Chapter 4 Classification, Definitions, and Descriptions of the Basic Massage Strokes and Relaxed Passive Movements

As the brief history of massage presented in Chapter 1 revealed, there have been, and still are, many different ways of defining the various massage techniques. This chapter provides specific information about each of the traditional massage strokes that are based on the system known as Swedish remedial massage. The definitions and descriptions represent a current view of the various techniques. Of course, some of the descriptions of the strokes are at variance with earlier ones. This is not surprising, given the considerable disagreement over massage terminology used in the past. Indeed, it is hoped that the classification and descriptions detailed in this chapter are logical, accurate, and worthy of adoption. In most cases, photographic examples are given of each of the strokes to several body parts, and many of these strokes are also featured in Chapters 7 and 8, which address general and local massage techniques.

The DVD that accompanies this text demonstrates each of the basic strokes to all the main regions of the body in a way that cannot be replicated with still photographs. For each technique, the DVD section is identified, making it easy for the reader to view the technique in question. Of course, it is possible to pause and repeat the video section as needed. The video provides an opportunity for viewers to understand the finer points of each technique, such as the rate and rhythm. In addition, the surface anatomy sections of the DVD provide essential information to support the practical techniques demonstrated in the video.

A section on the techniques known as relaxed passive movements or simply passive movements follows the descriptions of the basic massage techniques. Although these techniques are not massage per se, they are important soft tissue manipulation techniques that need to be addressed. In general, these techniques should be used after massage and before active exercise. The basic techniques are demonstrated on the accompanying DVD, which features a section on relaxed passive movements for the neck, the upper limb, and the lower limb (see DVD Chapter 4).

Before defining the individual massage strokes, it is helpful to start with a definition of the general concept of soft tissue manipulation itself. Several terms are often used interchangeably, so it may be useful to mention these here as well. Soft tissue manipulation is described as follows:

A variety of manual techniques to the soft tissues of the body, designed to improve intertissue mobility and produce pain-free function.

What then are the soft tissues of the body? Essentially, the soft tissue of the body comprises all structures that are not a direct part of the skeleton. Thus, the bones, and therefore the joints, can be considered as the hard tissues, together with articular and fibrous cartilage. In addition, the teeth, fingernails, and toenails can be classified as hard tissue. Although there is an entire discipline of manual therapy dedicated to mobilizing and manipulating the joints, one can argue strongly that even these techniques are directed at the soft tissues rather than the bones and joints themselves. The bones and joints do not bend and stretch during or in response to these techniques. Instead, it is the soft tissues surrounding the joints (skin, capsules, ligaments, tendons, etc.) that are affected, together with those muscles whose tendons span the joints being treated. A simple classification of soft and hard tissues is shown in Table 4-1.

Table 4-1 A Classification of Soft and Hard Tissues

SOFT TISSUES	HARD TISSUES
Skin	Bones
Subcutaneous tissues	Teeth
Muscles	Finger and toenails
Tendons	Articular and fibrous cartilage
Ligaments
Joint capsules
Nerves
Blood vessels
Lymph vessels
Heart and lungs^*
Abdominal organs^*
Pelvic organs^*
Brain^*
Eyes^*

* These structures/tissues are soft tissue in nature but cannot be massaged because of their anatomical locations.

Some of the structures/tissues listed in Table 4-1 are soft tissue in nature but cannot be massaged because of their anatomical locations (e.g., brain, heart, lungs). Although soft tissue manipulation can affect the abdominal viscera in a general way, it cannot be applied directly to a specific abdominal or pelvic organ. Clearly then, soft tissue manipulation can have an effect on almost all tissues of the body. Many of these effects are discussed in Chapter 5. There are a variety of techniques that can be considered as types of soft tissue manipulation, and these are listed in Box 4-1.

With regard to the various systems of massage and bodywork (another common term for a type of soft tissue massage), this text differentiates two basic groupings: recreational massage and therapeutic massage. Some of the specific massage strokes described in this text (or modifications of them) can be used for both recreational and therapeutic massage. In this regard, it is important to clearly differentiate between the two categories.

Collins English Dictionary defines the word recreation as “refreshment of health or spirits by relaxation and enjoyment.” Other major English dictionaries use similar descriptions, and it is in this context that the term recreational massage is intended.

Dorland’s Medical Dictionary defines therapeutics as “the branch of medical science concerned with the treatment of disease.” Clearly intended in this definition is the assumption that a health problem exists that requires healing. For this reason, the term therapeutic massage is used to denote a massage treatment intended to facilitate healing when a specific health problem exists. This text deals only with various forms of therapeutic massage.

There are numerous variations of technique used in recreational massage. Although many of these techniques certainly feel good to the client, some may have little therapeutic value. Other techniques seem similar to the more therapeutic procedures. Of course, all of these techniques have considerable psychological value. For this reason, it is helpful to distinguish between recreational massage and therapeutic massage.

Recreational massage is defined as follows:

The use of a variety of manual techniques designed to relieve stress and promote relaxation and general wellness in a person who has no definable health problem.

Therapeutic massage is defined as follows:

The use of a variety of manual techniques designed to promote stress relief and relaxation, mobilize various structures, relieve pain and swelling, prevent deformity, and promote functional independence in a person who has a specific health problem.

In addition to these major distinctions, it may be helpful to define three basic ways in which therapeutic massage may be given to a patient. A specific chapter in the text is devoted to each of these concepts. In each case, various techniques are combined to form a massage sequence, and these may be given to the entire patient (Chapter 7), to one or more regions of the body (Chapter 8), or to a specific anatomical structure (Chapter 9).

General massage is defined as follows:

A combination of different massage strokes applied to all the major regions of the body in a single treatment session in order to achieve particularly desired effects.

Local massage is defined as follows:

A combination of different massage strokes applied to an individual region of the body in order to achieve particularly desired effects.

Focal massage is defined as follows:

A combination of one or more different massage strokes applied to specific anatomical structures in order to achieve particularly desired effects.

In addition to a detailed description of each massage stroke, the following sections discuss the specific effects of each technique and the common contraindications. This approach brings together all of the information pertinent to each stroke.

CLASSIFICATION OF MASSAGE STROKES

Individual massage strokes can be classified in a number of ways. Here, they are grouped on the basis of the way in which each one is performed (e.g., a pressure stroke). Individual strokes are classified as described in Table 4-2.

Table 4-2 A Classification of Massage Strokes

MANIPULATION (STROKE)	VARIATIONS
Stroking manipulations	Stroking
Stroking manipulations	Effleurage
Pressure manipulations (pétrissage)	Kneading
	Picking up
	Wringing
	Skin rolling
Percussion manipulations (tapotement)	Hacking
	Clapping
	Beating
	Pounding
Vibration and shaking
Deep frictions	Transverse
	Circular

STROKING MANIPULATIONS

Stroking

Figures 4-1, 4-2, and 4-3 show the different directions for the technique of stroking. In addition, the DVD demonstrates stroking on several body areas.

Figure 4-1 Stroking to the Back

In this example (A, B), stroking is performed in a 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 direction—that is, down the back (C, D) and across the low back region (E). See also DVD Chapter 4-2.

Figure 4-2 Stroking to the Upper and Lower Limbs

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 diagonally). 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 surfaces 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.

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.

Contraindications to the Use of Stroking

The general concept of contraindications is covered in Chapter 3. As a technique, stroking may be contraindicated when any of the situations listed in Table 4-3 are present.

Table 4-3 Main Contraindications to the Use of 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 be possible)	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 who are very sensitive/ticklish to touch)	R
Extremely hairy areas in the areas to be treated (if stroking causes pain)	R

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

Effleurage

Definition

Effleurage (from the French word effleurer: to skim) is a slow, stroking movement performed with increasing pressure in the direction of flow in the veins and lymph vessels (i.e., centripetal direction). The stroke finishes with a definite pause and, whenever possible, in a group of superficial lymph glands.

Purpose

Effleurage is a stroke designed to move the fluid contents of the superficial veins and lymph vessels. It is particularly useful as a means of stimulating the circulation and as a stroke used between manipulations that tend to mobilize tissue fluids. For example, after a series of deep kneading strokes to a muscle, effleurage given to the area will help to move the fluids that have been mobilized by the kneading. It can also be a useful stroke to finish off a massage sequence.

Basic Technique and Direction of Movement

Effleurage is always given in the direction of the venous and lymphatic flow (i.e., toward the heart, in a centripetal direction). The manipulation is performed with the palmar surface of one or both hands, working either alternately or simultaneously. Small areas such as the face or foot can be treated with the fingers or the thumb of one or both hands.

The hand, or hands, must be relaxed and molded accurately to the shape of the part being treated. The stroke should be smooth and rhythmic and is directed toward a group of lymph glands, following the course of superficial veins and lymphatics, with the therapist always working from distal to proximal areas. At the end of each stroke, the therapist’s hands may be allowed to gently stroke back to their starting position, or they may be lifted from the surface of the body and returned through the air to the starting position for the next stroke. Each method has advantages and disadvantages, so in practice, either technique is acceptable.

Rate of Movement

Effleurage is performed quite slowly (about 7 inches per second) because the pressure exerted on the tissues is much greater than just the weight of the therapist’s hands. Rhythm is extremely important with this stroke: as usual, it should be even so that each stroke is smoothly performed throughout the area being treated.

Depth and Pressure

To affect the contents of the superficial veins and lymphatics, effleurage must be performed with significant pressure. Pressure should gradually increase throughout the stroke so that the venous blood and lymph are pushed through the veins and lymph channels. There should be a definite pause at the end of each stroke, at or near the appropriate group of superficial lymph glands. This allows the valves in the vessels to close, thus minimizing back flow. These changes in pressure during the stroke make it important to maintain firm but comfortable pressure on the tissues. The greatest pressure is exerted at the end of the stroke when the hands or hands are stationary.

Effleurage to a variety of body areas is depicted in Figures 4-4 throuh 4-6. In addition, on the DVD effleurage is demonstrated to several body areas, as noted in the following table.

Figure 4-4 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 in a 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.

Figure 4-5 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 cover the 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.

Figure 4-6 Effleurage 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.

Primary Effects of Effleurage

The therapeutic effects of effleurage are produced mainly through a direct mechanical impact on the tissues; however, there are reflex effects mediated through the sensory nervous system. When performed properly, effleurage has the following primary effects:

• An increase in the flow of venous blood in the superficial and deep veins toward the heart. When pressure is relaxed, the valves in the veins prevent backward flow.

• A stimulation of lymph flow, resulting in more rapid elimination of waste products.

• An increased flow in the veins and lymphatic vessels relieves the congestion in the capillaries, allowing vascular and lymphatic fluids to flow more readily into and out of the capillary beds, thereby stimulating the circulation and facilitating healing.

• An increase in the mobility of the skin and subcutaneous tissues, which in turn increases range of motion in joints and limb segments.

• Dilation of the superficial arterioles through the axon reflex, thereby stimulating the circulation.

• Stimulation of the large-diameter mechanoreceptors in the skin, thereby relieving pain (pain-gating mechanism), reducing muscle spasms, and promoting relaxation.

Therapeutic Uses of Effleurage

When included in a treatment sequence, effleurage can be used to do the following:

• Increase blood and lymphatic flow in the superficial and deep circulation.

• Promote the absorption of inflammatory exudates in the subacute and chronic stages of soft tissue injuries (edema).

• Relieve pain and muscle spasm, thereby promoting relaxation.

• Follow other strokes (e.g., kneading, friction) that have deeper effects and thereby encourage the absorption of waste products into the lymphatic system.

• Help both patient and therapist become accustomed to the feel of each other’s tissues. For the patient, it is the sensation of the therapist’s hands. For the therapist, it is the contours and quality of the patient’s tissues.

• Join various massage manipulations (strokes) together into a smooth sequence and thus give continuity to the massage treatment.

Contraindications to Effleurage

The general concept of contraindications is covered in Chapter 3. As a technique, effleurage may be contraindicated when any of the situations listed in Table 4-4 are present.

Table 4-4 Main Contraindications to the Use of 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 or any other heart condition with which lower limb edema is associated	U
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 be possible)	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 stroking causes pain)	R

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

PRESSURE MANIPULATIONS

Pétrissage

Pressure manipulations (pétrissage, from the French word pétrir: to knead), include several different massage strokes that are characterized by the application of firm pressure to the tissues. In the majority of cases, these strokes aim to mobilize deep muscle and tendon tissue, including the skin and subcutaneous tissues covering them. Four distinct types of stroke are discussed in this section: kneading, picking up, wringing, and skin rolling.

Kneading

Definition

Kneading is a manipulation in which the muscles and subcutaneous tissues are alternately compressed and released. The technique produces movement in a circular direction. Each circular movement is divided into two roughly equal phases: compression and relaxation accompanied by a sliding movement of the hands, fingers, or thumbs. During the pressure phase of each stroke, the therapist’s hands (or fingers or thumbs) and the skin move together on the deeper structures. During the release (relaxation) phase, the hands (or fingers or thumbs) glide smoothly to an adjacent area of tissue where the movement is repeated.

Purpose

Because of the compressive forces applied to the tissues, kneading strokes have a strong mechanical action and are designed to affect deep tissue. In particular, kneading aims to mobilize muscle and tendon fibers and other deep structures, thus promoting the normal function of muscles, which is not only to contract to produce movements but also to lengthen and allow movement in the opposite direction. To allow this, muscle fibers and other structures must be mobile. Kneading is also useful for mobilizing chronic swelling, especially where such swelling has become organized and is preventing normal joint and limb motion.

Basic Technique and Direction of Movement

Kneading is a stroke in which the therapist’s hands and the patient’s skin move together on the deeper structures whenever pressure is applied to the tissues. It can be performed with several parts of one or both hands, including the entire palmar surface and the pads/tips of the fingers or thumbs. In each case, the basic direction of the movement is circular. Pressure is applied during half of the circular motion and released with relaxation during the other half. Although kneading can be performed in a stationary manner (stationary kneading), it is more usual for the hands to move across the body surface during the technique. Movement of the hands is achieved during the relaxation phase of each circular motion. The hands usually move in parallel lanes to cover the entire area to be treated. The larger the area, the more lanes are needed. This type of kneading compresses the tissues and is therefore known as palmar kneading. Several variations of the technique can be used, and these will be considered in a later section. Figure 4-7 illustrates the concept of circular motion and movement in parallel lanes. It is common to most, but not all, types of kneading.

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.

Rate of Movement

Kneading is performed slowly because of the pressure exerted on the tissues. If it is performed too quickly, it is likely to be ineffective or uncomfortable for the patient. The rate of movement is similar for both stationary kneading and the more common mobile versions. When using the whole hand(s), each circular movement should take about 3 to 4 seconds to complete. Obviously the rate is much lower if the finger pads or thumb pads are used to perform the massage, as they are so much smaller.

Depth and Pressure

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 should be performed with much less pressure, especially on more delicate structures such as the backs of the hands or face. It is important for the pressure to be applied during only half of each circle. At such times, the hands are not moving on the skin; rather, the hands and the skin move over the deeper structures. It is not easy to quantify the actual pressure needed during kneading, but the experienced therapist will be able to apply the correct amount of pressure to treat the deep tissues effectively without harming the patient.

Variations

Several variations of the basic kneading stroke are used, and these are explained in the following sections.

Palmar Kneading.

When the entire palmar surface is used, the technique may be called palmar kneading. The basic palmar kneading stroke is also called compression kneading, circular kneading, flat-handed, and whole-hand kneading. In this manipulation the tissues are compressed upward and inward in a circular motion against the underlying tissues and then released. Overlapping lanes of circular strokes are used to cover a large area of the body, such as the back. If the tissues are flat, such as the back region, both hands can be used on the same plane of motion (side by side). In the limbs, however, the hands usually work opposite to each other (on either side of the limb). This produces more movement of the whole muscle masses involved.

Figures 4-8 and 4-9, A, illustrate the basic two-handed technique. The techniques shown in Figure 4-9 are good examples of the therapist’s hands working opposite each other and out of phase. Palmar kneading, using one- and two-handed techniques, is also demonstrated on the DVD.