The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, I), reflecting the strength of evidence and the magnitude of net benefit (benefit minus harm).

A The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concluded that the balance of benefits and harms is too close to justify a general recommendation.

D The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective, or that harms outweigh benefits.

I The USPSTF concludes that evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

From U.S. Preventive Services Task Force Ratings: Grade definitions: guide to clinical preventive services, ed 3, Periodic updates, Rockville, Md, 2000-2003, Agency for Healthcare Research and Quality.

How the Body Responds to Massage

Massage effects appear to be determined by a combination of reflexive and mechanical responses to forces imposed on the body by massage (Box 3-2) (Figures 3-1 and 3-2).

Box 3-2 Mechanical Forces Produced by Massage

Log on to your Evolve website to view videos 3-1 through 3-6 on these mechanical forces produced by massage.

Forces created by massage include tension loading, compression loading, bending loading, shear loading, rotation or torsion loading, and combined loading.

Tension Loading

Tissues elongate under tension loading with the intent of lengthening shortened tissues. Tension force is created by methods such as traction, longitudinal stretching, and stroking with tissue drag. Tension forces cause an aggregation of collagen, resulting in thicker and denser tissue to improve the direction of fiber development, stiffness, and strength. Tension loading is effective during the secondary phase of healing after the acute inflammatory stage has begun to dissipate.

Compression Loading

During compression loading, tissue shortens and widens, increasing pressure within the tissue and affecting fluid flow. Compression is effective as a rhythmic pump-like method in facilitating fluid dynamics. Sustained compression results in more pliable connective tissue structures and is effective in reducing tissue density and binding.

Bending Loading

In bending loading, the therapist applies combined forces of tension on the convex side and compression on the concave side of the tissue. Bending is used when combined effects of lengthening and shortening and an increase in pliability are desired.

Shear Loading

In shear loading, the massage therapist moves tissue back and forth, creating a combined pattern of compression and elongation of tissue. This method is particularly effective in creating controlled inflammation and in ensuring that tissue layers slide over one another instead of adhering to underlying layers, creating binding.

Rotation or Torsion Loading

Rotation or torsion loading is a combined application of compression and wringing, resulting in elongation of tissue along the axis of rotation. It is used when a combined effect of fluid dynamics and connective tissue pliability is desired.

Combined Loading

In combined loading, two or more forces are used to load tissue. The more forces are applied to tissue, the more intense is the response. Tension and compression underlie all the different modes of loading; therefore, any form of manipulation is tension, compression, or a combination of these. Tension is important in conditions in which tissue needs to be elongated; compression is important when fluid flow needs to be affected. Oscillation of tissue can be considered combined loading.

FIGURE 3-1 Massage applications systematically generate force through each tissue layer. This figure provides a graphic representation of force applied, which would begin with light superficial application, progressing with increased pressure to the deepest layer. (From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 3, St Louis, 2004, Mosby.)

FIGURE 3-2 Examples of mechanical force loading during massage.

A, Tension loading occurs when tissue is elongated. Gliding massage methods and stretching can create tension forces in tissues.

B, Tension forces occur as tissues are stretched.

C, Compression loading occurs when force moves into tissues at a 90-degree angle. In this example, a forearm is used to create compression force in tissues of the shoulder with the client in a side-lying position.

D, Forearm used to compress calf with client in side-lying position.

E, Bending loading. In this example, the hands are used to bend tissues of the calf around the thumbs.

F, Using force compression to displace tissues of the calf, creating a bending force.

G, Example of shear loading. The tissues of the calf are pushed down.

H, Then the same tissues as in part G are pulled up. The back-and-forth movement creates the shear force.

I, Torsion forces twist tissue around a fixed point. In this example, thigh tissues are twisted around the femur.

J, Rotational or torsion forces in massage are generated by kneading. Move tissues by pushing one hand forward and around the fixed point while pulling the other hand back and around.

K, Example of combined loading when two or more mechanical forces are generated. Bending force caused by grasping and lifting.

L, Then client creates the tension force and the wrist is moved.

M, In this example of combined loading, compressive force is created as the therapist presses down on arm tissues and then moves the forearm back and forth to add torsion, bend, and shear forces.

Reflex response results from stimulation of the nervous system to activate feedback loops with the therapeutic intent of adjusting neuromuscular, neurotransmitter, endocrine, or autonomic nervous system (ANS) homeostatic mechanisms. For example, light stimulation of the skin usually results in a tickle or itch response and is arousing and stimulating. Our current understanding is that the effects of massage occur through the interrelationships of the central nervous system (CNS) and the peripheral nervous system (and their reflex patterns and multiple pathways), the ANS, and neuroendocrine control. Current consensus is that massage produces effects through a combination of neural, chemical, mechanical, and psychological factors that are important in supporting athletic performance and a fitness lifestyle.

In general terms, the total sensory input to the CNS affects overall tension throughout the body. This is why nonphysical emotional and mental stress can lead to physical symptoms such as headaches, digestive problems, and muscular discomfort. Massage works on many levels, which aim to reduce the symptoms that cause negative sensory input and to increase positive sensory input. This accounts for the general well-being that clients usually feel after treatment.

Massage can affect the nervous system in several ways. It stimulates nerve receptors in the tissues that control tissue tension. On a sensory level, the responses of mechanoreceptors to touch, pressure, warmth, and so on are stimulated. Generally, a reflex effect leads to further relaxation of the tissues and a reduction in pain.

Tension in the soft tissues can cause overactivity in the sympathetic nervous system. By releasing this tension, massage can restore balance and stimulate the parasympathetic system, resulting in a positive effect on minor and sometimes major medical conditions, such as high blood pressure, migraine, insomnia, and digestive disorders.

Mechanical responses to massage most often result from tissue deformation and the response of the intricate facial system. Structure can be thought of as anatomy, and function as physiology. Some massage applications can shift structure, primarily through influence on the connective tissues of the body. Massage always has a physiologic result because of required adaptation to the presence of the massage practitioner, the sensory stimulation of various touch receptors, and the client’s perception of the therapeutic interaction. Therefore, massage can achieve primarily physiologic responses of the body, and massage results cannot be isolated as strictly structural outcomes. This is an important concept in understanding the synergistic and multidisciplinary use of various methods to support the athlete.

It is reasonable that massage application is likely to influence the adaptive, restorative, and healing capacities of the body. Anatomic and physiologic outcomes include the following:

• Local tissue repair, as with a sprain or contusion

• Connective tissue normalization that affects elasticity, stiffness, and strength, as when pliability of scar tissue or overall flexibility is improved

• Shifts in pressure gradients to influence body fluid movement

• Neuromuscular function interfacing with the muscle length-tension relationship; force couples; motor tone of muscles; concentric, eccentric, and isometric functions; and contraction patterns of muscles working together to support efficient movement

• Mood and pain modulation through shifts in ANS function, yielding neurochemical and neuroendocrine responses

• Increased immune response to support systemic health and healing

Each of these common outcomes for massage supports rehabilitation, fitness, and performance recovery.

Sport/Fitness and Rehabilitation Outcomes

Objective

2. List and describe four general outcomes for the athlete/fitness and physical rehabilitation population.

Research often attempts to answer the question, “Does this (medicine, surgery, exercise, machine, food, and so forth) affect this outcome?” Before the evidence is explored, the outcomes need to be defined. The main outcomes of massage for sport and fitness are increased body stamina, stability, mobility, flexibility, and agility; reduced soft tissue tension and binding; normalized fluid (blood and lymph) movement; management of pain; reduction of suffering; support of healing mechanisms; alteration of mood; improved physical and mental performance; and experiences of pleasure. All of these outcomes can be appropriately applied to athlete care or rehabilitation after pathology, especially within the context of a multidisciplinary system.

These outcomes can be classified as four goal patterns for sport and fitness:

1. Performance enhancement/recovery

2. Condition management

3. Rehabilitation/therapeutic change

4. Palliative care

The question is, “Is the evidence that supports massage as an intervention to achieve these outcomes as good as or better than that for other types of interventions, and can massage be supportive in conjunction with other approaches to care?”

Performance Enhancement/Recovery

As was previously discussed, fitness and performance are not the same. Optimal performance is most often achieved when fitness is attended to first. Performance motivation and activity exceed fitness requirements by pushing the body to achieve activities that are outside the fitness parameters. Performance therefore becomes a strain on the system. Balancing fitness and performance is tricky with athletes. It is important for those whose goals are fitness oriented to not exceed the beneficial physical outcomes by getting caught up in performance demands that lead to increased strain on adaptive capacity.

Continual performance demand interferes with fitness and compromises health. Normal function and performance are not the same. A person who is learning to walk again after an accident exerts effort and has similar physical manifestations and demands on the body as an athlete does when seeking to decrease his or her 40-yard dash time. However, one is seeking to regain normal function, and the other is striving for peak performance. Performance is more than normal function.

The sports massage therapist needs to consider how the massage application supports the following client goals:

• Achieve normal function through rehabilitation and conditioning

• Maintain fitness

• Reduce the negative effects that performance demand places on the body in excess of normal function

All people who engage in exercise may strive for excellence at some performance level. The elderly person who is beginning a cardiac rehabilitation program, the professional athlete striving for success in competition, and the child learning to walk—anyone who uses the body in a precise way—are all concerned about the ability to carry out an action with skill. Their motivations may vary but the desired outcome is the same—increased proficiency when performing the activity. Physical performance involves training, practice, and demand on the body. When desired performance levels are achieved and practiced, they become automatic.

Performance enhancement requires increasing demand on the body through practice. Maintaining performance involves attention to demand on the body and reinforcement. Each individual has a range of peak performance with the triad of body/mind/spirit function in his or her optimal range. As discussed in Chapter 8, this is called “the zone.” Peak performance is difficult to maintain for extended periods of time. Recovery is necessary to restore depleted energy and regenerate damaged soft tissue. Most athletes train at levels below peak performance with the desired outcome of reaching that peak during competition. This process is compromised if ongoing competition is extended over periods of time. This is common among professional athletes, especially in team sports such as baseball, basketball, football, hockey, and soccer.

Massage application can support performance by facilitating recovery and removing impediments to training.

General Massage Benefits and Safety

Objective

3. Explain evidence that indicates that massage is a supportive and safe intervention.

Benefits and safety are the most important factors to consider for any client population. In the sport and fitness world, we have the ability to use research evidence to justify general massage as the foundational approach for this population.

Research findings are mixed regarding the efficacy of massage. Generally, massage as the primary treatment for various conditions was not found to be a definitive treatment on its own, but studies were supportive of many other interventions used in enhancing effects or managing side effects of other treatments. This means that typically massage would be a beneficial part of a fitness program but should not be expected to provide optimal outcomes when it is the only therapeutic intervention used.

The “why massage works” remains elusive, but recurring findings suggest possible physiologic mechanisms for massage benefit. One study by Field and her associates (2005) is particularly relevant for this text because it deals with serotonin, which is associated with body pain modulation mechanisms. In other studies, Diego et al. (2004, 2009) speaks to how massage needs to be applied with sufficient nonpainful compressive force to stimulate an anti-arousal response, and that massage that is considered light tends to stimulate the sympathetic ANS response (Field et al., 2010).

Pressure Depth

Pressure-based massage produces different physiologic changes than are produced by light touch (Sefton et al., 2011; Rapaport et al., 2010). Application of moderate pressure massage appears necessary to influence hypothalamic-pituitary-adrenal function (Rapaport et al., 2010; Field et al., 2010) and diastolic blood pressure (Moraska et al., 2010). Light or moderate pressure massage (or a combination) may reduce the sensitivity of spinal nociceptive reflexes (Sefton et al., 2011; Roberts, 2011).

Light pressure gliding stroke–based massage has been shown to lower heart rate and systolic blood pressure and to decrease the deterioration of natural killer cell activity; however, no effects were identified for cortisol levels and diastolic blood pressure (Hillier et al., 2010; Billhult et al., 2009). Pressure levels used during massage are an important concept for athletes seeking restorative benefits from massage. It appears that moderate to light pressure can affect generalized restorative function, and deep aggressive massage application is not necessary to achieve these benefits.

The study “Massage Reduces Pain Perception and Hyperalgesia in Experimental Muscle Pain: A Randomized, Controlled Trial” (Frey Law et al., 2008) suggests that massage is capable of reducing myalgia symptoms by approximately 25% to 50% (extent of effect varies with the assessment technique used to measure pain). The purpose of this study was to determine the effects of massage on pressure pain thresholds (PPTs) and perceived pain. Researchers used delayed-onset muscle soreness (DOMS) as a model of myalgia (muscle pain). This condition is a major issue for athletes and those attempting to integrate an exercise program into their lifestyle.

The way Frey Law and associates conducted the research was to randomly assign participants to a no treatment control, superficial touch, or deep tissue massage group. A specific type of wrist exercise was performed at visit 1 to cause DOMS 48 hours later at visit 2. Pain, assessed using a visual analog scale (VAS), and pressure needed to cause pain were measured at baseline, after exercise, before treatment, and after treatment.

Results of the study showed that deep massage decreased pain (48.4% DOMS reversal) during muscle stretch. Mechanical hyperalgesia (increased pain response to pressure) was reduced (27.5% reversal) in both the deep massage and superficial touch groups when compared with the control group. The control group did not receive any massage and experienced an increased pain perception of 38.4%. Resting pain did not vary between treatment groups.

If we analyze the Frey et al. study, we can consider that both deep and light pressure massage reduced the sensation of pain, and deep pressure massage helped reduce pain when accompanied by stretching of sore muscles. However, the sensation of pain when there was no activity was not reduced by massage. Now if we think about how this information is used during massage practice, it might be seen as follows.

Example

A client just increased the intensity of his conditioning program and is sore and achy. The client feels stiff, and it hurts to stretch. Based on information provided in the study, massage would likely be most beneficial if a variety of pressures were used, and deeper pressure massage should target those areas that hurt when the client stretches. It might be important to explain to the client that he may still feel achy, but he should be able to move better.

Adverse Effect

Objective

4. Describe the potential for adverse effects from massage application.

Massage is not always the best technique for managing symptoms. According to Hanley et al. (2003), despite very strong patient preference for therapeutic massage, it did not show any benefit over a relaxation tape used to control postsurgery pain. Massage was effective in reducing anxiety but was no more effective than relaxing in a quiet room (Sherman et al., 2010).

Although these studies indicate that massage is effective for anxiety management, it is no more effective than other relaxation interventions. Key, however, is that people liked massage, which is an important factor in compliance with treatment. Muller-Oerlinghausen et al. (2004) concluded that slow-stroke massage is suitable as an intervention for depression, along with other treatment, and is readily accepted by very ill patients. A reduction in distress has been noted among oncology patients in response to massage, regardless of gender, age, ethnicity, or cancer type.

The athletic population often undergoes surgery to repair muscle skeletal injury. During the healing and rehabilitation process, it is common for depression and anxiety to occur based on the change in daily life schedule, as well as concern for future performance ability. Massage and other forms of relaxation intervention can be helpful.

Potential for Harm

When any treatment is assessed, safety is a primary concern (i.e., do no harm). If harm is possible, then the benefits of receiving massage must exceed the potential for harm. A summary of a review of massage safety by Ernst et al. (2006) concludes that massage is generally safe. Massage is not entirely risk free, and we need to be aware of potential harm. However, serious adverse effects are rare. Most adverse effects resulting from massage were associated with aggressive types of massage or massage delivered by untrained individuals. Also, these effects were associated most often with massage techniques other than “Swedish” (classic) massage. These findings are extremely important for those working with athletes. In general, over the years, “sport massage” has incorporated aggressive methods.

Another situation in which adverse effects may occur is when massage interferes with various types of implants such as stents, ports, prostheses, and so forth. Haskal (2008), in the Journal of Vascular and Interventional Radiology, reported a case where a stent placed in the lower limb as treatment for peripheral artery disease migrated to the right atrium after 3 years. Open heart surgery was required to remove the embedded stent fragments. The mechanism attributed with dislodging and moving the stent was deep tissue massage of the thigh. Although this outcome is rare, it is important to pay attention to adverse effects caused by massage. Athletes may have had various surgeries to repair injuries. Often various stabilizing devices such as pins and screws are used. Care needs to be taken to avoid compressing tissues into these areas to prevent potential damage to tissues as they are pushed into the stabilizing devices. Also, the “deep tissue” approach is often used with athletes without considering the potential for damage. Moderate to heavy pressure applied with a small contact such as at the tip of the elbow or with a massage implement such as a hand-held pressure device is more likely to cause tissue damage than pressure applied with a broad contact such as the forearm. Aggressive stretching procedures provide other opportunities for structural damage.

Benefits of stretching in general are being questioned (see later in chapter). A physiologic and safe range of motion has been determined for joints. Any stretching beyond this motion increases the potential for harm. In a cross-sectional study of 100 clients, 10% of massage clients experienced some minor discomfort after the massage session; however, 23% experienced unexpected, nonmusculoskeletal positive side effects. Most negative symptoms started within 12 hours after the massage and lasted for no longer than 36 hours. Most of the positive benefits began to be noted immediately after massage and lasted longer than 48 hours. No major side effects occurred during this study (Cambron et al., 2007). Soreness after massage can affect performance for an athlete. Based on findings of this study, it may be prudent for the athlete to avoid massage a day and a half before competition; however, because the benefits last for at least 2 days, the athlete should still experience positive results from massage.

In My Experience

I worked with two NBA basketball players while they were playing for the world championship. I flew into the location 3 days before the game that would decide which team would be the champions that year. It had been a long, hard season for both teams, and many players were playing with injuries. The two individuals I was working with were injury-free at the time but were tired. I had adjusted the intensity of the massage to be more general and limited the amount of specific work. This approach worked well for the first 2 days I was there; however, on the day before the game, I could tell that their fatigue had increased, and one of the players told me it felt like he was getting sick. I was there, and the guys wanted a massage. Again I adjusted the massage to primarily support sleep. On the day of the game, the sick player woke up with a headache and neck stiffness. Both wanted a massage. I moved into palliative mode for both and allowed the massage to evolve into a nap. After the nap, I used some simple methods to loosen up the sick player’s neck. The game was played later that day. I was concerned about the effects of massage on the day of the game. Even though I had worked with both individuals for 3 years, I remained concerned about providing massage on the day of the game. My clients’ team lost the game by a very narrow margin. It was a really hard-fought game. Both guys informed me that the massage helped, and I was relieved. One of the other players on the team had received a massage the night before the game from a local massage therapist whom he did not know but who was recommended by the hotel concierge. The massage included some trigger point application and stretching. He missed a couple of very important shots during the game. Later, one of my clients told me that the individual had woken up really stiff on the morning of the game. One of the staff members who work with the team in the training room was really upset about the condition of the player and blamed the massage. He asked me what I thought. I was not there to observe the nature of the work, nor did I actually speak with the player. However, I did explain what is considered appropriate massage before competition. Makes you wonder, doesn’t it?