Massage

Principles of massage

Basic theory

Massage uses pressure to direct venous and lymphatic flow back towards the heart. It is therefore important that the movement is always in this direction so that there is no undue pressure on the closed valves in the veins. These valves prevent backflow of blood by only allowing blood to move in one direction (i.e. toward the heart). As the pressure from the heart pumping subsides and the blood moves back, the valves close and prevent any further back flow.

Massage may also be used to stretch muscle fibres. In this case, the direction is not as important as the strokes are much shorter and therefore pressure in the wrong direction is not significant enough to cause damage.

Posture

Your ability to administer a good massage will depend largely on your own comfort, therefore maintaining a good posture is beneficial to both you and your client. The following are only basic guidelines and it may be that because of the environment you're in, adjustments may need to be made.

• Work with your back as straight as possible. By flexing your hips and knees, you will be able to move more efficiently and with less stress on your back.
• Foot position is also important and should be such that you can move in an antero-posterior direction without placing undue strain on your back.

Hand position

• The most useful areas of the hand to use are the ulnar border and base of the thumb.
• Other important areas are the palm and the palmar surfaces of the fingers and thumbs. They provide sensory feedback, thus allowing you to adapt your massage with regard to timing and pressure according to the nature of the tissue. It is for this reason that the use of elbows and knuckles should be avoided.
• Keep your arms and hands relaxed while massaging, with the hands conforming to the contours of the body.
• Always pour the oil onto your own hands, never directly onto the client.
• Try to warm the oil (and your hands) before applying to the naked skin. If this is not possible, at least warn the client of what is to come.

Physical contact

• Try to always maintain contact with your client. This allows them to relax, especially if they are lying face down. Removal of the hands may also be interpreted as an indication that the session is over and so cause unwanted movement.
• If for some reason you must break contact, for example at a sports meeting where situations are not ideal, then make sure you cover the client and do not leave them exposed.

Massage techniques

Effleurage (stroking)

The hands are passed rhythmically and continuously over a client's skin, in one direction only, with the aim of increasing blood flow in that direction, stretching tissues, relaxing the client and aiding the dispersal of waste products. The word effleurage is derived from French, meaning "to skim". It involves stroking movements of the hands sliding over the skin and is always the first and last technique (as well as being used between other techniques) applied in a massage session. Effleurage may be used with varying tempo and pressure according to the stage of the condition and whatever the desired effect of the massage is.

Performing effleurage

You should use a wide surface area of the palmar surfaces of the hands and fingers, either with both hands simultaneously or by alternating hands. Pressure is sustained throughout the stroke and is always toward the heart to encourage venous return. On the return stroke, the hands should maintain light contact and avoid the same path taken by the upward stroke. The position, speed and direction of the movements will vary depending on aim of technique and the part of the body being massaged. For example, long, stroking movements may be used on the legs and arms, while a more circular motion may be preferred for the back and neck.

Effleurage should be carried out in a smooth, rhythmical and relaxed manner, beginning with light touch at the start of the session. This should build up to deeper pressure with slower movements for increased circulation and stretching of the tissues at a later stage in the session. The hands should be relaxed and should follow the natural contours of the client's body. The technique should not be rushed, as you need time and quality of movement to determine any tissue abnormalities that require attention. Quick movements will not allow the client to relax and will certainly be more painful if any areas are tender.

When passing your hands over any bony prominences, pressure should be eased, both since there is no therapeutic value of massaging over bone, and to reduce discomfort felt by the client. To complete any massage, use effleurage to relax the client, especially if intense/painful techniques have been used during the session.

Aims of effleurage

• Introduce touch to the client
• Put the client at ease
• Warm the superficial tissues
• Relax the muscles
• Allow you to palpate and sense the condition of the tissue
• Stimulate the peripheral nerves
• Increase blood and lymph flow, thus aiding in the removal of waste products
• Stretch tissues
• Relax the client before the end of the session

Not all of these aims may necessarily be accomplished in one session. Much depends on what the requirements of the client are. Lighter, brisk movements may be indicated is the client is about to participate in sport and needs to be stimulated and energized. The same techniques applies more slowly will be better employed after exercise to relax the client and aid in the removal of waste products.

It is very important to achieve your aims using effleurage before moving onto other techniques, such as petrissage. If the muscles have not relaxed sufficiently, deep tissue massage may be uncomfortable and painful. The more pliable the superficial tissue is after effleurage, the more beneficial the deeper massage will be.

Petrissage (kneading)

The skin is lifted up, pressed down and squeezed, pinched and rolled. Alternate squeezing and relaxation of the tissues stimulates the local circulation and may have a pain-relieving effect with some muscular disorders. Petrissage is derived from a French word, meaning "to knead". The basic movement is to compress, pick up and then release the soft tissues. It is generally used when a deeper effect than effleurage is desired, and it's techniques include:

• Kneading
• Squeezing
• Picking up
• Shaking
• Rolling
• Wringing

Performing petrissage

As with effleurage, pressure is directed toward the heart to encourage venous return. Your hands remain in almost static contact with the client's skin, while moving them over the underlying muscle. The difference is that with petrissage the overall direction is from proximal to distal, as opposed to effleurage, in which the direction of the overall technique is from distal to proximal. This is achieved by first applying shorter strokes toward the heart, but then moving the hands distally before beginning the stroke again. This is supposed to force blood out of an area by the application of pressure, then releasing the pressure and repeating the technique distally to force fresh blood and nutrients into the area.

Aims of petrissage:

• Increase mobility between tissue interfaces
• Stretch muscle fibres
• Aid the interchange of tissue fluids
• Increase venous and lymphatic return
• Relax muscles
• Aid the removal of waste products

Since these techniques are applied to and have an effect on deeper tissues, they are ineffective and difficult to perform on narrow parts of the limbs. It is for this reason that you should pay careful attention to the purpose of the massage when using this technique.

Tapotement

A part of the body is struck rapidly and repeatedly with the hands. Tapotement of the chest wall in bronchitis patients often helps to loosen mucous within the air passages so that it can be coughed up and includes techniques such as hacking and cupping.

Hacking

This is a technique in which both hands alternately strike the client's skin with the ulnar borders. As the other fingers close on the little finger (when contact is made), a characteristic sound is made. It is known to stimulate both the skin and superficial muscle tissue, preparing the body for exercise and is therefore an option for pre-competition massage.

A common mistake is to flex and extend the elbows in order to deliver the alternating strikes to the body. This is inefficient for you and ineffective for the client, as you waste energy and your hands cannot move fast enough to give a decent massage. The technique is properly applied by fixing your upper limbs, with the humerus internally rotated and the elbow and wrists flexed to 90 degrees. Thus, by alternately supinating and pronating the forearms rapidly, the technique can be properly applied. It is important to keep the upper body, including upper limbs relaxed throughout, to conserve your energy and prevent the buildup of stress in your muscles.

Cupping

This involves making an air-tight concave shape with the hand, so that, as it strikes the surface of the body, the air caught beneath the hands is compressed, creating a vibration that penetrates the tissues.

A mistake in this technique is to again flex and extend the elbows to deliver the technique. As with hacking, this is counterproductive. Instead, fix the upper limbs with the humerus internally rotated about 45 degrees and the elbows flexed to 90 degree. Apply the technique by vigorously flexing and extending the wrists, with small, relaxed movements at the elbows to augment the wrist movement. As with hacking, keep the shoulders and upper body relaxed.

Frictions

Frictions are small movements using the pads of the fingers and thumbs to apply considerably more pressure than with other techniques, over isolated areas of the body. Your fingers move with the client's skin in either a circular or transverse direction, and may be used on muscles, tendons and ligaments. They should only be applied for a few minutes as they are painful and can be detrimental if applied too vigorously for too long. Used with medium to firm pressure, this technique may also be used for exploratory purposes, to feel small ares beneath the surface. Greater pressure is used for deeper and invariably more painful movements aimed at breaking down the random formation of scar tissue in an acute injury, as well as separating muscle fibres. Your fingers must remain in static contact with the skin, moving subcutaneous tissue over the deeper tissue.

Performing frictions

Begin by warning the client that the techniques you are about to use may be painful, or at the very least uncomfortable. Tell them the reasons for doing them i.e. to break down scar tissue and restore elasticity and the importance of this. Assure them that the pain will subside shortly afterwards.

Since this is one of the more advanced techniques (and a painful one at that), you should only use them if you are confident that:

• You can accurately locate the lesion/scar tissue.
• You know how to place the affected structure on full stretch i.e. you are aware of the origins and insertions of the structures you will be applying the technique to.
• There will be an overall benefit to your client's condition.

In order to be effective, frictions should be performed, with other massage techniques 2-3 times a week. The purpose is to deliberately break down tissue, stimulate vasodilation and restore elasticity. Particular attention should be paid to how long and how vigorously frictions are applied. You should aim to use this technique for at least a couple of minutes. Any longer and you run the risk of damaging the client's healthy muscle fibres and causing inflammation. Better to err on the side of caution and increase the amount of frictions at a later stage if necessary.

Aims of frictions

• Separate adhesions between fibres
• Break down scar tissue
• Restore elasticity
• Stimulate vasodilation and blood flow
• Stimulate the healing process
• Realign new scar tissue

Effects of massage

Massage can have several effects on the mind and body, including physical, physiological and psychological effects.

Physical effects of massage

Stretches soft tissue

Muscle fibres necessarily have good extensibility because of their function, which is to contract. Most of the restriction in the flexibility of muscles is a result of the surrounding connective tissue of the muscles and their fibres. Vigorous massage techniques, such as wringing and kneading (petrissage), stretch and loosen the skin and underlying tissue. This is achieved by the therapist's hands applying force on the surface in order to push and pull the underlying soft tissue. Other benefits of massage, such as increased blood circulation and temperature, assist in increasing the pliability of the tissues. With the additional force applied, parallel muscle fibres may become separated, which further increases extensibility. Added to this, the connective tissue surrounding muscle fibres is stretched and the fibres stretched longitudinally. This all helps to restore flexibility and separate adhesions.

Relieves muscle tension

The need to relieve tension within the muscle will become apparent either in the initial assessment or by judging the way in which the muscle reacts to the massage. You should be aware of the possibility that the muscle is merely inflexible and should vary your technique accordingly. Tension may be reduced simply by stroking actions that stimulate the peripheral nerve receptors. These nerve endings are situated in the skin and underlying fascia and can detect changes in the environment. These changes are transmitted to the brain via the nervous system, where they are perceived as conscious feeling. They may relate to temperature, pain and pressure. They often create a response in the underlying muscles, for example, extreme cold causes shivering, which creates heat to warm the body. Depending on the stimulus, the response may be for the tension within the muscles to increase or decrease. This is a reflex action, different from the use of mechanical force to stretch muscle fibres and connective tissue, as described above. This should make it clear how discomfort and pain during massage can cause muscles to tighten up, while stroking techniques help to relax them.

Improves muscle flexibility

Massage aimed at muscle relaxation can result in an increased range of motion. This is because of muscles spanning joints. It is because of this that they are able to approximate their origins and insertions (decrease the angle of a joint). By relaxing individual/groups of muscles, you can extend the limit to which the affected joint can move.

Reduce muscle spasm

Muscle spasm is an extreme level of tension in the muscle, usually brought about by the body's protective mechanism resulting from pain. The body reacts by contracting muscles to prevent further movement. As described above, even with extreme levels of tension, massage can help to relax the muscle and increase mobility.

Improves formation of scar tissue

Frictions applied across the overall direction of the muscle fibres ('cross-fibre') to a specific area may be used to separate fibres which may have adhered together as a result of some form of strain or minor tear. Similar actions may be used more aggressively to break down scar tissue and encourage the alignment of new scar tissue with the direction of the existing muscle fibres.

Reduce swelling

Swelling may be caused by blood which has leaked out from torn blood vessels, or by fluids moving through the capillary walls into interstitial spaces. By massaging the area, an increase in movement and temperature within the soft tissues will increase lymph flow - leading to fluids being reabsorbed into the circulatory system. While claims can be made and substantiated about the effects of massage, there is no evidence to suggest that there are any techniques which will increase the strength of a muscle (i.e. bring about hypertrophy). Nor is there any truth in massage being able to reduce fatty tissue.

Physiological effects of massage

Increase blood and lymph flow

Local blood circulation may be improved as a result of massage. As you increase the depth and pressure of the massage, the possibility of compressing and releasing the deep blood vessels increases as well, thus stimulating circulation. Massaging a limb using deep stroking and kneading has also been shown in increase blood flow in the contralateral limb. This is especially beneficial for the patient who has an immobilized limb as a result of fracture, or for partially-abled athletes. Prolonged massage has been demonstrated to increase lymph flow from the area being massaged through the lymph glands to the heart. Increased lymph flow from the extremities may be best stimulated by deep stroking and kneading techniques. It is also known that lymphatic drainage is influenced by gravity i.e. elevating the limb may therefore enhance the effects of massage on lymph flow.

Increase the supply of oxygen and nutrients to the soft tissue

Just as blood flow may be increased as a result of appropriate forms of massage, scientific experiments show that the haemoglobin and red blood cell count may also increase. Combined with an increase in blood and lymph flow, this leads to an improved supply of oxygen and nutrients tot he soft tissue.

Remove waste products

As lymph flow increases as a result of massage, waste products from areas of soft tissue may be reabsorbed via the lymphatic system into the circulatory system.

Relieve pain

There are a number of reflex actions that the therapist can induce which will have a sedative effect on the client or a relaxing effect on a specific muscles. One of these effects, which has a signigicant role to play in massage, is pain relief. Pain generated in an area is perceived by messages traveling to the brain via afferent nerves (sensory nerves, usually found with receptors in the skin and joints). Pain relief works on the principle of the "pain-gate theory". It is known that rubbing the painful area stimulates the cutaneous mechanoreceptors (sensory nerve endings situated in the skin), creating afferent signals that block the transmission of the pain signals to the spinal cord. As the messages to not reach the brain, the perception of pain is reduced.

Stimulate the nervous system

Massage is generally accepted to have various effects on the peripheral and central nervous systems, although these effects are not currently supported by scientific evidence. The theory is that stimulation of the nervous system may also be a major factor contributing to an increase in blood circulation and temperature - which brings about increased muscle elasticity, and delivers fresh nutrients and oxygen to the muscles.

Psychological effects of massage

Relieve tension and anxiety

Massage should be, for the most part, a pleasant, relaxing experience. Therefore, as clients learn this, the expectation often leads to them being in a more relaxed state before the massage begins. There is also considerable overlap between the physiological and psychological benefits of massage. For example, it is more difficult to achieve muscular relaxation without a conscious effort being made to relax mentally at the same time. In this way the neurological stimulus to muscles may be minimised. Consider the reverse. Someone who remains in an anxious state is likely to have much greater muscular tension, with the consequent energy expenditure leading to fatigue more rapidly.

In short, the pleasant feeling (physiological response) of appropriate massage techniques helps with the process of mentally "letting go" (psychological response), which in turn helps the muscles relax. So, it is impossible to separate the physiological and psychological effects of massage, and easy to see how a cycle between the tow is initiated during massage. Massage therefore may be considered to help with physical relaxation and relief of tension and anxiety.

Pain relief

Massage may also be used for pain relief. This is because by stimulating mechanoreceptors in the skin, the afferent signals block the transmission - and therefore the perception - of nociceptive (pain) signals. Once again, by using massage to effect physiological change, the psychological perception of pain will also be altered. This play an important role when dealing with injury management and rehabilitation.

Stimulate physical activity

Just as you can bring about a relaxed state with massage, so too can you alter the pace and intensity of a massage session to stimulate the client and encourage physical activity. You must assess your client's physical and mental state before deciding on an appropriate approach. For example, a client who is already tense and anxious needs to be relaxed with slower techniques, whilst others already relaxed need quicker movements to produce an invigorating effect.

Pre-competition massage, for example, can incorporate brisk, light movements to stimulate the athlete psychologically as well as physiologically.

Contraindications of massage

These are instances in which massage may be detrimental to a client's wellbeing. Questions regarding these precautions should be asked during the subjective assessment, with others perhaps becoming more apparent with observation, as well as during the treatment session. If the client does have a condition which my be contraindicated, you should refer them to a general practitioner. Raise the subject tactfully and without alarming the patient. Reassure them by telling them that it's a only precautionary measure.

Malaise or a high temperature

In these circumstances, the client may have an infection and the onset of illness may be accelerated by treatment with massage. If there's an excess of toxins in the body that's causing the client to feel unwell, both exercise and massage will increase the circulation of these toxins and exacerbate the condition. It is therefore advisable to refrain from both exercise and massage to allow the body's own defence mechanisms time to deal with the infection and to recover.

Acute trauma

Open wounds, recent bruising, muscle tears, sprained ligaments, contusions, burns must be avoided during their acute (healing) phases. During this phase, the damaged soft tissue will be in the early stages of healing and susceptible to further trauma if recently healed blood vessels are reopened by massage.

Skin infections

Look for any signs of skin infection, for example swelling, redness, etc. Any attempt to massage in the vicinity of these areas may spread the condition. The infection may also be passed on to you and others.

Tumours

A tumour is an abnormal mass of tissue, so where there is swelling that is inconsistent with recent bruising, avoid the area until you are aware of what the cause is. If in doubt, advise your client to consult a doctor. If the tumour is malignant and spreading, massage may encourage the spread to secondary sites.

Diseased blood vessels

Blood clots may sometimes be found in the deep veins in the back of the legs (deep-vein thrombosis). When a thrombosis is dislodged, it can have serious (and possibly fatal) consequences if it reaches the heart or lungs. It is a condition that is usually predisposed by a number of factors, including:

• A period of prolonged bed rest
• Varicose veins
• An impact injury
• Heart disease

The condition may be detected by using the following as a guide: when you apply pressure to the area you will feel particularly firm swelling in a localised area, and the client will experience severe pain. There may also be some swelling or discolouration distally (below the site) - as blood collects behind the thrombosis.

Adverse reaction to treatment

If a person reacts adversely to treatment and there is no apparent reason, stop the massage and seek advice. In such cases the usual effects of massage may be detrimental.

Undiagnosed symptoms

If you encounter signs or symptoms of a condition you are not sure of, ask your client to obtain permission from their doctor for massage therapy. Be tactful when you broach the subject with them so as not to give them cause for alarm.

Precautions of massage

The following conditions may not necessarily be contraindicated but do require a cautious approach.

Pregnancy

If you are massaging someone who is pregnant, extra care should be taken during the first 16 weeks, and the areas of the abdomen and lower back must be avoided during this time. If your client has experienced any problems or sickness during the early stages of pregnancy, ask them to seek advice regarding massage from their doctor. In the later stages of pregnancy, finding a comfortable position for your client for their massage may be the only problem you encounter (special couches are made for this purpose). Some women find massage beneficial in removing oedema (swelling) from around the ankles, as well as relieving pain in the lower back.

Diabetes

Diabetes is not contraindicated if is properly managed. If your client is able to exercise then they are unlikely to suffer any adverse reaction to massage. However, since massage does have the effect of stimulating blood circulation, blood sugar levels may be affected and your client should be aware of this so that they can adjust their medication accordingly.

Varicose veins

Varicose veins occur when valves in the veins fail and prevent the flow of blood back to the heart. This causes a pooling of blood, commonly in the legs. If someone has varicose veins that could be damaged by massage they will usually be under medical supervision and possibly awaiting surgery, so a simple check with the client will give you the information you need. If they are able to exercise, light effleurage, properly applied in the direction of the heart is generally harmless. Varicose veins should not be confused, particularly after exercise, with blood vessels that have become prominent due to physical exertion.