chronic edema (a mechanical vibrator may be
lable 4-7 Use of Vibration and Shaking
more useful in the relief of chronic edema)

indications for the Use Large open areas (e.g., burns or wounds) in A
of Vibration
the areas to be treated, especially if they
and Shaking
are infected
Percussive manipulations may be indicated as part of a treat- Severe rib fractures (flail chest): only very A
ment plan to help relieve or reduce the effects of the follow- fine, gentle vibrations may be used in the
ing conditions: presence of a rib fracture
* Respiratory disorders associated with mucus retention, Over the thorax in cases of acute heart failure, A
such as cystic fibrosis and bronchiectasis especially if coronary thrombosis or embolism
is involved
* Weak muscle contraction, or difficulty in initiating
Over the thorax in cases of acute pulmonary A
muscle activity associated with various neurological embolism
disorders Over the thorax in cases of severe hypertension A
* Chronic pain, especially that associated with damage to Cancer in the skin or any other tissue in the A
nerves or disturbances of the circulation area to be treated
* Chronic problems with flatulence Serious infections in the tissues to be treated A
(tuberculosis, septic arthritis, etc.)
Gross edema in the areas to be treated if there A
Contraindications to the Use of
seems to be a possibility of splitting the skin
Vibration and Shaking Lacerations, bruising, infections, or foreign A
The general concept of contraindications is covered in bodies (e.g., glass, grit, metal) in the skin or
Chapter 3. As a technique, vibration or shaking may be other tissues in the area to be treated
contraindicated when any of the situations listed in Table Arterial or venous pathology (especially A
thrombophlebitis and deep vein thrombosis) in
4-7 are present.
the areas to be treated
Acute muscle tears (especially deep A
DEEP FRICTIONS (CYRIAX FRICTIONS) intramuscular hematomas) in the areas to be
treated
Deep friction massage differs from the manipulations Chronic swelling in the lower limb in the areas to U
described previously. In effect, it is a massage system in be treated, associated with severe congestive
itself, although it is designed principally to affect the cardiac failure or any other heart condition
with which lower limb edema is associated
connective tissues of tendons, tendon sheaths, ligaments,
Acute or chronic skin conditions affecting the U
muscles, and other subcutaneous tissues. The most famous areas to be treated (e.g., psoriasis, eczema,
modern exponent of deep friction massage was James or dermatitis)
Cyriax, and his writings on the subject have become Marked varicosities in the areas to be treated if U
the established standards for the techniques (Chamberlain damage to the vein wall might result
1982; Cyriax, 1960; Cyriax & Coldham, 1984; Hammer, On bony regions in the areas to be treated, in U
very thin patients
19D).
Within 3 to 6 months following radiation therapy U
Deep frictions are particularly useful for treating local-
in the area to be treated (skin is usually
ized, chronic musculoskeletal lesions. The technique aims hypersensitive)
at mobilizing scar tissue secondary to fibrositis or trauma, Areas of hyperesthesia (i.e., those very sensitive/ R
as it is often painful and immobile. All of the soft tissues ticklish to touch) in the areas to be treated
of the body have their own natural mobility and elasticity. Extremely hairy areas (if treatment causes pain) R
This may be impaired by any local organization of fibrous in the areas to be treated

tissue (scar tissue). The production and organization of A, Always contraindicated; U, usually contraindicated; R, rarely
fibrous tissue is the inevitable result of trauma or a rheu- contraindicated.

matic inflammatory process that does not heal properly. The

result will likely be a painful loss of joint and limb function,
which may eventually lead to deformity if untreated.
Deep frictions have a reputation for being painful for the myofascial pain syndromes. It can be achieved using electri-
patient, and this can certainly be the case. After several cal stimulation or manual techniques. In fact, deep frictions
minutes of treatment, however, patients often feel very little are an excellent example of a manual treatment that pro-
discomfort or pain. Producing pain in the patient for thera- duces an effective, if painful, response that triggers a resolu-
peutic purposes is a time-honored concept (counterirrita- tion of chronic inflammation. If the patient cannot tolerate
tion) and can be a useful strategy. Painful stimulation is a the initial discomfort of deep frictions, a few minutes of ice
well-known technique for the treatment of chronic pain cube massage over the area can numb the skin and help the
(Quinn et al., 2002), particularly that associated with patient overcome the initial difficulty with the treatment.
 100 PART ONE GENERAL PRINCIPLES

a oe ee

Classification and Definition

Deep frictions consist of small, accurately localized, deeply
penetrating movements performed to specific structures.
Therapists usually perform these deep strokes with their fin-
gertips, though the thumb pad or palm can also be used.
There are two basic types of deep friction stroke: transverse
frictions and circular frictions. Transverse frictions consist of
a series of short, deep strokes performed transversely across
the fibers of the target tissue (see DVD Chapters 4-54 and 4-
67). Circular frictions consist of a series or three or four deep
circular movements performed on the same spot, gradually
(my getting deeper into the tissues (see DVD Chapter 4-8).

Purpose
Deep frictions are designed to mobilize tendons, tendon Figure 4-25 Finger Positions for Trans-
sheaths, ligaments, joint capsules, and muscle tissue, par- verse Frictions
ticularly when chronic adhesions or inflammation is The tip of the index finger, reinforced by the pad of the middle finger,
present. is usually used to apply pressure in this technique. Pressure is then
exerted with these fingers in a series of pulling or pushing motions
Basic Technique and Direction delivered at right angles to the fibers of the tissues involved. In most
of Movement cases, the fingers will need to apply pressure with a curved motion to
follow the contours of the limb. See also DVD Chapter 4-54.
To obtain the firm contact with the skin that is necessary to
apply deep friction movements, it is important that no lubri-
cant be used. Deep friction movements over dry, scaly scar skin and, if necessary, evaporating spirits may be
tissue should be applied without a lubricant, and when the applied to the part afterward to dry the skin surface
treatment is completed, a small amount of lubricant should even more.
be applied to the area with stroking movements. The two * The movement is delivered with a transverse motion
types of friction strokes are quite different and will be across the fibers. It is essential that the movement be
described separately. performed at right angles to the direction of the fibers.
This has been found to be the most effective method of
Transverse Frictions
mobilizing striated muscles. In addition, a slight arc of
Transverse frictions are always performed at right angles to
motion across the fibers is desirable, because most of
the long axis of the fibers in the target structures involved
the structures treated are not flat in cross section but
(i.e., across the fibers). Typically, the stroke is delivered by
curved. As the fingers move across the structure,
the index finger of one hand, reinforced by the tip of the
pressure is usually applied in one direction only, either
middle finger placed on top. This allows the therapist to
forward or backward. This produces a series of pulling
focus the necessary pressure to an exact spot during the
or pushing strokes (see following figure).
stroke. Figure 4-25 illustrates the basic position of the fingers
for the application of transverse frictions to a small area.
The following points of technique must be emphasized: Direction of movement
Pressure must be applied to exactly the correct spot.
Accurate localization of the lesion is essential if the
technique is to be successful. A thorough knowledge of
anatomy and excellent palpation skills are essential for
the therapist.
The structure to be treated must be placed on full
stretch. The structure to be treated is usually a tendon,
ligament, joint capsule, or muscle. Placing it on
maximal stretch requires accurate anatomical knowl-
edge and understanding of the applied biomechanics of
the involved tissues.
The fingers must move with the skin and subcutaneous Muscle, tendon, or ligament
tissues on the deeper ones. The fingertips and the skin
surface must move together on the deeper tissues; * The movements must have sufficient depth and
otherwise the strokes are ineffective and it is easy to sweep to
reach the target tissue (lesion). This usually requir
blister the skin. It may be helpful to wash and dry the es
reinforcement by using two fingers or thumbs,
especially
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

deca
when treating a large muscle such as the quadriceps. The
strokes should begin lightly, and the pressure should be
increased gradually until sufficient depth is reached. If
the massage stroke is too localized, the manipulation will
be ineffective and often painful. To be effective, it must
cover a sufficient area surrounding the lesion as well.
Transverse frictions, properly administered, can be
demanding on the terminal joints of the therapist’s fingers.
The use of a custom-made finger splint may help to prevent
problems and to maintain effective treatment (Steward,
Woodman, & Hurlburt, 1995). Figures 4-26 through 4-29
depict a variety of applications of transverse frictions.
Although deep friction techniques are usually given using the
pad of the index finger, reinforced by the middle finger, the
stroke can also be given with one thumb alone or reinforced
by the other thumb. Because the thumb pad is somewhat Figure 4-26 Transverse Frictions to
larger than the finger pad, it is useful for treating medium- the Lateral Ligament of
sized muscles, for example, the muscles of the forearm or leg. the Ankle
Deep frictions can also be given with the finger pads of either The lateral ligament is first put on maximal stretch by inverting the
forefoot and calcaneum. In this position, the exact point of tenderness
or both hands. For the treatment of large, deep muscles, a
is first determined, and the friction stroke is delivered at right angles to
reinforced finger pad technique can be helpful. The finger
the fibers of the ligament. Pressure gradually increases during each
pads of one hand are placed on the skin overlying the target pass across the ligament until significant pressure has been achieved.
tissue, and the finger pads ofthe other hand are simply placed This gives the stroke its deep effects. In this case, the friction stroke is
applied by the index finger and reinforced by the middle one.

Figure 4-27 Transverse Frictions to the Medial Ligament of

the Knee
The medial ligament is first put on maximal stretch. In the case of the medial (tibial collateral) ligament of
the knee, this can be achieved with the knee in either full extension (A) or full flexion (B). In this position,
the exact point of tenderness is first determined, and the friction stroke is delivered across the fibers of
the ligament. Pressure gradually increases during each pass across the ligament until a significant pressure
has been achieved. The stroke is delivered with the index finger and reinforced by the middle one. See also
DVD Chapter 4-54.
 PART ONE GENERAL PRINCIPLES
tieaenintOA...

Figure 4-29 Transverse Frictions to

te
i Zi 2 SME
the Extensor Tendons of
Figure 4-28 Transverse Frictions to the the Wrist
Common Extensor Origin of The wrist and finger extensor muscles are first put on maximal stretch by
the Forearm Muscles fully flexing the wrist and fingers with the elbow in extension and full pro-
The common extensor origin is first put on maximal stretch by fully nation. In this position, the exact point of tenderness is first determined,
flexing the wrist and fingers with the elbow in extension and full prona- and the friction stroke is delivered with a curved motion that follows the
tion. In this position, the exact point of tenderness is first determined, contours of the wrist and is at right angles to the fibers of the tendons.
and the friction stroke is delivered with a curved motion that follows the Pressure gradually increases during each pass across the tissues until a
contours of the arm and is at right angles to the fibers of the tendon. significant pressure has been achieved. This gives the stroke its deep
Pressure gradually increases during each pass across the tissues until effects. In this case, the friction stroke is applied by the index finger and
a significant pressure has been achieved. This gives the stroke its deep reinforced by the middle one. See also DVD Chapter 4-67.
effects. In this case, the friction stroke is applied by the index finger
and reinforced by the middle one.

B
Figure 4-30 Basic Finger Positions for Circular Frictions
A, The tips of the index, middle, and ring fingers are used to form a small
tripod-like arrangement.
B, Pressure is then exerted with these fingers in a series of three or four small
circles, each with gradually
increasing pressure. See also DVD Chapter 4-8.

on top of them. This allows significant pressure to be exerted paraspinal muscles. The tips of the index, middle,
and ring
on deep muscle when needed (see Chapter 9). fingers form a small tripod, and this is used to perform
the
stroke. This tripod allows the therapist to exert the necessa
Circular Frictions ry
pressure during the stroke. Figure 4-30 illustrates the
Circular frictions are usually performed along the long axis basic
position of the fingers for the application of circular
of the fibers in the target structures involved, typically the frictions
to a small area.
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4 idiipciaiiecaee
Dare
The following points of technique must be emphasized: it is important that the fingers do not move across the skin,
* Circular frictions may be performed with the tips of the
lest a blister result because of the pressure. In both cases,
second, third, and fourth digits or with the thumb. The pressure is gradually increased with the first few passes over
corresponding digits of the other hand may reinforce the the tissue being treated. This helps the patient to become
fingers if greater depth is required. When the fingertips accustomed to the sensation. It will be somewhat uncom-
are used, a small, tripod-like arrangement is made with fortable or even painful but should not be unbearable. An
the tips of the index, middle, and ring fingers, respec- ice cube rubbed over the area for a few minutes may assist
tively. The index and ring fingertips touch each other, some patients if the technique is particularly painful for
and the middle finger sits on top of them. An alternative them. The temporary numbing often allows for the neces-
technique is for the therapist to use the tip of the index sary pressure to be applied. Transverse and circular frictions
finger reinforced by the middle one. are also demonstrated on the DVD.
* The fingers should be pressed obliquely into the tissues
before beginning the movement and then should move
in very small circles, going slightly deeper with each
successive circle of pressure. In this way, the superficial
tissues are moved over the deeper ones. When the
required depth has been obtained (usually after three or
DEEP FRICTIONS
BODY PART DVD CHAPTER
four circles), the pressure is released gradually and the
Circular frictions to the back 4-8
fingers are lifted to an adjacent area so that the manipu- Transverse frictions to the medial 4-54
lation can be repeated. knee
Figure 4-31 illustrates the basic hand position for circular Transverse frictions to the 4-57
frictions to the paraspinal region. posterior wrist

Rate of Movement
Both transverse and circular frictions are performed slowly
with a steady rhythm.
Duration of Treatment
Depth and Pressure Treatment may last 5 to 20 minutes at each session; this may
Both transverse and circular frictions are very deep strokes. be repeated two or three times per week for as long as
Significant pressure is applied to a small area of tissue, and necessary.

Primary Effects of Deep Frictions

The main effects of deep frictions are produced through a
direct mechanical impact on the tissues. In addition, reflex
effects are mediated through the sensory nervous system,
especially in the skin. When performed properly, the deep
frictions have the following primary effects:
¢ Stretching of posttraumatic scar tissue in muscles,
tendons, tendon sheaths, ligaments, and joint capsules
¢ Local damage to the tissues, causing the liberation of a
histamine-like substance (H substance) and other
metabolites that act directly on the capillaries and
arterioles in the area, causing localized vasodilation
Vasodilatation producing an increase in the amount of
Figure 4-31 Circular Frictions to the tissue fluid in the local area, which distends the tissues
Paraspinal Region (in effect, the stroke produces a controlled inflammation
With the patient comfortably positioned in prone lying, the exact location
and at the same time mobilizes the structures that were
of the problem area is first determined. The tips of the first three digits not moving properly)
are used to form a small tripod-like arrangement. Pressure is applied
through the fingertips in a small circular movement, gradually getting Therapeutic Uses of Deep Frictions
deeper. Three or four circles on each tender area are usually sufficient
When included in a treatment sequence, deep frictions can
before pausing. The technique can then be repeated several times. The
be used to do the following:
sensation for the patient is expected to be uncomfortable or painful, but
* Mobilize contractures (scar tissue) in the superficial and
not unbearable, at the beginning of treatment. After several minutes,
however, the treated area should be somewhat desensitized. See also deep muscles, tendons, ligaments, joint capsules, and
DVD Chapter 4-8. neurovascular bundles
 PART ONE GENERAL PRINCIPLES
aint OF.
esx
ili
¢ Increase blood and lymphatic flow in the skin and in Main Contraindications to the
superficial and deep muscles javle 4-8 Use of Deep Frictions ,
Promote the absorption of inflammatory exudates ~y ¥)

(edema) in the subacute and chronic stages of soft tissue Open areas (e.g., burns or wounds) in the A
injury areas to be treated, especially if they are
* Relieve pain and muscle spasm, thereby promoting infected
relaxation and healing Cancer in the skin or any other tissue in the A
area to be treated
Serious infections in the tissues to be treated A
Indications for the Use of (tuberculosis, septic arthritis, etc.)
Deep Frictions Gross edema in the areas to be treated if A
Deep frictions may be indicated as part of a treatment plan there seems to be a possibility of splitting
to help relieve or reduce the effects of the following the skin
conditions: Lacerations, bruising, infections, or foreign A
bodies (e.g., glass, grit, metal) in the skin
¢ Chronic lesions in the skin and subcutaneous tissues,
or other tissues in the area to be treated
muscles, tendons, tendon sheaths, ligaments, and joint
Arterial or venous pathology (especially A
capsules; for example, chronic muscle tears, tendinitis thrombophlebitis and deep vein thrombosis)
and partial tendon ruptures (tenoperiosteal tears), in the areas to be treated
tenosynovitis, ligament sprains, induration of subcutane- Acute muscle tears in the areas to be treated A
ous areas, and scar tissue (especially deep intramuscular hematomas)
* Chronic pain associated with lesions in any of the Acutely inflamed joint tissues (joints, tendons, U
musculoskeletal tissues ligaments, tendon sheaths, joint capsules,
etc.) in the area to be treated
¢ Chronic superficial scar tissue in the skin and subcuta-
Hyper- or hypotonic limbs as the areas to be U
neous tissue, especially that associated with trauma treated (very gentle massage only)
Acute or chronic skin conditions affecting the U
Contraindications to the Use of areas to be treated (e.g., psoriasis, eczema,
Deep Frictions or dermatitis)
Marked varicosities in the areas to be treated U
The general concept of contraindications is covered in
if damage to the vein wall might result
Chapter 3. As a technique, deep frictions may be contrain- Within 3 to 6 months following radiation therapy U
dicated when any of the situations listed in Table 4-8 are in the area to be treated (skin is usually
present. hypersensitive)
Areas of hyperesthesia in the areas to be R
treated (i.e., those very sensitive/ticklish to
RELAXED PASSIVE MOVEMENTS touch)
Extremely hairy areas in the areas to be treated R
Terminology (if treatment causes pain)
Several terms are used interchangeably to describe these
A, Always contraindicated; U, usually contraindicated; R, rarely
techniques. In all cases, the patient should be completely contraindicated.
relaxed and play no part in the technique. This is why they
are often called relaxed passive movements. Passive move-
ments are those that can be performed without the patient
being completely relaxed; indeed, it is often difficult for that can be produced by active muscle contraction. Although
some patients to relax, perhaps because of pain. In this sense these movements take place at various joint surfaces, they
then, these patients may actually be helping the movement also involve stretching (movement) of the skin and subcuta-
with a little active contraction of their own. This action neous tissues, tendons, ligaments and joint capsules, and
could be described as an assisted passive movement, indi- neurovascular tissues. In contrast, passive accessory joint
cating that the therapist is producing the majority of the movements are performed through a range of motion that is
movement and the patient is assisting. Although this seems present in a joint but is not under voluntary control, hence
at first glance to be a reasonable concept, it is not the way the term accessory. For example, the metacarpophalangeal
passive movements are supposed to be performed. joints of the fingers (knuckles) allow several ranges of
These techniques are sometimes described as passive active
movement (1.e., flexion, extension, abduction, adductio
physiological movements to distinguish them from other n, and
circumduction). However, in addition to these ranges,
types of passive movement, especially passive accessory the
finger can be rotated to the left and right, on its long
joint movements, also known as mobilizations. They are axis.
Other ranges of accessory joint motion can be produce
called passive physiological movements because they are d at
these joints, but they can only be done passively. Accesso
performed through the normal physiological range of motion ry
Joint movements are also described as joint play,
present in the joint(s)—that is, the same range of motion as they
describe these important extra ranges of motion
that are
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

necessary for normal movement to occur in a joint. Of

hand, or the entire upper limb). Repeated stretching of
course, accessory ranges of motion in a joint are also physi- tissues helps to restore lost ranges of motion and maintain
ological in the sense that they are a normal aspect of joint
normal tissue length and viability.
function. In this sense, they are part of the normal design
features of the joint. It is just that these ranges are not under Basic Technique and Direction of Movement
the independent control of voluntary muscle action.
With the patient draped and properly supported in an appro-
Another technique, rightly classified as a specialized
priate position, the therapist holds the body parts to be
type of passive movement, is the so-called manipulation.
moved in a firm but comfortable grasp. For the upper and
These specialized techniques are usually performed through
lower limbs, movements will typically begin at the large,
a few degrees of motion at the extremes of normal joint
proximal joints (shoulder and hip) and progress down the
ranges. They are usually performed as a forceful, high-
limbs to the hands or feet. Three or four repetitions of each
velocity thrust and must be carefully localized to be safe
movement are performed, wherever possible going from the
and effective. A distinguishing feature between a manipula-
extreme of one movement to the limit of the opposite one
tion and other forms of passive movement relates to the (e.g., from the extreme of flexion to the limit of extension
degree of control that the patient has during the procedure. at the elbow). In this case, the elbow joint structures will be
During a manipulation, the movement occurs in such a appropriately stretched, but the muscles normally affecting
small range of motion and at such high speed that the patient movement at both of the joints (biceps and triceps) will not
cannot stop it even if he or she tried. In contrast, the patient be stretched. To stretch these two-joint muscles, the limb
is in complete control of all of the other types of passive must be put through a combination of ranges (i.e., full flexion
movement techniques, assuming that the patient does not at both elbow and shoulder, followed by full extension at
have paralysis of the appropriate muscles. For example, a both joints). The moving limbs travel through a greater
patient with a complete brachial plexus lesion resulting in a range of motion with each successive repetition, eventually
totally paralyzed (flaccid) limb cannot stop passive move- finishing at the point of maximal movement with sustained
ments performed on the arm, because this patient has no overpressure. This point in the range must be reached on a
voluntary muscle control in the affected limb. Both mobili- consistent basis in order for an increase in the available
zations and manipulations form part of the general concept range to be apparent. The position chosen for this technique
(along with soft tissue manipulations) of modern manual will depend on the patient and therapist’s preference because
therapy (Grieve, 1994). relaxed passive movements can be performed with the
Another type of passive movement technique that patient in a wide variety of positions.
deserves a brief mention is the so-called continuous passive
motion (CPM) technique. In this case, a mechanical device Rate of Movement
is attached to the limb and moves selected joints through a Relaxed passive movements should be slow and rhythmic so
controlled range of motion. The device can be set to produce as to encourage the patient to relax during the procedure. If
the movements at certain speeds and desired ranges of the patient experiences pain beginning at a certain point in
motion, either continuously or intermittently. This treatment the range, then the therapist should apply the movements up
concept has been widely used in orthopedic practice, espe- to the point of pain but not beyond. This means that move-
cially following joint replacement surgery. Because of their ments are given for the most part in a pain-free range. As
design characteristics, the relaxed passive movements pro- the patient relaxes into the movements, the range can be
duced by a CPM device are necessarily limited to restricted increased.
ranges of motion in certain joints (Morris, 1995; O’Driscoll
Depth and Pressure
& Giori, 2000; Sheppard et al., 1995).
In this text, the general term relaxed passive movements Relaxed passive movements should be applied with slight
will be used to describe techniques with the following traction to the joints whenever possible but always with a
characteristics. sustained overpressure at the very end of the available range.
The overpressure must be applied carefully, especially in
Definition those cases where the therapist has a significant mechanical
Relaxed passive movements are slow, stretching movements leverage on the joint (e.g., when rotating the shoulder). In
performed throughout the normal or available physiological such cases, 1t might be possible to damage joint structures
range of motion in a joint(s) or body region. Movements are by overstretching or even dislocating them. Induced pain is
repeated several times, with a gradually increasing degree always a major warning sign and limiting factor. Figures 4-
of motion and sustained overpressure at the end of range. 32 to 4-35 show the different hand positions for relaxed
passive movements to the neck, upper limb, and lower limb,
Purpose respectively. The techniques are also demonstrated on the
Relaxed passive movements are designed to stretch out all accompanying DVD (see DVD Chapters 4-21, 4-22, 4-55,
of the soft tissues associated with a particular joint(s) or 4-56, and 4-68).
limb segment (e.g., the elbow joint, all of the joints in the Text continued on p. 112.
106 GENERAL PRINCIPLES

Figure 4-32 Relaxe »vements to the Neck

With the patient comfortably positioned in supine lying, the therapist moves the patient’s
head and neck
into full flexion (A), and extension (B). The edge of the treatment table sometimes limits
the range of
extension in this position. The patient’s face and chin are supported by the therapist’s left
forearm as his
neck is moved into left rotation (C). In a similar manner, the neck is rotated to the right (D).
The patient’s
neck is then moved into left (E) and then right (F) side flexion as the therapist applies
counterpressure
to the opposite shoulder. See also DVD Chapter 4-1. Relaxed passive movements can
also be given with
the patient’s head supported on a pillow. This is helpful for the patient in extreme
pain who finds it difficult
to relax. Working well within the pain-free range, the head and neck are moved into flexion
(G), extension
(H), rotation to the left (1) and right (J), and then side flexion to the left (K)
and right (L). See also DVD
Chapters 4-21 and 4-22.
BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS SHAPTE 107
108 GENERAL PRINCIPLES

me4ecleerli
Rotation

Lateral
Rotation

the Lower Limb

Pr) (me | Lil rFrone

With the patient comfortably positioned in prone lying, many of the movements described
in Figure 4-32
are possible. This position allows the therapist to move the patient’s hip into
full extension (A) with the
knee held in midflexion. Internal (B) and external (C) rotation at the hip are also
easily performed in this
position. The knee can then be moved into full flexion (D) and then extension
(E). The edge of the treat-
ment table sometimes limits the range of extension in this position. This can
be followed by lateral (F) and
medial (G) rotation of the tibia on the femur. This is followed by dorsiflexion (H)
and plantarflexion (I) of
the ankle joint. Generalized circumduction (J), eversion (K), and inversion
(L) are also possible. Relaxed
passive movements can also be applied to the toes as a group, for example,
flexion (M) and extension
(N) and to each of the individual joints of the toes. See also DVD Chapter 4-56.
BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS 109

: Circumduction g

BAVA
=)B10) al
110 GENERAL PRINCIPLES

$3
Flexion

External
Lacelcc hale)a)

Figure

With the patient comfortably positioned in supine lying, the therapist moves the patient’s hip and knee
into
full flexion (A) and then knee extension (B). The treatment table limits a full range of hip extension
in this
position. Passive movements to the hip in this position can also include hip abduction (C),
adduction
(D), and internal (E) and external rotation (F). Passive flexion (G) and extension (H) at the knee
are
also possible in this position. In the foot and ankle region, dorsiflexion (I) and plantarflexion
(J) along with
inversion (K) and eversion (L) are included in a basic routine for the lower limb.
Relaxed passive move-
ments can also be applied to the toes as a group; for example, extension (M) and
flexion (N), and also
to the individual joints of each toe, for example, abduction (O) and adduction (P) of the
great toe. See
also DVD Chapter 4-55.
BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS 111

n
 112 GENERAL PRINCIPLES

Pain and muscle spasm relief (via a pain-gating mecha-

y RELAXED PASSIVE MOVEMENTS nism) leading to an increased range of motion and an
improvement in functional ability
BODY PARI
U\

ec 4-21, 4-22 Increased flow of blood and lymph in the limbs because
Posterior aspects of the lower limb 4-56
of the mechanical pumping effect produced as the
Anterior aspects of the lower limb 4-55
Upper limb 4-68
tissues are alternately squeezed and stretched (the
increased circulation promotes healing and all levels of
tissue viability)

When included in a treatment regimen, relaxed Passive

Therapeutic effects are produced mainly through the direct movements can be used to do the following:
mechanical impact of stretching the tissues and the passive Increase blood and lymphatic flow (passive pump)
pumping of blood and lymph during the movements. The in the superficial and deep circulation in the
primary effects of relaxed passive movements are as limbs
follows: Relieve pain and muscle spasm, thereby promoting
¢ A direct mechanical stretch on the connective tissues relaxation and improved range of motion
associated with all of the musculoskeletal and neurovas- Regain lost functional range of motion in skin, joint,
cular structures, leading to increased range of motion in muscle, tendon, and neurovascular tissue as a result of
these tissues and an improvement in functional ability contractures and adhesions
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS

Lateral
Rotation

Medial
Rele-tatelay /

VaAman?t
Figure xed vementi
f/iOVvel ne :
With the patient comfortably draped and seated, the therapist moves the patient’s right shoulder into the
fully elevated position, through flexion (A) and extension (B). Horizontal flexion and extension at the
shoulder are shown in (C) and (D), respectively. With the patient’s upper arm held horizontally and her
elbow positioned at approximately 90 degrees of flexion, medial (internal) and lateral (external) rotation are
performed in (E) and (F), respectively. Elbow flexion (G) and extension (H) are followed by flexion and
extension of the wrist in (1) and (J), respectively. Relaxed passive movements can also be applied to the
joints of the fingers as a group—that is, mass flexion and extension (K, L)—or to each of the individual
joints in the hand and fingers. Two examples are shown here: abduction of the thumb (M) and extension
of the thumb (N). See also DVD Chapter 4-68.
114 GENERAL PRINCIPLES
 BASIC MASSAGE STROKES AND RELAXED PASSIVE MOVEMENTS CHAPTER 4

Main Contraindications to the Contraindications to the Use of

: Use of Relaxed Passive Relaxed Passive Movements
Table 4-9 Movements The general concept of contraindications is covered in
Chapter 3. The technique of relaxed passive movements may
Large open areas (e.g., burns or wounds) A be contraindicated when any of the situations listed in Table
in the areas to be treated, especially if 4-9 are present.
they are infected
Gross edema in the areas to be treated if A
there seems to be a possibility of splitting
the skin
SUMMARY
Deep vein thrombosis or other serious A This chapter has reviewed the major elements of the tech-
vascular pathology in the areas to be
niques known as Swedish remedial massage, deep frictions,
treated
Cancer in the skin or any other tissue in and relaxed passive movements. In each case, a detailed
A
the area to be treated description was provided, together with illustrations and
Serious infections in the tissues to be treated A lists of therapeutic effects, uses, indications, and contrain-
(tuberculosis, septic arthritis, etc.) dications. The systematic organization of this material will
Lacerations, bruising, infections or foreign U hopefully allow the reader to choose appropriate techniques
bodies (e.g., glass, grit, metal) in the skin of for a given patient. The accompanying DVD provides the
the area to be treated
viewer with the opportunity to see how each technique
Marked varicosities in the areas to be treated U
should be given, and easy access to each video clip can be
if damage to the vein wall might result
Acute or chronic skin conditions affecting the R
found in the DVD menu.
areas to be treated (e.g., psoriasis, eczema,
or dermatitis)
Within 3 to 6 months following radiation R REFERENCES
therapy in the area to be treated (skin is
Brosseau L, Casimiro L, Milne S et al: Deep transverse friction
usually hypersensitive)
massage for treating tendonitis, Cochrane Database Syst Rev (4):
Areas of hyperesthesia in the areas to be R CD003528, 2002.
treated (i.e., those who are very sensitive/ Chamberlain G: Cyriax’s friction massage: a review, JOSPT 4(1):16-22,
ticklish to touch) 1982.
Cyriax J: Clinical applications of massage. In Licht S, editor: Physical
A, Always contraindicated; U, usually contraindicated; R, rarely
contraindicated. medicine library, vol 5; massage, manipulation and traction, pp 122-
139, Baltimore, 1960, Waverley Press.
Cyriax J, Coldham M: Textbook of orthopaedic medicine, vol 2, pp 9-
¢ Maintain the normal functional range of motion in body 21, London, 1984, Bailliere Tindall.
segments subjected to prolonged immobility or paraly- Dorland’s illustrated medical dictionary, ed 30, Philadelphia, 2003,
sis, thereby preventing contractures and adhesions Saunders.
Grieve GP: Modern manual therapy of the vertebral column, London,
1994, Churchill Livingstone.
Indications for the Use of Relaxed Hammer WI: The use of transverse friction massage in the management
Passive Movements of chronic bursitis of the hip or shoulder, J Manip Physiolog
Therapeutics 16(2):107-111, 1993.
Relaxed passive movements may be indicated as part of a
Morris J: The value of continuous passive motion in rehabilitation
treatment plan to help relieve or reduce the effects of the following total knee replacement, Physiotherapy JCSP 81(9):557-562,
following: 1995.
¢ Pain (acute or chronic) preventing movement O’Driscoll SW, Giori NJ: Continuous passive motion (CPM): theory
and principles of clinical application, J Rehab Res Dev 37(2):179-
¢ Muscle spasm (acute or chronic) preventing movement
188, 2000.
¢ Superficial and deep scar tissue in the skin and subcuta- Quinn C, Chandler C, Moraska A: Chronic tension headaches reduction
neous tissue ; with the use of cross friction massage techniques, Am J Public
¢ Prolonged immobility or paralysis Health 92(10):1657-1661, 2002.
Sheppard MS, Westlake SM et al: Continuous passive motion: where
* Contractures/adhesions in joint capsules, ligaments, are we now? Physiotherapy Can 47(1):36-39, 1995.
muscles, tendons, tendon sheaths, and neurovascular Steward B, Woodman R, Hurlburt D: Fabricating a splint for deep
tissues friction massage, JOSPT 221(3):172-175, 1995.
 Mechanical, Physiological,
Psychological, and
Therapeutic Effects of Soft
Tissue Manipulation
Soft tissue manipulation is an ancient art, practiced in many chological responses. All three types of effect give rise to
cultures and studied by both ancient and modern scholars. the therapeutic uses. It is worth noting at this stage that the
Despite its longevity and widespread use, however, com- anticipation of receiving a massage treatment is usually a
paratively few scientific studies were undertaken until the positive experience for the patient. Therefore, a psychologi-
twentieth century. Before the early 1900s, the scientific lit- cal effect might be produced even before the treatment
erature on massage consisted largely of descriptive reports begins.
and observational records of the areas under study. The According to the great Arabic philosopher and scholar
methods and standards used today did not exist 100 years Avicenna (980-1037), “The object of massage is to disperse
ago. In fact, much of medical science was devoted to a the effete matters [metabolites] formed in the muscles and
description of anecdotal reports and deductive reasoning not expelled by exercise. It causes the effete matter to dis-
based on them. Also, the investigative methods available in perse and so removes fatigue” (Gruner, 1930). This state-
the first half of the twentieth century were extremely crude ment from Avicenna clearly shows that classical scholars
by today’s standards. It is easy to forget that electricity was were very interested in understanding the mechanisms by
only available as a public utility shortly after 1900 and that which manipulation of the soft tissues (including massage)
the modern electronic age only began in the 1930s. Suffice might have beneficial effects; however, the majority of writ-
it to say that the electronic devices (especially computers) ings have concentrated more on describing the techniques
that are considered to be indispensable and taken for granted and the observed effects of treatment rather than on inves-
today did not exist in the early decades of the twentieth tigating these effects scientifically. The general effects of
century. Indeed, much of the modern understanding massage have been described and classified in several ways.
of human physiology only began to take shape in the late Mennell (1945) referred to mechanical (pressure and
1890s and early 1900s. This was the era of Sir Charles tension), chemical, reflex, and psychological effects, but
Sherrington, who is known as the father of modern physiol- other authors described only general and local effects. This
ogy. With these thoughts in mind, this chapter reviews both edition of the text continues to use the simple classification
the historical understanding of how massage has its effects of mechanical, physiological, and psychological effects
and some of the modern literature that continues to shed developed from the fourth edition.
light on this ancient treatment. The primary effects (mechanical, physiological, and psy-
The primary effect of manipulating the soft tissues of the chological) are considered separately here, although they are
body is mechanical in nature. The pressing, pulling, lifting, interdependent. Each area has been subdivided into several
stretching, rubbing, and squeezing obviously impart a sections, together with the appropriate research. In this way,
mechanical deformation on the tissues, and this occurs relevant research findings have been classified according to
before most, but not all, of the other effects. These mechani- the specific effects of massage—for example, the effect of
cal effects result in a wide variety of physiological and psy- massage on pain. Numerous studies have reported on the
 PART ONE GENERAL PRINCIPLES

babar
general effects of massage compared with other treatment Examples of Excitable and
techniques (e.g., Taylor et al., 2003); however, this text con- lable 5-1 Nonexcitable Tissues
centrates on the specific effects of massage. The reader
interested in the more general effects and comparisons of Excitable Tissues Nerve cells of all types
massage with other treatments is referred to computer data- Nerve fibers of all types
bases such as the Centre for Reviews and Dissemination Voluntary motor fibers
(2005). A meta-analysis of massage therapy research can be Autonomic muscle fibers
found in the Database of Abstracts of Reviews of Effective- Cardiac muscle fibers
Abdominal organ cells
ness (Issue 2, DARE-20043309). The specific effects, indi-
Glands
cations, therapeutic uses, and contraindications for each of
Nonexcitable Tissues Skin
the basic massage strokes were presented in Chapter 4. Bone
Cartilage
Collagen tissues
Ligamentous tissue
MECHANICAL EFFECTS Tendon tissue
Hair
The mechanical forces associated with squeezing, pulling,
Teeth
stretching, pressing, and rubbing strokes affect the tissues
Nails
in a variety of ways. For example, the various techniques of
kneading and wringing would be expected to have a consid-
erable mobilizing effect (loosening or stretching) on the
skin, subcutaneous tissue, and muscle tissue. In contrast,
the gradually increasing pressure of effleurage would be Table 5-1 lists various tissues as excitable or nonexcitable
expected to push the venous blood and lymph in the super- based on their ability to respond immediately to an external
ficial vessels toward the heart, thus promoting good circula- mechanical stimulus. Note that the stimulus does not neces-
tion and resolving chronic edema and hematoma. In a sarily have to produce its effect directly. The effect can be
similar manner, the pressure and direction of stroking and produced by the activation of an appropriate reflex. For
effleurage techniques can promote movement of the intesti- example, during the percussion strokes, the high-speed
nal contents. mechanical tapping of the skin and muscles activates the Ia
The principal effects of each of the basic massage tech- sensory endings in the muscle spindles of the muscle being
niques were outlined in Chapter 4. Although the mechanical percussed, thereby activating the stretch reflex and thus
effects of massage are important to identify, it is the physi- facilitating the muscle.
ological effects that need to be considered in some detail, Tissues labeled as excitable are capable of an immediate
because these give rise to the therapeutic potential of soft response to an external mechanical stimulus. The response
tissue massage. The primary effect of massage, then, is to can be mediated via an appropriate reflex or be the result of
produce mechanical deformation of the tissues by means of direct activation. Those tissues classified as nonexcitable
rhythmically applied pressure and stretching. Applied show no immediate response to an externally applied stimu-
mechanical pressure compresses and stretches the soft lus; however, over time, with repeated stimulation, struc-
tissues and thereby distorts both the excitable and the non- tural changes may become apparent.
excitable tissues of the body. Excitable tissues are those The externally applied mechanical pressure can also
structures that respond in some measurable and immediate affect the flow of blood and lymph and can therefore stimu-
way to an externally applied mechanical stimulus. Obvious late the circulation. This is a particularly important mechani-
examples are sensory nerves. The nonexcitable tissues are cal effect because the net result is an increased flow of blood
composed of structures such as bone, ligaments, and carti- and lymph in the target area, and this facilitates healing. A
lage. Although these structures do not appear to respond similar direct mechanical effect can occur in the lung tissue,
immediately to the applied mechanical stimulus, they do in where the percussion and vibration strokes can help to
fact respond, but over a much longer period of time, some- loosen mucus and promote drainage of excess fluids from
times taking several months. For example, a muscle that has the lungs (see Chapter 10).
undergone adaptive shortening (contracture) will obviously Box 5-1 summarizes the mechanical effects of soft tissue
feel tight when stretched. If a mechanical stretch is applied manipulation using two primary categories: the effect that
to the muscle, especially on a continuous basis (serial produces movement and the effect that mobilizes the tissues.
casting), the body will re-engineer (lengthen) parallel and In the case of the movement effect, the emphasis is on the
series elastic components, but this takes many weeks. movement of fluids in the circulatory system (blood and
Although the immediate effect of the stretching appears lymph). In the case of the mobilizing effect, the emphasis
nonexistent, over time it becomes apparent. For example, is on loosening and promoting intertissue mobility. These
Threlkeld (1992) investigated the mechanical effects of concepts are discussed in detail in the next section dealing
massage on connective tissues. with the physiological effects of massage.
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5

(Seamer rar
Primary Mechanical Effects of Soft a) Physiological Effects of Soft Tissue
BOX 5-1 Tissue Manipulation BOX 5-2 Manipulation
ovement of
Increased blood and lymph flow
Blood
Increased flow of nutrients
Lymph
Removal of waste products and metabolites
Lung secretions
Stimulation of the healing process
Chronic edema
Resolution of chronic edema and hematoma
Intestinal contents
Increased extensibility of connective tissue
Mobilization of Pain relief
Muscle fibers Increased joint movement
Muscle masses Facilitation of muscle activity
Tendons Stimulation of autonomic functions
Tendons in sheaths Stimulation of visceral functions
Ligaments Removal of lung secretions
Joint capsules Promotion of local and general relaxation
Skin and subcutaneous tissue
Fascia
Scar tissue
Adhesions
Chronic hematoma able to expect that they would have a considerable effect on
the flow of blood and lymph in these tissues. In addition,
swelling that has accumulated in such tissues would be
expected to be similarly affected. However, Mennell (1945)
The two primary effects of soft tissue manipulations are believed that it is impossible to affect arterial circulation
the movement of fluids and the mobilization of tissues. directly via the mechanical effects of massage. He theorized
These effects have important physiological consequences, that applying massage pressure in the direction of the venous
which give rise to the therapeutic uses for the various flow is comparable to the effect of squeezing any soft tube
techniques. to empty it of fluid. If the muscles are relaxed, they consti-
It is important to remember that tissues that have adap- tute a soft mass containing tubes filled with fluid. Any
tively shortened (contractures) cannot be suddenly made pressure applied to the mass should push the fluid in these
longer. The process of lengthening is one in which the tubes in the direction in which the pressure is applied;
natural mechanisms (collagen turnover) are stimulated by therefore if sufficient pressure is applied to the entire mass,
the mechanical stresses placed on the tissues. In effect, the the deeper veins will also be emptied. Such pressure might
tissues undergo an adaptive lengthening. Serial casting, at the same time retard arterial blood flow if it is forceful
where needed, can greatly facilitate this process as this enough to compress the arteries and the veins.
places a continuous mechanical stretch on the tissues. Of Theoretically, if massage can increase the amount of
course, soft tissue massage techniques can be used to prevent venous blood brought to the heart, the heart rate or the
contractures from developing in the first place. stroke volume might increase and a greater amount of arte-
rial blood would thus be carried to the periphery. In fact,
there is little evidence of such a simple mechanical reaction
PHYSIOLOGICAL EFFECTS
of the arterial and arteriolar system to massage. Wakim
The mechanical stimulus given to the tissues during soft (1949, 1955) found that following deep stroking and knead-
tissue massage causes the body to respond in different ways. ing massage, the average increase in total blood flow in
It is appropriate to consider these responses as the physio- normal, rheumatoid, arthritic joints was inconsistent. Mod-
logical effects of massage, as they are the direct and indirect erate, consistent, and definite increases in circulation were
effects of the individual massage techniques (Goats, 1994a, observed after such massage to flaccid, paralyzed extremi-
1994b). Some of the effects are immediate, whereas others ties. Vigorous, stimulating massage resulted in consistent
are only apparent over time. This gives rise to the idea that and significant increases in average blood flow of the mas-
massage can trigger a response in the tissues that begins a saged extremity but produced no change in blood flow in
cascade of other effects, and some of these effects can be the contralateral unmassaged extremity.
long lasting. This section considers the physiological effects” According to Pemberton (1932, 1939, 1950) the nervous
under categories that relate to various tissues. The physio- system, probably through the sympathetic division, contrib-
logical effects of soft tissue manipulations are listed in Box utes to a reflex influence on the blood vessels of the parts
5-2 and discussed in the following sections. concerned. He believed that it is probable, therefore, that
vessels in the muscles or elsewhere are emptied during
Effects on Blood Flow massage, not only by virtue of being squeezed but also
Because all massage techniques involve some degree of through a reflex action. Pemberton stated that microscopic
manipulation of the skin and underlying tissues, it is reason- observation thus reveals that massage may cause almost all
 PART ONE GENERAL PRINCIPLES
ditieieei AO...
ihe tied st,
the smaller vessels to become visible because it promotes for 10 minutes. Moreover, Bell showed that the effect lasted
blood flow through them. Although there is little informa- 40 minutes, as compared with only 10 minutes following
tion on the type of massage that was used, several convinc- exercise. Bell recommended massage to treat edema of frac-
ing experiments have been performed that show that massage tures because of its effects on venous and lymphatic flow.
increases circulation of the blood. Severini and Venerando (1967) also combined massage
Wolfson (1931) studied the effect of deep kneading with a hyperemia-producing drug containing vanillyl and
massage on venous blood flow in normal dog limbs and butoxyethyl nicotinate. The combined treatment led to a
showed that massage greatly increased flow initially, fol- significant and prolonged rise in skin temperature. When
lowed by a fairly rapid decrease to a less than normal rate the drug was used alone or with superficial massage, there
even before the end of stimulation. Immediately after ces- was no change in circulation in muscles; but with deep
sation of the procedure, he noted that the flow rate slowly massage, there was an appreciable and effective increase in
increased again to normal. He concluded that the actual blood flow in muscles. On a more central level, Barr and
volume of blood that passes through the limb during the Taslitz (1970) showed that systolic and diastolic blood pres-
period of stimulation and recovery is not greater than normal sure tended to decrease after a 20-minute back massage.
but that there is more complete emptying for a short time, Delayed effects were an increase in systolic pressure and a
so that a larger volume of fresh blood is brought to the part. small additional decrease in diastolic pressure. The heart
He suggested that it would seem logical to use short but rate increased. In addition, high blood pressure and associ-
frequent massage treatments. Recently, Gregory and Mars ated symptoms were shown to reduce with massage therapy
(2005) have shown that massage (using controlled com- (Hernandez-Reif et al., 2000).
pressed air and an animal model) increases capillary dila- Massage has been studied for its effect on the circulation,
tion and therefore blood flow in skeletal muscle. as a means of preventing pressure sores (Dyson, 1978; Ek,
Carrier (1922) showed that light pressure produces almost Gustavsson, & Lewis, 1985; Olson, 1989). Massage for this
instantaneous, though transient, dilatation of the capillary purpose, however, does not follow traditional massage tech-
vessels, whereas heavier pressure may produce more endur- niques. In most cases, it takes the form of a short period (30
ing dilatation. Microscopic observation of fields in which to 60 seconds) of skin rubbing, the intention being to stimu-
only a few capillaries are open shows that pressure may late circulation to the areas of skin that are prone to develop
cause nearly all the smaller vessels to become visible. pressure sores. Not surprisingly, the results of this kind of
Pemberton (1945) described the work of Clark and massage are difficult to interpret, let alone to use as a basis
Swanson, who made cinematographic studies of the capillary for making recommendations. In some studies, this type of
circulation in the ear of a rabbit utilizing a permanent window massage seemed to increase local circulation; in others, it
for observation. These studies demonstrated that following appeared to decrease it. It seems unlikely that a rapid skin
massage, more capillaries were opened and the rate of flow friction massage would produce the kind of genuine increase
was faster. The sticking and emigration of leukocytes evi- in circulation that would prevent pressure sores. This is
denced a change in the blood vessel wall. The increased blood because this type of massage simply produces a small degree
flow as a result of massage was demonstrated as long ago as of mechanical friction on the skin surface. This would prob-
the mid-1890s (Brunton & Tunnicliffe, 1894-1895). ably show up as a slight and short-lived change in surface
Many practitioners have claimed that the reflex effect of temperature. On the other hand, a different kind of massage
superficial stroking improves cutaneous circulation, espe- would be expected to produce a more profound effect on the
cially blood flow in superficial veins and lymphatics; aids in circulation, especially if it involved deep kneading to
the exchange of tissue fluids; increases tissue nutrition; and muscles around the area, were that possible. A more efficient
assists in the removal of the products of fatigue or inflamma- way of producing a rapid change in skin blood flow is mas-
tion. However, as long ago as 1939, Wright stated that such saging the area with an ice cube. In this case, it is the cold
claims must be examined critically in the light of present-day stimulus that produces profound vasodilation after the initial
knowledge of physiology. He maintained that it was difficult vasoconstriction (Michlovitz, 1996). Undoubtedly, a brief
to make positive statements about reflex effects produced by massage (1 to 3 minutes) with an ice cube is likely to be
massage. The situation today is in many ways similar. much more effective than a similar period of skin rubbing.
Severini and Venerando (1967) reported that superficial
massage produced no significant changes except in skin tem- Effects on the Lymphatic System
perature. Deep massage did, however, increase blood flow In the lymphatic capillaries and plexuses of the skin and
and systolic stroke volume and decreased systolic and dia- subcutaneous tissue, lymph can move in any direction. Its
stolic arterial pressure and pulse frequency. Interestingly, movement depends on forces outside the lymphatic system.
deep massage was also associated with increased blood flow Its course is determined by factors such as gravity, muscle
in the untreated, contralateral limb. Bell (1964) demonstrated contraction, passive movement, and massage. If obstruction
this effect using plethysmographic studies. He showed that of the deeper lymphatics occurs in a part, it is still possible
blood volume—and thus the rate of blood flow—had doubled to keep the superficial lymphatics open, and if the part is
following deep stroking and kneading of the calf of one leg massaged or given opportunity to drain by gravity, lymph
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5 sailed
eens

moves through these other channels in the direction of

The idea of using mechanical forces to affect the circula-
the external force. These issues are considered in detail in
tion of blood and lymph is not limited to manual massage
Chapter 12. techniques. A variety of pneumatic devices have been devel-
Animal experiments show that there is little lymph flow oped that deliver a series of controlled (and often graduated)
when a muscle is at rest. Von Mesengeil’s and Kellgren and pressure changes along a limb surface. In effect, these
Colombo’s studies on the effects of massage on lymph flow devices perform a kind of mechanical massage. They have
observed increased lymph flow when the muscles were mas- proved to be of considerable benefit in the treatment of many
saged. Cuthbertson (1933) noted that Von Mesengeil acute and chronic circulation disorders but especially in
repeatedly injected China ink into corresponding articula- the treatment of lymphedema (Yamazaki et al., 1988). Of
tions of rabbits. One joint was massaged and the corre- course, manual massage techniques also have an important
sponding one left as a control. In the legs without MASSAgE, role to play in the management of lymphedema (Andersen,
the tendency of the colored material to pass toward the 2000: Casley-Smith, 2000; Forchuk et al., 2004; Little &
heart was very small, but in those legs subjected to massage, Porsche, 1998; Mason, 1993; Nickalls, 1996; Weinrich &
there was great absorption of the ink above the joint in the Weinrich, 1990). See also Chapter 12 for an in-depth discus-
intermuscular connective tissues and in the lymphatic sion on the concept of decongestive therapy for the manage-
glands. The lymphatics passing up to the glands were ment of lymphedema.
deeply stained black.
Kellgren and Colombo found that
Massage always had a sure and effective influence in Effects on the Blood
increasing the rapidity of the absorption of substances In 1904, Mitchell stated that in both healthy and anemic
injected into animals in all the organs which can be sub- persons, the red cell count increased after massage. In
jected to manipulations— subcutaneous tissues, muscles, anemic subjects the increase is greatest | hour after treat-
articulations, and serous cavities. The course which the ment. Schneider and Havens (1915) also showed that abdom-
injected substance followed during its absorption, was inal massage increases the hemoglobin and red cell count
always that of the nearest lymphatic vessels and the glands in blood taken from the finger at ordinary barometric pres-
into which they pass. Deep Effleurage was probably less sures. Pemberton (1950) stated that massage unquestionably
effective than the squeezing and rolling of muscles and increases the hemoglobin and red cell values in the circulat-
subcutaneous tissue. ing blood and that there is a limited but definite increase in
McMaster (1937) also showed that massage increased lymph the oxygen capacity of the blood after massage. Lucia and
flow by experiments in which the limbs of normal healthy Rickard (1933) found that massage consisting of gentle but
subjects were massaged after intradermal dye injections. firm stroking of a rabbit’s ear at the rate of 25 strokes per
Drinker and Yoffey (1941) cannulated the cervical lymph minute for 5 minutes caused a local increase in the blood
trunks in an anesthetized dog and were able to sustain platelet count.
lymph flow all day long by massaging the head and neck Bork, Karling, and Faust (1971), reporting the effects of
above the cannulas. When the massage was stopped, lymph whole-body massage on serum enzyme levels in normal
flow either ceased or was negligible. The investigators stated persons, showed a significant rise in serum glutamic oxalo-
that, in treating chronic inflammatory conditions in which acetic transaminase, creatine phosphokinase, lactic dehy-
fibrosis is sure to advance if tissue fluid and lymph remain drogenase, and MK. These effects caused the authors to
stagnant in the part, massage in the direction of lymph flow advocate that whole-body massage should be contraindi-
is the preeminent artificial measure for moving extravascu- cated for patients with dermatomyositis, especially serious
lar fluid into lymphatics and for moving lymph onward cases.
toward the bloodstream. Drinker and Yoffey also found that Ernst et al. (1987) showed that a 20-minute whole-body
the effects of posture were obvious and that lymph flow muscle massage causes a dilution effect and changes blood
from a dependent, quiescent part was practically negligible. fluidity. This effect was observed in both normal subjects
Therefore, to influence the flow of lymph most efficiently in and patients with ankylosing spondylitis. When these effects
any area, it seemed logical that the part should be elevated are coupled with the increased blood and lymph flow pro-
during the application of massage. Elevation means placing duced by massage, it is clear that this form of treatment has
the part higher than the heart. In addition, the pathway for a significant role to play in maintaining and enhancing the
the fluids should be as straight as possible. ‘ overall nutrition of the tissues.
Ladd et al. (1952) compared the effects of massage, The changes described briefly here are not produced by
passive motion, and electrical stimulation on the rate of a direct effect on the blood itself, but rather they reflect the
lymph flow in the forelegs of 15 dogs and found that massage overall effects of massage given to the person. Because the
was “significantly more effective than either passive motion vascular system pervades every part of the anatomy, it is not
or electrical stimulation in this series of animals.” All three surprising that the blood reflects the mechanical and physi-
procedures were found to increase lymph flow much above ological effects of massage. Increased or decreased levels of
that of the control period. various substances carried in the blood are, in most cases,
iii ania PART ONE GENERAL PRINCIPLES

simply the result of the massage given to the soft tissues ers separately the effects of massage on normal and abnormal
rather than a direct effect on the blood itself. muscle tissue.

Effects on Metabolism and the Normal Muscles

Healing Process
Kellogg (1919) observed that “Massage produces an actual
Very little recent experimentation has been reported on the
increase in the size of the muscle structures. The muscle is
effects of massage on metabolism, although several studies also found‘to become firmer and more elastic under its influ-
were performed more than 50 years ago. Cuthbertson (1933)
ence.” McMillan (1925) wrote, “The muscles are strength-
reviewed the existing literature on this subject and con-
ened and made to grow by manipulation.” According to
ducted several experiments of his own. He arrived at the
Despard (1932), “Massage improves the nutrition of the
following findings:
muscles and consequently promotes their development.”
¢ Urine output increases, especially after abdominal
These observations are not supported by the contemporary
massage.
literature, which generally agrees that massage alone does
¢ Excretion of acid is not altered, and there is no change
not increase muscle strength. Of course, if the massage is
in the acid-base equilibrium.
used as a method of preparing muscles for exercise (e.g., in
¢ Excretion rates for nitrogen, inorganic phosphorus, and
sports massage, see Chapter 13), then strengthening would
sodium chloride increase.
be expected to occur, providing a suitable regime of exercise
In normal persons, there is no immediate effect on the
was performed. Nonetheless, exercise, not the massage, is
basal consumption of oxygen or on pulse rate or blood
the reason why muscle strength would increase.
pressure.
Mennell (1945) believed the theory that advocated knead-
Pemberton (1939) believed, “In general the studies which
ing a muscle (working a muscle up) and thereby making it
have been made suggest broad and general influences may be
stronger was a complete delusion. He stated,
exerted by massage and that it has no immediate or large
By one means alone can muscular strength be developed,
effect on general metabolism per se.” He agreed with the view
and that is by muscular contraction, and no form of massage
that its cumulative effect on various metabolic processes lies
can do more than aid means indrectly.
in its effects on the circulation of the parts concerned.
and again,
The resolution of acute trauma or of chronic inflamma-
To use massage aright we must consider it entirely as a
tion (healing) consists of a cascade of interrelated changes
means to an end, that end being restoration of fuction.
in the affected tissues. These changes depend entirely on the
As a means to an end, massage may make it possible for
efficiency of the local circulation to the part, as all of the
a muscle to perform more exercise and thus develop its
materials needed to resolve the inflammatory process must
strength. This fact has been proven by experimental work
arrive at the scene via the bloodstream. In addition, all of
done by Rosenthal, Mosso, and Maggiora (and by others
the waste products must be removed from the area via the
cited in Cuthbertson [1933]), who have shown that a muscle
blood and lymph channels (Evans, 1980). Because massage
has such profound effects on the blood and lymph systems, fatigued by work or by electrical stimulation will be restored
it seems obvious that it has the potential to be useful in much more rapidly and thoroughly by massage than by rest
alone of the same duration.
stimulating the healing process, especially in the subacute
Nordschow and Bierman (1962) studied 25 normal,
and chronic phases of recovery.
healthy, active subjects to determine whether massage man-
It is important to remember the crucial importance of the
ually applied could cause measurable muscle relaxation in
lymphatic system in removing plasma proteins and other
normal human subjects, expressed as increased muscle
large molecules once they have been deposited in the inter-
length. A finger-to-floor test was used to measure tension in
stitial fluid. These molecules are too large to reenter the
the posterior muscles of the back, thighs, and legs as each
capillaries and can only be eliminated via the lymphatic
subject, standing with knees straight, bent forward and
system. Facilitation of healing is therefore the by-product of
attempted to touch the floor with the fingertips. Following
the other (more direct) effects (e.g., increased blood and
lymph flow) on the tissues. such an attempt, each subject then assumed a comfortable,
well-supported prone position for 30 minutes of rest. The
Effects on Muscle Tissue finger-to-floor test was then repeated. The subject then reas-
More than 100 years ago, Maggiora (1891) described the sumed the prone position and was given 30 minutes of
physiological action of massage on muscle tissue. Many massage, 15 to the back and 15 to the posterior aspect of the
other writers have also described the effects of massage on lower extremity, allowing 7.5 minutes per limb. The authors
muscle tissue. Much of the literature contains a relatively concluded that manual massage causes relaxation, which is
large number of positive statements and implications about expressed as increased muscle length. Bell (1964) reported
the effects of massage on muscles, as compared with its that muscle fatigue was relieved more quickly by massage
effects on other systems and tissues of the body. Some of and rest than by rest alone and suggested alternate bouts of
these statements cannot be substantiated by clinical obser- exercise and massage in therapy (a method applied in some
vation or by scientific research. The present review consid- sports).
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5 ———

Smith and colleagues (1994) studied the effects of ath- an essential component in the restoration of muscle length
letic massage on delayed-onset muscle soreness, creatine and normal function.
kinase, and neutrophil count. Their results indicate that A number of experimental studies have investigated the
massage reduces the negative effects of exercise on normal effects of massage on both injured and denervated muscle.
muscle. Presumably these effects are due to the increased These are considered separately here because the issues
circulation of blood and lymph, effectively washing out the involved in each case differ significantly.
metabolic by-products of exercise. The positive effects of Injured Muscle
massage on muscle recovery following intensive exercise are Lucas-Championniere (cited in Mennell [1945]) described
well known and have been studied in a variety of profes- some of the earliest experimental work in this area and
sional sports (Perkes et al., 2004; Robertson et al., 2004; summarized the results of Castex’s work on the effects
Weerapong et al., 2005). of massage on injured muscles. Animal muscles were
The term muscle tone is often used to describe the subjected to crushing injury; then massage was given to
quality of a muscle that is firm and ready to contract; one group and another group was used as a control. The
however, muscles at rest show no electromyographic activity researcher later microscopically examined the muscle tissue
(Goodgold & Erberstein, 1983). Therefore a muscle that of both groups. The untreated parts showed the following
exhibits tone cannot be at rest; it must be in a state of con- characteristics: (1) dissociation into fibrils of the muscle
traction. Although some statements in the literature imply fibers, as shown by well-marked longitudinal striation; (2)
that massage increases muscle tone, evidence to support this hyperplasia (often simple thickening) of the connective
claim is inconclusive at best. Theoretically, however, several tissue; (3) an increased number of nuclei in the connective
massage strokes would be expected to increase the fusimo- tissue; (4) interstitial hemorrhages; (5) an enlargement of
tor drive to a muscle. For example, any of the percussion blood vessels, with hyperplasia of their adventitious coats;
(tapotement) strokes (hacking, clapping, beating, and pound- and (6) usually intact sarcolemma (but, in one section, mul-
ing) would be expected to increase muscle spindle firing tiplication of nuclei gave an appearance that somewhat
and, therefore, fusimotor output. Indeed, this is the mecha- resembled interstitial myositis). In contrast, the massaged
nism by which massage strokes facilitate muscle contrac- limbs had the following features: (1) normal-looking muscle,
tion. It amounts to direct stimulation of stretch reflexes (2) no secondary fibrous bands separating the muscle fibers,
within the stimulated muscle. (3) no fibrous thickening around the vessels, (4) greater
Deep massage to normal muscle tissue will obviously general muscle bulk, and (5) no signs of hemorrhage.
have a strong mechanical mobilizing effect on the physical Denervated Muscle
structure of the tissue itself. The mechanical effects (stretch- Although massage has been used quite extensively for the
ing, twisting, pressing, etc.) are likely to trigger physiologi- treatment of a muscle that has lost its nerve supply (dener-
cal changes, especially in the series and parallel elastic vated muscle), there is little information in the literature
components, effectively making it possible for the muscle to on its effectiveness. Some studies have been performed,
lengthen over time. The effect of stretching on human however, mainly in an effort to determine its effect on the
muscles is a complex issue, but the biophysics have impor- histopathological changes in the muscle itself, on atrophy,
tant implications for soft tissue massage techniques and the and on the strength of the muscle. No firm conclusions can
use of passive stretching movements (De Deyne, 2001; yet be drawn from these results.
Magnusson, 1998), especially in the sports sciences Chor et al. (1939) conducted an experiment to study the
(Hemmings et al., 2000). effects of massage on atrophy and the histopathological
changes that occur in denervated muscle in primates. Two
Pathologic Conditions of Muscle groups of rhesus monkeys were subjected to unilateral
Fibrosis tends to occur in muscles that have been immobi- section of the sciatic nerve; the researchers then immedi-
lized, injured, or lost their nerve supply. Significant shorten- ately sutured the nerves and immobilized the extremity in
ing ofthe parallel and series elastic components (contracture) a plaster cast. After 4 weeks, they applied massage (stroking
is often the end result. The muscle as a whole becomes and kneading) and passive motion daily for 7 minutes to one
shorter than its normal resting length, mainly because the group while keeping the control group at complete rest.
fibrous tissue lacks elasticity and adhesions form between After intervals from 2 months for some animals to 6 months
adjacent layers of connective tissue. for others, the researchers examined the muscles micro-
With the careful use of various massage techniques, it is scopically to determine the histopathological changes. The
possible to apply tension on this fibrous tissue, the objective muscles kept at rest were pale and surrounded by thickened
being to prevent adhesions from forming and to break down septa of fibrous tissue with whitish and yellowish streaks
small adhesions that have already formed. The techniques throughout. Microscopically, this fibrosis was clearly
best suited to this purpose are various pressure manipula- demonstrable, both surrounding muscle fibers and replacing
atrophic ones. The massaged muscles were supple and
tions (pétrissage) and the deep transverse friction technique
elastic and showed considerably less fibrosis and adhesions.
(Iwatsuki et al., 2001). When supplemented by appropriate
The extent to which muscle function is restored after
exercise and stretching regimens, massage techniques are
eased cite PART ONE GENERAL PRINCIPLES

iiiaabiscc
reinnervation is determined largely by the ratio of function- of the muscles differed considerably in 17 of the muscles
ing muscle fibers to fibrous tissue that has replaced degener- tested.
ated muscle fibers. To some extent, by preventing the Hartman and Blatz (1920) later tested the power of dener-
formation of inelastic fibrous tissue and adhesions, massage vated gastrocnemius muscles of 60 rabbits. The muscles on
helped maintain a favorable ratio for greater recovery of one side were massaged for periods of 2 to 20 minutes daily,
function. This would be particularly important in terms of and both legs were given daily passive movement. The
the overall length of a muscle, because this is a key factor investigators tested the muscles at intervals of 10 to 14 days.
in preserving the normal range of motion at any joint associ- They concluded (1) that “the treated limb on the whole did
ated with the muscle. not appear to be any better off than the control”; (2) that
In an earlier study, Chor and Dolkart (1936) compared massage was of no value; and (3) that there was invariably
muscle atrophy resulting from either disuse or denervation. a decrease in power and no significant difference between
They observed that disuse atrophy in a skeletal muscle treated muscles and controls.
develops slowly and is associated with simple structural Wright (1939) stated that more rigorous proof was
changes. The loss of muscle bulk was attributed to a dimin- required for the claims that muscle wasting can be prevented
ished quantity of sarcoplasm in the individual muscle fibers, or muscle nutrition improved by providing massage but not
the atrophic muscle fibers being narrower and packed closer movement. He believed that some local effects are undoubt-
together. The characteristic cross-striations persist, with no edly produced in the muscle and that they may be due to
actual degeneration of the muscle fibers. The intramuscular chemical agents liberated into the blood to produce local or
blood vessels remain unaltered. general effects. He also believed that massage might release
The muscle atrophy that follows nerve section or lesions some of the metabolites of muscle activity. He questioned
of the anterior horn cells (e.g., poliomyelitis) is more than whether direct mechanical stimulation could produce a
wasting from disuse. Its course is rapid, and characteristic direct muscle response in denervated muscle as reflex reac-
changes occur. In addition to the shrinkage of the muscle tions are obviously excluded.
fibers, degeneration of these cells follows. The cross- Suskind and colleagues (1946) studied the denervated
striations disappear, and the muscle cells begin to break gastrocnemius muscles of cats. Two 5-minute periods of
down. In later stages, the disintegrated muscle cells are effleurage and kneading were given daily to one limb; the
replaced by fibrous tissue and fat. Changes also occur in the other limb served as the control. The investigators measured
intramuscular blood vessels. The number of capillaries the strength and weight of the muscles 28 days after section-
increases, and the small intramuscular blood vessels show ing. Results showed that the denervated muscles treated with
hypertrophy of the endothelium and an increase in their massage were heavier and stronger than their untreated
fibrous structure. Chor and coworkers believed that atrophy contralateral controls. The effect on muscle weight was
and degeneration of denervated skeletal muscle are inevita- slight but statistically significant. It seemed that massage
ble and then showed that massage did not prevent atrophy had slowed down the gradual loss of contractile strength
up to a period of 6 weeks, but because of its effect on the observed in skeletal muscle after denervation.
amount of fibrous tissue formed, it did enable the muscles Wood and associates (1948) reported the effects of
to return to normal more rapidly upon reinnervation. massage on weights and tensions of the anterior tibial
In an early study, Langley and Hashimoto (1918) consid- muscles of 14 dogs. Bilateral section of sciatic nerves was
ered the effects of massage in denervated muscles from a performed, and one leg was given a daily period of massage
single rabbit. Firm massage was begun on the third postop- (stroking and kneading) lasting for 10 minutes. The other
erative day. Treatment was discontinued on the seventh day leg was used as the control. The researchers tested the
because open lesions developed on the limb. Treatment was muscles at intervals from 13% to 36 weeks following dener-
started again on the eleventh day with “gentler” massage, vation. Results showed that all anterior tibial muscles in the
which was continued until 23 days after denervation. The treated animals appeared pale and small in size, compared
researchers concluded that the effect of the treatment on with normal anterior tibial muscles. There was also a greater
atrophy was slight at best and that an increase in the growth proportion of tendon to total bulk than in normal muscles,
of connective tissue is a possible result of massaging dener- as well as a greater proportion of fatty tissue. It was impos-
vated muscle. Although interesting in itself, this study offers sible to distinguish treated tissue from untreated muscle on
limited possible conclusions. gross examination. Histological sections from anterior tibial
Hartman and colleagues (1919) tested both weight and muscles of treated animals (treated and untreated muscles)
work capacity of denervated muscles in 37 rabbits. One leg showed no significant histological differences. Wood con-
of the animals was given kneading and stroking massage. cluded, “Massage was not effective in delaying denervation
Both legs were given passive exercise. Treatment continued atrophy, as indicated by losses in strength and weight and
for periods of 7 to 190 days. The investigators noted no sig- by examination of histological sections in experimentally
nificant differences. They suggested that the weight of the denervated anterior tibial muscles of the dog.”
muscle did not necessarily indicate the amount of contrac- The primary effects of massage on muscle tissue can be
tile tissue present, because structural mass and function summarized as follows:
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5

* Massage does not directly increase the strength of bone repair after fracture, “The effectiveness and rapidity
normal muscle; however, as a means to an end it is more of growth of tissue are dependent upon efficient circulation
effective than rest in promoting recovery from fatigue in the parts... . Therefore every effort must be made from
produced by excessive exercise. Theoretically, then, the beginning to help the efficiency of the circulation.”
massage makes it possible to do more exercise, which, Mock (1945) believed that because recent research had
in turn, increases muscular strength and endurance. This shown the tendency for callus to be formed along the lines
is an important factor in treatment. It would seem of the new blood vessels formed at the site of fractures, any
logical that massage should be given between periods treatment that enhanced circulation in the area of the frac-
of exercise when exercise is used to develop muscle ture without producing motion of the fragments should
strength and endurance. This is particularly relevant for promote deposition of callus. Of course, this may be difficult
sports medicine. with many of the deeper massage strokes, the objective of
Generally speaking, massage does not increase muscle which is to deliberately squeeze and stretch the deeper
tone, but certain strokes can be used to facilitate muscle muscle tissues. It is hard to see how these techniques can be
activity (especially percussion techniques; see Chapter given effectively without causing the bone fragments at a
9) that inevitably develops in immobilized, injured, or fracture site to move; however, if the fracture site is stable,
denervated muscle. massage techniques might be very useful.
¢ Massage may reduce the amount of fibrosis. Many of the structures that surround the various joints
Massage does not prevent atrophy in denervated muscle. ofthe body, such as ligaments, bursas, capsules, and tendons,
Even though a muscle may undergo considerable are often the site of chronic problems. In many instances of
wasting, if fibrosis is minimal and circulation and chronic dysfunction, the goal of treatment is to break down
nutrition are good, a small muscle may have greater scar tissue in these structures and the adhesions between
power than a muscle with larger mass if the mass is the them. Traditionally, deep friction massage has been the
result of overgrowth of fibrous tissue that interferes with technique of choice because its strong mechanical effect on
the function and recovery of the remaining innervated scar tissue is useful in restoring a normal, painless range of
muscle fibers. motion to an affected joint (Cyriax, 1960, 1984; Hammer,
* The aims of massage in the treatment of denervated 1993). (See also Chapter 9.)
muscle should be to maintain the muscles in the best Clearly, joints are designed to move under the influence
possible state of nutrition, flexibility, and vitality, so that of muscles and gravity, and there are many reasons why
after recovery (if this is possible) from trauma or range of motion in a joint may be lost. Of course, continued
disease, the muscle can function at its maximal loss of range in a joint contributes to chronic pain and adhe-
potential. sion, with the accompanying loss of function. Impaired
range of motion can be restored to joints using a wide
Effects on Bones and Joints variety of treatments, including massage. This is particu-
Key and colleagues (1934a, 1934b) conducted an experi- larly the case if the limited range is due to muscle spasm,
ment to determine the effects of heat, massage, or active pain, or contracture in the tissues surrounding the joint.
exercise on local atrophy of the bone caused by immobiliza- Appropriate massage techniques can help to relieve pain and
tion of the part. Ten patients with normal lower extremities restore range of motion in these circumstances (Hernandez-
were used. Both extremities were placed in casts, which Reif et al., 2001).
were bivalved and removed during treatment. One extremity
was used as a control; the other was treated. The massage Effects on the Nervous System
was given for 10 minutes, twice daily for 6 weeks. Roent- Although the literature offers little direct information on the
genograms were made before and at the end of the experi- actual effects of massage on the function of the human
ment. The investigators observed no significant differences nervous system, the mechanical effects of massage clearly
between the treated and control limbs. They concluded that give rise to a number of important physiological effects.
short periods of heat (five patients), massage (two patients), Indeed, massage techniques specifically directed at periph-
or active exercise (three patients) had little, if any, effect on eral nerves were in common use in the early decades of the
local atrophy of bone secondary to immobilization in a twentieth century. In her book Massage and Medical Gym-
plaster of Paris cast. These results are interesting; however, nastics, Lace (1946) described so-called nerve manipula-
the experiment was performed on very small numbers of tions—such as nerve stroking, nerve pressure with vibration,
subjects and the results are certainly inconclusive. nerve friction, and nerve stretching—as a significant cate-
In the past, massage was used widely in the treatment of gory of strokes. These techniques, though rarely used today,
fractures, and it was considered beneficial for aiding repair are still being given for specific nerve problems (Jabre,
of the associated soft tissue injuries. It has not been estab- 1994).
lished, however, whether massage actually helps to heal Despite a paucity of information, it is possible to describe
bone. It was the opinion of the Fracture Committee of the some likely effects based on what is known of the neurobiol-
American College of Surgeons that, in the process of normal ogy of the nervous system. For example, whenever the skin
siti PART ONE GENERAL PRINCIPLES

is touched or the underlying tissues are manipulated, sensory The work of Barr and Norman (1970) and Barr and
receptors in a variety of tissues are activated. Afferent Taslitz (1970) is an example of the kind of studies that need
signals pass into the spinal cord, form synapses with various to be undertaken for a variety of massage treatments. In
spinal neurons, and eventually find their way to the sensory addition to the effects on blood pressure and heart rate of a
cortex and other brain centers. At a spinal level, several 20-minute back massage, Barr and Taslitz reported (1)
spinal reflexes could be triggered, depending on the type increased skin sweating and, thus, decreased resistance to
and depth of massage technique and the part of the body galvanic current (galvanic skin response, or GSR); (2) after
being massaged. Similar reflex activation is likely at a a slight decrease in body temperature (0 to 0.1°C) in the
variety of autonomic centers and brain nuclei. Some of these control period, an increase of 0° to 0.2°C at the end of the
concepts are discussed in the next section on the effects of massage; and (3) increased pupil diameter, which, in their
massage on pain. Clearly, there are many potential pathways opinion, may or may not have been a result of massage.
by which soft tissue massage might have direct and indirect Their results indicate an increase in sympathetic activity in
effects on the nervous system. most indexes. More recently, massage therapy has been
A number of studies have shown that many direct effects shown to be effective in treating problems associated with
are indeed possible. Clear evidence from several well- chronic neurological disorders, including Parkinson’s
controlled studies shows that massage (kneading) performed disease (Hernandez-Reif et al., 2002) and spinal cord injury
directly on a muscle causes significant depression of the (Diego et al., 2002).
amplitude of the H-reflex (Hoffman reflex) response, but The idea of producing specific effects in the nervous
only during the period of massage (Morelli et al., 1991; system, or indeed in the neural control of many organs and
Sullivan et al., 1991). This effect was also recorded in systems, is not a new one. Traditional acupressure and many
patients with spinal cord injury (Goldberg et al., 1994). In Eastern massage techniques are intended to affect a variety
contrast, Dishman and Bulbulian (2001) compared the effect of nervous system functions (Chen et al., 1998). Examples
of spinal manipulation and massage on motoneuron excit- of this principle can also be found in theories of reflexology,
ability and reported that the effects were transient, but the which hold that direct manual stimulation of various body
effects on the tibial H-reflex produced by spinal manipula- areas (mainly, but not exclusively, the feet and hands) pro-
tion lasted longer than those of massage. duces effects elsewhere in the body, and of the Japanese
Goldberg and colleagues (1992) studied the effect of two system of massage known as shiatsu. The more recent
intensities of massage on H-reflex amplitude and showed development of connective tissue massage (CTM) in the late
that a deeper massage technique produced a more pro- 1930s is another good example of a technique that relies
nounced reduction in H-reflex amplitude than did superficial heavily on reflex effects in the nervous system. All of these
massage. in each of the studies cited here, the inhibitory treatment concepts use the important principle of remote
effect of the massage on H-reflex amplitude effectively site stimulation to achieve their effects. This principle
lasted only during the time when massage was applied. simply means that stimulation in one part of the body can
Some subjects (especially those with spinal cord injury) did produce effects elsewhere. These concepts are discussed in
show a tendency for the inhibitory effect to continue when more detail in Chapters 9, 11, 16, and 17.
the massage had ceased, but it did not last long enough to
be useful therapeutically. These results are also important Effects on Pain
because they indicate that massage of muscle tissue and its Since the very earliest of times, primitive humans probably
related structures (e.g., skin, subcutaneous tissues) can knew that vigorously rubbing an injured area relieved pain.
change the level of excitability of the spinal motor neurons. This behavior is clearly instinctive and is displayed by
The effect is reflex in nature and is likely to be associated humans and many animals. Rubbing the skin stimulates
with increased firing of the pressure-sensitive receptors in cutaneous mechanoreceptors, and these afferent signals are
muscle, especially the Golgi tendon organs, which are able to temporarily block the transmission—and possibly
known to inhibit their relevant alpha motor nerve cells. the perception—of nociceptive (pain) signals. This effect is
Despite promising early experimental studies on reflex easy to demonstrate and is one that most people have expe-
control of circulation and neuromuscular responses to rienced many times. Other modalities, such as mechanical
massage (Cuthbertson, 1933; McMaster, 1937; Pemberton, vibration and electrical stimulation, can stimulate the same
1945) and strong support for hypotheses that massage has cutaneous receptors.
definite reflex effects, such effects seem to be hypothesized Since the mid-1960s, new theories and research on pain
for want of any other rational explanation. The specific and its mechanisms of generation, transmission, perception,
reflex mechanism responsible has not been clearly identi- and treatment have had a significant bearing on the ancient
fied, nor has how simple or complex the reflex action(s) may art of massage (Wall, 1994). This new understanding has
be. Much work still must be done to clarify and verify these revived interest in the use of electrical stimulation (Belamger
concepts by controlled clinical and laboratory studies, cor- 2002; Mannheimer & Lampe, 1984: Robinson & Snyder-
related with current physiological and neurophysiological Mackler, 1995) and many forms of manual mobilizing tech-
concepts. nique (Grieve, 1994),
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5 peer ee
Litt ans
A complex picture has developed that provides a ratio- Interaction of the somatic and the autonomic nervous
nale for intervention in a variety of soft tissue problems, systems and of the musculoskeletal and the visceral systems
including various chronic pain syndromes. The specificity has always been assumed. In recent years, better under-
of nociceptors and mechanoreceptors and their relationship standing has shown that these interrelationships are more
to the transmission and eventual perception of pain have direct and predictable than was previously thought. An
been elucidated, together with the alteration of tonic example of this better understanding can be found in the
levels of muscle activity. Because it is known that manual clinical approach to referred pain. It has long been assumed
stimulation of afferent fibers carrying sensory information that referred pain is only the central interpretation of vis-
can have a significant effect on pain, this constitutes ceral or deep musculoskeletal pain through spinal connec-
strong scientific support for the use of massage as a tions to areas overlying the painful structures or related to
therapeutic measure to relieve pain. Beginning with the them. In this view, permanent relief of this type of pain is
work of Melzack and Wall (1965), the concept of a neural achieved only by removing the original cause. Temporary
gate in the region of the dorsal horn of the spinal cord gray relief usually involves a centrally acting drug that blocks the
matter has been central to intervention or research strategies transmission or perception of pain. It has been demonstrated,
involving pain. Although the original theory has undergone however, that the peripheral pain site may contain reflexes
much review and revision, the central concepts remain that respond to direct peripheral intervention and that this
intact. intervention may even have a positive influence on the
A gate is designed to control movement from one place central cause of pain. This concept is illustrated particularly
to another. When a gate is open, movement through it is well in the trigger points of the myofascial pain syndrome
permitted (possibly in both directions), and when it is closed, (see Chapter 16). In this case, a variety of methods (some
passage is denied. In this regard, the spinal gate is no dif- manual) can be used to desensitize the painful trigger points
ferent. Various cells are able to control the flow of nocicep- (Travell & Simons, 1983, 1992).
tive (pain information) from distal body parts to central sites The effects of massage on the circulation of blood and
in the nervous system. Nociceptive information is transmit- lymph may also contribute to pain relief. Because certain
ted by small-diameter, slowly conducting fibers (A-delta and massage techniques have a significant effect on the circula-
C fibers). The spinal gate may be closed by specific sensory tion, they may be expected to enhance removal from an
impulses from mechanoreceptors (large-diameter fibers) in affected area of pain metabolites (e.g., kinins). This washing-
a variety of structures, but particularly in the skin of the out effect could be a significant contribution to pain relief
affected area. When the gate is closed, nociceptive input 1s achieved with soft tissue massage.
reduced, and this may significantly reduce the level of pain Pain relief can also come from the relaxation effect
the patient perceives. Descending impulses are also able to produced by certain massage techniques (Meek, 1993). If
affect the ability of the spinal gate to open or close. It should muscle spasm is a significant cause ofpain, then reducing the
be remembered that the actual nociceptive signals are not muscle spasm will help to relieve the pain. This effect was
in themselves painful. They are simply nerve impulses trav- well known by Lucas-Championniére, whose technique of
eling in the peripheral and central nervous systems. Only obtaining relaxation of muscles in spasm following a frac-
when these signals reach the higher brain centers are they ture by superficial stroking can be explained only as a reflex
interpreted as painful. effect. The more generalized relaxation that can be achieved
The neurophysiological basis for gate control is a complex with massage may also contribute to pain relief, especially if
and developing model. It involves not only the neural path- such pain is of a central nature. It seems most likely then that
ways of the system but also complex interactions between the pain of neuromusculoskeletal origin is relieved by a
various brain structures and neurotransmitters and_hor- number of mechanisms, depending on the specific pathology
mones (enkephalins and endorphins). The area has been involved. For example, the common label of “low back pain”
reviewed extensively in many texts that deal with different can refer to pain produced from a multitude of reasons.
aspects of the physiology and management of pain. A Massage therapy can be effective in an overall treatment plan
detailed description is well beyond the scope of this text, and probably achieves its effects via a combination of the
and interested readers are referred to Wall (1994) for an mechanisms previously described (Hernandez-Reif et al.,
excellent review of the subject. 2001). Chronic pain of neuromusculoskeletal origin is clearly
Clearly, massage techniques have the capacity to produce relieved by a number of mechanisms, depending on the spe-
significant afferent input by direct stimulation of large- cific pathology involved. For example, the common label of
diameter mechanoreceptors in many structures. Depending “ow back pain” can refer to pain produced from a multitude
on the techniques in question, these structures will be of reasons. Nonetheless, massage has positive effects in
mainly in the skin or in the skin and the deeper tissues. In relieving chronic pain (Walach et al., 2003), the serious dys-
either case, activation of the spinal gating mechanism, function of fibromyalgia (Field et al., 2003; Lemstra &
descending pain suppression influences, and release of Olszynski, 2005), mechanical neck pain (Haraldsson, 2005),
endogenous opiates are reasonable explanations for pain subacute low-back pain (Preyde 2000), and in reducing the
relief produced by massage techniques. many symptoms of migraine (Lemstra et al., 2002). Other
 PART ONE GENERAL PRINCIPLES

studies have considered the effects of massage on experi- nal organs (e.g., prostate), the effects probably reflect a reflex
mental pain (Kessler et al., 2006) and the effectiveness, reaction to mechanical stimulation. He said that it may be
safety, and cost of massage therapy compared with acupunc- possible also to produce reflex contraction of smooth muscle
ture and spinal manipulation for back pain (Cherkin et al., of the spleen, but physiologically it is difficult to explain any
2003). Very recently, Lewis and Johnson (2006) undertook beneficial effect. To expect any benefit from “shaking up the
a systematic review of the effectiveness of therapeutic liver,” as earlier writers had recommended, was quite wrong,
massage on musculoskeletal pain. The review reports equi- according to Mennell, though abdominal massage may stim-
vocal findings that highlight the need for more rigorously ulate portal circulation and, thus, liver functions.
controlled clinical trials. Some of the earlier writers have suggested massage treat-
ment of the pancreas. Mennell thought it might be affected
Effects on the Viscera
reflexly, but it seems likely that this is only an indirect effect
Abdominal Viscera of improved general vascular tone. Being a hollow organ,
Until quite recently, there was little published information the gallbladder is, according to Mennell, amenable to the
on the effects of massage on the abdominal viscera. Mennell mechanical effects of massage. Because current knowledge
(1945) believed that the forceful abdominal massage once of the effects of massage on the abdominal viscera is limited,
used primarily for its mechanical effects derived from a it would seem unwise to perform any type of abdominal
poor understanding ofthe gut. He pointed out that the slight- massage except to affect abdominal muscles—and possibly
est tap on the exposed intestine of a frog causes instant indirectly to influence the circulation and, through reflex
spasm of that portion plus cardiac inhibition, and that the response to pressure, to stimulate activity of the involuntary
effect of manipulation on involuntary muscle of the intes- muscles of the intestines.
tines can be observed during abdominal surgery. Exces- Special techniques are required to massage specific
sive handling may result in overstimulation and temporary organs, and they should only be applied by those specially
paralysis of the involuntary (smooth) muscle. This might pro- trained in these techniques. (Because of the harm that can
duce the opposite effect, namely, inhibition of normal bowel result from abdominal massage, it should not be included in
function rather than stimulation. a general massage without prior medical consultation.)
Mennell believed that it was impossible to empty the Mennell questioned the use of massage for the kidneys.
small intestine mechanically. He believed that any action of Although he noted that by kneading the kidneys during
massage on the intestines is almost, if not entirely, a reflex- cystoscopy it 1s possible to see urine pass from the ureter
ive response to the pressure of mechanical stimulation. This into the bladder, he doubted that this is clinically practical.
stimulation can increase peristalsis and thus hasten the emp- More recently, mechanical vibration massage has been
tying of the intestinal contents. He pointed out that some shown to be helpful in assisting patients to pass stone frag-
portions of the large intestine are quite constant in their ments following extracorporeal shockwave lithotripsy
relationship to the abdominal wall, and thus the direction of (Kosar et al., 1999).
the passage of the contents in the duodenum, the ascending
and descending colon, and the iliac portions of the colon Effects on Other Viscera
can be followed. The heart and lungs are organs that can be affected by massage
Beard and Wood were convinced that massage of the delivered to the thorax. Although massage is not applied
abdomen with kneading and deep stroking (see Chapter 9) directly to the heart except under special circumstances,
is effective in stimulating peristalsis to promote evacuation massage can have an effect on cardiac function, especially to
of flatus and feces from the large intestine. The patient can slow it down and promote relaxation (Diego et al., 2004).
be taught these procedures, which may be performed while Direct massage of the heart is used as an emergency treatment
seated. The contents of the abdomen, with the exception of in certain circumstances. When an abdominal incision has
the duodenum and fixed portions of the colon, may easily been made, the surgeon may massage the heart, either by
be displaced or glide away from any pressure exerted on the compressing it between the diaphragm and the ribs or by incis-
abdominal wall, making it impossible to exert any mechani- ing the diaphragm and directly grasping the heart. Mennell
cal effect of massage. knew of no direct action on the heart that could be achieved
Klauser and coworkers (1992) conducted a well-controlled by externally applied massage movements other than the
study of the effects of abdominal wall massage on colon func- obvious mechanical compression. Indeed, Kouwenhoven and
tion in both normal subjects and patients with chronic consti- associates (1960) reported a 70% long-term survival rate for
pation. This study showed no significant differences in colon patients with cardiac arrest who were given closed-chest
function in the two groups, and despite anecdotal reports cardiac massage (see the appendix). The specific effects of
from earlier writers, the results place in doubt the efficacy of massage on the lungs are considered in the next section.
such massage for the treatment of chronic constipation. Other Some forms of massage might be expected to affect
authors (Emly, 1993) have drawn similar conclusions about various organs of the body by virtue of their reflex effects.
the effects of abdominal wall massage. Connective tissue massage is an obvious example: stimula-
Mennell believed that, though it may be possible to tion of specific areas on the posterior trunk region is expected
produce a mechanical effect with massage to some abdomi- to produce effects on a variety of organs and structures
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5 iccmniis
gare i

elsewhere in the body, especially the major organs. This chological effects, so it is not difficult to see that this might
concept relies on evoking an autonomic reflex by stimulat- produce an effect on immune system function. In fact, the
ing cutaneous afferents reflexly related to specific organs effect of massage on immune system function has been
and structures (see Chapter 11). studied with varying results. Some studies, such as that
Another example of the potential for massage techniques conducted by Birk et al. (2000), show no significant effect
to reflexly affect the various organs of the body is expressed on immune system function in patients with HIV, although
in the treatment concept of acupressure (see Chapter 17). In Birk et al. did report that massage helped to minimize
this case, finger or thumb pressure applied to specific points stress and improve overall function. In contrast, Diego et al.
on the body is designed to produce reflex effects in various (2001) reported that adolescents with HIV responded well
organs and systems. This is yet another excellent example and showed improved immune function after massage
of the principle of a remote site effect, in which stimulation therapy.
at one part of the body produces an effect elsewhere, even Massage therapy seems to be helpful in improving
in an apparently unrelated area. immune system function in patients undergoing treatment
for various cancers, such as leukemia (Field et al., 2001) and
Effects on the Lungs breast cancer, where they show an increased immune and
Percussive and vibratory massage techniques can be used in neuroendocrine function as a result of massage therapy
combination with other measures of chest physical therapy (Hernandez-Reif et al., 2004). Massage also has a positive
to prevent or treat acute and chronic lung conditions. The effect on immune system function following — sport
few controlled studies on the effects of chest physical therapy (Hemmings, 2000).
do not separate the effects of the various measures; however, Positive effects on immune system function are also seen
many clinicians stress the importance of these types of with massage given during academic stress (e.g., taking a
massage techniques in the treatment of conditions such as test) (Zeitlin et al., 2000). Because massage 1s known to
emphysema, cystic fibrosis, bronchiectasis, asthma, atelec- relieve anxiety, it is not surprising that it might have positive
tasis, and pneumonia. effects on immune system function as there is a clear link
Cyriax (1960, 1984) stated that percussive techniques, between its overall strength and the effects of stress. Not
combined with postural drainage, can dislodge mucus and surprisingly then, massage can be an effective adjunct to the
mucopurulent material from the bronchi and that gravity treatment of various psychiatric disorders where anxiety and
and vibration help to move the secretions from the insensi- stress are significant issues (Field et al., 1992), particularly
tive periphery of the lungs to the area where the cough reflex when they lead to depression or compulsive behaviors such
is elicited. Such measures have been advocated in standard as bulimia (Field et al., 1998).
texts for many years. For example, Bendixen et al. (1965)
recommended vibration and percussion with cupped hands Effects on the Skin
(clapping) to shake loose secretions. Percussion is used in The direct effects of massage on the skin are difficult to
cases of “sticky, thick secretions that defy normal coughing evaluate because there are few studies in this area. Tradi-
efforts.’ Likewise, Cherniack, Cherniack, and Naimark tionally, however, the earlier writers proposed that massage
(1972) believed that the role of physical therapy in the care had a direct effect on the superficial layers of the epidermis
of patients with acute respiratory failure could not be over- that freed the openings of the sebaceous and sweat glands.
emphasized. They advocated that while postural drainage is The mechanism was improved circulation, which directly
being performed to stimulate removal of secretions, “the improved the function of these glands (Krusen, 1941). Other
chest should be pummeled with rapid repetitive strokes and early writers thought that sweating did not significantly
vibrated” by the therapist, and that the patient should fre- increase but that sebaceous secretions might be expressed
quently cough and expectorate the loosened secretions. (Wright, 1939). According to Rosenthal (cited in Cuthbert-
These techniques are also important in the prevention and son [1933]), massage increases the temperature of the skin
treatment of recurrent respiratory tract infection in children by 2° to 3°C. He found that neurasthenic persons showed a
(Zhu, 1998) and in other pulmonary issues in critical care greater increase in skin temperature than normal healthy
and chronic lung disease (Jones & Rowe, 2000; McCarren persons in response to massage, and women showed a
et al., 2003, 2006). greater increase than men. He explained the differences by
Current texts on the topic (Frownfelter & Dean, 2006; the fact that the entire nervous system, including the vaso-
Hillegass & Sadowsky, 1994; Irwin & Techlin, 1995; motor nerves, is stimulated more easily in neurasthenic
Watchie, 1995) continue to stress the importance of proper persons than in normal ones and in women more than in
airway clearance and the need to teach the patient to use men. The increase in skin temperature may be caused by
simple but effective home treatment techniques. For a more direct mechanical effects (friction) and indirect vasomotor
complete discussion of these issues, see Chapter 10. action.
In contrast, Severini and Venerando (1967) reported
Effects on the Immune System that both superficial and deep massage led to a significant
In addition to the direct mechanical effects described earlier, drop in skin temperature at the site of application. Barr and
massage therapy can have powerful physiological and psy- Taslitz (1970) observed increased sweating and decreased
eee ee PART ONE GENERAL PRINCIPLES

ee eee
skin resistance to galvanic current in response to massage. The primary effects of massage depend on the individual
They found much variation in skin temperature changes stroke. Therefore the primary effects are listed separately
in both control and treatment periods and felt they could for each of the major types of massage stroke (see Chapter
not infer that massage either increased or decreased skin 4 for details of each individual stroke).
temperature.
Clinical observation shows that, following massage to a
part that has been in a cast for some weeks, definite improve- Effect on Cellulite
ments in the texture and appearance of the skin can be The concept of cellulite is a controversial issue, but it is one
noted. If the skin has become adherent to underlying tissues that deserves a degree of examination. Cellulite is not a
and scar tissue has formed, friction movements and tension medical term, but it is in widespread use and is the source
can be used to loosen the adherent tissues mechanically and of much confusion. Many people have the mistaken belief
to soften the scar. Massage techniques can also be helpful that cellulite is the same as normal adipose (fat) tissue. This
in the management of hypertrophic scars (Patino et al., is certainly not the case. Cellulite is the name given to
1999): describe the lumpy, irregular fatty deposits that appear as
Bodian (1969) recommended massage to enhance the dimpled skin around the hips, buttocks, and thighs, giving
cosmetic results of eyelid surgery. The mechanism of the rise to the characteristic orange-peel appearance. Cellulite
method he described “seems to be stretching and disrup- is almost exclusively a female problem and is widespread.
tion of excess scar tissue.” He found this massage useful in It is difficult to find a generally accepted scientific descrip-
treating thick scars of the eyelid, keloids, overcorrected tion of exactly what cellulite is. It seems to be the result of
ptosis, overcorrected entropion, postoperative ectropion, the collapse of the connective tissue nef that supports the
and shallow fornices. As expected, the mechanical effects layer of subcutaneous fat cells in certain areas of the female
of massage tend to mobilize the skin and subcutaneous anatomy. There may also be some local changes in the fat
tissue, leaving it more pliable. cells, although this is not substantiated. The situation is
Because the skin is the organ that first comes into direct worsened if the individual 1s overweight, because there will
contact with the therapist’s hands, it is not unreasonable to be an extra accumulation of fat in the same areas that are
expect that massage would have at least some effects on prone to cellulite formation.
skin. These effects can be helpful or harmful. For example, Beneath the skin is a layer of fat that varies in thickness,
if too much powder or oil is used on the skin, it is likely that depending on many factors. Fat cells in the human are
the skin surface will become clogged with the residue of the spherical in appearance and are held in position in an orderly
lubricant. This might easily lead to rashes and possible arrangement, supported by a net of connective tissue. When
infections, especially in a patient with sensitive skin. the tissues are young, the skin usually appears smooth,
supple, and elastic. For many reasons, the connective tissue
net begins to degenerate and collapse in certain areas and
Effects on Adipose (Fat) Tissue is unable to support the fat cells in a smooth layer. These
Many have claimed over the years that massage removes changes can occur in the teenage years, but the layer of fat
deposits of adipose tissue (stored body fat). Krusen (1941) is usually less visible then because the skin is still supple
asserted that clinical observations did not support this theory and elastic. However, the condition can become more prob-
and that attempts to reduce local fat deposits are futile. lematic as one ages or if one is overweight, and this fat tends
Rosenthal (cited in Cuthbertson [1933]) investigated this to accumulate around the hips, buttocks, and thighs.
problem experimentally. Vigorous massage was applied to The issue of whether massage can reduce the effects of
certain areas of the abdominal wall of animals. Microscopic cellulite has led to many claims, some reasonable, some
studies of the massaged and untreated areas showed no fanciful, and others definitely misleading. Numerous treat-
change in the fat in treated areas, even when the massage ments for cellulite have come on the market, most with
had been forceful enough to cause frequent small hemor- many unsubstantiated claims. In recent years, a technique
rhages. Wright (1939) and Kalb (1944) came to similar has emerged that seems to be effective for some cases,
conclusions. although only on a temporary basis. This treatment involves
At the present time, there is no credible evidence to a mechanically induced, deep massage that resembles the
support the contention that massage has any ability to reduce manual stroke of skin rolling. These devices create a suction
stored body fat. Subcutaneous body fat represents the body’s effect that pulls a roll of tissue up from the underlying
attempt to store energy (metabolic fuel), and the only known structures, and then powered rollers enhance the lifting and
way to reduce this fat is to use it. This means it is necessary rolling motion as the device is moved forward and backward
to metabolize the stored energy, and the most reliable way across the skin and subcutaneous tissues. The concept is
to do this is with a program of active exercise. Because soft called endermologie (Figure 5-1). This technique does not
tissue massage is a passive treatment, it is intuitively unrea- break down the fat cells; rather, over time it might improve
sonable to expect that it can have any effect in reducing the the connective tissue support system under the skin (net).
total percentage of body fat. The end result is a smoother-looking skin contour.
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5

Low pressure
suction
Bey, Psychological Effects of Soft Tissue
BOX 5-3 Manipulation 2 hae
Physical relaxation
Relief of anxiety and tension (stress)
Back and forth Stimulation of physical activity
movement Pain relief |
across the skin
General feeling of well-being (wellness) |
Sexual arousal |
Roller General faith in the laying on of hands
J

<— Muscle
er eee eee eee eee eee ae, thought too trivial to report to a physician. In this situation,
of course, the therapist listens and holds any information in
Figure 5-41 Endermologie: A Mechanical confidence. The therapist is careful to see that the patient
Cellulite Treatment Concept does not become too dependent in the relationship and
The device imparts suction to the skin and subcutaneous tissues, encourages him or her to report relevant information to a
lifting them up from their underlying support structures. The fold of physician.
tissues is then rolled through the machine, producing a strong Massage treatment can have negative psychological
mechanical stimulation to the tissues. The treatment is known as
effects. The time and attention devoted to massage may
endermologie.
exaggerate the seriousness of the disability in the patient’s
mind. Mennell (1945) warned, “It is easier to rub a disability
into a patient’s mind than it is to rub it out of his limb.”
Several groups have studied the effects of the form of Therapists must therefore take care to reassure the anxious
deep mechanical massage known as endermologie, in both patient and to correct any misunderstandings about the
animal models and human subjects, with varying results reasons for treatment.
(Barel et al., 1997; Kinney et al., 1999; Lucassen et al., 1997; Many of the physiological effects of massage described
Pittet et al., 1999). Adcock et al. (2001), using a porcine earlier have a significant psychological component. For
model, showed that the treatment produced dense, longitu- example, pain relief has a dominant psychological compo-
dinal collagen bands in the middle dermal and deep subder- nent because it is strongly dependent on the patient’s percep-
mal regions, together with distortion and disruption of tion. In this way, pain relief is a legitimate psychological
adipocytes. These changes progressively increased with the effect of massage. Each of the major psychological effects
number of treatments. The authors also studied the effect of of massage is listed in Box 5-3 and discussed in the sections
applying the device to the tissues in various ways and on the that follow.
forces generated within the tissues. This led to the conclu-
sion that “deep mechanical massage is highly dependent on Relief of Anxiety and Tension
the individual operator of the device.” The demand for an (Stress) and the Promotion of
effective treatment of cellulite is fueling tremendous interest Physical Relaxation
in both the medical and cosmetic professions. The problem The relaxing and sedating effect of a general massage is well
of cellulite is certainly a real one; however, the solutions at known and easily demonstrated. Mennell (1945) stated,
present are inconclusive and some are definitely controver- “There is probably an effect on the central nervous system
sial. Various forms of massage, both manual and mechani- as well as a local effect on the sensory, and possibly the
cal, may prove to be effective treatments, but more research motor, nerves.” Most people find that massage treatments
is needed in this interesting area. are extremely relaxing. Certain strokes 1n particular promote
physical relaxation; however, the concept of relaxation is not
principally a physical one. It is just as much psychological
PSYCHOLOGICAL EFFECTS as physiological. For muscles to relax, especially in an entire
Most people are familiar with the soothing effect of gentle limb or the whole body, the person must be able to mini-
massage, even when no lesion or physical disability is mize the cortical drive passing to the relevant spinal motor
present (defined earlier as recreational massage). In thera- neurons. This requires a conscious effort to let go. The
peutic massage, the therapist’s concentrated attention to the reason some people find it difficult to relax their limbs might
patient, combined with the pleasant physical sensations of well be their inability to let everything go at the psychologi-
the massage, often establishes a close and trusting bond. In cal level. Suitable massage techniques can contribute to this
these circumstances, patients may reveal to the therapist process, as they help the patient let his or her muscles and
problems, worries, and facts about their health that they had limbs relax.
 PART ONE GENERAL PRINCIPLES

ahs tice
Relief of anxiety and tension (stress) through massage is to the fact that the patient is being touched by a caregiver.
strongly linked to the promotion of relaxation identified This is one reason why massage treatments can be so helpful
previously. A patient who has significant anxiety and tension for terminally ill patients who suffer significant pain.
(stress) will find it hard, if not impossible, to relax. As In recent decades, nonpharmacological methods have
massage promotes relaxation, it also helps to reduce anxiety become popular among nurses for the relief of pain in
and tension. This is because relaxation requires psychologi- terminally ill patients (Degner & Barkwell, 1991; Mobily
cal release from anxiety and tension. This is one of the main et al., 1994; Weinrich & Weinrich, 1990). A relatively new
reasons why recreational massage is so popular as part of a concept, known as therapeutic touch, has developed from
stress-reduction program. The relaxing and anxiety-reduc- this pursuit. The concept of therapeutic touch holds that pain
ing effects of massage have been investigated in many dif- relief can be achieved without actually touching the patient
ferent types of study, especially for the anxiety suffered in (Heidt, 1991; Ireland & Olson, 2000; Krieger, 1979, 1981;
terminal illness from cancer (Avakyan, 1990; Boone et al., Owens & Ehrenreich, 1991). Technically, such techniques
2001; Hernandez-Reif et al., 1999; Holland & Pokorny, are not massage because they do not produce mechanical
2001; Labyak & Metzger, 1997; Longworth, 1982; Meek, effects in the tissues. Their effectiveness must therefore be
1993; Rowe & Alfred, 1999; van der Riet, 1993). attributed to other (as yet undefined) mechanisms, but it
Massage is also gaining popularity as an adjunctive treat- cannot include activation of peripheral nerves if touching
ment for the patient undergoing stressful medical proce- does not occur.
dures, such as those used in the critical care unit. In these
cases, massage may be given to the foot or hand and is used
Sexual Arousal
to comfort the patient and to reduce the pain and anxiety
Massage techniques have been used for countless centuries
concerning the procedure (Hayes & Cox, 1999; Hulme
as a means of stimulating sexual arousal. There is, in fact,
et al., 1999; Kim et al., 2001; Richards et al., 2000). Massage
little difference in the actual massage strokes involved. The
also helps to reduce the anxiety, stress, and pain associated
major difference, however, lies in the specific areas of the
with the treatment of burns, especially in children (Field
body that are massaged. Stimulation of the skin of a number
et al., 1998, 2000; Hernandez-Reif et al., 2001). Massage
of body areas (the so-called erogenous zones) can produce
treatments also seem to help relieve the pain and anxiety
sexual arousal. These include all genital areas, the buttocks,
of premenstrual tension (Hernandez-Reif et al., 2000),
the insides of the upper thighs, the breasts, the neck, and
and they promote sleep and relaxation in the critically ill
many areas of the face. Stimulation of any of these areas
(Richards, 1998). In addition, massage may be helpful in
occupational situations as a means of relieving stress and has the potential to produce strong sexual arousal, espe-
cially if that is the intention of both parties.
anxiety in the workplace (Katz et al., 1999). The beneficial
effects of massage in relieving stress and anxiety are perhaps Sexual arousal is not a simple reflex matter that requires
the reason why recreational massage is so popular in the only sufficient stimulation of certain body areas. It is as
much a psychological process as it is physical: sexual arousal
present day and why massage has endured the test of time
occurs in the mind as well as the body. Peripheral stimula-
as a worthy procedure.
tion certainly helps, but the entire process is not a simple
Stimulation of Physical Activity reflex action. Sexual arousal is not a treatment goal of tra-
ditional therapeutic massage, of the type used in rehabilita-
Certain massage techniques can be stimulating and produce
tion, and for this reason the erogenous zones should be
a strong sense of invigoration. These techniques have proved
carefully avoided unless there is an overriding necessity to
useful in the sporting world and have given rise to the
treat the area. Although the erogenous zones are particularly
concept of sports massage, which simply reflects the notion
sensitive areas, massage to any part of the body can cause
of using certain massage techniques to promote physical
activity and optimal performance. A strong psychological
sexual arousal in a patient if that is the intention of the
impact often results from the application of suitable massage
patient or the therapist. This is a delicate matter and high-
techniques (see Chapter 13).
lights the importance of high ethical standards of practice
for the therapist. If it seems that the patient is exhibiting
Relief of Pain unwanted responses, treatment should be terminated
The physiological processes involved in pain relief through immediately.
massage were discussed previously; however, the perception
of pain is, of course, a psychological concept. It has impor- A General Feeling of
tant physiological substrates, but a conscious mind is Well-Being (Wellness)
required for the awareness of pain. Thus pain relief achieved There is little doubt that massage treatment is, by and large,
with massage is as much a psychological effect as it is a a pleasant form of therapy. The general state of relaxation
mechanical and physiological one. It is quite possible that and stress relief, possibly coupled with pain reduction,
massage can have direct physiological effects, simply related induces a feeling of well-being in the patient. This feeling
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5

might also be linked to the liberation of endogenous opiates Although some of these effects are common to all massage
or some other substances as yet unidentified. At the very strokes, each technique has its own particular list of effects.
least, massage is a significant way of achieving a sense of The principal effects of each of the strokes described in
wellness, and this may account, in part, for the popularity Chapter 4 are combined into a single comprehensive list in
of recreational massage around the world. Box 5-4. This list indicates the effects associated with all
of the techniques described in Chapter 4, under the headings
A General Faith in the “Laying/on for each individual stroke.
of Hands”
Many ancient cultures have a healing tradition in which a
“healer” places his or her hands on, or close to, the affected THERAPEUTIC USES OF MASSAGE
area and a belief system that some kind of healing force is
The therapeutic uses of massage are based on the primary
transferred to the tissues. This rather old idea has gained effects (mechanical, physiological, and psychological)
renewed interest, especially among nurses who call it thera- that were described earlier in the chapter. Although some
peutic touch. It is used widely for chronic pain management of these uses are common to all massage strokes, each
(see the earlier discussion). technique has its own particular list of therapeutic uses.
The idea that healing might be facilitated by the act of The primary therapeutic uses for each of the strokes
touching a person is, of course, very old and common to described in Chapter 4 are combined into a single compre-
many ancient cultures. Indeed, this may be why it resonates hensive list in Box 5-5. This table indicates the therapeutic
to this day, even in more technologically advanced societies. uses associated with all of the techniques described previ-
If the act of touching a person makes that person believe (a ously in Chapter 4, under the headings for each individual
psychological construct) that healing will take place, then it stroke.
is not difficult to imagine that healing could, in fact, happen. The therapeutic uses of massage depend largely on the
If we adopt the premise that the human mind has the power individual stroke. Therefore the therapeutic uses are listed
to control bodily functions, it is conceivable that the mind separately for each of the major types of massage stroke (see
could bring about positive physical changes in the body, Chapter 4 for details of each individual stroke).
including healing and pain control. This is the so-called
mind-body connection. It is essentially a belief system that
accepts the concept that the directives of the conscious mind
INDICATIONS FOR
can produce real physiological effects in the body. Because
THERAPEUTIC MASSAGE
these effects can be produced by massage and related activi-
ties, they could be classified as psychological effects of the The mechanical, physiological, and psychological effects of
treatment that bring about real physiological changes for the massage give rise to the therapeutic effects. In turn, the
patient. therapeutic effects are the basis for the therapeutic uses.
In large areas of the world, many people, especially the From these, it is possible to derive a list of indications for
elderly, have great faith in the religious healing tradition the use of therapeutic massage. Once more, many of these
known as the laying on of hands. For the Christian com- indications are common to all massage strokes, therefore
munity especially, this idea has great resonance because of each technique has its own particular list of indications. The
the numerous biblical references, especially in the New primary indications for each of the strokes described in
Testament, to the healing works of Jesus Christ and his Chapter 4 are combined into a single comprehensive list in
disciples. These convictions run deep in the psyche of Box 5-6. This list cites the indications associated with all
many individuals, and these people are likely to be receptive of the techniques described in Chapter 4 under the headings
to the positive effects of massage as a therapeutic tool, par- for each individual stroke.
ticularly because it involves direct touching by the
therapist.
CONTRAINDICATIONS TO MASSAGE
Specific contraindications for each massage stroke were
PRIMARY THERAPEUTIC EFFECTS described in Chapter 4 and are summarized in Table 5-2.
OF MASSAGE E
The presence of one of these conditions does not necessarily
The primary therapeutic effects of massage should now be mean that treatment cannot be given; rather it indicates that
obvious, as they are based on the mechanical, physiological, careful consideration must be given before any treatment is
and psychological effects described earlier. Relaxation performed. Each contraindication listed in Table 5-2 is fol-
(local and general), pain relief, increased range ofjoint and lowed by a letter (A, U, or R) to indicate how it should be
limb motion, stimulation of blood and lymph circulation, interpreted. The designation A means that the use of a par-
and facilitation of healing are among the most prominent. ticular technique is always contraindicated and should never
 PART ONE GENERAL PRINCIPLES

30)(4b) Primary Therapeutic Effects of the Various Massage Strokes

Stroking Effects on the Skin and Subcutaneous Tissues
Significant relaxation, producing a sedative effect, may be Increased blood and lymph flow in the skin and subcutane-
obtained and may help relieve pain and muscle spasm ous tissues, which in turn produces a slight increase in
(via a pain-gating mechanism) skin temperature
Stimulating effect (when performed rapidly) on sensory Stretching of posttraumatic scar tissue in muscle
nerve endings, resulting in a generalized, invigorating Increased extensibility and mobility of the skin and
effect subcutaneous tissues, which in turn increases range of
Dilation of the arterioles in the deeper tissues and in motion in joints and limb segments, thereby promoting
superficial structures when slow, deep stroking is normal function
applied Percussive Manipulations (Tapotement)
Effleurage Stimulation of mechanoreceptors in skin, muscle, and
Increased flow of venous blood in the superficial and deep tendons, which facilitates muscle contraction
veins toward the heart; when pressure is relaxed, the Stimulation of the circulation of blood and lymph in
valves in the veins prevent backward flow superficial and deep muscle tissue
Stimulation of lymph flow, resulting in more rapid Loosening of mucus in the lungs
elimination of waste products Pain relief as a result of stimulation of mechanoreceptors in
Increased flow in the veins and lymphatic vessels relieves the skin (pain gating)
the congestion in the capillaries allowing vascular and Dilation of the superficial arterioles through the axon reflex,
lymphatic fluids to flow more readily into, and out of, the thereby stimulating the superficial circulation
capillary beds, thereby stimulating the circulation and Increased blood and lymph flow in the skin and subcutane-
facilitating healing ous tissues, which in turn produces a slight increase in
Increased mobility of the skin and subcutaneous tissues, skin temperature
which in turn increases range of motion in joints and limb Vibration and Shaking
segments Stimulation of mechanoreceptors in skin, muscle, and
Dilation of the superficial arterioles through the axon reflex, tendons, which facilitates muscle contraction
thereby stimulating the circulation Loosening of mucus in the lungs
Stimulation of the large-diameter mechanoreceptors in the Pain relief as a result of stimulation of mechanoreceptors in
skin, relieving pain (pain-gating mechanism), reducing the skin (pain gating)
muscle spasms, and promoting relaxation Movement of gases when applied over the stomach and
Pressure Manipulations (Pétrissage) intestine
Effects on the Circulation Deep Frictions
Increased flow of venous blood in the superficial and deep Stretching of posttraumatic scar tissue in muscles,
veins toward the heart; when pressure is relaxed, the tendons, tendon sheaths, ligaments, and joint capsules
valves in the veins prevent backward flow Local damage to the tissues, causing the liberation of a
| Stimulation of lymph flow, resulting in more rapid elimina- histamine-like substance (H substance) and other
tion of waste products metabolites that act directly on the capillaries and
Increased flow in the veins and lymphatic vessels relieves arterioles in the area, causing localized vasodilation
the congestion in the capillaries, allowing vascular and Vasodilatation produces an increase in the amount of
lymphatic fluids to flow more readily into, and out of, the tissue fluid in the local area, which distends the tissues;
capillary beds, thereby stimulating the circulation and in effect, the stroke produces a controlled “inflammation”
facilitating healing and at the same time mobilizes the structures that were
Dilation of the superficial arterioles through the axon reflex, not moving properly
thereby stimulating the circulation Relaxed Passive Movements
Effects on Muscles A direct mechanical stretch on the connective tissues
Increased blood supply to superficial and deep muscles associated with all of the musculoskeletal and neurovas-
Increased elimination of metabolic waste products in cular structures, leading to increased range of motion in
superficial and deep muscles these tissues and an improvement in functional ability
_ Stretching of posttraumatic scar tissue in muscle Pain and muscle spasm relief (via a pain-gating mecha-
Increased range of motion in muscle and promotion of nism) leading to an increased range of motion and an
normal joint and limb function improvement in functional ability
Reduction of muscle spasm as a result of the stimulation of Increased flow of blood and lymph in the limbs because of
the large-diameter mechanoreceptors in the skin, the mechanical pumping effect produced as the tissues
thereby relieving pain (pain-gating mechanism) are alternately squeezed and stretched; the increased
Promotion of relaxation in superficial and deep muscle circulation promotes healing and all levels of tissue
tissue viability
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5

510454) Therapeutic Uses of Various Massage Strokes

Stroking Percussive Manipulations (Tapotement)
Increase blood and lymphatic flow in the superficial Increase blood and lymphatic flow in the skin and
circulation subcutaneous tissues
Relieve pain and muscle spasm, thereby promoting
Stimulate the circulation of the superficial and deep
relaxation muscle, thereby facilitating healing
Help both patient and therapist to become accustomed to Relieve pain and muscle spasm, thereby promoting
| the feel of each other’s tissues; for the patient, it is the relaxation
sensation of the therapist’s hands; for the therapist, it is Loosen mucus in the lungs, thereby assisting with
the contours and quality of the patient’s tissues expectoration
Join of various massage manipulations (strokes) together Facilitation of muscle contraction and reeducation of
into a smooth sequence to give continuity to the function
massage treatment Relief of neuralgic pain following amputation, trauma, or
Relieve flatulence or other intestinal movement disorders another pathology
by mechanical direct and reflex effects on the intestines Stimulation of organ function
Promote relaxation and help to induce sleep in persons Vibration and Shaking
who have insomnia Loosen mucus in the lungs, thereby assisting with
Effleurage expectoration
Increase blood and lymphatic flow in the superficial and Facilitate muscle contraction and reeducation of function
deep circulation Relieve neuralgic pain following amputation, trauma, or
Promote the absorption of inflammatory exudates in the another pathology
subacute and chronic stages of soft tissue injuries Reduce spasticity when applied longitudinally to a limb
(edema) while simultaneously applying traction in the long axis
Relieve pain and muscle spasm, thereby promoting Stimulate organ function
relaxation Relieve flatulence
Follow other strokes (e.g., kneading, friction) that have Resolve chronic edema (a mechanical vibrator may be
deeper effects, thereby encouraging the absorption of more useful for relieving chronic edema)
waste products into the lymphatic system Deep Frictions
Help both patient and therapist to become accustomed to Mobilize contractures (scar tissue) in the superficial and
the feel of each other’s tissues; for the patient, it is the deep muscles, tendons, ligaments, joint capsules, and
sensation of the therapist’s hands: for the therapist, it is neurovascular bundles
the contours and quality of the patient’s tissues Increase blood and lymphatic flow in the skin and in
Join various massage manipulations (strokes) together into superficial and deep muscles
a smooth sequence to give continuity to the massage Promote the absorption of inflammatory exudates (edema)
treatment in the subacute and chronic stages of soft tissue injury
Pressure Manipulations (Pétrissage) Relieve pain and muscle spasm, thereby promoting
Increase blood and lymphatic flow in the skin and in relaxation and healing
superficial and deep muscles Relaxed Passive Movements
Promote the absorption of inflammatory exudates Increase blood and lymphatic flow (passive pump) in the
(edema) in the subacute and chronic stages of soft superficial and deep circulation in the limbs
tissue injury Relieve pain and muscle spasm, thereby promoting
Mobilize the skin and subcutaneous tissues relaxation and improved range of motion
Mobilize contractures in the superficial and deep muscles, Regain lost functional range of motion in skin, joint,
tendons, ligaments, joint capsules, and neurovascular muscle, tendon, and neurovascular tissue due to
bundles contractures and adhesions
Remove the accumulation of metabolic waste products in Maintain the normal functional range of motion in body
superficial and deep muscles segments subjected to prolonged immobility or
Relieve pain and muscle spasm, thereby promoting paralysis, thereby preventing contractures and
| relaxation adhesions

be performed. The designation U means that the use of a to receive treatment using the technique. It is important to
particular technique is usually contraindicated and in most, remember that contraindications generally apply to the area
but not all, cases should not be performed. The technique being treated. It is safe to treat areas that are not affected.
can be used under these circumstances, but it can only be For example, it would be safe to massage the neck and
given with great care. The designation R means that the use shoulders of a patient who had significant arterial disease in
of a particular technique is rarely contraindicated and can, the lower limbs.
in most cases, be performed safely and effectively. Very As always, the causes of the patient’s current signs and
occasionally, however, an individual patient may not be able symptoms are extremely important. For example, a patient
 PART ONE GENERAL PRINCIPLES

iss
3045) Indications for the Use of the Various Massage Strokes
Stroking Vibration and Shaking
Pain (acute or chronic) Respiratory disorders associated with mucus retention,
Muscle spasm (acute or chronic) such as cystic fibrosis and bronchiectasis
Superficial scar tissue (in the skin) Weak muscle contraction, or difficulty in initiating muscle
Flatulence, constipation, and general abdominal dis- activity associated with various neurological disorders
comfort Chronic pain, especially that associated with damage to
Insomnia nerves or disturbances of the circulation
Effleurage Chronic problems with flatulence
| Chronic edema, especially in the extremities Deep Frictions
_ Chronic pain, especially that associated with disturbances Chronic lesions in the skin and subcutaneous tissues,
of the circulation muscles, tendons, tendon sheaths, ligaments, and joint
| Chronic muscle spasm capsules—for example, chronic muscle tears, tendinitis
Superficial scar tissue (in the skin), especially that associ- and partial tendon ruptures (tenoperiosteal tears),
ated with trauma to a limb tenosynovitis, ligament sprains, induration of subcutane-
Pressure Manipulations (Pétrissage) ous areas, and scar tissue
Chronic edema, especially in the extremities Chronic pain associated with lesions in any of the muscu-
Chronic pain, especially that associated with disturbances loskeletal tissues
of the circulation Chronic superficial scar tissue in the skin and subcutane-
Superficial scar tissue in the skin and subcutaneous tissue, ous tissue, especially that associated with trauma
especially that associated with trauma Relaxed Passive Movements
Contractures in muscles, tendons, ligaments, joint cap- Pain (acute or chronic) preventing movement
sules, and related structures. Muscle spasm (acute or chronic) preventing movement
Percussive Manipulations (Tapotement) Superficial and deep scar tissue in the skin and subcuta-
Weak muscle contraction, or difficulty in initiating muscle neous tissue
activity associated with various neurological disorders Prolonged immobility and/or paralysis
Chronic pain, especially that associated with damage to Contractures/adhesions in joint capsules, ligaments,
nerves or disturbances of the circulation muscles, tendons, tendon sheaths, and neurovascular
Respiratory disorders associated with mucus retention, tissues
such as cystic fibrosis and bronchiectasis

may present with chronic, gross swelling around the of inappropriate or inadequate treatment. It is also important
feet, ankles, and lower legs. On the surface, this seems an for therapists to protect themselves by taking precautions to
ideal indication for massage to mobilize the fluids and avoid personal injury, particularly to the back or the hands
remove the swelling. However, if the swelling is the result (Green, 2000). Good posture and ergonomics are essential
of underlying congestive heart failure, the condition might factors in reducing the risk of personal injury. These simple
contraindicate treatment unless the heart condition was well procedures minimize the risk of damage to the patient or to
controlled. In this instance, swelling in the legs is probably the therapist.
a mechanism by which the patient’s inadequate cardiovas-
cular system has off-loaded fluid into the periphery as a
SUMMARY
means of reducing the pumping load on the heart. Mobiliz-
ing this fluid back into the cardiovascular system might Therapeutic massage techniques have predictable mechani-
overtax the patient’s heart. This example highlights the cal effects on the tissues being manipulated, and these
importance of understanding the reasons for the patient’s effects cause measurable physiological changes in the person
signs and symptoms. being treated. These effects are therapeutically useful in the
treatment of a variety of conditions. Researchers have inves-
GENERAL PRECAUTIONS tigated soft tissue massage for many decades, but many of
the classic studies on the effects of massage briefly reviewed
Massage is a relatively safe treatment. However, patients can in this chapter have omitted any mention of the details of
come to harm if given treatment in an inappropriate manner the massage techniques. Therefore conclusions drawn by the
(Trotter, 1999). The therapist must carefully assess the experimenters and clinicians had to be stated in quite general
patient’s total situation. Box 5-7 lists many commonsense terms. Indeed, many references on the clinical use of
precautions that need to be observed before, during, and massage state that “massage does (or does NOL) eaeee
after treatment using massage. Observing these simple pre- “massage will (or will not)... .” “massage should (or should
cautions reduces the risk of damage to a patient as a result not) be used for... ,.” or “massage is indicated (or contra-
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5 5ST e te

Jable 5-2 Summary of the Contraindications for the Use of Massage”

Ed Banat tas 2

Stroking
Large open areas (e.g., burns or wounds) in the areas to be treated, especially if they are
infected A
Gross edema in the areas to be treated if there seems to be a possibility of splitting
the skin A
Cancer in the skin or any other tissue in the area to be treated
A
Serious infections in the tissues to be treated (tuberculosis, septic arthritis, etc.)
A
Lacerations, bruising, infections, or foreign bodies (e.g., glass, grit, metal) in the skin of the area to be treated
A
Acute or chronic skin conditions affecting the areas to be treated (e.g., psoriasis, eczema, or dermatitis)
U
Marked varicosities in the areas to be treated if damage to the vein wall might result (very light stroking may
U
be possible)
Within 3 to 6 months following radiation therapy in the area to be treated (skin is usually hypersensitive) U
Areas of hyperesthesia in the areas to be treated (i.e., those who are very sensitive/ticklish to touch)
R
Extremely hairy areas in the areas to be treated (if stroking causes pain)
R
Effleurage
Large open areas (e.g., burns or wounds) in the areas to be treated, especially if they are infected A
Cancer in the skin or any other tissue in the area to be treated
A
Serious infections in the tissues to be treated (tuberculosis, septic arthritis, etc.) A
Gross edema in the areas to be treated if there seems to be a possibility of splitting the skin A
Lacerations, bruising, infections, or foreign bodies (e.g., glass, grit, metal) in the skin of the area to be treated A
Chronic swelling in the areas to be treated, in the lower limb associated with severe congestive cardiac failure, U
or any other heart condition with which lower limb edema is associated
Acute or chronic skin conditions affecting the areas to be treated (e.g., psoriasis, eczema, or dermatitis) U
Marked varicosities in the areas to be treated if damage to the vein wall might result (very light stroking may U
be possible)
Within 3 to 6 months following radiation therapy in the area to be treated (skin is usually hypersensitive) U
Areas of hyperesthesia in the areas to be treated (i.e., those very sensitive/ticklish to touch) R
Extremely hairy areas in the areas to be treated (if stroking causes pain) R
Pressure Manipulations (Pétrissage)
Large open areas (e.g., burns or wounds) in the areas to be treated, especially if they are infected A
Cancer in the skin or any other tissue in the area to be treated A
Serious infections in the tissues to be treated (tuberculosis, septic arthritis, etc.) A
Gross edema in the areas to be treated if there seems to be a possibility of splitting the skin A
Lacerations, bruising, infections, or foreign bodies (e.g., glass, grit, metal) in the skin or other tissues in the area A
to be treated
Arterial or venous pathology (especially thrombophlebitis and deep vein thrombosis) in the areas to be treated A
Acute muscle tears in the areas to be treated (especially deep intramuscular hematomas) A
Hyper- or hypotonic limbs as the areas to be treated (very gentle massage only) U
Chronic swelling in the areas to be treated, in the lower limb associated with severe congestive cardiac failure U
or any other heart condition with which lower limb edema is associated
Acute or chronic skin conditions affecting the areas to be treated (e.g., psoriasis, eczema, dermatitis) U
Marked varicosities in the areas to be treated if damage to the vein wall might result U
Within 3 to 6 months following radiation therapy in the area to be treated (skin is usually hypersensitive) U
Areas of hyperesthesia in the areas to be treated (i.e., those very sensitive/ticklish to touch) R
Extremely hairy areas in the areas to be treated (if treatment causes pain) R
Percussive Manipulations (Tapotement)
Large open areas (e.g., burns or wounds) in the areas to be treated, especially if they are infected A
Severe rib fractures (flail chest); only very fine, gentle vibrations may be used in the presence of a rib fracture A
Over the thorax in cases of acute heart failure, especially if coronary thrombosis or embolism is involved A
Over the thorax in cases of acute pulmonary embolism A
Over the thorax in cases of severe hypertension A
Cancer in the skin or any other tissue in the area to be treated A
Serious infections in the tissues to be treated (tuberculosis, septic arthritis, etc.) A
Gross edema in the areas to be treated if there seems to be a possibility of splitting the skin A
Lacerations, bruising, infections, or foreign bodies (e.g., glass, grit, metal) in the skin or other tissues in the area A
to be treated
Arterial or venous pathology (especially thrombophlebitis and deep vein thrombosis) in the areas to be treated A
Acute muscle tears in the areas to be treated (especially deep intramuscular hematomas) A
Hyper- or hypotonic (spastic or flaccid) limbs in the areas to be treated (very gentle massage only) U
Over newly formed scar tissue in the areas to be treated 7
Chronic swelling in the lower limb in the areas to be treated, associated with severe congestive cardiac failure or
any other heart condition with which lower limb edema is associated

A, Always contraindicated; U, usually contraindicated; R, rarely contraindicated. Veo .

*The contraindications to the use of massage depend largely on the individual stroke. Therefore the indications are listed separately for each of
the major types of massage stroke (see Chapter 4 for details of each individual stroke).
ee ee PART ONE GENERAL PRINCIPLES

iiicctte iow
able 5-2 Summary of the Contraindications for the Use of Massage—cont’d

U
Acute or chronic skin conditions affecting the areas to be treated (e.g., psoriasis, eczema, or dermatitis)
Marked varicosities in the areas to be treated if damage to the vein wall might result
U
On bony regions in the areas to be treated, in very thin patients U
Within 3 to 6 months following radiation therapy in the area to be treated (skin is usually hypersensitive) U
Areas of hyperesthesia in the areas to be treated (i.e., those very sensitive/ticklish to touch) R
Extremely hairy areas in the areas to be treated (if treatment causes pain) R
Vibration and Shaking
Large open areas (e.g., burns or wounds) in the areas to be treated, especially if they are infected
Severe rib fractures (flail chest); only very fine, gentle vibrations may be used in the presence of a rib fracture
Over the thorax in cases of acute heart failure, especially if coronary thrombosis or embolism is involved
Over the thorax in cases of acute pulmonary embolism
Over the thorax in cases of severe hypertension
Cancer in the skin or any other tissue in the area to be treated
Serious infections in the tissues to be treated (tuberculosis, septic arthritis, etc.)
Gross edema in the areas to be treated if there seems to be a possibility of splitting the skin
Lacerations, bruising, infections, or foreign bodies (e.g., glass, grit, metal) in the skin or other tissues in the area rPrPr
to be treated
Arterial or venous pathology (especially thrombophlebitis and deep vein thrombosis) in the areas to be treated
Acute muscle tears (especially deep intramuscular hematomas) in the areas to be treated
Chronic swelling in the lower limb in the areas to be treated, associated with severe congestive cardiac failure or
any other heart condition with which lower limb edema is associated
Acute or chronic skin conditions affecting the areas to be treated (e.g., psoriasis, eczema, or dermatitis)
Marked varicosities in the areas to be treated if damage to the vein wall might result
On bony regions in the areas to be treated, in very thin patients
Within 3 to 6 months following radiation therapy in the area to be treated (skin is usually hypersensitive)
Areas of hyperesthesia (i.e., those very sensitive/ticklish to touch) in the areas to be treated
Extremely hairy areas (if treatment causes pain) in the areas to be treated
Deep Frictions
Open areas (e.g., burns or wounds) in the areas to be treated, especially if they are infected
Cancer in the skin or any other tissue in the area to be treated
Serious infections in the tissues to be treated (tuberculosis, septic arthritis, etc.)
Gross edema in the areas to be treated if there seems to be a possibility of splitting the skin
Lacerations, bruising, infections, or foreign bodies (e.g., glass, grit, metal) in the skin or other tissues in the area
to be treated
Arterial or venous pathology (especially thrombophlebitis and deep vein thrombosis) in the areas to be treated
Acute muscle tears in the areas to be treated (especially deep intramuscular hematomas)
Acutely inflamed joint tissues (joints, tendons, ligaments, tendon sheaths, joint capsules, etc.) in the area to be Pr
yp
yr
Grr
PP
CG
BVIcCe
treated
Hyper- or hypotonic limbs as the areas to be treated (very gentle massage only)
Acute or chronic skin conditions affecting the areas to be treated (e.g., psoriasis, eczema, or dermatitis)
Marked varicosities in the areas to be treated if damage to the vein wall might result
Within 3 to 6 months following radiation therapy in the area to be treated (skin is usually hypersensitive)
Areas of hyperesthesia in the areas to be treated (i.e., those very sensitive/ticklish to touch)
Extremely hairy areas in the areas to be treated (if treatment causes pain) sy
ee
Jee
Relaxed Passive Movements
Large open areas (e.g., burns or wounds) in the areas to be treated, especially if they are infected
Gross edema in the areas to be treated if there seems to be a possibility of splitting the skin
Deep vein thrombosis or other serious vascular pathology in the areas to be treated
Cancer in the skin or any other tissue in the area to be treated
Serious infections in the tissues to be treated (tuberculosis, septic arthritis, etc.)
Lacerations, bruising, infections, or foreign bodies (e.g., glass, grit, metal) in the skin of the area to be treated
Marked varicosities in the areas to be treated if damage to the vein wall might result
Acute or chronic skin conditions affecting the areas to be treated (e.g., psoriasis, eczema, or dermatitis)
Within 3 to 6 months following radiation therapy in the area to be treated (skin is usually hypersensitive)
Areas of hyperesthesia in the areas to be treated (i.e., those who are very sensitive/ticklish to touch)
DUVCC
 MECHANICAL, PHYSIOLOGICAL, PSYCHOLOGICAL, AND THERAPEUTIC EFFECTS CHAPTER 5

=), Summary of the Basic Precautions for Barel A, Lucassen G et al: The use of ultrasound imaging in the
BOX 3-7 the Use of Massage evaluation of cellulite treatment with a mechanical skin massage
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 Practice
“
 soft Tissue Manipulation
Techniques as an
Evaluation Tool
The human hand is, without doubt, a bioengineering marvel. gathered from the patient concerning his or her movement
It can rightly be classified as one of the wonders of nature. dysfunction.
It is capable of immense dexterity and sensitivity, yet it also A more encompassing sensory experience is also associ-
possesses tremendous strength and functional ability. ated with the hands. This may be loosely termed psychic
Indeed, there is no area of human ability or achievement sensitivity. Of course, all sensation is perceived at the corti-
that does not involve the hands as the center of the activity. cal level; however, the special sensitivity of the hands may
Everything made by humans involves the hands. Every allow some individuals greatly increased awareness and
activity of daily living and every area of art, music, litera- integration of the sensory experience provided by touching.
ture, and sporting ability involves the hands. Indeed, a It would not be surprising to find that a person born com-
person who loses both hands, or the use of them, is pro- pletely blind would develop extremely sensitive hands. In
foundly disabled and cannot survive without a great deal of fact, the history of massage makes it clear that people with
assistance. Given the tremendously important role of the serious visual loss were trained in massage, particularly
hand in all aspects of human existence, it is not surprising because of their increased sensitivity and manual ability.
that the control of all aspects of hand function is vested in There can be little doubt that the act of touching can produce
large areas of the sensory and motor cortex of the brain. significant responses in both parties. The act of touching can
Unlike any other species, humans have the enormous advan- communicate many human emotions, and this may be one
tage of an advanced brain that is able to control an amaz- reason why soft tissue manipulation has proven such a potent
ingly versatile hand. therapeutic tool over the millennia and why so many people
Two major functions—sensory and motor—can be still have great faith in the “laying on of hands.”
assigned to the hand. Sensory functions include the gather- Although palpation is an important part of the examination
ing of information received by the multitude of sensory of a patient, the value of soft tissue manipulation strokes as an
receptors in the various parts of the hand. These sensory evaluation tool has not been sufficiently appreciated. Palpa-
signals come from receptors in the skin and subcutaneous tion does play a major role in the examination of most body
tissues, ligaments and capsules from each of the many functions and certainly enjoys a prominent position in the
joints in the hands, and a multitude of muscle and tendon evaluation and treatment of musculoskeletal disorders. The
afferents associated with every muscle capable of producing fact that such information gathered by palpation appears to be
movement in the hand. Signals from these afferents are less objective than that gathered by instruments reflects more
relayed to the brain, synthesized, and eventually interpreted on the limitations of the instrumentation than on the powers
as the experience of touching. A wide variety of functional of human observation. There is clearly great potential for soft
information can be perceived in this manner, including tissue massage manipulations in the evaluation of all aspects
object recognition, temperature, and texture. Together, they of musculoskeletal function. This discussion examines the
form the important evaluative ability that is known as pal- potential value of the sensory information received during the
pation, and it is a major contributor to the information performance of the major groups of massage strokes.
 PART TWO PRACTICE

il
ii
STROKING AND EFFLEURAGE In this way, massage becomes a more dynamic part of
treatment.
Superficial stroking gives initial information about the skin There is a characteristic feel of normal muscle tissue as
and superficial muscle groups. Contour, texture, tone, and it moves relative to its deep and superficial neighbors when
temperature may reveal acute or chronic changes in these massaged using the pressure manipulations. A significantly
tissues. Tissues in one site can be compared with those of reduced degree of intermuscular mobility clearly indicates
adjacent areas to determine whether the changes are local a problem; however, less obvious changes in intertissue
or generalized. In particular, the general sensitivity of the
mobility can be the cause of considerable pain and dysfunc-
tissues can be determined. For example, if a patient flinches
tion. Information provided from feedback during these tech-
in pain as the hands move over the potential site of trigger
niques can be extremely useful in helping the therapist to
points, this reaction clearly indicates a sensitive area of
assess and monitor the patient’s progress.
tissue. Apart from pain, areas of altered skin resistance,
Other techniques, such as skin rolling, can be useful in
temperature, and compliance—factors secondary to local
identifying specific localized changes in the skin and sub-
and regional autonomic changes—are the keys to locating
cutaneous tissues. These are similar to the evaluative tech-
these points. Information that the therapist gathers by super-
niques of connective tissue massage (CTM). A therapist can
ficial stroking can also be used as a reference point after
feel local connective tissue changes as his or her fingers and
specific therapeutic procedures have been applied. Changes
thumbs roll the skin and subcutaneous tissues. This may
noted later during superficial stroking provide important
provide useful information concerning the mobility of the
data on the effect of the procedures used.
tissues and the appropriate areas that require treating (see
Superficial stroking is helpful in measuring centrally
Chapter 11 for more details).
induced, generalized muscle tension. It also provides time
for the patient to adapt to the feel of the therapist’s hands
and to become accustomed to the increased sensory input. PERCUSSION AND
These strokes have traditionally been used to relax the VIBRATION MANIPULATIONS
patient, though some patients who are tactilely defensive
Although percussion and vibration manipulations are tech-
may require a modified approach. It is important that the
niques used primarily in the treatment of pulmonary disor-
patient’s entire body and the specific areas to be treated are
ders (see Chapter 10), a certain amount of information can
relaxed; relaxation can be enhanced and evaluated by super-
be derived from their use, especially from vibrations.
ficial stroking. All human beings are individually unique,
Although the strokes are generally performed over the chest
as are their responses to treatment, including massage.
wall, specifically over the ribs and intercostal muscles, these
There is no reliable way to predict with certainty which type
techniques can provide indirect evidence of inflation and
of stimulation will have the greatest effect; however, experi-
compliance of the lungs and infiltration or adherence of the
ence indicates that sustained contact and rhythmic move-
lungs and surrounding structures.
ment are soothing and relaxing for most people.
The classic percussive manipulations (clapping, beating,
Deep stroking and effleurage can provide useful informa-
hacking, and pounding) involve the hands or fingers making
tion about the degree and type of swelling in an area. Obvi-
only momentary contact with the tissue. In contrast, vibra-.
ously, the more edema there is in an area, the tighter the
tion and shaking techniques involve the hand(s) in direct
tissues will feel as a reflection of the amount of interstitial
contact throughout the technique. Obviously, a certain
swelling. It is quite possible to gauge this and then deter-
amount of time is needed for the hands to receive tactile
mine whether there is improvement (less tightness) follow-
information from the underlying tissue. This is difficult in
ing treatment. Because deep stroking and effleurage involve
a technique that is necessarily applied at high speed.
greater tissue pressure than superficial stroking, they can
The therapist can use selective or precisely placed per-
also provide useful information concerning the patient’s
Cussive techniques to test the reflex responsiveness of the
overall sensitivity to pain in the treated areas.
patient’s muscles and to stimulate specific muscles and
tendinous structures. Rebound pain on percussion over a
sensitive structure (ligaments, bone, nerves, etc.) often has
PRESSURE MANIPULATIONS
(PETRISSAGE) specific meaning for certain orthopedic and neurological
conditions (e.g., Tinel’s sign).
The nature of pressure manipulations, especially kneading
and the various lifting strokes (wringing and picking up),
gives them a unique role, particularly in muscle assessment. DEEP FRICTION TECHNIQUES
Local or generalized muscle tightness or atrophy of these Deep friction strokes provide some of the most useful
structures can be identified as specific structures are isolated information about localized connective tissue structures.
and mobilized. During treatment, the therapist can come The compliance and adherence of connective tissue can be
back to an area that earlier resisted being mobilized or assessed. The compliance of fascia in various tissues and
lifted, this time to judge the effectiveness of treatment. the overall mobility of ligaments, tendons muscle, joint
 SOFT TISSUE MANIPULATION TECHNIQUES AS AN EVALUATION TOOL CHAPTER 6 cimnaiianiad

capsules, tendon sheaths, and related structures can be iden- at the same time, they are in the unique position of providing
tified and assessed. invaluable information to the therapist concerning the condi-
Transverse friction can be used to assess joint capsule tion of the patient’s tissues. This is the important evaluative
mobility, especially around superficial joints, and is gener- function of all massage techniques. All of the strokes men-
ally more effective than longitudinal friction in producing tioned here have value, both as a part of the art of massage
plastic deformity of the target tissues. It may be necessary and as an assessment tool. If the therapist takes care to relate
at times to combine the technique with passive movement findings to specific anatomical structures, much of what
or selected positioning to align specific structures and normally passes as subjective information may prove to be
thereby provide appropriate presentation and tension of more objective—and therefore more useful.
the tissue. As treatment is carried out over time, the During treatment, the therapist can come back to an area
patient’s perception of pain is altered as the connective that previously seemed very tight and resisted mobilization.
tissue lengthens. This does not happen quickly because the The therapist might also return to an area where the effec-
structure of the tissues is reengineered in response to tiveness of treatment was difficult to judge. In this way
repeated oscillatory stretching of adherent structures (plastic massage becomes a more dynamic part of treatment. For
deformation). example, a muscle might be unable to function effectively
because of contracture of its tendon sheath as determined
by palpation. When the problem is treated with the appropri-
SUMMARY ate deep friction technique or some other stroke, the muscle
All soft tissue manipulation techniques are designed primar- complex may become more mobile and therefore capable of
ily to move the tissues to some degree or other. Although the increased, pain-free range of motion. Thus, the therapist has
therapist’s hands are primarily intended to move the tissues, both assessed and treated the problem.
 General Massage Sequences

Part Two of this text concerns the practice of the various appropriate to view soft tissue manipulation as an excellent
soft tissue manipulations (massage strokes) described previ- way of preparing the tissues for active exercise. In this way
ously in Chapter 4. These techniques can be combined into it can be thought of as a passive warm-up. When followed
a wide variety of massage sequences. Such a sequence is by passive and active stretching, it can be an effective and
simply a collection of individual techniques put together indeed essential component of the routine of preparation for
with the intention of achieving a specific effect or series of exercise. This is one of the major ways in which massage
effects. Of the many massage sequences that are possible, techniques can be used in sports (see Chapter 13 for more
the selection of techniques should, to a large extent, be details).
determined by the specific treatment goals. The massage In certain circumstances, therefore, when normal active
sequences described in this text are by no means the only physical exercise is not possible and if massage is not con-
ones that could be practiced. Indeed, the possible sequences traindicated, general massage can be extremely helpful. For
are practically endless. In this context, massage applied to conditions that require prolonged confinement to bed (e.g.,
the entire body is usually called general massage, which terminal illness), daily massage of the entire body manually
was defined in Chapter 3 as follows: stimulates the general circulation and brings a sense of
A combination of different massage strokes applied to all comfort, relaxation, and pain relief to the patient. For older
the major regions of the body in a single treatment session people, general massage may substitute for some of their
in order to achieve particularly desired effects. former muscular activity, but again, it cannot replace active
In contrast, massage applied to an individual body part is exercise programs, nor is it intended as a replacement. It
termed local massage, and massage given to a specific site, may not be possible to apply massage to older and termi-
such as a ligament or tendon, is called focal massage. nally ill patients in exactly the same way as it is applied to
Local massage sequences are described in Chapter 8, younger and healthier individuals. For example, an older
and some examples of focal massage are discussed in person will probably not be comfortable lying facedown on
Chapter9. a treatment table or in bed. This means that the basic tech-
Massage is never intended to be a substitute for therapeu- niques will need to be modified to suit each patient. In many
tic exercise in restoring a patient to full function. Because cases, massage to the entire body on a daily basis is not
massage can improve the circulation of blood and lymph, practical; however, massage only to the lower limbs is likely
mobilize soft tissues of all types, and promote healing, to be an effective means of stimulating the circulation of the
relaxation, and pain relief, it has many of the effects of lower limbs, and this is important in improving the general
exercise, with one important difference. Therapeutic exer- circulation.
cise involves muscle contraction, usually with accompany-
ing joint and soft tissue movement. In contrast, therapeutic A SEQUENCE AND TECHNIQUE FOR
massage is entirely passive in nature. In fact, relaxation of GENERAL MASSAGE
the patient is a necessary part of the treatment. This in no
way implies that massage is inferior to exercise. It is simply A good general massage may produce fatigue in the
different but complementary in every respect. In fact, it is patient. A feeling of mild lassitude and the desire to rest
 PART TWO PRACTICE
edie, 199... rr

immediately after general massage are signs of a successful program is described next and can be followed from the
treatment, and for this reason the patient should rest for general massage sequence presented in the following
60 to 90 minutes after treatment if possible. Significant section.
fatigue should be avoided, and if the patient is not refreshed The sequence begins with the patient in supine lying
after a period of rest, the duration of the treatment has been (facing the ceiling) with the therapist on the patient’s right-
too long or the massage technique too vigorous. As a general hand side. A small pillow or rolled towel placed under the
guide, about 45 minutes to | hour is adequate for most patient’s head or neck allows the therapist’s hands to move
general massage treatments. In the general massage sequence smoothly around to the back of the patient’s neck and shoul-
described here, a recommended number of repetitions is ders when treating the chest and neck. A similar pillow may
given for each stroke so that the treatment can be completed be useful under the patient’s knees, but it must be small or
within this time frame. it will interfere with massage to the lower limb. The patient
To accomplish the relaxation and sedation usually desired turns to the prone position (facing the floor), and the treat-
in general massage, the change from one type of movement ment concludes with massage to the back. (The therapist
to another must be smooth and uninterrupted, and a definite does not have to change position for this part of the treat-
rhythm should be sustained through all movements. Certain ment.) This entire sequence may be reversed if the therapist
adaptations of the Swedish remedial massage system seem prefers to begin on the patient’s left side. It is usually a
to be well suited for this purpose. These movements are matter of personal preference, although in some cases the
performed on an entire segment of each extremity without layout of the room or treatment cubicle may determine on
giving special attention to a particular muscle or muscle which side of the patient it is best to begin massage. The
group. A type of massage sequence that follows specific entire sequence is outlined here, together with the number
muscle groups and muscles is more effective in the treat- of repetitions for each stroke.
ment of local injury or disease (see Chapters 8 and 9).
The sequence of strokes used in a general massage
TECHNIQUES FOR A GENERAL
sequence should be such that the patient is not required
MASSAGE SEQUENCE
to move or turn from side to side any more than is absolutely
necessary. The therapist should change position as little Tables 7-1 to 7-5 describe general massage sequences for the
as possible, and all movements should be efficient and lower limbs, upper limbs, anterior trunk, posterior trunk,
quiet. The order of movements that facilitates this type of and the head/neck area.

Right Thigh
Superficial stroking to the thigh
Palmar kneading to the quadriceps muscle
Palmar kneading to the posterior thigh i oo
Palmar kneading to the medial and lateral thigh muscles
Deep stroking to the thigh Owwarn
Right Leg and Knee
Superficial stroking to the leg
Thumb pad kneading to the anterior tibial muscles
Kneading to the calf muscles
Palmar kneading to the muscles of the leg |
Stroking around the patella
Deep stroking to the popliteal space
Deep stroking with both hands to the entire leg
WWNDNY
OFA
W
Right Foot
Superficial stroking to the dorsum of the foot
Thumb pad kneading to the dorsum of the foot
Deep thumb pad stroking to the plantar aspect of the foot
Deep palmar stroking to the plantar aspect of the foot
Deep digital stroking around the malleoli ak oo
NSN

Digital stroking to the Achilles tendon

Deep stroking to the leg and thigh
Superficial stroking to the right thigh, leg, and foot
D
RMN
ROA
Left Thigh, Leg, and Foot
All of the previous strokes are repeated on the left lower limb
 GENERAL MASSAGE SEQUENCES CHAPTER 7 since

lable 7-2 General Massage Sequence for Upper Limbs

Left Arm, Forearm, and Hand

Superficial stroking to the upper limb
7-15 =
Deep palmar stroking to the deltoid muscle
7-16 5
Thumb pad kneading to the upper limb
7-17 2
Palmar kneading to the arm and forearm
7-18 3
Alternate palmar kneading to the upper limb
f19 3
Thumb pad kneading to the dorsum of the hand
7-20 2
Thumb stroking to the palmar surface of the metacarpophalangeal joints 7-2) 4
Thumb stroking to the thenar and hypothenar eminences
f-22 4
Thumb pad kneading to the thumb and fingers
7-23 3
Deep stroking to the upper limb
= 3
Superficial stroking to the upper limb
= 4
Right Arm, Forearm, and Hand
All of the previous strokes are repeated to the right upper limb ==

lable 7-3. General assage Sequence for the Anterio r Trunk

bull a
inci YAR

Upper Chest, Neck, and Shoulders

Superficial stroking to the upper chest 7-24 4
Deep stroking to the shoulders and neck (2S) 4
Digital kneading from the sternum to the shoulder 7-26 3
Alternate deep stroking from the shoulder to the sternum — 4
Digital stroking to the neck 1-27 4
Deep stroking to the areas of the jugular veins 7-28 4
Deep stroking to the neck — 4
Abdomen
Superficial stroking to the abdomen — 4
Deep stroking to the lower abdominal muscles 7-29 4
Deep stroking to the upper abdominal muscles 7-30 4
Palmar kneading over the colon 7-31 3
Deep stroking over the colon 7-32 6
Alternate squeeze kneading over the entire abdomen 7-33 4
Deep stroking to the lower abdomen = 4

Jable 7-4 General Massage Sequence for the Posterior Trunk and Pelvis

Back and Hips

Superficial stroking to the back 7-34 4
Deep palmar stroking to the back 7-35 3
Finger pad kneading over the upper fibers of the trapezius 7-36 3
Deep stroking over the upper fibers of the trapezius 1-37 4
Reinforced palmar Kneading over the scapular region 7-38 3
Palmar kneading to the thoracic and lumbar regions 1-39 4
Palmar stroking to the lumbar region 7-40 4
Thumb pad kneading to the sacrum 7-41 4
Alternate palmar kneading to the gluteal muscles 7-42 2
Reinforced kneading to the gluteal muscles 7-43 2
Alternate palmar kneading over the entire back — 4
Digital kneading to the erector spinae muscles — 1
Deep stroking to the erector spinae muscles 7-44 4
Superficial stroking to the entire back — 4
Posterior Neck Region
Superficial and deep stroking to the upper fibers of the trapezius muscle — 8
Finger pad kneading to the upper fibers of the trapezius muscle a 3
Deep stroking over the upper fibers of the trapezius muscle _ 6
 PART TWO PRACTICE

Face and Anterior Neck

Superficial stroking to the face
Thumb pad kneading to the forehead
Deep stroking to the forehead
Thumb pad kneading to the nose
Deep stroking to the supraorbital ridge
Deep stroking to the infraorbital ridge
Finger pad kneading from the temple to the cervical spine
Finger pad kneading from the temples to the shoulders th On%
Deep stroking over the area of the jugular veins
Palmar kneading to the cheeks
Thumb pad kneading to the chin and lower jaw
Deep stroking to the chin and lower jaw
Deep stroking over the jugular veins
Superficial stroking of the face NV
AWWNHANN
Scalp
Finger pad kneading over the scalp | De)

SPECIFIC TECHNIQUES FOR A GENERAL

MASSAGE SEQUENCE
Lower Limb
Right Thigh
The therapist stands at the side of the table on the patient’s
right side.
Superficial Stroking to the Thigh
Both hands reach around the thigh, covering it as much as
possible, and stroke from the anterior superior iliac spine
(ASIS) of the ilium to the knee. The stroke may be per-
formed with the hands working alternately or simultane-
ously (Figure 7-1). The technique is repeated four times.
Figure 7-1
Palmar Kneading to the Quadriceps Muscle
Superficial stroking to the thigh.
Palmar kneading is a modified squeeze kneading technique
that begins with the ulnar border of the right hand placed
below the patella and the thumb on its lateral border. The fingers of each hand sustain their relationship to each other
fingers are placed on the medial border of the patella. The during the entire movement. The push and pull are accom-
left hand picks up the distal portion of the muscle above plished chiefly by flexion and extension of the arms at the
the patella (Figure 7-2, A). The right hand strokes over the shoulders and elbows as the movement progresses along the
patella toward the left hand as the ulnar border maintains thigh. As the origin of the muscle is approached, the left
firm contact during the upward pressure. The muscle is hand is removed, and the right hand gently squeezes out at
grasped between the thumb and the fingers using a lumbri- the origin of the muscle (Figure 7-2, D) and returns to the
cal action to draw the tissues into the palms of the hands. lower border of the patella with a superficial stroke. These
The palmar surface of the fingers of the left hand pulls the movements are repeated three times.
muscles laterally as the surface of the abducted right thumb Palmar Kneading to the Posterior Thigh
and palm simultaneously push the tissues medially (Figure The hip and knee are flexed a little and the thigh rotated
7-2, B). Then the surface of the palm and abducted thumb slightly externally. Both hands reach across the medial
of the left hand push the muscles medially as the palmar surface of the thigh, grasping the flexors at the knee (Figure
surface of the fingers of the right hand pulls the tissues later- 7-3, A), in a manner similar to the movement that was per-
ally (Figure 7-2, C). This push-pull movement is carried formed on the quadriceps muscle, except that the hands are
along the muscle, progressing from the distal part of the held more transversely to the muscles as the hands progress
quadriceps to the proximal part. Movement is accomplished along the muscle (Figure 7-3, B).
with gliding of the hands on the pull stroke of the kneading The movement is terminated a few inches below the hip
movement. This is not a pinching movement. The thumb and joint. The left hand is removed; it crosses over the right hand
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Figure 7-2
Palmar kneading to the quadriceps muscle.

to grasp the muscles above the knee (see Figure 7-3, C), and Right Leg and Knee
the right hand returns along the medial surface of the thigh The therapist continues to stand on the patient’s right side
with a superficial stroke. The movement is repeated three but is now positioned at the far end of the treatment table.
times. Superficial Stroking to the Leg
Palmar Kneading to the Medial and Lateral Thigh Muscles Both hands stroke from the knee to the ankle in the standard
The hip may be slightly flexed and laterally rotated for this method for this technique, covering the entire surface of the
stroke, or it may be performed with the limb straight. Both leg (Figure 7-5). This movement is also repeated three
hands grasp around the upper portion of the thigh (Figure times.
7-4, A); the hands perform the basic circular kneading tech- Thumb Pad Kneading to the Anterior Tibial Muscles
nique, alternately rolling the muscles between the palms The thumb pad (distal phalanx) of each hand is placed in
with firm pressure upward and relaxation while moving firm contact at the origin of the anterior tibial muscles; the
down the thigh toward the knee (Figure 7-4, B). Both hands remainder of the hand rests lightly on the surface of the leg
return to the starting position with a deep stroke. The stroke (Figure 7-6, A). The thumbs move alternately in the basic
is repeated three times. manner for kneading, applying pressure in a circular manner.
.
Deep Stroking to the Thigh The hands glide to the more distal adjacent area as each
Both hands grasp around the thigh just proximal to the knee circle is made. The movement progresses in this manner
joint, with the thumbs abducted and the fingers held together. (Figure 7-6, B) to the ankle joint (Figure 7-6, C). The hands
The fingertips of opposing hands are in contact with each return to the starting position as the thumbs give deep strok-
other on the posterior surface. With firm pressure of the ing and the rest of the hand maintains light contact. The
entire palmar surface, the hands stroke upward to the upper movements are repeated twice.
portion of the thigh and then return to the knee with a super-
ficial stroke. These movements are repeated three times. Text continued on p. 156.
154 ART TV PRACTICE

Figure 7-3
Palmar kneading to the posterior thigh muscles.

Figure
Palmar kneading to the medial and lateral thigh muscles.
Figure
Superficial stroking to the leg.

Figure
Thumb pad kneading to the anterior tibial muscles.
156 PART TWO PRACTICE

Kneading to the Calf Muscles roll the muscles between the palms with firm pressure
Kneading to the calf muscles is a modified squeeze knead- upward, working toward the ankle. The hands are returned
ing technique in which the right hand supports the slightly to the knee with a deep stroke over the muscles. (This is the
flexed knee joint at the medial border. The left hand grasps same technique used in palmar kneading of the thigh; see
the lateral part of the muscle group just distal to the knee, Figure 7-4.) These movements are repeated three times.
and the muscles are pulled toward the lateral border of the Stroking around the Patella
leg with the palmar surface of the fingers exerting pressure The heels‘of both hands are placed at the lower border of
(Figure 7-7, A). The palmar surface of the abducted thumb the patella; the palmar surfaces of the distal phalanges of
and thenar eminence push the muscles upward and toward the fingers are in contact with the skin above the superior
the medial border of the leg (Figure 7-7, B). The fingers then border of the patella (Figure 7-8, A). The thenar eminences
glide distally, and these movements are repeated until the of both hands stroke firmly around the patella in a circular
hand reaches the ankle (Figure 7-7, C). The hand returns to movement by allowing the fingers to flex while the tips
the knee with a deep stroke over the muscles. These move- maintain light contact (Figure 7-8, B). The heels of the
ments are repeated three times. hands return to the beginning position with a superficial
The therapist then changes hands to massage the medial stroke distally, allowing the thumbs to glide lightly over the
part of the muscle group. Supporting the knee with the left patella. These movements are repeated four times.
hand, the therapist repeats the procedure with the right hand Deep Stroking to the Popliteal Space
three times. The fingertips of both hands are placed together at the distal
Palmar Kneading to the Muscles of the Leg border of the popliteal space. Then they stroke firmly to the
The basic circular kneading stroke is performed as both proximal border and return to the starting position with a
hands grasp around the muscles at the knee and alternately superficial stroke. These movements are repeated four times.

Figure 7-7
Kneading to the calf muscles.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Figure 7-8
Stroking around the patella.

Figure 7-9
Superficial stroking to the dorsum of the foot.

Deep Stroking with Both Hands to the Entire Leg Thumb Pad Kneading to the Dorsum of the Foot
Both hands begin the stroke at the ankle in a position similar Each thumb pad (distal phalanx) is placed in firm contact
to that shown in Figure 7-6, C. Both hands then stroke with the dorsal surface of the foot, the fingers resting on the
firmly toward the knee, returning to their starting position foot’s plantar surface (Figure 7-10, A). Standard thumb pad
with a light, superficial stroke. These movements are kneading, as described for the anterior tibial muscle groups,
repeated three times. is performed progressing from the ankle to the metatarso-
phalangeal joints (Figure 7-10, B). The thumbs return to the
Right Foot ankle position while applying deep stroking over the same
The massage continues to the right leg and foot, with the area. Thumb pad kneading is repeated in successive lanes
therapist standing at the end of the treatment table facing until the medial, dorsal, and lateral surfaces (1.e., the entire
the patient. dorsum) of the foot are covered. These movements are
Superficial Stroking to the Dorsum of the Foot repeated twice.
The palmar surface of the right hand supports the sole of Deep Thumb Pad Stroking to the Plantar Aspect
the foot while the left hand strokes from the ankle (Figure of the Foot
7-9, A) to the end of the toes (Figure 7-9, B), alternating over The thumbs are placed at the base of the toes, the right one
the lateral and the medial dorsal surfaces. These movements at the medial border of the plantar surface, and the left one
are repeated twice. at the lateral border. The fingers rest lightly on the dorsum
 PART TWO PRACTICE

Figure 7-10
Thumb pad kneading to the dorsum of the foot.

Lae
Figure 7-11
Deep thumb pad stroking to the plantar aspect of the foot.

of the foot (Figure 7-11, A). The thumbs stroke firmly in Deep Digital Stroking around the Malleoli
opposite directions from the borders of the foot. passing in The therapist pivots back to face the head of the treatment
the center (Figure 7-11, B). The stroking progresses from table. Both hands are placed on the dorsum of the foot, with
the base of the toes to the heel. The thumbs are held rela- the tips of the fingers at the base of the toes and with the
tively still so that movements of the hands can be produced index fingers together and the thumbs crossed (Figure 7-13,
by abduction and adduction of each arm at the shoulder. The A). The fingers perform deep stroking toward the ankle joint
thumbs are lifted from the skin, and the fingers maintain with firm pressure. At the ankle the hands separate, with the
contact and return to the starting position with a superficial fingers of the left hand stroking around the lateral malleolus
stroke. These movements are repeated twice. as the fingers of the right hand stroke around the medial
Deep Palmar Stroking to the Plantar Aspect of the Foot malleolus (Figure 7-13, B). The palmar surfaces of the
The therapist pivots to face across the end of the treatment fingers keep firm contact, fitting into the contour of the foot
table. The left hand on the dorsum of the foot provides as they circle back to the dorsum of the foot and return to
support. The ulnar border of the right hand is placed firmly the base with a superficial stroke. These movements are
on the plantar surface at the base of the toes (the hand is supi- repeated four times.
nated as in Figure 7-12, A). As the hand strokes firmly toward Digital Stroking to the Achilles Tendon
the heel with deep pressure, it is pronated and made to fit well The wrists are flexed, and the radial sides of the index
into the arch (Figure 7-12, B), finishing with the palm flat on fingers stroke firmly upward on each side of the tendon
the table. These movements are repeated four times. (Figure 7-14, A). Without losing contact, the hands turn so
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Figure 7-12
Deep palmar stroking to the plantar aspect of the foot.

‘Figure 7-13
Deep digital stroking around the malleoli.

Figure 7-14
Digital stroking to the Achilles tendon.
160 PART TWO PRACTICE

that the ulnar side of the little fingers can stroke lightly ments described previously for the right lower limb are now
downward to the heel (Figure 7-14, B). These movements repeated on the left side. All of the movements are the same,
are repeated four times. but the right- and left-hand positions are reversed.
Deep Stroking to the Leg and Thigh
Upper Limb
The therapist returns from the foot to the side of the treat-
ment table, and the hands glide into position for deep strok- Left Arm, Forearm, and Hand
ing of the leg and thigh. Both hands perform deep stroking The therapist continues to stand at the left side of the treat-
beginning at the ankle region and covering all aspects ofthe ment table, in a position that enables him or her to massage
limb, returning to the foot with a superficial stroke. These the upper extremity easily.
movements are repeated three times. Superficial Stroking to the Upper Limb
Superficial Stroking to the Right Thigh, Leg, and Foot
Both hands are placed on the deltoid muscle mass (Figure
The therapist stands at the right side of the patient. Superfi-
7-15, A) and stroke together from the shoulder to the finger-
cial stroking movements are performed on all aspects of the
tips (Figure 7-15, B). This stroke may also be performed
right lower extremity, working from the hip down to the
using an alternate hand technique if preferred. These move-
foot. These movements are repeated four times.
ments are repeated four times.
Left Thigh, Leg, and Foot Deep Palmar Stroking to the Deltoid Muscle
The therapist now moves around the end of the treatment The hands are placed just distal to the borders of the deltoid
table to stand at the left side of the patient. All of the move- muscle (Figure 7-16, A). With firm contact, the right hand

Figure 7-1 5
Superficial stroking to the upper extremity.

Figure 7-1 6
Deep palmar stroking to the deltoid muscle.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

strokes upward over the posterior half of the deltoid toward the
forearm is kneaded (Figure 7-18, B). The therapist uses the
neck. As the right hand returns with a superficial stroke, the
right hand to knead tissues of the patient’s lateral part of the
left hand strokes upward over the anterior half of the deltoid
arm and forearm. The right hand returns to the shoulder,
toward the neck (Figure 7-16, B). As it returns with a superfi-
and the left hand returns to the elbow with a superficial
cial stroke, the right hand starts its second stroke. These move-
stroke, and kneading of the arm and forearm is repeated. At
ments are repeated five times to each side of the deltoid. the end of the second lane of kneading, the left hand returns
Thumb Pad Kneading to the Upper Limb to the shoulder and the right hand returns to the elbow to
Thumb pad kneading is performed to the entire surface of support the arm in slight external rotation with the forearm
the upper limb in three sections: the anterior, lateral, and in supination. Kneading to the medial tissues is then per-
posterior surfaces (Figure 7-17). Kneading is performed formed by the left hand as the right hand provides support.
from the shoulder to the wrist, the hands returning with a At the end of the second lane of left-hand kneading, both
deep stroke from the wrist to the shoulder. These move- hands return to the shoulder with a deep stroke (similar to
ments are repeated twice. that performed on the leg and thigh). These movements are
Palmar Kneading to the Arm and Forearm repeated three times with each hand, giving a total of six
With the right hand, the therapist performs palmar (com- lanes of kneading for each aspect of the limb.
pression) kneading as described for the leg while supporting Alternate Palmar Kneading to the Upper Limb
the patient’s arm with the left hand (Figure 7-18, A) and then Alternate palmar kneading, a two-handed movement, is per-
allows the arm to rest on the table while the supporting hand formed on the upper extremity in the same manner described
passes to the wrist, giving support to the wrist while the for the leg, this time working from the shoulder to the wrist
(Figure 7-19). On the last repetition, the hands do not return
to the shoulder with a deep stroke but remain at the wrist to
begin thumb pad kneading to the dorsum of the hand. These
movements are repeated three times.
Thumb Pad Kneading to the Dorsum of the Hand
Thumb pad kneading is performed to the spaces between
the metacarpals. The stroke begins at the wrist and pro-
gresses toward the metacarpophalangeal (knuckles) joints
(Figure 7-20). The movements finish with a deep stroking
down the metacarpal spaces back to the wrist. The entire
dorsum of the hand can be covered in this manner, working
in the tissue spaces between the metacarpals. These move-
ments are repeated twice.
Thumb Stroking to the Palmar Surface of the
Metacarpophalangeal Joints
The patient’s hand is held in supination and is supported on
Figure 7-17 the fingers of both hands, with the left thumb at the medial
Thumb pad kneading to the upper limb. border and the right thumb at the lateral border (Figure 7-21,

Figure 7-18
Palmar kneading to the arm and forearm.
PART TWO PRACTICE

Figure 7-1 9
Alternate palmar kneading to the upper limb.

Figure 7-20
Thumb pad kneading to the dorsum of the hand.

Figure 7-21
Thumb stroking to the palmar surface of the metacarpophalangeal joints.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

A). The thumbs stroke toward and past each other (Figure of the little finger with firm pressure across the digit. The
7-21, B) with firm pressure and return with light pressure, thumb passes lightly over the dorsum of the fingers and
as described for the plantar surface of the foot. These move- kneads on the lateral aspect. The thumb then strokes back
ments are repeated four times. lightly over the dorsum of the finger and repeats the move-
Thumb Stroking to the Thenar and Hypothenar Eminences ment in the area just distal. This procedure is continued to
The patient’s hand is again held in supination, supported on the tip of the finger (Figure 7-23, A). The thumb and the first
the fingers of both hands, with the left thumb on the hypo- finger then stroke firmly back to the base of the finger. The
thenar eminence and the right thumb on the thenar emi- entire movement is performed twice on each finger. The
nence (Figure 7-22). The thumbs stroke alternately toward thumb is massaged in the same manner, except that the right
the wrist with firm pressure, returning with a light stroke. hand gives support while movements are performed with the
These movements are repeated four times. left (Figure 7-23, B). These movements are repeated three
Thumb Pad Kneading to the Thumb and Fingers times.
The hand is held in pronation and supported in the palm of Deep Stroking to the Upper Limb
the left hand. The right thumb, beginning at the metacarpo- Both hands stroke firmly upward from the wrist to the shoul-
phalangeal joint, kneads on a small area of the medial aspect der and return with a superficial movement. These move-
ments are repeated three times. After the third deep stroke,
the return stroke becomes the start of superficial stroking.
Superficial Stroking to the Upper Limb
Both hands stroke alternately from the shoulder to the fin-
gertips. These movements are repeated four times.

Right Arm, Forearm, and Hand

The therapist walks around the foot of the treatment table
and stands at the patient’s right side, near the right hand,
and repeats all of the previous strokes, this time to the right
upper limb. In each instance, the therapist’s hand positions
are now reversed.

Anterior Trunk
Upper Chest, Neck, and Shoulders
Superficial Stroking to the Upper Chest
The hands alternately stroke from the shoulders to the
sternum. The relaxed hands stroke alternately from the left
Figure 7-22 shoulder to the sternum, covering the area with a few over-
Thumb stroking to the thenar and hypothenar eminences. lapping strokes before moving to the right side without

Figure 7-23
Thumb pad kneading to the thumb and fingers.
Seeeete48 = PART TWo PRACTICE

breaking contact (Figure 7-24). Alternatively, the right hand

may start from the patient’s right shoulder, and as it finishes
the stroke at the sternum, the left hand starts the stroke from
the left shoulder so that contact is not broken. These move-
ments are repeated four times.
Deep Stroking to the Shoulders and Neck
Both hands, with the thumbs adducted, are placed with the
fingertips at the mid to lower end of the sternum (Figure
7-25, A). The hands stroke simultaneously, the right hand
passing lightly upward, then laterally and around the left
shoulder joint, and the left hand passing lightly upward, then
laterally and around the right shoulder joint (Figure 7-25,
B). Both hands continue the movement, stroking toward the
midline of the body along the upper fibers of the trapezius
muscle (Figure 7-25, C). Figure 7-24
After the fingertips meet at the lower cervical spine, the Superficial stroking to the upper chest.
hands stroke around the neck, firmly drawing the muscles
forward (Figure 7-25, D). Pressure is reduced as the hands
stroke over the anterior surface of the neck and return to the
starting position at the sternum. These movements are
repeated four times.

"Figure 7-25
Deep stroking to the shoulder and neck.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

iia
Digital Kneading from the Sternum to the Shoulder joint and return to the sternum with firm pressure (as in the
The fingertips of the left hand are placed at the sternum over previous movement). The movement is repeated on the right
the upper fibers of the left pectoralis major muscle, and the side. This alternate stroking is repeated four times.
right hand is placed over the left hand to reinforce it (Figure Digital Stroking to the Neck
7-26, A). The reverse hand position is equally acceptable. The hands start in the position shown in Figure 7-26, A. The
Kneading is then performed with the fingertips, moving in right hand strokes over the top of the left shoulder and in
small clockwise circles with light pressure on the upward toward the midline of the body. When the fingertips reach
and outward part of the circle and firm pressure in the the lower cervical spine, they stroke upward until the palm
downward and inward part. Four circles are made, each is in contact with the neck. The hand then draws the muscles
succeeding one in an area nearer to the shoulder. As the forward with firm pressure (Figure 7-27, A), exerts light
fingertips reach the shoulder joint, the palm strokes around pressure over the anterior surface of the neck and the clavi-
the joint (Figure 7-26, B), and the entire hand strokes deeply cle, and then returns to the starting position. The stroking
on its way to the sternum. These movements are repeated is then performed in the same manner on the right side
three times on the left side. With the hands in a reversed (Figure 7-27, B). The stroking is repeated four times.
position (or the same position), the therapist performs the Deep Stroking to the Areas of the Jugular Veins
movement on the right side in counterclockwise circles With the thumbs widely abducted, the fingers (palmar
(Figure 7-26, C). These movements are repeated three times surface) of the right hand are placed on the left side of the
on the right side. neck and those of the left hand are placed on the right side
Alternate Deep Stroking from the Shoulder to the Sternum of the patient’s neck, with the borders of the index fingers
The hands are in the same position as in Figure 7-25, A. at the lower tips of the ears (Figure 7-28, A). The hands
With the entire palmar surface, the right hand strokes lightly stroke firmly downward to the base of the neck as the fore-
to the left shoulder joint. The hands then stroke around the arms are pronated and the arms abducted (Figure 7-28, B).

Figure 7-26
Digital kneading from the sternum to the shoulder.
PART TWO PRACTICE

Figure 7-27
Digital stroking to the neck.

Figue 7-28 | a = —_—

Deep stroking to the areas of the jugular veins.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

The thumbs do not make any contact with the neck. With Deep Stroking to the Upper Abdominal Muscles
gradually lessening pressure, the hands continue the stroke One hand is placed so that the fingers lie over the costal
to the tips of the shoulders (Figure 7-28, C). These move- margins of the lower left ribs while the palm is at the base
ments are repeated four times. of the sternum; the other hand is placed over the top for
Deep Stroking to the Neck reinforcement (Figure 7-30, A). The hands stroke lightly in
The therapist repeats the movements for deep stroking over a lateral direction over the ribs, then down over the upper
the shoulder and around the neck (see Figure 7-25) but abdominal muscles (Figure 7-30, B), and then return to
gradually reduces the pressure with each stroke until the last the starting position with firm pressure over the upper
stroke is performed as superficial stroking. abdomen. These movements are repeated four times on the
left side.
Abdomen
One hand is then placed with the fingertips at the base of
The therapist stands at the side of the treatment table to the the sternum and the palm over the lower anterior border of the
right of the patient. The patient’s knees are flexed and sup- right ribs (Figure 7-30, C). The therapist repeats the strokes
ported on a pillow so that there is no tension on the anterior described previously on the right side (Figure 7-30, D). To
and lateral abdominal muscles. have the palm in good contact on this side of the abdomen,
Superficial Stroking to the Abdomen the wrist must be in full extension at the start of the stroke.
With the thumb widely abducted, the right hand is placed These movements are repeated four times on the right side.
over the lower border of the left ribs; the left hand is simi- Palmar Kneading over the Colon
larly placed over the lower border of the right ribs. Both This stroke is designed to knead over the various sections
hands may stroke the tissues simultaneously or they can be of the colon. It is important therefore that the massage be
used alternately. The stroke passes down over the abdomen given in the normal direction of flow in the colon. To begin
and finishes at the upper margin of the symphysis pubis. the stroke, the therapist’s right hand is placed over the lower
Several lanes may be needed to cover the entire abdomen. right quadrant of the patient’s abdomen (beginning of the
The hands are lifted off at the end of the stroke and returned ascending colon), so that the ulnar border of the hand lies
through the air to the starting position without contacting alongside the pubic bone, just medial to the ASIS. The left
the skin. These movements are repeated four times. hand reinforces the right hand directly or by gripping the
Deep Stroking to the Lower Abdominal Muscles right wrist. The ulnar border of the right hand lifts up the
The therapist places the fingertips of both hands side by side tissues in a scooping-like movement, performed by pressure
on the abdomen at the upper margin of the symphysis pubis with the ulnar border of the hand, rolling the hand over to
(Figure 7-29, A). Both hands stroke lightly outward and the thenar border as the palm is pushed toward the finger-
upward, toward their respective left and right ASIS. Both tips, which are kept in contact with the skin during this
hands continue following the crest of the ilium around toward scooping action. The fingertips are then moved to a more
the upper lumbar spine. The palms then turn and stroke proximal point on the ascending colon as the hand rolls back
forward with firm pressure around the waistline (Figure 7- onto its ulnar border and the movement is repeated. Using
29, B) and over the abdomen and back to the starting posi- this movement, the massage progresses over the abdomen,
tion. (The purpose of this movement is to manipulate the covering the areas overlying the ascending, the transverse,
abdominal musculature, not to exert pressure on the abdomi- and the descending colon (Figure 7-31, A). The movement
nal viscera.) These movements are repeated four times. is changed slightly over the descending colon so that the

4 Figure 7-29
Deep stroking to the lower abdominal muscles.
PART TWO PRACTICE

Figure 7-30
Deep stroking to the upper abdominal muscles.

Figure 7-31
Palmar kneading over the colon.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Figure 7-32
Deep stroking over the colon.

firm pressure is applied with the thenar eminence of the

palm. The movement is completed with a firm stroke down-
ward over the lower part of the area of the descending colon
(Figure 7-31, B), with the hand passing lightly over the
midline of the lower abdomen to the beginning of the
ascending colon (starting position). These movements are
repeated three times.
Deep Stroking over the Colon
The fingertips of the right hand are placed at the lower part
(beginning) of the ascending colon, with the left hand rein-
forcing the right (Figure 7-32, A). The fingertips stroke
firmly upward over the area of the ascending colon, across
the area of the transverse colon (Figure 7-32, B), downward
over the descending colon (Figure 7-32, C), and then lightly—
over the midline of the lower abdomen to the starting point.
These movements are repeated six times. Figure 7-33
Alternate Squeeze Kneading over the Entire Abdomen Alternate squeeze kneading over the entire abdomen.
At the right side of the abdomen, both hands, with the
thumbs abducted, grasp the tissues and, by alternate flexion
and extension at the elbows and the shoulders, progress
across the abdomen with a kneading movement (Figure
7-33). Both hands return together to the right side with a
 PART TWO PRACTICE

ee
ee eee
superficial stroke. These movements are repeated four |. The fingers of both hands start the deep stroke at the
times. lower border of the sacrum; the thumbs are crossed for
Deep Stroking to the Lower Abdomen reinforcement (Figure 7-35, A), and the hands stroke
Deep stroking to the lower abdomen is repeated (see Figure upward on each side of the spinous processes with firm
7-32) with gradually reduced pressure to eventually become pressure.
superficial stroking. These movements are repeated four 2. The hands separate at the neck and stroke over the
times. top of the shoulder as the thumbs stroke up to the
NOTE: If the patient suffers from chronic constipation, first cervical vertebra on both sides of the spinous
many of these strokes will need to be done in a depletive processes (Figure 7-35, B). The hands then stroke
manner, beginning with the descending colon. See Colon back, drawing the muscles back also until the
Dysfunction in Chapter 9. fingertips are at the top of the shoulder (Figure 7-35,
C). At the same time, the thumbs stroke down on
Posterior Trunk and Pelvis both sides of the cervical vertebrae. The hands, with
Back and Hips thumbs adducted, then stroke laterally to the shoulder
The therapist stands at the side of the treatment table on the joint (Figure 7-35, D), down the sides of the back to
patient’s left. The patient is repositioned and comfortably the waistline, and then toward the midline (Figure
supported in prone lying, with a pillow under the abdomen 7-35, E) and down until the fingertips are at the
(lumbar spine region) and another under the ankles. The lower border of the sacrum. (The thumbs cross to
patient’s head may be positioned in a number of reinforce as the hands start the downward stroke to
ways, depending on what is comfortable (see Chapter 3; the sacrum.)
Figure 3-8). 3. The hands stroke upward and over the shoulders as in
Superficial Stroking to the Back step 2 (Figure 7-35, A) and return the stroke downward
The therapist’s right hand is placed over the right shoulder, until the fingertips are even with the axilla (Figure 7-
and the left hand is placed over the left shoulder, with the 35, F), then pass laterally and stroke to the sacrum,
thumbs just lateral to the spinous processes of the first cervi- again as in step 2.
cal vertebra (Figure 7-34, A). Both hands, with thumbs 4. The hands stroke upward and over the shoulder as in
abducted, stroke simultaneously to the sacrum, covering as step 2, return the stroke downward until the wrists are
much of the back as possible (Figure 7-34, B). The hands at the waistline (Figure 7-35, G), then pass laterally and
then return in the air to the starting position. These move- stroke to the sacrum, again as in step 2.
ments are repeated four times. The technique can also be 5. The hands stroke upward and over the shoulder as in
performed using alternate hands, in the manner described in step 2, return the stroke downward until the fingertips
Chapter 4. At the end ofthe fourth stroke, the hands maintain are at the waistline, then pass laterally and stroke to
contact so that they are in position to start deep palmar the sacrum (Figure 7-35, H), as in step 2.
stroking. 6. The hands stroke upward, as in step 2, and return the
Deep Palmar Stroking to the Back stroke over the shoulder and then downward, with the
For descriptive purposes, the technique is described in six hands spread to cover the entire back, and return to the
steps, but in practice, each step blends in with the next as sacrum (Figure 7-35, /).
follows: These movements are repeated three times.

Figure 7-34
Superficial stroking to the back.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Figure 7-35
Deep palmar stroking to the back.

Finger Pad Kneading to the Upper Fibers of the Trapezius same manner, except that circles are worked counterclock-
The finger pads of the right hand, reinforced with the left wise. Again, the movements are repeated three times.
hand, are placed at the upper cervical region of the upper Deep Stroking to the Upper Fibers of the Trapezius
fibers of the right trapezius muscle (Figure 7-36, A). They The stroke begins with each thumb placed on the borders of
knead in small clockwise circles, progressing over to the the upper fibers of the trapezius muscle, lateral to the spinous
acromion process (Figure 7-36, B). The fingers return to the processes of the upper cervical vertebrae. The palms of the
starting position with a superficial stroke. These movements hands rest on the belly of the upper fibers. Both hands stroke
are repeated three times. The left side is kneaded in the firmly along the muscle to the acromion process on each
172 PRACTICE

tl

Figure
Finger pad kneading to the upper fibers of the trapezius.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

side, picking up the muscle as the thumbs reach the lower kneading is performed in the same manner as for the right
cervical region (Figure 7-37). The hands then relax and side, except that the circles are made counterclockwise.
return with superficial strokes to begin again. These move- These movements are repeated three times.
ments are repeated four times. Palmar Kneading to the Thoracic and Lumbar Regions
Reinforced Palmar Kneading over the Scapular Region Palmar kneading to the thoracic and lumbar regions is a
Reinforced by the left hand, the right hand is placed with two-handed technique, but the hands work alternately on
the palm above the spine of the right scapula and the thumb each side of the back. The therapist stands facing the patient’s
just lateral to the spinous process of the upper thoracic feet. Both hands are placed on the upper thoracic region
vertebra. The palm kneads in a clockwise circle over the with the thumbs together in the midline. The technique
upper scapular region (Figure 7-38), then glides to make a begins with the left hand stroking across to the lateral border
second circle over the lateral border of the scapula, a third of the right dorsal region with firm pressure (Figure 7-39,
circle over the lower angle of the scapula, and a fourth circle A). The left hand then kneads the tissues in the reverse
over the medial border of the scapula. The movements are direction back to the midline, where it remains stationary.
repeated three times. At this point, the right hand strokes across to the left side
Transition is made from one side to the other with no of the thorax and kneads the tissues on its way back to the
break in contact, the hand simply gliding across with a midline. As the right hand returns, it remains stationary in
superficial stroke. To massage the left scapular region, the the midline, while the left hand again strokes laterally to the
right hand is placed with the palm above the spine of the right side, this time a little lower on the thoracic wall. These
left scapula and the ulnar border of the hand just lateral to strokes are repeated, the hands alternating in direction and
the spinous processes of the upper thoracic vertebrae. The progressing to the lower border of the lumbar region (Figure

Figure 7-37 Eure 7-38

Deep stroking to the upper fibers of the trapezius. Reinforced palmar kneading over the scapular region.

‘Figure 7-39 )
Palmar kneading to the thoracic and lumbar regions.
 PART TWO PRACTICE

7-39, B). Before the left hand completes the stroke at the palms in contact with the back just above the iliac crest
lower lumbar area, the right hand is removed and is placed (Figure 7-41). The thumbs knead alternately in small circles
on the upper dorsal region to start the entire kneading with upward pressure, progressing to the lower border of the
sequence again. The movements are repeated four times. sacrum. At this point, both thumbs stroke along the sacrum
Palmar Stroking to the Lumbar Region with firm pressure to return to the upper border to begin the
The right hand, reinforced by the left, is placed over the stroke again. The movements are repeated four times.
lower ribs on the right side, the fingers extending along the Alternate Palmar Kneading to the Gluteal Muscles
ribs (Figure 7-40, A). The hand strokes lightly from The ulnar border of the right hand is placed at the lower
the spine to the lateral lumbar region of the right side and border of the gluteus maximus muscle (gluteal fold), and the
returns below the ribs, stroking toward the spine with firm ulnar border of the left hand is placed in the area of the
pressure (Figure 7-40, B). These movements are repeated origin of the gluteal muscles. The muscle mass is then
four times. The left side is massaged in the same manner as grasped and kneaded in an alternating movement similar to
the right, except that the right hand is placed with the fin- that described for the quadriceps muscle. Several lanes of
gertips at the spine for the initial stroke. These movements kneading may be required in order to cover the entire muscle
are repeated four times. group. Pressure is applied in such a manner as to avoid
Thumb Pad Kneading to the Sacrum separating the buttocks (Figure 7-42). The left buttock is
The therapist faces the patient’s head and places the thumbs massaged in the same manner as the right. These move-
of both hands at the upper border of the sacrum, with the ments are repeated twice on each side.

Figure 7-40
Palmar stroking to the lumbar region.

Figure 7-41
Fate: 1-42
Thumb pad kneading to the sacrum.
Alternate palmar kneading to the gluteal muscles.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Reinforced Kneading to the Gluteal Muscles (distal phalanges) of the first and second fingers of both
One hand reinforces the other and performs deep kneading hands are placed just lateral to the spinous processes at the
over the right gluteal muscle mass (Figure 7-43) in the same lower cervical region, and the distal phalanx of each thumb
manner as for kneading over the colon, except that the heel is placed an inch or two below the fingertips. (This relative
of the hand exerts firm pressure toward the midline through- position of fingers and thumb is maintained for each hand
out the movement to avoid separating the buttocks. This throughout the movement.) Using a circular motion and firm
movement is repeated twice. The left buttock is kneaded in pressure, the fingers of the right hand draw a portion of the
the same manner as the right, with the same number of muscle downward; simultaneously the left thumb, also with
repetitions. firm pressure, presses a portion of the muscle upward; then
Alternate Palmar Kneading over the Entire Back the right thumb presses a portion upward as the fingers of
This movement is the same as for alternate palmar kneading the left hand draw a portion of the muscle downward, again
over the thoracic and lumbar regions (see Figure 7-39), using a circular motion. The therapist progresses from one
beginning at the upper scapular region and continuing over area to the next by gliding of the fingers during the period
the entire back. These movements are repeated four times. of firm pressure while the thumb of the same hand superfi-
Digital Kneading to the Erector Spinae Muscles cially strokes the area to be covered next. (This kneading of
For digital kneading to the erector spinae muscles, the thera- the tissues between the thumb of one hand and the fingers
pist kneads the tissues between the thumb of one hand and of the other is produced by alternate flexion and extension
the fingers of the other. This technique is similar to the at the elbows and the shoulders.) The kneading is continued
wringing stroke described in Chapter 4. The finger pads to the sacrum. This movement usually is not repeated.
Deep Stroking to the Erector Spinae Muscles
The hands are used alternately in this classical deep stroking
technique. The thumb pad of the therapist’s right hand is
placed over the center of the spine at the cervical region and
moves with a deep stroke down the right side of the back to
the sacrum. This allows the rest of the hand to cover the
mass of the erector spinae muscles as it passes over the
tissues. As the right hand approaches the end of the stroke
(Figure 7-44, A), the left hand starts another deep stroke,
this time over the left side of the back. The right hand
returns in the air (Figure 7-44, B). These movements are
repeated four times.
Superficial Stroking to the Entire Back
Superficial stroking to the entire back is given to finish the
general sequence to this region. The technique is identical
to that described for the erector spinae muscles, except that
Figure 7-43 the pressure used is significantly less and the entire back is
Reinforced kneading to the gluteal muscles. covered with overlapping lanes of the stroke.

Figure 7-44
Deep stroking to the erector spinae muscles.
: - 5 f bia PART TWO PRACTICE

Posterior Neck Region small pillow or neck roll. The therapist stands facing the
patient on either side of the table. All movements are per-
Superficial and Deep Stroking to the Upper Fibers of the
formed with both hands in unison, with the exception of
Trapezius Muscle
thumb pad kneading over the nose.
The thumbs are placed on the borders of the upper fibers of
An alternative position is for the therapist to sit behind
the trapezius muscle on both sides, just lateral to the spinous
the patient’s head (facing the patient’s feet). In this case, the
processes of the upper cervical vertebrae. The palms of the
strokes are performed in a similar manner, but some of the
hands are in contact over the tops of the shoulders. Both
directions will need to be reversed. It is important for
hands stroke lightly to the acromion process on each side,
the therapist to be comfortable during massage to the face
picking up the muscle as the thumbs reach the lower cervical
because these tissues are so delicate compared to the rest of
region. The hands return to the starting position with a
the body. It is therefore essential that the therapist has com-
superficial stroke. This movement is performed eight times,
plete control of his or her hands, especially around delicate
with increasing pressure, so that by the fifth stroke the
structures such as the eyes. Although the patient’s eyes are
therapist is applying deep stroking; the hands return to the
starting position with superficial stroking. usually closed during facial massage, they are still vulnera-
Finger Pad Kneading over the Upper Fibers of the ble to damage because the thin layer of skin that comprises
Trapezius Muscle the eyelids is their only protection.
The fingertips of the right hand, reinforced by the left hand, Superficial Stroking to the Face
are placed at the upper cervical region of the left trapezius 1. The therapist’s palms are placed side by side on the
muscle. As usual, the fingers knead in small clockwise forehead, with the thenar eminences on either side of
circles, exerting heavier pressure over one half of each the midline. The fingers are flexed slightly to fit over
circle. Kneading progresses to the acromion process. The the head, with the fingertips resting lightly on the top
fingertips return to the starting position with a superficial of the head (Figure 7-45, A). The palms stroke to the
stroke. These movements are repeated three times. The right lateral borders of the forehead (Figure 7-45, B) and
side is kneaded in the same manner, except that the circles return to the starting position by moving through the
are made counterclockwise. These movements are repeated air while the hands pivot on the fingertips. These
three times. movements are repeated twice.
Deep Stroking over the Upper Fibers of the 2. The movements are the same as in step 1, except that
Trapezius Muscle the fingertips rest at the hairline so that the palms are
Deep stroking over the upper fibers of the trapezius muscle placed over the cheeks (Figure 7-45, C, D). They are
is performed in the same manner as that described for super- repeated twice.
ficial and deep stroking over the upper fibers of the trapezius 3. The fingertips glide lightly from the hairline to the
muscle (described earlier), except that the pressure starts temples. The thumb pads are placed together at the
deeply and is gradually lessened to superficial stroking. center of the chin (Figure 7-45, E). The thumb pads
These movements are repeated six times. then stroke laterally along the border of the mandible
to the tip of the ear (Figure 7-45, F) and return to the
chin through the air. These movements are repeated
Head and Neck
twice.
Face and Anterior Neck 4. The movements are the same as in step 3, except that
Facial massage may be added to a general massage. Patients the thumb pads start under the chin and stroke under
with insomnia frequently respond particularly well to facial the jaw to the tip of the ear. The movements are
massage, and it is a useful sedative in the treatrnent of head- repeated twice.
ache. The movements are performed over a small area and Thumb Pad Kneading to the Forehead
should be gentle so that a lubricant is not usually necessary. The fingertips of each hand keep contact at the temple, and
As always, the therapist’s hands should be washed and thor- the thumb pads are placed together at the center of the lower
oughly dried before treatment. A small amount of fine border of the forehead (Figure 7-46, A). The thumb pads
unscented baby (talcum) powder may be used if the skin is knead simultaneously, but out of phase with each other, in
moist from perspiration, but it should never be applied small circles (Figure 7-46, B), continuing up to the hairline.
directly to the patient’s face. Care is needed to ensure that They return in the air to the lower border of the forehead at
the patient does not breathe the powder whenever it is used. an adjacent lateral area. The strokes are repeated until the
The technique for facial massage that follows is a type entire forehead is covered in a series of overlapping lanes.
recommended for sedation in the treatment of headache and The movements are repeated twice.
insomnia. If general massage has not been given, the treat- Deep Stroking to the Forehead
ment should include the chest and upper back movements The fingertips of each hand are kept in contact at the temples,
described previously for general massage, and for the face, and the palms are placed with the thumbs together in the
head, and neck (in the following section). The patient should midline of the forehead (Figure 7-47, A). The palms stroke
be lying supine (recumbent) with the head supported on a laterally from the midline, with firm pressure (Figure 7-47,
 GENERAL MASSAGE SEQUENCES 177

Superficial stroking to the face.

B), returning through the air. The movements are repeated ridge (eyebrow) before returning through the air (Figure
three times. 7-48, B). These movements are repeated three times.
Thumb Pad Kneading to the Nose At the end of the third kneading stroke, the thumbs keep
The fingertips are kept in contact at the temples, and the contact at the hollows, ready to start the next movement.
distal phalanges of the thumbs are placed at the tip of the Deep Stroking to the Supraorbital Ridge
nose (Figure 7-48, A). Alternate thumb pad kneading is This movement flows from the previous one without break-
performed on the sides of the nose, up to the bridge. The ing contact. The thumbs stroke outward with firm pressure
thumbs pause with firm pressure in the hollows formed by over the supraorbital ridge (eyebrow) and return through the
the bridge of the nose and the medial part of the supraorbital air (Figure 7-49). The movements are repeated four times.
PART TWO PRACTICE

Figure 7-46
Thumb pad kneading to the forehead.

Figure 7-47
Deep stroking to the forehead.

pote 7-48
Thumb pad kneading to the nose.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Figure 7-49
Figure 7-50
Deep stroking to the supraorbital ridge.
Deep stroking to the infraorbital ridge.

Figure 7-51
Finger pad kneading from the temple to the cervical spine.

Deep Stroking to the Infraorbital Ridge trapezius, gradually reducing pressure to the tips of the
The hands remain in the same position as for stroking the shoulders. The hands again return to the temples through
supraorbital ridge, allowing the thumbs to stroke over the the air. These movements are repeated twice.
infraorbital ridge (Figure 7-50) and return through the air. Finger Pad Kneading from the Temples to the Shoulders
The movements are repeated four times. The fingertips knead in small circles from the temples
Finger Pad Kneading from the Temple to the (Figure 7-52, A), passing in front of the ears to the mastoid
Cervical Spine processes. The strokes continue over both sternocleidomas-
Continuing on from the previous stroke, the thumbs remain in toid muscles and the upper fibers of the trapezius muscles
the air, and the fingertips (again without breaking the contact (Figure 7-52, B) to the tips of the shoulders. The hands
with the temples) simultaneously knead in small circles, start- then return through the air. The movements are repeated
ing at the midline of the temples and, following the hairline. twice.
(Figure 7-51, A), continuing along the back ofthe ears until the Deep Stroking over the Area of the Jugular Veins
fingers meet at the cervical spine (Figure 7-51, B). This stroke is the same as that previously described for deep
Without breaking contact, the fingers stroke with firm stroking over the areas of the jugular veins. With the thumbs
pressure down the cervical spine to the seventh cervical widely abducted, the fingers (palmar surface) of the thera-
vertebra. The thumbs then make contact with the anterior pist’s right hand are placed on the left side of the neck and
borders of the trapezius muscle, and the stroking is contin- those of the left hand are placed on the right side of the
ued with the thumbs and fingers over the upper fibers of the patient’s neck, with the borders of the index fingers at the
 PART TWO PRACTICE

B
Figure 7-52
Finger pad kneading from the temples to the shoulders.

Figure 7-53
Palmar kneading to the cheeks.

lower tips of the ears (Figure 7-28, A). The hands stroke Thumb Pad Kneading to the Chin and Lower Jaw
firmly downward to the base of the neck as the forearms The fingertips glide lightly to make contact below the ears.
are pronated and the arms abducted (Figure 7-28, B). The The thumbs are placed together at the center of the lower
thumbs do not make any contact with the neck. With gradu- border of the chin (Figure 7-54, A) and knead simultane-
ally lessening pressure, the hands continue the stroke to the ously, but out of phase with each other, in small circles
tips of the shoulders (Figure 7-28, C). These movements are upward to the lower lip, returning with superficial stroking
repeated four times. to knead over more lateral areas of the chin. They continue
Palmar Kneading to the Cheeks this kneading over the mandibles to the tips of the ears,
The fingertips rest on the forehead while the palms rest covering the tissues in a series of overlapping lanes (Figure
lightly on the cheeks and knead in circles, three times in 7-54, B). These movements are repeated three times.
opposite directions (i.e., the right hand clockwise and the Deep Stroking to the Chin and Lower Jaw
left counterclockwise) (Figure 7-53, A) and three times in Keeping the fingers in contact, the thumbs return to the
the reversed directions (Figure 7-53, B). As with standard midline of the chin as they were at the start of the previous
kneading, the palms do not move over the skin but with movement. They then stroke with firm pressure from the
gentle pressure move the tissues over the bony surface chin to the tips of the ears (Figure 7-55) to return through
underneath. The movements are repeated twice. the air. These movements are repeated three times.
 GENERAL MASSAGE SEQUENCES CHAPTER 7

Figure 7-54
Thumb pad kneading to the chin and the lower jaw.

with firm pressure in small circles, in sections, until the

entire head is covered. In the one-handed technique, both
hands are placed on the scalp, but one hand is stabilizing
the head while the other hand kneads the scalp tissues. The
hands are then reversed to massage the other half of the
scalp. In the two-handed technique, the fingertips knead
the tissues simultaneously but out of phase with each
other. The fingertips keep contact with the skin and hair and
move the scalp over the bony surface underneath. The pres-
sure must be released before the fingertips are moved to each
surrounding area, to avoid pulling the hair. The entire scalp
can be covered twice with this technique.

SUMMARY
Figure 7-55 The massage sequences described in this chapter are
Deep stroking to the chin and the lower jaw. designed to cover the entire body in a single treatment
session. The massage would take about 45 minutes to 1 hour
Deep Stroking over the Jugular Veins to complete in the average patient. The actual sequence is,
Without breaking contact after the preceding movement, the of course, made up of a series of individual massage strokes.
therapist repeats the procedures described for deep stroking As mentioned previously, there are many ways in which
over the area of the jugular veins (described earlier; see these basic massage strokes can be combined into a general
Figure 7-28). These movements are repeated four times. massage sequence. This is simply one example of the pos-
Superficial Stroking to the Face sibilities. The number of repetitions indicated for each tech-
The movements are those described previously for superfi- nique is the approximate number required to give a general
cial stroking to the face (see Figure 7-45). massage within | hour at the usual rate of speed for each
stroke (see Chapter 4). This must not be interpreted to mean
Scalp that all general massage must be given for exactly 1 hour or
Finger Pad Kneading over the Scalp that in all instances every movement must be performed in
The therapist’s thumbs are placed at the temples with the every area exactly the number of times suggested. The sug-
fingers spread apart and the fingertips placed on either side gested massage sequence for each region of the body
of the medial line of the scalp. A one-handed or two-handed described in this chapter can also be used as a template for
technique may be used, depending on patient comfort and performing local massage. This concept is addressed in
therapist preference. In either case, the finger pads knead more detail in the next chapter.
 Local Massage Sequences

Local injury or disease can affect many different tissues, technique. For example, if tendon and muscle contractures
including skin, muscles, tendons, joints, nerves, blood, and are limiting joint motion, then the mobilizing effects of
lymph vessels. A therapist must have a thorough knowledge kneading, wringing, picking up, and deep frictions might be
of the anatomy and physiology of the structures involved, helpful, especially when combined with other treatments
together with an understanding of the pathological condi- such as exercise and appropriate electrophysical agents
tions in the tissues to be treated, if the treatment is to be as (EPAs). It is therefore proper for an experienced therapist to
effective as possible. Muscles may be atrophied, decreased develop his or her own particular combination of massage
in tone, fibrotic, flaccid, or in spasm. Tissues may be edema- techniques (a sequence) to be used as part of a specific treat-
tous; joint effusion and inflammation may limit movement ment plan for local trauma or disease in a patient. Modern
and produce pain. Adhesions and contractures may cause rehabilitation practice now encompasses a wide variety of
tendons to adhere to the surrounding structures, and the treatment concepts, including many types of soft tissue
circulation may also be impaired. These problems are likely manipulation. Although some of today’s treatment con-
to prevent normal limb motion and therefore everyday func- cepts have been developed over the past 50 years, other
tional abilities. Each of these potential problems must be techniques have been practiced for many centuries (see
evaluated and treated by techniques selected according to Chapter | on the history of massage). The combination of
the changes present and the specific treatment goals. time-honored techniques and newer ideas has significantly
A variety of massage strokes can be a useful part of a increased the treatment options available to both patient and
total treatment plan for managing an individual patient’s therapist.
condition, but massage techniques are simply one of many It is important to recognize that there are many different
different options for the treatment of local trauma or disease. ideas about massage strokes and how they can be combined
The best results are most likely to be achieved when the into a massage sequence, sometimes called a massage
appropriate manual techniques, including massage, are system. Many of these systems of massage were popular in
combined with a suitable exercise program (or rest) and the early 1900s and were effective then, as indeed they are
appropriate electrophysical agents (modalities). In this today; however, the development of modern rehabilitation
context, all soft tissue manipulation techniques, including methods has produced other procedures that are more effec-
massage, are simply adjunctive to the total treatment plan. tive than massage alone. For this reason, massage is rarely
Each of the individual techniques described in Chapter used as a sole treatment today; in fact, it can be argued that
4 can be used separately or in combination with each other massage has its most beneficial effects when it is combined
and with many other treatment approaches. The important with other treatments to give a more rounded approach to
point is for the therapist to gain a thorough understanding the management of the patient’s problem. In this regard, it
of how the patient’s problems are affecting the tissues. Once is most appropriate to select suitable techniques from those
this is properly understood, identifying appropriate treat- detailed in Chapter 4 and combine them with any of a
ment goals and choosing a suitable massage technique 1s number of complementary techniques. This may well result
relatively easy—it is simply a question of matching the in a mini-sequence of strokes, designed to achieve a particu-
needs of the tissues with the known effects of the massage lar effect, especially if it is directed to a specific anatomical
initia aan “4

structure such as a ligament or tendon. This may be termed therapist could use all of the techniques affecting these
focal massage to distinguish it from local or general massage structures.
(see Chapter 9 for examples). The rest of this chapter is devoted to a local massage
The term local massage was defined in Chapter 4 as sequence based on a concept of local massage developed by
follows: Albert Hoffa (1859-1907). Although this system can be used
A combination of different massage strokes applied to an alone, it can also be combined with other suitable treat-
individual region of the body in order to achieve particu- ments. A modified version is presented here to suggest how
larly desired effects. this approach might be used. For purposes of completeness,
A combination of individual strokes represents a local all of the important areas of the body are discussed. Each
massage sequence, and the specific strokes included in such area can be considered separately, and, when appropriate,
a list can be many and varied. Based on the description and they may be combined.
use of the individual strokes described in Chapter 4, the
sequences listed in Tables 8-1 to 8-4 can be used for local
THE HOFFA SYSTEM
massage treatments to the regions specified. The therapist
can modify each list as desired and as needed to treat an Albert Hoffa’s original work, Technic der Massage, was
individual patient. For example, a therapist could select a published in four editions, the last one in 1903 (see Chapter
local sequence of techniques to treat the major muscles of a 1). The system developed by this eminent surgeon follows
patient’s upper arm (biceps and triceps). In this case, the an anatomical pattern and is based on a knowledge of physi-

lable 8-1 Local Massage Sequence for the Lower Limbs (I)

Anterior Aspects (Patient in Long Sitting)

Superficial stroking to the whole limb 3
Effleurage to the whole limb 3
Compression kneading to the thigh muscles 3
Picking up to the quadriceps muscles 3
Wringing to the medial thigh muscles 3
Effleurage to the whole limb 3
Finger pad kneading around the patella 2
Picking up to the calf muscles 4-49 3
Thumb pad kneading to the anterior tibial muscles 2
Finger pad kneading to the ankle region 2
Thumb pad kneading to the dorsum of the foot and toes 2
Knuckle kneading to the plantar aspects of the foot 3
Effleurage to the whole limb 3
Relaxed passive movements to the lower limb 3

lable 8-2 Local Massage Sequence for the Lower Limbs (II)

Posterior Aspects (Patient in Prone Lying)

Superficial stroking to the whole limb
Effleurage to the whole limb
Compression kneading to the thigh muscles
Picking up to the hamstring muscles
Wringing to the hamstring muscles
Effleurage to the whole limb
Finger pad kneading around the knee joint regions
Compression kneading to the calf muscles te o9NS)
Picking up to the calf muscles
Wringing to the calf muscles
Thumb pad kneading to the calf muscles
Finger pad kneading to the ankle region
Thumb pad kneading to the plantar aspects of the foot and toes
Effleurage to the whole limb
Relaxed passive movements to the lower limb
OWONNNWW
 LOCAL MASSAGE SEQUENCES CHAPTER 8

lable 8-3 Local Massage Sequence for the Upper Limbs

All Aspects (Patient in Sitting)

Superficial stroking to the whole limb
3
Effleurage to the whole limb
3
Compression kneading to the deltoid, biceps, and triceps muscles
3
Picking up to the deltoid, biceps, and triceps muscles
3
Wringing to the biceps and triceps 3
Finger pad kneading around the elbow joint
2
Effleurage to the whole limb 3
Thumb pad kneading to the wrist and finger extensors 2
Thumb pad kneading to the wrist and finger flexors
Z
Thumb pad kneading to the wrist and hand 2
Effleurage to the whole limb 3
Relaxed passive movements to the upper limb 3

lable 8-4 Local Massage Sequence for the Posterior Trunk and Pelvis
bastard Ss

Back (Patient in Prone Lying)

Superficial stroking to the entire back region
Effleurage to the entire back region
Compression kneading to the posterior trunk muscles
Reinforced kneading to the lumbar region
Effleurage to the entire back region
Wringing to the muscles of the lateral body wall
Skin rolling over the posteriolateral chest wall
Circular frictions to the paraspinal muscles
Effleurage to the entire back region WW
ONWWWWW

ology. The movements are applied to certain muscles or deposits, and thickenings in tissue around joints and
muscle groups; this contrasts with some other systems that tendons and to help remove the waste products through
apply strokes either to an entire extremity or to a certain the lymphatic system. Vibration and tapotement (percus-
area of the body. Hoffa classified the essential massage sion) are recommended to increase blood supply, reduce
strokes as effleurage (stroking), pétrissage (Kneading), fric- nerve irritability, and increase contraction of muscle fibers.
tion, vibration, and tapotement (percussion) and stated that These techniques are probably of little value in the treatment
these are only the framework on which an experienced of local trauma, but they do have some specific uses for
therapist with good judgment may build up an effective certain lesions; for example, the percussion and vibration
treatment for a given patient’s problem. He emphasized the techniques can be useful in treating some respiratory
value of massage for increasing venous and lymphatic cir- problems.
culation: One must keep in mind, however, the context in
which he developed his system and, in particular, the range Classification and Description of
of treatment options available at the time and the state of Local Massage Strokes Used in
medical knowledge. (The rehabilitation professions as we the Hoffa System
currently know them did not exist at that time.) The following classification and description of massage
According to Hoffa, effleurage (stroking) is employed to strokes is a modification of the Hoffa system of massage as
stimulate circulation in the small veins in the muscles, par-, described by Gertrude Beard in the early editions of this
ticularly in the large veins or venous plexuses that lie in the text. In general, all of these descriptions match those defined
grooves between the individual muscles. This is accom- in Chapter 4. The Hoffa system uses only a selected number
plished by making the hand conform closely to the contours of these techniques, and, of course, any appropriate combi-
of the part as the thumb and fingertips proceed along these nation of these techniques is possible.
interstices. Pétrissage (kneading) is used chiefly to increase
Stroking (Superficial or Deep)
the circulation in the muscles and to remove products in a
manner analogous to that of friction. Friction movements Note that in the Hoffa system, deep stroking is similar to
are applied chiefly to break down pathologic exudates, effleurage.
 emetic PART TWO PRACTICE

icc
ii
|. The direction of the deep stroke is always in the muscle, finishing with a squeeze-out movement
direction of venous blood and lymph flow. (Figure 8-1, C).
i). The stroke is applied to the entire length of the muscle 5. The thumb and fingers work simultaneously, but the
or muscle group, beginning at the insertion and pressure must be diminished as they approach each
continuing to the origin. other, to prevent pinching.
3. The hand returns over the same area with light pres- 6. Care must be used to keep the bulk of the muscle well
sure (superficial stroking). back in the palm of the hand between the thenar
4. The hand is made to conform to the shape of the eminence and the metacarpal pad of the palm (see
muscle or muscle group, attempting to reach around Figure 8-1, A).
and lift up the bulk of the muscle or group. The palmar 7. At the origin of the muscle, the hand is brought
surfaces of the entire hand or the distal phalanges of over into pronation and returned to the starting
the fingers (finger pads) or of the thumb (thumb pad) position with a superficial stroke over the area
are used, according to the size of the muscle. (Figure 8-1, D, E).
5. The pressure is regulated according to the bulk of the Two-Handed Kneading
muscles: light at the beginning of the deep stroke, 1. One hand is placed at the insertion of the muscle, as in
increasing over the bulkiest part of the muscles, single-handed kneading; the other hand is placed just
diminishing at the end of the stroke, and finishing with proximal to it (Figure 8-2, A).
a squeeze-out movement. In performing the squeeze- 2. Both hands grasp around as much of the muscle as
out movement, the grasping surfaces of the hand are possible. The palmar surface of the fingers of the left
gradually approximated more closely as the muscle hand pulls the muscles laterally as the surface of the
bulk decreases and the hand approaches the origin of abducted right thumb and palm simultaneously pushes
the muscle. As the hand reaches the point of origin, it the tissues medially. Then the surface of the palm and
is pronated. The bulk of the tissue being massaged is abducted thumb of the left hand pushes the muscles
thus squeezed out of the hand, and the hand is in medially as the palmar surface of the fingers of the
position to start the return stroke. right hand pulls the tissue laterally (Figure 8-2, B).
6. The movements should be performed rhythmically. Progression from the distal to the proximal part of the
7. The rate of movement should be relatively slow. muscle is accomplished with a gliding of the hands on
the pull stroke of the kneading movement. This
Kneading
procedure is similar to the technique of wringing
The kneading movements in the Hoffa system are performed described in Chapter 4, but it is not a pinching type of
with one or both hands (single-handed or two-handed knead- movement. The thumb and fingers of each hand should
ing). The therapist can also perform these strokes with the be kept in the same relation to each other during the
distal phalanges of the thumb (thumb pad kneading) or the entire movement. The push-and-pull movements are
index and middle fingers (finger pad kneading) of one or both accomplished chiefly by flexion and extension of the
hands. Finger pad kneading is also called digital kneading. arms at the shoulders and elbows. At the origin, the
Single-handed kneading is used on muscles that are not proximal hand is removed, and the distal hand finishes
too large to be grasped in one hand. For very large muscles, with the squeeze-out movement (see Figure 8-1, D, E)
two-handed kneading can be used. Digital kneading is used and returns to the starting position with a superficial
on narrow or flat muscles that cannot be grasped easily by stroke, as in single-handed kneading.
the entire hand. As in stroking, the hand must conform to Two-Handed Digital Kneading
the size and shape of the muscles and make firm contact. The therapist uses both hands (between the thumb and the
The movement begins at the insertion of the muscle and is index and middle fingers of each hand) to grasp the muscle
carried through to the origin. at its insertion. The palmar surface of the left fingers pulls
Single-Handed Kneading the tissues toward the therapist, while the right thumb pushes
1. The hand is placed at the insertion of the muscle with the adjacent tissues away. Then the right fingers pull the
the palmar surface of its ulnar border in firm contact tissues while the left thumb pushes the adjacent tissues
(Figure 8-1, A). (Figure 8-3). Progression from origin to insertion is accom-
2. The hand grasps around the bulk of the muscle and plished with a gliding of the fingers on the pull movement.
lifts it as much as possible from the underlying tissues Again, this should not be a pinching movement. The thumb
(Figure 8-1, B). and fingers of each hand are kept in the same relation to each
3. The fingers and ulnar border of the hand follow along other during the entire movement. The push and pull are
one border of the muscle or muscle group, and the accomplished chiefly by flexion and extension of the arms at
thumb follows along the opposite border (see the shoulders and elbows. The return stroke is performed
Figure 8-1, B). with the fingers of the distal hand. This movement is used
4. The movement is one of grasping and releasing the mainly for muscles of small to medium bulk. Care must be
tissues, and it is carried through to the origin of the taken to ensure that the hands are held parallel to the length
 LOCAL MASSAGE SEQUENCES CHAPTER 8 eB Msgs 2.

E e ; j oll J { ia (i } }
Figure 8-1
Single-handed kneading to the upper arm and thigh.

of the muscles, thereby allowing as much contact as possible.” from the classical Hoffa system. In the application of these
This technique produces a movement similar to the stroke massage strokes to an extremity, the proximal portion should
called wringing; however, there is no twist in this stroke. be treated first, followed by the more distal segment or
segments. Then special attention may be given to areas that
Modified Hoffa Technique for require additional treatment. The stroking and kneading
Local Massage movements may be adapted to conform to the muscles of
The technique of local massage described next and its appli- any body area. In the beginning of treatment, stroking pre-
cation to the anatomical sections of the body are modified cedes the kneading movement, and periods of stroking and
 PART TWO PRACTICE

Figure 8-2
Two-handed kneading to the thigh and upper arm.

detailed description follows with specific references to

figures in the text that illustrate the various techniques. As
a general guide, the therapist will repeat each technique
three times. This modified Hoffa sequence is not demon-
strated on the accompanying DVD.

Local Massage Sequence (Modified

Hoffa System)
Tables 8-5 to 8-8 describe local massage sequences for the
lower limbs, upper limbs, posterior trunk and pelvis, and
head/neck area. -

TECHNIQUE FOR A LOCAL

MASSAGE SEQUENCE
Figure 8-3
Upper Limb
Two-handed digital kneading to the leg.
Right Arm
The therapist stands next to the treatment table on the right-
kneading should alternate according to the pathologic con- hand side of the patient. The patient is appropriately draped,
dition being treated, the desired effect, and the result being lying supine in a comfortably supported position (see Figure
obtained from the massage. The final stroke should always 3-7, C, in Chapter 3), with the right arm slightly abducted.
be superficial stroking. For treatment purposes, the arm is divided into three muscle
The order in which massage is given to the various groups: the deltoid muscle, the elbow extensors, and the
muscle groups of each anatomical region depends on the elbow flexors.
condition being treated and the ability of the patient to be Deltoid Muscle Group
moved into the required positions. It may be necessary to Stroking. The therapist’s hands stroke alternately. Begin-
alter the techniques slightly to avoid unnecessary changes ning at the insertion of the deltoid muscle (Figure 8-4, A),
of the patient’s position. In general, the position of the the thumb of each hand passes up the midline of the patient’s
patient should be changed as little as possible. The tech- muscle; the fingers of the left hand follow the posterior
niques, as described, are those that should be followed when border of the muscle and curve around the origin to the
it is possible to place the patient in the ideal position to center (Figure 8-4, B); the fingers of the right hand follow
perform each stroke. Under most circumstances, the patient the anterior border in the same manner (Figure 8-4, C).
should lie recumbent while receiving massage treatment. Each hand returns to its starting position with a superficial
All of the local sequences suggested for each body region stroke (Figure 8-4, D).
are summarized at this point so that the reader can gain If the muscle is small, the entire muscle may be stroked
a clear understanding of their structure. Where possible, a with the left hand as the right hand supports the inner side
of
 LOCAL MASSAGE SEQUENCES CHAPTER 8

Jable 8-5 Local Massage Sequence for the Upper Limbs

Wiis SEEN ORR OS eA FE TTR CTE ST

Right Arm
Deltoid muscle group 8-4 3
Elbow extensor muscle group (triceps and anconeus)
8-5 3
Elbow flexor muscle group (biceps, brachialis, and coracobrachialis) 8-6 3
Right Forearm
Medial muscle groups 8-7 3
Lateral muscle groups 8-7 3
Right Hand
Muscles of the radial section (thenar muscles, adductor pollicis, lumbricals, and interossei) 8-9 3
Muscles of the ulnar section (hypothenar muscles, lumbricals, and interossei) 8-10 3
Palmar surface 8-11 3
Dorsal surface 8-12 3
Right Thumb and Fingers
Dorsal surface 8-13 3
Palmar surface 8-14 3
Left Arm, Forearm, and Hand
All of the previous strokes are repeated to the left upper limb

Table 8 -6 Local Massag e Sequence for the Lower Limbs

5) cS

Right Buttock Region

Gluteal muscles (gluteus maximus, medius, and minimus) 8-15 3
Right Thigh
Medial hamstring muscles (semimembranosus and semitendinosus) 8-16 3
Lateral hamstring muscle (biceps femoris) 8-17 3
Tensor of the fascia lata (including the iliotibial tract/band) 8-18 3
Anterior thigh group (rectus femoris, vastus medialis, vastus 8-19 3
intermedius, vastus lateralis, and articularis genu sartorius)
Adductor muscle group (adductor, longus, adductor magnus, and gracilis) 8-20 3
Right Leg
Anterior tibial muscles (tibialis anterior, extensor digitorum longus, 8-21 3
extensor hallucis longus, and fibularis/peroneus tertius)
Fibularis (peroneal) muscles (fibularis longus and fibularis brevis) 8-22 3
Calf muscles (gastrocnemius, soleus, and plantaris) 8-23 3
Right Foot*
Medial section 8-24 3
Lateral section 8-25 3
Dorsal section 8-26 3
Plantar section 8-27 3
Right Toes = 3
Left Buttock, Thigh, Leg, and Foot
All of the previous strokes are repeated on the left lower limb —

“Various structures in the foot, including skin, subcutaneous fat and connective tissues, muscles, tendons, tendon sheaths, ligaments, joint
capsules, and neurovascular bundles.

Jable 8-7 Local Massage Sequence for the Trunk and Peivis

Back and Hips i

Paraspinal muscles 8-28 3
Trapezius and scapular muscles (trapezius, supraspinatus, infraspinatus, levator 8-29 g
scapulae, rhomboid major, rhomboid minor, and teres major)
Latissimus dorsi muscle 8-30 3
Abdomen
Stroking over the entire abdomen 8-31 3
Stroking over the area of the colon re oOine) wo

Kneading over the area of the colon 8-33 3

190 PART TWO PRACTICE

lable 8-8 Local Massage Sequence for the Head and Neck
| FACIAL MUSCLES | ey Ter FIGURE RED RTE fe aS e MarREN eee TD

Frontalis 1

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Nasalis
Levator anguli oris
Zygomaticus major and minor
Orbicularis oris
Depressor anguli oris
Platysma G&
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Figure 8-4
Local massage to the deltoid muscle group.
 LOCAL MASSAGE SEQUENCES CHAPTER 8

Figure 8-4, cont’d

the upper arm. The fingers of the left hand follow the poste- border, and the fingers follow the medial border of the elbow
rior border of the muscle, and the thumb follows the anterior flexor muscle group as the hand strokes over the muscles.
border (Figure 8-4, E); they meet at the acromion process in At the end of the stroke, the thumb passes around the ante-
a squeeze-out movement (Figure 8-4, F). The left hand rior border of the deltoid muscle, while the fingers move into
returns to its starting position with a superficial stroke. the axilla and the hand performs a squeeze-out movement
Kneading. Two-handed kneading is performed to the entire (Figure 8-6, B). The hand then returns to the starting posi-
deltoid muscle, with the patient’s arm partially abducted. tion with a superficial stroke.
Kneading progresses from the insertion to the origin of the Kneading. Single-handed kneading is performed over the
muscle (Figure 8-4, G). The left hand performs a squeeze-out same area that was stroked (Figure 8-6, C, D). Two-handed
movement at the origin and returns to the starting position kneading may be used if the muscle group is large. Hand
with a superficial stroke as the right hand returns through the positions are the reverse of those described for two-handed
air. Single-handed kneading may be performed with the left kneading of the triceps muscle group (see Figure 8-5, £).
hand if the muscle is small, in which case the right hand
would support the rest of the arm (Figure 8-4, 1). Right Forearm
The therapist’s forearm is divided longitudinally into two
Elbow Extensor Muscle Group muscle groups: medial and lateral. Each group contains
Triceps and Anconeus some of the wrist and finger flexors and extensors. Although
Stroking. The therapist’s right hand supports the elbow; this is not a strictly anatomical division, it greatly facilitates
the left hand grasps around the muscle group at its insertion. local massage to the forearm.
The thumb follows the lateral border, and the fingers follow Medial Muscle Group
the medial border of the triceps as the hand strokes over the The patient’s elbow is slightly flexed with the forearm in
muscle (Figure 8-5, A). At the end of the stroke, the thumb supination, while the arm rests on the table. A small pillow
passes around the posterior border of the deltoid, while may be used to support the arm if necessary.
the fingers move into the axilla and the hand performs a Stroking. The left hand supports the forearm at the wrist.
squeeze-out movement (Figure 8-5, B). The hand then The right hand starts the stroking by grasping around the
returns to the starting position with a superficial stroke. medial half of the forearm at the wrist (Figure 8-7, A).
Kneading. Single-handed kneading is performed over the The thumb then passes up the midline of the forearm to the
same area that was stroked (Figure 8-5, C, D), and the hand elbow and over the medial condyle of the humerus as
returns with a superficial stroke. Two-handed kneading may the fingers pass up along the ulna and over the medial aspect
be used if the muscle group is large. The patient’s arm is to meet the thumb in a squeeze-out movement (Figure 8-7,
partially abducted, and both of the therapist’s hands grasp B). The hand returns to the wrist with a superficial stroke.
the triceps muscle, with the left hand at the insertion and Kneading. Single-handed kneading is performed over the
the right hand just proximal to it (Figure 8-5, £). same area that was stroked (Figure 8-7, C, D), with the hand
returning with a superficial stroke. Two-handed kneading is
Elbow Flexor Muscle Group possible if the patient’s forearm is particularly large.
Biceps, Brachialis, and Coracobrachialis Lateral Muscle Group
Stroking. The left hand supports the elbow, and the right Stroking. The therapist’s right hand supports the wrist.
hand grasps the muscle group at its insertion below the The left hand starts the stroke by grasping around the lateral
elbow joint (Figure 8-6, A). The thumb follows the lateral half of the forearm (Figure 8-8, A). The thumb then passes
 PART TWO PRACTICE

Figure 8-5
Local massage to the extensor muscle group (triceps and
anconeus).

up the midline of the forearm to the elbow and over the Right Hand
lateral condyle of the humerus as the fingers pass along the Muscles of the Radial Section
radius and over the lateral condyle to meet the thumb in a Thenar Muscles, Adductor Pollicis, Lumbricals,
squeeze-out movement (Figure 8-8, B). The hand returns to
and Interossei
the wrist with a superficial stroke. The patient’s forearm and hand are in supination (facing the
Kneading. Single-handed kneading is performed over the ceiling), with the thumb abducted and the forearm comfort-
same area that was stroked. The hand returns with a super- ably supported on the table. For treatment purposes, the
ficial stroke. Two-handed kneading is also possible if the various surfaces of the hand are divided in two different
but
patient’s forearm is particularly large. overlapping ways. First, the hand is divided longitudinally
 Figure 8-6
Local massage to the flexor muscle group (biceps, brachialis,
and coracobrachialis).

C ; L Devel a ear
Figure 8-7
I aral maceana tn the medial forearm miscle arouns.
 PART TWO PRACTICE

Figure 8-8
Local massage to the lateral forearm muscle groups.

into two halves—this time, a radial and an ulnar section.

The hand is then divided into front (palmar) and back
(dorsal) sections. All four sections are massaged. Once
again, this division is not strictly anatomical, but it is suit-
able to use for local massage of the hand.
Stroking. The therapist’s right hand supports the patient’s
hand. The left hand grasps the radial half of the hand at the
metacarpophalangeal joints. The thumb then passes up the
midline of the palm (Figure 8-9) around the thenar eminence to
the wrist. The fingers pass up the midline of the dorsal surface
of the hand to join the thumb at the wrist with a squeeze-out
movement. The hand returns with a superficial stroke.
Kneading. Single-handed kneading is performed over the
same area that was stroked (see Figure 8-9). The hand
returns with a superficial stroke in the usual manner.
Figure 8-9
Muscles of the Ulnar Section Local massage to the muscles of the radial border of the hand.
Hypothenar Muscles, Lumbricles, and Interossei
Stroking. The therapist’s left hand supports the patient’s and the hypothenar eminence, from the fifth metacarpopha-
hand. The right hand grasps the ulnar section of the patient’s langeal joint to the wrist (Figure 8-11, C). The thumb returns
hand at the metacarpophalangeal joint line. The thumb then with a superficial stroke after each movement.
passes up the midline of the palm (Figure 8-10, A) around Kneading. The thumb pad kneads in small circles over the
the hypothenar eminence to the wrist. The fingers pass up same areas and in the same order as indicated for the stroking
the midline of the dorsal surface of the hand to meet the (see Figure 8-11), returning each time with superficial strokes.
thumb at the wrist with a squeeze-out movement. The hand Dorsal Surface
returns with a superficial stroke. The patient’s hand is in pronation. In effect, the therapist
Kneading. Single-handed kneading is performed over the will be stroking in the interosseous Spaces between the
same area that was stroked (Figure 8-10, B), and the hand metacarpals, with pressure directed to each of the interos-
returns with a superficial stroke. seous muscles.
Palmar Surface Stroking. The therapist’s left hand supports the patient’s
The patient’s hand is supinated and supported by the thera- hand. Using his or her right thumb, the therapist strokes over
pist’s hands. the ulnar side of the first metacarpal. The stroke is just
Stroking. The therapist’s right hand supports the patient’s proximal to the first interphalangeal joint, continuing to the
hand while the thumb of the therapist’s left hand strokes wrist (Figure 8-12). The thumb pad returns with a superfi-
over each of the following areas: the thenar eminence, from cial stroke along the radial side of the second metacarpal to
the first metacarpophalangeal joint to the wrist (Figure 8-11, its first interphalangeal joint; the thumb then strokes over
A); the interosseous and the lumbrical muscles, from the this same area to the wrist. The thumb then slides over so
metacarpophalangeal joints to the wrist (Figure 8-11, B); that it can return along the ulnar border of the second meta-
 195

Figure 8-10
Local massage to the muscles on the ulnar border of the hand.

Figure 8
Local massage to the palmar surface of the hand.

carpal to the first interphalangeal joint and then strokes over Right Thumb and Fingers
the same area to the wrist. The same procedures are per- Dorsal Surface
formed on the third and fourth metacarpal areas and the The patient’s hand is pronated and supported on the palmar
radial side of the fifth metacarpal. surface by the fingertips of the therapist’s left hand (Figure
Kneading. The thumb pad kneads in small circles along 8-13, A). These fingers also support the phalanges as needed
each interosseous muscle from the insertion to the wrist, to prevent flexion during the movements. The therapist’s
following the routine described for stroking. right thumb and index finger first stroke, then knead, the
PART TWO PRACTICE

Figure 8-12
Local massage to the dorsal aspect of the hand.

Figure 8-13
Local massage to the dorsum of the thumb and fingers.
 LOCAL MASSAGE SEQUENCES CHAPTER 8

thumb and each succeeding finger in the following 8-14, A). The right thumb and index finger first stroke (Figure
manner: 8-14, A, B), then knead (Figure 8-14, C, D), the thumb and
Thumb Stroking. The thumb and the index finger grasp all the fingers in a manner similar to that performed on the
around the tip of the patient’s digit (Figure 8-13, A). The dorsal surface, except that the massage begins with the little
index finger passes along the radial side of the digit to finger and progresses toward the thumb.
the metacarpophalangeal joint as the thumb passes along
the ulnar side (Figure 8-13, B, C) and continues the stroke Left Upper Limb
into the metacarpal-interosseous space (Figure 8-13, D). The therapist stands by the treatment table on the left side
The thumb and the finger return to the tip of the digit with of the patient. The movements described for the right upper
a superficial stroke. limb can be used on the left side by simply reversing the
Thumb Pad Kneading. The finger supports, while the hand positions described in the text and figures (see Figures
thumb pad kneads over the same areas that were previously 8-4 to 8-14).
stroked (Figure 8-13, E, F). The thumb and the finger return
to the tip of the digit with a superficial stroke. The therapist’s Lower Limb
hand is then supinated so that the thumb can knead on the Right Buttock Region
radial side of the patient’s digit while the index finger sup- The therapist stands next to the treatment table on the patient’s
ports the ulnar side. The thumb and the finger return to the right side. The patient is lying prone, with pillows under the
tip of the digit with a superficial stroke. abdomen and the ankles; the head may be turned to either
Palmar Surface side for comfort, if required, or supported in the midline in
The patient’s hand is positioned in supination and supported a face hole or on folded towels (see Figure 3-8, B, in Chapter
by the therapist’s left hand. 3). Obviously, good draping is an important part of any
Stroking and Kneading. The fingertips of the therapist’s left massage technique to this part of the body. To massage the
hand support the patient’s hand on the dorsal surface (Figure tissues properly, the entire posterior and lateral hip regions

Figure 8-14
Local massage to the palmar surface of the fingers.
dee NPS... PART TWO PRACTICE

Sane ee
need to be fully accessible. If the patient is wearing loose- small pillow should be placed under the shin and ankle
fitting underwear, he or she may be able to lift the back part regions so that the knees are in slight flexion. This position
of the right side up and over the entire right buttock so that reduces the stretching effect of the sciatic nerves and will
the underwear rests around the patient’s waist. Provided that be much more comfortable for the majority of patients (see
the clothing remains loose and is not constrictive in any way, Figure 3-8, B, in Chapter 3).
the procedure is perfectly acceptable. Alternatively, the Medial Hamstring Muscles: Semimembranosus
patient will have to remove his or her underwear. A sheet, and Semitendinosus
folded lengthways, can be placed along the entire left lower Stroking. While the therapist’s right hand supports the
limb so that it covers the left buttock region, leaving the right patient’s limb, the left hand begins at the insertion of the
buttock fully exposed. The rest of the folded sheet can be muscles, just below the medial condyle of the tibia, and
turned so that it covers the patient’s waist and right lateral grasps around the muscle group (Figure 8-16, A). The thumb
hip region (Figure 8-15, B). strokes up the midline of the thigh as the fingers follow the
medial border of the muscle group to meet the thumb at the
Gluteal Muscles gluteal fold. The stroke finishes with the usual squeeze-out
Gluteus Maximus, Medius, and Minimus movement (Figure 8-16, B). The hand returns with a super-
Stroking. The left hand starts the stroke at the insertion ficial stroke.
of the gluteus maximus into the fascia lata (Figure 8-15, A) Kneading. Two-handed kneading is performed over the
and follows the fibers of this muscle to its origin at the same area that was stroked.
sacrum, coccyx, and ilium (along the gluteal fold in the Lateral Hamstring Muscle Biceps Femoris
midline). The right hand follows the fibers of the gluteus Stroking. The therapist’s left hand supports the patient’s
medius from its insertion at the greater trochanter of the limb at the medial aspect of the right knee. The therapist’s
femur to its origin on the crest of the ilium (see Figure 8-15, right hand begins at the insertion of the muscle on the head
A). The hands stroke alternately and return with a superficial of the fibula, grasping around the muscle. The thumb passes
stroke. If the muscles are large, each one may be stroked up the midline of the thigh (Figure 8-17, A), the fingers fol-
separately. In this instance, the thumbs of the hands pass up lowing the lateral border of the muscle to meet the thumb
the midline of the muscle being stroked. in a squeeze-out movement (Figure 8-17, B). The hand
Kneading. Two-handed kneading is performed over the returns with a superficial stroke.
same area that was stroked (Figure 8-15, B). At the end of Kneading. Two-handed kneading is performed over the
the stroke, the right hand performs a squeeze-out movement same area that was stroked. Single-handed kneading may
and returns with a superficial stroke, as the left hand returns be used for both inner and outer hamstring groups if the
through the air. If the patient is large, several lanes of knead- muscles are small.
ing will be required in order to cover the muscle group. NOTE: The stroking and kneading movements to both
inner and outer hamstring muscles may also be performed
Right Thigh with the patient lying supine or on one side if he or she is
The therapist stands at the side of the table on the patient’s unable to assume the prone position. In the supine position,
right. The therapist faces the patient, who lies prone and is one hand supports the knee in slight flexion, while the other
comfortably supported. In most cases, a rolled towel or hand performs the movement.

| ou 8-1 5
Local massage to the right buttock.
 LOCAL MASSAGE SEQUENCES CHAPTERS jim

Tensor of the Fascia Lata (Including the Iliotibial Kneading. Two-handed kneading is performed over the
Tract/Band) area that was stroked. Single-handed kneading may be used
The therapist stands next to the treatment table on the if the muscle is small.
patient’s right side. The patient is now comfortably reposi-
tioned in supine lying with appropriate draping (see Figure Anterior Thigh Group
3-7, B, in Chapter 3). A small rolled towel or pillow may be Rectus Femoris, Vastus Medialis, Vastus Intermedius,
placed under the knee to support the knee in slight flexion, Vastus Lateralis, Articularis Genu, and Sartorius
but it must not interfere with the massage. The therapist stands next to the treatment table on the
Stroking. The therapist’s right hand supports the patient’s patient’s right side. The patient lies in the supine position,
thigh at the medial side of the knee, and the left hand starts comfortably positioned and draped. A small pillow or
the stroke at the insertion of the iliotibial tract (band) on the rolled towel may be placed under the knee, and the limb can
head of the fibula (Figure 8-18, A). The thumb follows the be allowed to roll out a little into external rotation if
anterior border of the fascia and muscle, and the fingers preferred.
follow the posterior border of the fascia and muscle as the Stroking. The right hand supports the limb at the knee.
hand strokes toward the origin. As the hand approaches the The left hand is placed at the insertion of the patella tendon,
muscular portion, it spreads out to stroke over the muscle with the thumb at the medial side and the fingers at the
belly to its origin on the pelvis (Figure 8-18, B) and finishes lateral border of the patella. The hand passes lightly over
with a squeeze-out movement. The hand returns with a the patella, grasps around the muscle (Figure 8-19, A), and
superficial stroke. strokes to the origin of the rectus femoris at the anterior

B
Figure 8-16
Local massage to the medial hamstring muscle group (semimembranosus and semitendinosus).

B
“Figure 8-17
Local massage to the lateral hamstring group (biceps femoris).
 PART TWO PRACTICE

Figure 8-18
Local massage to the tensor fasciae latae muscle.

superior iliac spine (ASIS), where the thumb and fingers Right Leg
meet in a squeeze-out movement (Figure 8-19, B). The hand The therapist stands at the foot of the treatment table, facing
returns with a superficial stroke. the patient. A small rolled towel is particularly useful to
Kneading. The right hand is placed at the lower border of support the knee and still allow the therapist’s hands to work
the patella and passes lightly over it; the left hand picks up around the knee. A small pillow can also be used for this
the muscle above the patella (Figure 8-19, C), and both purpose (see Figure 3-9 in Chapter 3).
hands knead the entire muscle to its origin (Figure 8-19, D). Anterior Tibial Muscles: Tibialis Anterior, Extensor
The right hand performs a squeeze-out movement (Figure Digitorum Longus, Extensor Hallucis Longus, and
8-19, £) and returns with a superficial stroke (Figure 8-19, Fibularis/Peroneus Tertius
F). The left hand returns through the air. Single-handed Stroking. The right hand is placed slightly distal to the
kneading may be performed with the left hand while the ankle joint, and the right hand supports the ankle by grasping
right hand supports the extremity (Figure 8-19, G). the foot at the medial arch. The left thumb passes along the
Adductor Muscle Group: Adductor, Longus, Adductor anterior border of the tibia, and the index finger follows
Magnus, and Gracilis the lateral border of the muscle group (Figure 8-21, A) to the
NOTE: There are other muscles in this group (e.g., obturator anterior surface of the head of the fibula, meeting the thumb
externus, pectineus), but these are probably too deep to be in a squeeze-out movement. The other fingers maintain light
effectively massaged. contact with the skin throughout the movement. The hand
Stroking. The right hand, reinforced by the left hand, returns to the starting position with a superficial stroke.
starts the stroke at the insertion of the muscle group on the Kneading. Two-handed digital kneading is performed
medial condyle of the tibia by grasping around the entire over the same area that was stroked. The therapist may stand
group (Figure 8-20, A). The thumb passes along the anterior at the foot of the table and turn his or her body so as to reach
border of the muscle group, and the fingers follow the pos- across the tibia to knead the muscles. The right hand is
terior border toward the origin, finishing with a squeeze-out placed proximally and the left hand distally (Figure 8-21,
movement (Figure 8-20, B). The hand returns with a super- B). The left hand performs the squeeze-out movement at the
ficial stroke. end of the procedure, returning with a superficial stroke
NOTE: Theoretically this stroke should end at the origin of while the right hand returns in the air.
the muscle, close to the symphysis pubis, but for obvious Alternatively, the therapist may move to the right side of
ethical and practical reasons, it should be completed a few the table (facing the patient) and perform two-handed knead-
inches below the inguinal ligament. In fact, it is best to ing with the left hand placed proximally and the right hand
remain below the midpoint of the femoral triangle in both distally. The right hand performs the Squeeze-out movement
male and female patients. at the end of the movement and returns with a superficial
Kneading. Two-handed kneading is performed over the stroke while the left hand returns in the air.
same area that was stroked, observing the same restrictions Fibularis (Peroneal) Muscles: Fibularis Longus,
over the femoral triangle. The right hand performs a squeeze- Fibularis Brevis
out movement at the end of the kneading and returns with NOTE: These muscles were formerly called peroneus longus
a superficial stroke. The left hand returns through the air. and brevis.
Single-handed kneading may be used on a small adductor Stroking. The left hand is placed distal to the lateral mal-
mass; the left hand can reinforce the right hand. leolus while the right hand supports the ankle by graspin
g
 LOCAL MASSAGE SEQUENCES CHAPTER 8

Figure 8-19
Local massage to the quadriceps muscle group.
 ne PART TWO PRACTICE

iia sais Sci

Figure 8-20
Local massage to the hip adductor muscle group.

Figure 8-21
Local massage to the anterior tibial muscle group.

the foot at the medial arch (Figure 8-22, A). The left thumb border of the Achilles tendon and passes up the lateral
follows the anterior border while the index finger follows border of the muscle group as the fingers follow along
along the posterior border of the muscle group (Figure 8-22, the medial border of the tendon and muscle group. The
B) to the posterior surface of the head of the fibula, meeting hand grasps around the muscle group and strokes toward
the thumb in a squeeze-out movement. The hand returns to the origins of the gastrocnemius muscle. The first stroke
the starting position with a superficial stroke. The other ends in a squeeze-out movement over the medial head
fingers maintain light contact with the skin throughout the (Figure 8-23, B); the second stroke ends in a squeeze-out
movement. movement over the lateral head (Figure 8-23, C). Additional
Kneading. Two-handed digital kneading is given over the strokes continue to alternate until the area is covered. The
same area that was stroked. Procedures are similar to those hand returns to the starting position with a superficial
described for two-handed digital kneading of the anterior stroke.
tibial muscle group (Figure 8-22, C). If the muscle group is too large to be grasped in one hand,
Calf Muscles: Gastrocnemius, Soleus, and Plantaris it may be massaged in two sections. The medial side of the
The therapist stands next to the treatment table on the muscle group is stroked with the left hand as the right hand
patient’s right. The patient is comfortably supported and supports the knee (Figure 8-23, D). The left thumb passes
draped in prone lying (see Figure 3-8, B, in Chapter 3). along the midline of the muscle group, and the squeeze-out
Stroking. The therapist’s left hand is placed on the heel, movement is performed at the medial head of the gastroc-
and the right hand stabilizes the patient’s leg at the knee nemius muscle. The lateral side of the muscle group is
(Figure 8-23, A). The left thumb follows along the lateral stroked with the right hand as the left hand supports the
 LOCAL MASSAGE SEQUENCES CHAPTER 8

Figure 8-22
Local massage to the peroneal muscle group.

knee (Figure 8-23, E). The squeeze-out is done at the lateral Right Foot
head of the gastrocnemius muscle. The therapist stands at the end of the table, facing the patient.
Kneading. Two-handed kneading is performed to the The patient lies in supine position, comfortably supported
same area that was stroked (Figure 8-23, F). The left hand and appropriately draped, with a pillow supporting the knee.
returns to the starting position with a superficial stroke, and As an alternative, the patient may sit up on the treatment
the right hand returns in the air. If the muscle group is very table (see Figure 3-9 in Chapter 3). For treatment purposes,
large, two-handed kneading is given over each half of the the various surfaces of the foot are divided in two different
muscle group (Figure 8-23, G). Alternatively, if the muscle but overlapping ways. First, the foot is divided longitudi-
group is small, single-handed kneading may be used over nally into two halves—this time, a medial and a lateral
the whole muscle group. In this case, the left hand kneads section. The foot is then divided into top (dorsal) and bottom
as the right hand supports the extremity. (plantar) sections. All four sections are massaged. Once
If it is not possible for the patient to lie prone, this muscle again, this division is not strictly anatomical, but it is suit-
group may be massaged with the patient supine. With the able for use in local massage of the hand. The toes may be
patient in this position, one hand supports the knee in slight massaged separately from the rest of the foot.
flexion while the other performs the stroking movement Medial Section
(Figure 8-23, H). . Stroking. The left hand supports the ankle on the lateral
Two-handed kneading is given with the therapist stand- side, just proximal to the heel (Figure 8-24, A) while the right
ing at the side of the table on the patient’s right. The patient's hand grasps the medial half of the foot at the toes. The thumb
thigh is rotated laterally so that both hands can grasp the passes up the midline of the dorsum of the foot and below
muscle group easily (Figure 8-23, /). If the muscle group is the medial malleolus as the fingers pass along the midline of
small, single-handed kneading may be given with the left the plantar surface and around the heel to meet the thumb in
hand as the right hand supports the knee in slight flexion a squeeze-out movement (Figure 8-24, B). The hand returns
(Figure 8-23, J). to the starting position with a superficial stroke.
 PART TWO PRACTICE

Figure 8-23
Local massage to the posterior muscle group of the leg (calf muscles).

Kneading. Single-handed kneading is given over the same and below the lateral malleolus. At the same time, the fingers
area that was stroked. The hand returns to the starting posi- pass up the midline of the plantar surface and around the
tion with a superficial stroke. heel to meet the thumb in a squeeze-out movement (Figure
Lateral Section 8-25, B). The hand returns to the starting position with a
Stroking. The right hand supports the ankle on the medial superficial stroke.
side, just proximal to the heel, while the left hand grasps the Kneading. Single-handed kneading is performed over the
lateral half of the foot at the toes (Figure 8-25, A). The same area that was stroked. The hand returns to the starting
thumb passes along the midline of the dorsum of the foot position with a superficial stroke.
 LOCAL MASSAGE SEQUENCES CHAPTER 8

Figure 8-23, cont’d

Figure 8-24
Local massage to the medial border of the foot.

Dorsal Section with a superficial stroke; they repeat the movements in each
Stroking. The fingers of both hands are placed on the metatarsal space (Figure 8-26).
plantar surface of the foot to support it. The thumbs perform Kneading. Kneading is given with one thumb moving in
short, alternate strokes between the first and second meta- small circles over the same area that was stroked. The right
tarsal bones, progressing from the base of the toes to the thumb kneads over the first and second metatarsal spaces,
ankle. Both thumbs together return to the starting position and the left thumb kneads over the third and fourth
 PART TWO PRACTICE

Figure 8-25
Local massage to the lateral border of the foot.

Left Lower Limb

The therapist stands next to the treatment table at the
patient’s left side and facing the patient’s head. The move-
ments are performed as described for the right leg, except
that the right hand substitutes for the left and the left hand
for the right.

Posterior Trunk and Pelvis

Back
The therapist stands next to the treatment table on the
patient’s left side and facing the patient’s head. The patient
is appropriately draped and positioned comfortably, lying
prone with pillows under the abdomen and ankles and rolled
towels under the shoulders. The patient’s head and face can
Figure 8-26 be supported in a face hole or on a small folded towel (see
Local massage to the dorsum of the foot. Figure 3-8, A, in Chapter 3). Local massage to the back may
be performed to three basic muscle groups—the paraspinal
metatarsal spaces. The thumb returns to the starting position (erector spinae) group, the trapezius and scapular group, and
with a superficial stroke. the latissimus dorsi muscle—although, of course, some
Plantar Section parts of these muscles overlap each other and are therefore
Stroking. The left hand supports the foot by grasping the massaged at the same time. With the exception of stroking
forefoot and toes so that the dorsal surface of the foot fits into to the paraspinal (erector spinae) group, all movements are
the palm ofthe left hand (Figure 8-27, A). The fingers of the given at one time to one side of the back.
right hand are flexed at the metacarpophalangeal and proxi- Paraspinal Muscles
mal interphalangeal joints. The proximal phalanges are Stroking. The therapist’s thumbs are placed at the sides of
placed in firm contact at the base ofthe toes (see Figure 8-27, the patient’s spinous processes of the upper cervical verte-
A). In this position, the flexed fingers stroke firmly toward brae, and the fingers are placed in the supraclavicular fossae
the heel (Figure 8-27, B). As the movement progresses, the (Figure 8-28, A). Both thumbs stroke down firmly over the
right hand is rolled into pronation (Figure 8-27, C), and the cervical region and, at the seventh cervical vertebra, are lifted
fingers are extended to allow the heel of the hand to fit into and crossed. The fingers are then drawn backward lightly
the medial arch of the foot. The right hand is removed and toward the seventh cervical vertebra (Figure 8-28, B), and the
returns through the air to the starting position. palms stroke firmly over the paraspinal (erector spinae)
muscles from the seventh cervical vertebra to the sacrum.
Right Toes
The hands then separate and, with thumbs adducted, stroke
If there is reason to massage the toes, stroking and kneading with light pressure over the iliac crests (Figure 8-28, C) to the
techniques similar to those described for the thumb and inguinal region and return to the sacrum (Figure 8-28, D).
fingers are appropriate (see Figure 8-13). The hands then stroke back over the paraspinal muscles to the
 LOCAL MASSAGE SEQUENCES CHAPTER 8

Figure 8-27
Local massage to the plantar surface of the foot.

Cc

seventh cervical vertebra, the thumbs again being lifted and the acromion process. As it reaches the acromion, the left
crossed. Light pressure is used for the return stroke. hand starts the first stroking movement over the upper fibers
Kneading. Two-handed digital kneading is performed, of the trapezius. The right hand then strokes over the middle
first to the right side and then to the left side, beginning at fibers (Figure 8-29, B), and the left hand strokes over the
the cervical region and continuing to the sacrum (Figure lower fibers. The movements are performed in the same
8-28, EF). The right hand returns with a superficial stroke manner on the left side, except that the left hand substitutes
as the left hand returns through the air. for the right and the right hand for the left.
Trapezius and Scapular Muscles: Trapezius, Kneading. The kneading movement starts on the right
Supraspinatus, Infraspinatus, Levator Scapulae, side.
Rhomboid Major, Rhomboid Minor, and Teres Major Upper fibers. Two-handed digital kneading is given over
Stroking. Starting on the right side, the therapist’s right the same area that was stroked. The right hand returns
hand is placed over the patient’s upper fibers of the trapezius with a superficial stroke as the left hand returns
muscle with the thumb at the lateral border of the spinous through the air.
processes of the upper cervical vertebrae. The hand grasps Middle and lower fibers. Two-handed kneading is per-
around the upper fibers of the right half of the trapezius formed over both areas (Figure 8-29, C). The right
muscle and strokes laterally to the acromion process. As the| hand returns with a superficial stroke while the left
right hand completes the movement, the left hand begins at hand returns through the air.
the origin of the middle fibers of the trapezius muscle (Figure The movements are performed in the same manner on the
8-29, A) and strokes across with the thumb abducted laterally left side, except that the left hand substitutes for the right
toward the acromion process. Then the right hand, with the and the right hand for the left.
thumb abducted, is placed with the thumb beside the spinous Latissimus Dorsi Muscle
processes and the ulnar border at the edge of the lower fibers Stroking. Starting on the right side, the therapist places
of the trapezius (at the level of the twelfth thoracic vertebra). his or her right hand (reinforced by the left hand) with the
From this position, the hand strokes upward and laterally to thumb at the lateral border of the spinous processes of
 PART TWO PRACTICE

Figure 8-28
Local massage to the erector spinae muscle group.

the lumbar area and the ulnar border on the crest of the ilium Kneading. Two-handed kneading is performed over the
(Figure 8-30, A). The thumb follows along the medial border same area that was stroked (Figure 8-30, C). The right hand
of the muscle while the fingers follow along the lateral returns with a superficial stroke as the left hand returns
border. The hand turns into pronation as the fingers meet through the air. If the muscle is too large to be covered with
the thumb in the axilla in a squeeze-out movement (Figure one hand, the stroking and kneading may be performed in
8-30, B). The hand returns with a superficial stroke. two sections. The movements are given in the same manner
Figure 8-29
Local massage to the trapezius and scapular muscles.

Figure 8-30
Local massage to the latissimus dorsi muscle.
dence i AIO nes PART TWO PRACTICE

pli ess dat

on the left side, except that the left hand substitutes for the Stroking over the Entire Abdomen. Starting with the
right and the right hand for the left. fingertips of both hands at the symphysis pubis (Figure
8-31, A), the hands stroke over the rectus abdominis
Anterior Trunk and Pelvis muscle to its origin (Figure 8-31, B). The hands then stroke
Abdomen laterally with light pressure (Figure 8-31, C), with the fingers
The therapist stands next to the treatment table on the right passing over the lower ribs. As the hands continue the
side of the patient. The patient is appropriately draped and lateral stroking over the dorsal part of the fibers, they turn
positioned in supine lying, with the head and knees sup- (Figure 8-31, D) so that the fingertips stroke toward the
ported by pillows (see Figure 3-7, A, in Chapter 3). spine.

ote 8-31
Local stroking massage to the entire abdomen.
 LOCAL MASSAGE SEQUENCES CHAPTER 8

The hands then return over the same area with a firm with firm pressure is repeated several times in this one area
stroke to the transverse abdominal muscles (Figure 8-31, E) and then followed by a firm stroke (Figure 8-33, B) over the
and a light stroke down the rectus abdominis to the sym- area of the distal portion of the colon toward the rectum.
physis pubis. The stroking to the rectus abdominis and the With a light stroke, the therapist’s hand returns to a point
lateral stroking are repeated, but the return stroke is given about 2 inches (Scm) proximal to the starting point and
over the oblique abdominal muscles (Figure 8-31, F) toward repeats the movements. Progression is made in this manner
the symphysis pubis. over the rest of the areas of the descending colon, the trans-
Stroking over the Area of the Colon. The fingertips of the verse colon, and the ascending colon (Figure 8-33, C). It is
right hand, reinforced by the left hand, are placed over the important to perform this stroke in the direction specified,
beginning of the ascending colon (cecum) in the right lower although this appears to be opposite to the normal direction
quadrant of the abdomen (Figure 8-32, A). They stroke of peristalsis. Performed in this manner, the kneading tends
upward with firm pressure over the area of the ascending to clear the colon rather than cause congestion (see Chapter
colon (Figure 8-32, B), across the abdomen over the area of 9, Figure 9-7, for more details).
the transverse colon, and downward over the area of
Head and Neck
the descending colon. The hands return with a superficial
stroke across the lower abdomen to the starting point (Figure Face
8-32, C). The therapist stands or sits at the head of the treatment table.
Kneading over the Area of the Colon. The fingertips of the The patient lies supine with a small pillow or neck roll to
reinforced right hand are placed about 2 inches (5 cm) above support the head. The following technique for massage of the
the area of the distal part of the descending colon (Figure face is based on the principles of the Hoffa method to the
8-33, A). The fingertips are kept in contact with the skin, extent that the strokes are applied to individual muscles or
and together they move on the underlying tissue (as in stan- muscle groups and the stroking movements follow
dard palmar kneading movements). A circular movement the general longitudinal direction of the muscle fibers. It

Figure 8-32
Local stroking massage over the colon.
PART TWO PRACTICE

Figure 8-33
Local Kneading massage over the colon.

Figure 8-34
Local massage to the muscles of the face.
 PRR

Figure
 PART TWO PRACTICE

able 8-9 Summary of the Actions of the Muscles of the Face itl aaaiaitias
MUSCLE
recy ts

Occipitofrontalis Elevates eyebrow and root of the nose—wrinkles

Orbicularis oculi Controls sphincter muscle of eyelids; reflex and voluntary control, fast or slow
eyelid closure
Corrugator Draws eyebrow medially and downward—frowning and in bright sunlight
Procerus Draws down medial angle of eyebrow—transverse wrinkles on bridge of nose
Nasalis, two parts (transverse, Elevates and widens nostrils as in deep breathing/sniff giving dilation of nose
alar dilator naris)
Levator labii superiori, alaeque nasi Lateral slip (long one) raises and everts upper lip; medial slip dilates nostril
Levator labii superioris Raises and everts upper lip (sadness or serious look)
Zygomaticus minor Elevates upper lip
Zygomaticus major Draws angle of mouth upward and laterally as in laughing
Levator anguli oris Raises angle of mouth NB: muscles 7, 8, 9, form naso-labial furrow
Orbicularis oris Controls closure of lips; deep and oblique fibers compress lips against teeth;
superficial parts—kiss
Risorius Retracts angle of mouth—sardonic grin
Depressor anguli oris Draws angle of mouth downward and laterally Opens mouth and sadness
Depressor labii inferioris Draws lower lip down and slightly laterally (eating)
Mentalis Raises and protrudes the lower lip (drinking) and expressing doubt
Muscles of Mastication
Temporalis Elevates jaw, close mouth, pulls jaw back
Buccinator (p) Compresses cheeks against teeth
Masseter Elevates jaw, clenches teeth
Medial and lateral pterygoids Opens jaw, side-to-side grinding movements

must be kept in mind that the facial muscles are small and Both stroking and kneading are performed with the distal
delicate. They have little mass, are thin, and are located phalanges of the digits. One or more fingers, either or both
immediately over bony surfaces. A significant part of their thumbs, or the thumb and one or more fingers may be used
structure is attached to the subcutaneous layers of the facial to conform to the shape, size, and location of the muscles
skin. For these reasons, the pressure of the massage strokes (see Figure 8-34). The muscles and muscle groups that are
must be very light, particularly when the massage is massaged are as follows:
being given to flaccid muscles. This type of massage is par-
Muscle Figure
ticularly applicable for facial paralysis and may help to
Frontalis Figure 8-34, A
prevent contractures and resolve fibrosis. Facial massage
also provides significant sensory stimulation to the tissues,
Orbicularis oculi Figure 8-34, B, C
and this may assist in the recovery process if possible. This
Nasalis Figure 8-34, D
type of massage can also be readily taught to the patient. In Levator anguli oris Figure 8-34, E
this manner, treatment can be administered more frequently Zygomaticus major and minor Figure 8-34, E
and at home. Orbicularis oris Figure 8-34, F
Depressor anguli oris Figure 8-34, G
In general, each stroke passes from insertion to origin,
Platysma Figure 8-34, H
following the normal muscle action. Whenever possible,
paralyzed muscles are supported in the position of normal At the completion of the local massage movements to the
function as the massage is being performed. In this regard, face, both hands perform superficial stroking from the chin
it is best for the patient to rest in supine lying, because to the temples (see Figure 8-34, 7). Table 8-9 summarizes
gravity will have less effect on the facial muscles and struc- the main functions of the muscles of facial expression. Any
tures than in the sitting position. Support may be given by of these muscles can be massaged in the manner described
one hand or by the fingers (Figure 8-34). in this section.
 Focal Massage Sequences

This chapter is designed to give a number of examples of * Colon dysfunction

how soft tissue manipulation (massage) techniques can be ¢ Muscle dysfunction
used as part of the treatment for specific pathologic situa- For each problem in the list, a specific massage sequence
tions. Focal massage sequences were defined in Chapter 4 is suggested in a table format. The strokes that are given
as follows: directly to the lesion/target tissue constitute the focal
A combination of one or more different massage strokes massage and have been italicized to mark their importance
applied to specific anatomical structures in order to achieve in the sequence. The other strokes have their own impor-
particularly desired effects. tance, in particular their effects on the surrounding circula-
For example, a patient may have a large, chronic hematoma tion, thereby facilitating the entire healing process. All of
in the quadriceps muscle as a result of a severe blow to the the clinical problems discussed here are either subacute or
thigh. When various massage techniques are directed to the chronic in nature. As a general rule, massage is not given to
treatment of the injured skin, subcutaneous tissues, and acutely inflamed tissues.
muscle tissues, it can rightly be called focal massage. In
practice, however, massage techniques are given to more
DEPLETIVE MASSAGE
than just the affected tissues, so that the treatment is more
like a combination of local and focal techniques. In the case Before discussing each of the clinical situations listed, it is
of a hematoma in the thigh, some strokes will be given to important to consider the concept of depletive massage.
the whole limb, whereas others will concentrate on the thigh Because therapeutic massage is generally given to subacute
and still others on the actual hematoma. or chronic conditions, there is commonly a significant
It is obviously not possible to describe focal massage problem with the local circulation. This may result in sub-
techniques for all of the various structures in the body, stantial interstitial swelling, more commonly called edema.
nor is it necessary. Instead, the principles involved in Both subacute and chronic edema can be readily treated
the focal. treatment of specific pathologies will be consid- using a variety of massage techniques; however, the impor-
ered. It is important to emphasize that the focal massage tant adjunctive principle of depletive massage is needed for
techniques suggested here are meant to be used in addition the treatment to be maximally effective.
to all of the other rehabilitation strategies that would Depletive massage is a concept used to describe the way
be appropriate for a given situation. These can then be in which certain strokes are applied to the tissues in the
applied to any part of the anatomy affected by a similar presence of subacute or chronic edema. Depletive massage
problem. The following specific clinical problems are can therefore be defined as:
considered: The application of different massage strokes applied in a
¢ Subacute or chronic edema series of overlapping stages, beginning proximally and
¢ Subacute or chronic hematoma working distally in a subacute or chronically swollen
¢ Subacute or chronic cutaneous scar tissue limb.
¢ Tendon or ligament adhesion An important prerequisite for depletive massage tech-
¢ Muscle contracture niques to be effective is the adjunctive use of elevation of
 PART TWO PRACTICE

Se eee
the swollen limb. Because gravity tends to promote the col-
lection of edema in the most distal parts of the affected limb,
it makes sense that the swollen part should be elevated
during treatment and afterward if possible. Elevation means
that the swollen tissues must be higher than the patient’s
heart. In general, this means that the patient will lie supine
on the treatment table and his or her limb will be supported
on a bolster or several pillows (see Figure 3-6, B, for an
example). It is important that the vessels draining blood and
lymph from the swollen area have as straight a path as pos-
sible to the heart. Under these conditions, the various strokes
are given to the tissues, beginning proximally and working
distally to the end of the limb. This concept is depicted in
Figure 9-1.
Depletive massage is therefore not a massage technique
in itself, but rather a method of applying certain strokes. The
techniques most often used in this way are stroking, effleu-
rage, palmar kneading, finger pad kneading, and thumb pad
kneading. A depletive method of application for each of
these strokes simply involves massaging over proximal
tissues first and then moving on to the more distal areas.
In Figure 9-1, A, the lower limb is divided into four sec-
tions, beginning at the thigh and finishing at the foot. The
longer the limb, the more sections may be used. Typically,
in the lower limb, section | would be the upper thigh and
section 4 would be the forefoot and toes. Likewise, the upper
limb is divided into four sections (Figure 9-1, B). Section |
would be the upper arm, and section 4 would be the fingers
and hand. The limbs are divided in this way to stress the
importance of beginning the massage in the proximal sec- B
tions. The rationale for this approach is that because the Figure 9-1 The Concept of Depletive
tissues are already congested, a pathway needs to be cleared Massage for the Treatment of
before working on the swollen areas themselves. In this way, Chronic Edema
the venous and lymphatic channels will be opened to receive A, The foot and lower leg region are chronically swollen. The patient is
the fluids from the swollen areas. positioned so that the swollen limb is elevated higher than the heart,
Effleurage to the lower limb is a good example of this with the patient’s legs comfortably supported and straight. The limb is
idea. Normally the stroke begins distally at the foot and divided into four sections: (1) the upper thigh, (2) the lower thigh and
ankle and finishes proximally in the femoral triangle (see knee, (3) the calf and leg, and (4) the ankle and foot. Massage strokes
Chapter 4). If this technique were applied to a very swollen begin at the thigh section and progress in several stages along the limb
foot, there would be no space to receive fluids, because the to eventually reach the toes. Stroking, effleurage, and the various forms
of kneading can all be given in this manner. B, The forearm and hand
swelling causes collapse of the local capillaries, veins, and
are chronically swollen. The patient is positioned so that the swollen
lymphatic vessels. The depletive massage concept aims to
limb is elevated higher than the heart, with the entire limb comfortably
open up these vessels in the more proximal tissues first, supported and straight. The limb is divided into four sections: (1) the
thereby producing open channels that allow the fluids to upper arm, (2) the elbow, (3) the forearm, and (4) the wrist and hand.
move. Once the circulation is flowing in a more normal Massage strokes begin at the upper arm section and progress in several
manner, the conventional direction and methods for the Stages along the limb to eventually reach the fingers. Stroking, effleu-
various strokes can be used. rage, and the various forms of kneading can all be given in this
At the end of treatment, there is the important issue of manner.
how to prevent the return of swelling in the limb when it
becomes dependent again. The basic issue is one of pressure
in the circulatory system. Essentially, there is a greater pres-
sure (including gravity) forcing fluids into the tissue spaces cized stockings or socks. Many different types of stockings
than there is driving it back into the circulation. Over time, are available, but they all work in the same basic way. The
this pressure produces a net accumulation of fluids into the better ones feature some kind of graduated pressure from
tissues (edema). The pressure tending to drive fluids back distal to proximal in the garment. It is important that such
into the circulation can be increased with the use of elasti- a garment is applied at the end of treatment while the limb
 FOCAL MASSAGE SEQUENCES CHAPTER 9

is still in elevation. Of course, the patient is instructed to tissues. Because the lymphatic vessels are thinly walled,
keep the limb elevated as much as possible during the day. without a well-defined valve structure, any massage stroke
that involves alternate squeezing and relaxation of pressure
CHRONIC EDEMA will have a powerful effect in promoting flow in this system.
However, the normal architecture of the lymphatic system
Chronic interstitial swelling in the limbs (edema) is a poten- has to be in place for this to work efficiently. Where the
tially serious condition if it is allowed to persist, especially lymphatic network has been disrupted, such as may be the
in older patients. It is typically produced by trauma to the case with significant lymph node resection, the swelling
tissues (such as a fall), or it is the result of an underlying may be more widespread and treatment more challeng-
problem with the circulation. In either case, long-term con- ing. This situation is considered at length in Chapter 12,
gestion of the tissues can lead to stiffness and pain, which which explores decongestive therapy for the treatment of
can result in deformity and loss of function. In the lower lymphedema.
limb, this may mean an inability to walk, resulting in the Localized, chronic edema can be mobilized using a
patient spending most of the day in a chair or bed. If the variety of techniques, including massage. The basic sequence
patient is older, this can lead to a serious health decline is listed in the tables that follow, and the specific focal
caused by inactivity. Removing edema and increasing func- massage techniques are italicized. Because the limb is ele-
tional range of motion in joints and soft tissues is therefore vated, the therapist may need to stand on a suitable platform,
a top priority, especially in the elderly patient with a swollen or the therapist may face the patient’s foot and reverse the
lower limb. An exception to this case might occur if the usual positioning (i.e., by working from knee to hip and
swelling in the lower limbs is the end result of severe con- from foot to knee). In each case, the massage is always
gestive heart failure. Fluids are then offloaded into the performed from distal to proximal structures (Tables 9-1
tissues to relieve the load on the heart (less fluid to pump). and 9-2).
In this case, vigorous attempts to treat the swelling might
result in cardiac complications. Obviously, close coopera-
HEMATOMA
tion with the patient’s medical team will be needed to
manage the situation properly. A hematoma (bruise) is the consequence of bleeding in the
One of the reasons chronic edema is a potentially serious tissues, usually as the result of direct trauma. In many cases,
problem is that it tends to organize; it becomes thickened, the trauma produces a compressive force on the tissues, such
thereby preventing normal movement and function. In addi- as in a kick, punch, or fall. The compressive force of the
tion, the stiffness is often painful, adding to the patient’s blow ruptures small capillaries and possibly the small arte-
unwillingness to move the affected parts. This lack of move- rioles and venules. The end result is bleeding into the tissue
ment results in even more stiffness. Much of the stiffness is
produced by a fibrosis that occurs in the interstitial spaces.
Under normal circumstances, the plasma proteins are unable
Focal Massage Sequence for
to escape from the capillaries into the interstitial fluid
Chronic Edema in the Foot and
(tissue fluid) because their molecular size is too large to pass
Jable 9-1 Ankle Region
through the vessels. However, one of the consequences of
local trauma to the tissues is that the capillary walls open Jjz{e B RE*

up and allow these large molecules to pass into the tissues. Depletive stroking to the whole limb
Many of the plasma proteins are concerned with the ability Depletive effleurage to the thigh
of the blood to clot, and this process is triggered in the tissue Palmar kneading to the thigh
Wringing to the medial thigh
spaces. The end result of the clotting process is the forma-
Picking up to the thigh
tion of fibrin threads, eventually leading to scar tissue. Such Depletive effleurage to the thigh
interstitial scarring causes adhesion of the various layers of Finger pad kneading around the knee
the tissues and prevents the free movements of one tissue Palmar kneading to the calf and leg WW
PWWNHWW

on another. A classic sign of this process is the presence of muscles

Thumb pad kneading to the anterior tibial 4
pitting edema. In this case, an indentation (pit) is left behind
muscles
in the skin and subcutaneous tissues when the thumb is
Picking up to the calf 4
pushed into a chronically swollen area. Depletive effleurage to the thigh, calf, 3
The importance of the lymphatic system in the resolution and leg
of chronic edema cannot be overstated. Once the acute Finger pad kneading around the ankle 4
inflammatory stage has passed and the capillary walls have region
closed up, the plasma proteins and other large molecules Thumb pad kneading to the foot £

Effleurage to the whole limb 3

cannot get back into the capillary network. The only place
for them to go is into the lymphatic vessels. In many ways, Italics indicate specific focal massage techniques.
the lymphatic vessels act as the drainage system for the
*Performed with the patient supine and the lower limb elevated.
 PART TWO PRACTICE

Focal Massage Sequence for Blood Intermuscular

Chronic Edema in the Forearm hematoma

‘abie 9-2 and Hand Region

Depletive stroking to the whole limb 3

Depletive effleurage to the upper arm 3
Palmar kneading to the biceps and 3 Fascia
triceps
Picking up to the biceps and triceps 3
Depletive effleurage to the upper arm 3
Finger pad kneading around the elbow 3
A
region
Palmar kneading to the forearm muscles 3 Intramuscular
hematoma
Thumb pad kneading to the forearm 3
muscles
Depletive effleurage to the upper arm 3
and forearm
Thumb pad kneading to the wrist, 4
hand, and fingers Blood Fascia
Effleurage to the whole limb 4

Italics indicate specific focal massage techniques. B

“Performed with the patient sitting or supine and the upper limb
elevated.
Blood Intermuscular
hematoma

spaces. Alternatively, the bleeding can result from trauma

associated with tearing of the tissues, perhaps by a broken
bone or shattered glass fragments. In either case, the end
result is bleeding into the tissue spaces as a result of a com-
pressive force. Although the hope is that the bleeding will Fascia
cease after a few minutes, especially with appropriate first-
aid treatment, the trauma will initiate the body’s reaction to
injuries of all types, namely inflammation.
For minor trauma (a simple fall with no broken bones), Cc
the classic signs and symptoms of acute inflammation (pain,
Figure 9-2 Intermuscular and
swelling, redness, and heat) will become maximal at about
Intramuscular Hematoma
24 hours after the injury. If all goes well, the healing process
These diagrams represent a cross-section through the mid-thigh region.
will take over and in about 7 to 10 days postinjury, most, if
Each muscle is contained within its own connective tissue bag. This
not all, of the original problems should be well on the way
bag is extremely thin, and a fine serous fluid is normally present in the
to full recovery. If healing is delayed for some reason (e.g.,
potential space between the muscle bags. A, Trauma has caused
by poor circulation or infection), the condition may become bleeding into these potential spaces, between the muscles (hence the
subacute and eventually chronic if healing continues to be name), and into the subcutaneous tissues. The surface bruise may be
slow. During the acute stages of traumatic inflammation, widespread, affecting many different tissues in a wide area. B, Fibers
massage is generally contraindicated because of the possi- have been ruptured deep within the muscle, and most of the bleeding
bility of causing further disruption, and therefore possible is contained within the affected muscle. In this case, surface bruising
bleeding, of the damaged capillaries. In the subacute and may be much less than expected. C, A combination of both intermus-
chronic stages, however, massage techniques can be particu- cular and intramuscular bleeding is depicted—the result of severe
larly useful. These issues are addressed in much more detail trauma to a limb, perhaps in an automobile crash. There will be exten-
in Chapter 5. sive surface bruising and bleeding deep with the muscles. M, Muscle;
B, bone.
Intermuscular Hematoma
A variety of massage techniques are useful as part of the interstitial spaces, especially between the fascial planes that
treatment plan for a chronic hematoma. Of course, most separate one muscle from another (Figure 9-2, A). This kind
bruises eventually heal, and the tissues return to normal of bruise is the so-called intermuscular hematoma. It is
color and texture. The colors of the bruise represent the characterized by a widespread visible bruise, tenderness on
different absorption rates of the bile pigments in the blood palpation (especially at the site of the initial trauma), and
(bilirubin and biliverdin). The bruise confirms that capillar- pain on stretching of the tissues such as during related joint
ies have been broken and blood has leaked out into the movements. In the limbs, gravity will usually cause the
 FOCAL MASSAGE SEQUENCES CHAPTER 9

blood to track along the fascial planes between muscles and hematoma. Typically, this will be at the margins of the
subcutaneous tissues toward the most distal areas. The best visible bruise. The overlapping circles of kneading gradu-
example of this effect is probably seen in the upper limb ally converge toward the center of the hematoma (Figure 9-
following a fracture of the head of the humerus. Although 3). If the tissues are tender and treatment elicits a painful
the fracture occurs at the shoulder region, the entire arm can response, it is a sign that the kneading should be given with
appear purple in color as the blood tracks down the limb only light pressure, especially to an intramuscular hema-
toward the hand. Interestingly, the discoloration spirals toma. These strokes are followed by effleurage to the entire
around the limb, clearly showing the pathway taken by the limb. For best results, this type of massage sequence should
blood. In most cases, this type of hematoma will eventually be included with other treatment approaches, such as the use
heal, leaving minimal aftereffects. Occasionally, however, of appropriate electrophysical agents (modalities) and active
the bleeding between the muscles results in scar tissue for- exercise programs.
mation, which causes muscle and skin stiffness because the Suitable focal massage sequences to address an intermus-
muscles are not sliding properly on each other. The situation cular and an intramuscular hematoma to the thigh are given
can be improved with a variety of treatments, especially in Tables 9-3 and 9-4.
massage and active movements where possible.

Intramuscular Hematoma CUTANEOUS SCAR TISSUE

A more potentially serious result of deep trauma is the for- The treatment of cutaneous scar tissue has a long history in
mation of an intramuscular hematoma. As the name sug- massage. Whenever the skin and subcutaneous tissues are
gests, the bleeding has occurred from torn capillaries deep cut, bleeding ensues, although it eventually ceases because
within the muscle tissue itself. There may be only a small of the clotting mechanisms of the blood. The clot is eventu-
surface bruise, but there is sizable internal swelling, which ally converted to scar (fibrous) tissue, sealing the damage
is often exquisitely tender in the acute stages of injury to the tissues. Depending on the size and depth of the origi-
(Figure 9-2, B). It is likely that muscle fibers have been nal cut, the skin may be able to regenerate so that eventually
ruptured during an explosive muscle contraction, such as
might occur during a sporting event. Alternatively, it can
occur when the tissues are struck by an object traveling at
high speed, such as a baseball or golf ball. The tremendous
kinetic energy of the ball is absorbed in a small area of
tissue, causing a huge compressive force. As a result, the
tissue is destroyed, and the capillaries rupture and cause
bleeding. Once triggered, the inflammatory process is
implemented with all of the common signs of acute inflam-
mation. The situation must be handled carefully because of
the chance of causing further bleeding, especially within the
next several days after the initial injury. In the acute and
subacute situation, focal massage to this type of hematoma
is usually contraindicated. If the hematoma becomes
chronic, then focal massage can be an effective method of
mobilizing the superficial and deep tissues. Great care is
still needed, however, at this time because of the possibility
of myositis ossificans, initiated by an overly vigorous
treatment.
Although the two kinds of hematoma are obviously dif-
ferent, it is quite possible to have both types within the
tissues at the same time. These hematomas might easily Figure 9-3 The Concept of Concentric
occur following severe trauma to a limb as a result of a Kneading to Treat a Chronic
motor vehicle crash. Figure 9-2, C, illustrates such a com- Intermuscular or Intramuscu-
bination. In all cases, however, the basic approach to treat- lar Hematoma
ment using massage is similar. First, a series of depletive Finger pad or thumb pad kneading is given in a series of overlapping
strokes is given to the region, followed by strokes that gener- concentric circles, beginning at the margins of the visible bruise and
ally mobilize the tissues. These strokes are followed by focal gradually working toward the center of the hematoma. The entire series
massage using finger pad and thumb pad kneading around of overlapping circles is repeated four times. Kneading pressure is light
the center of the hematoma. The finger pad and thumb pad for the first series of strokes and gradually becomes deeper by the
kneading is performed in a series of overlapping, concentric fourth repetition. If the tissues are tender and massage elicits pain, then
circles, beginning several inches from the center of the only light pressure should be used.
 PART TWO PRACTICE

Focal Massage Sequence for a

Subacute/Chronic Intermuscular
able 9-3. Hematoma in the Thigh Region

Depletive stroking to the whole limb 3

Depletive effleurage to the whole limb 3
Palmar kneading to the thigh 3
Finger pad kneading in concentric 4
circles around the margins of the
hematoma
Picking up to the thigh 3
Wringing to the thigh 3
Effleurage to the whole limb 3
Italics indicate specific focal massage techniques.
“Performed with the patient supine and the lower limb elevated.

Figure 9-4 Thumb Pad Kneading for a

Focal Massage Sequence for a Linear Scar
~~ Chronic Intramuscular Several rows of thumb pad kneading are given to the skin adjacent to
a linear scar, gradually working toward the scar. The direction of pres-
avle 9-4 Hematoma in the Thigh Region
sure in each circle of kneading is such that the tissues are pulled away
we e os we pe = @ r. from the scar. This means that the therapist applies pressure in a
Depletive stroking to the whole limb 3 clockwise direction on the right side of the scar and counterclockwise
Depletive effleurage to the thigh S on the left side. Alternatively, one side of the scar can be held down
Palmar kneading to the thigh 3 with one hand, while thumb pad kneading is given with the thumb pad
Finger pad kneading in concentric 4 of the other hand. As an alternative, thumb pad kneading can be given
circles around the margins of the with both hands working simultaneously but out of phase with each
hematoma other.
Thumb pad kneading in concentric 4
circles around the margins of the
hematoma
Wringing to the thigh 3 for such cases. Two different types of cutaneous scars will
Picking up to the thigh 3 be considered here, although the basic massage treatment
Effleurage to the whole limb 3 concepts are similar. These are linear and diffuse scars.
Italics indicate specific focal massage techniques. Great care is needed when dealing with any fresh scar,
*Performed with the patient supine and the lower limb elevated. especially one where the tissues are very thin. In these
cases, focal massage techniques are probably best avoided
until the scar has further healed.
the scar is difficult, if not impossible, to see. Obviously, the
regenerative powers of the skin are closely related to the age Linear Scars
of the individual. The older a person gets, the more time the This type of scar is typically the result of surgery or trauma
skin takes to heal and the more obvious is the scarring that with a very sharp object, such as a knife or glass. The focal
occurs following injury. massage techniques concentrate on mobilizing the scar by
As the largest organ of the body, the skin is an important using thumb pad kneading. The concept of beginning the
structure, and damage to the skin can have profound effects massage a short distance away from the target tissue and
on the functional mobility of the patient. Human skin, and then working toward the lesion applies here. This technique
the subcutaneous tissues supporting it, is designed to be an mobilizes the surrounding tissues as well as the target
elastic and mobile structure in most parts of the body. When tissues. The therapist may also find it helpful to hold down
it is cut surgically or lacerated by trauma, there is a strong one side of the scar with the thumb and thenar muscles of
tendency for the scar tissue to stick the various tissue layers one hand while the thumb pad of the other hand kneads the
together. When this happens, the skin loses its mobility, and other side of the scar, pulling the tissues away from the scar.
functional movements are often impaired. For example, a This means that the kneading will be given in a clockwise
deep laceration in the anterior thigh region can seriously direction on the right side of the scar and a counterclockwise
restrict knee flexion. Without proper treatment, functional motion on the left side. Thumb pad kneading can also be
active range of motion in the knee can be seriously reduced, given with both hands working simultaneously but out of
making it difficult for the patient to descend a flight of stairs phase. These concepts are depicted in Figure 9-4. Table 9-5
or sit down in an armchair. Mobilization of the scar and presents a suggested sequence for focal massage to a linear
surrounding tissue is therefore an important treatment goal scar.
 FOCAL MASSAGE SEQUENCES CHAPTER 9

Focal Massage Sequence for Focal Massage Sequence for

lable 9-5 Linear Scar Tissue in the Skin lable 9-6 Diffuse Scar Tissue in the Skin
a oe

Stroking to the surrounding area 3 Stroking to the whole area 3

Effleurage to the area (or limb) 3 Palmar kneading to the whole area 3
Palmar or finger pad kneading to the 3 Finger pad kneading in concentric 4
surrounding areas circles around the margins of the scar 4
Thumb pad kneading along each side 4 Thumb pad kneading along the area of the 4
of the scar scar
Skin rolling across the scar in different 4 Skin rolling across the scar in different 3
directions directions
Effleurage to the area (or limb) 3 Effleurage to the whole limb 3
Italics indicate specific focal massage techniques. Italics indicate specific focal massage techniques.
“Performed with the patient comfortably supported and positioned “Performed with the patient comfortably supported and positioned
so that the scar is readily available for treatment. so that the scar is readily available for treatment.

MUSCLE, TENDON, OR
LIGAMENT ADHESION

a) A Nd en ie i Whenever there is unresolved (chronic)

involving a muscle, tendon, tendon sheath, or ligament,
inflammation

there will be a certain amount of fibrous tissue forming a

scar that tends to adhere to the surrounding tissues. Thus
there will be a marked decrease in intertissue mobility,
resulting in a greater or lesser degree of pain and dysfunc-
tion. Mobilizing these adherent tissues is an obvious priority
in the treatment plan. A certain degree of improvement can
be expected when tissues are stuck to their neighbor, but if
this situation has existed for many weeks or months, adap-
tive shortening will have set in and it will be much more
difficult to see improvements in range of motion in a short
time frame. As mentioned previously in this chapter, the
Figure 9-5 Thumb Pad Kneading for a reengineering of collagen tissue does not occur overnight,
Diffuse Scar and many weeks of treatment are often needed for patients
A series of overlapping, concentric circles of thumb pad kneading is to recover from serious contractures in muscles, tendons
given to the entire area. Kneading begins in the healthy tissues adjacent ligaments, and joint capsules. Some form of serial casting
to the margins of the scar and then gradually works inwardly toward will probably be needed to produce long-term lengthening
the center of the scar. The kneading is performed so that the tissues
in contracted tissues, especially muscles and tendons.
are pulled away from the center of the scar. Alternatively, the area of
In the case where there is a local binding of tissues,
the scar can be halved and the same principles of kneading for a linear
without serious adaptive shortening, focal massage tech-
scar can then be applied (see Figure 9-4).
niques can be helpful for restoring pain-free range of motion.
The general principle is that the techniques are given at right
angles to the long axis of the affected, muscle, tendon,
tendon sheath, or ligament. Here the technique aims at loos-
ening the individual fibers in the structure by rolling them
Diffuse Scars on their neighboring tissues. This is, in fact, the primary
A diffuse scar is usually the result of major trauma or concept already described for the technique of deep friction
burning to the area; for example, extensive complicated. (see Chapter 4). Although deep friction techniques are
fractures following a serious motor vehicle crash. A similar usually given using the pad of the index finger, reinforced
concept to the focal massage of a linear scar can be applied by the middle finger, the stroke can also be given with one
to the treatment of a diffuse scar. In this case, the total area or two thumbs and with the finger pads of either or both
of the scar can be divided in half and thumb pad kneading hands. For example, the larger the muscle tissue to be
given to each side in a manner similar to that used for a treated, the more digits will be needed to cover the tissues.
linear scar (see Figure 9-4). Figure 9-5 and Table 9-6 Deep frictions can also be given by the finger pads of one
presents a suggested sequence for focal massage to a diffuse hand, reinforced by the other, when the structures to be
scar. treated are deep in the tissues. To be effective, deep frictions
 PART TWO PRACTICE

must be performed properly. The specific points of tech- niques will need some adjustment to coincide with the larger
nique for transverse frictions were discussed in Chapter 4, physical size of most muscles, but the principles remain the
and the reader is directed there for more details. Figure same as those discussed previously. A suitable sequence of
9-6 illustrates the direction of the transverse friction strokes is listed in Table 9-8. Note that there are more
strokes. strokes directed toward mobilizing the whole muscle, espe-
The general principles of mobilizing the areas surround- cially if the muscle is large, such as the quadriceps femoris.
ing the target tissue first and then working in to focus on If the muscle is small, such as one of the thenar muscles, it
the lesion itself are used in the sequence presented in Table may not be possible to perform some of the techniques, so
9-7. Finger pad and thumb pad kneading are given to the they will be omitted. Nonetheless, the aim of the treatment
local area in order to promote the deep circulation and is to produce as much mobility as possible between the
mobilize the tissues generally. Deep transverse frictions are individual components of the muscle and its surrounding
then used to mobilize the exact areas of adhesion. Finally, tissues. In this regard, a full range of relaxed passive move-
effleurage is given over the area to promote the general cir- ments will greatly help to maintain and increase muscle
culation of blood and lymph throughout the treated area. length (see Chapter 4 for examples).
Generally speaking, the techniques used to treat an
adherent tendon or ligament are the same ones used to treat
COLON DYSFUNCTION
a muscle contracture. Obviously, the majority of muscles are
much larger than tendons and ligaments; therefore the tech- Various types of abdominal massage have been advocated
for the treatment of disorders of colon (large intestine) func-
tion. Essentially, the goal of these forms of massage is to
stimulate the normal flow of the contents of the large intes-
tine. This technique can be taught to the patient and used at
home, although in a modified way. As usual, the focal
Muscle massage strokes are both preceded and followed by some
Tendon
Ligament general techniques to the abdominal wall. For treatment in
a clinic, the patient is comfortably supported in the supine
position, lying with pillows under both knees so that the hips
and knees are in a small degree of flexion. This position
removes stress on the anterior abdominal muscles, thereby
helping the patient to relax (see Figure 3-7, A).
Figure 9-6 Direction for Mobilizing The two focal treatment techniques are deep stroking and
Muscle, Tendon, or Ligament reinforced kneading, and both are given using a modified,
Adhesion
Massage strokes are given at right angles to the long axis of the involved
tissue. A curvilinear direction is used in most cases because the tissues
are somewhat rounded in cross-section. Focal Massage Sequence for
lable 9-8 Muscle Contracture/Adhesion
ss
nie B

Depletive stroking to the whole limb 3

Depletive effleurage to the whole limb
Focal Massage Sequence for 3
Palmar kneading to the affected
Table 9-7 Tendon or Ligament Adhesion muscle(s)
3
mae eae
PROCED *
R Finger pad kneading in concentric 4
Deep stroking to the whole limb 3 circles around the areas of the
contracture
Finger pad kneading in concentric 3
Thumb pad kneading to the contracture 4
circles around the margins of tendon
or ligament Deep transverse frictions to the muscle 4
Thumb pad kneading around the tendon at the contracture site
4
or ligament Wringing to the affected muscle 4
Deep transverse frictions to the tendon Picking up to the affected muscle 3
4
or ligament Effleurage to the whole limb 3
Effleurage to the whole limb 3 Italics indicate specific focal massage techniques.
“Performed with the patient comfortably supported and positione
Italics indicate specific focal massage techniques. d
so that the muscle is readily available for treatment; in most
*Performed with the patient comfortably supported and positioned cases
the affected muscle should be on full stretch for the treatment
so that the tendon or ligament is readily available for treatment; the to be
effective. If the affected muscle is small, it may not be possible
tendon or ligament should be on full stretch for the treatment to be to
perform palmar kneading, wringing, or picking up, in
effective. which case
these strokes should be omitted.
 FOCAL MASSAGE SEQUENCES CHAPTER 9

depletive manner. The normal direction of flow in the large

wall is mobile, these strokes can be given through a thin
intestine is clockwise, and it is important not to use massage
layer of material, such as a cotton T-shirt. This makes it easy
strokes in the reverse direction. However, to facilitate the
for the patient to slide his or her hands over the abdominal
normal emptying of the colon, a modified depletive tech-
tissues during the various stroking techniques. At the same
nique is used. For the purposes of the massage strokes, the
time, when the deep kneading is performed, there is suffi-
colon can be divided into four parts, beginning at the distal
cient friction between the patient’s hand, the T-shirt, and the
end: (1) the sigmoid colon and rectum, (2) the descending
skin of the abdomen for the stroke to be performed
colon, (3) the transverse colon, and (4) the ascending colon.
properly.
These segments of the colon are depicted in Figure 9-7.
Assuming the colon is congested, it is important to clear the
distal parts of the intestine before the proximal parts. If MUSCLE DYSFUNCTION: FACILITATION
treatment began at the proximal end, it would clearly increase OF MUSCLE CONTRACTION
the already congested colon. Therefore, both stroking and Focal massage techniques can be used to facilitate a muscle
kneading follow a course that begins at the distal end of the contraction when the patient finds it difficult to initiate
intestine and works backward to the beginning of the colon. muscle activity. These techniques facilitate voluntary con-
Each segment (numbered | to 4) is treated in order, starting traction of the muscle and do not strengthen it in any way.
at the proximal end of the segment and working in the Several techniques are able to facilitate muscle contraction
appropriate direction to the distal end. Although each and therefore can be classified as legitimate focal massage
segment is treated in the same direction as the normal flow strokes. The object is to stimulate afferent (sensory) nerve
in the colon, the progression of the segments is in the oppo- fibers in the muscle(s) concerned and the skin overlying the
site direction (counterclockwise). In this manner, the con- same muscle(s). In most, but not all, cases, the sensory
tents of the colon are moved in a depletive manner. This nerve fibers innervating the skin that overlies a muscle(s)
concept is also illustrated in Figure 9-7. come from the same segments of the spinal cord that supply
A sequence of strokes, including focal techniques for the motor fibers to the same muscle(s). Therefore stimulating
colon, is listed in Table 9-9. The sequence can be given to the skin over a muscle activates a wide range of mechano-
the patient by the therapist in a clinical setting, or the various receptors that discharge a sensory barrage of impulses into
strokes can be taught to the patient so that they may be the spinal cord at the same levels, which supply the motor
performed at home several times per day. The patient is nerves to the muscle beneath the skin. This barrage of
usually taught to use his or her right hand, reinforced by the sensory impulses raises the level of central excitability of
left, while performing each stroke. Because the abdominal the motor cells in the spinal cord, thereby making it easier
for the patient to initiate a voluntary contraction.
In addition to stimulating sensory fibers in the skin, focal
massage to a muscle has a much more powerful and direct
effect on the muscle. The sensory fibers in the muscle spin-
dles (especially the Ia afferents) are exquisitely sensitive to

Focal Massage Sequence for

3 Jable 9-9: Colon Dysfunction

Superficial stroking to the abdomen in 3

a clockwise direction
Deep, depletive stroking in a 3
counterclockwise direction, beginning
at the sigmoid colon
Reinforced palmar kneading in a 4
counterclockwise direction, beginning
at the sigmoid colon
Deep, depletive stroking ina 4
Figure 9-7 Segments of the Colon and counterclockwise direction to the
Direction of Treatment for the whole abdomen, beginning at the 3
Depletive Strokes sigmoid colon
Each of the four segments of the colon is shown, together with an arrow Superficial stroking to the abdomen in 3
to indicate the direction and order in which the depletive strokes are a clockwise direction
used. The four segments are (7) the sigmoid colon and rectum, (2) the Italics indicate specific focal massage techniques.
descending colon, (3) the transverse colon, and (4) the ascending *Performed with the patient supine, with knees supported in slight
colon. flexion.
 PART TWO PRACTICE

changes in its overall length. Activating these fibers will sive strokes, especially hacking, clapping, and vibrations.
stimulate the stretch reflex pathway, directly activating the These techniques can be integrated into the rest of a treat-
muscle being massaged. ment program as and where they seem most appropriate.
The type of manipulations that are most likely to be They should be viewed as yet another option in the list of
effective in facilitating muscle contraction are the percus- techniques available for muscle reeducation.
 Massage for the Patient with
a Respiratory Condition

Massage techniques for patients suffering from respiratory tuberculosis and the emergence of new and dangerous
disorders center around two basic concepts: (1) helping strains of flu viruses. It is clear from the statistics that the
patients gain control of their breathing pattern by assisting quality and duration of many lives are significantly affected
them to relax, and (2) helping patients to loosen and clear by this disease. In effect, COPD is rapidly becoming one of
mucus from their lungs. Although these are important issues the most important health problems of our time. It behooves
for the patient, they are a relatively small part of the overall health professions to upgrade their understanding and capac-
rehabilitation process for the management of pulmonary ity to provide effective treatment. As with just about every
disorders. A wide variety of treatment techniques, including facet of modern health care, a coordinated and consultative
massage, have been used for this purpose over many decades approach involving a variety of expert practitioners is likely
in most parts of the world. This treatment is generally to provide the best care for the patient.
referred to as chest physical therapy (Frownfelter & Dean, Several important treatment concepts are involved in
2006; Hillegass & Sadowsky, 1994; Irwin & Techlin, 2005; chest physical therapy, the most important of these being
Watchie, 1995; Webber & Pryor, 1993). postural drainage, percussion, vibration and shaking, facili-
Many patients who suffer from chronic respiratory dis- tation techniques, breathing exercise and retraining, relax-
tress could be significantly helped by some simple and cost- ation techniques, posture correction and retraining, graded
effective procedures. These techniques might be tried before exercise, and endurance programs. In addition, patient and
more expensive equipment and medications are ordered, and, caregiver education are critical for patient compliance and
of course, much of the physical therapy involves teaching long-term success. A detailed discussion of all these areas
patients a variety of strategies to help themselves through dis- is well beyond the scope of this chapter. Instead, the inten-
tress plus techniques to prevent further episodes. These valu- tion here is to define and describe the contributions of
able and cost-effective treatments are lost if the patient receives massage techniques to the treatment of patients with a respi-
only a machine and medication. Thus the typical goals of a ratory disorder; the part played by methods such as percus-
chest physical therapy program are listed in Box 10-1. sion and vibration is presented in detail, and other techniques
Health statistics show a consistent increase in the inci- are mentioned only briefly. The references cited earlier,
dence of chronic obstructive pulmonary disease (COPD). together with other materials, provide excellent discussions
From 1950 to 1960, for example, deaths attributable to of the specialty area of cardiopulmonary physical therapy,
emphysema and chronic bronchitis increased more than including details of treatment techniques (Frownfelter,
fourfold (Carey, 1967). In an additional study (1950-1965), 1987; Frownfelter & Dean, 2006; Hillegass &
the mortality rate was shown to double every 5 years. Deaths Sadowsky, 1994; Irwin & Techlin, 2005; Mackenzie, Imle,
increased almost eightfold, from 3157 patients in 1950 to” & Ciesla, 1989; Watchie, 1995; Webber & Pryor, 1993).
23,700 patients in 1965 (Weiss et al., 1969). By the late
1970s, data suggest that about 27% of adult males and 13% RELAXATION
of females have symptoms of spirometric abnormalities
indicative of COPD (Petty, 1978). To make matters worse, Relaxation is often an important issue for patients
there has been a resurgence of serious diseases such as suffering from respiratory disease, especially one that is
icles ae ae

Typical Goals of Chest Position

EULA Physical Therapy

Prevent the accumulation of secretions.
Improve mobilization and drainage of secretions.
Instruct patients in home bronchial hygiene programs.
Promote relaxation to avoid muscle splinting.
Maintain and improve chest wall mobility.
Percuss
Restore the most efficient breathing pattern.
Instruct and retrain the use of respiratory muscles.
Develop respiratory muscle endurance and prevent
venous stasis. Figure 10-1 Basic Steps in an Airway
Improve and promote good posture. Clearance Technique
Improve cardiopulmonary exercise tolerance.
The technique begins with the patient properly supported in the
Educate patients in every aspect of their condition so that
they can take control of their own respiratory health. appropriate postural drainage position. The patient is allowed to
rest and drain in this position for approximately 10 to 15 minutes. Per-
cussion and vibration techniques are then applied, followed by deep
breathing and an attempted cough. Deep breathing and coughing can
be repeated a few times if the mucus is easily removed. The patient
characterized by constricted airways or marked shortness of
then rests in the postural drainage position, and the cycle is repeated
breath. Anxiety, fear, and outright panic are symptoms com- until the chest is clear.
monly associated with an inability to breathe. Not surpris-
ingly then, people, especially children who suffer from
chronic respiratory diseases such as asthma, find it difficult
to relax and thus develop many postural problems related to
their overactive muscles. Helping the patient to learn how cardiopulmonary rehabilitation for both children and adults,
to relax, breathe properly, and clear the airway of mucus is and a variety of techniques have been developed to make
therefore an important goal of treatment. Because massage this possible (Ciesla, 1996; Hugh, 1999; Jones & Rowe,
is especially effective in promoting relaxation and lowering 2000; Oberwaldner & Zach, 2000; Rivington-Law et al.,
anxiety and other techniques are effective in clearing the 1984; Spotnitz, 1978; Williams et al., 2000; Zhu, 1998).
airway, it is not surprising that massage can be an effective Airway clearance requires the removal of adherent (and
treatment, especially for children with asthma (Fiels, possibly infected) mucus with the application of three basic
1998). techniques:
Various techniques are available to teach the patient 1. Appropriate postural drainage
how to relax. Two common strategies—the contrast and 2. Appropriate manual techniques to help loosen mucus
the induction methods—were discussed in some detail in 3. Controlled breathing exercises and coughing to remove
Chapter 3 and will not be repeated here. Either of these the mucus from the lungs
methods are suitable; even a combination of the two These three procedures are integrated into a total treatment
approaches would also work well for some patients. An process, in which there is an orderly progression from
important modification, however, for both techniques relates one part to another. Assuming the patient has been thor-
to the position of the patient. Supine lying is a position in oughly screened and there are no contraindications to the
which most, if not all, patients with a respiratory disease procedure, treatment begins with the patient properly sup-
will have difficulty breathing. A suitable alternative would ported in the appropriate postural drainage position. The
be sitting upright in the bed or a comfortable armchair. patient is allowed to rest in this position while the lung
Appropriate pillows should support the knees, lumbar spine segments drain. Following a period of approximately 10 to
neck, and perhaps the elbows and forearms. As patients 15 minutes, percussion and vibration techniques are admin-
learn to relax, they are better able to control their breathing. istered to the appropriate parts of the patient’s chest.
Being able to control breathing gives patients an important Deep breathing and a cough then follow, several times
method to reduce their anxiety level and avoid panic. It also if necessary. The patient is then allowed to rest in the
makes it possible for them to pay attention to their posture drainage position, and the cycle is repeated until the chest
and to correct and prevent problems. is clear, unless the patient is fatigued, in which case
treatment is discontinued. The basic concept is depicted in
AIRWAY CLEARANCE Figure 10-1.

The removal of mucus (sputum) from the airways and lungs

is a major goal of treatment for any patient who has a pul- POSTURAL DRAINAGE
monary disorder characterized by significant mucus produc- Postural drainage consists simply of allowing gravity to
tion. Clearing the airway paths is therefore a vital part of promote movement (drainage) of lung secretions toward the
 MASSAGE FOR THE PATIENT WITH A RESPIRATORY CONDITION = CHAPTER 40 las

bronchial tree and the trachea, where the patient can expel
Primary Effects of Postural Drainage
them by coughing. Gravity both helps and hinders the
The therapeutic effects of the postural drainage techniques
normal movement of lung secretions. Essentially, gravity
are produced mainly through a direct mechanical impact on
tends to drain the upper lobes and pool secretions in the
the tissues. Mucus that has pooled in the lower segments of
lower lobes. The consistent movement of the cilia, which the lungs is drained away using the effect of gravity to draw
line the respiratory passages, together with the normal
it out of the lungs. When performed properly, postural drain-
cough reflex usually ensure proper airway clearance of
age has the following primary effects:
the respiratory passages. Under normal circumstances, the
¢ Loosening and drainage of mucus from the lungs
system is extremely efficient at keeping the airway clear;
¢ Increased blood and lymph flow in the skin and
however, disease or the effects of surgery may render the
subcutaneous tissues, especially in the head
patient unable to expel retained mucus from the lungs.
¢ A tendency for increased blood, intracranial, and
Mucus retained in the lungs is a major focus for infection.
intraocular pressure
The warm, dark, and damp environment deep within the ¢ Unloading of the spine and abdominal viscera
lungs is the perfect incubation chamber for bacteria and
viruses. If a serious infection occurs, it is costly to treat and Therapeutic Uses of Postural Drainage
can have serious, possibly fatal, consequences. When included in a treatment sequence, postural drainage
The technique of postural drainage requires a detailed can be used to do the following:
understanding of the anatomy and physiology of the respira- ¢ Loosen and drain mucus from one or more lung
tory system. Placing the patient sequentially in a variety of segments or lobes, thereby assisting with airway
positions makes it possible for gravity to promote the flow clearance and expectoration
of secretions toward the mouth, where they can be expelled. ¢ Encourage breathing if particular lung segments and
Positioning depends on the specific part of the lung involved. lobes
Three basic positions are used:
Indications for the Use of
1. Sitting upright
Postural Drainage
2. Lying flat on the back
3. Lying on one side Postural drainage techniques may be indicated as part of a
With the exception of the upright sitting position, the patient treatment plan to help relieve or reduce the effects of the
will need to be tipped; to do this, the therapist raises one following:
end of the bed or treatment table to an appropriate angle. ¢ Respiratory disorders associated with mucus retention,
Two basic tipping heights are used: such as cystic fibrosis and bronchiectasis, in which the
patient needs regular airway clearance for the rest of his
Low tip = 12 to 14 inches (30 to 35 cm) or her life
High tip = 18 to 20 inches (45 to 50 cm) Respiratory infections associated with mucus/fluid
All measurements are made from the floor to the tip of the buildup in specific lung segments or lobes
leg of the table or bed. The high tip is used mainly to drain Contraindications to the Use of
various parts of the lower lobes. It is the combination of Postural Drainage
positioning and tipping the patient that makes postural The general concept of contraindications is covered in Chapter
drainage so effective. Because a detailed description of all 3. As a technique, postural drainage may be contraindicated
of the postural drainage techniques is beyond the scope of when any of the situations listed in Box 10-2 are present. The
this chapter, Figure 10-2 has been included to provide an contraindications listed for the use of postural drainage tech-
easy-to-follow summary of the various positions. The reader niques are all listed as U, meaning that the presence of the
is referred to other texts on the subject, including Frownfel- quoted conditions would normally contraindicate treatment.
ter and Dean (2006) and Hillegass and Sadowsky (1994). However, if it comes to a choice between airway clearance
Certain diseases, such as cystic fibrosis, cause the pro- and the possible negative effects of postural drainage, then
duction of large amounts of respiratory secretions. It is clearing the airway takes priority. Postural drainage tech-
extremely important, especially in small children, that these niques can be modified, especially in terms of the degree to
secretions be removed daily; otherwise, the patient is likely which the therapist tips the patient’s bed.
to develop a serious, perhaps fatal, chest infection. Figure.
10-3 illustrates a variety of postural drainage positions suit- PERCUSSION TECHNIQUES
able for the treatment of small children. The positions illus-
trated in Figure 10-2 are not suitable for small children for Percussion techniques are discussed in more detail in Chapter
many reasons, not the least of which is that the child will 4 and encompass several techniques, but only clapping is
probably not keep still long enough for the drainage to be used in the present context. The technique of clapping
effective. As the child grows older, adult positioning tech- (or cupping) is used to help mobilize retained secretions
niques can be used. Watchie’s book (1995) is another excel- adherent to the tracheobronchial tree. Percussion strokes
lent source of information in this area. send mechanical waves ofvibration (pressure waves) through
 PART TWO PRACTICE

UPPER LOBES
Anterior Posterior
apical segments apical segments
RUL & LUL

Anterior segments
P, RUL & LUL

45°
(18") [
\ pea Se Turn from prone. Rest on left side; support with pillows.
Turn from prone. Rest on right side. Head and
shoulders are raised, supported on pillows.

<<
Lingular segments RML

Tip bed 12" Pe ae Tip bed 12"

Turn from supine. Rest on right side; support with pillows. Turn from supine. Rest on left side; support with pillows.

LOWER LOBES
Basal segments
Anterior LLL & RLL a Posterior LLL & RLL

gS ox i=
LD» S a

= Tip bed 18"—20"

la p bed 18"-20"
Supine, pillow under knees.
on
rone, two pillows under abdomen.

Anterior LLL & RLL Ecral Segineni Posterior LLL & RLL
y= :
— ——

N Tip bed 18"—20"

Lie on left side; shoulders must not
rest on head pillow.

Prone, pillow under abdomen

to flatten back.

Figure 10-2 Basic Postural Drainage Positions

Postural drainage positions to drain various lung segments in the adult patient. LUL, Left upper lobe;
RUL, right upper lobe; LLL, left lower lobe; RLL, right lower lobe. (From White GC: Basic clinical compe-
tencies for respiratory care: an integrated approach, Albany, NY, 1988, Delmar.)
 MASSAGE FOR THE PATIENT WITH A RESPIRATORY CONDITION CHAPTER 10

J
Figure 10-3 Postural Drainage Positions Suitable for the
Pediatric Patient
Postural drainage positions to drain various parts of the lungs of small children. A, Apical segments of both
upper lobes (BUL). B, Posterior segment of left upper lobe (LUL). C, Anterior segment of LUL. D, Anterior
segment of right upper lobe (RUL). E, Posterior segment of RUL. F, Superior, or apical, segments of both
lower lobes (BLL). G, Anterior segments of BLL. H, Right middle lobe (also done on other side for lingular
segment of LUL). I, Lateral segment of right lower lobe (RLL); also done on other side for lateral segment
of left lower lobe (LLL). J, Posterior segments of BLL. (From Watchie J: Cardiopulmonary physical therapy:
a Clinical manual, Philadelphia, 1995, Saunders.)
 PART TWO PRACTICE

Box 10-2 Main Contraindications to the Use of If necessary, the technique may be delivered through a
OK Postural Drainage folded towel placed over the patient’s chest wall, as this
dampens the force a little and helps to prevent unnecessary
Severe rib fractures (flail chest). U skin irritation or pain. Skin erythema (redness) can have
Acute heart failure, especially when coronary U
thrombosis or embolism is involved
several causes. If the therapist’s hands are improperly
Acute pulmonary embolism cupped, a slapping or stinging effect may be produced, or
Severe hypertension too much force may be used over extremely sensitive tissues.
Arterial or venous pathology affecting the head The technique of clapping is discussed in detail in Chapter
| and neck
4 and demonstrated on the accompanying DVD (see DVD
_ Recent surgery to the brain or eye
| Congestive cardiac failure or any other heart ete
(Sere
Chapters 4-9 and 4-11). Figure 10-5 illustrates the technique
| condition in which heart function may be affected of clapping to the right lower lobe, with the patient in a high
| by the pressure exerted on the heart by the tip position.
| postural drainage position | If the patient finds the technique uncomfortable, the
U, Usually contraindicated. therapist may place a thin towel, gown, or sheet over the
area being treated. This does not significantly reduce
the effectiveness of the technique, but it is usually much
more comfortable for the patient. Figure 10-6 illustrates this
concept, and it is also demonstrated on the accompanying
DVD (see DVD Chapters 4-9 and 4-11).
Percussion is comfortable for patients when the technique
is applied properly; the rhythm and consistency of force and
the direction of movement can have a relaxing effect. Gener-
ally, little force is needed for percussion; it is the cupping,
not the force, that is effective. The force of the percussion
must be determined for each patient. For example, different
amounts of force would be needed for a child, a large adult,
or a frail, elderly patient who has recently had surgery.
Conditions such as cystic fibrosis, atelectasis, and bronchi-
ectasis are characterized by the presence of thick, tenacious
secretions and may need more vigorous chest physical
Figure 10-4 The Hand in the Cupped therapy and more percussive force to mobilize and remove
Position Used to Perform secretions. At the other extreme, a modified clapping tech-
the Technique of Clapping nique can be performed on the neonate, using just the finger
In this position, a layer of air is trapped and compressed as the hand pads of the index and middle fingers. The two fingers are
strikes the skin surface. A vibrating wave is set up and travels into the held straight but fairly relaxed. The technique is one of rapid
tissues, producing the mechanical effects that help to loosen secre- alternation of flexion and extension of the metacarpophalan-
tions. The line drawn on the hand represents the margins of the cup geal joints, keeping the fingers straight. Only the pads of the
(see also Figure 8-18).
two fingers touch the chest wall. The force of the percussion
is easily modified to suit the patient’s condition. The tech-
the rib cage and into the lungs to shake loose adherent mucus nique is simple to practice on the edge of a table, but it is
plugs in the bronchial tree. Because a mucous plug in a seg- difficult to maintain a rapid tapping for any length of time.
mental bronchus could collapse a lung segment, it is extremely This is not an issue for the neonatal chest because prolonged
important that it be removed as soon as possible. Percussion tapping is probably not helpful. Short bursts of finger clap-
and vibration techniques, together with the proper postural ping, each lasting 15 to 30 seconds, are easy for the therapist
drainage positioning and deep breathing exercises, can help to perform and for the patient to tolerate. In most cases, the
to dislodge a plug and to reexpand the lung segment or lobe. pressure will be extremely light.
These techniques can also prevent mucus plugs from build- The therapist should have a plan for hand movements
ing up and closing off parts of the airway. during percussion so that the hands do not wander aimlessly
To perform clapping, the therapist keeps his or her hands on the patient’s thorax. The therapist’s hands can work in a
cupped, fingers extended and held together, with wrists and circular pattern or along the chest, but the pattern should be
arms relaxed and loose. The hands strike the chest wall consistent throughout the treatment. Percussion should not
rhythmically and alternately, focusing on the area of the be applied in one spot for any length of time because it
lung being drained. Cupping the hands provides a cushion becomes irritating. Once skin contact is made, the percus-
of slightly compressed air between the hands and the sion should continue consistently for approximately 1 to
patient's chest wall, thereby mechanically delivering a vibra- 3
minutes, although the time varies according to the toleranc
tion wave to the lungs (Figure 10-4; see Figure 8-18). e
and needs of the patient.
 MASSAGE FOR THE PATIENT WITH A RESPIRATORY CONDITION CHAPTER 231

Figure 10-5 Clapping to the Righ’

A, The patient is in the left side-lying position with the foot of the bed elevated 18 to 20 inches (high tip).
B, The wrist movements alternate during the performance of clapping to the right lower lobe.

+ tho
tO We % ia t

The patient is in the left side-lying position with the foot of the bed elevated 18 to 20 inches (high tip). A
towel covers the anterolateral and posterolateral aspects of the chest during the performance of
clapping.

Percussion should be applied only over the bony thorax. therapist’s hand should not make contact with bony promi-
Although the vibration wave spreads out into the tissues in nences such as the spine of the scapula, clavicles, or verte-
all directions, it must be remembered that the lower margin bral column, especially if the patient is thin and elderly.
of the lungs is adjacent to the eighth rib in the midaxillary For obvious reasons, percussion must not be given over
line. When the patient is lying in the high tipped position,_ the breast tissue in a female patient. If necessary, when
the pressure of the abdominal organs may push the lungs treating the anterior aspects of the middle lobes, the whole
toward the neck. In short, if the objective of percussion is chest should be covered with a towel and the patient
to affect the lungs, it is essential that the therapist perform instructed to gently push the breast tissue toward her neck,
the technique over lung tissue rather than the abdominal away from the area to be percussed. This is usually easier
viscera. Care should be taken when applying percussion to to do with the opposite hand, but either hand can be used,
the anterior aspects of the chest and at the lateral basilar rib depending on which is more comfortable for the patient.
areas because the rib ends are attached loosely and some- The therapist can then mold the towel around the patient's
times not attached at all (i.e., floating ribs). The heel of the hand so as to make it clear which area is to be treated. The
— ‘ a ) PART TWO PRACTICE

patient keeps her hand on the breast tissue at all times during
the percussion. In the case of an obese patient, it will also
help if the patient raises the same arm above her head during
the percussion. For example, if percussion is given to the
anterior aspect of the right middle lobe, the right forearm
would be flexed upward toward the patient’s head. The
patient’s left hand would then be free to lift the right breast
tissue away from the area to be treated. The right arm should
be supported on pillows as needed for patient comfort.
The primary effects, therapeutic uses, indications, and
contraindications of the percussive manipulations are listed
in Chapter 4. Special attention should be paid to the list of
contraindications with regard to the use of clapping. If the
thorax is damaged (e.g., multiple rib fracture) or there is
serious cardiac disease, clapping may be contraindicated, in Figure 10-7 Vibration to the Right
which case a less vigorous technique such as fine vibrations Lower Lobes
may be needed. The patient is in the left side-lying position with the foot of the bed
elevated 18 to 20 inches (high tip). The therapist applies the vibration
technique only during the expiratory phase of the patient’s breathing
VIBRATION AND SHAKING cycle.
Vibration and shaking techniques are also used routinely
with postural drainage, although they can be used with the cocontraction allows the therapist to transfer a vibration
patient in many positions. They are generally performed wave to the patient’s chest wall and lung tissue. The
after percussion, or they alternate with it. Percussion is given vibration continues throughout exhalation. The shaking
to loosen adherent mucus plugs and to aid in their movement maneuver is identical to vibrations, except that it is per-
toward the bronchi and trachea, where the secretions can be formed with a lower frequency and higher amplitude of
coughed up or removed by suction. movement. In effect, the vibrations are much slower and
Vibration and shaking are both performed during the deeper than they are with the standard vibration technique.
patient’s expiratory phase of breathing, at which time the If a more aggressive form of chest compression and vibra-
patient’s chest is compressed simultaneously with the vibra- tion (or shaking) is needed, the patient takes a deep breath
tory movement. Chest compression is extremely important and the therapist springs the ribs in compression three or
in making vibration effective. The amount of chest compres- four times during exhalation. If the patient is unable to take
sion is determined by several factors such as chest wall a deep breath on his or her own, intermittent positive-
mobility, age of the patient, chest deformities, new postop- pressure breathing (IPPB) devices or a self-inflating bag
erative incisions, chest trauma, or fractured ribs. In some technique may be used to promote deep breathing. The
cases, the therapist may actually perform a rib-springing vibration technique is the same in both procedures. The
technique with the vibration, using a good deal of force in patient is mechanically given a large breath, and vibration
mobilizing the chest wall. This technique is possible only is performed from the peak of inhalation through the expira-
in a patient with a mobile thorax. tory phase. Experience has demonstrated that atelectasis and
To accomplish the vibration or shaking stroke, the patient pneumonia can be cleared more quickly when an ultrasonic
is asked to take a deep breath in through the nose, pause for nebulizer or heated aerosol is used half an hour before the
a moment, and then blow all the air out through the mouth. chest physical therapy treatment, whether or not the IPPB
As the patient begins to inhale, the therapist applies slight or self-inflating bag technique is used.
resistance to the movement of the chest wall. This encour- For some patients, vibration may be indicated even
ages localized expansion of the lungs in the areas beneath when percussion techniques would not be applicable. These
the therapist’s hands. The resistance offered to inspiration include patients who have recently undergone surgery
is gradually reduced as the peak of inhalation is reached. (including open heart surgery and thoracotomy, in which
After a momentary pause, chest compression and vibration pain and splinting would be increased) and those who have
are performed as the patient exhales. To obtain maximal hemorrhaged or fractured ribs. It must be emphasized that
benefit, the patient is encouraged to breathe out for as long the contraindications to postural drainage, percussion,
as he or she can, always within tolerance. Figure 10-7 illus- vibration, and shaking are relative. Priorities must always
trates the vibration technique, and a demonstration can be be considered. For example, if a patient has a poor cardio-
viewed on the accompanying DVD (see DVD Chapters 4-10 vascular function that is exacerbated by atelectasis, the
and 4-12). atel-
ectasis must be cleared. This situation calls for
To perform the vibration or shaking stroke, the therapist proper
decision making from the various members of
tenses all of the muscles in both shoulders and arms. This the team
caring for the patient.
 MASSAGE FOR THE PATIENT WITH A RESPIRATORY CONDITION CHAPTER 10

DEEP BREATHING AND COUGHING PASSIVE MOVEMENTS OF THE

LOWER LIMBS
The basic procedure illustrated in Figures 10-4 to 10-7
can be repeated several times. However, it is helpful for There seems to be a potential use for relaxed passive move-
patients to breathe normally between each percussive ments of the lower limbs to significantly modify alveolar
session; otherwise they may become dizzy from too many ventilation during sleep in patients with congenital central
deep inspirations. As the mucus loosens, the patient may hypoventilation syndrome (CCHS). Gozal and Simakajorn-
wish to cough and clear the secretions. A suitable covered boon (2000) showed that moving the lower limbs passively
receptacle or facial tissues should always be within the has an effect on ventilation during sleep, possibly via activa-
patient’s reach. If the patient wishes to pause and attempt to tion of mechanoreceptor-afferent pathways rather than
cough to expel the mucus, it is often best to try this at the by respiratory entrainment. This interesting finding has
end of an expiration. Certainly the patient needs to inhale important implications for the use of passive movement
procedures.
and get some air behind the mucus, but the cough is likely
to be more productive if given at the end of the expiration,
especially if the patient is unable to develop sufficient pres-
SUMMARY
sure behind the cough. It is as if the mucus is already on its
way out of the airway and the cough at the end of expiration The clinical effectiveness of chest physical therapy has been
gives it the final push. This is important with sticky mucus, demonstrated on patients with a wide spectrum of respira-
because the patient can become exhausted quickly from tory problems that are either the direct result of respiratory
wasted efforts to clear mucus using an ineffective coughing disease or secondary to some other medical or surgical
technique. condition—for example, spinal cord injury, cerebrovascular
The normal cough requires the patient to take a deep accident, myocardial infarction, or neuromuscular disor-
breath and to hold it briefly (closing the glottis and vocal ders. These patients have many common respiratory prob-
cords). As the breath is held, the intrathoracic pressure is lems—poor ventilation and ineffective cough—and, as a
increased mainly because of the contraction of the abdomi- result, they have retained and often infected lung secretions.
nal muscles. The pressure is suddenly released (opening the Factors that contribute to these problems are muscle weak-
glottis and vocal cords) in an explosive exhalation. The ness or paralysis, poor coordination, lack of endurance, and
patient with an endotracheal tube cannot cough because abnormal breathing patterns.
the tube passes through the glottis and between the cords, Debilitated and dependent patients exhibit a marked
preventing them from closing. Similarly, a tracheostomized decrease in general activity level, often including an inabil-
patient has a tube below the cords and is unable to build up ity to change basic body positions. In a bedridden patient,
intrathoracic pressure by closing the glottis and cords. In turning from side to side affects general postural drainage
either case, coughing, the major mechanism for clearing of each lung. Gravity becomes both a positive and a negative
secretions from the lungs, is not functioning. A cough may factor in lung drainage: positive in that the uppermost part
be simulated by using the self-inflating bag (with tracheos- of the lung is drained, and negative in that secretions accu-
tomy or endotracheal cuff inflated to seal off the airway), mulate in the dependent lobes. Thus patients paralyzed on
giving a large inspiratory volume and holding the bag for 2 the right side are more likely to turn to the right because
or 3 seconds, then popping the bag open quickly. The thera- they have use of the left extremities. They find it difficult to
pist begins chest compression and vibration during the hold turn to the left side and may develop pneumonia in the right
period of bag inflation and continues throughout the exhala- lung. Quadriplegic patients lying on their backs are likely
tion phase. to develop bilateral posterior basal pneumonia or pneumo-
A variety of devices, such as the ultrasonic nebulizer, can nia in the superior segments of the lower lobes. The impor-
be of tremendous benefit, especially if given just before tance of frequent position changes for postural drainage
postural drainage. This form of therapy helps liquefy secre- cannot be overemphasized. These frequent changes for par-
tions, making them easier to loosen and expectorate. IPPB alyzed patients require a total team effort from the staff
treatments can also be administered in conjunction with caring for the patient.
postural drainage, percussion, vibration, and shaking to dis- Patients with neuromuscular disorders such as myasthe-
tribute air peripherally in the lungs. This air distribution nia gravis or Guillain-Barré syndrome require help in
increases the chances of getting air beyond the secretions achieving or maintaining clear lungs so that they can maxi-
mize their rehabilitation. Shortness of breath is often caused
and making the cough more productive. A variety of
by the accumulation of secretions in the airways; this fright-
mechanical vibrating devices have also been used to loosen
ens many patients and greatly limits their activity and prog-
lung secretions. Because these are not manual techniques,
ress. A program of bronchial hygiene—consisting of postural
they are not considered further here. The interested reader
drainage, percussion, vibration, and breathing retraining—
is referred to Doering et al. (1999). In addition, reference to
should be given before exercise. This will allow the patient
their use can be found in many of the standard texts men-
tioned previously in this chapter. to tolerate more activity because the airway is clear. The
 PART TWO PRACTICE

patient should rest after bronchial hygiene procedures, as Frownfelter DL, Dean E: Cardiovascular and pulmonary physical
therapy, ed 4, St Louis, 2006, Elsevier.
they are often tiring.
Gozal D, Simakajornboon N: Passive motion of the extremities modifies
To gain expertise in chest physical therapy, therapists alveolar ventilation during sleep in patients with congenital central
must be skilled in giving percussion and vibration, postural hypoventilation syndrome, Am J Resp Crit Care Med 162(5):1747-
drainage, breathing exercises, exercise programs geared to 1751, 2000.
Hillegass EA, Sadowsky HS: Essentials of cardiopulmonary physical
the patient with respiratory problems, and other modalities
therapy, Philadelphia, 1994, Saunders.
of respiratory therapy. Although the trend is toward ever Hugh: The child with a chronic condition: children with cystic fibrosis
more expensive high-tech equipment and medications, the benefit from massage therapy, J Child Fam Nurs 2(5):366-367,
intelligent use of basic chest physical therapy concepts can 1999.
Irwin S, Techlin JS: Cardiopulmonary physical therapy, ed 4, St Louis,
prevent problems from arising in the first place and is a more
2004, Mosby.
cost-effective approach in the long term. This is especially Jones A, Rowe BH: Issues in pulmonary nursing. Bronchopulmonary
the case for patients who have chronic lung disease and wish hygiene physical therapy in bronchiectasis and chronic obstructive
to spend as much time as possible in their own homes. It is pulmonary disease: a systematic review, Heart Lung: J Acute
Critical Care 29(2):125-135, 2000.
worth remembering that the need to breathe is paramount.
Mackenzie CF, Imle PC, Ciesla N: Chest physiotherapy in the intensive
No human being can survive for more than a few minutes care unit, ed 2, Baltimore, 1989, Williams & Wilkins.
without being able to breathe, yet breathing is a vital func- Oberwaldner B, Zach MS: Mucous clearing respiratory-physiotherapy in
tion that most people completely take for granted until they pediatric pneumology [in German], Schweiz Med Wochenschr
130(19):711-719, 2000.
are unable to do so. Teaching a patient to maintain a clear Petty TL: Chronic obstructive pulmonary disease, New York, 1978,
airway can have a profound impact on the patient’s ability Marcel Dekker.
to live a normal life. Rivington-Law BA, Epstein SW, Thompson GL et al: Effect of chest
wall vibrations on pulmonary function in chronic bronchitis, Chest
85(3):78-381, 1984.
REFERENCES Spotnitz B: A system for self-administration of vibration in respiratory
physiotherapy, Respir Care 23(10):960-961, 1978.
Carey FE: Emphysema: the battle to breathe, US Department of Health, Watchie J: Cardiopulmonary physical therapy: a clinical manual,
Education and Welfare Public Health Service Publication No. 1715, Philadelphia, 1995, Saunders.
1967. Webber BA, Pryor JA: Physiotherapy for respiratory and cardiac
Ciesla ND: Chest physical therapy for patients in the intensive care unit, problems, Edinburgh, 1993, Churchill Livingstone.
Phys Ther 76(6):609-625, 1996. Weiss EB et al: Acute respiratory failure in chronic obstructive lung
Doering T, Fieguth HG, Steuernagel B et al: External stimuli in the disease, I. Pathophysiology, Disease-a-Month, October 1969.
form of vibratory massage after heart or lung transplantation, Am J Williams MT et al: Energy expenditure during physiotherapist-assisted
Phys Med Rehabil 78(2):108-110, 1999. and self-treatment in cystic fibrosis, Physiother Theory Pract
Fiels TP: Children with asthma have improved pulmonary functions 16(2):57-67, 2000..-
after massage therapy, J Pediatrics 132(5):854-858, 1998. Zhu S: A clinical investigation on massage for prevention and treatment
Frownfelter DL: Chest physical therapy and pulmonary rehabilitation: of recurrent respiratory tract infection in children, J Trad Chinese
an interdisciplinary approach, Chicago, 1987, Year Book. Med 18(4):2285-2291, 1998.
 Connective Tissue Massage

Unlike previous chapters, which have considered the various Dicke, a German physiotherapist, was the first to describe
strokes that make up the method known as Swedish reme- the technique in the late 1920s and early 1930s. Dicke was
dial massage, this chapter is the first to focus on a different suffering from a serious circulatory impairment in her right
but parallel system of soft tissue manipulation. Connective leg that resulted in the development of endarteritis obliter-
tissue massage (CTM)—or in German, bindegewebsmas- ans of the limb. This painful condition was so severe that
sage—is a total system of specialized soft tissue manipula- surgeons recommended amputation. In an attempt to relieve
tion techniques originally developed in Europe between the the accompanying low-back pain, Dicke discovered an
two world wars. It is a good example of a treatment that unexpected effect in her leg when she rubbed certain areas
produces a remote site effect. This concept is well known on the posterior pelvic region. While she applied pulling
in many Eastern systems of massage and traditional methods strokes to the skin of her posterior pelvic region, she was
of treatment. Essentially, stimulation given to one part of aware of a sensation of warmth rushing into her affected
the body has a profound effect on tissues apparently unre- leg. After 3 months of this massage (performed by a col-
lated to the treatment site. Acupuncture, reflexology, and the league), the severe symptoms began to subside. Within a
more modern concept of trigger point stimulation share this year, she was back at work as a physiotherapist. A great deal
conceptual foundation. of clinical study and evaluation followed this initial experi-
As modern understanding of physiology increases, it is ence. Dicke, along with her colleagues, refined her original
becoming clearer that there is a sound rationale for the use stroking technique to treat many pathologically involved
of these concepts, even though they may seem at first glance tissues and organs. She went on to develop the method of
unlikely. CTM is a significant area of practice, deserving of bindegewebsmassage now widely used in Europe, espe-
a book in its own right. As with the other systems of massage cially in Germany, and well known in most parts of the
described briefly in this text, the intention in this chapter is world. Broadly speaking, Dicke and others claimed that this
only to introduce the reader to the basic concepts involved. massage affects the autonomic nervous system and, by reflex
Many massage textbooks address this topic, but the most action, corrects imbalances in the vegetative functions of the
comprehensive and authentic materials on the subject in body. CTM is not just another massage stroke but rather a
English are still probably the works of Elizabeth Dicke complete system of treatment that happens to use soft tissue
(1978) and Maria Ebner (1985). Other important sources of massage as a means of inducing reflex activity in various
information in this area can be found in Bischoff and Elm- tissues.
inger (1963), Holey (1995b), and Luedecke (1969).
REFLEX ZONES (HEAD’S ZONES)
BRIEF HISTORY AND Since the late 1890s, it has been known that visceral disease
THEORETICAL FOUNDATIONS can be associated with visible and palpable changes in the
Connective tissue massage, as its name suggests, is a system skin in well-defined areas of the body. These areas are
of manual techniques specifically aimed at affecting the known as Head’s zones, after Head (1889), who first
connective tissues in the body, especially the skin. Elizabeth described them.

235
 PART TWO PRACTICE

As the primitive embryo develops, three layers of tissue dermatomes, myotomes, and sclerotomes (areas, respec-
begin to differentiate into an outer layer (ectoderm), a tively, of skin, muscle, and bone that are supplied by a single
middle layer (mesoderm), and an inner layer (endoderm). spinal nerve root). The skin of the posterior trunk retains
The ectoderm develops into the skin and nervous system, most of the orderly innervation, originally derived in
while the endoderm forms the various internal organs of the company with the 38 to 44 primitive segments. This gives
body. The middle layer (mesoderm) gives rise to the various rise to the: notion that areas of skin on the posterior trunk
structures of the musculoskeletal system. By the end of the have an embryonic link to various musculoskeletal and
fourth week of gestation, a series of approximately 39 to 44 internal organs of the body (Head’s zones). Figure I1-]
distinct cube-shaped bulges develop bilaterally within the illustrates this concept.
mesodermal layer. These bulges are known as the mesoder- A key concept underpinning CTM and other systems
mal somites, and they divide the mesoderm into 44 seg- involving manipulation of the soft tissues is that pathologic
ments (cranial to caudal). changes affecting any of the structures derived from a meso-
As the nervous system develops further (from the ecto- dermal somite eventually give rise to signs and symptoms
derm), a pair of nerve roots (spinal nerves) form adjacent to in any related structures, especially in the skin and connec-
most of the original mesodermal somites. These nerve roots tive tissues. The fact that visceral lesions may give rise to
will eventually contain sensory, motor, and autonomic nerve changes in other areas is well known; for example, liver and
fibers that will innervate skin, muscle, bone, and viscera. gallbladder problems can be reflected in the right mid- to
These connections give rise to the important concepts of lower posterior costal segments (T6 to 10) and in the right

| Head |

QUI\SS
Liver
Heart Gallbladder

Menstruation

Genital

Figure 11-1 Body Areas (Head’s Zones) Represented on the

Posterior Trunk
The number of zones depicted is not exhaustive. The intent is to show
considerable overlap of zones and
the functions they represent. There are zones for many parts of the
body, including one for the head and
zones for menstrual, genital, and colonic function, all overlying
or radiating from the sacrum. These narrow
zonal bands are generally described as being 5 to 8cm wide. A
stomach zone lies within the heart zone
and may also be represented above the left scapula. (Modified
from Ebner M: Connective tissue massage:
theory and therapeutic application, ed 2 Huntington, NY, 1985, Robert
E Krieger.) |
 CONNECTIVE TISSUE MASSAGE CHAPTER 11

upper rectus region. The changes that take place in a related

zone are detectable by palpation of the skin and subcutane- Spinal cord
ous tissues of the same area. The connective tissues have
characteristic areas of local tension. There is a certain tight-
Sympathetic chain
ness of the different layers against each other where nor-
mally there would be a limited amount of movement between
them (Hirschberg, Fatt, & Brown, 1986). Within each zone Receptors Effectors
of influence of a spinal segment or segments, there is often Skin Smooth muscle in
Blood vessels ¢ Blood vessels in viscera
a circumscribed area that is related to a particular organ;
Muscles e Viscera
these areas are known as maximal points. These changes Viscera ¢ Blood vessels in general
can be detected by palpation of the area. Holey (1995a) and ¢ Glands (e.g., sweat glands)
¢ Arrector pilorum
Holey and Watson (1995) described the basic concepts of
zone recognition and inter-rater reliability in the detection
Figure 11-2 Principles of an
of these zones. Autonomic Reflex
A key treatment concept in CTM is the following: An autonomic reflex consists of a response in the effectors, produced
Since visceral pathology is known to produce changes in by stimulation of the receptors. The receptors are part of the somatic
the connective tissues of the skin in well-defined zones, nervous system, whereas the effectors consist of largely smooth muscle
treatment to the connective tissues of the skin in a defined tissue in the autonomic nervous system. Interconnections at the spinal
zone can produce effects on other structures that are derived cord, the sympathetic chain, and the sacral outflow provide the pathway
from the same mesodermal segment. for the reflex.
This concept forms an important part of the rationale for
the effects of CTM. There is no direct mechanical effect in
many cases because the areas of skin treated are some dis-
tance away from the point of effect. This is more obvious
with treatments such as acupressure and reflexology. Because vasoconstriction. When sympathetic fiber activity decreases,
there is often no direct mechanical effect from the manipu- however, the smooth muscle relaxes and vasodilation occurs.
lation, the most likely explanation for the treatment effect is This brings more blood, and therefore oxygen and nutrients,
that it is the result of a reflex, in this case an autonomic to the tissues. It also allows waste products from the tissue
reflex. An autonomic reflex has all of the usual characteris- to be removed more efficiently. These effects are likely to
tics of a reflex—namely, it has receptors at one end, effectors facilitate healing in the tissues. It is also possible that a
at the other, and a pathway in between. The receptor side of similar effect could be produced by a chemical rather than
the reflex is part of the somatic nervous system, whereas the neural activation of autonomic reflex activity. Soft tissue
effector part belongs to the autonomic nervous system. The manipulation could cause the local or general liberation of
pathway in between is formed by nervous connections from chemical substances that activate such a reflex. For example,
both systems. vasoactive intestinal polypeptide (VIP) has a profound effect
The receptors are a wide variety of afferent endings on the circulation and on systemic pain relief and has been
in the skin, subcutaneous tissues, blood vessels, muscles, associated with CTM (Kaada & Torsteinbo, 1987, 1989). It
and the viscera. The effectors are largely smooth muscle is also possible that afferent signals reaching the sensory
fibers in a variety of tissues, such as blood vessels, viscera, cortex might also trigger the release of various brain chemi-
glands, and the skin. The pathway is formed by the various cals, thereby stimulating reflex autonomic activity. For more
interconnections between the afferent fibers of the somatic detailed descriptions of the theory and practice of CTM, the
nervous system and the efferent fibers of the autonomic reader is referred to Dicke (1978), Ebner (1962, 1965, 1968,
nervous system, especially through the sympathetic chain 1978, 1985), Goats and Keir (1991), Haase (1968), Helmrich
of the sympathetic division and the sacral outflow of the (1969), Michalsen and Buhring (1993), Schhack (1965,
parasympathetic system. Figure 11-2 illustrates —this 1978), and Tophoj (1970).
concept.
The autonomic reflex described previously connects the BASIC DIAGNOSTIC TECHNIQUE FOR
stimulation (including massage) of afferent receptors in the- CONNECTIVE TISSUE MASSAGE
skin and subcutaneous tissue with potential responses in
many different types of tissue. It is an important concept to The patient sits on a firm surface with the hips and knees
help explain the mechanisms involved with the remote-site at right angles and the feet supported on a stool. The whole
effects seen with CTM and other soft tissue manipulations. of the back must be exposed, but the patient’s anterior
It is important to remember that the lumen of the small aspect should be covered during evaluation and treatment.
arterioles is largely under the control of sympathetic nerve The therapist may sit or stand behind the patient, whichever
fibers. When these fibers are active, they cause the smooth is most comfortable or suitable. No lubricant should be
muscle in the arteriolar walls to contract, thereby producing used.
 The evaluation begins with a careful observation of the
posture and muscles of the patient’s back, together with
careful palpation of the cutaneous structures. Some zones
may appear swollen, whereas others may seem drawn inward.
Diagnostic palpation may reveal tightness and tissue tension
in certain areas of the back. These areas are often unilateral
and fairly well defined. The object of the examination is to
map out the areas of abnormal contour/palpation and relate
these to the patient’s other signs and symptoms, but the eval-
uation itself may have a profound effect on the patient’s
autonomic nervous system (Kisner & Taslitz, 1968). The
therapist makes an accurate record of the findings of the
examination for future reference and comparison.
There are two distinct types of technique in CTM. One
is a diagnostic stroke and the other a treatment technique,
although many times these two strokes are identical. During
the examination phase, the therapist uses manual techniques
to identify changes in the surface connective tissue that may
not be visible. These diagnostic techniques are used in a
bilateral, symmetrical fashion to compare the two sides of Figure 11-3 A Diagnostic Stroke Using a
the body. Lifting of skin folds is performed with a fold of Skin Fold
tissue large enough to distract the skin from the fascial layer The tissues are grasped to pull a roll of tissue into the hands. Lifting of
underneath (Figure 11-3). skin folds is done to compare the two sides of the body. The fold of
In another technique, the fingertips are used to move the tissue must be large enough to distract the skin from the fascial layer
underneath.
skin over the underlying structures (Figure 11-4). The force
of the fingertips is sufficient only to maintain contact with
the skin and is directed in line with the reflex zones. These

A B
Figure 11-4 Diagnostic Techniques Using the Fingers to Move
the Tissues
A, Both hands are used to push a fold of tissue over the areas of interest.
B, The fingertips of one hand
are used for the same purpose. Pressure may be exerted with one
or more of the fingertips, the objective
being to feel the underlying tissue contours and tensions.
 CONNECTIVE TISSUE MASSAGE CHAPTER 11 eaaidiiiia

reflex zones have definite boundaries and locations (see the responses detected in patients who have a demonstrated
Figure 11-2). problem and in those who are healthy.
Another diagnostic stroke pulls a fold of tissue under the All massage techniques require skill and experience on
third finger, followed by and reinforced by the fourth finger the part of the practitioner if they are to be maximally effec-
(Figure 11-5). Individual preference for a particular diagnos- tive. This skill must be developed under the supervision of
tic technique determines which procedure is most effective an experienced therapist; it cannot be learned from a text-
for a given patient and therapist. All are equally acceptable. book. The basic concepts, however, can be learned from
Resistance encountered during any of these manual tech- reliable sources. In this regard, Ebner’s descriptions of the
niques usually corresponds with a cutting or scratching techniques are excellent. Bischoff and Elminger (1963),
sensation felt by the patient. The therapist may feel a tearing Teirich-Leube (1976), and Tappen (1988) also offer excellent
sensation if the movement is carried too far. descriptions and illustrations.
Anecdotally, this method of massage seems to have a
profound influence on autonomic function and has been
successful in treating fibromyalgia (Brattberg, 1999),
BASIC TREATMENT TECHNIQUE
cervical syndromes (Heipertz, 1965), reflex sympathetic Following the initial examination, the treatment proper may
dystrophy (Solheim & Weber, 1980), pain (Teirich-Leube, begin. Two types of strokes are usually performed: short and
1968), anxiety states (McKechnie et al., 1983), subacute long. These strokes always start in the sacral, gluteal, or
asthma (Robertson et al., 1984), and decubitus ulcers lumbar region, in that order. The strokes are produced by a
(Zandonini et al., 1980). Applied skillfully, CTM can be tangential pull of the middle finger supported by either the
directed to specific pathologic conditions with predictable ring or the index finger. Some practitioners prefer to use the
results (Frazer, 1978). In contrast, Reed and Held (1988) index finger supported by the middle one. In effect, it makes
were not able to demonstrate changes in autonomic function no difference to the technique; however, it is important for
in a range of healthy middle-aged and elderly patients. Of the individual therapist to use a technique that works well
course, there is likely to be considerable difference between for his or her own hand and yet is effective in treating the
patient. The issue largely relates to the relative lengths of
the individual fingers and the manual dexterity of the thera-
pist. Figure 11-6 shows a suitable finger position that is
effective for most people, particularly because it is easier to
deliver controlled pressure with the index finger than with
any of the other digits, especially when it is reinforced by
the middle finger.
Strokes progress upward and outward to the affected
zones as soon as possible. Ebner suggested that “the inter-
relation of all autonomically supplied structures makes it
advisable to start every treatment in the sacral area, to make
certain of a normal vascular reaction at the root of the auto-
nomic supply tree. It is, however, important to progress as
soon as possible into the affected segments.” This concept
gives rise to the notion of the basic back section as the
beginning of a treatment session with CTM (Ebner, 1962).
Because the lowest part of the autonomic nervous system is
the sacral outflow of the parasympathetic division, the skin
overlying the sacral areas is the place where the back section
begins. Long and short CTM strokes are used around the
borders of the sacrum and lower back regions, progressing
upward. Figure 11-7 illustrates the length (short or long) and
direction of these strokes.
Figure 11-5 Diagnostic Techniques Using,
CTM techniques can be applied to most areas of the
the Fingers of One Hand to body, not only the back; however, it is common for therapists
Move the Tissues to treat the back first (the basic back section) and a more
The fingertips of one hand are used to pull a fold of tissue under the peripheral body part. A detailed discussion of this technique
third finger, followed by and reinforced by the fourth finger, the objective for all body parts is beyond the scope of this text, but several
being to feel the underlying tissue contours and tensions for diagnostic excellent works describe the basic concepts of CTM and its
purposes. (NOTE: This technique is also used as a treatment technique
use in most parts of the body. Although last published in the
in connective tissue massage, although some clinicians prefer to use
mid-1980s, Maria Ebner’s book (1985) on CTM remains
the index finger reinforced by the middle one in a similar manner to the
deep friction technique.) arguably the most authoritative source on this topic in the
 PART TWO PRACTICE

Figure 11-6 Finger Positions Suitable for the Treatment Phase

of CTM
The pad of the index finger, reinforced by the middle finger (A
and B), can be used to deliver both the short
and long connective tissue massage (CTM) strokes. Alternati
vely, the pad of the middle finger, reinforced
by either the index or ring finger, can be used (C). The individua
l preference of the therapist determines
which hand position is most effective.

English language. Figure 11-8, A, illustrates CTM strokes Local Responses

for a variety of areas in the upper limb, and part B
of the The most obvious response to CTM is the
figure illustrates those strokes when applied to areas local response
of the visible over the treated areas. After several
lower limb. minutes, bright-
red stripes appear on the skin, tracing the
areas where the
therapist has applied pressure. This local eryth
ema (redness)
is the result of a triple response produced in
the tissues. The
EFFECTS OF CONECTIVE pressure of the fingers on the tissues produ
ces minor trauma
TISSUE MASSAGE to the area, and this releases various substa
nces that trigger
the reflex. Release of histamine, together
The patient usually feels either a cutting or with other sub-
a scratching stances, produces the marked vasodilatation
sensation, or possibly dull pressure. These respon of the area. The
ses gradu- local sensations are not usually painful
ally fade as the patient recovers from the condit for the patient, but
ion. Local if the skin is very hairy, the patient may
and general responses are produced. experience some
uncomfortable sensations when the hair
is pulled.
 CONNECTIVE TISSUE MASSAGE \APTER 1 241

a <é

an excellent example of such a condition, although the

present understanding of this syndrome is far from complete
(Brattberg, 1999; Fialka; Sadil, & Ernst, 1991: Solheim &
Weber, 1980). CTM techniques may be helpful for the treat-
ment of various pain syndromes (Heipertz, 1965; Teirich-
Leube, 1968), especially those associated with vascular
disorders. CTM has also been used to treat various psycho-
somatic and anxiety disorders (Helmrich, 1969: McKechnie
et al., 1983).

TREATMENT FREQUENCY\
Second step AND DURATION

margin Subcostal
SY Following the initial examination at each treatment session,

a es
the treatment proper may begin. Each session usually con-
sists of a general back treatment (a back section) followed
by specific treatment to various zones or parts of the back
or other body areas. A total treatment (including back exam-
ination) may take 30 to 40 minutes to complete and may be
repeated daily for up to 10 to 12 treatments. Some patients
occasionally require longer courses of treatment (several
weeks); alternatively, others may show significant improve-
ment within a few days of commencing treatment.

CONTRAINDICATIONS
Third step Fourth step
There are relatively few contraindications to CTM; however,
Figure 11-7 Short and Long CTM Strokes
the patient must be carefully monitored throughout treat-
to the Posterior Trunk
ment for signs of an abnormal autonomic response. If the
The arrows indicate the length (short or long) and the direction of the
patient complains of dizziness, heart palpitations, or other
connective tissue massage (CTM) strokes in the basic back section.
unusual sensations, treatment should be stopped and the
(Adapted from Ebner M: Connective tissue massage: theory and therapeutic
application, ed 2, Huntington, NY, 1985, Robert E Krieger.) patient allowed to rest. Treatment with CTM may not be
possible when the patient has certain cardiac conditions,
General Responses cancer or tuberculosis, certain generalized skin conditions
(e.g., psoriasis) affecting the skin to be treated, and open
The general response to CTM varies greatly, particularly
wounds, sores, or other skin lesions over the areas where
depending on which areas are treated. General responses
CTM would be given.
consistent with an effect on the autonomic nervous system
Note that hairy skin on the back or other body areas may
can last several hours after treatment. These effects include
be too painful for the patient to receive treatment. With the
stimulation of the circulation, reduced blood pressure (with
patient’s permission, the hair may be removed so that treat-
extensive treatment), shortness of breath, heart palpitations,
ment can be given.
headache, dizziness, perspiration, increased glandular
activity, increased visceral organ function, and rebalancing
of autonomic activity by stimulation of parasympathetic SUMMARY
activity.
Connective tissue massage is a relatively new treatment
concept but one that continues to grow in popularity. The
TREATMENT INDICATIONS
use of CTM undoubtedly requires specialized knowledge
Connective tissue massage has diagnostic and therapeutic and experience to be maximally effective. As with most, if
implications and has been used clinically to treat the signs not all, modern rehabilitation practices, CTM is likely to
and symptoms of circulation disorders, rheumatic diseases, achieve the best results when used in combination with other
malfunctions of internal organs, autonomic and central techniques in a total treatment plan tailored to meet the
nervous system disorders, respiratory conditions (Robertson needs of the individual patient. The therapist wishing to
et al., 1984), connective tissue disorders, and decubitus incorporate CTM in his or her daily practice will need spe-
ulcers (Zandonini et al., 1980). CTM has also been widely cialized training to develop skill and competence in its use.
used in the treatment of autonomic disturbances of the car- As a treatment option, CTM provides an important addition
diovascular system. Reflex sympathetic dystrophy (RSD) is to the repertoire of rehabilitation techniques.
PART TWO PRACTICE

Deltoid Region

Stimulating stroke rome

in subclavian triangle

Anterior capsule ;
stroke
Biceps stroke ————>

Deltoid
Shoulder and
Arm Region

Wrist strokeS =m
Hand strokeS mmm }>

Digital strokes —————>

Flexor
retinaculum

A
Figure 11-8 Short and Long CTM Strokes to the Upper and
Lower Limbs
A, The arrows indicate the length (short or long) and the direction
of the connective tissue massage (CTM)
strokes for a variety of areas in the upper limb. (Adapted
from Ebner M: Connective tissue massage: theory
and therapeutic application, ed 2 Huntington, NY, 1985, Robert
EKneger.)
 CONNECTIVE TISSUE MASSAGE CHAPTER 11

Anterior thigh region Posterior aspect of leg

Gluteus
maximus

Semitendinosis
Adductor stroke
longus :
g Biceps
stroke
Sartorius
Gastroc nemius
strokes
Anterior aspect
of Knee :
P Trigger
Quadriceps
point
Patella

Tendon
Short strokes => Tibial Achilles
Long strokes ——»> tubercle stroke

Lateral aspect of knee

Peroneal
strokes :

Peroneus longus —#—t- |

y |

| Dorsal aspect of foot

/ Malleolar Strok€S EEttsmsm)>

Ankle StrOK@S sxccnnse >
Interosseous strokes ———_—»
Short plantar strokes —————>

Lwr Malleolus

SN
>
me,

B
Figure 11-8, cont’d
B, The arrows indicate the length (short or long) and the direction of the CTM strokes for a variety of areas
in the lower limb.
 244 PART Twe PRACTICE

Holey EA, Watson M: Inter-rater reliability of connective tissue zones

recognition, Physiotherapy JCSP 81(7):369-372, 1995.
Bischoff I, Elminger G: Connective tissue massage. In Licht S, editor: Kaada B, Torsteinbo O: Vasoactive intestinal polypeptides in connective
Massage, manipulation and traction, Baltimore, 1963, Waverley tissue massage: with a note on VIP in heat pack treatment, Gen
Press. Pharmacol 18(4):379-384, 1987.
Brattberg G: Connective tissue massage in the treatment of fibromyal- Kaada B, Torsteinbo O: Increase of plasma beta-endorphines in
gia, Euro J Pain 3(3):235-244, 1999, connective tissue massage, Gen Pharmacol 20(4):487-489, 1989.
Dicke E: Origin and development of the method. In Dicke E, editor: A Kisner C, Taslitz N: Connective tissue massage: influence of the
manual of reflexive therapy of the connective tissues, Scarsdale, NY, introductory treatment on autonomic functions, Phys Ther 48(2):
1978, Sidney S Simon. 107-119, 1968.
Ebner M: Connective tissue massage: theory and therapeutic applica- Luedecke U: History, basis, and techniques of connective tissue
tion, Edinburgh, 1962, E & S Livingstone. massage, Aust J Physiotherapy 15(4):141-148, 1969.
Ebner M: Connective tissue massage, South Afr J Physiother 21(3):4-7, McKechnie AA, Wilson F, Watson N et al: Anxiety states: a prelimi-
1965, nary report on the value of connective tissue massage, J Psychoso-
Ebner M: Connective tissue massage: therapeutic application, N Z J matic Res 27(2):125-129, 1983.
Physiother 3(14):18-22, 1968. Michalsen A, Buhring M: Connective tissue massage [in German],
Ebner M: Connective tissue massage, Physiotherapy JCSP 64:208-210, Wien Klin Wochenschr 105(8):220-227, 1993.
1978. Reed B, Held J: Effects of sequential connective tissue massage on
Ebner M: Connective tissue massage: theory and therapeutic applica- autonomic nervous system of middle-aged and elderly adults, Phys
tion, ed 2, Huntington, NY, 1985, Robert E Krieger. Ther 68(8):1231-1234, 1988.
Fialka V, Sadil V, Ernst E: Reflex sympathetic dystrophy (RSD): a Robertson A, Gilmore K, Frith PA et al: Effects of connective tissue
century of investigation and still a mystery, Eur J Phys Med Rehab massage in subacute asthma [letter], Med J Aust 140(1):52-53, 1984.
2(2):26-28, 1991. Schliack H: Scientific bases of the connective tissue massage according
Frazer F: Persistent postsympathetic pain treated by connective tissue to Dicke (reflex massage of the connective tissue), Scalpel
massage, Physiotherapy JCSP 64:211-212, 1978. 118(23):467-477, 1965.
Goats GC, Keir KA: Connective tissue massage, Brit J Sports Med Schliack H: Theoretical bases of the working mechanism of connective
25(3):131-133, 1991. tissue massage. In Dicke E, editor: A manual of reflexive therapy
Haase H: Connective tissue massage: physiological effectiveness of the connective tissues, Scarsdale, NY, 1978, Sidney S
fundamentals and technics [in German], Z Arztl Fortbild (Jena) Simon.
62(13):734-736, 1968. Solheim LF, Weber L: Post-traumatic reflex dystrophy: conservative
Head H: Die Sensibilitatsstorungen der Haut bei viszeral Erkrankun- treatment with connective tissue massage and exercise [in Norwe-
gen, Berlin, 1889. gian], Tidsskr Nor Laegeforen 100(25):1497-1499, 1980.
Heipertz W: Significance of new studies on connective tissue massage Tappen FM: Healing massage techniques: holistic, classic, and
in the treatment of the cervical syndrome [in German], Beitr Orthop emerging methods, ed 2, Norwalk, Conn, 1988, Appleton & Lange.
Traumatol 12(6):332-334, 1965. Teirich-Leube H: Connective tissue massage in pain syndromes,
Helmrich HE: Psychosomatic aspect of connective tissue massage [in Hippokrates 39(15):577-579, 1968.
German], Z Psychosom Med Psychoanal 15(1):56-62, 1969, Teirich-Leube H: Grondbeginselen van de Bindweefselmassage,
Hirschberg G, Fatt I, Brown RD: Measurement of skin mobility in the Uitgeversmaatchappij Lochem, 1976, De Tijdstroon, B.V.
upper back, Scand J Rehab Med 18(4):173-175, 1986. Tophoj EA: The hypothetical basis for connective tissue massage [in
Holey EA: Connective tissue manipulation: towards a scientific Danish], Nord Med 83(44):1403-1404, 1970.
rationale, Physiotherapy JCSP 81(12):730-739, 1995a. Zandonini G, Leoni V, Marcato MG: Connective tissue massage in the
Holey EA: Connective tissue zones: an introduction, Physiotherapy treatment of decubitus ulcer [in Italian], Arch Maragliano Patol
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JCSP. 8(7):366-368, 1995b. 36:71-75, 1980.
 We
Decongestive Therapy for the
Treatment of Lymphedema

Lymphedema, a disorder characterized by chronic swelling, (Kissin et al., 1986). A comprehensive literature review con-
affects approximately 140 million to 250 million people cluded that the overall incidence of arm edema after mastec-
worldwide. This chapter explores a treatment technique tomy was 26% with a range from 0% to 56% within 2 years
for lymphedema known as complete decongestive therapy (Erickson et al., 2001). Patients who undergo treatment for
(CDT). The components consist of skin and wound care, cervical, vulvar, and prostate cancer have similar incidences
lymphatic massage, compression, exercise, and patient edu- for lymphedema of the lower extremities. The risk increases
cation. Because of the possible complications associated with an increase in the number of lymph node dissections
with lymphedema, this technique should only be performed and radiation therapy (Petereit et al., 1993).
by or under the direction of a licensed medical professional
after a thorough evaluation and plan of care have been
THE LYMPHATIC SYSTEM
established.
Lymphedema is an excessive accumulation of protein- The lymphatic system is a one-way drainage system that
rich fluid in the tissues caused by a transport failure of the functions in concert with the circulatory system. It is pri-
lymphatic system and may be acquired through primary or marily responsible for the uptake of plasma proteins that
secondary causes. Primary lymphedema is usually caused leak from the vascular system, as well as uptake of antigens
by a developmental disorder of the lymphatic system. It may and bacteria from the interstitium. It also transports fat from
manifest in infancy, adolescence, or late adulthood. Primary the gastrointestinal system, filters body fluids, and fights
lymphedema occurs predominantly in females and typically diseases with the production of white blood cells. Uptake of
affects either of the lower extremities. It is estimated that these molecules from the tissue spaces occurs via diffusion
approximately | in 6000 individuals will acquire primary and osmosis across the lymph capillary membranes. Once
lymphedema (Dale, 1985). in the lymph capillaries, the lymph fluid moves through a
Secondary lymphedema is most commonly caused system of vessels and lymph nodes, where it is filtered and
throughout the world by filariasis, a parasitic infection that eventually returned to the circulatory system.
is carried by mosquitoes and settles in the lymphatic vessels.
According to the Centers for Disease Control, filarial lymph- Lymphotomes
edema is thought to affect as many as 120 million people in Tissue fluid drainage occurs in distinct regions of the body
more than 80 countries. called /ymphotomes. These lymphotomes contain lymph
In developed countries, cancer or its treatment is the most vessels (collectors) that carry lymph fluid along their routes
common cause of secondary lymphedema—the result of to a common chain of lymph nodes. Lymphotomes are
blockage by the tumor itself, excision of lymph nodes, or divided by watersheds, narrow anatomical zones where the
radiation therapy. Kissin et al. reported a 25% incidence of direction of lymphatic flow changes. There are four lympho-
lymphedema after mastectomy, rising to 38% in patients tomes of the trunk, which are separated by watersheds in
treated with axillary lymph node dissection and radiation the midsagittal and transverse planes. These are designated
right and left thoracic lymphotomes and right and left
Refer to DVD Chapter 12 for video demonstrations of the techniques
described in this chapter. abdominal lymphotomes. Each of the extremities contains
 PART TWO PRACTICE

Figure 12-1
Drawing of body designating lymphotomes, watersheds, and direction of flow.

numerous lymphotomes as well. If a particular lymphotome

Overlapping endothelial cells
becomes overwhelmed with excess fluid, superficial tissue
fluids may cross the watersheds by way of collateral vessels
Fluid entering
called anastomoses that offer alternate routes of drainage.
lymphatic capillary
In this way, excess fluid can be drained into a normally
functioning area and decrease the lymphatic load on the
involved lymphotome (Figure 12-1).
Direction
of flow
Lymph Capillaries Valve closed
The lymphatic circulation originates with microscopic
vessels called lymph capillaries. They are located in most Valve open
tissues of the body except for the central nervous system,
splenic pulp, and bone marrow. The endothelial cells walls Anchoring fibers
of these vessels open and close at the cell junctions to allow Figure 12-2
the passage of fluids in response to pulse pressure, relaxation
Schematic of lymph capillary. (From Thibodeau G, Patton K: Anthony’s
and expansion of adjacent arterioles, external compression, textbook of anatomy and physiology, ed 17 St Louis, 2003, Mosby.)
and muscle activity. The lymph capillaries contain two sets
of valves; the interendothelial junctions prevent the back-
flow into the interstitium during contraction, and the intra- tually unite to form larger lymphatic trunks, which finally
lymphatic valves prevent backflow within the lumen during lead to the main ducts: the thoracic duct or the right
expansion (Figure 12-2). lym-
phatic duct (Figure 12-3).

Collectors Trunks
The lymph capillaries combine to form larger afferent col- The right lymphatic duct terminates at the juncture
lectors located in the subdermal channels. The cell walls of of the
right internal jugular and right subclavian vein, where
the collectors are muscular and also contain valves to prevent the
fluid is returned to the vascular system. It is
backflow of the lymphatic fluid. The sections between these primarily
responsible for draining the right thoracic lymphotome
valves, called /ymphangions, contract in response to auto- and
arm and the right side of the face and neck. The
nomic sensory input and lymph volume. The afferent col- thoracic
duct originates in the pelvic region at about the level
lectors eventually lead to lymph nodes where the lymphatic of the
second lumbar vertebrae and begins with a large expans
fluid is filtered. The filtered lymphatic fluid then exits the e of
lymphatic tissue called the cisterna chyli. The thoraci
nodes through the efferent collectors. These collectors even- c duct
receives lymph from the trunks of the lower extremi
ties and
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12 in é —

Right lymphatic duct Thoracic duct

su Left
subclavian subclavian
vein vein

Figure 12-3
The right lymphatic duct drains into the right subclavian vein, and the thoracic duct drains into the left
subclavian vein. (From Thibodiau GA, Patton KT: The human body in health and disease, St. Louis, 2008,
Mosby.)

the intestinal trunk, and it eventually empties into the junc- accumulation of inflammatory agents occurs in the
ture of the left internal jugular and subclavian vein. It is tissues, triggering a chronic inflammatory response.
responsible for drainage of the gut, the abdominal lympho- Ultimately, these processes may lead to fibrosis of
tomes, the lower extremities, the left thoracic lymphotome, the subcutaneous tissues and other skin changes
the left arm, and the left side of the face and neck (Figures such as hyperkeratosis and papillomatosis.
12-4 and 12-5). In addition to the subcutaneous skin changes that occur
in chronic lymphedema, the risk of infection increases as a
result of the decreased ability to fight infection and the
PATHOPHYSIOLOGY increased concentration of tissue proteins. Multiple bouts of
Lymphedema may occur under several conditions: cellulitis can lead to even further degradation of the subcu-
* When a high load is placed on the lymph system that taneous tissues. The individual’s normal activities may
exceeds its working capacity. The lymph system is decrease as well, resulting in decreased pumping action of
intact; however, it is unable to handle the increased the muscles. This contributes even more to the insufficiency
load, and the excess fluid builds up in the tissues. This of the lymphatic system. Without treatment to minimize the
condition is sometimes known as high-flow edema, edema, the patient may begin to experience other complica-
high-volume insufficiency, or dynamic insufficiency. tions associated with chronic swelling, such as loss of mobil-
* When there is a breakdown in the transport capacity of ity, joint stiffness, weakness, pain, and poor psychological
adjustment (Figure 12-6).
the lymphatic system, either because of dysplasia of the
lymphatic structures (primary lymphedema) or
mechanical interruption of the system as a result of
surgery or injury (secondary lymphedema). This PRINCIPLES OF TREATMENT
condition may be referred to as low-flow edema,
Because of the complexity of the disorder, it is often best to
low-volume insufficiency, or mechanical insufficiency.
adopt a team approach to management. Members of the
* Finally, a combination of the two conditions is called
of team may include a physician, nurse, physical or occupa-
safety-valve insufficiency. Insufficiency or blockage
system can cause an increas e in the tional therapist, the patient, family members, certified
the lymphatic
their garment fitter, nutritionist, and psychologist. Always use
hydrostatic pressure within the vessels. This causes
which leads to leaking of the protein s sound clinical judgment when initiating treatment, and
walls to weaken,
intersti tium. This in turn causes an consult the referring physician when in doubt. Also, be
and fluids into the
mindful of absolute and relative contraindications and pre-
increase in the colloid osmotic pressure in the tissue
1998; cautions before initiating treatment (Table 12-1). Absolute
spaces, leading to even more fluid leakage (Davis,
consequ ence, an increas ed contraindications indicate that treatment is not appropriate
Humble, 1995). As a
 PART TWO PRACTICE

Tonsils

Entrance of
Cervical thoracic duct into
lymph subclavian vein
node

Right
lymphatic
duct

Peyer's
patches in | /
intestinal
wall

Red
bone
marrow

Figure 12-4
Schematic of lymphatic system. (From Thibodeau G, Patton K: Anthony's
textbook of anatomy and physiology, ed 17 St. Louis, 2003, Mosby.)

in the presence of certain conditions. Relative contraindica-

tions and precautions indicate that treatment may be appro-
priate in the presence of certain conditions only with proper
monitoring and good clinical reasoning. When in doubt,
consult the prescribing physician.
Figure 12-5
Treatment for lymphedema begins with a thorough
The dark-shaded area is drained by the right lymphatic
assessment of the patient and includes a comprehensive duct. The light-
shaded area is drained by the thoracic duct. (From Thibodeau
history and physical examination. Once the evaluation has G, Patton
K: Anthony’s textbook of anatomy and physiology, ed
17, St. Louis, 2003,
been completed, treatment may be initiated. Although sever- Mosby.)
ity of the disease process, physical limitations, and lifestyle
will ultimately determine the frequency and duration of
After the initial treatment phase is completed,
treatment, in general the best results are achieved with daily the patient
will begin the second phase of the treatm
treatments over a period of 2 to 3 weeks. If there are com- ent with a
self-management program. Follow-up may or
plications such as fibrosis, scar tissue, or wounds, the treat- may not be
necessary afterward, depending on the patient’s
ment may need to be extended beyond this time frame. response to
treatment.
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA 249

Figure 12-€
Examples of upper extremity (A) and lower extremity (B) lymphedema.

Jable 12-1 General Contraindications and Precautions for Therapy

Absolute Absolute Precaution

Acute bacterial infection
Relative Relative Precaution
Malignancy
Absolute Absolute Absolute
Acute congestive heart failure
Precaution
Diabetes or arterial disease
Precaution Precaution
Insensate limb
Absolute Absolute Absolute
Acute deep vein thrombosis
Precaution
Low blood counts

event that predisposed the individual to a compromised lym-

% phatic function. This may include lymph node excision,
stOr) radiation therapy, neoplasm, or paralysis. Note whether a
The initial evaluation is the first step in the management of precipitating event such as an injury, infection, air travel, or
lymphedema, and a good evaluation begins with a detailed punctures to the skin may have triggered the onset of
medical history. First, identify the causative factor, or the noticeable swelling. Also, rule out the possibility of heart
 250 rwWO PRACTICE

failure, unidentified neoplasms, deep vein thrombosis, or The volumetric method is a water displacement method
other vascular disorders that may present similarly. Next, using a tool called a volumeter. Water is filled into a special
identify any other treatments for lymphedema that the vessel just to the overflow spout. The extremity is placed in
patient may have had and whether they were successful. the vessel, and the displaced water flows out of the spout
Also determine the patient’s lifestyle. Is he or she working, and into a beaker where the volume can be measured.
retired, or disabled? How has the swelling affected his or Girth measurements can be performed by taking circum-
her daily life and function? Has the patient had to give up ferential measurements at 10-cm intervals and applying the
hobbies or has participation become more difficult? Finally, following formula for volume of a truncated cone at each
determine the patient’s goals for treatment. Perhaps his or segment: *
her goals are to improve mobility, to restore a healthy body
V=(h)(C2+Cco+c*)/12(z)
image, or simply to be able to lift a gallon of milk out of
the refrigerator. where V is the volume, / is the height between intervals, C
is the circumference at one end of the segment, and c is the
Physical Exam circumference at the other end of the segment. The total
After taking the medical history, it is time to move on to the volume is the sum of all segments. In unilateral involve-
physical exam. Observe the patient’s posture and alignment, ment, the normal limb can be used to determine the amount
and note any abnormalities. Observe the skin in the entire of edema present. Progress should be tracked on a weekly
affected quadrant. Look for excessive skin folds, lack of basis to determine the efficacy of treatment (Casley-Smith,
bony prominences, scarring or adhesions, and skin changes 1998; Karges et al., 2003; Sander et al., 2002).
such as thickening of the skin (hyperkeratosis), rough areas After the examination has been completed, take some
(papillomatosis), orange peel consistency (peau d’orange), time to discuss your findings and explain the treatment
or wounds (Figure 12-7). It may be necessary to perform a rationale. Patients tend to be more compliant when they have
full musculoskeletal examination of adjacent joints includ- clear goals and a basic understanding of the treatment ratio-
ing palpation, strength, range of motion, and special tests to nale. This is especially important for this type of therapy
address any concomitant problems that may have arisen as because so much of the success is directly related to the
a consequence of the lymphedema. patient’s ability to follow through with the program at
The next step in the physical exam is to quantify the home.
amount of edema in the extremity. This can be done using
water displacement methods or calculated volume derived
from girth measurements. It has been shown that geometric SKIN AND WOUND CARE
formulas correlate strongly with water displacement methods Before beginning treatment, the skin needs to be cleansed
(Karges et al., 2003; Sander et al., 2002), and because girth thoroughly and moisturized using a pH-balanced, alcohol-
measurement is quicker and easier to perform, it is the pre- free, and fragrance-free lotion. The presence of a wound
ferred method for many clinicians. It is also a good idea to necessitates an evaluation performed by a medical profes-
take pictures initially and periodically during the course of sional licensed to perform wound care. Ideally, the wound
treatment to help support the data. care can be performed in the clinic before each session, but
if not, the patient will need to have this addressed elsewhere
before initiating treatment.

LYMPH FLUID MOBILIZATION

Lymph fluid mobilization is the Massage component of the
five-part treatment regimen known as decongestive therapy.
The goals of the technique are fourfold: increase peristalsis
of the lymphangion, break down fibrotic tissue, increase
lymph volume in collateral and primary vessels, and decrease
congestion in the interstitium.
There are several basic principles to keep in mind when
performing lymph fluid mobilization:
* Treatment begins at the termination of the lymphatic
system, clearing proximal lymphotomes before moving
into more distal, affected lymphotomes.
The direction of the massage is in the direction of
a
cleared lymphotome.
Figure 12-7
An affected area is treated long enough to elicit
Hyperkeratosis. a tissue
response.
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12

* Gentle pressure is applied, just enough to stimulate the palm. Gradually return to the cupped position as you
lymphatic system but not the circulatory system. progress proximally along the extremity (Figure 12-9).
Some schools teach highly specific stroke techniques to Turn stroke. Applied mainly on large surfaces, such as the
accomplish this technique, whereas others maintain that the abdomen, chest, back, or thigh. Begin this stroke with
specific manner in which the actual strokes are performed the hand slightly cupped and the ulnar aspect of the
is not critical to the outcome. The following strokes are hand in contact with the skin and facing the direction
commonly applied in lymph fluid mobilization, but may be
adapted depending on the body area being treated.

STROKES
Standing circles. Applied mainly over lymph nodes and
large areas such as the abdomen. Using the palmar
surface of the hand or fingers, a stretch is applied to
the skin in a circular pattern. Gentle pressure is applied
in the direction of lymph flow. The pressure is then
released while maintaining skin contact through the
remainder of the arc (Figure 12-8).
Pump stroke. Applied mainly to the extremities. Place the
hand on the extremity with the thumb and fingers
facing proximally along the long axis. Begin with the
hand cupped and thumb and distal fingers in contact Figure 12-8
with the skin. Slowly lower the hand and flatten the Standing circles at the axilla.

Figure 12-9
Start (A), middle (B), and end (C) of the stroke along the arm.
252 ART TWC PRACTICE

of intended lymph movement. Gradually transfer skin Common Sequences

contact across the palm as the hand is brought into Brief Cervical Sequence (Figure 12-12)
ulnar deviation and the palm flattens. Then lift the
Patient Is Supine (Figure 12-13)
ulnar side of the palm slightly, and finish the stroke
¢ Standing circles to bilateral supraclavicular fossae and
with the tips of the thumb, index, and middle fingers
cephalic chains, alternating five times each, for a
adducted slightly and in contact with the patient’s skin
minimum of 25 revolutions
(Figure 12-10).
Thumb circles. Used in very small or fibrotic areas. Apply
a half-are with the distal end of the left thumb. Apply a
half-arc with the other thumb in the opposite direction.
Alternate this movement as you progress in the desired
direction of lymph flow (Figure 12-11).
These strokes may be combined in a variety of ways as
you progress through the massage sequence.

SEQUENCES AND PATHWAYS

The instructions in this section are meant to provide a
general plan for mobilizing stagnant tissue fluid through the
lymphatic system and should be considered guidelines only,
as each unique case will determine the best course of action.
Common sequences in this section are combined to form Figure 12-11
larger treatment pathways. Thumb circles at the lateral knee.

Figure 12-10
Start (A), middle (B), and end (C) of the stroke.
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12 ei 2iiiidicnana
hala aaa
Brief Abdominal Sequence (Figure 12-14) Standing circles to the anticubital area, pumping in an
Patient Is Supine (Figure 12-15) upward direction
Turn strokes x 5 to each quadrant of abdomen, with the Standing circles around the olecranon process in a
pumping direction toward the cisterna chyle. Repeat the doughnut pattern (Figure 12-18)
entire abdominal sequence five times. Pump or turn strokes along the medial forearm, then the
Patient should perform diaphragmatic breathing lateral forearm, spiraling medially and laterally from
consisting of a deep breath followed by forced exhalation the midline to the anterior side
and simultaneous compression of the abdominal muscles Thumb circles to the dorsum of the hand, from the base
using the palms of the hands. Repeat five times. of the fingers to the wrist, then massage each finger
separately if involved (Figure 12-19)
Secondary Arm Sequence (Figure 12-16)
Secondary Leg Sequence (Figure 12-20)
Patient Is Supine
e Pump stroke from shoulder to neck Patient Is Supine
¢ Pump stroke along lateral aspect of upper arm to deltoid * Standing circles to the inguinal nodes of the involved side
region ¢ Pump or turn strokes along the thigh
¢ Pump stroke along posterior aspect of upper arm to
deltoid region
¢ Pump stroke along medial aspect of upper arm in a
spiral pattern toward lateral or posterior aspect and on
to deltoid region (Figure 12-17)

r,
z
Right Left
Fe ey. aN

Figure 12-12 Figure 12-14

Schematic of the brief cervical sequence. Schematic of the brief abdominal sequence.

i Figure 42-13 |
Both hand positions for the brief cervical sequence.
254 PRACTICE

Figure 1a="

Schematic of the secondary arm sequence.

 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12

¢ From the lateral knee to the iliac crest

¢ From the anterior knee to the iliac crest
¢ From the medial knee to the lateral iliac crest
¢ Standing circles with both hands in the popliteal fossa
(Figure 12-21)
¢ Alternating thumb circles toward the popliteal fossa
along lateral knee from the posterior to the anterior
aspect (Figure 12-22)
¢ Alternating thumb circles along the medial knee from
the posterior to anterior aspect
¢ Pump strokes along the anterior lower leg from the
ankle to the knee
¢ Pump strokes along the posterior lower leg from the
ankle to the popliteal fossa
Figure 12-17 * Standing circles around the lateral and medial malleoli
Spiral motion from the elbow to the deltoid. ¢ Alternating thumb circles along the dorsum of the foot
from the base of the toes to the ankle
¢ Effleurage of the entire leg

Treatment Pathways
Secondary Unilateral Upper Extremity
Involvement (Figure 12-23)
Patient Is Supine
¢ Brief cervical sequence
¢ Standing circles progressing along the supraclavicular
nodes from both shoulders to the supraclavicular fossa
¢ Brief abdominal sequence
¢ Standing circles to the contralateral axilla
* Standing circles to the ipsilateral groin
* Standing circles to the ipsilateral axilla
¢ Turn strokes across the chest
¢ From the anterior superior midsagittal watershed to
the contralateral axilla
Figure 12-18 ¢ Across the watershed
Doughnut pattern around the olecranon. ¢ From the ipsilateral axilla to the watershed and across
to the other side
¢ Pumping direction toward the contralateral side
¢ Pump or turn strokes along the anterior ipsilateral trunk
* From the ipsilateral transverse watershed to the
inguinal area
e Across the watershed
¢ From the axilla to the watershed and across
Patient Is Prone or Sidelying
* Turn strokes across the back
* From the posterior superior midsagittal watershed to
the contralateral axilla
* Across the watershed
¢ From the ipsilateral axilla to the watershed and across
* Turn strokes along the side of the trunk
¢ From the posterior ipsilateral transverse watershed to
the ipsilateral iliac nodes
¢ Across the watershed
* From the ipsilateral axilla to the watershed and across
Figure 12-19 Patient is Supine
Thumb circles to the dorsum of the hand. See Figure 12-16 for the secondary arm sequence.
NOTE: Be sure to repeat clearance of the proximal areas of
lymphatic flow occasionally.
 PART TWO PRACTICE

Left Left ~~ [Right

Figure 12-20
Schematic of the secondary leg sequence.

Figure 12-21
Figure 12-22
Stationary circles in the popliteal fossa.
Alternating thumb circles to the lateral knee.
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12

Figure 12-23
Schematic of trunk clearance for secondary unilateral involvement.

Figure 12-24
Schematic of trunk clearance for secondary bilateral upper extremity involvement.

Secondary Bilateral Upper Extremity ¢ From the transverse watershed to the inguinal area
Involvement (Figure 12-24) + Acrossthe watershed
Patient Is Supine e From the axilla to the watershed and across
* Brief cervical sequence Patient Is Prone or Sidelying
* Standing circles progressing along the supraclavicular ¢ Turn strokes along the right side of the trunk
nodes from both shoulders to the supraclavicular fossa 5 ¢ From the posterior transverse watershed to the iliac
times e nodes
* Standing circles to right axilla 25 times ¢ Across the watershed
* Standing circles to right groin 25 times ¢ From the right axilla to the watershed and across
¢ Brief abdominal sequence ¢ Secondary arm sequence to the right side
* Pump or turn strokes along the right side of the Patient Is Supine
trunk * Repeat pathway on the left side
iii ae Se

NOTE: Be sure to repeat clearance of the proximal areas of ¢ Turn or pump strokes along ipsilateral buttocks
lymphatic flow occasionally. ¢ Along side of hip to iliac crest
¢ From gluteal fold to iliac crest
Secondary Unilateral Lower Extremity ¢ From iliac crest to transverse watershed and across
Involvement (Figure 12-25) ¢ Secondary leg sequence
Patient Is Supine
Brief cervical sequence Secondary Bilateral Lower Extremity
Brief abdominal sequence Involvement (Figure 12-26)
Standing circles to ipsilateral axilla Patient Is: Supine
Standing circles to contralateral groin ¢ Brief cervical sequence
Standing circles to ipsilateral groin ¢ Brief abdominal sequence
Turn or pump strokes along ipsilateral side of trunk ¢ Standing circles to right axilla
* From transverse watershed to axilla ¢ Standing circles to right groin
* Across transverse watershed ¢ Turn or pump strokes along right side of trunk
* From ipsilateral groin and iliac crest to watershed and ¢ From transverse watersheds to ipsilateral axilla
across ¢ Across transverse watersheds
Turn strokes along lower abdomen * From bilateral groin and iliac crest to ipsilateral
* From midsagittal watershed to contralateral groin and watershed and across
iliac crest Patient Is Prone or Sidelying
* Across midsaggital watershed ¢ Turn strokes along right side of the back
* From ipsilateral groin and iliac crest to midsaggital * From posterior transverse watershed to ipsilateral
watershed and across axilla

Left

Figure 12-25
Schematic of trunk clearance for unilateral lower extremity involvem
ent.
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12

Figure 12-26
Schematic of trunk clearance for bilateral lower extremity involvement.

¢ Across watershed the lymph nodes, and be sure to clear proximal areas
* From iliac crest and buttocks to ipsilateral watershed often.
and across Filarial lymphedema can be treated through the normal
¢ Turn or pump strokes along right buttocks lymphatic pathways.
¢ Along side of hip to iliac crest * Chronic venous insufficiency is usually associated with
* From gluteal fold to iliac crest lymphostasis. It can be treated similarly to primary LE
¢ From iliac crest to transverse watershed and across lymphedema.
* Secondary leg sequence to the right side
* Repeat the entire pathway on the left side. COMPRESSION THERAPY
Immediately following lymph fluid mobilization, compres-
Other Lymphedema of the Extremities sion must be applied. During the clinical phase of treatment,
Follow the appropriate pathways used for secondary lymph- this usually involves a multilayer system of bandages con-
edema with these exceptions: sisting of a stockinette, padding, and layered compression
bandages. The purpose of the compression is to prevent
* Primary UE lymphedema is usually associated with
reaccumulation of evacuated tissue fluid, augment the exter-
lymphedema in other areas as well. Use the normal
nal compression achieved through the skin and atmospheric
routes of drainage through the nodes, but do not direct
fluid into another lymphotome that may be involved. pressure, break up fibrosis, and reshape the limb. It should
* Primary LE lymphedema is often unilateral, so be worn at all times during the day and night but may be
tissue fluid may be directed into adjacent, uninvolved taken off for showering, provided it is reapplied immedi-
lymphotomes. You may use the normal pathway through ately afterward.
 PART TWO PRACTICE
Miettinen ROO...

Bandaging Components Short stretch bandages (depending on the size and shape
¢ Stockinette of the leg)
* The initial layer used to keep the bandages clean and ¢ One 6-cm width
absorb moisture from the skin ¢ One to two, 8-cm width
¢ No compression component to this layer ¢ One to two, 10-cm width
* Tubular dressing sold in large rolls can be cut to fit ¢ One to two, 12-cm width
the length of the arm
¢ Softer, nonelastic products are best
Compression Garments
Padding Once the: patient has achieved maximal reduction of the
* The second layer is used to provide protection to bony limb, he or she can be fitted into a compression garment.
prominences and to facilitate more even compression There are many different options for patients, including
and shape the limb various styles, colors, fabrics, and compression ratings.
* No compression component to this layer Unless you have been certified, your best bet is to establish a
¢ Sold in individual rolls in varying widths relationship with a certified fitter and collaborate on the best
* Foam options for your patient. These garments can be costly, so
* Used in conjunction with the padding layer to help there is little room for mistakes. It is suggested that each
shape the limb and break up fibrotic areas patient is issued two garments, one to wash and one to wear.
Varying densities of foam sold in precut shapes or in Make sure they are replaced according to the manufacturer’s
sheets for custom shaping instructions in order to maintain the optimal compression.
Commonly used around malleoli, knees and elbows,
dorsum of hand and foot, and areas of high fibrosis THERAPEUTIC EXERCISES
* Foam chips also available for very fibrous areas
These exercises facilitate the action of the muscle pump,
* Short stretch bandages
which helps drive the tissue fluid through the lymphatic
* Final layer of bandages used to provide compression
system. These and other appropriate exercises also increase
* All-cotton fibers sold in individual rolls of varying
the strength and range of motion of the affected limb and
widths
should improve function and mobility, which is often the
Short stretch achieved via the weave of the fibers; no
ultimate goal of therapy.
elastic in these bandages
Remember the following key points when prescribing an
* Short stretch provides high working pressure and low
exercise program for your patients (Table 12-2):
resting pressure
* Normal movements cause desirable changes in total
* Because a change in tissue pressure helps drive tissue
tissue pressure. Encourage patients to use the limb as
fluid into the lymphatic vessels, short stretch bandages
normally as possible.
are desired over long stretch bandages because they
* All exercises should be performed with compression on
provide higher pressure with muscle activity and
the limb.
lower pressure at rest
* The exercises should progress proximally to distally to
* Applying more layers distally and decreasing the
empty central lymphatics first.
amount and width of layers, while progressing proxi-
* The exercises prescribed for lymphedema should be
mally, helps to achieve a proper compression gradient.
performed without weights or with very low weight, and
Application of compression bandages to the arm they should be performed with few repetitions and
(Box 1221):
plenty of rest between sets.
Supplies
* These exercises may need to be modified according to
l-yard stockinette
the individual abilities of the patient.
One to two rolls elastic gauze wrap, 1- to 2-cm width
* Remember that only licensed medical professionals are
Foam padding in various shapes
qualified to prescribe an exercise program to individuals
Two rolls cotton padding, 10-cm width
with chronic or acute medical conditions.
One short stretch bandage, 6-cm width
One to two short stretch bandages, 8-cm width
PATIENT EDUCATION
| short stretch bandage, 10-cm width
Paper tape, 2-inch width Patient education regarding management of lymphedema
Application of compression bandages to the leg should begin with the first day that the patient walks
into
(Box 12-2): the clinic and continue with every visit. The educational
Supplies goals for therapy are as follows:
1 to 2 yards stockinette * Understanding and compliance of all precautions related
One to two elastic gauze bandages, I- to 2-cm width to lymphedema
Various foam pieces as indicated * Independence with self-bandaging
Two to three rolls of cotton padding, 10- to 15-cm width
Text continued on p. 263.
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12

OP Application of Compression Bandages to the Arm

1. Apply stockinette to the 5. Anchor padding layer at 9. Next, secure the 8-cm bandage
arm from the hand to the the wrist, then bring across just above the wrist, over the
shoulder; make a cutout for dorsum of hand, through the web previous layer, and spiral up the arm
the thumb. space of thumb, and repeat. with a %4-inch to 1-inch overlap.

2. Anchor the finger bandage . Continue spiraling up the arm,

at the wrist, then cross over folding extra padding into the
the dorsum of the hand to the anticubital area; it may require two
fifth digit, spiraling distal to rolls to cover the entire arm.
proximal.

10. When you reach the elbow,

use a figure-8 (spica) pattern
to prevent binding in the
anticubital space; you should
end just above the elbow.

3. Bring the bandage around the wrist, Ut Lightly anchor the 6-cm
over the dorsum of the hand to the compression bandage at the
fourth digit, and spiral distal to wrist, then cross over the
proximal; continue in this manner dorsum of the hand, through
until all fingers and the thumb are the web space of the thumb,
covered. and repeat (be sure to get
compression across all
metacarpophalangeal joints).

11. Begin spiraling with the

10-cm bandage at the point
where you left off with the
6-cm bandage (approx.
midway up the forearm);
with a 1.5 to 2-cm overlap.
4. Apply foam over any areas
of fibrosis or where reshaping 12. Use a figure-8 pattern at the elbow; |
i}
|

. Continue by spiraling up you may continue with this pattern

is desired.
the arm with a %4-inch overlap; up the arm; widen your use of layers
you should end about midway as you progress up the arm.
up the forearm; secure with
tape.
262 PART TWO PRACTICE

510.1774) Application of Compression Bandages to the Leg

1. Apply stockinette along 5. Begin spiraling the padding <). Apply padding from the knee to
the entire length of the leg layer up the leg from the foot to the hip; add any foam as needed;
and foot. the knee. the remainder of the bandaging
may be done in the standing
2. Anchor the elastic gauze position.
bandage at the forefoot and
over the dorsum to the tip of 10. Begin with the second 10-cm
the great toe; spiral up distally compression bandage using
to proximally, then around the a spica wrap at the knee; spiral
forefoot and across the dorsum. up the thigh with a 1-to 2-inch
overlap.

6. Begin with the 6-cm compression

bandage at the metatarsophalengeal
joints and spiral up to the heel;
make figure-8 patterns crossing
over the ankle and heel until the
heel is entirely covered; use a V4-
inch to Y2-inch overlap.

3. Bring the bandage to the distal end of

the second digit and spiral distally to 11. Continue with the 12-cm
proximally, then around the forefoot to bandage with increasing width
the third digit; continue in this pattern of overlapping; can be
until all toes are covered, wrapping continued around the waist for
the fourth and fifth digits together. extra security.

7. Continue up the leg

with the 8-cm bandage;
use a ¥%-inch to 1-
inch overlap.

8. Continue with the 10-cm call

4. Apply foam over bandage to just below the knee;
fibrous areas or where the layers should be wider as 12. Apply wide tape to the bottom
reshaping is desired. you continue up the leg; secure
x
and back of the heel, forming
with tape. a Stirrup to lock the bandages
in place; it may also be
necessary to tape around the
knee and vertically up the
thigh to secure bandages well.
 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12

lable 12-2 Suggestions for Exercises

UPER EXTREMITY LYMPHEDEMA
_____ LOWER EXTREMITY LYMPHEDEMA__
Deep abdominal breathing Shoulder circles Trunk rotation
Cervical rotation Shoulder flexion Marches
Cervical flexion/extension Shoulder abduction Heel slides
Cervical sidebending Shoulder ER/IR Hip abduction
Elbow flexion/extension Straight leg raises
Forearm pronation/supination Long arc quads
Wrist extension/flexion Ankle pumps
Finger extension/flexion Ankle circles

0)¢4 48), Lymphedema Risk Reduction Practices

Skin Care: Avoid Trauma/Injury and Reduce Infection Risk Monitor the extremity during and after activity for any
° Keep extremity clean and dry. change in size, shape, tissue, texture, soreness, heavi-
e Apply moisturizer daily to prevent chapping/chaffing of ness, or firmness.
skin. e¢ Maintain optimal weight.
e Pay attention to nail care; do not cut cuticles. Avoidance of Limb Constriction
e Protect exposed skin with sunscreen and insect e |f possible, avoid having blood pressure taken on the at-
repellent. risk arm.
e Use care with razors to avoid nicks and skin irritation. e Wear loose-fitting jewelry and clothing.
e If possible, avoid punctures such as injections and blood Compression Garments
draws. e Garments should be well-fitting.
¢ Wear gloves while doing activities that may cause skin e Support the at risk-limb with a compression garment for
injury (e.g., gardening, working with tools, using chemi- strenuous activity (e.g., weight lifting, prolonged stand-
cals such as detergent). ing, running).
e If scratches/punctures to skin occur, wash with soap and ¢ Wear a well-fitting compression garment for air travel.
water, apply antibiotics, and observe for signs of Extremes of Temperature
infection (i.e., redness). e Avoid exposure to extreme cold, which can be associ-
lf a rash, itching, redness, pain, increased skin tempera- ated with rebound swelling or chapping of skin.
ture, fever, or flulike symptoms occur, contact your ¢ Avoid prolonged (>15 minutes) exposure to heat,
physician immediately. particularly hot tubs and saunas.
Activity/Lifestyle ¢ Avoid immersing limb in water temperatures above 120° F.
¢ Gradually build up the duration and intensity of any Additional Practices Specific to Lower-Extremity Lymphedema
activity or exercise. @ Avoid prolonged standing or sitting.
¢ Take frequent rest periods during activity to allow for e When possible, avoid crossing legs.
limb recovery. e Wear proper, well-fitting footwear.

From National Lymphedema Network, Inc., 2007.

¢ Independence with self-massage and varying lifestyles may play a role in the ability of the
* Independence with home exercise program patient to be compliant with a rigorous home program. The
On the first visit, the therapist gives the patient a thor- therapist will help the patient to set reasonable goals and a
ough lesson in the basic anatomy and physiology of the home management program that fits his or her lifestyle,
lymphatic system and explains the rationale for treatment. personality, and individual goals. Occasional follow-up ses-
Precautions are discussed, and the patient is given a written sions will allow the therapist to monitor progress and adapt
the home program if necessary.
handout. On the second visit, the patient is taught the home
exercise program, which he or she performs daily in the
clinic after bandages have been applied. The patient learns
self-bandaging on the third visit and should be independent REFERENCES
before the weekend because bandages will need to be reap- Araujo JA, Curbelo JG, Mayol AL et al: Effective management of
plied during that time. The patient learns self-massage at the marked lymphedema of the leg, /ntl J Dermatol 36:389-392, 1997.
start of the second week and reviews it until independence Ayrahami R, Haddad M, Zelikovski A: Combined surgical correction
of bilateral congenital lower limb lymphedema with associated
is achieved (Box 12-3).
anomalies, Lymphology 31:65-67, 1988.
After the patient is discharged from therapy, he or she Augustine E: Physical therapists play an important role in treating
should continue with phase 2, consisting of daily self- lymphedema, Oncol Nurs Forum 23:421-422, 1996.
com-
massage and exercises, adherence to precautions, and Bernas MJ, Witte CL, Witte MH: The diagnosis and treatment of
peripheral lymphedema, Lymphology 34:84-91, 2001.
pression. Remember that each patient’s goals are different,
 PART TWO PRACTICE

Box R, Reul-Hirche H, Bullock-Saxton J et al: Physiotherapy after Leduc O, Leduc A, Bourgeois P et al: The treatment of upper limb
breast cancer surgery; results of a randomized controlled study to edema, Cancer 83(suppl):2835-2839, 1998.
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 DECONGESTIVE THERAPY FOR THE TREATMENT OF LYMPHEDEMA CHAPTER 12

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 <

Massage in Sport

Sports massage has gained popularity since the 1980s with chological effects that can be attained to enhance
the increased participation of all ages in aerobics and the performance. A positive adjustment in mood, an acquired
worldwide visibility of sport. However, it is insufficient to sense of well-being, a decrease in anxiety, and a decrease
define sports massage simply as massage applied to athletes. in fatigue—all of these are reported and demonstrated psy-
Often the term sports massage is used synonymously with chological responses associated with massage intervention
the term deep tissue massage to justify the use of painful (Hernandez-Reif et al., 2001; Robertson et al., 2004; Stock
pressures on athletes. This usage is often based on the mis- et al., 1996). The athlete can benefit from these effects
conception that the muscular bulk of an athlete necessitates before competition or between bouts of training to manage
abuse to the connective tissues to deliver an effective inter- the associated stressors of sport (Loehr, 1994).
vention. This generalization is also an inaccurate descrip- Sports massage based on the timing of performance or
tion of sports massage. Sports massage is the use of soft in response to injury is applied to attain different goals, such
tissue mobilization to enhance performance among indi- as to promote relaxation, increase circulation, diminish
viduals who are placed in physical achievement situations. adhesion formation, or decrease pain (Farr et al., 2002). It
An achievement situation is one in which (1) there is public is adjustment based on the demands of the sport and to best
verifiability of performance (an audience), (2) there is a enhance performance that distinguishes sports massage
Known criteria of success, (3) an individual is responsible from another clinical therapeutic intervention. It is the
for the outcome, and (4) there is a challenging task. Athletes skilled ability on the part of the therapist that adds the psy-
spend most of their time in physical achievement situations chological and anxiety management effects for performance
during training or competition. that contribute to positive functional outcomes.
The idea that sports massage differs from therapeutic Sports massage, as with any therapeutic treatment, must
massage applied to nonathletes may be misleading. It is not begin with a comprehensive evaluation to ascertain the
that the techniques used with sports massage are so radically source of the problem and construct a treatment plan. For
different; rather, the difference lies in the ability of the prac- any population requiring therapeutic intervention, one treat-
titioner to vary the dosage, timing, and amount of pressure ment modality is insufficient to fully restore full function
based on the needs of the athlete to best enhance perfor- or treat disability. Similarly, with an athletic population,
mance outcomes. This requires an understanding of peri- massage is but part of a regimen of treatment that also
odization for a sport (Mayhew, 1995): specifically, the includes resistance or flexibility exercises: physical agents
therapist must know the repetitive cycle that an athlete will such as ice, ultrasound, or electrical stimulation; and
undertake several times during a year in order to prepare for other
manual therapy interventions such as joint manipulation.
peak performance during competition. The knowledgeable It
is this combination of applied therapeutic intervention
practitioner is aware of what point in this cycle an athlete or to
address imbalances that will promote healing and perfor-
team is in order to apply the appropriate skills and, thereby, mance, thus enhancing functional movement for the
assist the athlete with preparation and recovery. elite
athlete. Although the body of knowledge regarding
The additional value that sports massage provides to ath- the
mechanisms through which these effects occur continue
letes when compared with other populations is in the psy- s
to expand with scientific investigations, it is importan
t to
 MASSAGE IN SPORT CHAPTER 13
vases ,
i a
remember that sports massage is not a new intervention and ing common for elite competitors to require soft tissue
has been in existence since early civilizations (Callaghan, massage as part of their training and competition regimen.
1993; Hemmings, 2000). Why are massage techniques in such high demand? Why do
therapists apply them so frequently? This may be due both
to the perceived and validated effects of massage.
HISTORY OF SPORTS MASSAGE
Massage as a form of treatment for athletes has existed for
THERAPEUTIC EFFECTS OF MASSAGE
thousands of years. The Greeks may have been the first to
FOR AN ATHLETE
use massage for athletes as a precompetition and postcom-
petition intervention. In truth, the original writings regard- The effects of massage for athletes are similar to those for
ing massage are from the works of Hippocrates dated around nonathletes as listed in Box 13-1 and discussed in Chapter
400 Bc (De Domenico & Wood, 1997; Schoitz, 1958). Wres- 5. Although limited conclusive investigations have been per-
tling was a popular sport in ancient Greece, as were track formed regarding the mechanisms of action to date, specific
and field events. Early manuscripts describe manual therapy massage techniques continue to be used to induce specific
intervention to treat trauma as well as promote recovery. change within athletic populations.
Historical accounts describe the treatment for a wrestler
who has finished a wrestling match and sustained a dislo- Delayed Onset Muscular Soreness
cated shoulder by stating that, “The physician must be expe- Athletes are at high risk for delayed onset muscular soreness
rienced in many things, but assuredly also in rubbing; for (DOMS). DOMS is the soreness and stiffness in the exer-
things that have the same name have not the same effect. cised joints and muscles that occurs with a new physical
For rubbing can bind a joint that is too loose and loosen a activity or with strenuous activity undertaken after an
joint that is too hard” (De Domenico & Wood, 1997). Also, extended rest period. Although often associated with eccen-
Hippocrates describes that “it is necessary to rub the shoul- tric exercise because of the hypothesized microtearing of
der gently and smoothly; but the joint should be moved fibers associated with these activities (Connolly et al., 2003),
about, not violently but so far as it can be done without DOMS occurs after other forms of training activities as
producing pain” (Paris & Loubert, 1990). This account well. Temporary soreness can last for several hours after any
describes the intervention for shoulder realignment by dif- unaccustomed exercise; however, a distinguishing charac-
ferent manual maneuvers and the use of massage to coax teristic with DOMS is that pain appears later and can last
the tissues to respond to realignment. Thus, sports massage— from 24 to 96 hours after activity (MacArdle et al., 2001).
that is, massage applied to enhance performance for ath- DOMS can vary from muscle tenderness to debilitating pain
letes—has existed as one of the early applications of soft and affects athletic performance by causing reduced joint
tissue mobilization intervention. motion, shock attenuation, and reduction in peak torque
The different professionals who use massage techniques (Cheung et al., 2003). Compensatory mechanisms can place
were described in Chapter |. As these practitioners continue an athlete at increased risk of further injury. To date, there
to apply and advocate the value of massage therapy, sports is not one definitive documented cause of DOMS; however,
massage continues to gain validity among athletes and various hypotheses exist as to the manifestation of DOMS.
administrators. Athletic trainers are constantly bombarded These are listed in Box 13-2. It is most probable that the
with participants in aquatic and athletic events clamoring cause of DOMS is a combination of these factors rather than
for massage techniques to manage musculoskeletal concerns any one factor.
(Bell, 1999). In present-day competition, the medical teams
as part of the United States delegations to the Atlanta (1996)
and Sydney (2000) Olympic Games were responsible for
administering daily comprehensive massage and specific Bei Lil Positive Effects of Sports Massage
soft tissue mobilization to the more than 100 athletes of the |
. Improve circulation.
United States Olympic team. The delegation for Great
. Decrease edema/inflammation.
Britain administered more than 1000 soft tissue treatments _ Promote relaxation and decrease arousal.
during the Atlanta Olympic Games in 1996. An investiga- _ Decrease stress and competitive anxiety.
tion performed in the United Kingdom to quantify the use . Enhance mental recovery/invigoration. |
of massage by physiotherapists at athletic events revealed Decrease/manage pain.
important findings. Specifically, the study found that the . Decrease delayed onset muscular soreness (DOMS).
percentage of time devoted to providing massage therapy
. Increase range of motion (ROM).
. Decrease adhesions.
ODYNOnNRWON=
treatment to athletes ranged from 24% to 52.2%, and the
10. Increase tissue extensibility.
overall median percentage of total treatments for massage | 11. Decrease spasm.
ath-
was 45.2% (Galloway & Watt, 2004). More and more 42. Enhance sense of well-being.
letes seek this treatment from qualified professionals with 13. Promote neurological excitability.
positive results. These statistics demonstrate that it is becom-
sional PART TWO PRACTICE

BOX 13-2 Potential Causes of Delayed Onset et al., 2001). Some argue that massage can mechanically
Muscular Soreness (DOMS) promote lactate removal. Hemmings et al. (2000) found no
significant difference in blood lactate levels between two
1. Exercise can result in the local accumulation of
metabolic waste, which sensitizes A-delta and C fibers groups of boxers that performed two bouts, of upper-body
causing pain (McArdle et al., 2001). ergometry. The groups were measured between bouts, with
| 2. Acute inflammation may result in DOMS. the control group (N=8) performing passive rest and the
3. According to DeVries (1966), exercise induces muscu- experimental group (N=8) receiving massage therapy. The
lar edema resulting in pain substance production, blood lactate level was higher in both groups following
producing a reflex spasm and thereby prolonging
the second bout of exercise performance without massage
ischemia.
4. Eccentric exercise leads to minute tears or damage of
intervention; therefore, there was no significant difference
the connective tissues of the muscle-releasing creatine |
in blood lactate levels after maximal activity. A significant
kinase (CK), myoblobin (Mb), and troponin |, all difference was found with a higher perception of recovery
contributing to the manifestation of pain. level reported by the massage intervention group, suggesting
5. DOMS may also arise from calcium regulation altera- that DOMS can manifest without elevated lactate levels and
tions of the cell.
can be relieved with massage treatment.
6. Any combination of the above factors may lead to
DOMS.
Conclusive evidence regarding the effectiveness of
massage on DOMS is lacking (Jonhagen et al., 2004). It
Adapted from McArdle WD, Katch FI, Katch VL: Exercise physiology:
appears that for each investigation that demonstrates posi-
energy, nutrition, and human performance, ed 5, Philadelphia, 2001,
Lippincott Williams & Wilkins. tive physiological effects of massage on DOMS recovery,
there is another with findings to the contrary. Robertson et
al. (2004) demonstrated no significant difference in the
physiological effects of massage when compared with pas-
sive recovery in a group (N=9) performing high-intensity
cycling. A systematic review by Ernst (1998) failed to gener-
Researchers have hypothesized that massage intervention ate a meta-analysis because of variations in methodologies
can decrease soreness and promote recovery to facilitate of included investigations. Investigations with larger samples,
continued training and competition for an athlete. The greater methodological rigor, and a comparison of standard
mechanical pressure applied with massage techniques can treatment protocols are needed to arrive at a definitive con-
increase muscle compliance, decrease passive and active clusion. Results of this systematic review emphasized the
stiffness, and thereby increase joint and muscular range of potential systemic effects of massage therapy with emphasis
motion (Weerapong et al., 2005). The mechanical pressure on the fact that massage intervention need not be an extended
can also help to increase blood flow and promote increased full-body session but that benefits are attained by the direct
tissue temperature through rubbing (Hinds et al., 2004), and local mechanical pressure effects on the muscles
Investigative results have varied because of differences treated.
in investigative rigor and methodologies. However, in a ran- Therefore comprehensive or full-body massage as well
domized clinical trial with a control group (N=7) and an
as spot work, as the abbreviated specific tissue treatment has
experimental group (N=7), Smith et al. (1994) demonstrated been called, continue to be used on athletes regularly
positive results. This group found that 30 minutes of soft (Galloway & Watt, 2004). These techniques, which are used
tissue massage administered 2 hours after isokinetic eccen- to promote recovery for DOMS, allow continued intensiv
tric exercise of the upper extremity resulted in decreased e
training with lower levels of pain and fatigue reported
reported levels of DOMS and decreased measures of serum by
elite and novice athletes (Hinds et al., 2004; Hemmin
creatine kinase levels within the massage group. An inves- gs et
al., 2000; Robertson et al., 2004; Smith et al., 1994),
tigation was conducted with 8 male subjects performing
downhill walking to induce DOMS followed by a 30-minute Technique and Dosage for DOMS
massage therapy intervention on one leg of each subject
When treating DOMS, the primary goal is to decrea
(Farr et al., 2002). Significantly higher levels of pain and se pain.
Treatment can vary from an extended full-body
tenderness were measured in the nonmassaged limb 24 massage
that can be | hour in length to an abbreviated
hours after activity with a significant difference between 15- to 20-
minute session for the extremities or a specific
limbs. There was also a demonstrated decrease in isometric body part.
To begin a treatment session, effleurage such
strength compared with baseline 1 hour after the walk. as stroking
with light pressure should be used to promot
These findings support the hypothesis that sports massage e circulation,
stimulate superficial blood flow, and facilitate
following activity can promote recovery and thereby local and
general relaxation. This gentle introduction of
facilitate continued training and competition at the therapist’s
peak hands to the athlete’s tissues will begin to allow
performance. relaxation
of the mind and body and thereby decrease
DOMS has been incorrectly attributed to an accumula- any protective
spasm that might be present as a result of pain.
tion of lactic acid or elevated serum lactate levels (MacAr The pressure
dle should be light to accommodate the tissue
tenderness that
 MASSAGE IN SPORT CHAPTER 13

is the hallmark of DOMS. The therapist should pay par- The acute phase of an injury with the initial inflammatory
ticular attention to signals denoting relaxation by the reaction lasts from onset of the injury to 4 to 6 days later and
athlete. These signs could include deep, rhythmic breathing; is characterized by tissue sensitivity. Pain results from vas-
decreased tension within the superficial tissue being stroked; cular and cellular responses with the altered chemical state
or closed eyes with relaxation of facial muscles. If any of irritating nerve endings (Cailliet, 1996). There can be
these signs do not begin to occur within 5 minutes, the pres- increased edema, muscle guarding, and increased tissue
sure may be too deep and an adjustment must be made to tension. The initial inflammatory reaction occurs with the
decrease the force applied. signs of inflammation including heat, redness, and loss of
Following initial relaxation, which can begin to occur function. Pain at rest is also present and can be can be exac-
within 4 to 5 minutes, the therapist can then progress to erbated with movement. Some argue that massage should not
moderate compression with pétrissage such as_ gentle be undertaken during this stage because of the potential for
kneading and wringing. This is a deeper application of greater harm. This greater harm can occur if the therapist is
massage but should not cause the athlete to perform sus- not skilled with the application of massage and is not attuned
tained muscle contractions or increase tension in the tissues. to tissue response and tissue texture changes. The view that
If this begins to occur, the pressure is too deep and should massage is absolutely contraindicated with acute injury is
either be modified or the technique adjusted. Pétrissage negated with findings by Stearns (1940). In a classic work
could be discontinued and only effleurage used for the entire regarding the effect of movement on fibroblastic activity, the
treatment dose. To avoid inducing pain and causing further researcher concluded that fibrils form almost immediately
tissue damage, pétrissage techniques should not be applied during the healing process and external forces are responsi-
with deep pressure or long duration when treating DOMS. ble for the physical arrangement of these fibers. Therefore,
No more than half of the entire duration of the massage skilled massage with passive movement of the traumatized
intervention should be used for pétrissage. This is then fol- tissues can enhance the healing process.
lowed by moderate-pressure effleurage. Active range of Although it is not reasonable to apply great pressure to a
motion exercise without resistance has been demonstrated bruised or painful region, moderate to light pressure in the
to facilitate recovery from DOMS in combination with application of massage to an acute injury can facilitate for-
massage (Lane & Wenger, 2004). Therefore, active assisted mation of fibroblasts and also manage pain through the
range of motion (AAROM) can be incorporated within a stimulation of mechanoreceptors. Light to moderate effleu-
treatment session before the final transition to light pressure rage (as recommended with the treatment of DOMS) can
effleurage to conclude the treatment. One can envision the promote circulation to manage fluid imbalance and prevent
treatment session as one-third initial light effleurage, one- excessive edema. Specific and deep pressures should not be
third moderate pétrissage, and a final one-third with moder- applied directly to muscles with palpable tears, to inflamed
ate effleurage to include AAROM concluding with light tendons, or to ligaments with laxity caused by strain. Rather,
effleurage. effleurage to promote circulation, manage pain, and promote
DOMS can last for 96 hours (4 days), so that repetitive the formation of fiber should be applied to adjacent struc-
treatments can be applied over a period of days to alleviate tures rather than directly on these newly injured tissues.
symptoms. Multiple treatments with massage appear to be Rhythmic effleurage strokes with light to moderate pres-
more effective than a single dose of treatment (Tidus & sure can convey calm in the midst of an injury situation that
Shoemaker, 1995). Also, just as DOMS is most likely caused may appear out of control to an athlete. There is an invalu-
by a combination of factors, it appears that the ideal treat- able sense of confidence that the therapist can help instill in
ment is a combined approach that includes massage therapy, the athlete (Moritz et al., 2000) through this therapeutic
active recovery, and even cryotherapy (Cheung et al., touch. The repetitive movement can contribute to relaxation
2003). and diminish the anxiety or sense of threat felt by an athlete
when confronted with an injury (Brewer, 1994). Massage
Massage for Acute Injury can also be a helpful means to convey support. The athlete
Initial Inflammation who receives manual massage treatment may also acquire a
Acute injuries frequently occur during sport competitions, sense of support and empathy from the therapist providing
or so it may appear. Most of us can remember seeing an care. Adherence to rehabilitation has been associated with
athlete sustain a strained hamstring while running a 400- social support (Duda et al., 1989; Prochaska & Marcus,
meter sprint, a cyclist take a tumble when racing in a pack, 2001). The athlete who perceives support through the mas-
or a quarterback receive a blow to the trunk and double
saging hands of a therapist will be better able to commit to
over to the ground in pain. This initial acute stage of an
a treatment regimen and begin the road to a successful
injury results in obvious pain and short-term dysfunction;
recovery.
however, this initial stage also results in physiological Repair and Healing
changes beyond the dysfunction. These include electrolyte
Repair and healing follow the inflammatory reaction of an
imbalance and fluid imbalance as well as local and general
injury and can continue for approximately 14 to 21 days
circulation alterations (Cailliet, 1996).
 PART TWO PRACTICE
dininnids OO. a
lea
after the onset of injury (Enwemeka, 1991). Inflammation to realign fibers, and, again, exercise to include gentle
continues to decease with removal of noxious stimuli. There stretching can be applied until the tenth to fourteenth week
is new growth of capillary beds, and granulation and colla- of recovery. Beyond this period of time, the scar formed will
gen tissues begin to form. The newly formed tissues are resist elongation and remodeling, so that lengthening will
fragile at this time. Morphological changes in rat tendons have to occur at tissues away from the injury site.
demonstrate increased fibroblast proliferation in tendonitis- This stage of healing demands deeper pressures to affect
induced rats that were treated with soft tissue mobilization healing. However, the therapist should continue to monitor
(Davidson et al., 1997). Although this may not directly the athlete during the treatment session to ascertain the
translate to humans, these findings suggest that healing may appropriate depth needed to reach the tissue lesion area
be promoted through increased fibroblast recruitment result- while not causing excessive pain. If the pressure is too great,
ing from massage treatment. the muscle will tense to prevent trauma to the tissue. If the
Newly formed connective tissue fibers are fragile because therapist insists on using deep pressures while the muscle
they are unorganized. Massage therapy techniques can be is in a protective spasm or contraction mode, bruising
applied more specifically to the affected tissues to facilitate can occur. Some athletes believe that this is a good
alignment of connective tissue fibers. As pain continues outcome and a necessary indicator of an effective massage
to subside, massage techniques can increase in pressure. treatment. Sometimes therapists mistakenly encourage these
Treatment should once again begin with light effleurage to beliefs.
promote relaxation and prepare the tissue for deeper pres- There is an analogy used within the discipline of Chinese
sures to follow with pétrissage. Deep friction massage medicine when discussing massage therapy for tissues that
(DFM), initially described by Cyriax and Russell (1990) are resistant to pressure because of protective spasm. The
and as described in Chapter 4, can be applied without exces- therapist should think about wanting to visit a friend at
sively painful pressures. Care should still be taken when home. One would go to the friend’s house and politely knock
applying pressure to healing muscle fibers and tendons on the door. It may be necessary to knock a couple of times
because of the fragility of the newly formed tissues. if the person inside did not hear the first knock. If there is
no answer, it would not be appropriate to “charge through”
Massage for the Chronic Injury or crash into the front door without being invited. One might
Injuries have been classified as chronic based on time from go to a side window and tap there in case the friend is in
initial onset as well as according to the events occurring the back of the house and did not hear the front door. Your
within the healing process. Some authors would argue that friend may let you in by the side door (Figure 13-1).
chronic is anything that is not acute and therefore would Similarly, the tissue that you are treating may be too
include injuries that are in the subacute phase. Within this sensitive for the pressure used or the tissue tension may be
discussion, a chronic injury is one in which the events of unresponsive to the specific technique. Instead of adding
healing have progressed through the acute and subacute
phases. Therefore the tissues have completed the initial
inflammatory process of the acute phase with reduction in
inflammation, followed by the beginning of repair and
healing of the injured site that occurs in the subacute phase
(Kisner & Colby, 2002). Maturation and remodeling of
tissue are the events within the chronic stage of tissue
healing.

Maturation and Remodeling

The maturation process overlaps with the end of the sub-
acute phase and, depending on the severity of the injury, can
continue for months. During this stage of maturation, the
collagen fibers increase in tensile strength, they begin to
align into a more organized orientation (Enwemeka, 1991;
Noyes et al., 1984), and the size of the wound and scar
decreases. Remodeling of tissue is affected by factors such
as vascular supply and stressors placed on the tissue. It is
during this stage of healing that deep cross-friction massage
can be most beneficial to facilitate organized alignment of
the connective tissue fibers (Brosseau et al., 2007). Effleu-
rage to promote circulation with stronger pressure to reach Figure 13-1
the full thickness of the involved structure should be used. When trying to produce changes upon deep tissues, alternate tech-
Massage with pétrissage to penetrate deeper tissues, DFM niques may need to be applied for superficial tissues to relax.
 MASSAGE IN SPORT CHAPTER 13
icin
baba ce
more pressure with the same technique on the same tissue, insult. Chronic injuries as described in the previous section
a different pressure with a different technique may be necessitate deeper pressures and transverse fiber techniques
needed to coax the tissue to relax and allow the application to promote remodeling with exercise to return to full sport
of an effective treatment. participation.
Deeper pressure may be merited to relieve a protective Chronic inflammatory conditions are the result of repeti-
spasm; however, if there is no relief of tissue tension within tive stress with insufficient time for recovery and repair.
a short period of time (approximately 60 seconds maximum), Muscular imbalances can contribute to the manifestation
pressure should be changed and another approach used. This and lack of healing with chronic inflammatory conditions.
is Similar to tapping at the front door; the therapist should There exists a continual state of inflammation with increased
then try the side window. The session should not continue collagen production resulting in immature, fragile tissue.
with painful pressure applied that, because of charging The continually formed young structure, whether it be
through the tissue, can result in bruising. If you knock on tendon, ligament, or fascia, is constructed of weaker and
the door and your friend is not home, and if you knock on inflamed tissue. As the microtrauma or stretch continues to
the side window and no one is home, you would come back be placed on the tissue, myofibroblasts can remain overac-
another day. This is true for massage intervention as well. tive, limiting motion. The constant inflammation can be of
If the tissue is not ready for that depth of pressure and par- a low grade with periods of exacerbation, and this inflam-
ticular technique, the therapist should use patience by mation contributes to pain and limited function.
varying technique and pressure to decrease tissue tension The initial massage therapy treatment is the same as for
and return to that tissue during another session. When inju- an acute injury in the inflammatory stage. The treatment
ries are in the chronic stage, the athlete can become frus- sequence should include adjunct therapy such as ice and
trated with the time needed to heal and the therapist must AAROM (Goats, 1994a, 1994b; Meeusen & Lievens, 1986;
encourage the athlete and display patience to continue to Swenson et al., 1996). The imbalance should be identified
progress with recovery. If the tissue is resistant to relaxation, in the surrounding musculature and targeted to intervention.
the therapist should not rush or force tissue to relax because Deep tissue work, positional release, and myofascial release
this impatience may further frustrate or worry the athlete. techniques (described in Chapter 4) can be beneficial to
It is never a positive outcome to have bruising or hematoma reestablish normal tissue extensibility in conjunction with
formation after massage therapy. This can slow healing and flexibility exercises. When the inflammatory phase can be
impair performance as a result of pain (Figure 13-2). controlled, progressive exercise should be introduced fol-
lowing soft tissue massage to further establish normal move-
Chronic Inflammatory Conditions ment patterns and muscular balance.
Athletes will commonly train or compete with a chronic Athletes will train and compete with chronic inflamma-
injury. This term can be misleading because it is used to tory conditions such as tendonitis and fascitis. Most com-
refer to the healing phase of injury and also to an injury that petitive athletes with a competitive season longer than 6
is of a chronic inflammatory nature. The choice of massage months will receive treatment for tendonitis or fascitis of
intervention should vary with these manifestations of tissue some affected body part during the competitive or training
season. It has been found that fascial components lose their
pliability as the ground substance solidifies, elastin loses its
resiliency, and collagen can develop aberrant cross-links.
Thus, tissue injuries that have not completed the full cycle
of rehabilitation to correct imbalance will cycle through the
inflammatory process repetitively. The tissue will progres-
sively tighten as it is subjected to microtrauma and mis-
guided, nonsystematic attempts to return to full activity.
If a chronic condition has resulted in scar tissue forma-
tion, deeper tissue intervention may be needed. One such
technique, called augmented soft tissue mobilization
(ASTM), is based on the principles of cross-friction massage.
Itis a soft tissue technique that “uses ergonomically designed
instruments that assist therapists in rapid localization
and effective treatment of areas exhibiting excessive soft
tissue fibrosis” (Melham et al., 1998). The purpose is to
introduce microvascular trauma and capillary hemorrhage
that results in a localized inflammatory response. This
intervention is similar to the deep tissue technique per-
Figure 13-2
formed with a massage T-bar (Figure 13-3) to treat chronic
Bruising of superficial tissue is an outcome of inappropriate excessive
tendinopathy.
pressure with massage therapy techniques.
 PART TWO PRACTICE

Figure 13-3 Figure 13-4

Excessive pressure will deter relaxation and also cause the athlete to Athlete education regarding the timing for massage is critical.
contract muscles, thus hindering an effective massage intervention.

These techniques attempt to increase cellular activity and therefore, decrease the arousal needed for competition.
promote circulation to a tissue that has excessive scarring Another misconception espoused by athletes is that massage
from prolonged inflammation (National Athletic Trainers’ before competition will make their muscles weak. In a
Association, 2004). The acute injury phase is induced to review, Weerapong et al. (2005) concluded that although
then progress the tissue through the subacute and chronic massage therapy produced positive effects such as to reduce
healing phases of recovery. Initial findings demonstrate muscular soreness, there was no evidence to support the
improved healing on fibrous tissues, such that comparison claim of muscle functional loss. Although the beliefs that
groups with varying pressure of ASTM demonstrated a sig- athletes possess may be unfounded, perception is critical to
nificantly higher number of fibroblasts in the groups that performance. The knowledgeable professional will not only
received ASTM with heavy pressure when compared with educate the athlete about the positive impact of massage but
groups that received lighter or moderate pressure (Gehlsen will also use techniques within the massage therapy reper-
et al., 1999). These treatment techniques show promise in toire to diminish the feeling and perception of fatigue or
early stages of investigation and should be monitored for excessive relaxation before competition (Figure 13-4).
outcomes with larger samples to validate inclusion in future The specific timing of the massage intervention is related
therapy protocols. to the goal of treatment. The athlete with a chronic injury
Chronic inflammatory conditions can impair an athlete’s may need assistance to prepare the tissues for activity. This
ability to train and compete at full potential. As training treatment would be spot work, or specific techniques applied
proceeds, the inflammation can be exacerbated and the to a particular body part. This pre-event warm-up can be
athlete must alter the practice regimen. The use of massage done within 30 minutes of the preparatory activity for com-
techniques can facilitate the healing process. In the case petition. For example, in the treatment of patellar tendonitis,
of chronic inflammatory conditions, skilled massage is effleurage is initially used upon the anterior thigh and
essential for healing to occur (National Athletic Trainers’ peri-
patellar region to promote circulation and prepare the tissue
Association, 2004). for further intervention. Specific acupressure and muscular
release techniques can be applied to the rectus femoris
Massage Dosage proximal insertion to release tension at the attachme
nt.
Deep friction massage with moderate pressure
Massage before Competition can be
applied at the insertion points of the patellar tendon
The seasoned athletic competitor is more likely to use and
along the midsubstance area of the tendon. Pétrissage
massage therapy before competition than is the novice com- such
as kneading followed by tapotement should be used
petitor. This is the result of more frequent exposure to pro- before
AAROM and stretching. This pre-event warm-up
fessionals who implement therapeutic massage and also should
take approximately 20 minutes so that the athlete
greater knowledge regarding the athlete’s own to this modal- can then
continue with active warm-up before activity. Therefor
ity. Elite athletes have greater experience with competition e pre-
competition massage techniques are limited effleura
and have had more opportunity to experiment with interven- ge and
pétrissage followed by specific muscular release
tions to promote recovery. techniques
and moderate pressure transverse friction to
All athletes can have misconceptions regarding massage, promote spe-
cific tissue circulation, ending with tapotement
such as massage therapy will make them too relaxed and elonga-
and, tion activities (Figure 13-5),
 MASSAGE IN SPORT CHAPTER 13

iinet
mance is imperative in sport, particularly with events that
have multiple rounds or bouts of activity. Events such as a
cricket test match, a baseball road trip, the Olympic Games,
or a tennis grand slam event can last for days and require
efficient recovery and replenishment to maintain peak
performance.
Massage has been demonstrated, although inconclusively,
to promote lactate mobilization from the bloodstream, but
massage has not been definitively linked to performance. An
investigation by Mondero and Donne (2000) performed
with 18 trained cyclists tested four recovery interventions to
include passive recovery, active recovery at 50% maximal
oxygen update, massage, and a combined regimen of massage
and active recovery. Participants performed two simulated
5-kilometer maximal effort cycling bouts separated by 20
minutes of recovery time. Measurements of blood lactate,
Figure 13-5 performance time, and heart rate were taken at 3-minute
Specific techniques to enhance alertness, improve circulation, and intervals during recovery. Results demonstrated that
decrease stress can be used before competition. combined recovery of massage with active motion was the
most efficient intervention for maintaining performance
time during the second bout of cycling. Massage therapy
The athlete who is reporting worry, tension, fatigue, mus- allows the athlete to maintain peak performance for each
cular soreness, or heaviness in the legs (which can be a competition.
symptom of fatigue and dehydration) would benefit from a When treating an athlete between exercise bouts, it is
comprehensive massage intervention before competition. important to note that sports massage, similar to any thera-
The treatment should be completed with a minimum of | peutic massage intervention, necessitates attention to prin-
hour before competition. Massage has been demonstrated to ciples of hygiene. An athlete should never be massaged
decrease pain in orthopedic conditions as well as alter elec- without having cleansed the area to be treated. The only
troencephalography (EEG) patterns and increase serotonin exception to this practice would be a medical emergency
levels indicative of relaxation and diminished arousal. It is such as muscle cramping as a result of heat illness. In this
recommended that athletes not receive a full-body massage instance, immediate intervention is needed, and sustained
immediately before competition because they may not have massage pressure can alleviate this painful symptom.
sufficient time to attain the needed arousal to perform; Every athlete should be required to bathe before thera-
however, the timing before performance can vary with per- peutic massage to decrease the spread of bacteria.
sonal preference. The athlete should experiment with This practice contributes to a comfortable environment for
massage before a practice bout outside of competition to the practitioner and the athlete and helps ensure a more
ascertain his or her response to this type of treatment. effective treatment session. Although there are no contrain-
The comprehensive precompetition massage treatment dications to performing massage immediately after compe-
should provide relaxation with effleurage stroking followed tition, it is in the athlete’s best interest to consume some
by pétrissage with specific muscular release techniques on form of carbohydrate and begin fluid replenishment after
tight insertions and acupressure release performed on spe- competition and before massage therapy intervention. This
cific trigger point areas found (see Chapter 4 regarding replenishment of nutrients and fluids promotes ideal recov-
Travell’s trigger point therapy). Tapotement with tapping, ery, decreases the potential for muscular cramping, and
cupping, and shaking of the extremities and spine should be begins preparation for the next bout of competition or
used to counter excessive relaxation and potential malaise training.
that may occur with too much effleurage. The use of chop- The structure of the massage session will be determined
ping can create an invigorating sensation for competition by the timing of the next bout of competition or training. If
later in the day. Gentle AAROM activity can be done with the athlete is to continue to compete on the same day,
effleurage to complete the treatment. The therapist must be massage can be beneficial and will necessitate a shortened
sure to check the athlete’s specific response later in the day intervention rather than a thorough, full-body massage.
for future use of massage before competition. Long strokes—with moderate pressure on the extremities to
decrease soreness and enhance circulation—are commonly
Massage Between Competitions referred to as a quick flush of the extremities. This move-
Many athletes have more than one competition within the ment can take approximately 30 minutes and may be all that
same day. Some sports necessitate performance for several is needed with gentle stretching to prepare for the next
consecutive days. Recovery for subsequent athletic perfor- competition.
‘icine ici —

Massage after Competition ing and competition routine. Because of the repetitive nature
A postcompetition intervention is usually associated with of training and the continuous demands placed on the con-
preparation for another competition on a subsequent day. nective tissues while executing the repetitive movements of
However, this intervention can be used for recovery or pre- sport, tissues can develop excessive tension. If not addressed
paration on the same day between bouts of competition. The with flexibility and range of motion movements, this exces-
effleurage described previously can be applied with moder- sive tissue tension can result in a tightened myofascial
ate pressure followed by deeper pressure, continuing with system. Elite athletes demonstrate tissue imbalances, such
deep kneading and tapotement of the trunk and extremities. as baseball players with external rotation beyond 100
Release techniques specific to the muscles used in the sport degrees and limited internal rotation less than 90 degrees
can be applied. For example, the pitcher in baseball should (Ellenbecker, 2001).
have deeper pressure applied to the subscapularis insertion Massage therapy restores imbalances that cause limited
points or the midsubstance of the teres minor. Cross-friction functional mobility. In a randomized clinical trial, pretest/
can be applied along these muscles to promote tissue relax- posttest design of 20 subjects, soft tissue mobilization
ation. The tennis player and football player will need spe- combined with proprioneuromuscular facilitation on the
cific release techniques performed to the piriformis muscle subscapularis muscle was been demonstrated to increase
and other deep rotators of the hip. The cyclist should have shoulder external rotation and overhead reach after just one
the iliopsoas at the lower abdominal region released with session (Godges et al., 2003). This is another example of the
deep tissue pressure and cross-fiber massage bilaterally. benefits massage can provide the elite athlete to restore
Familiarization with the movements and demands of the balance of the musculoskeletal system during training and
athlete’s sport will direct the therapist to the treatment competition.
needed for specific muscles.
Tapotement used toward the end of the massage promotes
an invigorating feeling for the athlete. Finishing with effleu- Periodization Training
rage and gentle stretching enhances relaxation and tissue In 1972, Leonid Mateyeev first introduced periodized
elongation. A full-body comprehensive treatment between training as a resistance training concept. It has developed
matches (postcompetition) can take an hour or longer into a training structure for informed athletes desiring to
depending on the tissue tensions encountered and the readi- peak and compete systematically. The theory is that train-
ness of the athlete to release tension (Figure 13-6). ing should occur in cycles to enhance performance. A large
training cycle is called a macrocycle and is divided into
Massage as Maintenance smaller cycles known as mesocycles. There are four meso-
The fascial system has been demonstrated to tighten as a cycles: the preparation phase, the first transition phase (pre-
protective response to repetitive microtrauma. Competing competition), the competition phase, and the second
and training for sport is nothing if not trauma. Comprehen- transition phase (active recovery). Each mesocycle has
sive massage and massage techniques used for a specific specific training components, and this regimen is used
part of the body is often part of an informed athlete’s train- to prevent staleness and injuries that can occur with
overtraining.
Training was initially phased within cycles to attain one
period of peak performance during the macrocycle of a year.
This concept has been adjusted in sports that require peak
performance several times throughout a year. Sports such
as cycling, tennis, football, and golf require the creation of
several macrocycles. The informed practitioner will ascer-
tain within which mesocycle the athlete is competi
ng
and adjust the massage therapy treatment dose (Figure
13-7).
The preparation phase emphasizes high-volume and low-
intensity strengthening with aerobic conditioning and
flexi-
bility. This is the beginning of a training macrocycle,
and
the athlete who has not been active will experience
signifi-
cant DOMS. Techniques described in the DOMS
section
presented earlier in the chapter are critical to keep
this
athlete injury-free and motivated to continue with
training.
Weekly full-body therapy intervention is benefic
Figure 13-6 ial at this
time. The first transition phase (precompetition)
Postcompetition massage entails more comprehensive treatmen is charac-
t. terized by strength training of moderate intensi
ty and
 MASSAGE IN SPORT CHAPTER 13

Moderate
volume
massage were compared with a group that received progres-
Moderate
\V Volume sive muscle relaxation. The treatment dosage was 20-minute
intensity
Flexibility
® Intensity sessions two times per week for 5 weeks. The massage
Aerobic Low intensity therapy group demonstrated statistically higher levels of
internals Competition Controlled rest
phase with variety serotonin and dopamine. This may explain in part the
improved mood reported by individuals who received
* Volume
\ Intensity massage therapy. Subjects within this group were also mea-
First Active
transition recovery
sured to have lower levels of anxiety. In a pretest/posttest
Preparation Preparation design, adults (N=26) were given chair massage and a
phase phase
control group of adults (N=24) were asked to relax in a
Figure 13-7 chair (Field et al., 1996). Findings demonstrated that the
The periodization cycle optimizes athletic performance throughout the massage group had de-creased levels of anxiety. Although
year. (Adapted from McArdle WD, Katch FI, Katch VL: Exercise physiology: this was not applied to athletes, the result does suggest that
energy, nutrition, and human performance, ed 5, Philadelphia Lippincott single does massage intervention can affect anxiety levels.
Williams & Wilkins.) Changes in hormonal levels as measured by cortisol levels
following massage induce a relaxation response and reduce
anxiety, and the adjustment of the mood state also causes
relaxation through psychological mechanisms (Weerapong
et al., 2005).
moderate resistance, as well as aerobic interval training with Cailliet (1997) maintained that pain is a sensory experi-
sprint activities interspersed by recovery. Sport-specific ence that is no longer considered to be proportional to the
drills are performed to prepare for competition. The massage degree oftissue damage. Furthermore, pain is influenced by
dosage remains similar to the first phase of this cycle with expectancy, anxiety, fear, attention, learning, and, of course,
flexibility being an important adjunct to treatment. The injury. Massage has been directly demonstrated to decrease
competition phase follows with emphasis on low-volume, pain, and this has been hypothesized to be part of the healing
high-intensity strengthening one to two times in the week process. However, a soft tissue intervention that can dimin-
of competition and interval training with sport-specific ish anxiety and promote alertness though invigorating
activities. The athlete should receive daily massage therapy techniques could diminish the perception of pain through
intervention if possible while in competition. The second the psychological pathways in addition to the physical
transition phase (active recovery) includes low-intensity pathways.
conditioning with recreational activities. Massage interven-
tion can be done three to four times per week, and if there
is an injury, it should be performed daily to promote healing.
Sport-specific activities are avoided until the beginning of Evidence Regarding Massage
the next first transition phase. The current evidence regarding massage therapy interven-
Applying massage therapy techniques and varying the tion is limited with a dearth of available data regarding the
dosage specific to the training cycle of an athlete is the dis- transfer to performance of the hypothesized effects. The
tinguishing feature of sports massage. This is the science available evidence is even more scant with regard to elite
applied to the art of the healing touch that constitutes excel- athletes. For example, there has been a reduction in systolic
lence among practitioners and enhances performance for the and diastolic blood pressure in individuals who received a
athlete. 15-minute massage therapy intervention in the workplace
(Cady & Jones, 1997). This has yet to be demonstrated
among elite athletes. Systematic reviews have attempted to
Psychological Effects That provide recommendations based on the current body of
Enhance Performance knowledge.
Everyone experiences stress. Elite athletes are no exception Deep friction massage, also known as cross-friction
to this fact (Anshel, 2000). One of the powerful effects massage to promote healing, initially proposed by Cyriax
of therapeutic massage for an athlete in competition is (1990), presents with varied reports regarding effectiveness.
relaxation and mental stress relief. Competitive state The systematic review by Brosseau et al. (2007) was unable
anxiety, which is a sense of threat induced by a competitive to validate the use or nonuse of DFM to enhance functional
situation, has been shown to be detrimental to performance outcomes with tendonitis because of the small sample size
of the randomized clinical trials. At this point in time,
(Anshel, 2000; Martens et al., 1990). Massage intervention
has the potential to affect anxiety levels among elite ath- therapists can choose to use DFM based on the varied
letes. In an investigation by Hernandez-Reif et al. (2001), success rate, clinical experience of success, and immediate,
two randomly assigned groups of adults who received short-term pain-relief characteristics reported by athletes.
icin BES PART TWO PRACTICE

More investigations with rigorous methods are needed for the therapist will be able to select the appropriate mass-
conclusive evidence. age treatment dose and technique to best enhance
A randomized clinical trial design by Preyde (2000) performance.
included subjects with a mean age of 46 years with subacute Certain caveats come to mind when dealing with elite
back pain. These subjects reported less intensity of pain and and recreational athletes based on the fact that these indi-
a decrease in the quality of pain when compared with groups viduals are used to pushing through pain. Many cyclists
that received soft tissue manipulation alone, remedial exer- train to “feel the burn” that comes with high-intensity train-
cise with postural education, or sham comprehensive ing and revel in the ability to remain in that painful zone
massage (control group). Similar findings have been dem- for long periods of time. This is not uncommon for athletes
onstrated with chronic low back pain. The conclusion drawn who are truly passionate about their sport and their training.
by the systematic review by Dryden et al. (2004) is that the This is why we watch and appreciate sport—because we see
current evidence supports the use of massage therapy for individuals reach deeply within to move beyond the physical
orthopedic patients with low back pain. Other patients may fatigue and pain to accomplish unbelievable feats. The ther-
experience pain that can be relieved with massage as an apist must remember this when applying treatment. An
adjunct to a full, comprehensive program. athlete may have a greater ability to ignore or overcome
These pain-reduction effects of massage therapy have physical pain that is being applied to the tissues by the
been long lasting. All of the systematic reviews regarding therapist. In applying massage techniques, the focus should
the physiological and psychological effects of massage be on the response of the athlete but also on the response of
emphasize the need to identify the mechanisms of action the tissue beneath the therapist’s fingers. This response
with massage and randomized controlled trials with rigor to should be gauged throughout the treatment. Inattention to
capture the definitive effect of massage therapy. It should be signals of pain or changes can prolong recovery because of
noted that elite athletes provide an excellent population on inadvertently induced trauma.
which to investigate the effects of massage on healing tissue Understanding the phases of tissue healing, the cycles of
but are an underinvestigated population because of lack of training, and the anatomy of the body is critical when apply-
access. This group requires the attention of the evidence- ing sports massage. Using deep friction massage on a newly
based practitioner. injured hamstring muscle that is in the inflammatory phase
of healing can cause localized edema, which adds days to
Caveats Specific to Elite Athletes healing. The application of ASTM to athletes who are in the
All sports massage should begin with a quick interview of competition phase of the periodization cycle could decrease
the athlete to determine his or her schedule for the day, their ability to change direction during their event later in
any existing injuries, the athlete’s current training regimen, the day. The knowledge that the pectoralis minor inserts at
and his or her next bout of activity. With this knowledge the coracoid process directs the therapist to release tension

Figure 13-8
A, Effective sports massage can include active ran ge-of-mo
tion techniques. B, Effective sports massage
can also include stretching techniques.
 MASSAGE IN SPORT CHAPTER 13%)

on this tendon when massage along the midsubstance of the Goats GC: Massage—The scientific bases of an ancient art:
pectoralis musculature is painful or does not decrease tissue techniques, Br J Sports Med 28(3):149-152, 1994a.
Goats GC: Massage—The scientific basis of an ancient art: part
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Physiological and therapeutic effects, Br J Sports Med 28(3):1k
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tissue mobilization with proprioceptive neuromuscular facilitation \
glenohumeral external rotation and overhead reach, J Orthop Sports
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delayed onset muscle soreness and muscle function following Paris S, Loubert P: Foundation of clinical orthopaedics, St Augustine,
Fla, 1999, Institute Press.
downhill walking, J Sci Med Sport 5(4):297-306, 2002.
Field, T, Ironson G, Scafidi F et al: Massage therapy reduces anxiety Pope A, Silverberg R, Johnson J et al: The effects of soft tissue
mobilization on the immature burn scar: results of a pilot study, J
and enhances EEG pattern of alertness and math computations, Intl J
Neurosci 86(3-4):197-205, 1996.
Burn Care Rehabil 17(3):252-259, 1996.
4 Preyde M: Effectiveness of massage therapy for subacute low-back pain:
Frulan AD, Brosseau L, Imamura M et al: Massage for low-back
pain, Cochrane Database Syst Rev 4:CD001929, 2002. a randomized controlled trial, CMAJ 162:1815-1820, 2000.
Galloway SD, Watt JM: Massage provision by physiotherapists at major Prochaska JO, Marcus BH: The transtheoretical model: application ot
exercise. In RK Dishman, editor: Advances in exercise adherence,
athletics events between 1987 and 1998, Br J Sports Med 38(2):235-
Champaign, Ill, 2001, Human Kinetics.
236, 2004.
1n Quinn C, Chandler C, Moraska A: Chronic tension headaches reduction
Gehlsen GM, Ganion LR, Helfst R: Fibroblast responses to variation
with the use of cross friction massage techniques, Am J Public
soft tissue mobilization pressure, Med Sci Sports Exerc 31(4):531-
Health 92(10):1657-1661, 2002.
oS by WEEE
 PART TWO PRACTICE

Robertson A, Watt JM, Galloway SD: Effects of leg massage on Stock D, Baum M, Rosskopf P et al: Electroencephalogram activity,
recovery from high intensity cycling exercise, Br J Sports Med catechyolamines, and lymphocyte subpopulations after resistance
38(2):173-176, 2004. exercise and during regeneration, Eur J Appl Physiol Occup Physiol,
Schoitz EH: Manipulation treatment of the spinal column from the 72(3):235-242, 1996.
medical-historical standpoint, J Norwegian Med Assoc 78:359-372, Swenson C, Sward L, Karlsson J: Cryotherapy in sports medicine,
1958. Scand J Med Sci Sports 6(4):193-200, 1996.
Smith LL, Keating MN, Holbert D et al: The effects of athletic massage Tidus PM, Shoemaker JK: Effleurage massage, muscle blood flow and
on delayed onset muscle soreness, creatine kinase, and neutrophil long-term post-exercise strength recovery, /nt J Sports Med 16:478-
count: a preliminary report, J Orthop Sports Phys Ther 19(2):93-99, 483, 1995.
1994, Weerapong PR, Hume PA, Kolt GS: The mechanisms of massage and
Stearns ML: Studies of the development of connective tissue in effects on performance, muscle recovery and injury prevention,
transparent chambers in the rabbit ear, Am J Anat 67:55-97, 1940. Sports Med 35(3):235-256, 2005.
 Massage for the Baby
and Infant

The use of various forms of soft tissue manipulation As an extension of this common practice, the use of
(massage) for babies and infants has been described and specific massage techniques for babies and infants is a well-
promoted for many centuries and in some Eastern cultures recognized method to promote bonding between the child
(India and China) for millennia. The use of various forms and the parent or caregiver. Massage has a beneficial effect
of tactile stimulation is therefore a time-honored method of on the development, alertness, and emotional status of the
promoting relaxation, contentment and normal development baby and can continue to any age. It strengthens the bonding
in babies and infants. Rocking the baby, gently rubbing the process and helps establish a warm, positive parent-child
head, stroking the hands and feet, and simply touching the relationship.
baby’s skin are examples common to many cultures. Massage is beneficial for all babies and infants, regard-
less of whether they have problems. In terms of an age dif-
ferential between babies and infants for massage, a baby is
usually considered to be a child less than 3 months old and
an infant is 3 to 12 months of age. Obviously, the major
difference between the use of massage in these two groups
is that the younger the baby, the greater the care required
(especially much less pressure). Benefits to both parents and
baby include pleasure, confidence, communication, relax-
ation, reassurance through skin contact, development of
body awareness, and calmness (Adamson, 1996; Agarwal et
al., 2000; Booth et al., 1985; Debelle, 1981; Field, 1995,
1999; Ireland, 2000; Lindrea & Stainton, 2000; Mainous,
2002; McClure, 1989, 2000; Ottenbacher et al., 1987; Reid,
2000; Wall, 1998; Watson, 1999). In addition, infant massage
may also be of value in improving the mother-infant interac-
tion for mothers with postnatal depression, thereby avoiding
the many problems that can result for both mother and child
(Onozawa, 2001) (Box 14-1).
Infants who undergo surgery can be included in this cate-
gory, as can the preterm baby. These babies need to learn that
touch can be pleasurable because some of their early experi-
ences (such as monitoring devices, various life support, and
other invasive procedures) have been painful or uncomfort-
able. A variety of studies provide evidence of the benefits of
massage for the preterm infant, such as improved weight
gain, fewer facial grimaces, less fist clenching, and enhanced

279
 BOX 14-1 Situations That Suggest the Benefits massaged may be covered with a light blanket or towel if
of Massage for a Baby or Infant necessary to maintain body temperature. Maintaining a
proper body temperature is important because the baby’s
* For a colicky baby who cries when being fed. Often the
entire skin surface may be exposed during massage.
| baby continues to be tense and irritable long after the |
cause of the colic has been identified and treated. For a very young baby, massage should begin with the
¢ For an anxious baby who dislikes rapid changes of baby positioned in supine lying on a soft pillow supported on
| position, does not need much sleep, and is hypersensi- | the lap of the parent, caregiver, or therapist. In this position,
tive to external stimuli. eye contact with the baby can be maintained while massage
|¢ For an irritable baby who exhibits abnormal neurologi- to the front of the body is completed. It is also important for
| cal signs, hyperactivity, and persistent primitive
the parent or therapist to talk in soothing tones to the baby
| reflexes.
during the procedure. An older baby or infant can be posi-
tioned on a soft pillow on a table, bed, sofa, or some other
suitable surface in such a way as to allow the person per-
development of the sympathetic nervous system (Browne,
forming the massage to be comfortable and maintain good
2000; Dieter et al., 2003; Feldman, 1998; Field et al., 1986,
posture. The baby or infant can be positioned in prone lying,
1987; Kuhn et al., 1991; Ottenbacher et al., 1987; Rice, 1975;
although the head will obviously need to be turned to one
Scafidi et al., 1993; Solkoff et al., 1975; White-Traut &
side. Again, this is probably most easily accomplished with
Goldman, 1988; White-Traut & Pate, 1987). Although many
the child lying on a soft but thick pillow.
studies report beneficial effects of massage in the preterm
Because the baby or infant will most likely want to move
infant, there are significant methodological issues that still
need to be resolved (Vickers et al., 2000). In contrast, babies around during the massage, it 1s important that each tech-
who are not particularly active can be stimulated, rather than nique be adapted to suit the individual circumstance. As
relaxed, with massage techniques that alternate light tickling such, the various massage techniques cannot be rigidly pre-
with gentle, firm pressure. scribed or applied to the baby, and this is especially the case
Massage has effects on babies and infants similar to with the timing of each stroke and the parts of the hand used
those on adults, and it is not surprising that it can be for these techniques. If the baby or infant is very small, the
helpful for a number of conditions, such as asthma (Field, person performing the massage may only need to use his or
1998), colic (Huhtala et al., 2000; Larson, 1990), and infan- her fingertips, whereas the anterior surface of the fingers and
tile congenital myogenic torticollis (Xu, 1992). Although palm may be used on a larger child. Quite obviously then,
massage is beneficial, it is not without risk, and a few studies
the size of the therapist’s hand and the child’s body will
affect the specific modification needed. Frequent pauses
have explored issues that might be a problem, especially for
the baby or infant (Joyce, 1996; White-Traut & Goldman, may be needed and will interrupt the usual flow of individ-
1988). ual massage strokes. In general, massage flows from head
Further reading can be found in a number of texts that to toe, covering all of the body, back and front. The tech-
address various aspects of the many benefits and techniques nique applied consists of a gentle modified stroking, and the
of baby or infant massage (Auckett, 1982; Drehobl, 2000: position is adapted to wherever the baby is most comfortable
Fan, 1999; Gordon & Adderly, 1999; Heinl, 1991; Leboyer, at any given time. If the baby or infant begins to cry or
1976a, 1976b; McClure, 1989; Prudence,
becomes distressed or agitated, massage should obviously
1984; Schneider,
1982; Tiquia, 1986; Walker, 1996). cease.

TECHNIQUE FOR BABY OR GENERAL WHOLE-BODY STROKING

INFANT MASSAGE
The baby or infant is comfortably positioned in supine lying.
Preparations for massage of a baby or infant include atten- Gentle stroking begins at the side of the head and passes
tion to all of the factors listed previously (see Chapter 3), down each upper limb to the hands. A second stroke begins
with special attention paid to creating a peaceful atmosphere again at the side of the head, this time passing down the
(no phones or loud noises, etc.). Soothing music may be chest and abdomen and along each lower limb to the feet.
beneficial, as well as subdued lighting, appropriate room Each stroke is slow and gentle, and the entire sequence of
temperature (no drafts), and the use of a natural massage movements can be repeated at least six times. The posterior
oil (e.g., almond, olive, or apricot). A small amount of baby aspect of the baby or infant can also be massaged in a
powder can be used as an alternative, being careful not to similar manner. This time, the baby or infant is positioned
pepper the baby with powder as this may create a problem in prone lying with the head comfortably turned to one side.
if the powder is inhaled. Although massage may be given at The first stroke begins at each shoulder girdle region, and
almost any time of the day or night, it will probably be most the therapist’s hands pass out and along the arms to the
effective when both parent and baby are relaxed and the hands. The therapist then lifts his or her hands off the baby,
baby is not hungry. A suitable time might be immediately and the second stroke begins again at the shoulder girdle.
following a warm bath. Parts of the baby or infant not being This time, the therapist’s hands move down the baby’s back,
 MASSAGE FOR THE BABY AND INFANT CHAPTER 14

over the buttocks, and along the lower limbs to the foot. The UPPER LIMBS
entire sequence of strokes is then repeated at least six times.
A single- or two-handed technique can be used, as seems With the child supported in the supine position, massage
appropriate. When a two-handed technique is used, the can begin with the therapist’s hands placed on the shoulder
therapist’s hands may be used in a simultaneous or alternate girdle of each upper limb, with the fingertips resting on each
fashion. Figure 14-1 illustrates these techniques. scapula region. The therapist then passes the hands across
the baby’s shoulders, rounding them forward, moving down
HEAD AND FACE the arms to the hands. The therapist’s hands should encircle
the baby’s arms and gently squeeze each arm from shoulder
The therapist strokes the crown of the baby’s head with his to wrist, then massage the baby’s hands and fingers using
or her thumbs using gentle, circular movements. Then, with gentle pressure applied between the tips of the therapist’s
the fingertips, the therapist strokes from the head down thumb and forefinger. Stroking the back of the hand with
along the side of the face, including the forehead, eyebrow, the thumb tends to encourage the fingers to open. Each
temple, eye, ear, nose, cheek, and lower jaw. A single- or stroke should finish by taking the hands off the body to
two-handed technique may be used. Figure 14-2 illustrates begin again at the shoulders. It is usual to massage both
stroking to the head and face. upper limbs at the same time, although a single limb can be

Figure 14-1 Stroking to the Whole Body

The baby (or infant) is comfortably positioned in supine lying. Gentle stroking begins at the side of the head
of the
and passes down each upper limb to the hands (A, B, and C). The next stroke begins at the side
along each lower limb to the feet (F, G,
head (D), this time passing down the chest, abdomen (E), and
H, and 1). The sequence of movements is then repeated at least six times. The entire sequence of strokes
L,
is then performed to the posterior aspect, with the baby or infant repositioned into prone lying (J, K,
with
and M). A single- or two-handed technique can be used, as seems appropriate. Movements are slow,
only light pressure.
PART TWO PRACTICE

Figure 14-1, cont’d

 MASSAGE FOR THE BABY AND INFANT CHAPTER 14

Figure 14-1, cont’d

massaged at a time if desired. Figure 14-3 illustrates strok- LOWER LIMBS

ing to the upper limbs and hands. With the child supported on a soft pillow in supine lying,
massage begins with the therapist’s hands placed on the
CHEST AND ABDOMEN sides of the hip (hip adductor muscles) of each lower limb
The anterior and lateral chest walls can be stroked using a (Figure 14-5, A). The hands then pass down the limb to the
two-handed technique, in which the finger pads stroke feet, finishing at the toes (Figure 14-5, B). The therapist’s
outward from the chest from the sternum, following the line hands should be removed at the toes and begin again at the
of the ribs to the side of the body. The strokes can be given hips. This stroke can be performed with one or two hands
alternately or simultaneously (Figure 14-4, A). Abdominal and should be repeated several times.
Beginning at the upper thigh, massage continues as the
discomfort may be helped by the use of circular, clockwise
therapist’s hands encircle the baby’s legs and gently squeeze
stroking, beginning around the umbilicus (Figure 14-4, B)
each area from hips to feet (Figure 14-5, C). The ankles,
and then following the course of the large intestine. The
feet, and toes can be massaged using gentle pressure applied
movements must be performed in a clockwise manner to
between the tips of the therapist’s thumbs and fingers. In
follow the normal direction of intestinal flow. Pressure
should be applied with the finger pads and may increase this case, the thumb pads should be used to massage
slightly as they move over the right side of the lower abdomen the muscle on the soles of the feet (Figure 14-5, D). Massage
(iliac region). Figure 14-4, C illustrates this technique. may be given simultaneously to each leg, or they can be
PART TWO PRACTICE

Figure 14-2 Stroking to the Head and Face

The baby (or infant) is comfortably positioned in supine. Gentle stroking is given
to the skin on the crown
of the head (A) and the forehead (B) using only gentle strokes, especially
to the very young baby. Stroking
then continues down the face, including around the eye and ear (C), the
cheek and nose region (D), and
then the lower jaw (E). A single- or two-handed technique can be used, as
seems appropriate. Movements
are slow, with only minimal pressure.
 MASSAGE FOR THE BABY AND INFANT CHAPTER 14

Figure 14-3 Massage to the Upper Limbs

The child is supported on a pillow in the supine position. Massage can begin with the therapist’s hand
placed on the shoulder girdle of either upper limb or both, with the fingertips resting on the scapular region
(A). The hand then passes from the shoulder and moves down the arm to the elbow (B), forearm, and
hand (C). The therapist’s hands should encircle the baby’s arms, gently squeeze each arm from shoulder
to wrist, and then massage the baby’s hands and fingers using gentle pressure applied between the tips
of the therapist’s thumb and forefinger (D). It is common to massage both upper limbs at the same time,
although the limbs can be massaged separately, especially if the child is restless.

treated individually. Each stroke should finish by taking at the buttocks (Figure 14-6, A). Once again, it may be pos-
the hands off the body to begin again at the upper sible for a therapist to use a single hand on a very small baby
thigh. Rubbing the soles of the feet together is usually pleas- or infant. The technique can be given using one or two hands
ant and calming for the baby. Depending on the size of the as seems most appropriate.
baby or infant’s limbs and the therapist’s hands, it may be A second stroke, resembling a gentle finger-pad kneading
necessary to reposition the baby into prone lying so that the technique, can be applied in a circular motion down either
side of the baby’s spine, from the neck to the buttocks
therapist can properly reach the posterior aspects of the
lower limb. In most cases, however, the hands of the person (Figure 14-6, B). As in whole-hand kneading to the back of
an adult, care is required in order to avoid pinching the
massaging the baby will be able to reach all the way around
the limbs, and it should not be necessary to change tissues together in the midline when using a two-handed
positions. technique. Because the tissues in a baby or infant are rela-
tively small in area, it may be best to perform the stroke
with only one hand at a time.
BACK
The baby or infant can be positioned in either prone or side BUTTOCKS
lying. In either position, the child’s head will need careful
support. Using flat hands, gentle stroking begins from the The mass of muscles that together form the buttock region
base of the neck, the hands moving down the back, finishing can be massaged with a gentle jiggling of the area. The open
 PART TWO PRACTICE

Figure 14-4 Massage to the Chest and Abdomen

The baby (or infant) is comfortably positioned on a soft pillow in supine lying. Gentle stroking
is given to
the anterior and lateral chest walls, using only gentle strokes, especially to the very young baby.
A, Stroking
begins with the fingertips together in the center of the sternum, moving down and outward,
following the
line of the ribs to the lateral chest wall. A single- or two-handed technique can be used,
as seems appropri-
ate. Movements are slow, using only light pressure. B, The fingertips stroke over the
abdomen with a
clockwise motion beginning at the umbilicus. Pressure is light but may increase slightly
over the right illiac
region (C).

fingers are simply placed on the buttock, and a jiggling SUMMARY

(coarse vibration) is imparted to the tissues. The buttocks
can also be massaged using a modified squeeze kneading Close body contact can be provided through activities other
technique, using the fingers and thumb pads. Care must be than massage, such as breast-feeding, bottle-feeding with
used to avoid pinching the buttocks. Figure 14-7 illustrates the baby cuddled against the bare chest, a cuddle in bed with
these techniques. parent(s), carrying in a front pack, and having a bath
with
parent(s). All of these activities will help to foster close
SUCKLING bonding between the baby and parent(s) and provide
a
strong basis for the emotional and physical development
Stimulating the rooting reflex causes the baby to open the of
the child. Obviously, these activities are necessarily
mouth and nuzzle, searching for the nipple. This may be limited
to certain individuals, whereas massage can be given
achieved by gently stroking from the cheek to the mouth. by a
variety of people, including parents, siblings,
Such gentle touch may help a baby who is having difficulty relatives,
Caregivers, and many types of health care professi
suckling. onals.
Apart from the desirable emotional (psychological)
benefits
 D
Figure 14-5 Massage to the Lower Limbs
A, Massage to the lower limbs begins with the therapist's hands at the sides of each hip with the thumbs
placed medially. The hands then stroke down the limb (B) to the feet, finishing at the toes with gentle
pressure. During the stroke, the hands reach around the entire surface of each limb, but the hands should
be removed at the toes to begin again at the hips. This stroke can be performed with one or two hands
and should be repeated several times. Beginning again at the upper thigh, massage continues as the ther-
apist’s hands encircle the baby’s legs (C), gently squeezing each area from hips to feet. The ankles, feet,
and toes are massaged using gentle pressure applied between the tips of the therapist’s thumbs and fingers.
D, The thumb pads are also used to massage the muscle on the soles of the feet.

B
Figure 14-6 Massage to the Back
to either
The baby (or infant) is comfortably positioned in prone or side lying. A, Gentle stroking is given
surfaces of the fingers, using only gentle strokes, especially
side of the spine with flat hands or the palmar
type
to the very young baby. The strokes proceed from the base of the neck to the buttocks. A modified
kneading is performed to the tissues on either side of the spine, again beginning at the neck
of finger-pad
using either
and moving to the buttocks. B, Gentle circular movements are performed with the fingertips,
a single- or two-handed technique as seems appropriate .
 PART TWO PRACTICE

B
Figure 14-7 Massage to the Buttock Region
A, The baby (or infant) is comfortably positioned in prone lying on a soft pillow. The open finger pads are
placed on the buttock region, and a gentle jiggling (vibration) is imparted to the muscles. This can be a
single- or two-handed technique. B, Modified squeeze kneading can also be performed to each buttock.
The thumb and finger pads gently squeeze the skin and underlying tissues, slowly covering each buttock
area.

of massage to both the child and the person performing the Feldman A: Intervention programs for premature infants: how and do
Strokes, it is important to remember that these techniques they affect development? Clin Perinatol 25(3):613-626, 1998.
Field T: Massage therapy for infants and children, J Dev Behav Pediatr
have all of the other direct mechanical and physiological
16(2):105-111, 1995.
benefits described previously (see Chapter 5). All aspects of Field T: Children with asthma have improved pulmonary functions after
so-called normal child development will be facilitated by massage therapy, J Pediatr 132(5):854-858, 1998.
effective massage, and the sensitive parent, caregiver, or Field T: Massage therapy: more than a laying on of hands, Contemp
Pediatr 16(5):77-78, 1999.
therapist will be able to identify, at an early stage, any
Field T, Scafidi S, Scafidi F et al: Tactile/kinesthetic stimulation effects
abnormality in the child’s anticipated motor abilities. For on preterm neonates, Pediatrics 77:654-658, 1986.
these reasons, massage to the baby and infant is an excellent Field T, Scafidi F, Schanberg S: Massage of preterm newborns to
way to promote the physical and psychological development improve growth and development, Pediatr Nurs 13(6):385-387, 1987.
Gordon J, Adderly B: Brighter baby: boosting your child’s intelligence,
of the child. health and happiness through infant therapeutic massage, New York,
1999, Regnery.
Heinl T: The baby massage book: shared growth through the hands,
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Agarwal K, Gupta A, Pushkarna R et al: Effects of massage and use of Ireland A: Massage therapy and therapeutic touch in children: state of
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Auckett A: Baby massage: Parent-child bonding through touching, BMJ 313(7052):299, 1996.
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Dieter J, Field T, Hernandez-Reif M et al: Stable preterm infants gain c
torticollis, J Trad Chinese Med 12(3):202-203, 1992.
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Ottenbacher K, Muller L, Brandt D et al: The effectiveness of tactile Walker P: Baby massage: a practical guide to massage and
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 Massage in Palliative Care

The term palliative care is usually described as the use of day, the available medical options for treatment were greatly
various procedures designed to relieve anxiety and suffer- limited; however, it can be argued that the simple care of
ing, without treating the direct cause of the problem, on a the dying patient was much more personal. This is partly
person who is terminally ill. In many cases, the person who because so few medical options were available and when
is terminally ill will also be elderly, but of course, terminal nothing further could be done, there was little choice for
illness can and does affect individuals of all ages. This the patient and his or her relatives. In addition, the com-
chapter will consider the contribution that massage can mon practice was for elderly relatives to live with their
make as a palliative treatment, especially to the quality of own family members. Indeed, today it is still the custom
life for the elderly person who is terminally ill. in many parts of the world for the eldest son in a family
to have the first responsibility for taking care of
ANCIENT VERSUS MODERN his elderly parents. In this way, several generations of
CARE
OF THE DYING family members live in the same household. Because life-
threatening childhood and adult diseases were rampant, it
It seems obvious that health care in the developed world is was not uncommon for a child to experience the death of
radically different in the twenty-first compared to the first one or more siblings or parents. In these circumstances,
century. In ancient times, the patient was certainly the center children grew up with direct personal experience of caring
of attention, and there was little technology and few invasive for a relative who was dying.
procedures. Health care of the day relied on natural remedies In many parts of the industrialized world, there is a
of all kinds, especially on medicines derived from plant and growing tendency for elderly relatives to live alone or with
animal sources, and massage, in all its ancient forms, was a their spouse until they are at the stage where they can no
widely used and well-respected treatment. In contrast, longer take care of themselves, at which point they are
modern health care has become high tech and in many cases admitted to various levels of nursing home care. As the end
depersonalizing for the patient and his or her family members. of a normal life span approaches, illnesses of various kinds
It is often conducted in noisy, busy, and confusing circum- are unfortunately very common. At this time, modern
stances, and this has special importance for those patients medical and surgical procedures can be highly invasive,
who are terminally ill and approaching the end of life. painful, uncomfortable, and a source of great anxiety for the
A century ago, whether as the result of trauma, disease, patient and his or her relatives. In these situations, massage
or old age, it was common for a person to die at home sur- treatment can be especially helpful in easing the suffering
rounded by family and loved ones. Typically the atmosphere of the dying patient and in promoting a caring communica-
was quiet, calm, and respectful. Family members them- tion between health care providers, relatives, and the
selves cared for the dying relative directly. Physicians of the patient.
Thus, the caring bond that develops has effects similar
day attended patients in their home for those able to afford to
the massage given to a baby or infant (see Chapter 14).
their services, and often pro bono for those who could not. In
this way, massage has a special role to play at both
When required, physicians had powerful narcotics at their the
beginning and end of life, and, of course, at all times
disposal to relieve patient suffering. Compared to the present in
between.
 MASSAGE IN PALLIATIVE CARE CHAPTER 15 suimeiaiiias

Increasing medical mechanization and pharmacological otherwise healthy, these are the only reservations to be
advances can contribute to a dehumanizing patient experi- considered; otherwise, any of the techniques previously
ence. The isolation and lack of physical contact perceived described are suitable. However, some modifications of
by many patients has encouraged a search for ways to these techniques will be needed for the elderly patient who
provide closer human contact, such as therapeutic touch and is terminally ill.
a renewed interest in massage. A wide variety of health care The importance of touch as a means of communication,
practitioners, with varying levels of training, use massage to impart a sense of well-being and confidence, should not
in providing care for their patients. For patients of all ages, be ignored or underestimated. The average person has
the judicious use of massage can ameliorate the discomfort approximately 18,000 cm/ of skin, a sensitive area for touch,
of invasive techniques and provide a sense of reassurance and, of course, the skin is the largest organ of the body. It
and caring. has millions of nerve endings, and stimulating them can be
A variety of studies have shown massage to be an effec- a potent way of accessing the wider nervous system. This
tive treatment in the palliative care of the dying (Billhult & might induce autonomic reflexes, which in turn can account
Dahlberg, 2001; Birk et al., 2000; Burke et al., 1994; Evans, for many of the observed physiological effects of massage
1995; MacDonald, 1997; Simpson, 1991; Stevensen, 1995; (Labyak & Metzger, 1997; Skull, 1945; see also Chapter 5).
White, 1988; Wilkinson, 1996). In particular, massage has Massage creates pleasant sensations (in most cases) that can
been shown to be an effective adjunct for the management have a soothing or stimulating effect, promotes increased
of the anxiety and pain of terminal illness, especially that flexibility and elasticity in the skin and underlying tissues,
caused by cancer (Ahles et al., 1999; Grealish et al., 2000; and improves interactions between patient and therapist
McCaffery & Wolff, 1992; Pan et al., 2000; Simpson, 1991; (Montague, 1978; Pratt & Mason, 1981). Hippocrates (ca.
Weinrich, 1990; Wilkie et al., 2000; Wolff, 1992). 460-375 Bc) wrote of mobilizing the body’s natural recu-
Another technique that appears to be helpful in palliative perative powers (White, 1988).
care is the so-called therapeutic touch. As mentioned in Touching another person can have powerful effects on
Chapter 1, this concept is somewhat controversial. Although both parties. Touch can communicate an intention—in the
the name implies a touching technique, the original concept case of therapeutic touch and massage—to heal, recruit,
of therapeutic touch does not require the therapist to physi- balance, or share inherent energy or promote relaxation
cally touch the patient. The therapist’s hands move over the (Krieger, 1979; Regan & Shapiro, 1988). An increase in
part to be treated without making physical contact. Obvi- hemoglobin has been reported (Krieger, 1973, 1976;
ously then, the technique cannot have any direct mechanical Pemberton, 1945), as has the release of acetylcholine and
histamine (as well as histamine-like substances; Skull,
effect on the tissues. This does not mean that the technique
has no benefit: it simply means that it cannot be explained 1945). Furthermore, Siegel (1986) believed that it is possible
to activate the body’s immune system through loving,
by the accepted mechanical and physiological mechanisms.
In fact, the original technique claimed to balance energy healing touch and self-healing.
fields around the affected parts (Feltham, 1991; Krieger,
1973, 1979, 1981). Obviously, any technique for which the TECHNIQUES
therapist does not have to physically touch the patient is
potentially useful, especially for the patient who is hyper- The massage techniques that can be used for the frail-elderly
sensitive. However, it would be incorrect to describe this and terminally ill person include effleurage, stroking, and
technique as a form of massage. light kneading. The patient may not be able to be comfort-
ably positioned in the more usual positions adopted for
massage treatments (see Chapters 4, 7, and 8). Therefore the
therapist must be able to adapt his or her technique to the
MASSAGE TECHNIQUES FOR particular needs of the patient. This also applies to individ-
THE ELDERLY PATIENT WHO IS ual techniques, as these may have to be modified if the
TERMINALLY ILL patient cannot tolerate the more usual techniques. Often the
most valuable technique may be one that involves pressure,
Massage can be particularly useful for reducing anxiety,
as in stationary kneading or squeeze kneading. In some
promoting relaxation, and relieving pain, not only for
cases, a modified shiatsu or acupressure technique (see
patients suffering from a wide range of musculoskeletal and
Chapter 17) might effectively relieve symptoms (Stevensen,
neurological problems (Doehring, 1989; Furlan et al., 2000;
person 1995). The usual rate, rhythm, pressure, timing, and other
Hayes, 1999; Kim et al., 2001) but also for the elderly
features of each stroke may need to be modified to suit the
who is terminally ill. Of course, not all terminally ill patients
particular patient. For example, stroking performed at the
are elderly. Regardless of age, however, the constantly
usual speed may be uncomfortable, but it may be quite
changing needs of the patient must be considered at all
n effective when performed at a slow rate and slightly deeper
times. An individual’s tolerance, age, and skin conditio
account pressure. The therapist will need to experiment to determine
(dryness, tightness, fragility) must be taken into
1s the most effective techniques for an individual patient.
when massage is performed. For the elderly person who
 PART TWO PRACTICE

Effleurage, stroking, and light kneading can be applied, REFERENCES

as needed, to body parts where symptoms are present. For
example, if the patient has significant leg pain, massage can Ahles TA, Tope DM, Pinkson B et al: Massage therapy for patients
undergoing autologous bone marrow transplantation, J Pain Symptom
be directed to the affected areas. If, however, the patient Manage 18(3):157-163, 1999.
cannot tolerate the sensation of the therapist’s hand moving Billhult A, Dahlberg K: A meaningful relief from suffering: experiences
on his or her skin, an alternative technique will be needed. of massage in cancer care, Cancer Nurs 24(3):180-184, 2001.
Attention to the feet, hands, and face may be all that is Birk TJ, McGrady A, MacArthur RD et al: The effects of massage
therapy alone and in combination with other complementary therapies
acceptable or needed. Indeed, those who are hypersensitive on immune system measures and quality of life in human immunodefi-
and cannot tolerate even the lightest brush of a bed sheet on ciency virus, J Altern Complement Medicine 6(5):405-414, 2000.
their skin may often be physically and emotionally com- Burke C, Macnish S, Saunders J et al: The development of a massage
forted by gentle pressure to the face and scalp. Reflexology service for cancer patients, Clin Oncol 6:381-385, 1994.
Dobbs BZ: Alternative health approaches, Nurs Mirror 160(9):41-42,
(see Chapter 16) techniques may be particularly well suited 1985.
for this purpose because they can be performed on the palm Doehring K: Relieving pain through touch, Advanc Clin Care 4(5):
of the hand, the sole of the foot, and the ear. These tech- 32-33, 1989.
niques have been used to good effect for patients who have Evans B: Nursing: an audit into the effects of aromatherapy massage
and the cancer patient in palliative and terminal care, Complement
terminal cancer (Stephenson et al., 2000). Ther Med 3(4):239-241, 1995.
Terminally ill patients have specific needs: Feltham E: Therapeutic touch and massage, Nurs Standard 5(45):26-28,
1. Pain control. Pain may be preventing sleep, restricting 1991.
eating, or interfering with communication. Furlan AD, Brosseau L, Welch V et al: Massage for low back pain,
Cochrane Database Syst Rev [computer file](4): CD001929, 2000.
2. Material comfort. Comfort can be provided by a bed or Graham D: Massage, manual treatment, remedial movements: history,
chair, privacy, and physical attention from caregivers. mode of application and effects, indications and contraindications,
3. Psychological comfort. This need includes the respect Philadelphia, 1913, JB Lippincott.
for personal dignity that comes from attentive Grealish L, Lomasney A, Whiteman B: Foot massage: a nursing
intervention to modify the distressing symptoms of pain and nausea in
caregivers who provide appropriate information, the patients hospitalized with cancer, Cancer Nurs 23(3):237-243, 2000.
presence of loved ones, physical contact, and the Hayes J: Immediate effects of a five-minute massage on patients in
opportunity to express feelings. critical care, Intensive Crit Care Nursing 15(2):77-82, 1999.
Kim MS, Cho KS, Woo H et al: Effects of hand massage on anxiety in
Principles of reflexology have the potential to address
cataract surgery using local anesthesia, J Cataract Refract Surg
these needs. A practitioner—a family member, friend, or 27(6):884-890, 2001.
caregiver—can provide physical contact in a private place, Krieger D: The relationship of touch with intent to help or heal, studies
with the patient in a preferred position in bed or in a chair. of in-vivo haemoglobin values, In Proceedings of the American
Nurses Association Ninth Nursing Research Conference, Kansas
As the section on reflexology explains (see Chapter 16), the
City, 1973, American Nurses Association.
relaxing and pain-relieving effects are achieved through Krieger D: Nursing research for a new age, Nurs Times 72:1-7, 1976.
stimulation of autonomic reflexes and improved circula- Krieger D: Therapeutic touch: how to use your hands to help or to
tion, both physiologically and functionally, as in the flow heal, Englewood Cliffs, NJ, 1979, Prentice Hall.
Labyak SE, Metzger BL: The effects of effleurage backrub on the
of energy (Dobbs, 1985). Further reading on the topic of
physiological components of relaxation: a meta-analysis, Nurs Res
massage in palliative care can be found in Graham (1913), 46(1):59-62, 1997.
Krieger (1979), Levine (1982), Montague (1978), Pemberton Levine S: Who dies? Garden City, NY, 1982, Anchor/Doubleday.
(1945), Pratt and Mason (1981), Regan and Shapiro (1988), MacDonald G: Massage as an alternative respite intervention for
primary caregivers of the terminally ill, Altern Ther Clini Pract
and Siegel (1986).
4(3):86-89, 1997.
McCaffery M, Wolff M: Pain relief using cutaneous modalities
,
positioning, and movement, Hosp J 8(1/2):121-153, 1992.
Montague A: Touching, Toronto, 1978, Harper & Row.
SUMMARY Pan CX, Morrison RS, Ness J et al: Complementary and
alternative
medicine in the management of pain, dyspnea, and nausea
The willingness, tolerance, and needs of frail-elderly and and
vomiting near the end of life: a systematic review, J Pain
Symptom
dying persons should always guide the application of Manage 20(5):374-387, 2000.
massage. The use of massage in palliative care is growing Pemberton R: Physiology of massage. In AMA Handboo
k of physical
medicine, ed 3, Chicago, 1939, American Medical Associat
rapidly and can be performed by many different health care ion.
Pratt JW, Mason A: The caring touch, London, 1981, Heyden.
professionals, as well as by the patient’s relatives and friends. Regan G, Shapiro D: The power of touch. In The healer’s
handbook,
The basic techniques can easily be adapted and taught to New York, 1988, Element Books.
family members and caregivers. No less important than the Siegel BS: Love, medicine & miracles, New York, 1986,
Harper & Row.
Simpson J: Massage: positive strokes in palliative care,
technical skill of the hands is the caring intention of the NZ Nurs J
84(6):15-17, 1991.
person performing the massage. Although modern medical Skull CW: Massage: physiologic basis, Arch Phys Med
261:159-167,
science has much to commend it, there is no real substitute 1945.
for the loving touch of a human being who genuinely cares Stephenson NL, Weinrich SP, Tavakoli AS: The effects
of foot
reflexology on anxiety and pain patients with breast
about the suffering of a dying person. Oncol Nurs Forum 27(1):67-72, 2000.
and lung cancer,
 MASSAGE IN PALLIATIVE CARE CHAPTER 15

Stevensen C: The role of shiatsu in palliative care, Complement Ther pilot study of a randomized clinical trial conducted within hospice
Nurs Midwifery 1(2):51-58, 1995. care delivery, Hosp J 15(3):31-53, 2000.
Weinrich MW: The effect of massage on pain in cancer patients, Appl Wilkinson S: Palliative care: “get the massage,” Nurs Times 92(34):
Nurs Res 3(4):140-145, 1990. 61-64, 1996.
White JA: Touching with intent: therapeutic massage, Holistic Nurs Wolff M: Pain relief using cutaneous modalities, positioning, and
Pract 2(3):63-67, 1988. movement, Hosp J: Physical 8(1/2):121-153, 1992.
Wilkie DJ, Kampbell J, Cutshall S et al: Effects of massage on pain
intensity, analgesics and quality of life in patients with cancer pain: a
 i?
soft Tissue Manipulation
in Complementary/
Alternative Medicine
Modern health care practice has begun to embrace the sure, shiatsu, myofascial release, and rolfing structural
concept of complementary/alternative medicine (CAM) as integration.
an important approach for treating illness and promoting The body therapies, as many of the complementary tech-
health and wellness. Other terms that encompass similar niques are called, encompass a wide range of both ancient
ideas are holistic medicine and integrative medicine. Since and modern treatment concepts, including, but not limited
the 1980s, there has been a growing acceptance of the effi- to, the following:
cacy of CAM as an alternative to orthodox medical practice. * Acupressure
Many of the treatment concepts that fall into the category ¢ Acupuncture
of CAM have their origins in traditional Eastern medicine. * Alexander techniques
Systems of care such as acupuncture and acupressure are Applied kinesiology
good examples. In contrast, some more modern concepts * Biodynamic massage
also fit into this category. These techniques include myofas- Chiropractic
cial release and rolfing structural integration. This chapter * Craniosacral therapy
briefly considers several treatment concepts that are good * Deep muscle therapy
examples of both ancient and modern specialized systems ¢ Feldenkrais
of soft tissue manipulation. They are sometimes referred to * Hellerwork
as bodywork systems (McPartland & Miller, 1999: Oschman, * Huna techniques
1997): * Integrated psychophysical balancing
Further evidence of the growing interest in CAM can be * Integrative neuromuscular therapy (NMT)
seen in the increasing support from many national research * Internal organ chi massage (Chi Nei Tsang)
granting agencies. Many of these organizations have been * Lomi massage (various systems)
promoting vigorous research into the efficacy and use of * Muscle energy techniques
techniques such as acupuncture, acupressure, shiatsu, * Myofascial release
reflexology, herbal medicine, moxibustion, and homeopathy * Neuromuscular release or technique
(Vickers, 1995). Surveys of Western medical practitioners
* Orthobionamy
in the Netherlands, Great Britain, New Zealand, the United
Osteopathy
States, and Canada have highlighted a growing interest in
Pilates method
and willingness to accept CAM (Carpenter & Neal, 2005 ; * Point percussion therapy
Eisenberg et al., 1993; Hadley, 1988; Lynoe & Svensson,
* Polarity therapy
1992; Micozzi, 1996: Verhoef & Sutherland, 1995; Wharton
* Postural integration
& Lewith, 1986). This is particularly the case in the man-
Reflexology
agement of chronic pain and musculoskeletal dysfunction
Reiki
(Sarac & Gur, 2006). The most widely used techniques are
Rolfing structural integration
those that appear to be more efficacious, such as acupunc-
* Shiatsu
ture, the deep pressure and stretching employed in acupres-
* Therapeutic touch
 SOFT TISSUE MANIPULATION IN COMPLEMENTARY/ALTERNATIVE MEDICINE CHAPTER 16

¢ Tragerwork A key principle in many of the treatment concepts listed

¢ Trigger point techniques earlier is the idea of balancing various body systems.
* Zone therapy Although this notion has its roots in ancient Chinese phi-
Although a detailed discussion of all of these methods is losophy, it has an important modern-day equivalent. Here
well beyond the scope of this book, a number of these tech- the emphasis is placed on the proper integration of body
niques are briefly explored here, especially those in which systems, both within a system and from one system to
soft tissue manipulation is an important part of the treatment another. For example, this concept has well-known parallels
concept. These techniques include myofascial release, in the proper regulation of autonomic functions. In this case,
reflexology, trigger point massage, rolfing structural integra- the proper balance of sympathetic and parasympathetic
tion, and a brief discussion of the lesser-known techniques activity results in the efficient functioning of the digestive
of point percussion therapy and craniosacral therapy. system (balancing within the system). This in turn contrib-
Chapter 17 reviews some more ancient systems of massage, utes to the proper functioning of the whole body, leading to
especially those with an Eastern heritage. These include wellness, and a well body is less prone to disease and
acupressure, shiatsu, traditional Oriental massage, and Huna dysfunction.
(Hawaiian) massage. Many of the complementary/alternative therapies incor-
The proliferation of complementary/alternative practitio- porate soft tissue manipulation techniques (massage) as a
ners, both within and outside of the established health care major part of their practice (Westland, 1996), especially to
systems, is evidence of dissatisfaction with the orthodox counterbalance the negative effects of gravity on the body.
medical approach. In general, modern (orthodox) medicine The ever-present force of gravity coupled with aging and a
has focused on treating illness rather than promoting well- stressful modern lifestyle place a significant burden on the
ness and preventing disease. In contrast, much of the focus musculoskeletal system in just about everyone. Muscles,
of CAM is directed toward promoting wellness and prevent- tendons, fascia, joint capsules, and ligaments often become
ing disease, without the use of drugs or surgery (Fritz, 2004; tight (shortened), resulting in postural malalignment and
Jahnke, 1985) and detoxification (Cassar, 1999). Although movement dysfunction. The net result is often chronic pain
these techniques are popular, they are not without risk. and a host of other physical and psychological symptoms.
Many of the complementary/alternative techniques produce In contrast, many ofthese issues can be significantly reduced,
their beneficial outcomes by invoking a reflex autonomic if not eliminated, by restoring the correct structural integ-
effect. It is important to note that when autonomic responses rity (valance) to the affected body system(s). This concept
are elicited—for example, with connective tissue massage will be a familiar theme in many of the treatment systems
(CTM), acupressure, shiatsu, reflexology, trigger point, and described in this chapter and Chapter 17.
myofascial techniques—problems can arise. Although most
techniques are perfectly safe, contraindications need to be
taken seriously. These may include pregnancy, serious car- MYOFASCIAL RELEASE TECHNIQUES
diopulmonary conditions, and psychological problems such
as panic disorder. The safe and effective practice of any of Myofascial release is a relatively new concept in the larger
the complementary/alternative therapies requires proper picture of Western medical thought; however, techniques
training and certification where appropriate. similar to it can be found in classical Eastern health and
A large and varied group of individuals practices the medical writings. As its name suggests, the techniques of
bodywork therapies. Many of them are established health myofascial release refer to a specialized system of prolonged
care professionals, such as physicians, nurses, physical and manual stretching of the fascial tissues of the body, to the
occupational therapists, and many others. These profession- point where there is a release of tension. This release of
als have incorporated complementary/alternative techniques tension is felt by the therapist and implies a slight lengthen-
ing of the fascial tissues (J.F. Barnes, 1997; M.F. Barnes,
into their daily practice in an effort to broaden the treatment
1997a: M.F. Barnes, 1997b). It should be emphasized that
options available for their patients. In other cases, the prac-
the stretching technique is a subtle one. Tension is applied
titioner may simply specialize in one type of treatment
slowly and gently and is released in a similar manner. There
(e.g., reflexology). In all situations, it is in the patient’s best
is some evidence to suggest that fascia may have an ability
interest to carefully research and discuss all of the potential
to contract in a way similar to smooth muscle, and, if so, it
treatment options available. Once a particular treatment
may have the ability to relax and thereby lengthen (Schleip
option has been determined, choosing a well-qualified and
et al., 2005).
appropriately certified therapist becomes extremely impor-
to Fascia is a much-neglected tissue of the body, often being
tant. One need only search the Internet for a short time
of compleme ntary/al ternativ e thought of as simply a connective tissue scaffolding associ-
realize the enormous number
ated with muscles and tendons. In fact, it is an extremely
therapies being advertised. More importantly, there are very
on important whole-body network, on a par with the vascular
few regulations governing the content or claims made
ng claims and incorrect or nervous system. Fascial tissue does indeed provide a scaf-
some of these web sites. Misleadi
fold-like net to every type of tissue in the body, even down
information are unfortunately quite common.
 PART TWO PRACTICE

to the extracellular level. As such, the fascial system con- Technique

nects all parts of the body together with a continuous web The patient is comfortably positioned and well supported so
of tissue. There is a tradition of describing different body that he or she is able to relax as much as possible. Typically,
systems in a particular order. For example, there is a ten- the patient will be in prone or supine lying on a treatment
dency to think of the bony skeleton as the foundation of the table. Once the therapist has identified the areas to be treated
body, with all the other structures attached to it or contained (from the assessment), his or her hands are gently but firmly
by it. Alternatively, bones can be rightly considered as rigid placed on the skin surface. Once the hands are in the proper
spacers entrapped in a fascial net. One might imagine a position, no‘movement occurs between the therapist’s hands
classic circus tent, where the canvas material and rigging and the underlying skin. For this reason, it is important for
are held up by the giant wooden masts. Without the tent both the patient’s skin and the therapist’s skin to be clean
poles, the material of the tent has no defined shape and will and dry. No lubricant should be used.
not function properly on its own. A wide variety of specific techniques can be used,
Fascia is a type ofconnective tissue that has three layers: depending on the body part to be treated. For example, on
superficial, potential space, and deep. It has important bio- the posterior trunk, the therapist’s hands can be placed flat
mechanical properties and greatly assists in maintaining on the patient’s back, whereas on the limbs, the therapist’s
muscle force. The interconnectedness of the fascial system hands may lightly grasp around the patient’s tissues. Figure
throughout the body is extremely important, because many 16-1 illustrates these two different types of hand positions.
acute and chronic musculoskeletal problems have their There are, of course, many variations, depending on the
origins in this tissue. Excessive strain, poor ergonomic envi- areas to be treated.
ronments, trauma, and abnormal postural alignment are In Figure 16-1, A, the therapist gradually applies pressure
among the common causes of strain of the fascial system. to the patient’s skin and underlying tissues while simultane-
This strain leads to a type of contracture (tightness), which ously stretching them apart. The therapist achieves this result
in turn causes pain and restricted movements. In fact, a host by pushing his or her hands apart in opposite directions. The
of symptoms can be caused in many different body parts as therapist’s right hand pushes toward the patient’s right hip
the long-term result of restricted fascial movement. Whereas while the therapist’s left hand applies pressure toward the
a fasciotomy to release tight fascia can result in a 15% loss patient’s left shoulder. Good body mechanics are essential
of muscle strength, myofascial release techniques reduce during this technique, especially because it can take several
constriction and pain without compromising muscle strength minutes to complete. Wherever possible, the therapist should
(Manheim, 2001). Symptomatic relief of the pain produced use his or her own body weight to provide the pressure
by this situation obviously will not cure the underlying tight- needed during the technique. As the tissues are stretched,
ness somewhere in the fascia. A treatment technique that is some movement (lengthening) will occur, but eventually, a
directly applied to the fascia is likely to be more effective block to further stretching will be felt. At this point, pressure
at producing a long-term solution. For example, myofascial is maintained for as long as it takes for the tissues to release
release techniques, in conjunction with trigger point stimu- the tension. The therapist will feel this release of tension as
lation, can be extremely important to the long-term success the resistance to the stretching gives. This can typically take
of therapy because the fascia tightens and shortens with anywhere from 90 to 120 seconds to happen, although some-
inflammation (as the potential space swells), heals slowly times it will occur sooner. As the tissue tension is released,
(because ofapoor blood supply), and is a pain focus (because the therapist’s hands remain in the same position but con-
of its abundant nerve supply). tinue to apply a stretching tension at the new tissue length. In
this manner, the tissues are stretched out as the therapist
follows the releasing of the tissues. It may take several appli-
Assessment
cations of tension to chase the tight areas of fascia in
Myofascial release techniques cannot be effective unless the
tissues. Once again, it must be emphasized that the technique
they are applied following a detailed assessment of the is a subtle one. Pressure is gentle but firm. The therapist’s
patient. In addition to the more usual multisystem examina- hands are feeling their way into the tight areas.
tion of the patient, a detailed assessment of the myofascial Figure 16-1, B, illustrates a different technique. In
system is required. Visual assessment of the patient’s posture this
case, a gentle traction force is applied to the entire
is essential in order to identify the areas where the fascial upper
limb. As the limb elongates in a telescopic-like manner
system is tight. This can be seen as postural asymmetry, , a
block to further movement is felt, at which point the
sometimes obvious and at other times subtle. This cannot tension
is maintained until the tissues release. Further
be done properly unless the patient is suitably undressed so tension is
applied at the new length. Once again, this
that the surface features are clearly visible. These findings process is
repeated several times until a more normal tissue
can be confirmed by palpation later in the procedure. length has
been achieved.
Although a certain degree of postural asymmetry is normal,
Myofascial release is a specialized technique,
it is important to recognize when it is associated with the requiring
proper training and experience. As with many
patient’s symptoms and when it is not. other forms
of soft tissue manipulation, it does not replace
other reha-
 SOFT TISSUE MANIPULATION IN COMPLEMENTARY/ALTERNATIVE MEDICINE CHAPTER 16 sinieisiioaids

Figure 16-1 Two Different Myofascial Release Techniques

A, The therapist’s hands are placed flat on the patient’s lower back. The therapist’s arms are crossed so
that a stretching effect can be given to the underlying tissues. B, The patient’s wrist is lightly grasped with
the upper limb in external rotation and elbow in full extension. Gentle traction is applied to the whole limb
to produce a sustained lengthening effect.

bilitation procedures, but rather it compliments them in an by acupuncture, acupressure, ice massage, and trigger point
important way. Myofascial release allows the tissues to stimulation. This hyperstimulation analgesia is one of the
return to their normal physiological state (or close to it) so oldest recorded remedies and should become a useful tech-
that other techniques, such as therapeutic exercise and nique for relieving pain of musculoskeletal lesions, espe-
manual mobilization, can be maximally effective. Manheim cially when chronic conditions have affected posture, gait,
(2001) has provided postural assessment methods and a and other activities (Ehrett, 1988; Friction et al., 1985,
detailed description of techniques of myofascial release. Friedmann, 1989; Ingber, 1989; Kine & Warfield, 1986).
Other authors have provided a wide range of descriptions of The presence of type C nociceptors and adaptive shortening
the technique and its use (Mock, 1997a, 1997b, 1998; Morris, in the muscles and fascia contribute to the pain of chronic
1999: Shea & Keyworth, 1997; Stone, 2000; Whalen, disorders (Reynolds, 1981; Rubin, 1981). Mobilization of
1999). peripheral nerves and manipulation (stretching and releas-
Although the exact mechanisms responsible for the effec- ing) of the fascia that is continuous with nerve roots relieve
tiveness of myofascial release techniques have not been clearly pain and help to restore function (Cantu & Grodin, 2001).
identified, there are several possibilities. Although connective TRIGGER POINT THERAPY
tissue has a certain degree of extensibility, it does not behave
like an elastic band. The tensions placed on the fascia during A trigger point—also called a myofascial trigger point
myofascial release techniques are often relatively small] and (MTrP)—is a sensitive spot on the body surface that, when
subtle. Once a significant degree of intertissue adhesion (con- stimulated, causes local and referred pain elsewhere in the
tracture) has occurred, it is unlikely that these techniques can body. The stimulated spot literally triggers a painful response
effectively restore a normal range of motion to the tissues. In somewhere else in the body—hence its name. Depending on
this case, especially if significant deformity has occurred, a the location of the trigger point, it may also cause a local,
different approach is required. Stretching techniques are painful muscle twitch. Myofascial trigger points are com-
important; however, the tension needs to be continuous so as monly found in taut bands, which are often felt as contrac-
to provide a triggering mechanism for the connective tissue tion knots within a muscle. Both local twitch responses and
the referred pain are mediated through a spinal cord reflex.
to increase in physiological length. Serial castingis an example
Many of these sensitive spots occur in the myofascial struc
of a technique that uses the concept of continuous tension to
4 tures of the body and are often the focal points of the
increase the range of tissue motion.
in in myofasci al pain and its disper- concept of a myofascial pain syndrome. This syndrome is
The role of myoglob
often confused with fibromyalgia and is characterized by
sion (and associated pain relief) by massage techniques has
musculoskeletal pain that originates from a hyperirritable
been studied (Brendstrup et al., 1957; Danneskiold-Sams¢e
spot (Brendstrup et al., 1957; Danneskiold-Samsg¢e et al.,
et al., 1982, 1986; Krusen et al., 1965; Simons, 1990).
1982. 1986: Friction et al., 1985; Hey & Helewa, 1994;
Ronald Melzack (1981) has reported on the similarity of the
Kine & Warfield, 1986; Kostopoulos & Rizopoulos, 2001;
neural mechanisms involved in the relief of pain produced
 PART TWO PRACTICE

Reynolds, 1981; Rubin, 1981; Simons, 1990; Waylonis et al., ated with manual or electrical stimulation of an active
1988; Yunus et al., 1988). trigger point:
These trigger points—called myofascial triggers by ¢ Sharp, localized pain
Janet Travell and myodysneuric points by R. Gutstein—are ¢ Sharp, referred pain
sensitive points or areas that produce pain some distance ¢ Movement restriction
away (Travell, 1981; Travell & Simons, 1983, 1992). ¢ Muscle weakness
An active trigger point may be found in tight or taut ¢ Protective muscle spasm
fascial or muscular bands. It may be in the skin (scar tissue), ¢ Lowered skin resistance
a ligament, a tendon, or even deeper at the joint capsule or ¢ Fibrositic nodules
periosteal level. Knowledge of the location of acupuncture * The “jump” sign on palpation
points associated with pain may help to locate an active ¢ Secondary trigger points in agonistic and antagonistic
trigger point, as about 70% of both points are located at the muscles (overloaded through splinting the injured
same site (Hong, 2000; Melzak, 1981). Active trigger points muscle in compensation)
often produce a localized sharp pain that may radiate to the ¢ Autonomic responses
referred, or target, area some distance away. Any or all of Figure 16-2 illustrates the sites of common trigger points
the signs or phenomena in the following list may be associ- and associated muscle groups. The referred pain and any
ANTERIOR POSTERIOR

Figure 16-2 Common Trigger Points

A, The common sites of trigger points in the body. B, The muscles
associated with these points.
 SOFT TISSUE MANIPULATION IN COMPLEMENTARY/ALTERNATIVE MEDICINE CHAPTER 16

ANTERIOR POSTERIOR

Spinalis capitis
ie
cervicis
Anteriordelteid Sternocleidomastoid Levator scapulae
phil Ne o S *
upraspinatus
Rhomboids IS), C3
Pectoralis minor a ee
: x SC Posterior deltoid
x Subscapulars
Anterior deltoid
x ° x Teres major
— Infraspinatus
Latissimus dorsi
vi Te *5

=
Extensor carpi © _ lliocostalis
Brachialis radialis
Quadratus
Brachioradialis
Wy) Ly X
lumborum
Gluteus
minimus
Gluteus

Adductor First 7 tole piven

longus x interosseus x ella
a ( maximus
~ 4)

Vasti lliotibial
Rettie ws X tract

femoris Extensor digitorum

longus (St 36) Semi- Lower end
phteraie membranosus alee iliotibial tract
longus Biceps femoris

Tibialis Gastrocnemius
anterior Long flexors
Short
extensors Soleus

Figure 16-2, cont’d

motor, sensory, or autonomic responses are ameliorated (Kostopoulos & Rizopoulos, 2001; Kovacs et al., 2000;
by desensitizing (releasing) the active primary point(s). Manheim, 2001; Peppard, 1983; Travell & Simons, 1983).
Together with appropriate myofascial release techniques
Stimulation Technique
(discussed earlier), the treatment of active trigger points is
an important adjunct to the management of chronic muscu- Active trigger points can be located in a number of ways,
loskeletal conditions (Laing et al., 1973; Lundberg et al., including direct digital palpation by the therapist (or patient,
1984). In addition, careful palpation and awareness of any where appropriate) or with the use of trigger point location
devices. These devices are usually small, handheld instru-
associated acupuncture points can assist in the assessment
ments that are used to apply a small voltage to the skin and
of related soft tissues (Fischer, 1988; Goldenberg, 1989).
An active trigger point can be desensitized using a sus- tissues. The device emits a low continuous tone when applied
to the skin a short distance (6 to 8 inches) away from an
tained pressure. There are several ways in which mechanical
active point. The probe is then moved toward the trigger
pressure may be given, including the use of one finger, two
point. When located directly over the point, the tone changes
or more fingers, a knuckle, an elbow, or by strumming (as in
to a high-pitched note and an indicator light may also illu-
applying connective tissue massage) with the fingers extended
beinsiiade:
SOO 5 PART TWO PRACTICE

Wiiicsatccas.
2:1
minate. In effect, the device has located the area of lowered 3. The local and referred pain increase (negative
skin resistance associated with an active trigger point. response).
Ohm’s law predicts that when the same voltage is applied to The preferred response is that the local and referred pain
a lowered resistance, a greater current will flow, and this is should begin to decrease with this brief period of stimula-
the operating principle for these devices. Although these tion. If the local and referred pain are unchanged, then this
devices can be useful, they do have limitations, not the least may also be regarded as a positive response because it may
of which is the fact that they are usually removed in order mean that a longer period of pressure is needed for the
for direct digital pressure to be applied. A much more useful patient to experience a decrease in symptoms. Ifthe patient’s
device is a ball-headed hand probe. These devices allow local and referred pain increase with the brief application of
pressure to be concentrated into a small area without punc- pressure, it is a negative response and indicates that contin-
turing the skin. They are ideal for manual trigger/acupunc- ued application of pressure will probably be unsuccessful.
ture point stimulation and may allow the patient to Because the point is extremely sensitive, a different strategy
self-administer treatment at home. These probes are also is indicated. It is often the case with chronic musculoskeletal
ideal for electrical stimulation of trigger points. Figure 16-3 lesions that more than one active trigger point is present and,
illustrates such a device. in some way, there is a complicated interaction between the
Once located, pressure is gradually applied to the point points. In effect, they may be triggering each other. If local
for a brief period of time (5 to 10 seconds). During this time and referred pain increase significantly with the initial, brief
the patient should experience significant discomfort/pain at application of pressure, treatment should cease and the ther-
the trigger point site and, importantly, in the referred areas. apist should look for other active points in the area. These
The patient may often exclaim loudly, confirming that the should be treated, and then the therapist can return to the
pressure is on the right spot. This is important because the point that was initially made worse by stimulation, as it may
technique does not work well if pressure is applied to now be responsive to treatment. If it continues to be exac-
the wrong area. Following the initial, brief, 5- to 10-second erbated by direct pressure, an alternative treatment should
period of stimulation, the patient should be asked to report be tried (for example, electrical stimulation or perhaps ice
his or her sensations. One of three possible reactions is cube massage using the corner of a standard rectangular ice
likely: cube). Assuming that the patient’s pain symptoms decrease
1. The local and referred pain decrease (positive with the initial 5 to 10 seconds of pressure, then treatment
response). can continue for about | to 5 total minutes of stimulation.
2. The local and referred pain are unchanged (positive An alternative protocol consists of rapid icing with the
response). edge of an ice block or parallel sweeps of vapocoolant spray

B
Figure 16-3 Ball-Headed Hand Probe for Trigger/Acupuncture
Point Stimulation
A, A ball-headed hand probe used to apply manual pressure to an
active trigger/acupuncture point. The
ball has a diameter of approximately 5mm and is m ade of chrome-
plated steel. Other sizes of probe-tip
are available and can be interchanged with the handle. B, A ball-hea
ded probe is used to apply pressure
to a sensitive acupuncture point (large intestine 4) in the hand. The
probe can also be used to apply electri-
cal stimulation to the same point.
 SOFT TISSUE MANIPULATION IN COMPLEMENTARY/ALTERNATIVE MEDICINE CHAPTER 16

given at the rate of 4cm per second, holding the bottle/can interesting to note that Fitzgerald claimed that the body
50cm away from the skin (Mance et al., 1986; Simons, could be divided into 10 longitudinal zones. This concept
1985; Wolfe, 1988). Simons (1985) claimed that fluorimeth- relates to the 10 main lines in traditional Thai massage (see
ane sprays are safe. Immediately following the icing (cube Chapter 17). Furthermore, some authors suggest that the
or spray), a gentle sustained stretch is applied. As the muscle energy channels, or meridians, of acupuncture and the zones
relaxes, it lengthens slightly. This is the so-called spray-and- of reflexology correspond (Dougans & Ellis, 1991). One of
stretch technique. Next, the therapist applies pressure for Eunice Ingham’s students, Doreen Bayly, introduced reflex-
about | minute (as for acupressure) over the trigger point. ology into the United Kingdom in the 1960s (Bayly, 1982).
The depth of pressure can be gradually increased, or it can In 1973 the International Institute of Reflexology was
be applied intermittently, alternating with slight release. Ice founded in the United States, and there are other associa-
or spray and stretch can be repeated as required. tions in various countries (Adamson, 1994).
It must be emphasized once again that the various tech- Proponents of reflexology claim that applying pressure
niques used to desensitize active trigger points are just one systematically to reflex areas on the feet clears congested
part of the total treatment program, customized for each energy channels and returns the body to homeostasis. That
individual patient. In addition, a suitable home program is, the natural healing powers of the body are recruited,
incorporating postisometric relaxation (contact—relax) tech- toxins are cleared in the circulation of blood and lymph, and
niques can be used to maintain gains after trigger point flow in the indefinable energy channels (Booth, 1994) is
treatment. Depending on the location of the active trigger restored.
points, it may be possible for the patient to apply a self-treat- Although some of these claims may seem unreasonable,
ment at home. The home program should also involve there is, in fact, a rational physiological explanation for how
stretching gently to resistance, contracting against gentle reflexology might work. The explanation is based on the
pressure for 10 seconds, maintaining this range and relax- activation of the well-known concept of an autonomic reflex.
ing, and then gently and passively taking up the slack to gain This is the same reflex activated during connective tissue
greater range. The cycle should be repeated three to five massage techniques and previously described in Chapter I]
times and may be used with self-administered trigger point (see Figure 11-2). Stimulation of various mechanoreceptors,
stimulation (Chaitow, 1981). especially in the skin, activates the sensory (input) side of
Active trigger points may also be desensitized using an autonomic reflex. The effector (output) side of the reflex
other treatment techniques, including dry needling, ultra- involves the various glands and smooth muscles of the inter-
sound, low level laser therapy (LLLT), acupuncture, acu- nal organs and small arterioles in the affected areas. The
pressure, and various forms of electrical stimulation (Alon small arterioles are extremely important because they
& De Domenico, 1987; Gam et al., 1998; Lein et al., 1989; provide a blood supply to the vast majority of the tissues of
Offenbacher, 2000; Travell & Simons, 1983, 1992). the body and are absolutely essential to the normal healing
process.
The anatomy of the nervous system, both central and
REFLEXOLOGY autonomic, provides the framework to explain these path-
Reflexology is an ancient concept of health promotion and ways. For example, the skin on the soles of the feet receives
treatment based on the principle of activating reflex responses innervation from the upper sacral nerve roots (Sl and 82),
to the manual stimulation of various areas of the skin on the relaying impulses to the same levels of the sacral parts of
feet, hands, and ear, corresponding to the internal organs the spinal cord. This is the same part of the spinal cord
and other structures. Reflexology, also known as reflex zone where the motor nuclei of the sacral portion of the cranio-
therapy, dates back to folklore in China and India around sacral division of the parasympathetic nervous system are
5000 years ago (Crane, 1997). Having not been used actively located. Interconnections between these two systems could
over many centuries, the Rwo-Shr method reemerged in provide the reflex pathway needed for an autonomic reflex
Taiwan during the twentieth century (Adamson, 1994). that could affect organs and structures supplied by this divi-
sion. Furthermore, sensory information from the soles of the
There is evidence of its use in Egypt before 2000 Bc, and
in Europe a book on the topic was written in 1582 (Sahai, feet travels in the posterior columns of the spinal cord (fas-
ciculus gracilis) to eventually synapse in the nucleus graci-
1993). Two of the most influential contemporary contribu-
lis. The nucleus gracilis is physically located in the region
tors to the revival of interest in reflexology were Americans:
the of the junction between the spinal cord and the medulla
an ear, nose, and throat specialist, William Fitzgerald, in
oblongata of the brain stem. This is the same area in which
early 1900s, and a physical therapist, Eunice Ingham, inthe
fibers from the vagus and other cranial
1930s. They undertook research into the therapeutic use of
efferent (motor)
nerves are located. Because the vagus nerve (tenth cranial)
pressure and found that it relieved pain in areas of the body
supplies the major organs, activation of the motor fibers can
that corresponded to zones identified on the feet (Ingham,
sites potentially affect the function of these organs and, through
1984). Crystalline deposits were found at nerve ending
them, the rest of the body. In a similar way, connections are
in the feet and hands, and they were thought to reflect
It is also possible between the sensory input from the skin of the
disease in the corresponding organ or area of the body.
| 302 PART TWO PRACTICE

enact
sole of the foot and the sympathetic side of the autonomic fingers and thumbs. A more usual approach is to use acu-
nervous system. In this case, neurons in the fasciculus graci- puncture, because it is much easier to localize the stimula-
lis traveling in the thoracic portions of the posterior columns tion using a fine needle. This kind of therapy is usually
are in close proximity and, through branching collateral called auriculotherapy. The points on the ear can also be
axons, may synapse with cells in the lateral horns of the stimulated using electrical stimulation (electrotherapy).
spinal cord. The lateral horns contain the cells of origin of In most cases then, pressure is applied to the skin of the
the sympathetic nervous system, innervating not only the hands and feet; for example, the skin of the posterior medial
major organs of the body but also the smooth muscles of the heel corresponds to the prostate, whereas the skin on the
small arterioles of the entire vascular system. Thus, a posterior lateral heel relates to the ovary. Centrally, farther
number of potential pathways exist to explain how stimula- forward but still over the calcaneum is the sciatic nerve
tion of the sole of the foot might affect internal organs and zone. The medial border of the foot represents the spinal
other parts of the body. column: the cervical spine is at the base of the great toe,
In a similar manner, sensory input from the skin and and the coccyx is at the upper part of the calcaneum. The
tissues from the palm of the hand is relayed to the nucleus great toe is related to the head, the pineal and pituitary
cuneatus (via the fasciculus cuneatus), located adjacent to glands, and the sinuses; the throat area lies over the meta-
the nucleus gracilis. Presumably, interconnections exist tarsophalangeal joint. On the medial two toes are the eye
between these systems, thereby allowing stimulation of zones; the fourth and fifth toes correspond to the ear. Over
sensory afferents in the hand to activate an autonomic reflex the metatarsal heads, from medial to lateral, are the thyroid
mediated by efferent fibers in the vagus and other cranial and parathyroid glands, the bronchial tree, the chest, and the
nerves in the vicinity. Interestingly, the skin overlying the lungs. Beneath the thyroid and parathyroid are the stomach
external ears is supplied primarily by sensory neurons from and then the pancreas zone. The heart, spleen, kidney, and
the third cervical nerve roots and can theoretically use the central nervous system are in zones in the center of the foot,
same pathways. Of course, it is also possible that sensory the liver along the lateral border below the metatarsal heads,
input from the feet, hands, or ear reaching the sensory and the ascending (right foot) and descending (left foot)
cortex is relayed to the various motor components of the colon down the remainder of the lateral border to the calca-
autonomic nervous system, thereby activating an autonomic neum. The bladder is represented in the medial arch, and
reflex with multiple segments (peripheral, spinal, brain the sigmoid colon is represented along the anterior border
stem, and cortical) in the pathway. of the calcaneum.
Because the two sides of the autonomic nervous system On the palms of the hands, the spinal column runs from
tend to work in harmony with each other (e.g., sympathetic the outer border of the proximal phalanx of the thumb (the
activity causes the heart rate to increase, whereas parasym- cervical spine) to the wrist. Again, the representation of
pathetic activity slows it down), it may indeed be possible various organs mirrors that found on the feet, from the tips
to rebalance internal organ activity. In contrast to a reflex of the fingers to the proximal aspect of the wrist, where the
effect on the internal body organs, other Oriental massage Ovary or prostate zone is situated. The various body parts
systems are designed to affect the organs by direct mechani- represented on the sole of the foot and the palm of the hand
cal stimulation through the overlying tissues (Chia & Chia, are subjects of considerable research. Omura (1994), ina
1997): lengthy review of the topic, describes this concept in detail
The same relaxing benefits of a full body massage are and offers an excellent source of information. There are a
attributed to reflexology techniques. Indeed, Thomas (1989) number of different maps of the areas representing different
reported reduced anxiety levels in elderly patients, whereas body parts, and two of these are illustrated in Figure 16-4.
Lockett (1992) reported a calm feeling with a desire to sleep, Illustrations of the zones can be found in many texts and
In a randomized controlled study of 35 women with premen- articles (Booth, 1994; Downing, 1974; Hillman, 1986:
strual syndrome, Oleson and Flocco (1993) found that
Lidell, 1984; Omura, 1994; Tappan & Benjamin, 1998).
reflexology techniques decreased symptoms significantly Reflexology involves an initial assessment of the feet to
(P<0.01) when compared to a placebo. The women reported
palpate for tender areas and signs of thickening or tension.
that the principal benefit was relaxation; many fell asleep The therapist also checks for calluses, corns, hard
during a 30-minute treatment session. Subjects reported that skin, and
signs of skin disruption secondary to peripheral vascula
they had greater energy on the following day and continued r
disease or diabetes. Individual reflex zones are given
to feel more relaxed 2 months after the study. more
attention if they are tender, but typically an overall
The soles of the feet and the palms of the hand are the reflexol-
ogy session lasts between 30 and 40 minutes. The
primary areas of skin used in reflexology. These areas are client
should be seated in a reclining chair or with the feet
then divided into zones representing various internal organs. elevated
on a stool. The therapist sits in a comfortable, well-su
This concept is also applied to the skin over the outer ear p-
ported position facing the soles of the client’s
(pinna) where the various body structures are also repre- feet. The
therapist’s thumb and index finger are most often
sented. Of course, the ear is rather small, making it more used to
move in the manner of a caterpillar across the client’s
problematic to treat with a manual technique that uses the reflex
zones.
SOFT TISSUE MANIPULATION IN COMPLEMENTARY/ALTERNATIVE MEDICINE CHAPTER 16

A Right foot, bottom view Throat and tonsils

ee Sinlises
Pituitary
Bronchial tube is he |
t Neck
Back of head =

Ear vA@ BS
Lung- —~) a
x f Stomach
Shoulder and arm joints
Pancreas
Liver Thyroid
Adrenal gland
Gallbladder
Kidney Spinal vertebrae

Transverse colon

Ascending colon
Small intestine

Hip joint

Knee K
VS lleocecal valve
aN) ;
Appendix
Sciatic nerve

B Right hand, palmar view Sinuses

(e)

O
iS)
~a
®
—
Q
pj
@
=
~ Adrenal
@
Lung : Pineal
Solar plexus ard Stomach Pituitary
Kidney ¥ ee Go Brain
Liver Cay é
Shoulder)
Pancreas FOr)
Gallbladder “a SLT
\ PY
Appendix Colon; oe g
‘gs
Intestines Vt o ve
Lower lumbar .
Testes
ak Hi ei :
2? hyroid
Thyroi
Ovaries——__ J Bladder
Lower lumbar . Hemorrhoids
rh : Prostate
7 Uterus
Penis

Figure 16-4 Areas on the Hand and Foot Used in Reflexology

hand (B), used
A map of various organs and body parts on the sole of the foot (A) and the palm of the
healing massage techniques: holistic, classic and
in reflexology. (From Tappan FM, Benjamin P: Tappan’s
emerging methods, ed 3, Norwalk, Conn, 1998, Appleton & Lange.)
 PART TWO PRACTICE

A typical treatment might begin with relaxation, using tissue manipulation and movement education. From a tech-
three techniques on each foot. First, the palms and fingers nique point of view, it has many similarities to a number of
of each of the therapist’s hands cradle both borders of the massage traditions, especially myofascial release techniques,
client’s foot. Pressure is applied to push forward with the and yet it has many characteristics all of its own.
palm of one hand while pulling backward with the fingers Rolfing aims at a whole-body effect, produced by the
of the other; then the pushing and pulling are reversed to proper alignment and movement of many structures, such
rotate the foot alternately into inversion and eversion. as muscles, tendons, joints, fascia, and skin. For this reason,
Contact should be maintained at all times. Next, the thera- Rolfing was named as structural integration, meaning that
pist holds the metatarsals firmly with one hand, ensuring the treatment is designed to achieve the proper integration
that the ball of the thumb is placed in the transverse arch. of various body structures so that they are able to function
The other hand grasps the toes and flexes them over the in the most efficient way possible. Rolf claimed that when
thumb, working it sequentially along the base of the meta- the body tissues are properly aligned and functioning, they
tarsophalangeal joints from medial to lateral. The third produce the optimal conditions for the health of the mind
technique is rotation of the ankle and is used to accustom and body as a fully integrated system. Of course, these
the client to having his or her feet handled and to promote concepts are not unique to Rolfing. In fact, they are the basis
relaxation. Supporting the heel in the contralateral hand, the of many different treatment methods, both ancient and
therapist holds around the outside of the lateral malleolus modern. Rolf died in 1979 at the age of 83, but her work
with the thumb to stabilize the leg, grasps the medial side continues through the Rolf Institute of Structural Integra-
of the toes and foot, and rotates it in alternate directions a tion, which certifies practitioners in her methods.
few times, moving through dorsiflexion, pronation, plantar A significant part of the traditional Rolfing approach is
flexion, and supination. These three introductory techniques devoted to a careful analysis of the client’s postural and move-
are repeated on the other foot. ment patterns. Treatment intervention may then combine deep
The treatment involves alternately holding with one hand pressure to trigger points in muscles and other structures, with
and manipulating with the other. The thumbs are used on myofascial stretches along the muscles to achieve structural
the soles to press into the reflex zones, while the other hand integration. Some Rolfing techniques can involve very deep
and fingers work the foot over the thumb. Bending the joints strokes akin to those used in CTM. They can be applied to
of the thumb allows it to walk forward and backward over trigger points using the thumbs, the elbows, the heels of the
a point, much like the movement of a caterpillar. A hooking hands, and even the knees. Deep strokes and intense pulling
stroke with the thumb, akin to a short stroke in CTM, is on the soft tissues can provoke acute and intense erythema—
used on tougher areas on the heel. In the forefoot, the pha- and even local bruising. The use of very deep strokes can
langes and metatarsals can be rotated over the thumb. The produce severe discomfort for the client and is an unfavorable
index fingers can be used to walk along the toes and to flex side effect; indeed, some clients may experience a cathartic
and extend them. response with intense negative psychological effects such as
Beginning with the toes, the therapist works systemati- depression and anxiety. Fortunately, less intense techniques
cally through the zones to the heel. In the hand, he or she can be used to avoid significant problems.
works from the fingertips to the wrist. Specific techniques Any technique that produces serious discomfort or
for each zone are suggested in texts on reflexology, espe- pain should be chosen advisedly, because less vigorous
cially Ingham’s revised work. It is not within the scope of techniques claim a similar neurophysiological effect and
this book to provide prescriptive details for reflexology; achieve the desired pain relief and soft tissue mobilization
rather, the intention is only to introduce the concepts and to integrate relationships among structures and return
basic techniques. Specialized training is necessary for them to their normal alignment. In addition to the various
anyone interested in using reflexology in a clinical setting. manual techniques used in Rolfing, client education in
Further reading can be found in Bayly (1982), Dougans and the use of more effective and less stressful movement pat-
Ellis (1991), Downing (1974), Holey and Cook (1998), terns now forms a significant part of the treatment session.
Inghan (1984), Kunz and Kunz (1987), Lidell (1984), and Further reading on Rolfing can be found in Oschman
Tappan and Benjamin (1998). (1997).

ROLFING STRUCTURAL INTEGRATION POINT PERCUSSION THERAPY

Rolfing structural integration is a treatment concept in As its name implies, point percussion therapy is a type ot
which the proper alignment and functioning of various body massage in which various parts of the therapist’s hand are
structures (e.g., muscles, tendons, joints, nerves, fascia, used to percuss (strike) the patient’s tissues. To apply poin
skin) is promoted. Rolfing is the popular name for the origi- percussion therapy, familiarity with both Western anc
nal concept developed in the United States by Ida P. Rolf Eastern techniques is required. In particular, a knowledg¢
and now known around the world. It is a treatment concept of traditional Chinese medicine facilitates one’s understand.
based on the notion of whole-body alignment through soft ing of the rationale and mechanisms involved.
 SOFT TISSUE MANIPULATION IN COMPLEMENTARY/ALTERNATIVE MEDICINE CHAPTER 16

Principles of Therapy GENERAL SEQUENCE

Positioning of the Muscles and Soft Tissues
An application of point percussion therapy for a child with
¢ Sustained stretch (for inhibition) cerebral palsy, aimed to inhibit muscle spasticity, could be
* Placement of postural muscles in middle to inner range, undertaken using the following sequence:
of phasic muscles in outer range or on stretch (both for 1. The therapist assesses the child thoroughly, analyzes
facilitation) the findings in relation to spasticity, and plans a
treatment program based on priorities.
Techniques
2. If there is limited range of motion in a joint, the
* To achieve inhibition, slow, deep, and penetrating therapist assesses the focus of the restriction or
massage is used in a regular and soothing manner. tightness of muscles.
* To achieve facilitation, fast, light, changing, and 3. The spastic muscle is slowly positioned in a sustained
stimulating massage is used. stretch posture.
In each case, it is important to concentrate on the rhythm. 4. The therapist prepares the muscle by using a general
massage technique. Effleurage, gentle picking up, and
General Techniques
kneading may be used, depending on the body part.
General massage using effleurage:
5. The therapist selects and locates the acupuncture
¢ Picking up (with one hand or both)
points according to the priorities in relation to
* Circular kneading (using the web space, four fingers or
spasticity (for example, points at or near the joint,
the whole palm, one hand, or both hands)
muscle, tendon, or other soft tissue structures; points
* Clapping using a slightly cupped, relaxed palm for analgesic effect; or stimulation of energy flow
e Shaking (for each muscle bulk) [chi] along the channels or meridians).
¢ Squeezing (for each muscle bulk) 6. Using specific techniques to press the acupuncture
Specific Techniques points, the therapist performs deep frictions to any
trigger points or area of tightness, concentrating on
For localized sites such as trigger points or acupuncture
rhythm.
points, the following specific treatment techniques can be
7. Percussion (using three fingers) is performed, moving
applied to the points or areas of tightness:
downward along the meridians and including all
* Cross-fibers techniques (transverse deep friction using a
those relevant to the area to be treated. Concentrating
thumb or index finger).
on the acupuncture points or area of tightness, the
¢ Pressure techniques (using a thumb or index or middle
therapist applies percussion a few more times.
finger reinforced with other fingers) by any of the
8. More stretching is applied as soon as the muscle
following methods: press in and release, press in and
relaxes.
rotate, press in and vibrate (upward and downward to
9. Massage is applied to clear the channels and disperse
each side of the point).
tension.
¢ Percussion using a tapping movement:
10. Stimulation massage or percussion is directed to the
* One finger (the index or middle finger reinforced with
antagonistic muscle group.
other fingers) is used. The movement comes mainly
11. The sequence is repeated three to five times,
from the wrist. depending on the condition.
¢ Three fingers held together (thumb, index and middle 12. The child is asked to contract the antagonistic muscle
fingers). This is a medium to strong tapping, and the
group or is positioned so as to facilitate contraction of
movement comes from the elbow.
the muscle.
* Five fingers held together. With all the fingers held Point percussion therapy has also been suggested for
together, the tapping is very strong, with the move- intellectual stimulation (when applied to the head), for epi-
ment coming from the shoulder and elbow. lepsy and other systemic disorders, around specific joints,
* It is recommended that therapists begin more gently and on the trunk (Jia, 1984; Wang, 1991).
and progress to the stronger technique.
* Knocking achieved by using the fingers held loosely in a
line. The movement is carried out in the line of the CRANIOSACRAL THERAPY
meridians or channels.
* Pinching with the thumb and index finger, either Craniosacral therapy (CST) is a treatment concept that
involving a pinch and release or a pinch and rotational claims to be able to promote self-healing and wellness by
or vibrating movement. detecting and releasing restrictions in the flow of cerebro-
* Flicking, a specific technique for the fingers and toes spinal fluid in the craniosacral system. Other terms used to
from the sides of the fingers and toes to the tips on the describe these concepts include the following:
anterior and posterior aspects of the nail roots to the * Cranial osteopathy
tips. * Cranial therapy
iitiobiat, SOG... PART TWO PRACTICE

Widiemiiio esc.)
* Biocranial therapy The so-called craniosacral rhythm is detected by the
* Craniopathy therapist’s fingertips, and an interpretation is then made.
* Sacro-occipital technique (SOT) Because there is no instrument available to detect or measure
The modern understanding of the concept of craniosacral this rhythm or its normal fluctuations in a noninvasive
therapy has developed from the original work of Andrew manner, there are no objective data of healthy versus
Taylor Still (1828-1917). Still’s study of anatomy and physi- unhealthy rhythms. Indeed, the evaluation and the entire
ology and their interrelationship to form and function even- treatment process are subjectively based and are likely due
tually led to the foundation of the osteopathic profession. to a strong placebo effect.
By the late 1880s, the fundamental principles of osteopathy Practitioners of CST claim to be able to not only detect
included the notion that the healthy body is an integrated, the craniosacral rhythm but also to use gentle pressure
self-regulating, and self-healing system. In 1892, Still was (about 5 grams) to release restrictions in the craniosacral
instrumental in starting the American School of Osteopathy system. They further claim that this will balance the system
along with William Smith. Interestingly, in 1893, Daniel D. and lead to an improvement in the functioning of the central
Palmer visited the school for consultation with Still, and by nervous system and thereby the body as a whole. CST is
1897, he began his own school of manipulative therapy, claimed to stimulate the natural healing processes and
which launched the chiropractic profession. to imcrease resistance to disease; see Elsdale (1996),
William G. Sutherland (1873-1954), a student at the Greenman and McPartland (1995), Gillespie (1985),
osteopathic school under the leadership of Still, is credited Upledger (1995, 1997), and Upledger and Karni (1979).
as the originator of the techniques known as cranial oste- Practitioners of CST also claim to be able to evaluate and
opathy, more commonly called craniosacral therapy. free movements in the bones of the sacrum and skull.
Sutherland developed the concept that small degrees of Because the cranial bones eventually fuse, it is impossible
motion might be possible between the individual cranial to see how they could move one on another.
bones and that such movement might be able to be felt by Craniosacral therapy is, then, an evaluation and treat-
palpation of the skull. His ideas included the notion that ment system with a dubious scientific foundation. Nonethe-
when the flow of brain and spinal fluids are inhibited, there less, advocates of the therapy have developed and made
would be an effect on the central nervous system and numerous claims for many techniques, including but not
therefore on many other body systems. By the mid-1940s, limited to the following:
Sutherland’s ideas had grown in popularity in the field of * Cranial base release
osteopathy. * Fourth ventricle technique
A number of Sutherland’s students went on to make sig- * Sphenoid release technique
nificant contributions to the refinement of cranial osteopathy ¢ Ear-pull decompression
(craniosacral therapy), especially Harold I. Magoun. In turn, * Palming-decompression technique
one of Magoun’s best-known students is John E. Upledger. In * The parietal hold and lift
fact, the more recent development of craniosacral therapy is Frontal decompression
usually credited to Upledger because ofthe work he did from Balancing the glabella and bregma
1975 to 1983 at Michigan State University in the United * Zygoma palpitation
States. Bertrand DeJarnett introduced similar evaluation and * Mandible compression/decompression
treatment concepts to the chiropractic profession, now known Sacral release technique
as craniopathy and sacro-occipital techniques. * Sacroiliac decompression
Significant controversy has surrounded CST since the Core link technique
technique began to be popular in the mid-1980s. Numerous Practitioners claim that CST can be effective in a wide
authors have challenged the fundamental concepts involved range of conditions, listed in Box 16-1. Practitioners also
and the assumptions made concerning the functioning of claim that the benefits of CST include the following:
the supposed craniosacral system, such as Gilliam * Increased sense of relaxation
(1998), Green et al. (1999a), Hartman and Norton (2002a), * Pain relief
Green et al. (1999b), Kostopoulos and Keramidas (1992), * Change in behavior patterns, leading to an improvement
McPartland and Mein (1997), Quaid (1995), and Rogers and in relationships with friends, family, colleagues, and so
Witt (1997). Proponents of CST claim to be able to detect a on
craniosacral rhythm or pulse that has a frequency of Greater capacity to manage life in general
approximately 10 to 14Hz and is independent of the * Better management of specific disease symptoms
cardiovascular pulse. CST advocates claim that the so-called
* Reduced stress
pulse or rhythm can be felt in the cranium, sacrum, cere- * Improvement of psychological issues
brospinal fluid, and membranes (meninges) that contain the Reduction of effects of past trauma
craniosacral system. The various characteristics of this * Improved sense of well-being
pulse are considered essential to a well-balanced and healthy Despite the development of an outwardly complex system
body. of evaluation and treatment, CST continues to have serious
 SOFT TISSUE MANIPULATION IN COMPLEMENTARY/ALTERNATIVE MEDICINE CHAPTER 16

BOX 16-1 Indications Claimed for the Use of Our own and previously published findings suggest that the
Craniosacral Therapy proposed mechanism for cranial osteopathy is invalid and
Arthritis POD igen 7 a that interexaminer (and, therefore, diagnostic) reliability is
Asthma approximately zero. Since no properly randomized, blinded,
Autism and placebo-controlled outcome studies have been pub-
Back pain lished, we conclude that cranial osteopathy should be
Birth trauma removed from curricula ofcolleges of osteopathic medicine
Bronchitis and from osteopathic licensing examinations.
toon poe In conclusion, CST is a treatment concept surrounded by
Depression serious controversy. Although there is not a great deal of
Digestive problems evidence to support the claims of its advocates, there is little
Drug withdrawal doubt that satisfied clients and patients can be identified.
Dyslexia One need only search the Internet to find dozens of web sites
Exhaustion touting the many benefits of CST. To the uninformed, CST
Fall or injury seems plausible and credible; however, the most important
Frozen shoulder claims of CST cannot be scientifically justified. Therefore,
Hormonal imbalances the technique cannot be recommended as a legitimate form
Hyperactivity
of soft tissue manipulation. The issue of whether CST and
Immune system disorders
Insomnia similar techniques should be taught at all in modern reha-
Lethargy bilitation practice is an important question (Ehrett, 1988).
Menstrual pain, premenstrual syndrome In general, CST is not taught because the evidence to support
Migraine its use is sparse and dubious at best.
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 a
Eastern Systems of Soft
Tissue Manipulation

Various forms of massage have been practiced in Eastern force—and yang—the negative, passive female force—in
cultures for millennia. Indeed, some of the world’s oldest which ill health is seen as an excess or deficiency in the flow
medical writings come from ancient Eastern cultures and of the vital energy. Treatment is therefore aimed at rebalanc-
describe various forms of soft tissue manipulation (massage) ing the system by using various methods (including acu-
as an important medical healing art (see Chapter 1). Several puncture and acupressure) to restore the correct energy flow
of these systems are closely linked and have since been (Maciocia, 1989). A detailed and exhaustive treatment of
adapted by different cultures in many parts of the modern each of these systems is well beyond the scope of this book.
world. This chapter explores some of these systems and the The intention here is simply to introduce the reader to a
interrelationships among them. Many of these systems are selected number of Eastern systems of massage and explore
related to ancient Chinese culture, specifically to Taoism. some of their interrelationships.
This philosophy recognizes health as a state of balance or
harmony within the individual and between the individual
ACUPRESSURE
and nature. A state of ill health is seen primarily as an
imbalance within the various internal and external forces As its name suggests, the concept of acupressure is closely
that affect overall health. Intervention is therefore directed related to acupuncture. In both cases, the skin and underly-
to restoration of the natural balance and harmony within the ing structures are stimulated at specific sites, known as
individual. acupuncture points. Stimulation at such sites should be seen
In traditional Chinese medicine, the human bodily func- as a method of accessing internal body systems, primarily
tions are controlled by a vital force or energy, called qi by means of the peripheral nervous system. As its name
(often written as chi but pronounced as chee), which circu- implies, acupressure can be simply described as the applica-
lates between the organs and throughout the body along tion of pressure to specific acupuncture points, and in order
channels called meridians. There are 12 main meridians, to understand the principles of acupressure, one must first
corresponding to 12 major organ functions of the body. The address the basic elements of acupuncture.
organ systems have the same names as those used today (i.e., In classical acupuncture, stimulation is usually performed
stomach, kidney, heart, liver, etc.), but they represent a using several very fine but solid needles (acupuncture
functional aspect of the organ, rather than an anatomical/ needles). Figure 17-1 illustrates an acupuncture treatment tc
physiological description. According to traditional Chinese the lower limb in a child with hemiplegia affecting the right
medical thinking, good health results when the vital energy side of the body. Multiple needles have been inserted ai
(qi) flows in sufficient quantity and quality through each of specific points along the lower limb. In addition, needles are
the 12 meridians and organ systems. Each of the 12 systems also inserted into the upper limb and head of the patient (not
can be affected by appropriate stimulation of acupuncture shown).
points located along each meridian. In this way, the flow of As an alternative, stimulation can also be given using
the vital energy (qi) of the body can be regulated. electricity, and this is known as electroacupuncture. Two
Traditional Chinese medical theory is grounded largely basic techniques are used: electrical stimulation (from <
in the Taoist concept of yin—the positive, active male specially designed unit) is applied directly to the needles
 EASTERN SYSTEMS OF SOFT TISSUE MANIPULATION CHAPTER 17

for selecting acupuncture points for treatment, namely,

select points:
* According to syndromes
* According to affected channels
* According to time-related points
The selection of acupuncture points for treatment within
the scope of traditional Chinese medicine is usually made
according to syndromes, whereas the Japanese-based Merid-
ian Therapy School emphasizes the selection of points
according to the channels involved. Other historical methods
of selecting points for treatment include those determined
according to point category, symptoms, seasons, and five
elements. Modern acupuncture practice uses a combination
of historical and contemporary methods to locate and select
ie LLY
points for treatment (McDonald, 1999).
Figure 17-1 Acupuncture Treatment to a Acupuncture/acupressure points may be situated in an
Child with a Hemiparetic isolated location on the skin surface, or they may be found
Lower Limb along a specific line of distribution—the so-called meridi-
A series of acupuncture needles have been inserted into a variety of ans. The meridians represent pathways (lines) on the body
points along the lower limb in a child with hemiplegia affecting the right that run from various internal organ systems to the skin
side of the body. The affected right upper limb and the child’s head (not surface. Although the history of acupuncture and herbal
shown) were also treated with acupuncture during this procedure.
medicine can be traced back to northern and southern China
more than 4000 years ago, it was not until around 300 Bc that
that have already been inserted into the tissues; alterna- the first text on traditional Chinese medicine (TCM) appeared
tively, electrical stimulation can be applied directly to each and the concept of acupuncture was fully described. This
acupuncture point, using various surface electrodes. In this famous text was the Huangdi Nei Ching Su Wen (usually
case, needles are not used and the skin is not penetrated. referred to as the Nei Ching) or The Yellow Emperor’s Classic
This technique can only be used safely with certain types of Internal Medicine. The text is said to have been written by
of stimulation, such as high-voltage pulsed direct current Huang Ti (Huangdi), the Yellow Emperor himself, and in it,
(HVPDC). In the case of acupressure, stimulation is usually the meridians along which the life force, or energy, of the
provided by direct digital pressure (finger or thumb), or with body (qi) flows and their acupuncture points are presented in
a handheld probe, to each appropriate acupuncture point. diagrams. In total there are about 1000 acupuncture points,
There is a wealth of information on the topic of acupunc- and in TCM, stimulating them is said to affect the flow of yin
ture, both on its place as a foundational concept in traditional and yang (the opposing and complementary negative and
Chinese medicine and regarding its emergence into contem- positive energy sources) so that the body systems are main-
porary health care (Filshie & White, 1997; Hopwood, 1997; tained in proper balance (Beal, 1992). Figure 17-2 illustrates
Lewis, 1999; Linde et al., 2001; Sorgen, 1998; Vickers & the location of some of the classical acupuncture points and
Zollman, 1999). In fact, acupuncture is rapidly becoming an the meridians associated with them.
integral part of modern rehabilitation practice (Kerr et al., The effects of acupuncture on pain have been studied for
2001) and a useful tool in primary care settings (Rega, 1999; many years, both from a neurophysiological viewpoint and
Ross, 2001). The effect of acupuncture on various internal from its clinical application in both acute and chronic pain
organ functions is another area in which there is a growing (David et al., 1998; Lao et al., 1999; Romoli et al., 2000;
body of knowledge that in many, but not all, cases supports Vickers et al., 2004; Wedenberg et al., 2000). Of course,
this ancient practice (Beal, 1999; Hu 2000; Takeuchi et al., pain relief using hyperstimulation techniques can also be
1999: Vickers, 1966; Vilholm et al., 1998; Wan 2000; Zhou achieved through acupuncture and acupressure, as well as
et al.1999). However, acupuncture is not a treatment without through techniques already presented such as trigger point
some risk to the patient (Odsberg et al., 2001; White et al., stimulation, reflexology, point percussion therapy, and con-
2001). Of particular concern is the possibility of introducing nective tissue massage. These techniques are effective
serious infection by the use of “dirty” needles. There has, because, histologically, the points and their immediate sur-
therefore, always been an important need to sterilize the rounding areas are associated with the same nerves, pres-
sure, and stretch receptors (Weaver, 1985). Associated
needles used in acupuncture treatments. With the advent of
modalities—for example, cupping and the use of transcuta-
disposable needles, the risk of cross-contamination has been
greatly reduced. Other adverse effects consist largely of neous electrical nerve stimulation (TENS)—can_ have
unwanted reactions to the treatment. similar effects (Anderson et al., 1974; Baldry, 1989; Fox &
From an historical perspective, there have been three Melzack, 1976; Han, 1987; Lewit, 1979; Melzack, 1981,
_main schools of thought concerning the preferred method 1985; Travell & Simons, 1983, 1992).
 PART TWO PRACTICE

Figure 17-2 Location of Selected

Classical Chinese Acupunc-
ture Points and Meridians
A, The location of a variety of classical Chinese acupuncture points.
Some of the points are used to invoke pain relief, whereas others are
used to produce stimulation or inhibition of various body organ systems.
B, The location of the 10 classical meridians is illustrated. The meridi-
ans represent {ines of association between a number of acupuncture
points and an internal organ system (e.g., the liver organ system).
Stimulation of points along the meridians is a way of affecting the func-
tion of the organ system they represent. Thus, each of the acupuncture
points is named after a specific system (e.g., St-36 is the stomach 36
point and has a specific location on the skin, just below the knee).

neurophysiological concepts. The insertion of an acupunc-

ture needle stimulates A delta nociceptor fibers, entering the
spinal cord in the region of the dorsal horn. The A delta
fibers are activated in response to the needle insertion/
removal and to the twisting of the needles during the treat-
ment. These fibers are rapidly adapting and responsible for
the sharp, stabbing quality of pain. Activation of these fibers
can produce a segmental inhibition of impulses traveling in
the unmyelinated C fibers. Pain relief is also mediated by
activation of the descending pain suppression mechanism
and stimulation of endogenous opioid peptide release in the
periaqueductal gray matter, spinal cord, and elsewhere.
Various other substances, including serotonin, catechol-
amines, glutamate, and gamma-aminobutyric acid (GABA),
may also mediate cardiovascular and analgesic effects. In
addition, evidence that nitric oxide may play a role in medi-
ating cardiovascular responses through the gracile nucleus—
thalamic pathway has recently become available. Activation
of these mechanisms helps to explain how the insertion of
needles in one part of the body can have a long-lasting effect
ere
ee
a
on pain felt elsewhere (He, 1987; Kerr et al., 1978; Sheng-
Xing, 2004). These mechanisms also explain how acupres-
sure and electroacupuncture can relieve pain.
Originally, acupuncture was one of a range of external
therapies that included moxibustion (burning of the herb
Artemisia vulgaris, a type of chrysanthemum) and traditional
Chinese (amma) massage (Armstrong, 1972; Cheng, 1987).
Before the invention of material capable of being honed fine
enough to actually puncture the skin, pieces of stone and bone
were used to press points on the skin. The response to stimu-
lation of some points corresponds to that associated with the
Head’s zones mentioned previously in association with reflex-
ology and connective tissue massage (see Chapters 11 and
16). It is widely accepted that some acupuncture points cor-
respond to sites in specific Head’s zones and some with
Although it is beyond the scope of this book to provide trigger or motor points. At least 50% of acupuncture points
detailed information concerning the neurophysiological are located directly over nerve trunks, the other
basis of acupuncture and associated techniques in pain half are
within 0.5 cm of the trunks, and more than 70% coincide
relief, there is abundant evidence of their effectiveness. The with
trigger points (Chaitow, 1979, 1981; Melzack, 1981).
therapeutic effects of acupuncture, especially on pain, can In modern rehabilitation practice, acupressure is growin
be explained in part by the conventional understanding of g
rapidly in popularity (Romanchok, 1997), particularly
as a
 EASTERN SYSTEMS OF SOFT TISSUE MANIPULATION CHAPTER 17

technique that may be taught to the patient for self-treatment would elucidate both the underlying philosophy and the two
purposes. It is effective for relieving pain of musculoskeletal frameworks, or diagnostic models, of the five elements and
origin and for relieving muscle fatigue (Avakyan, 1990; eight principal patterns.
Heinke, 1998; Hsieh et al., 2006; Li & Peng, 2000; Yip & Tse, Acupressure should not be given over contusions, scar
2006). Acupressure also appears to be effective for treating a tissue, vascular problems such as varicose veins, or an irreg-
number of problems in the area of women’s health and repro- ularity in the skin (e.g., moles, warts, acne lesions). An
ductive medicine (Beal, 1999; Hoo, 1997). Acupressure adverse autonomic or psychophysiological response may
seems to be particularly effective for reducing the problems occur in children younger than 7 years, whose autonomic
of nausea and vomiting in a wide variety of situations (Bowie, nervous system is immature, and in those with severe cardiac
1999; Chen et al., 2005: Cummings, 2001; Dibble et al., conditions.
2000; Harmon et al., 2000; Klein & Griffiths, 2004; The many hundreds of acupuncture points can be divided
Shenkman et al. 1999; Steele et al., 2001; Stern et al., 2001; into two main groups, those associated with pain relief and
Youngs, 2000). Acupressure can also promote relaxation, those concerned with the stimulation of various organ
reduce anxiety, and encourage restful sleep (Agarwal, 2005; systems. In fact, both acupuncture and acupressure are good
Chen et al., 1999; Tsay et al., 2005). In contrast, acupressure examples of treatment concepts that produce a remote site
does not seem to promote weight loss (Ernst, 1997). effect, largely mediated by an autonomic reflex (see Chap-
Although acupressure is typically applied to the acupunc- ters 5, 11, and 16). Points are named by their meridians,
ture points by means of pressure applied through the thumbs which are linked to their sources in the internal organ
or fingers, it can also be given with the heel of the hand or, in systems. Two examples are the powerful acupuncture points
some cases, with the elbow. Finger pressure to acupuncture used in anesthesia and in the treatment of pain: the large
points can be administered with the tip of one finger (the intestine (LI-) 4 and the stomach (St-) 36. LI-4 is found in
index or the middle digit), or pressure can be applied with the the middle of the web space between the metacarpals of the
thumb tip. Limited circular frictions progressing more deeply thumb and index finger. In Chinese it is called Ho-Ku,
to static pressure over the point are given for 1 to 5 minutes. which means “meeting valley.” The St-36 point is located
Numerous texts are available that prescriptively give infor- slightly lateral and distal to the insertion of the patella
mation about point location and indications for applying tendon onto the tibial tuberosity (Figure 17-3).
acupressure, particularly for orthopedic conditions and pain Stimulation of the St-36 point is illustrated in Figure 17-3,
relief. A plan for selecting points should take into account not B. The point lies slightly lateral and distal to the insertion
only the symptoms but also the relative deficiency or excess of the patella tendon on the tibial tuberosity and, once again,
in the meridian on which the point is situated. Further reading is a location in which self-treatment is possible.

Figure 17-3 Acupressure Technique to the LI-4 and

St-36 Points
to
A, Stimulation of the LI-4 point. In many cases, the patient can be taught to self-administer treatment
and
this point, as it lies in an easily accessible area, midway in the web space between the thumb (first)
to the
second metacarpal bones. B, Stimulation of the St-36 point. The point lies slightly lateral and distal
insertion of the patella tendon on the tibial tuberosity and, once again, is a location in which self-treatment
is possible.
 PART TWO PRACTICE

Table 17-1 has been adapted from a number of the texts

the use of directions given in body inches (cun). Each per- (Academy of Traditional Chinese Medicine, 1975; Chaitow,
son's cun is slightly different in length and should be used 1971; Tappan & Benjamin, 1998). It provides examples of
Oeate each point on the body. The length of the middle useful points for a range of symptoms, injuries, and related
phalanx of the middle finger, or the distal phalanx of the problems that are common. A number of other points may
nb, can be used as the unit of length for the body inch, be of use for the conditions and symptoms referred to in
bor the LI-4 point, the interphalangeal joint of the Table 17-1. Those interested in using acupressure as part of
nb is placed in the middle of the outstretched web of a comprehensive treatment plan should look for them in the
the other hand. By rolling up onto the tip of the thumb, the texts listed in conjunction with this section. If acupressure
meeting valley point is found. It is hypersensitive and is techniques prove to be useful, it may be possible to teach
readily detected by palpation and other methods. the patient how to self-administer the treatment, thereby
A point finder can be used, or the simple method of enabling the patient to manage his or her own problem when
Wentilying the sore spot by digital palpation can be used. A needed.
point finder is a small, handheld device that is moved slowly
over the skin surface in the target area. A small voltage is
applied to the skin, and when the probe is placed over an
SHIATSU
acupuncture point (a point of much lower resistance), a light The modern practice of shiatsu has enjoyed a great deal
Or a buzzer is activated. Stimulation of LI-4 may be indi- of popularity, especially because of the growing interest
cated in the classic hemicranial and frontal headache, tooth- in complementary/alternative medicine (CAM). Shiatsu
ache, pain and paralysis of the upper limb, asthma, means “finger pressure” and is a form of bodywork that
hemuplegia, facial paralysis, temporomandibular joint pain, originated in Japan around the turn of the twentieth century.
und for anesthesia and analgesia in general. St-36, Tsu-san-li Although the name is relatively new, the basic concepts of
“walk 3 more miles”), is one cun lateral and distal to the shiatsu have come from the ancient Chinese practice of
ial tuberosity. It is highly sensitive and is also favored for Amma (meaning to press and rub), which is still practiced
anesthesia and analgesia. It can be useful for nausea and throughout China. Shiatsu includes stimulation of specific
vomiting: lumbar pain; headache; edema; or aching of the points and rotation and stretching of joints (Nolan, 1989),
hips. knees, or legs in general. In classical shiatsu, the hands, thumbs, elbows, forearms,

--< 1/1 Some Acupuncture Points, Their Positions, and Related Indications
mflick eley-Vale))
B-40 Center of popliteal fossa Leg cramp, low back pain,
(bladder 40, Wei-Chung) sciatica, knee joint pain, heat
stroke
5-60 (bladder 60, Kunlun) Midpoint between posterior Low back pain, sciatica, ankle
margin of lateral malleolus and joint disorders, soft tissue
Achilles tendon sprains
GB-20 Midpoint of line from tip of Tension headache, migraine,
(gallbladder 20, Feng-chih) mastoid to posterior midline stiff neck, vertigo
groove between trapezius and
sternocleidomastoid
GB-21 Midpoint between the C7 and Shoulder pain, neck pain with
(gallbladder 21, Chieng-ching) the acromion process rigidity, upper extremity motor
problems
GB 30 Point at outer one-third of a line Hip joint pain, soft tissue
(gallbladder 30, Huan-tiao) from greater trochanter to base disorders of the hip, low back
of coccyx pain
LI-15 Acromial depression in Pain and motor problems of arm
large intestine 15, Chien-yu) mid-deltoid with arm abducted and elbow, shoulder joint, and
>
to 90 degrees soft tissue disorders
Y -3
Apex of the distal palmar crease Low back pain, neck pain and
(small intestine 3, Hou-chi) on ulnar side of a clenched fist rigidity, upper extremity
weakness
Anterior to the neck of the Knee and lower extremity pain
fibula
At radial end of flexed elbow Shoulder pain, elbow pain, soft
fold tissue disorders of the elbow
 EASTERN SYSTEMS OF SOFT TISSUE MANIPULATION CHAPTER 17 215.
Lesa iis
knees, soles of the feet, or toes can be used to administer therapist is careless in applying pressure over sensitive areas
treatment. There is also strong evidence of the influence of (Herskovitz, 1992; K., Tsuboi & Tsuboi, 2001).
ancient Chinese medical culture on the practice of shiatsu; There are several different emphases, or types, of shiatsu.
for example, some proponents include moxibustion in treat- These include namikoshi, which reflects a Western approach
ment regimens and, of course, the use of manual pressure with a physiological basis; tsubo therapy, which aligns
on specific acupuncture points. Furthermore, the belief that closely with acupuncture; and Zen shiatsu, which incorpo-
human beings are dependent on the flow of energy or life rates the complexities of the meridians. All varieties have a
force (ki in Japanese) is the basis for the stimulation of spe- common theme, and that is to rebalance and therefore revi-
cific points. talize both the body and the mind.
Shiatsu, like most of the Oriental systems, approaches There are three main shiatsu techniques:
health from a holistic viewpoint. The overriding concept is ¢ Sustained pressure on a tsubo, or pressure point, at right
that there are dynamic relationships between the individual angles to the body, used to tone the body by increasing
and the environment. Essentially, the ascending, male, active the flow of blood and energy in the area. This is similar
principle, yang, should be in harmonious balance with the to the basic acupressure technique.
descending, passive, female principle, yin, as this deter- ¢ Passive and active stretching and squeezing for the
mines the proper flow of the life force energy, ki. Disrup- muscles and joints, used to disperse blocked blood or
tions in this flow are said to result in imbalance, disharmony, energy flow.
and illness, which can be detected through the hara, or ¢ Holding and gently rocking the body part, using little or
lower abdomen. The hara is also the point from which the no pressure, used to calm and counteract overactive, or
pressure of the body’s weight comes from the person apply- agitated, energy.
ing shiatsu. This simple and effective holistic approach has The basic shiatsu pressure technique can be applied to
been acknowledged worldwide and has gained significantly the body through any of the parts mentioned previously.
in popularity. With the therapist’s body well balanced, the body weight is
Because shiatsu has much in common with acupressure applied through the hands, the ball (hypothenar eminence)
techniques, it is not surprising that it can be used for similar of the thumb (the part used most often), or another part of
purposes. It can be effective in treating pain and many the arm or leg. Figure 17-4 illustrates these techniques.
musculoskeletal problems. Shiatsu treatments have also A systematic procedure for shiatsu treatment is described
been used to manage postoperative issues involving intesti- in Box 17-1. The box gives the order and type of technique
nal obstruction (H 2000). In addition, shiatsu techniques using a variety of body areas. The procedure described in
have been used in pregnancy and childbirth (Hunter, 1999; the box is only one of many possibilities, and the selection
Yates, 1999). In contrast to its usefulness during pragnancy of techniques to be used in a particular treatment is deter-
and childbrith, shiatsu also has a place in palliative care mined by the therapist each time he or she treats the
(Stevensen, 1995). In company with many other deep pres- patient.
sure techniques, shiatsu treatments are not without prob- Some shiatsu techniques are similar to those of tradi-
lems. Damage to nerves and blood vessels is possible if the tional Thai massage and have much in common with the

Figure 17-4
Examples of shiatsu techniques.
 siimasieacot coi PART TWO PRACTICE

Sen ae
310.) An Example of a Sequence of Techniques for a Shiatsu Treatment

With the client lying prone on a mat on the floor or a broad, The arms should be managed one at a time. Press down
wide, low plinth, begin on the back, stretching to loosen it the inside with the palm facing up using a flat hand, then
and to establish a rhythm. Apply pressure down both sides with the palm facing down, along the back of the forearm
of the spine with the palms and thumbs. Points on the sacrum to the tip of the shoulder. Pull the fingers, concentrating on
and iliosacral joints are pressed; then the buttocks are the point between the thumb and the forefinger (LI-4). End
squeezed and pressure is applied through the elbow to their by shaking the arm to relax it. Work with both hands flat
| upper curve. Press down the center of the back of each leg, using a circular kneading technique on the hara in the
first with the palms, then with the knees. Press on the ankle lower abdomen, then press up gently under the lower
| points; stretch the leg in each direction; then crook the knee borders of the ribs and thence down the midline, ending at
in and the foot out to press down the lateral border. Walk the the navel. Use a rocking motion to calm the hara. Massage
hands along the soles of the feet. Press along the top of each the legs one at a time, working from the groin to the feet.
_ shoulder; rotate the shoulder blades; press the area between Press down the inside of the leg to the knee, then return to
the shoulder blades; then loosen the shoulder muscles using the groin and work down the front of the thigh. Manipulate
the feet. Turn the client to the supine position, and open the the patella to loosen it; then press down the inside with
chest by leaning the body weight through the hands onto the one thumb and down the outside of the calf with the other.
client’s shoulders. Press along the spaces between the ribs, Dorsiflex and plantarflex the foot, pull the toes, and
then press underneath on the back and sides of the neck, conclude by shaking the leg to relax it.
ending with a stretch to the neck achieved by gently elongat-
ing it by lifting the head upward and forward. Beginning at
the top of the head, run the fingers through the hair, gently
pull it, then finger-massage the ears. Work with the fingertips
on the face, including the temples, around the eyes, the
| nostrils, the mouth, and across the jaw, concluding behind
the midline of the base of the skull.

Huna massage tradition of Hawaii. Detailed information can duced in 1868 during the Meiji restoration in Japan. The
be gained from specific texts and in particular from a general Japanese recognized the similarities of the two and com-
massage book that includes both Eastern and Western bined them to develop their own system of six basic massage
methods. Further reading on shiatsu can also be found techniques that incorporated the rubbing, pressure, and
in Beresford-Cooke (1998), Booth (1993), Box (1984), finger work of Amma massage and some Swedish tech-
Dahong (1984), Finger (1998), Formby (1997), Greim niques, especially vibration and percussion (tapotement).
(1999), Hare (1988), Harris and Pooley (1998), Lidell (1984), The six basic techniques include the following:
Nolan (1989), Pooley (1998), Tappan and Benjamin (1998), * Rubbing and stroking, using flat hands or the ball
and Woodhouse (1998). (thenar eminence) of the thumb or the palmar surface of
the metacarpophalangeal joints of the fingers. A
TRADITIONAL ORIENTAL MASSAGE constant but light pressure is applied.
* Circular motion massage, using the relaxed palm or the
Various massage techniques have enjoyed a prominent place tips of the fingers but with the motion originating at the
in the history and practice of TCM (see Chapter 1). In the wrist and light to moderate pressure.
Oriental medical tradition, various pressure and rubbing Kneading massage, using the thumb, index and middle
strokes are known as Amma massage. Amma massage has finger alone, or all four fingers together for tendons
an ancient history and has been associated with blind prac- crossing joints.
titioners. It is used to normalize body functions and to * Pressure massage, using the palms, the thumbs, or four
encourage relaxation of the tired soft tissues of the body. It fingers to apply 3 to 5kg of pressure for 3 to 5 seconds.
has a calming influence on the nervous system (Serizawa, The body weight, not the fingers alone, is used to apply
1973). There are three types of Amma massage: the pressure. Pressure should always be directed toward
* Rubbing and pressure, much like kneading and frictions the center of the client’s body and should be increased
but applied with the knuckles of the lightly clenched gradually. It is similar to the pressure techniques applied
hand in shiatsu.
* Finger and palm work, as in picking up and wringing * Vibration massage, in which the fingers or palms are
* Passive stretches for the joints, similar to relaxed placed firmly on the skin and vibrated rhythmically and
passive movements gently.
Amma massage was used only to reinvigorate tired
Tapping massage, alternating hands to tap the client’s
muscles and joints. Similar Western-based techniques, the
body rhythmically with the palms, fingertips, and backs
so-called Swedish remedial massage techniques, were intro-
of the fingers or with the lateral border of the hand. The
 EASTERN SYSTEMS OF SOFT TISSUE MANIPULATION CHAPTER 17 vieaiiiaie

tapping is light and rapid. The pressure should be over the top of the left side of the head, ending at the
around | kg. These techniques are closely related to left nostril.
those used in point percussion therapy (Jia, 1984). 2. Pingkala runs the same route as /tha but on the right
The massage techniques practiced as part of TCM are side. Both /tha and Pingkala should be attended to for
effective in the management of musculoskeletal pain and headache or neck or back pain.
dysfunction (Cheng, 2001; Hong, 1997; Li & Zhong, 1998; 3. Smana runs up the middle of the thorax, through the
Puustjarvi & Pontinen, 1990; Zumo, 1984). Further reading neck and chin, and along the upper surface of the
on the topic of massage in the general concept of TCM can tongue. Chest, heart, jaw, and oral symptoms may
be found in Ehling (2001), Hao (1997), James (1996), arise from disruption along Smana.
Serizawa (1973), and Wright (1995). 4. Kalathale runs down both arms, through the fingers,
through both legs, and through the phalanges.
Symptoms in the arms or legs are related to
Kalathale.
TRADITIONAL THAI MASSAGE
5. Sahutsarungsi runs down the inside of the left leg,
As its name suggests, traditional Thai massage is a form across the base of the toes, up the outside of the left
of bodywork integral to the historical medical culture of leg, across the left tibial crest, through the left nipple,
Thailand. The true origins of Thai massage are unknown, and diagonally up to the left eye. The left leg and eye
but given its similarities to other Oriental systems, it is pos- are governed by the functional circulation along
sible to speculate that massage was more than likely intro- Sahutsarungsi.
duced from India with the expansion of the Indian culture 6. Thavare runs the same route as Sahutsarungsi but on
and Buddhism into Thailand. the right side of the body. Symptoms in the right leg
Recommendations for healing massage are recorded in and eye are related to Thavare.
the Ayur Veda, the classic Indian text of around 1800 Bc (see 7. Chunthapusang runs up to the left nipple and up the
Chapter 1). At Wat Pho, a famous temple in Bangkok where left side of the neck, and it ends on the left ear lobe.
traditional Thai massage is taught, Ajahn Chivakakomara- The left ear relies on uninterrupted flow along
pad, a Buddhist medical doctor, claimed in a stone inscrip- Chunthapusang.
tion on the wall (Silajarug) that he knew the origins of all 8. Ruchum runs the same route as Chunthapusang but
the lines of linkage in the human body. He presented around on the right side. Ruchum is the line for the right ear.
72,000 lines, but 10 main lines (Sen Pratarn) were the most 9. Sukhamung runs to the stomach, internal organs,
important. Today, knowledge of these 10 lines is the basis anus, and urethra. The health of the internal organs
of traditional Thai massage (Tapanya, 1993). depends on Sukhamung.
The imaginary lines in Thai massage closely match the 10. Sikkhine runs to the genital organs, and their
meridians of traditional Chinese medicine along which the functioning depends on Sikkhine.
life force energy called chi flows and on which the acupunc- There are two main types of traditional Thai massage.
ture points lie. Similarly, the 10 Thai main lines function as Thai massage in the grand palace is given using the hand,
energy pathways or are described as the functional circula- arm, or elbow. There is no stretching, and it is used only for
tion in the body. These nonspecific systems function as therapeutic purposes. Thai massage for the people is under-
balancing mechanisms for the body, linking a series of spe- taken to maintain the functional circulation and for general
cific points on the surface with the deeper organs. In this health and well-being. The therapist’s hand, arm, elbow, leg,
way, the body’s mental, digestive, nervous, circulatory, and and foot are used, and stretching is included, much as in
reproductive processes, and, thus, nutrition, consciousness, shiatsu (Box 17-2).
and energy, are harmonized. Thai massage has much in common with other Oriental
Illness and functional disorders are claimed to be the and Western massage traditions. This is not surprising, as
result of disruption of 1 or more of the 10 main lines. It is Per Henrik Ling developed much of the Western concepts
suggested that pressure applied to a specific point (similar
to acupressure techniques) along the relevant line may
produce a physiological effect in the periosteum, fascia,
evs iVE"4) Major Elements of Thai Massage
muscles, blood vessels, or nerves that is perceived as a
pressing and releasing, the Hesse of pressure aie |
moving impulse. As a result, pain may be relieved, circula- judged in relation to the tolerance of the recipient. Pressure
tion improved, muscles relaxed, and organ function is applied along the main lines in a regular and rhythmic
improved. The 10 main lines of traditional Thai massage fashion at points around 5cm apart, beginning at the origin
originate at the level of the umbilicus and are listed in order near the umbilicus and proceeding to the end point. Picking
| up, where muscle is lifted away from the bone and squeezed
as follows:
| hacking, particularly to the calf muscles stretching for joints
1. Itha runs down the front of the left leg, up the back of manipulation of joints, especially those of the fingers and
the left leg, across the left buttock, up the left side of toes.
the back, up the back of the left side of the head, and
 PART TWO PRACTICE

Bi
of Swedish remedial massage (see Chapter 1) from tradi- who want to do professional body and mind work. In
tional Chinese massage techniques. Further reading on tra- Scandinavia, the training is built up in seven modules, each
ditional Thai massage can be found in Lidell (1984), Nolan a complete unit. This makes it possible for anyone to take
(1989), and Gold (2006). the modules at his or her own pace and as required. In New
Zealand and Australia, a module is presented twice a year
that has been adjusted to the needs of these countries. Apart
HUNA MASSAGE from basic instruction in Huna massage and the principles
The ancient cultures from the Hawaii islands are famous for of Huna philosophy, special techniques such as pregnancy
a unique combination of massage techniques and healing massage, joint massage, draining, astral dancing, and body
traditions known as Huna massage. It is based on the life reading are included.
principles in the millennia-old Polynesian philosophy of The old Hawaiian traditional method of massage, using
Huna, which has been described as “Kahuna magic” (Steiger, the hands and emphasizing special breathing techniques, is
1982). This body and mind work was formerly reserved for combined with release techniques, which include the Eastern
the shamans (healers) of Polynesia who mastered the wisdom. philosophies of polarity, energy points, and energy flows (or
The fundamental concepts of the Huna tradition are described chakras). The links between the Chinese traditions of main-
in Biegler (1999), Feinberg (1990), Hoffman (1982), A. taining balance in the energy level for optimal health are an
Lawrence (1994), L. Lawrence (1994), and Paltin (1986). integral part of the Huna philosophy. Like many of the
Huna is a Hawaiian word that, when split up and put techniques described in Chapters 16 and 17, Huna massage
together in different ways, has several meanings: huna is aims to enhance energy and teach intuitive guidance in
“the secret or hidden knowledge”; hu is yang, the male order to train the senses to transform and direct energy.
principle, the giving and active part; na is yin, the female
principle, the receiving and passive part; una is telepathy, a
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 Closed-Chest (External)
Cardiac Massage

External cardiac massage (also known as_ closed-chest nal contents. Pressure is applied directly to the lower third
cardiac massage) is included here because it is a technique of the sternum.
that all persons involved in direct patient care of any type Because the sternum is a relatively narrow structure, the
should know for emergency treatment of cardiac arrest. The heel of the palm of only one hand is positioned in direct
external cardiac compression is part of the concept of car- contact with the skin while the other hand is used to rein-
diopulmonary resuscitation (CPR). The technique some- force it (Figure A-3). The rescuer’s fingers are spread and
what resembles the shaking and vibration procedures raised so that pressure is applied only to the sternum and
described in Chapters 4 and 10; however, it is performed not to the ribs or abdomen. Vertical pressure sufficient to
only over the sternum and much more slowly. depress the sternum | inch (2.5 cm) ora little more is applied
If a quick check for the presence of the pulse at the and quickly released. If the patient is a child, one hand may
carotid arteries on both sides of the trachea confirms that a be used with less pressure. If an infant (less than | year old)
patient’s heart has stopped, the patient should be placed is being resuscitated, the fingertips may be used, and much
supine on a solid support such as the floor or a firm plinth less pressure, at a rate of at least 100 times per minute.
or stretcher (whichever is quickest). The patient’s head It is assumed in CPR training that respiratory suppport
should then be tilted backward to ensure an open airway. will be required with all cardiac arrests. Therefore a single
This can usually be achieved by placing one hand under the provider of CPR must perform a basic cycle of both circula-
neck and lifting the cervical spine upward (Figure A-1), tory support and artificial ventilation. The provider applies
allowing the head and neck to fall into the extended position a basic cycle of chest compression at approximately 100
(head tilt, chin lift). If the airway is obstructed internally strokes per minute, giving two quick breaths to the patient
(perhaps by the tongue), it must be cleared before any after each set of 30 compressions. After approximately five
other procedures are performed. The reader is referred to complete cycles (30 compressions and two breaths per
national or local Heart Association guidelines for currently cycle), the patient should be reassessed to determine whether
recommended procedures for clearing an obstructed a pulse is present, in which case the CPR ceases immedi-
airway. ately. When two providers are available, one performs the
Before compression and ventilation can begin, the CPR compression and the other delivers ventilation. This regimen
provider must determine where to place his or her hands on of CPR can be applied to children and adults. During the
the patient’s chest. One of several ways to do this is to place ventilation phase, the patient’s nostrils may be lightly
the index finger of one hand on the patient’s xiphoid process squeezed to seal off the nasal passages during the inflation
(see Chapter 2). Two fingers of the other hand are then cycle of the ventilation (see Figure A-I).
placed next to this finger (Figure A-2). The first finger1 is In all situations, an advanced life support or emergency
removed and the flat hand placed on the chest next to the medical team must be summoned at the earliest moment,
two fingers, on the same side as the patient’s head. It is and CPR efforts should be continued until the team arrives
important that no pressure be applied to the ribs or abdomi- or until effective circulation and ventilation have been
 APPENDIX CLOSED-CHEST (EXTERNAL) CARDIAC MASSAGE

de,

Figure A-1 Hand Positions to Ensure Figure A-3 Hand Positions for External
An Open Airway for Cardiac Compression
Artificial Respiration In an adult, pressure is applied using the heel of the palm of one hand
An open airway is ensured by lifting the cervical spine upward while the reinforced by the other. Sufficient pressure is applied to displace the
patient is lying supine. This causes the head to fall into extension (head sternum by approximately 1 inch (2.5 cm). Pressure must be applied
tilt, chin lift) and prevents blockage of the airway, provided there is no only to the sternum to avoid damaging the ribs or abdominal organs. A
internal blockage. The nostrils may be squeezed together lightly to close single-handed technique may be used to deliver cardiac compression
them off when blowing into the patient’s lungs. to a child.

restored. When the patient is a child or when cardiac arrest

is associated with hypothermia, prolonged resuscitation
efforts may be justified and should be continued even after
long periods of unconsciousness.
Unless much care is taken to perform these procedures
properly, fractures of the ribs and sternum, as well as lacera-
tion and rupture of soft tissues, such as liver, spleen, pan-
creas, lungs, and blood vessels, can easily occur. Although
there are, of course, individual variations, most medical
standards for CPR and emergency cardiac care recommend
that all health care workers involved in any capacity in
direct patient care be certified in basic life support tech-
niques and be well-informed about the CPR plan of the
facility in which they work. It is usual, nowadays, for a basic
CPR certificate to be valid for 1 year. For certification, a
Figure A-2_ Locating the Area over qualified CPR instructor must verify that the person has
the Sternum Where demonstrated knowledge of when to perform CPR. Suffi-
Pressure Is Applied during cient psychomotor skills for correct timing and technique
External Cardiac for both one- and two-person rescues must also be demon-
Compression strated. The practice necessary to develop these skills and
The index finger of the hand farthest from the patient’s head locates the repeated demonstration of them should be performed on
the xiphoid process as the other hand is placed on the sternum, two a training manikin under the supervision of a certified CPR
finger breadths from the xiphoid. instructor.
 Index

Page numbers followed by b indicate boxes; f, Chest (Continued) Ethical issues, in soft tissue manipulation, 49-50
figures; f, tables. physical therapy for, 225, 226b Evaluation, of lymphedema, 249-250
superficial stroking to, 163-164, 164f External occipital protuberance, 37, 38f
A Chest wall Extremities. See under specific body parts
Abdomen lateral
alternate squeeze kneading over, 169-170, 169f vibration to, 98f F
in baby and infant massage, 283, 286f wringing to, 89f Face
deep stroking to, 167, 167f, 168f, 170 posterior in baby and infant massage, 281, 284f
local massage to, 210, 210f clapping over, 94f local massage to, 211, 212-213f, 214
superficial stroking to, 167 skin rolling to, 90f superficial stroking to, 151, 176 , 177f, 181
viscera, 128-129 Chin Fatty tissue, effects of massage on, 130
Achilles tendon, digital stroking to, 158, 159f deep stroking to, 180, 181f Femoral condyle, lateral and medial, 44f
Acromion process, 38, 39f thumb pad kneading to, 180, 181f Femoral triangle, 43, 43f
Active trigger points, 298-301 Chinese massage, 316-317 Finger pad clapping, 92, 93f, 94f
Activity, physical, effects of massage on, 132 Circular frictions, 102-103, 102f, 103f Finger pad kneading, 81, 83, 83f, 84f
Acupressure, 310-314, 311f, 312f, 313f, 314t Circular kneading, 80-81, 81f Finger
Adipose (fat) tissue, effects of massage on, 130 Circulation, effects of pétrissage on, 90 clapping technique to, 230
Airway clearance, in respiratory condition, 226, 226f Clapping (cupping), 92, 92f, 227, 230, 230f, 231f in connective tissue massage, 239-240, 239f, 240f
Amma massage, 316-317 Colon local massage to dorsum of, 195, 196f, 197
Anatomical position, 37 deep stroking over, 169, 169f local massage to palmar surface of, 197f
Anconeus, massage of, 191, 192f dysfunction, focal massage sequence for, 222-223, thumb pad kneading to, 163, 163f
Ankle 223f, 223t Fingertips technique, in connective tissue massage,
anterior structures of, 44-46, 45f kneading massage over, 169, 169f, 211, 212f 238-239, 238f, 240f
in baby and infant massage, 283, 287f palmar kneading over, 167, 168f, 169 Flat-handed kneading, 80-81, 82f
chronic edema in, focal massage sequence for, stroking over, 211, 211f Focal massage, 149
217t Comfort, patient positioning for, 61, 63 Focal massage sequences, 70, 215
finger pad kneading around, 84f Complementary/alternative medicine (CAM), Foot
transverse frictions to, LOIf 294-307 anatomical landmarks of, 44-46, 45f
Anxiety, effects of massage on, 131-132 Complete decongestive therapy (CDT), 245 areas used in reflexology, 302, 303f, 304
Arm Compression kneading, 80-81, 82f in baby and infant massage, 283, 285, 287f
anatomical landmarks of, 39, 39f Compression therapy, 259-260, 261b, 262b chronic edema in, focal massage sequence for,
in baby and infant massage, 281, 285f Connective tissue massage (CTM), 7, 235-243 217t
effleurage to, 78f Continuous passive motion (CPM), 105 knuckle kneading to, 87f
left, 151t, 160-161, 160f Contrast relaxation method, 64, 64b left, 160
palmar kneading to, 82f, 161, 16lf Coracobrachialis, massage of, 191, 193f right, 157-158, 157f, 158f, 159f, 160, 203-206,
relaxed passive movements to, 113-114f Coughing, in respiratory conditions, 233 205f, 206f
right, 151t, 188, 191, 193-194f, 194 Craniosacral therapy (CST), 305-307, 307b thumb pad kneading to, 85-86f
stroking to, 73f Creams, in hand preparation, 52-53 Forearm
wringing to the muscles of, 89f Cutaneous scar tissue, 219-221 anatomical landmarks of, 39-40, 39f
Assisted passive movement, 104 Cyriax friction massage, 99-104 chronic edema in, focal massage sequence for, 218t
Auriculotherapy, 302 general massage sequence for, 151t
Autonomic reflex, 237, 237f D palmar kneading to, 161, 161f, 162f
Decongestive therapy, 250 thumb pad kneading to, 85f
B Deep frictions, 99-104, 104t, 146-147 transverse frictions to, 102f
Babies, massage for, 279-288 Delayed onset muscular soreness (DOMS), 267-269, Forehead
Back 268b deep stroking to, 176-177, 178f
alternate palmar kneading over, 175 Deltoid muscle group, massage of, 188, 190-191f, 191 thumb pad kneading to, 176, 178f
anatomical landmarks of, 41-42, 41f, 42f Denervated muscle, 123-125 Frequency, of massage, 23, 65-66
in baby and infant massage, 285, 287f Depletive massage, 215-217, 216f Friction, 7, 14
deep palmar stroking to, 170, 171-172f Diagnostic stroke, 238, 238f circular, 102-103, 102f, 103f
effleurage to, 76-77f Diffuse scars, 221, 22It deep, 99-104, 104t, 146-147
general massage sequence for, 151t Digital kneading, 81, 83 description of, 14, 16-17t
local massage sequence for, 185t Direction, of massage, 18-19, 65 transverse, 100-102, 100f, 101f, 102f, 147
palmar kenading to, 82f Dorsum
of foot, 157, 157f, 158f G
stroking to, 72f, 206-210, 208f
superficial stroking to, 170, 170f, 175 of hand, 161, 162f, 195-196, 196f General massage, definition of, 149
Beating strokes, 93, 94f Draping, of patients, 55-57, 57-61f General sequence, in complementary/alternative
Biceps, massage of, 191, 193f Dry massage, 21 medicine, 305
Bicipital aponeurosis, 39, 39f Duration, of massage, 22-23, 65-66 Gluteal muscles
Blood, effects of massage on, 119-120, 121-122 Dying, ancient versus modern care of, 290-291 alternate palmar kneading to, 174, 174f
massage to, 198, 198f
Body therapies, 294-295
E reinforced kneading to, 175, 175f
Bolster, in massage, 54, 56f
Bone, effects of massage on, 125 Eastern massage systems. See Massage, Eastern
systems of H
Boric acid powder, in massage, 21
Edema, chronic, 216, 216f, 217t, 218t Hacking strokes, 93, 95, 95f
Brachialis, massage of, 191, 193f
Effleurage, 146. See also Stroking Hair powder, in massage, 21
Breathing, deep, in respiratory conditions, 233
contraindications to use of, 80t Hamstring muscle group, local massage to, 198, 199f
Buttocks
in baby and infant massage, 285-286, 288f description of, 14-15, 17-18t, 75 Hand
history of, 14-15 anatomical landmarks of, 40-41
kneading to, 175
in massage, 75, 76-77f, 77, 78-79f areas of hands used in, 52b
Cc Elbow, finger pad kneading to, 83f areas used in reflexology, 302, 303f
Elderly, massage for, 291-292 in baby and infant massage, 281, 283, 285f
Calf muscles, kneading to, 156, 156f
Electroacupuncturé, 310 chronic edema in, focal massage sequence for,
Cellulite, effects of massage on, 130-131, 131f
Equipment, for massage, 53-55, 54b, 54f, 55f, 56f 218f
Cheeks, palmar kneading to, 180, 180f
Erector spinae muscles local massage to the dorsal aspect of, 196f
Chest. See also Chest wall massage to palmar surface of, 195f
in baby and infant massage, 283, 286f deep stroking to, 175, 175f
digital kneading to, 175 preparation of, 50-52, 52f
clapping technique to, 231f
local massage to, 206-207, 208f thumb pad kneading to, 85f, 161, 162f
massage sequence for, 163-164, 164f
 INDEX

Hard tissue, classification of, 70t Local massage sequence (Continued) Massage (Continued)
Head for lower limbs, 184t recreational, 5, 70
anatomical structures of, 37, 38f, 50b for posterior trunk and pelvis, 185t requirements for
in baby and infant massage, 281, 284f for upper limbs, 185t equipment as, 53-55, 54b, 54f, S5f, S6f
general massage sequence for, 152t Lower limbs. See also under specific body parts ethics as, 49-49
local massage sequence for, 190t anatomical structures of, 51b hand preparation as, 50-52, 52b, 52f
Head’s zones, in connective tissue massage, 235-237, in baby and infant massage, 283, 285, 287f lubricants as, 52-53
238f general massage sequence for, 150t surface anatomy knowledge as, 50
Healing, effects of massage on, 122 local massage sequence for, 184t, 189t sequence for, 183
Hematoma, 217-219 muscles, wringing to, 89f signs and symptoms changes, 66
intermuscluar, 218-219, 218f, 219f passive movements of, 233 sports, 132, 266-277, 267b
intramuscular, 218f, 219, 219f relaxed passive movements to, 108-112f terminology of, 6-7
Hips short and long CTM strokes to, 242-243f « chronology of, 8-1It
anatomical landmarks of, 42 Lubricants therapeutic, 5, 70, 149
general massage sequence for, 15It in hand preparation, 52-53 therapist position as, 21-22
Hoffa system, of local massage, 184-188 in massage, 20-21 wedge, 54, 56f
Huna massage, 318 Lumbar region Mechanical effects, of massage, 117, 118-119, 119b
Hyperkeratosis, 250, 250f palmar kneading over, 173-174, 173f Mesodermal somites, 236
Hypothenar eminence, 163, 163f, 194, 195f palmar stroking to, 174, 174f Metabolism, effects of massage on, 122
reinforced kneading to, 87f Metacarpophalangeal (MCP) joints, 41, 161, 162f,
Lumbricles, massage to, 194, 195f 163
Immune system, effects of massage on, 129 Lungs, effects of massage on, 129 Muscle
Infants, massage for, 279-288 Lymphedema, 245-263 denervated, 123-125
Infraorbital ridge, deep stroking to, 179, 179f Lymph fluid mobilization, in lymphedema, 240-251 dysfunction, focal massage sequence for, 223-224
Injury Lymph system effects of massage on tissue, 122-125
to muscle, 123 effects of massage on, 120-121 effects of pétrissage on, 90
sports, 269-275 function of, 246-247, 246f, 247f, 248f focal massage sequence of, 221-222, 222f
Intermittent positive pressure breathing (IPPB) mobilizing stagnant tissue fluid through, 252-253, injured, 123
devices, 232, 233 253f, 254f, 255, 255f, 256f, 257-259, 257f, normal, 123
Interossei, massage to, 194, 195f 258f, 259f pathologic conditions of, 123
tibial, anterior, thumb pad kneading over, 153,
J M Losi
Jaw Malleoli, deep digital stroking around, 158, 159f tissues of, effects of massage on, 122-125
deep stroking to, 180, 181f Manipulations tone, 123
thumb pad kneading to, 180, 181f pressure, 146 Myofascial release techniques, 295-297, 297f
Joint play, 104 in specialized passive movement, 105 Myofascial trigger point (MTrP), 297-299
Joints, effects of massage on, 125 Massage. See also Connective tissue massage;
Jungular veins, deep stroking over, 165, 166f, 167, Kneading; Stroking N
179-180, 181 complementary/alternative medicine in, 294-307, Neck
305 anatomical structures of, 37-38, 38f, 5Ob
K craniosacral therapy as, 305-307 deep stroking to, 164, 164f, 167
Kneading. See also Massage; Stroking general sequence as, 305 digital kneading from sternum to, 165, 165f
characteristics of, 79-81, 81-83f, 83 myofascial release as, 295-297, 297f digital stroking to, 165, 166f
compression, 80-81, 82f point percussion therapy as, 304-305 effleurage to, 79f
description and definition of, 15t, 79-81, 83 reflexology as, 301-302, 303f, 304 general massage sequence for, I5It, 152t
digital, 81, 83 rolfing structural integration as, 304 local massage sequence for, 190t
finger pad, 81, 83, 83f, 84f trigger point stimulation as, 297-301, 298-299f, relaxed passive movements to, 106-107f
flat-handed, 80-81, 82f 300f stroking to, 74f
history of, 14 component of, 15, 18-21, 24-34t, 63b Nervous system, effects of massage on, 125-126
knuckle, 83, 87f comfort and support as, 61, 63 Nose, thumb pad kneading to, 177, 178f
palmar, 80-81, 82f direction as, 18-19, 65
reinforced, 83, 87f duration as, 22-23, 65-66 O
single-handed, 186, 187f frequency as, 23, 65-66 Oils, in hand preparation, 53
squeeze, 81 patient position as, 21-23
thumb pad, 83, 85-86f, 153, 155f pressure as, 19-20, 65 IP
two-handed, 186, 188f relaxation as, 63-65, 63b, 64b Pain, effects of massage on, 126-128, 132
two-handed digital, 186-187, 188f signs and symptoms changes as, 66 Palliative care, massage in, 290-292
Knee therapist position as, 21-23 Palmar kneading, 80-81, 82f. See also under body
anatomical landmarks of, 43-44, 44f contraindications to, 66-67, 133, 135-136, 137-138t regions
finger pad kneading around, 84f definitions of, 6 Palpation, 145
transverse frictions to, 1OIf description of techniques (strokes), 7, 11-12, 12- Paraspinal muscles
Knuckle kneading, 83, 87f 13t, 14-15, 15t, 16-18t circular frictions to, 103f
dry, 21 massage to, 206, 208f
L
Eastern systems of Passive accessory joint movements, 104
Latissimus dorsi muscle, 42, 42f acupressure as, 310-314, 311f, 312f, 313f, 314t Passive physiological movements, 104
local massage to, 207-208, 209f, 210 Chinese, 316-317 Patella, stroking around, 156, 157f
Laying on of hands, 133 Huna, 318 Patient
Leg. See also Thigh shiatsu as, 314-316, 315f, 316b, 316t draping and positioning of, 55-57, 56b, 57-61f
anterior structures of, 44, 45f Thai, 317-318, 317b lymphedema and education of, 260, 263, 263b
in baby and infant massage, 283, 285, 287f effects of position of, 21-23
deep stroking to, 155f, 157, 160 mechanical, 117, 118-119, 119b relaxation of, 63-65, 63b, 64b
palmar kneading to, 82f, 156, 156f physiological, 119-131, 119b with terminal cancer, massage techniques for, 292
pick up to muscles in, 87f psychological, 131-133, 131b Pediatric patients, postural drainage positions for,
posterior structures of, 46-47, 47f, 48f therapeutic, 133, 134-135b 229f
relaxed passive movements to, 108-112f focal, 149 Pelvis
right, 200, 202-203, 202f, 204-205f general, 149
stroking to, 73f anatomical structures of, SOb
hacking in, 93, 95, 95f general massage sequence for, 151t
superficial stroking to, 153, 155f, 160 history of, 3-6 local massage sequence for, 185t, 189t
thumb pad kneading to, 85f, 153, 155f local, 70, 149, 184 Percussion
two-handed digital kneading to, 188f local sequences
wringing to the muscles of, 89f classification of, 91-93, 95-97
Hoffa system, 184-188 contraindications to, 97t
LI-4, acupressure technique to, 313, 313f media (lubricant) as, 20-21
Ligament adhesion, focal massage sequence for, 221- manipulations in, 91-93, 95-97
movement in techniques, 227, 230-232
222, 222k. 222t friction as, 14, 16-17t
Linear scars vibration manipulations in, 146
kneading as, 14, 15t Peroneal muscles, 44
in skin, focal massage sequence for, 221t prétissage as, 7, 11, 12-13t
thumb pad kneading for, 220f, 221f Pétrissage. See also Stroke; Stroking
stroking and effleurage as, 14-15, 17-18t contraindications to, 91, 91t
Local massage, 70, 149, 184 in palliative care, 290-292
Local massage sequence description of, 7, 11-12, 12-13t
precautions in, 136, 139b effects of, 90-91
Hoffa system of, 184-188 rate and rhythm as, 20, 65 evaluation of, 146
 INDEX

Pétrissage (Continued) Shoulder Thigh

history of, 7, 11-12 anatomical landmarks of, 38-39, 38f anterior muscles, 199-200, 201f, 202f
indications for, 91 deep stroking to, 164, 164f, 165, 165f beating to, 94f
kneading as, 79-81, 83-84, 86, 146 digital kneading from sternum to, 165, 165f hacking to, 95f
picking up as, 83-84, 86, 87f, 88 effleurage to, 79f pounding to, 96f
primary effects of, 90-91 finger pad kneading from temples to, 179180f structures of, 42-43, 43f
skin rolling as, 88, 90, 90f Skin, massage of deep stroking to, 153, 160
therapeutic uses of, 91 effects on, 129-130 finger pad clapping to, 93f
wringing as, 88, 89f focal sequence, 221t left, 150t, 160
Physical activity, effects of massage on, 132 for lymphedema, 250 palmar kneading to, 152-153, 153f 154f
Physiological effects of massage rolling of, 88, 90, 90f, 146 posterior structures of, 46-47, 46f, 47f
on blood, 119-120, 121-122 Soap, in hand preparation, 53 right
on cellulite, 130-131, 131f Soft tissue local massage to, 58f, 198-199
on immune system, 129 classification of, 70t massage sequence for, 150t, 152-153
on lungs, 129 classifications of hard tissues and, 70t superficial stroking to, 152, 152f
on lymphatic system, 120-121 in complementary/alternative medicine, 294-307 two-handed kneading to, 188f
on metabolism and healing, 122 manipulation, description and types of, 69, 70b Thoracic region, palmar kneading over, 173-174,
on nervous system, 125-126 massage of, 5 173f
on pain, 126-128 Spine, cervical, finger pad kneading from temple to, Thumb circles stroke, for lymphedema, 252, 252f
on skin, 129-130 179, 179 Thumb pad kneading. See Kneading, thumb pad
on soft tissue manipulation, 119b Sports massage, 132, 266-277, 267b Thumb, local massage to dorsum of, 195, 196f,
on tissues Spray-and-stretch technique, 301 197
adipose (fat), 130 Squeeze kneading, 81 Tibial muscles, anterior, thumb pad kneading over,
muscles, 122-125 Standing circles strokes, 251, 251f S35 1555
Picking up, 83-84, 86, 87f, 88 Sternocleidomastoid muscle, 37, 38f Tibial tuberosity, 44, 44f
Pillow, prone, in massage, 53-54, 55f Stimulation techniques, 299-3--301, 300f Tissues
Point hacking, 95-96, 96f Stroke excitable and nonexcitable, 118t
Point percussion therapy, in massage, 304-305 clapping, 92, 92f soft and hard, classification of, 70t
Popliteal fossa, 46, 46f classification of, 70, 71t Toes, 196f, 206
Popliteal space, deep stroking to, 156 direction of, 65 Transverse frictions, 100-102, LOOf, 1O1f, 102f,
Position effleurage as, 75, 76f, 77, 78-79f 147
of patient, 21-22, 55-57, 56b, 57- 61f hacking, 93, 95, 95f Trapezius
of therapist, 21-22 kneading as, 79-81, 81-83f, 83 deep stroking to, 171, 173, 173f, 176
Postural drainage, 226-227, 228f, 229f, 230t long, 239-240, 241f finger pad kneading to, 170-171, 172f
Pounding, 95-97, 96f for lymphedema patients, 251-252, 251f, 252f local massage to, 207, 209f
Powder percussion manipulations as, 91-93, 95-97 superficial stroking to, 176
in hand preparation, 52 pétrissage as, 7, 11-12, 79-81, 81-87f, 91 Treatment tables, for massage, 53-54, 54b, 54f
use in massage, 21 picking up as, 83-84, 86, 87f, 88 Treatment technique, in connective tissue massage,
Precautions, in massage, 136, 139b pounding, 95-97, 96f 238
Pressure pressure of, 65 Triceps, massage for, 191, 192f
in massage, 19-20, 65 shaking as, 98-99 Trigger point stimulation, 297-301, 298-299f, 300f
in stroking, 19-20, 65 short, 239-240, 241f Trunk
Prone pillow, in massage, 53-54, 55f skin rolling as, 88, 90, 90f anatomical structures of, 50b
Psychological effects, of massage, 131-133, 131b, stroking as, 71, 72-74f, 74-75 general massage sequence for, 15It
Peps) tapotement as, 91-93, 95-97 local massage sequence for, 185t, 189t
Pump stroke, in lymphedema, 251, 251f vibration as, 97-99, 98f Tsubo therapy, 315
wringing as, 88, 89f Turn stroke, for lymphedema, 251-252, 252f
Q Stroking. See also Kneading; Massage
contraindications to use of, 75t U
Quadriceps muscle group, local massage to, 201f
deep, 71, 72-74f, 146 Ulna, styloid process of the, 39f
R in Hoffa system, 185-186 Ulnar border
Rate, of massage, 20, 65 definition of, 71 hacking to, 95
Recreational massage, 5, 70 description of, 14-15, 17-18t of right hand, massage to, 194-195, 195f
Reflexology, in massage, 301-302, 303f, 304 history of, 14-15 Unction, 20
Reflex stroking, 21 manipulations in, 71, 72-74f, 74-75, 76-79f, 77, 79 Upper limbs. See also under specific body parts
Reflex zones, in connective tissue massage, rate of movement in, 71 anatomical structures of, 51b
235-237 reflex, 21 in baby and infant massage, 281, 283, 285f
Reinforced kneading, 83, 87f superficial, 71, 146 general massage sequence for, 15It
Relaxation in Hoffa system, 185-186 general massage sequences for, 160-161, 160f,
as component of massage, 63-65 whole-body, in baby and infant, 280-281, 281-283f 161f, 162f, 163, 163f
environmental factors promoting, 64b St-36, acupressure technique to, 313, 313f local massage sequence for, 185t, 189t
factors inhibiting, 63b Subcutaneous tissues, effects of pétrissage on, 91 muscles, wringing to, 89f
for patients with respiratory condition, 225-226 Suckling massage, 286 relaxed passive movements to, 113-114f
Support, patient positioning for, 61, 63 short and long CTM strokes to, 242-243f
physical, promoting, 131-132
Relaxed passive movements, 69, 104-105, 106-114f, Supraorbital ridge, deep stroking to, 177, 179f
Surface anatomy, knowledge of, 50 v
1125 Wis eiiSe
Swan feathers, in massage, 21 Vertebra prominens, 40, 41f
Rhythm, of massage, 20, 65
Rib-springing technique, 232 Symptoms, changes in, 66 Vibration
contraindications to, 99t
Right lower lobe, clapping to, 231f
Risk reduction practices, for lymphedema, 263b
of in respiratory conditions, 232, 232f
Tapotement, in massage, 91-93, 95-97 technique of, 97-99, 98f, 146
Rolfing, in massage, 304
Tendon Viscera, effects of massage on, 128-129
Rolling, skin, 88, 90, 90f, 146
Achilles, digital stroking to, 158, 159f Volumetric method, for lymphedema, 240
S focal massage sequence for, 221-222, 222f, 222t
Ww
Sacro-occipital technique (SOT), 306 Tension, effects of massage on, 131-132
Tensor fasciae latae muscle, massage to, 200f Water, hot, in hand preparation, 53
Sacrum, thumb pad kneading over, 174, 174f
Thai massage, 317-318, 317b Wedge, in massage, 54, 56f
Safety valve insufficiency, 247
Therapeutic effects, of massage, 133 Wellness, effects of massage on, 132-133
Scalp, finger pad kneading over, 181
Therapeutic exercises, for lymphedema, 260, 263t Whole-hand kneading, 80-81, 82f
Scapular muscles, local massage to, 207, 209f
Therapeutic massage;5, 70, 149 Wound care, for lymphedema, 250
Scapular region, kneading over, 173, 173f
Therapeutic touch, 5, 132, 133, 291 Wringing, in massage, 88, 89f
Scarpa’s triangle, 43
Therapist Wrist
Sexual arousal, effects of massage on, 132
body mechanics of, 57, 59, 61, 62f, 63f anatomical landmarks of, 40, 40f
Shaking, in massage, 98-99, 99t, 232
position of, 21-23 transverse frictions to, 102f
Shiatsu, 314-316, 315f, 316b, 316t
Perfect your timing and technique with the companion DVD

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Anatomical Landmarks for Therapeutic Massage
Focal Massage Sequences
Decongestive Therapy for the Treatment of Lymphedema
Massage in Sport
Massage for the Baby and Infant
Massage in Palliative Care
Soft Tissue Manipulation in Complementary/Alternative Medicine

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