Objectives

Indirect functional techniques are usually referred to as indirect techniques or indirect methods of treatment. These methods are very gentle and safe. Rather than being treated as a specific modality, functional indirect methods need to be incorporated into the massage application, regardless of whether the focus is soft tissue or joint movement. These methods, rather than engaging and attempting (by whatever means) to overcome resistance (bind), do the exact opposite. The soft tissue or joint is taken in all directions to the point of maximum ease. The massage practitioner simply maintains the joint or tissue in this ease position. No further treatment is provided at this point, and after a couple of minutes, the position is gently released.

Direct functional techniques are the opposite of indirect methods. These methods begin at the restriction barrier (bind) and move into resistance. Direct methods are more invasive than indirect methods. Because these methods produce changes by increasing the intensity of the mechanical force application to move tissue beyond the point of bind, the potential for adverse effects is increased.

Regardless of how methods are done, the underlying principles are assessment of ease and bind and the natural tendency of the body to seek homeostasis.

Soft tissue or joint mobility is assessed for motion restriction by palpation and/or joint movement, and restricted motion is treated by taking the dysfunctional tissue or joint in the direction of easier movement, which would be away from the restriction or bind, and toward the way the tissue or joint wants to go in all planes of movement (sagittal, frontal, transverse). The soft tissue ease position is maintained until a sense of softening is perceived. If the massage practitioner cannot easily palpate or identify this sensation, the position should be held in this area 30 to 60 seconds. Breathing can enhance the ease position and is assessed by having the client inhale and exhale, typically holding the breath for a few seconds in the direction that further contributes to the ease of tissue tension. Because indirect functional techniques are noninvasive methods, they should be the first approach attempted to normalize tissue and joint movement.

On the other hand, stretching is considered a direct technique because it engages the bind and moves through it. Stretching is more invasive than indirect methods, increasing the potential for adverse reactions.

A modification that incorporates the indirect method and more aggressive direct stretching involves moving back and forth between the ease position and the bind position. This can be described as indirect/direct. First, the ease position is identified and held, as previously described. Then the restrictive barrier of a joint or tissue is engaged in each plane of motion and is held taut at the barrier until softening occurs. The corrective activating force moves slightly through the restrictive barrier and again sustains the area in this position for 30 to 60 seconds, until the tissue softens. Various forms of oscillation can be added. It is effective to alternate 2 or 3 times between direct and indirect application.

Ease/indirect and bind/direct methods can be combined with muscle energy methods. As discussed, during muscle energy application, muscles (contractions) are actively used to support the response. Muscles are placed in a specific direction, which can be ease or bind; the client then pushes slowly in a controlled manner against a counterforce usually supplied by the massage therapist.

A variation is to introduce a mild degree of overpressure at the point of maximum ease, which actually results in taking the soft tissue just into a bit of bind. The result is release of previously restricted tissues. It is essential that all movements are directed and controlled by the practitioner. A refinement of this application involves adding gentle focused oscillation while the tissue or the joint is in the ease position. Vibration, tiny shaking movements, and small focused rocking all are effective. In another variation, the client produces the oscillation with tiny pulsed movements against resistance provided by the massage practitioner (pulsed muscle energy).

Indirect and direct functional methods serve as the basis for connective tissue methods, described in greater depth later in the chapter. Connective tissue methods can be indirect (i.e., a restricted area is placed into a position of little resistance until subsequent relaxation occurs) or direct (i.e., the affected area is placed against a restrictive barrier with constant force [stretched] until fascial release occurs).

A sequence of indirect and direct functional techniques is shown in Figure 13-1.

Log on to your Evolve website to view additional examples of direct and indirect application.

Objective

The body is an interconnected network of fluid compartments that contain blood, interstitial fluid, lymph, synovial fluid, and cerebrospinal fluid. Normal flow within the tissue and exchange of fluid between compartments are essential for homeostasis. Any impediment to normal flow leads to fluid stagnation, resulting in impaired tissue nutrition and repair. Stagnant tissue fluid becomes toxic, which, as the protein content increases, can lead to fibrotic tissue changes.

Fluid tension in the body is called hydrostatic pressure. Body fluid is classified as extracellular (outside the cell) and intercellular (within the cell). About one-third of body fluid is extracellular and is located in two compartments:

Fluids also move across compartments by diffusion from areas of high salt concentration to areas of lower salt concentration. The rate and volume of fluid movement are determined by pumping mechanisms such as the heart, muscle contraction and relaxation, rhythmic compression of fascial structures during movement, and respiration. Other factors influencing fluid movement include the viscosity of the fluid, the permeability of the membranes, and the size of the various vessels through which fluid travels.

Vasodilators and constrictors of the circulatory system therefore influence the movement of body fluid. Massage that addresses the extracellular fluid can mechanically support the movement of fluid within these compartments by stimulating hydrokinetics (transport of fluid) along pressure gradients from high pressure to lower pressure. The mechanical pumping and oscillation applications of massage and the reflexive release of vasodilators (primarily histamine) produced during massage, coupled with the vasodilatation or constriction response of hydrotherapy, interplay in various ways to influence the outcome of the application.

Inflammation and Fluid Dynamics

Inflammation results in increased interstitial fluid, which then raises hydrostatic pressure in the area. Tissue swelling produces pain caused by pressure on pain receptors. This increase in tissue pressure can serve a protective function by mechanically limiting movement and producing pain. This is important during the first few days after an acute injury, but the process then needs to begin to reverse itself for normal healing to take place.

The inflammatory process heightens the influence of chemical vasodilators affecting the venules and capillaries. Greater permeability of blood vessels is noted locally, with reduced flow velocity. This leads to the formation of local edema and stasis, with reduced exchange of nutrient and waste products. Pressure on vessels, or reduction of tissue space by changes in muscle tone, fascial pliability and length, and bony impingement, can also impede fluid exchange in the tissue. Carpal tunnel syndrome is an example in which the median nerve is impinged by fascial shortening and edema. Restoration of fascial pliability and reduction of edema support normal function. Massage treatment uses tensile forces to elongate shortened connective tissue, compressive forces to support the pumping action, encouraging the movement of tissue fluid, and neuromuscular applications to reduce and normalize muscle tone.

1. Interstitial fluid flows into the lymphatic capillaries. Plasma is forced out of blood capillaries into spaces around the cell walls. As fluid pressure between cells increases, cells move apart, pulling on the microfilaments that connect the endothelial cells of the lymph capillaries to tissue cells. This pull on the microfilaments causes the lymph capillaries to open like flaps, allowing tissue fluid to enter the lymph capillaries.

2. Lymph moves through a network of contractile lymphatic vessels. The lymphatic system does not have a central pump, as the heart does. Various factors assist in the transport of lymph through the lymph vessels.

Objective

Contraindications and Cautions

Edematous tissues have poor oxygenation and reduced function, and they heal slowly after injury. Chronic edema results in chronic inflammation and fibrosis, making the edematous tissue coarse, thicker, and less flexible.

Lymphatic drain massage may lower blood pressure. If the client has low blood pressure, the danger is that it may fall further, and the client may be dizzy when standing up.

When a person is ill with a viral or bacterial infection and fever, circulation of lymph through the nodes slows, giving the lymphocytes more time to destroy the bacteria or virus. Because massage moves fluid through the lymphatic system more quickly, it can interfere with the body’s efforts to defeat attacking cells and can prolong the illness. During fever, white blood cells multiply rapidly, but bacteria and viruses multiply more slowly; fever therefore is part of the body’s healing process. Because lymphatic drain massage lowers body temperature, do not give such a massage to a client with a fever.

Lymphatic drain massage affects the circulation of fluid in the body and can overwhelm an already weak heart or kidneys. Do not perform lymphatic drain massage on anyone with congestive heart failure or kidney failure, or undergoing kidney dialysis, unless the massage is specifically ordered by the client’s physician.

Indications

Simple edema, screened for contraindications, responds well to massage focused on the lymphatic system. This approach is helpful for soft tissue injury, which includes surgery (with supervision), because it speeds healing and reduces swelling.

Traveler’s edema is the result of enforced inactivity, such as sitting in an airplane or a car for several hours. It can affect anyone who sits for extended periods. Interstitial fluid (tissue fluid) responds to gravity, causing swelling in the feet, hands, and buttocks of a person who has to sit without moving very much for a few hours. Lymph drainage massage can remove the edema and reduce the pain and stiffness caused by the edema. Caution is indicated for the formation of blood clots with prolonged inactivity. Because many professional athletes often travel, this is a concern for massage.

Exercise-induced, delayed-onset muscle soreness is partly the result of increased fluid pressure in the soft tissues. Lymphatic drain massage is effective in reducing pain and stiffness associated with this condition.

Lymphatic drain massage softens scar tissue and stimulates improved circulation.

Principles

Pressure provided by massage mimics the drag and compressive forces of movement and respiration and can move the skin to open the lymph capillaries. The pressure gradient from high pressure to low pressure is supported by creating low-pressure areas in the vessels proximal to the area to be drained.

Depth of pressure, speed and frequency, direction, rhythm, duration, and drag are adjusted to support the lymphatic system. Pressure should be just sufficient to move the skin.

Disagreement exists about the intensity of pressure used. Some schools of thought recommend very light pressure. Others use deeper pressure and hold that the stronger the compression used, the larger will be the increase in the flow rate of lymph. This text combines the two approaches.

Lymphatics are located mostly in superficial tissues, in the outer 0.3 mm of the skin; surface edema occurs in these superficial tissues, not in deep tissue. Moving the skin moves the lymphatics. Stretching the lymphatics longitudinally, horizontally, and diagonally stimulates them to contract.

Simple muscle tension puts pressure on the lymph vessels and may block them, interfering with efficient drainage. Massage can normalize this muscle tension. As muscles relax, lymph vessels open, and drainage is more efficient.

Treatment

In general, massage first drains the surface area using lighter pressure; then areas of muscle tension are worked on using appropriate massage methods and pressure. Finally, work is finished in the area with another surface lymph drain.

The greater the amount of fluid in the tissue, the slower the massage movements. Massage strokes are repeated slowly, at a rate of approximately 10 per minute; this is approximately the rate at which the peripheral lymphatics contract.

Move lymph fluid toward the closest cluster of lymph nodes, which for the most part are located in the neck, axilla, and groin. Massage near the nodes first, then move fluid toward them, working proximally from the swollen area toward the nodes. Massage the unaffected side first, then the obstructed side. For instance, if the right arm is swollen because of scar tissue from a muscle tear, massage the left arm first.

The approach is a rhythmic, slow repetition of massage movements. Full-body lymph drain massage lasts about 45 minutes. Focus on local areas for about 5 to 15 minutes.

The methods of lymphatic drain massage are fairly simple, but this is a very powerful technique that elicits body-wide responses. Although disagreement about the method has been expressed, all approaches have some validity. Therefore, the technique described in this text combines the various methods used to support lymphatic movement in the body.

The massage session begins with a pumping action on the thorax. Place both hands on the anterior surface of the thoracic cage. While the client exhales completely, passively follow the movements of the thorax with your hands. When the client starts inspiration, resist the movement of the thorax for 5 to 7 seconds. Repeat this procedure 4 or 5 times. Pumping action on the thorax increases lymph drainage through the lymphatic ducts by additionally lowering intrapleural pressure and exaggerating the action of inhalation and exhalation of breath.

The massage application consists of a combination of short, light, pumping, gliding strokes beginning close to the torso at the node cluster and those directed toward the torso; the strokes methodically move distally. The phase of applying pressure and drag must be longer than the phase of release. The releasing phase cannot be too short because the lymph needs to drain from the distal segment. Therefore, the optimal duration of the pressure and drag phase is 6 to 7 seconds; for the release phase, it is about 5 seconds. This pattern is followed by long, surface gliding strokes with a bit more pressure to influence deeper lymph vessels. The direction is toward the drainage points (following the arrows on the diagram in Figure 13-2).

The focus of initial pressure and finishing strokes is on the dermis, just below the surface layer of skin, and on the layer of tissue just beneath the skin and above the muscles. This is the superficial fascial layer, which contains 60% to 70% of the lymphatic circulation in the extremities. It does not take much pressure to contact the area. If too much pressure is applied, the capillaries are pressed closed, which nullifies any effect on the more superficial vessels. Generally, light pressure is indicated initially, and this increases to a moderate level (including kneading and compression, as well as gliding) during repeated application to the area to reach the deep lymphatic vessels; it then returns to lighter pressure over the area.

Drag is necessary to affect the microfilaments and to open the flaps at the ends of the capillary vessels. A pumping, rhythmic compression on the soles of the feet and the palms of the hands supports lymph movement. Rhythmic, gentle passive and active joint movement reproduces the body’s normal means of pumping lymph. The client helps the process through deep, slow breathing, which stimulates lymph flow in the deeper vessels.

When possible, position the area being massaged above the heart, so that gravity can assist lymph flow. (See specific protocol, beginning on page 219.)

Objective

The circulatory system is a closed system composed of a series of connected tubes and a pump. The heart pump provides pressure for the blood to move through the body via the arteries and eventually into the small capillaries, where actual blood gas and nutrient exchange occurs. Blood returns to the heart by way of the veins. Venous blood flow is not under pressure from the heart. Rather, it relies on muscle compression against the veins to change interior venous pressure. As in the lymphatic system, backflow of blood is prevented by a valve system.

Massage Methods

The purpose of circulatory massage is to stimulate efficient flow of blood through the body. Current research seems to indicate that this effect is not as pronounced as was once believed (see Chapter 3). However, because the research findings are somewhat mixed, it is prudent to consider a form of massage application that logically would support this body function by mimicking normal function.

Massage to encourage blood flow to the tissues (arterial circulation) is different from massage performed to encourage blood flow from the tissues back to the heart (venous circulation). Because of the valve system of the veins and lymph vessels, deep, narrow-based stroking over these vessels from proximal to distal (from the heart out) is contraindicated. A small chance exists of breaking down the valves if this is done. However, compression, which does not slide, as does gliding or stripping, is appropriate for stimulating arterial circulation.

Treatment

Compression is applied over the main arteries, beginning close to the heart (proximal), and systematically moves distally to the tips of the fingers or toes. Manipulations are applied over the arteries, with a pumping action at a rhythm of approximately 60 beats per minute, or whatever the client’s resting heart rate is. Compressive force changes internal pressure in the arteries, stimulates intrinsic contraction of arteries, and encourages movement of blood out to the distal areas of the body. Compression also begins to empty venous vessels and forms an arterial-venous pressure gradient, encouraging arterial blood flow (Figure 13-3).

Rhythmic, gentle contraction and relaxation of the muscles powerfully encourage arterial blood flow. Both active and passive joint movements support the transport of arterial blood.

The next step is to assist venous return flow. This process is similar to lymphatic massage in that a combination of short and long gliding strokes is used in conjunction with movement. The difference is that lymphatic massage is done over the entire body, and movements are usually passive. With venous return flow, gliding strokes move distal to proximal (from fingers and toes to the heart) over the major veins. The gliding stroke is short—about 3 inches. This enables the blood to move from valve to valve. Long gliding strokes carry blood through the entire vein. Both passive and active joint movements encourage venous circulation. Placing the limb or other area above the heart brings gravity into assistance (Figure 13-4).

Athletes experience fluid dynamics issues in various ways. Hydration is especially important and is discussed in Unit One. In terms of methodical application, the massage outcome can target each main fluid area: arterial, venous, and lymphatic functions. All of these areas are strained during exercise. Cardiovascular fitness is a major focus of many exercise programs and of sport conditioning and training. Application of massage support to influence fluid dynamics is dependent on whether massage is applied as part of the “warm-up–cool-down–recovery,” or as part of the rehabilitation process.

In general, massage application targeted to increase arterial flow is part of the warm-up process. Venous congestion can occur post exercise, as does an increase in interstitial fluid. Methods to address venous return can decrease interstitial fluid by moving it into the lymphatic system.

Recovery involves normalizing all fluid movement. Injury rehabilitation involves managing swelling and encouraging effective circulation to the injured area to support healing.

Specific situations involving focused massage applications include injury swelling; sprains, strains, or other contusions; surgery swelling; delayed-onset muscle soreness; and chronic swelling (joint).

Strains, sprains, contusions, and surgery require specific treatment. These local injuries of the first and second degree (mild and moderate) benefit from both local and systemic lymphatic drain massage. It is important to decongest the entire drainage area affecting the injured area, for example, a sprained ankle requires drainage of the entire leg into the trunk.

PRICE (protection, rest, ice, compression, elevation) treatment should be used for the first 24 hours. Movement of fluid from superficial tissues can begin after the acute stage begins to diminish—as always, proper medical care needs to be provided and medical team orders followed.

Treatment of delayed-onset muscle soreness can begin as a preventive measure immediately after activity begins. Part of the process of delayed-onset muscle soreness involves inflammation with increased capillary permeability. Increased influence of the sympathetic autonomic nervous system on blood pressure leads to increased fluid movement from capillary beds into tissues. This increases interstitial fluid and hydrostatic pressure within the tissues. Lymph capillaries are unable to effectively drain the area, and congestion increases, which puts pressure on the pain-sensitive receptors.

Chronic swelling usually occurs around joints, tendons, and bursae. Edema acts as a protective mechanism in attempting to reduce the problem that is causing the inflammation. A portion of the treatment for this condition involves addressing fluid issues of both blood and lymph. When massage is used, the goal is to reduce the fluid enough to increase function—not to interfere with the protective process and increased stability provided by hydrostatic pressure (Figure 13-5).

The entire area around the contusion needs to be drained, but caution is necessary because the capillaries have been damaged, and the massage must not interfere with the healing process. However, blood in the interstitial fluid increases the protein content of the fluid, which increases the potential for formation of fibrotic tissue. This is why it is essential that the lymphatic system remove interstitial fluid containing blood. Appropriate massage application can enhance this process.

Use of massage to increase arterial and venous circulation and lymphatic movement will be recommended throughout the text to serve the athlete and others who are involved in fitness and rehabilitation programs.

The following section provides a precise description of the massage application that affects first arterial flow, and then venous return; both approaches involve addressing capillary beds. Next, lymphatic drain massage for interstitial (extracapsular) tissue fluid and intracapsular fluid (inside the joint capsule) is described. These three approaches are easily and effectively combined.

Methods of mechanical and reflexive fluid movement are primarily focused on mechanical force. To understand them, it is necessary to understand both the structure and the function of vascular and lymphatic systems. It is also necessary to appreciate the properties of a fluid, including properties of water, colloids, and viscosity.

Fluids naturally move from high pressure to low pressure with gravity. The more viscous (thick) the fluid, the slower it moves. Fluid moves against gravity only with a pump. The faster and stronger the pump, the more fluid is moved.

Permeability is the rate at which a fluid (water) moves across a membrane. Fluid moves by osmosis and diffusion. The application of effective massage is dependent on all of these factors (Figure 13-6).

Objective

Log on to your Evolve website to watch Video 13-1: Lymphatic Drain.

Phase 1—Preparing the Torso

Phase 2—Decongesting and Draining the Torso (Figure 13-7)