Massage

Introduction

Massage is the starting point of the physiotherapy profession. Swedish massage was the basis for the strokes and principles used by the first members of the Chartered Society of Physiotherapists. There is evidence of massage being used in many ancient civilisations. The word massage may derive from the Arabic ‘mass’, meaning to press, or the Greek word ‘massien’ meaning to knead.

Definition

Massage is an age-old process that involves stimulation of the tissues by rhythmically applying both stretching and pressure (Watt 1999). Holey and Cook (2003) define therapeutic massage as ‘…the manipulation of the soft tissues of the body by a trained therapist as a component of a holistic therapeutic intervention.’

Preparation

Preparation encompasses the treatment room, couch, self, patient and contact medium.

Treatment room

The treatment room needs to be kept at a comfortable temperature to ensure the patient is not subjected to chills or draughts. It must also afford the necessary privacy without contravening the patient’s rights. There must be a treatment couch, small arm table and chair.

Couch

In the clinical setting most treatment couches/plinths can have the height adjusted to suit the individual therapist. To get a good height for performing massage, stand side-on to the couch, rest your hand with fingers loosely flexed at the metacarpal phalangeal joints and elbow not quite fully extended. Adjust height of couch until you can comfortably rest your hand as above. This takes time, trial and error to gain the optimum position (Figure 21.1). The couch should have a fresh clean cover and also a paper couch roll, pillows, a face hole or face pillow, and blanket/towels to cover the patient.

Figure 21.1 Setting the plinth to the correct height.

Self preparation

Stance

It is very important to ensure that your stance allows you to reach all the parts to be massaged in a specific stroke without having to keep altering position. Stand in lunge position to perform long strokes, such as effleurage and stroking (Figure 21.2). To reach across the patient assume a similar position facing the couch (Figure 21.3). Do not stand still – let your whole body go with the stroke and always keep your pelvis tucked and knees slightly bent to protect your back. Ensure your shoulders are relaxed, comfortable and not hunched.

Palpation

The sense of touch and palpation skills must be highly developed in the person performing massage. It requires practice to attune and improve our sense of touch and therefore palpation skills. Start by feeling the differing textures of various types of material. Sit with a pillow on your knees and feel the pillow slip between fingers and thumb, then do the same with a towel (Figure 21.7a). Once you are happy you can easily tell one type of fabric from another repeat the exercise with your eyes closed (Figure 21.7b). Use your own body to identify anatomical landmarks and accustom your hand to the feel of differing tissues. Start by feeling the point of your elbow first with thumb tip, then each finger separately and together, and then with the palm of your hand. Repeat with each hand in turn; close your eyes and focus on the message you receive from your hands. Try the same routine on the calf, shin, anterior aspect of the thigh, forearm, neck, shoulders and abdomen.

Your sense of touch can be improved by many different methods. Put a selection of different round objects of various size and texture into a bag and then try to identify each by touching only. As this becomes easier choose smaller articles of more closely related textures and time how long it takes to identify correctly.

It is also important to learn the depth of contact. Too light can be uncomfortable and ticklish and is frequently referred to as ‘skin polishing’. Too-heavy firm pressure may well produce trauma and damage tissue. Practise depth again on your own skin – try to move your hand across your leg as lightly as possible and then increase depth until you feel it is producing pain. Try out on a friend or colleague and agree a score rate from, say, 1–5 of very light to heavy. You make your mind up what depth/number you are contacting then ask your model for their answer. Always listen to what the model tells you and alter to get to the score they think it is.

Patient preparation

It is important that the patient is fully informed of exactly what the massage session will involve. Consent is dealt with in ‘Legal aspects’ and must always be in place before any massage starts.

It is vital to request the patient to remove the specific pieces of clothing required to permit the treatment. Always explain the reasons behind these requests. The patient’s decency and modesty has to be respected at all times.

Neither the physiotherapist nor patient should ever feel uncomfortable, threatened or embarrassed by the manipulations being used. Always tell the patient exactly what you are doing and why. Explain why strokes have to be taken right up into the lymph drainage areas and make sure they are content to have this done.

Draping or covering the patient has to be properly carried out. Use shorts, towels of various sizes, towelling robes and togas (Figure 21.8). Patient’s own clothing is also very useful. Again, explain why you want the towel tucked in and wherever possible get the patient to do this for themselves.

Never remove any article of the patient’s clothing without asking their specific permission to do so. Remember it is possible to apply some forms of massage through one layer of clothing or over a thin cloth or towel.

Coupling media

Many and varied products are used as coupling media in massage. Massage oils, creams, gels and powders, and aromatherapy products are readily available. The first and most important step is to ensure that the lubricant selected is acceptable to both patient and masseur, and there are no contraindications to its use.

It is essential that there is full information on all the contents of the chosen product. This is vital if the recipient or masseur has any allergies. Many massage oils/creams use nut oils as a base and, obviously, this should never be applied in cases of nut allergy. Very hairy skin can be irritated and damaged by the use of powder or too little lubricant during massage. Powder should never be applied to hot sweaty skin as it clogs pores and tends to form hard lumps on the surface.

Ice massage can be extremely useful but great care must be taken to ensure the skin is not damaged by the effect of the ice. Always ensure the ice is kept moving, regularly check skin colour and reaction. Stop if the patient reports feeling uncomfortable or cooling too fast.

Apply oils directly to your hands and do not use too much. Always make sure the whole area to be treated is clean before starting and also clean thoroughly at the end of massage.

Water alone or soapy water can be used with good effect as a lubricant and the addition of a small amount of oil can be beneficial when dealing with dry, scaly skin.

Never apply any heating agent/cream when you are treating any area where there has been tissue damage and healing. A hot cream may produce too much superficial increase in skin temperature and create further damage.

Legal aspects

It is mandatory to acknowledge and implement all pertinent legal requirements before, during and after using massage. The practitioner must explain the reasons for applying massage and explain exactly what is involved. Written informed consent must be obtained – to apply massage without such consent can be construed as assault. Throughout the whole treatment both patient and physiotherapist must be totally comfortable and at ease with the methodology. Keep inquiring if the patient is happy and content with the proceedings.

All child protection, chaperone and local laws must be obeyed. Remember to keep accurate, legible, dated and signed treatment notes. Don’t just write ‘massage’: give a short description of techniques used and list outcomes.

Contraindications

In some conditions massage can exacerbate problems and can be dangerous. Always have a diagnosis, carry out an assessment and be clear on the aims of the treatment.

1. Skin infections of viral, fungal or bacterial origin are contraindications to massage. Any type of skin infection in the area to be massaged or involving the hands of the physiotherapist would preclude the application of massage.

2. Open wounds should not be massaged. Apart from being painful, massage can damage the healing tissue and restart bleeding and may cause infection.

3. Circulatory problems can be adversely affected by massage which increases blood flow and manipulates the blood vessels. Bleeding disorders, such as haemophilia, arteriosclerosis, haemorrhage, thrombosis and artificial blood vessels, are all contraindications to massage. Remember deep vein thrombosis is a total contraindication to massage.

4. Recent injury, if massaged too early in the healing process, will cause further damage. Massage at that stage will cause trauma to the fragile healing tissue leading to delay in repair, further bleeding and resultant excess scar tissue. It is recommended that massage should not be started until 48 hours after injury. Always ensure bleeding has stopped. Proceed with great care and use very gentle strokes initially.

5. Tumours can be mechanically stimulated by massage which speeds up metabolism and so spreads the tumour. Do not massage directly over or close to a tumour. Remember massage can be very effective and prove an invaluable aid to cancer victims and in palliative care.

6. Acute inflammation is contraindicated for massage as the inflammatory process can be increased by the effects produced.

7. Myositis ossificans should not be massaged directly. This can produce increased formation of bony cells and further damage the soft tissues surrounding the site. Vigorous deep massage has been known to separate small bony particles from the site of ossification.

8. Diabetes – although not a total contraindication to massage, great care must be used when treating diabetics with massage. It is usual for the peripheral circulation to be affected in diabetes and as a result blood vessels and skin can be easily damaged. Apply massage with great care.

9. Alteration of skin sensation can be a contraindication to the use of massage.

Massage may be used in certain circumstances, provided the experienced practitioner has an accurate diagnosis and knows the extent and reason for the changes. Loss of sensation, heightened sensation, presence of tingling or neurological skin alteration all contraindicate massage.

Techniques

Massage manipulations are grouped into various headings. The three listed are the main components of basic massage.

1. Stroking manipulations.

2. Pressure or petrissage manipulations.

3. Percussive or tapotement manipulations.

Stroking manipulations

There are two strokes in this group:

• stroking and

• effleurage.

Stroking

This is, as the name suggests, a stroking movement, traditionally performed from distal to proximal in the direction of the lymph drainage (Figure 21.9a). It can also be performed in the opposite direction or in a cross over method.

This manipulation can be applied using pads of fingers, thumbs, one, two or alternate hands (Figure 21.9b). A specific type of stroking is ‘Thousand Hands’, as first described by Hollis (2009). In this case, one hand is used to perform a short stroke and then the second hand performs the same movement overlapping the first. This is a fairly light touch, but must not be so light as to irritate or tickle, and can be applied in fast or slow strokes.

Effects of stroking

• Gets the patient used to your touch.

• Allows assessment of the state of the skin and tissues of the area to be treated.

• Improves sensory analgesia.

• Slow stroking will relax and sedate and decrease muscle tone.

• Faster strokes will stimulate superficial blood flow, accelerate lymph drainage.

• Used at start and end of session.

Effleurage

The meaning of this word is to stroke; in massage it is a deeper form of stroking (Figure 21.10a). As such, it can be applied as described for stroking and also be reinforced with one hand over the other, or using lightly clenched fist (Figure 21.10b) or forearm. Because this manipulation goes deeper it can be graded. Grade 1 is sufficient to influence flow in superficial vessels; grade 2 affects deeper vessels; and grade 3 applies to reinforced effleurage, with one hand on top of the other. Effleurage can be applied in the direction of the lymph glands, or opposite, in all sorts of patterns from a Figure 7 or 8, to a circular or T shape.