Massage theory and application



Massage theory and application


This chapter reviews massage application.* Expert opinion and some research evidence appear to indicate that basic massage methods exert mechanical force to alter tissue structures or to stimulate reflexive responses in the nervous system with the intent of creating beneficial structural and physiologic changes in the body. Even though massage can be explained in this simple way, the actual application is seldom simple. Expert application of massage is a complex intentional interaction of the subtle influences of pressure changes, drag, duration, rhythm, and speed.



The components of massage application


Qualities of touch


Massage is the manual manipulation of the soft tissues. Analysis of the various aspects of manual manipulation means that massage therapists use some part of their body (i.e., hands, arms, legs, feet) to alter the soft tissue of the person receiving the massage. Obviously, massage involves physical contact. However, some methods are thought to apply a stimulus to the body without touching it. Typically called energy-based modalities, these methods are not massage, even though they are easily incorporated into a massage as an adjunct method. All massage consists of a combination of the following aspects of touch:



• Depth of pressure (compressive force), which can be light, moderate, deep, or variable. Most soft tissue areas of the body consist of three to seven layers of tissue, which include the skin; the superficial fascia; the superficial, middle, and deep layers of muscle; and the various fascial sheaths and connective tissue structures. Pressure must be delivered through each successive layer to reach deeper tissue layers without causing damage and discomfort to the more superficial tissues. The deeper the pressure, the broader the base of contact required with the surface of the client’s body. Otherwise, the surface tissue tightens and guards against compression injury. It takes more pressure to address thick, dense tissue than delicate or thin tissue.


• Drag is the amount of pull (stretch) on the tissue (tensile force). Many structural and functional tissue changes depend on the amount of drag on the tissue. Connective tissue changes, in particular, appear to be attained during massage applied with drag on the tissues.


• Direction can move outward from the center of the body (centrifugal) or inward from the extremities toward the center of the body (centripetal). It can proceed from proximal to distal attachment (or vice versa) of the muscle, following the muscle fibers, transverse to the tissue fibers, or in circular motions. Direction is particularly useful when addressing fluid movement in the body and stretching methods.


• Speed of manipulation can be fast, slow, or variable.


• Rhythm is the regularity of application of a technique. If the method is applied at regular intervals, it is considered even, or rhythmic. If the method is disjointed or irregular, it is considered uneven, or nonrhythmic. Massage usually is applied in a rhythmic fashion, especially if fluid movement and relaxation are the goals.


• Frequency is the rate at which a method repeats itself within a given time frame. Typically, the massage therapist repeats each method about three times before moving or switching to a different approach. In general, the first application is assessment, the second is treatment/intervention, and the third is post assessment. If the first application assesses normal tissue, the next two applications are typically slightly slower and slightly deeper to maintain the continuity of the general massage. If post assessment indicates remaining dysfunction, the frequency is increased to repeat the treatment and post assessment until desired results have been achieved or it is evident that the tissue will not change at this time.


• Duration is the length of time a method lasts or a manipulation stays in the same location. Typically, the duration should not be longer than 30 to 60 seconds if the nervous system is being targeted. A connective tissue application may be sustained longer but usually not longer than 2 or 3 minutes.


Through these varied qualities of touch, basic massage methods are adapted to the client’s desired outcomes. The qualities of touch provide the therapeutic benefit. The mode of application (e.g., gliding, kneading) provides the most efficient application. Mode of application can be varied, depending on the desired outcome, by adjusting depth, drag, direction, speed, rhythm, frequency, and duration. In perfecting massage application, the quality of touch is more important than the method. Quality of touch is altered when a contraindication or a caution exists for massage. For example, when a client is fatigued, the duration of the application often is reduced; if a client has a fragile bone structure, the depth of pressure is altered.


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Mechanical forces


All massage manipulations introduce mechanical forces into the soft tissues. These forces are able to stimulate various physiologic responses. Force may be perceived as mechanical, which is discussed in relationship to massage, or as a field force, such as gravity or magnetism, which is not part of massage application. Examples of actions that create mechanical forces are those that involve pushing, pulling, friction, or sudden loading (e.g., a direct blow). Mechanical forces can act on the body in a variety of ways. They can cause injury, or they can be beneficial if applied appropriately.


It is helpful to identify the different types of mechanical forces and to understand the ways in which mechanical forces applied during massage act therapeutically on the body.


Variations in depth of pressure, drag on the tissue, speed of application, direction of movement, frequency of application, duration of application, and rhythm allow for extensive application options based on treatment plan and the individual session planning to carry out the treatment plan.


The forces created by massage are as follows:



How these forces are applied during massage becomes the mode of application. The historical terms used to describe the mode of application are effleurage, pétrissage, tapotement, and so forth. These terms are being replaced gradually with terms such as stroking, gliding, kneading, percussion, and oscillation. When studying for exams, it is necessary to be able to recognize multiple terms that describe the same application. When force is applied to the tissue through the mode of application, this is called loading.



Structural and mechanical effects


Manual methods of massage that most specifically affect body structure involve the application of mechanical forces to the body to load the tissue. For example, the pumping mechanisms of the heart, arteries, veins, lymphatic vessels, muscles, respiratory system, and digestive tract can be supported by applying massage methods with a rhythmic pumping action.



Tension loading

Tension force (also called tensile force) occurs when two ends of a structure are pulled apart from one another. This is different from muscle tension. Muscle tension is created by excessive muscular contraction or by an increase in fluid pressure, not by strong levels of pulling force applied to the tissue. Tissues elongate under tension loading during massage, which fulfills the intent of lengthening shortened tissues. Tension force is created by methods such as traction, longitudinal stretching, and stroking with tissue drag. Tensile forces also cause an aggregation of collagen, resulting in thicker, denser tissue; this improves 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. It also is thought to be effective in moving body fluids.


Certain tissues, such as bone, are highly resistant to tensile forces. An extreme amount of force is needed to break or damage a bone by pulling its two ends apart. However, soft tissues are very susceptible to tension injuries. In fact, tensile stress injuries are the most common soft tissue injuries. Examples of such injuries include muscle strains, ligament sprains, tendonitis, fascial pulling or tearing, and nerve traction injuries (i.e., sudden stretching of nerves, such as occurs in whiplash). Muscles and other soft tissues that are long yet taut are being pulled apart by tensile force. However, this taut condition is often mistaken for short, contracted tissue because it is palpated as “tight,” when actually the tissue is overstretched, much like an overstretched rubber band. Typically tension force is not applied to tissues that are long and taut; this will result in further stretching and dysfunctional tissue. Tension force is used during massage with applications that drag, glide, lengthen, and stretch tissue to elongate connective tissues and lengthen short muscles.



Compression loading

Compressive force occurs when two structures are pressed together. In massage applications, compressive force is described as depth of pressure. This kind of force may be sudden and strong, as with a direct blow (tapotement), or it may be slow and gradual, as with gliding strokes combined with compression. The magnitude and duration of the force are important in determining the outcome of the application of compression. Some tissues are resilient to compressive forces, whereas others are more susceptible. Nerve tissue is an interesting example. Nerve tissue can withstand a moderately strong compressive force if the force does not last long (e.g., a sudden blow to the back of your elbow that hits your “funny bone”). However, even slight compressive force applied for a long time (as occurs with carpal tunnel syndrome) can cause severe nerve damage. The massage therapist needs to consider this when determining the duration of a massage application that uses compression, especially over areas of nerves.


Ligaments and tendons are sturdy and resistant to strong compressive loads. Muscle tissue, on the other hand, with its extensive vascular structure, is not as resistant to compressive forces. Excessive compressive force will rupture or tear muscle tissue, causing bruising and connective tissue damage. This is a matter of concern when pressure is applied to deeper layers of tissue. To avoid tissue damage, the massage therapist must distribute the compressive force of massage over a broad contact area on the body. The greater the compressive force that is used, the broader should be the base of contact with the tissue.


Compressive force is used therapeutically to affect circulation, nerve stimulation, and connective tissue pliability. Compression is effective because it acts as a rhythmic, pumplike method of facilitating fluid dynamics. With this technique, tissue shortens and widens, increasing pressure within the tissue and affecting fluid flow. Sustained compression, especially with a drag component, seems to result in more pliable connective tissue structures and is effective in reducing tissue density and binding.



Bending loading

Bending force is a combination of compression and tension forces. One side of a structure is exposed to compressive forces, whereas the other side is exposed to tensile forces. Bending occurs during many massage applications. Pressure is applied to the tissue, or force is applied across the fiber or across the direction of the muscles, tendons or ligaments, and fascial sheaths. Bending forces rarely damage soft tissues; however, they are a common cause of bone fracture. Bending forces are used therapeutically to increase connective tissue pliability and affect proprioceptors in the tendons and belly of the muscles.


The massage therapist applies combined forces of tension to the convex side and compression to the concave side of the tissue to create the bend force load on the tissue Bending is used when the combined effects of lengthening and shortening and an increase in pliability are desired.






The methods of massage


Terminology for massage methods is not consistent. This part of the textbook presents the multiple terms used to name massage. While studying for exams, it is important to become familiar with terminology variations.



The mode of application


Holding/resting position


Initial contact with the client must be made with respect and with a client-centered focus that includes a clear intention and understanding of the outcome of the massage. The body needs time to process all the sensory information it receives during a massage. Holding is achieved by stopping the motions and simply resting the hands on the body to provide moments of integration.



Gliding/stroking/effleurage


The distinguishing characteristic of gliding strokes is that they are applied horizontally in relation to the tissues, thus generating a tensile force. The amount of drag on the tissues is modified by the lubricant type and amount used during application. When lubricant is not used, drag during gliding is maximized.


During a gliding stroke, light pressure remains on the skin, and moderate pressure extends through the subcutaneous layer to reach muscle tissue but does not penetrate deeply enough to compress the tissue against the underlying bony structure. Moderate to heavy pressure that puts sufficient drag on the tissue mechanically affects connective tissue and the proprioceptors (spindle cells and Golgi tendon organs) found in the muscle. Heavy pressure produces a distinctive compressive force of soft tissue against bone.


Strokes that use moderate pressure from the fingers and toes toward the heart, in keeping with the muscle fiber direction, are excellent for mimicking mechanical and reflexive stimulation of blood flow, particularly venous return and the lymphatics. Light to moderate pressure with short, repetitive gliding with a drag component, consistent with the patterns for lymph vessels, forms the basis for manual lymph drainage, which encourages interstitial fluid to move into lymphatic cavities. Light stroking over nerve pathways can be called a nerve stroke.



Kneading/pétrissage/pulling/skin rolling


Kneading is a technique in which the soft tissue is lifted, rolled, and squeezed. Terms related to knead/petrissage methods are fulling, wringing, and rolling


The main purpose of this manipulation is to lift tissue by applying bending, shear, and torsion forces. Kneading is effective for reducing muscle tension. The lifting, rolling, and squeezing action affects muscle spindles in the muscle belly. As the belly of the muscle is squeezed (thus squeezing the muscle spindles), the muscle becomes less tense. When lifted, the tendons are stretched, thus increasing tension in both the tendons and the Golgi tendon organs.


Kneading is effective for mechanically softening the superficial fascia. Kneading methods support circulation by squeezing the capillary beds in tissues and helping fluid exchange. Kneading may incorporate a wringing or twisting component (torsion) after the tissue is lifted. Changes in depth of pressure and drag determine whether the client perceives the manipulation as superficial or deep. By the nature of the manipulation, pressure and pull peak when the tissue is lifted to its maximum and then decrease at the beginning and end of the manipulation. Skin rolling is a variation of the lifting manipulation. Whereas deep kneading attempts to lift the muscular component away from the bone, skin rolling lifts only the skin and superficial fascia from the underlying muscle layer. It has a warming and softening effect on the superficial fascia, causes reflexive stimulation of the spinal nerves, and is an excellent assessment method. Areas of “stuck, bound, dense, thick” tissue often suggest underlying problems.


Skin rolling is one of the few massage methods that is safe to use directly over the spine. Because only the skin and superficial fascia is accessed and the direction of pull to the tissue is up and away from the underlying bones, risk of injury to the spine is minimal, unlike when any type of downward pressure is used.


Sometimes a client’s tissue does not lift. This may be caused by excessive edema (swollen tissue), a heavy fat layer, scarring that extends into the deeper body layers, or thickened areas of connective tissue, especially over aponeuroses (flat sheets of superficial connective tissue). If these conditions exist, applications of kneading or skin rolling are uncomfortable for the client. Shifting to gliding and compression with drag may soften the tissue enough that kneading can be used more effectively later in the massage session.



Compression


Compression applies forces then moves down into the tissues, with varying depths of pressure adding bending and compressive forces. The manipulations of compression usually penetrate the subcutaneous layer, whereas in the resting position, the forces stay on the skin surface. Much of the effect of compression is caused by tissue that is pressing against underlying structures, causing it to spread. This can be called tissue displacement.


Compression used in the belly of the muscle spreads the muscle spindles, causing the muscle to sense that it is stretching. The theory of benefit is that to protect the muscle from overstretching, the muscle spindles signal for the muscle to contract. The lift-press application stimulates muscle and nerve tissue. The combination of these two effects makes compression a good method for stimulating muscles and the nervous system. However, because of this stimulation, compression is a little less desirable for a relaxing or soothing massage.


Compression is thought to be an excellent method for enhancing circulation. Pressure against the capillary beds changes pressure inside the vessels, which encourages fluid exchange. Compression appropriately applied to arteries allows back pressure to build, and release of compression promotes arterial flow.


Compression can be done with the point of the thumb or with a stabilized finger; with the palm and heel of the hand, the fist, the knuckles, and the forearm; and, in some systems, with the knee and the heel of the foot. Even though compressive pressure is exerted perpendicular to the tissue, the position of the forearm in relation to the wrist allows the wrist to remain within the acceptable position of less than 60 degrees of extension. Application against a 45-degree angle of the body plus the 45-degree angle of the therapist’s hand and forearm results in 90-degree contact on the tissue. If you are using your knuckles or fist, make sure the forearm is in a direct line with the wrist. Use of the thumb should be avoided if possible, because the thumb joints can be damaged by extensive use, especially on large muscle masses.


Compression proceeds downward into the tissues; the depth is determined by what is to be accomplished, where compression is to be applied, and how broad or specific the contact with the individual’s body is. Deep compression presses tissue against underlying bone. Because of the diagonal pattern of the muscles, the massage therapist should stay perpendicular (i.e., at a 90-degree angle) to the bone, with actual compression somewhere between a 60- and 90-degree angle to the body. Beyond those angles, the stroke may slip and turn into a glide.



Oscillation: Shaking, vibration, and rocking


Oscillation is the rhythmic or dysrhythmic movement of tissues on a body part. Oscillation is one of the most effective methods of normalizing the motor tone of muscles. Shaking is a massage method that is effective for relaxing muscle groups or an entire limb. Shaking manipulations seem to confuse the positional proprioceptors, because the sensory input is too disorganized for the integrating systems of the brain to interpret; muscle relaxation is the natural response in such situations.


Shaking warms and prepares the body for deeper bodywork and addresses the joints in a nonspecific manner. Shaking is effective when the muscles seem extremely tight because motor tone has increased. This technique is reflexive in effect, but a small mechanical influence may be exerted on the connective tissue as well as a result of the lift-and-pull component of the method. Shaking begins with a lift-and-pull component. Either a muscle group or a limb is grasped, lifted, and shaken.


Shaking is not a manipulation to be used on the skin or superficial fascia, nor is it effective for use on the entire body. Rather, it is best applied to any large muscle groups that can be grasped and to the synovial joints of the limbs. Good areas for shaking are the upper trapezius and shoulder area, biceps and triceps groups, hamstrings, quadriceps, gastrocnemius, and, in some cases, the abdominals and the pectoralis muscles close to the axilla. The joints of the shoulders, hips, and extremities also respond well to shaking.


The larger the muscle or joint, the more intense the method must be to be effective. If the movements are performed with all the slack out of the tissue, the focus point of the shake is very small, and the technique is extremely effective. The more purposeful the approach, the smaller is the focus of the applied shaking. Always stay within the limits of both range of motion of a joint and elastic give of the tissue.


Vibration is a smaller, more focused oscillation that involves very fast, small movements. Rocking is a soothing, rhythmic method. Rocking also works through the vestibular system of the inner ear and feeds sensory input directly into the cerebellum. Other reflex mechanisms are most likely affected as well. For this reason, rocking is one of the most productive massage methods for achieving entrainment. Recall that entrainment is the tendency for synchronizing of rhythms. During massage, external rhythms such as the pace of the massage, music, and rhythmic stroke application can support the inherent trend for the client’s physiology to respond beneficially.


Rocking is rhythmic and should be applied with a deliberate, full body movement. The easiest way to do this is to take the client’s pulse and match the rhythm to that of the pulse. Work within the rhythm to maintain and amplify it by attempting to gently extend the limits of movement or by slowing the rhythm if it is too fast. Clients seem to relax more easily when a subtle rocking movement that matches the client’s innate rhythm pattern is part of the generalized massage approach, along with such techniques as gliding, kneading, compression, joint movement, and, especially, passive movement.



Percussion (tapotement)


Percussion, also called tapotement, is classified as light or heavy (i.e., surface or deep). The difference between light and heavy tapotement involves whether the compressive force of the blows penetrates only to the superficial tissue of the skin and subcutaneous layers (light) or more deeply into the muscles, tendons, and visceral structures, such as the pleura in the chest cavity (heavy).


Percussion is a stimulating manipulation that involves nerve responses. Because of its intense stimulating effect on the nervous system, percussion initiates or enhances sympathetic activity of the autonomic nervous system. The effects of the manipulations are reflexive except for the mechanical results of percussion in loosening and moving mucus in the chest. When applied to the joints, percussion affects the joint kinesthetic receptors responsible for determining the position and movement of the body. The quick blows confuse the system, similar to the effect of joint-focused rocking and shaking, but the body muscles tone instead of inhibit. Therefore, this method is useful for stimulating weak muscles. The force used must move the joint but should not be strong enough to damage it. For example, one finger may be used over the carpal joints, whereas the fist may be used over the sacroiliac joint.


Percussion is very effective when used at motor points that usually are located in the same area as traditional acupuncture points. Repetitive stimulation causes the nerve to fire repeatedly, thus stimulating the nerve pathway.


Percussion that is focused primarily on the skin affects the superficial blood vessels of the skin, initially causing them to contract. Heavy percussion or prolonged lighter application dilates the vessels as a result of the release of histamine, a vasodilator. Although prolonged percussion seems to increase blood flow, surface application enhances the effect of cold application used in hydrotherapy.


Heavy percussion should not be done over the kidneys or other endangerment site areas, or anywhere that pain or discomfort is present. Terms related to tapotement/percussion are slapping, tapping, hacking, cupping, beating, and pincement.



Friction


Friction can be superficial, such as fast back-and-forth movement on the skin. Deep friction consists of small, deep movements performed in a local area. It creates shear force to the tissue. Friction burns may result if the fingers are allowed to slide back and forth over the skin. Friction prevents and breaks up local adhesions in connective tissue, especially over tendons, ligaments, and scars, by creating therapeutic inflammation. This method is not used over an acute injury or a fresh scar and should be used only if the client’s adaptive capacity can respond to superimposed tissue trauma.


Modified use of friction after a scar has stabilized or the acute phase has passed may prevent adhesions and can promote a more normal healing process. This application also reduces pain through the mechanisms of counterirritation and hyperstimulation analgesia.


Movement in deep friction usually is transverse to the fiber direction, and the technique generally is applied for 30 seconds to 10 minutes. This type of friction initiates a small, controlled inflammatory response. The chemicals released during inflammation activate tissue repair mechanisms and reorganize connective tissue. This type of work, coupled with proper healing and rehabilitation, is valuable therapeutically.


Friction is a mechanical approach that is best applied to areas of high connective tissue concentration, such as the musculotendinous junction. Microtrauma caused by repetitive movement and overstretching is common in this area. Microtrauma predisposes the musculotendinous junction to inflammatory problems, connective tissue changes, and adhesion.


Experts disagree on whether an area that is to receive friction should be stretched or relaxed. Because both methods have merit, both positions should be included in frictioning. Another use for friction is to combine it with compression, thereby adding a small stretch component, but with movement that includes no slide. This application has mechanical, chemical, and reflexive effects and is the most common approach for the use of friction.


Remember that the main focus when deep friction is used is to move tissue under the skin. Do not use lubricant, because the tissues must not slide. Place the area to be frictioned in a soft or slack position. To produce movement, begin with a specific and moderate to deep compression using the fingers, the palm, or the flat part of the forearm near the elbow. After reaching the depth of pressure required to contact the target tissue, move the upper tissue back and forth across the grain or fiber of the underneath tissue for transverse or cross-fiber friction, or around in a circle for circular friction.


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Joint movement methods


Joint movement is effective because it provides a means of controlled stimulation to the joint mechanoreceptors. Movement initiates motor tone readjustment through the reflex center of the spinal cord and lower brain centers. As positions change, supported movement gives the nervous system an entirely different set of signals to process. Joint sensory receptors are able to learn not to be so hypersensitive. As a result, protective spasm and movement restriction may lessen.


Joint movement also encourages lubrication of the joint and contributes an important enhancement to the lymphatic and venous circulatory systems. Much of the pumping action that moves these fluids within the vessels results from compression of the lymph and blood vessels during joint movement and muscle contraction. Also, movement warms the tendons, ligaments, and joint capsule. This mechanical effect helps keep these tissues pliable.



Types of joint movement methods


Joint movement involves moving jointed areas within the physiologic limits of the client’s range of motion. The two types of joint movement are active movement and passive movement.


In active joint movement, the client moves the joint by means of active contraction of muscle groups. Active joint movement is subcategorized as active-assisted movement, which occurs when both the client and the massage therapist move the area, and active resistive movement, which occurs when the client actively moves the joint against a resistance provided by the massage therapist.


In passive joint movement, the client’s muscles remain relaxed and the massage therapist moves the joint with no assistance from the client. For example, joint oscillation is a passive joint movement.


Joint movements are used to assess the range of motion of an individual joint. Available range of motion is measured from the neutral anatomic position (0). If the 0 appears first (hip abduction, 0-45), this means that the joint movement begins at anatomic and moves away. If the number appears first (hip adduction, 45-0), this mean that the joint position is beginning outside of the anatomic position and is moving back into anatomic position.



Normal range of motion for each joint

Normal values (in degrees):



• Hip flexion, 0-125


• Hip extension, 105-0


• Hip hyperextension, 0-15


• Hip abduction, 0-45


• Hip adduction, 45-0


• Hip lateral (external) rotation, 0-45


• Hip medial (internal) rotation, 0-45


• Knee flexion, 0-130


• Knee extension, 120-0


• Ankle plantar flexion (movement downward), 0-50


• Ankle dorsiflexion (movement upward), 0-20


• Foot inversion (turned inward), 0-35


• Foot eversion (turned outward), 0-25


• Shoulder flexion with scapular movement 0-180


• Shoulder (glenohumeral joint only) flexion, 0-90


• Shoulder extension, 0-50


• Shoulder abduction with scapular movement 0-180


• Shoulder (glenohumeral joint only) abduction, 0-90


• Shoulder(glenohumeral joint only) adduction, 90-0


• Shoulder lateral (external) rotation, 0-90


• Shoulder medial (internal) rotation, 0-70


• Elbow flexion, 0-160


• Elbow extension, 145-0


• Elbow pronation, 0-90


• Elbow supination, 0-90


• Wrist flexion, 0-90


• Wrist extension, 0-70


• Wrist abduction, 0-25


• Wrist adduction, 0-65



Stretching


Stretching is a mechanical method of introducing various forces into connective tissue to elongate areas of connective tissue shortening. Stretching affects the fiber component of connective tissue by elongating the fibers past their normal give so that they can enter the plastic range past the existing bind or resistance barrier.


Stretching is an intervention that is used purposefully to cause an adaptation in the soft tissues, including tissue around joints of the body. Joint movement and palpation are the assessments used to determine if stretching should be used to address areas of tissue shortening and increased density involved in a lack of flexibility.


Stretching methods can be passive or active. Passive stretching occurs when a second person applies the force to stretch the tissue. Active stretching occurs when the person stretches him or herself. Stretching of both types can also be included into the massage session. During massage, each jointed area should be moved actively, passively, or both ways as part of an assessment to determine the range of motion available. It is important not to confuse joint movement with stretching. Joint movement assesses for the limits of movement as indicated by the palpation of the resistance barrier. If assessment indicates hypomobility in the joint, then stretching begins at the bind and moves into it in order to change the amount of movement available, which is called flexibility. Using muscle energy methods before stretching enhances the effect by increasing the client’s tolerance to the stretch sensation.


Because stretching is an intervention that requires adaptation, it is important to determine if



Stretching as an intervention method needs to be used carefully to avoid adverse outcomes. Joints should not be stretched beyond the normal range of motion. Stretching should not be painful. If an increase in flexibility is indicated, stretching methods should be introduced gently and progressively over a period of time over multiple sessions. Hypermobile joints should not be stretched; however, direct tissue stretching between the joints can be effective.



Muscle energy techniques (METs)


Muscle energy techniques involve a voluntary contraction of the client’s muscles in a specific and controlled direction, at varying levels of intensity, against a specific counterforce applied by the massage therapist. Muscle energy procedures have a variety of applications and are considered active techniques in which the client contributes the corrective force. The methods are used in conjunction with stretching to help increase the stretch response by increasing the client’s tolerance to the stretch sensation. The exact mechanisms of action are not understood.






Body mechanics


Effective body mechanics is essential for the massage therapist. The profession does not agree on what constitutes proper body mechanics. However, the following basic concepts appear to provide the foundation for body mechanics–type questions. Four basic concepts pertaining to body mechanics are common to all techniques used to apply compressive force to body tissues during massage application:



Weight transfer allows the massage therapist to transfer his or her body weight by shifting the center of gravity forward to achieve a pressure that is comfortable for the client. Perpendicularity is necessary to ensure that the pressure exerted sinks straight into the tissues. The line from the shoulders to the point of contact (e.g., forearm, heel of the hand) must be 90 degrees to the plane of the contact point on the client’s body. The client should be positioned in such a way that pressure is applied against a 45-degree incline whenever possible.


Stacking of the joints one atop another is essential to the concepts of perpendicularity and weight transfer. The therapist’s body must be in a straight line from the heel of the weight-bearing rear foot through the knee, hip, and shoulder, and then from the shoulder to the forearm, or through the elbow, which acts as an extension of the shoulder, to the heels of the hands. The ankle, knee, hip of the back leg, and spine are stacked and stable in a close-packed joint position. The pelvic girdle and the shoulder girdle are lined up. The shoulder is stacked over the elbow, which in turn is stacked over the wrist. Stacking the joints in this way allows the pressure exerted by the massage therapist to travel straight and effortlessly into the client’s body as the therapist’s center of gravity moves forward.


Keeping the back straight involves the ability to stack the joints and then provide stability using the core muscles involved in upright posture.


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Sanitation/standard precautions


Massage therapists should always be meticulous about hygiene and sanitation. However, this behavior is even more important in the medical setting, in which exposure to disease is increased and clients are more susceptible to pathogens. The concepts of disease transmission and response to infection are the basis for understanding the importance of the first line of defense in preventing disease. Infectious diseases can spread only under certain circumstances. Infection starts with the infectious agent. The five groups of potentially pathogenic organisms are viruses, bacteria, protozoa, fungi, and rickettsiae as well as lice and mites. For infection to occur, an infectious microorganism must be present. Any disease caused by the growth of pathogenic microorganisms in the body falls into the category of infectious (communicable) diseases. The goal of sanitation is to prevent the spread of infectious disease. Pathogens can be spread by direct and indirect contact, through food or liquids that are ingested (vehicle transmission), and from other insect or animals that carry the pathogen. Infection from the bites of insects or animals or exposure to their waste products is called vector transmission.


The best way to prevent the spread of disease is to use adequate infection control procedures; these include consistent hand washing and including washing up past the elbow since forearms are used during massage application, proper use of antiseptics, and disinfection and sterilization methods. The Occupational Safety and Health Administration has established guidelines for sanitation. Because these standards are written to cover employees in all health fields, only some of the regulations apply to the practice of therapeutic massage. The information presented here is what applies most to massage therapists. There is a difference between cleaning and sanitation. Cleaning activities revolve around general housekeeping needs and can be accomplished with specialized cleaning products or common household products such as soap, vinegar, or baking soda, whereas sanitation goes a step further to address pathogenic organisms. Sanitation involves use of a method or product that will kill pathogens and reduce the exposed to infection. High heat is a form of sterilization, and the intent is to kill all pathogens. Bleach and other approved disinfecting products such as quaternary ammonium compounds may also be used.



Hand washing


One of the simplest and most effective techniques for preventing the spread of disease is hand washing. In medical practice, every procedure begins and ends with hand washing. Normally, two types of bacteria can be found on the skin: transient bacteria, which are surface bacteria that remain a short time, and resident bacteria, which are found under the fingernails, in hair follicles, in the openings of sebaceous glands, and in the deeper layers of the skin. The goal of thorough hand washing is to eliminate or reduce the number of transient bacteria on the skin surface, thus preventing transient bacteria from becoming resident bacteria. The most effective barrier against infection is unbroken skin.


It is impossible to sterilize hands; therefore, the goal of hand washing is to reduce the number of bacteria on the skin by using mechanical friction, antimicrobial soaps, and warm, running water. A good antimicrobial soap with chlorhexidine (e.g., Hibiclens) that has antiseptic residual action and lasts several hours should be used for hand washing in the health care environment. Each sink should be equipped with a liquid soap dispenser.


The water should be warm, because water that is too hot or too cold causes the skin to become chapped. Friction involves firmly rubbing all surfaces of the hands, wrists, and forearms. Remember that fingers have four sides, and fingernails have two sides. All jewelry is removed for hand washing. The hands and forearms are washed under running water, with the fingertips pointing downward. Soap and friction are applied to the hands, wrists, and forearms, because these areas are used for massage application. Allow the water to wash away debris from the elbows down toward the fingertips.


A water-soluble lotion may be rubbed into the hands after they have been washed and dried. Dry, cracked, chapped skin is an interruption of the skin’s integrity and can result in the transmission of disease. An antiseptic can be used on the skin.




Positioning


Positioning is placing a client into the position that best enhances the benefits of the massage. The four basic massage positions are supine (face up), prone (face down), side lying, and seated, which includes a semi-reclined position.


A client may be placed in all four positions during a massage session because remaining in one position longer than 15 minutes may become uncomfortable. The exception is a painful situation that limits the client’s ability to be comfortable in a certain position.


Pillows or other supports, such as folded towels, blankets, or specially designed pieces of foam, are used to make the client comfortable. These supports fill any gaps in contour when the client is positioned and provide soft areas against which the client can lean. Supports generally are used under the knees, ankles, and neck.



Draping


Draping has two purposes:




Principles of draping




• Draping can be done in many ways, although certain primary principles apply.


• All reusable (multiple use) draping material must have been freshly laundered with bleach or other approved solution for each client. Disposable (single-use) linens if used must be fresh for each client and then disposed of properly.


• Only the area that is being massaged is undraped.


• The genital area is never undraped. The breast area of women is not undraped during routine wellness massage. Specific massage that targets the breast under the supervision of a licensed medical professional may require special draping procedures for the breast area of women. Breast massage for medical purposes follows a specific method and a consent process. These methods are out of the scope of practice for the wellness massage practitioner.


• Draping methods should keep the client covered in all positions, including the seated position.


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Effective and intelligent application of massage


There are basically two approaches to the delivery of massage. One approach can be considered a routine or protocol-based method. The client’s intent is to experience the method rather than achieve a specific change in a body condition or behavior. Examples might include a signature spa massage or a general relaxation massage. There is a general therapeutic value in this approach, and it provides an important service for clients.


The other is considered outcome based and consists of a comprehensive, integrated, process to assess client needs, determine goals for the massage, plan massage application to achieve the goals, and measure outcomes of treatment at regular intervals based on measurable changes in the conditions or behavior of an individual as a result of a specific intervention or action. No one massage type is used exclusively. Instead, methods are used together to achieve client goals. Common outcomes include relaxation, stress management, pain management, and improvement of mobility and physical function.


Regardless of approach, the effective and intelligent application of massage is dependent on knowledge of anatomy, physiology, kinesiology, biomechanics, pathology, and pharmacology and considers the following:



• Structure can be thought of as anatomy, and function as physiology. Most massage outcomes influence physiology through both reflexive and mechanical applications.


• The massage therapist most often works with the structural fluid and fiber aspects of the body, and with the functional interplay of body system function coordinated by chemicals and electrical signals.


• Chemicals and electrical signals control the body, and fluid and fibers make up the bone and soft tissue.


• Soft tissue includes the skin, fascia and other connective tissues, muscles, tendons, ligaments, cartilage, bursae, joint capsules, nerves, and vascular and lymphatic tubes.


• The various body fluids include blood, lymph, interstitial fluid, synovial fluid, mucus, cranial sacral fluid, digestive fluid, and various fluids produced by membranes in the body.


• All massage methods introduce mechanical forces into the soft tissues. These forces mimic and stimulate various physiologic responses. Some massage applications are more mechanical than others:


• Neuroendocrine stimulation occurs when forces are applied during massage that generate various shifts in physiology.


• Massage causes the release of vasodilator substances that then promote circulation in a particular area.


• Massage stimulates the relaxation response, thus reducing sympathetic autonomic nervous system dominance.


• Forces applied during massage stimulate proprioceptors, which alter motor tone in muscles. Some of the listed benefits are supported by valid research and some by less rigorous forms of evidence such as consensus of expert opinion.



Assessment and care/treatment plan development


Assessment identifies the structures that need to be addressed, establishes clear intentions for treatment goals, provides a baseline of objective information for measuring the effectiveness of treatment, and helps identify conditions in which a particular treatment may be contraindicated. The massage therapist must gather specific information about treatment goals, both long-term and short-term, as well as data that are pertinent to the massage treatment.


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Jun 22, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Massage theory and application

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