Massage and Soft Tissue Manipulation
Richard Radnovich
OVERVIEW
Massage as a therapeutic modality has been written about and used for hundreds of years (1). In the athletic community, massage has been popular for decades (2). Recently, awareness of its use in athletes has increased, and a newer form, “sports massage,” has been coined. Sports massage maintains a well-established place in the care of athletes in other countries, particularly those of Eastern Europe. Most professional sports teams in the United States have massage therapists on staff. The underlying component strokes of sports massage are derived from traditional massage therapy strokes; it is the application and timing of these techniques that vary. Dynamic stretching through passive range of motion is frequently used in sports massage as a modality, although it is not generally found in other traditional massage techniques.
Sports massage has been promoted as beneficial to athletes for many reasons, such as pain relief, relief of muscle tension, improved athletic performance, improved flexibility, and reduced delayed-onset muscle soreness (3,4). Proposed mechanisms for its salutary effects include improved circulation, enhanced elimination of wastes, decreased motor neuron excitability, and lengthening of both tendons and muscle tissue. Rigorous trials have not supported these claims, however (5,6).
VALIDITY
The appeal and use of massage in the athletic community are well documented (3,6). Demonstrating the physiologic basis for these perceived benefits has proved more daunting a task. There are no large studies on athletic populations to demonstrate a competitive edge from massage or any study showing reduced injuries or better performance in a real-world setting. Such studies would, of course, be extremely difficult to design and execute. Physicians must rely on small sample sizes and studies that look at surrogate end points (e.g., decreased lactate level, increased blood flow, or reduced fatigue of an isolated muscle group as indicators of better performance). Few of these studies, however, are done on athletic populations. Evidence exists supporting the use of massage for depression and anxiety (7,8).
In addition, there is no scientific evidence claiming that sports massage is physiologically different from or superior to traditional massage. The term sports massage is more of a philosophical construct rather than a discipline based on science. Many of its benefits are plausible without supportive data, and few side effects or negative outcomes have been reported.
Despite these shortcomings, the physician who treats athletes should have a familiarity with massage techniques so that he or she can communicate with athletes and therapists. In addition, it is probable that the physician who can adequately perform some soft tissue techniques will have a hands-on connection with athletes that enhances his or her image, although this too remains unstudied. Because of its safety, massage deserves a continued place in the care of the athlete while the medical community awaits better methods to study its benefits (7).
PRINCIPLES
A fundamental premise of sports massage is that the treatment should be tailored to the athlete’s stage of training (5). In sports massage philosophy, techniques used with a runner training for a competition, for example, will be different from the massage used for a runner recovering from a race, which again will differ from the massage techniques used in rehabilitation from injury. The various phases of massage treatment have been referred to as “pre-event,” “post-event,” “recuperative,” and “rehabilitation.” Others have described these phases as “training,” “preparatory,” “intermediary,” and “warm-down” (5). Although we discuss the application of techniques for specific phases, none of this is validated through studies and no one really knows if, for example, effleurage is superior to petrissage before a race.
The components of massage therapy (i.e., the individual strokes) have been used for centuries. Over the years they have been “repackaged” in many different ways, sometimes with slight additions, modifications, or different emphasis. Massage has been called “Rolfing,” “Hellerwork,” myotherapy, muscle therapy, or sports massage, to name a few. None of the techniques has any rigorous scientific basis to convincingly show either the physiologic basis for the technique or an objective standard for success.
Several of the basic massage strokes are typically performed with some form of lubricant, usually oil or lotion, to prevent friction of the practitioner’s skin on that of the athlete. There are many commercially available products but usually any oil will suffice. The strokes demonstrated in this chapter are shown without the use of lubricant, as performed by most physicians.
TYPES
Effleurage
Petrissage
Friction
Tapotement
Vibration
Effleurage
Long, slow stroking motions performed with the palmar surface of the hands characterize effleurage. It is usually executed distal to proximal in the extremities and generally parallels the tissues. Pressure is applied lightly at first and can get gradually deeper. This stroke is usually used at the beginning of the treatment, to distribute lubricant and establish contact with the athlete, and at the conclusion of treatment (10). Among the purported benefits for this stroke, when applied with light pressure, are reduction in muscle tone, generalized relaxation, and relief of muscle spasm (9). With deeper pressure, the supposed benefits include accelerated blood and lymph flow. Rapid strokes are supposed to be stimulating, and increase muscle tone. A deep, focused variation of this stroke (deep tissue, Rolfing, Hellerwork) includes applying abundant pressure along the fascial planes, within and between muscle groups, without using any lubricant. Pressure is applied with much smaller surface areas, for example, the fingertips, knuckles, and elbows, allowing greater force to be applied and helping to release adhesions that limit range of motion (3). This process can be painful due in part to the skin friction created between athlete and clinician.
The use of effleurage in sports massage includes different variations depending on the situation of the athlete. Rapid superficial strokes are usually applied before an event (pre-event) to ready the muscles for activity. Use of lubricants is discouraged because of potential impairment of sweat gland efficiency. After competition (post-event), deeper, slower strokes are applied without lubricant (6). During the recuperative phase in between days of competition or practice, both deep and superficial pressures are used (6). For extended rehabilitation, deep, focused strokes at sites of restricted range of motion can be applied (Fig. 9.1).
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