Chapter 8 Local Massage Sequences

Local injury or disease can affect many different tissues, including skin, muscles, tendons, joints, nerves, blood, and lymph vessels. A therapist must have a thorough knowledge of the anatomy and physiology of the structures involved, together with an understanding of the pathological conditions in the tissues to be treated, if the treatment is to be as effective as possible. Muscles may be atrophied, decreased in tone, fibrotic, flaccid, or in spasm. Tissues may be edematous; joint effusion and inflammation may limit movement and produce pain. Adhesions and contractures may cause tendons to adhere to the surrounding structures, and the circulation may also be impaired. These problems are likely to prevent normal limb motion and therefore everyday functional abilities. Each of these potential problems must be evaluated and treated by techniques selected according to the changes present and the specific treatment goals.

A variety of massage strokes can be a useful part of a total treatment plan for managing an individual patient’s condition, but massage techniques are simply one of many different options for the treatment of local trauma or disease. The best results are most likely to be achieved when the appropriate manual techniques, including massage, are combined with a suitable exercise program (or rest) and appropriate electrophysical agents (modalities). In this context, all soft tissue manipulation techniques, including massage, are simply adjunctive to the total treatment plan.

Each of the individual techniques described in Chapter 4 can be used separately or in combination with each other and with many other treatment approaches. The important point is for the therapist to gain a thorough understanding of how the patient’s problems are affecting the tissues. Once this is properly understood, identifying appropriate treatment goals and choosing a suitable massage technique is relatively easy—it is simply a question of matching the needs of the tissues with the known effects of the massage technique. For example, if tendon and muscle contractures are limiting joint motion, then the mobilizing effects of kneading, wringing, picking up, and deep frictions might be helpful, especially when combined with other treatments such as exercise and appropriate electrophysical agents (EPAs). It is therefore proper for an experienced therapist to develop his or her own particular combination of massage techniques (a sequence) to be used as part of a specific treatment plan for local trauma or disease in a patient. Modern rehabilitation practice now encompasses a wide variety of treatment concepts, including many types of soft tissue manipulation. Although some of today’s treatment con-cepts have been developed over the past 50 years, other techniques have been practiced for many centuries (see Chapter 1 on the history of massage). The combination of time-honored techniques and newer ideas has significantly increased the treatment options available to both patient and therapist.

It is important to recognize that there are many different ideas about massage strokes and how they can be combined into a massage sequence, sometimes called a massage system. Many of these systems of massage were popular in the early 1900s and were effective then, as indeed they are today; however, the development of modern rehabilitation methods has produced other procedures that are more effective than massage alone. For this reason, massage is rarely used as a sole treatment today; in fact, it can be argued that massage has its most beneficial effects when it is combined with other treatments to give a more rounded approach to the management of the patient’s problem. In this regard, it is most appropriate to select suitable techniques from those detailed in Chapter 4 and combine them with any of a number of complementary techniques. This may well result in a mini-sequence of strokes, designed to achieve a particular effect, especially if it is directed to a specific anatomical structure such as a ligament or tendon. This may be termed focal massage to distinguish it from local or general massage (see Chapter 9 for examples).

The term local massage was defined in Chapter 4 as follows:

A combination of individual strokes represents a local massage sequence, and the specific strokes included in such a list can be many and varied. Based on the description and use of the individual strokes described in Chapter 4, the sequences listed in Tables 8-1 to 8-4 can be used for local massage treatments to the regions specified. The therapist can modify each list as desired and as needed to treat an individual patient. For example, a therapist could select a local sequence of techniques to treat the major muscles of a patient’s upper arm (biceps and triceps). In this case, the therapist could use all of the techniques affecting these structures.

Table 8-1 Local Massage Sequence for the Lower Limbs (I)

Table 8-2 Local Massage Sequence for the Lower Limbs (II)

Table 8-3 Local Massage Sequence for the Upper Limbs

Table 8-4 Local Massage Sequence for the Posterior Trunk and Pelvis

The rest of this chapter is devoted to a local massage sequence based on a concept of local massage developed by Albert Hoffa (1859–1907). Although this system can be used alone, it can also be combined with other suitable treatments. A modified version is presented here to suggest how this approach might be used. For purposes of completeness, all of the important areas of the body are discussed. Each area can be considered separately, and, when appropriate, they may be combined.

THE HOFFA SYSTEM

Albert Hoffa’s original work, Technic der Massage, was published in four editions, the last one in 1903 (see Chapter 1). The system developed by this eminent surgeon follows an anatomical pattern and is based on a knowledge of physiology. The movements are applied to certain muscles or muscle groups; this contrasts with some other systems that apply strokes either to an entire extremity or to a certain area of the body. Hoffa classified the essential massage strokes as effleurage (stroking), pétrissage (kneading), friction, vibration, and tapotement (percussion) and stated that these are only the framework on which an experienced therapist with good judgment may build up an effective treatment for a given patient’s problem. He emphasized the value of massage for increasing venous and lymphatic circulation. One must keep in mind, however, the context in which he developed his system and, in particular, the range of treatment options available at the time and the state of medical knowledge. (The rehabilitation professions as we currently know them did not exist at that time.)

According to Hoffa, effleurage (stroking) is employed to stimulate circulation in the small veins in the muscles, particularly in the large veins or venous plexuses that lie in the grooves between the individual muscles. This is accomplished by making the hand conform closely to the contours of the part as the thumb and fingertips proceed along these interstices. Pétrissage (kneading) is used chiefly to increase the circulation in the muscles and to remove products in a manner analogous to that of friction. Friction movements are applied chiefly to break down pathologic exudates, deposits, and thickenings in tissue around joints and tendons and to help remove the waste products through the lymphatic system. Vibration and tapotement (percussion) are recommended to increase blood supply, reduce nerve irritability, and increase contraction of muscle fibers. These techniques are probably of little value in the treatment of local trauma, but they do have some specific uses for certain lesions; for example, the percussion and vibration techniques can be useful in treating some respiratory problems.

Classification and Description of Local Massage Strokes Used in the Hoffa System

The following classification and description of massage strokes is a modification of the Hoffa system of massage as described by Gertrude Beard in the early editions of this text. In general, all of these descriptions match those defined in Chapter 4. The Hoffa system uses only a selected number of these techniques, and, of course, any appropriate combination of these techniques is possible.

Stroking (Superficial or Deep)

Note that in the Hoffa system, deep stroking is similar to effleurage.

1. The direction of the deep stroke is always in the direction of venous blood and lymph flow.

2. The stroke is applied to the entire length of the muscle or muscle group, beginning at the insertion and continuing to the origin.

3. The hand returns over the same area with light pressure (superficial stroking).

4. The hand is made to conform to the shape of the muscle or muscle group, attempting to reach around and lift up the bulk of the muscle or group. The palmar surfaces of the entire hand or the distal phalanges of the fingers (finger pads) or of the thumb (thumb pad) are used, according to the size of the muscle.

5. The pressure is regulated according to the bulk of the muscles: light at the beginning of the deep stroke, increasing over the bulkiest part of the muscles, diminishing at the end of the stroke, and finishing with a squeeze-out movement. In performing the squeeze-out movement, the grasping surfaces of the hand are gradually approximated more closely as the muscle bulk decreases and the hand approaches the origin of the muscle. As the hand reaches the point of origin, it is pronated. The bulk of the tissue being massaged is thus squeezed out of the hand, and the hand is in position to start the return stroke.

6. The movements should be performed rhythmically.

7. The rate of movement should be relatively slow.

Kneading

The kneading movements in the Hoffa system are performed with one or both hands (single-handed or two-handed kneading). The therapist can also perform these strokes with the distal phalanges of the thumb (thumb pad kneading) or the index and middle fingers (finger pad kneading) of one or both hands. Finger pad kneading is also called digital kneading.

Single-handed kneading is used on muscles that are not too large to be grasped in one hand. For very large muscles, two-handed kneading can be used. Digital kneading is used on narrow or flat muscles that cannot be grasped easily by the entire hand. As in stroking, the hand must conform to the size and shape of the muscles and make firm contact. The movement begins at the insertion of the muscle and is carried through to the origin.

Single-Handed Kneading

1. The hand is placed at the insertion of the muscle with the palmar surface of its ulnar border in firm contact (Figure 8-1, A).

2. The hand grasps around the bulk of the muscle and lifts it as much as possible from the underlying tissues (Figure 8-1, B).

3. The fingers and ulnar border of the hand follow along one border of the muscle or muscle group, and the thumb follows along the opposite border (see Figure 8-1, B).

4. The movement is one of grasping and releasing the tissues, and it is carried through to the origin of the muscle, finishing with a squeeze-out movement (Figure 8-1, C).

5. The thumb and fingers work simultaneously, but the pressure must be diminished as they approach each other, to prevent pinching.

6. Care must be used to keep the bulk of the muscle well back in the palm of the hand between the thenar eminence and the metacarpal pad of the palm (see Figure 8-1, A).

7. At the origin of the muscle, the hand is brought over into pronation and returned to the starting position with a superficial stroke over the area (Figure 8-1, D, E).

Figure 8-1 Single-handed kneading to the upper arm and thigh.

Two-Handed Kneading

1. One hand is placed at the insertion of the muscle, as in single-handed kneading; the other hand is placed just proximal to it (Figure 8-2, A).

2. Both hands grasp around as much of the muscle as possible. The palmar surface of the fingers of the left hand pulls the muscles laterally as the surface of the abducted right thumb and palm simultaneously pushes the tissues medially. Then the surface of the palm and abducted thumb of the left hand pushes the muscles medially as the palmar surface of the fingers of the right hand pulls the tissue laterally (Figure 8-2, B). Progression from the distal to the proximal part of the muscle is accomplished with a gliding of the hands on the pull stroke of the kneading movement. This procedure is similar to the technique of wringing described in Chapter 4, but it is not a pinching type of movement. The thumb and fingers of each hand should be kept in the same relation to each other during the entire movement. The push-and-pull movements are accomplished chiefly by flexion and extension of the arms at the shoulders and elbows. At the origin, the proximal hand is removed, and the distal hand finishes with the squeeze-out movement (see Figure 8-1, D, E) and returns to the starting position with a superficial stroke, as in single-handed kneading.

Figure 8-2 Two-handed kneading to the thigh and upper arm.

Two-Handed Digital Kneading

The therapist uses both hands (between the thumb and the index and middle fingers of each hand) to grasp the muscle at its insertion. The palmar surface of the left fingers pulls the tissues toward the therapist, while the right thumb pushes the adjacent tissues away. Then the right fingers pull the tissues while the left thumb pushes the adjacent tissues (Figure 8-3). Progression from origin to insertion is accomplished with a gliding of the fingers on the pull movement. Again, this should not be a pinching movement. The thumb and fingers of each hand are kept in the same relation to each other during the entire movement. The push and pull are accomplished chiefly by flexion and extension of the arms at the shoulders and elbows. The return stroke is performed with the fingers of the distal hand. This movement is used mainly for muscles of small to medium bulk. Care must be taken to ensure that the hands are held parallel to the length of the muscles, thereby allowing as much contact as possible. This technique produces a movement similar to the stroke called wringing; however, there is no twist in this stroke.

Figure 8-3 Two-handed digital kneading to the leg.

Modified Hoffa Technique for Local Massage

The technique of local massage described next and its application to the anatomical sections of the body are modified from the classical Hoffa system. In the application of these massage strokes to an extremity, the proximal portion should be treated first, followed by the more distal segment or segments. Then special attention may be given to areas that require additional treatment. The stroking and kneading movements may be adapted to conform to the muscles of any body area. In the beginning of treatment, stroking precedes the kneading movement, and periods of stroking and kneading should alternate according to the pathologic condition being treated, the desired effect, and the result being obtained from the massage. The final stroke should always be superficial stroking.

The order in which massage is given to the various muscle groups of each anatomical region depends on the condition being treated and the ability of the patient to be moved into the required positions. It may be necessary to alter the techniques slightly to avoid unnecessary changes of the patient’s position. In general, the position of the patient should be changed as little as possible. The techniques, as described, are those that should be followed when it is possible to place the patient in the ideal position to perform each stroke. Under most circumstances, the patient should lie recumbent while receiving massage treatment.

All of the local sequences suggested for each body region are summarized at this point so that the reader can gain a clear understanding of their structure. Where possible, a detailed description follows with specific references to figures in the text that illustrate the various techniques. As a general guide, the therapist will repeat each technique three times. This modified Hoffa sequence is not demonstrated on the accompanying DVD.

Local Massage Sequence (Modified Hoffa System)

Tables 8-5 to 8-8 describe local massage sequences for the lower limbs, upper limbs, posterior trunk and pelvis, and head/neck area.

Table 8-5 Local Massage Sequence for the Upper Limbs

LIMB	FIGURE	REPETITIONS
Right Arm
Deltoid muscle group	8–4	3
Elbow extensor muscle group (triceps and anconeus)	8–5	3
Elbow flexor muscle group (biceps, brachialis, and coracobrachialis)	8–6	3
Right Forearm
Medial muscle groups	8–7	3
Lateral muscle groups	8–7	3
Right Hand
Muscles of the radial section (thenar muscles, adductor pollicis, lumbricals, and interossei)	8–9	3
Muscles of the ulnar section (hypothenar muscles, lumbricals, and interossei)	8–10	3
Palmar surface	8–11	3
Dorsal surface	8–12	3
Right Thumb and Fingers
Dorsal surface	8–13	3
Palmar surface	8–14	3
Left Arm, Forearm, and Hand
All of the previous strokes are repeated to the left upper limb

Table 8-6 Local Massage Sequence for the Lower Limbs

LIMB	FIGURE	REPETITIONS
Right Buttock Region
Gluteal muscles (gluteus maximus, medius, and minimus)	8–15	3
Right Thigh
Medial hamstring muscles (semimembranosus and semitendinosus)	8–16	3
Lateral hamstring muscle (biceps femoris)	8–17	3
Tensor of the fascia lata (including the iliotibial tract/band)	8–18	3
Anterior thigh group (rectus femoris, vastus medialis, vastus intermedius, vastus lateralis, and articularis genu sartorius)	8–19	3
Adductor muscle group (adductor, longus, adductor magnus, and gracilis)	8–20	3
Right Leg
Anterior tibial muscles (tibialis anterior, extensor digitorum longus, extensor hallucis longus, and fibularis/peroneus tertius)	8–21	3
Fibularis (peroneal) muscles (fibularis longus and fibularis brevis)	8–22	3
Calf muscles (gastrocnemius, soleus, and plantaris)	8–23	3
Right Foot*
Medial section	8–24	3
Lateral section	8–25	3
Dorsal section	8–26	3
Plantar section	8–27	3
Right Toes	—	3
Left Buttock, Thigh, Leg, and Foot
All of the previous strokes are repeated on the left lower limb	—

*

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Soft Tissue Manipulation Techniques as an Evaluation Tool Massage in Palliative Care Massage for the Patient with a Respiratory Condition Connective Tissue Massage Classification, Definitions, and Descriptions of the Basic Massage Strokes and Relaxed Passive Movements Decongestive Therapy for the Treatment of Lymphedema

Stay updated, free articles. Join our Telegram channel

Join