BRIEF HISTORY AND THEORETICAL FOUNDATIONS

Connective tissue massage, as its name suggests, is a system of manual techniques specifically aimed at affecting the connective tissues in the body, especially the skin. Elizabeth Dicke, a German physiotherapist, was the first to describe the technique in the late 1920s and early 1930s. Dicke was suffering from a serious circulatory impairment in her right leg that resulted in the development of endarteritis obliterans of the limb. This painful condition was so severe that surgeons recommended amputation. In an attempt to relieve the accompanying low-back pain, Dicke discovered an unexpected effect in her leg when she rubbed certain areas on the posterior pelvic region. While she applied pulling strokes to the skin of her posterior pelvic region, she was aware of a sensation of warmth rushing into her affected leg. After 3 months of this massage (performed by a colleague), the severe symptoms began to subside. Within a year, she was back at work as a physiotherapist. A great deal of clinical study and evaluation followed this initial experience. Dicke, along with her colleagues, refined her original stroking technique to treat many pathologically involved tissues and organs. She went on to develop the method of bindegewebsmassage now widely used in Europe, especially in Germany, and well known in most parts of the world. Broadly speaking, Dicke and others claimed that this massage affects the autonomic nervous system and, by reflex action, corrects imbalances in the vegetative functions of the body. CTM is not just another massage stroke but rather a complete system of treatment that happens to use soft tissue massage as a means of inducing reflex activity in various tissues.

REFLEX ZONES (HEAD’S ZONES)

Since the late 1890s, it has been known that visceral disease can be associated with visible and palpable changes in the skin in well-defined areas of the body. These areas are known as Head’s zones, after Head (1889), who first described them.

As the primitive embryo develops, three layers of tissue begin to differentiate into an outer layer (ectoderm), a middle layer (mesoderm), and an inner layer (endoderm). The ectoderm develops into the skin and nervous system, while the endoderm forms the various internal organs of the body. The middle layer (mesoderm) gives rise to the various structures of the musculoskeletal system. By the end of the fourth week of gestation, a series of approximately 39 to 44 distinct cube-shaped bulges develop bilaterally within the mesodermal layer. These bulges are known as the mesodermal somites, and they divide the mesoderm into 44 segments (cranial to caudal).

As the nervous system develops further (from the ectoderm), a pair of nerve roots (spinal nerves) form adjacent to most of the original mesodermal somites. These nerve roots will eventually contain sensory, motor, and autonomic nerve fibers that will innervate skin, muscle, bone, and viscera. These connections give rise to the important concepts of dermatomes, myotomes, and sclerotomes (areas, respectively, of skin, muscle, and bone that are supplied by a single spinal nerve root). The skin of the posterior trunk retains most of the orderly innervation, originally derived in company with the 38 to 44 primitive segments. This gives rise to the notion that areas of skin on the posterior trunk have an embryonic link to various musculoskeletal and internal organs of the body (Head’s zones). Figure 11-1 illustrates this concept.

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 8 cm 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.)

A key concept underpinning CTM and other systems involving manipulation of the soft tissues is that pathologic changes affecting any of the structures derived from a mesodermal somite eventually give rise to signs and symptoms in any related structures, especially in the skin and connective tissues. The fact that visceral lesions may give rise to changes in other areas is well known; for example, liver and gallbladder problems can be reflected in the right mid- to lower posterior costal segments (T6 to 10) and in the right upper rectus region. The changes that take place in a related zone are detectable by palpation of the skin and subcutaneous tissues of the same area. The connective tissues have characteristic areas of local tension. There is a certain tightness of the different layers against each other where normally there would be a limited amount of movement between them (Hirschberg, Fatt, & Brown, 1986). Within each zone of influence of a spinal segment or segments, there is often a circumscribed area that is related to a particular organ; these areas are known as maximal points. These changes can be detected by palpation of the area. Holey (1995a) and Holey and Watson (1995) described the basic concepts of zone recognition and inter-rater reliability in the detection of these zones.

A key treatment concept in CTM is the following:

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 distance away from the point of effect. This is more obvious with treatments such as acupressure and reflexology. Because there is often no direct mechanical effect from the manipulation, the most likely explanation for the treatment effect is that it is the result of a reflex, in this case an autonomic reflex. An autonomic reflex has all of the usual characteristics of a reflex—namely, it has receptors at one end, effectors at the other, and a pathway in between. The receptor side of the reflex is part of the somatic nervous system, whereas the effector part belongs to the autonomic nervous system. The pathway in between is formed by nervous connections from both systems.

The receptors are a wide variety of afferent endings in the skin, subcutaneous tissues, blood vessels, muscles, and the viscera. The effectors are largely smooth muscle fibers in a variety of tissues, such as blood vessels, viscera, glands, and the skin. The pathway is formed by the various interconnections between the afferent fibers of the somatic nervous system and the efferent fibers of the autonomic nervous system, especially through the sympathetic chain of the sympathetic division and the sacral outflow of the parasympathetic system. Figure 11-2 illustrates this concept.

Figure 11-2 Principles of an Autonomic Reflex

An autonomic reflex consists of a response in the effectors, produced by stimulation of the receptors. The receptors are part of the somatic nervous system, whereas the effectors consist of largely smooth muscle tissue in the autonomic nervous system. Interconnections at the spinal cord, the sympathetic chain, and the sacral outflow provide the pathway for the reflex.

The autonomic reflex described previously connects the stimulation (including massage) of afferent receptors in the skin and subcutaneous tissue with potential responses in many different types of tissue. It is an important concept to help explain the mechanisms involved with the remote-site effects seen with CTM and other soft tissue manipulations. It is important to remember that the lumen of the small arterioles is largely under the control of sympathetic nerve fibers. When these fibers are active, they cause the smooth muscle in the arteriolar walls to contract, thereby producing vasoconstriction. When sympathetic fiber activity decreases, however, the smooth muscle relaxes and vasodilation occurs. This brings more blood, and therefore oxygen and nutrients, to the tissues. It also allows waste products from the tissue to be removed more efficiently. These effects are likely to facilitate healing in the tissues. It is also possible that a similar effect could be produced by a chemical rather than neural activation of autonomic reflex activity. Soft tissue manipulation could cause the local or general liberation of chemical substances that activate such a reflex. For example, vasoactive intestinal polypeptide (VIP) has a profound effect on the circulation and on systemic pain relief and has been associated with CTM (Kaada & Torsteinbo, 1987, 1989

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