Review of massage application

Review of massage application

The history of massage provides an understanding of the present and guidance for the future. The time line in Figure 3-1 presents the historical highlights.

Figure 3-1 Historical time line.

Body mechanics

Physical ergonomics deals with the human body’s responses to physical and physiologic loads. Relevant topics include manual materials handling, workstation layout, job demands, and risk factors such as repetition, vibration, force, and awkward/static posture as they relate to musculoskeletal disorders/repetitive strain injury. All work activities should permit the worker to adopt several different but equally healthy and safe postures. If muscular force has to be exerted, this should be done using the largest appropriate muscle groups available. Awkward posture is associated with an increased risk for injury, and the more a joint deviates from the neutral (natural) position, the greater the risk of injury. Every joint in the body has a neutral position at which joint spaces are even and symmetrical. The muscles around a joint in the neutral position are neither short nor long but are at their neutral physiologic resting lengths. Joint stability is provided by joint shape, joint capsule, ligaments, and normal co-contraction of the muscles around the joint. Joint stability is necessary for proper body mechanics.

Four basic concepts of body mechanics are common to all techniques used to apply compressive force against the body tissues during massage application. These concepts are as follows:

1. Weight transfer

2. Perpendicularity

3. Stacking the joints

4. Keeping the back straight and maintaining core stability

Weight transfer allows the massage practitioner to transfer body weight by shifting the center of gravity forward to achieve a pressure that is comfortable to the client. To transfer weight, the practitioner stands (or kneels) with one foot forward and the other foot (or knee) back in an asymmetrical stance. In the standing position, the front leg is in a relaxed knee flexion, with the foot forward enough to be in front of the knee. The back leg is straight, and the hips and shoulders are aligned so that the back is straight. The transfer happens by taking the weight off the front leg and moving it to the heels of the hands or whichever part of the arm is being used to apply pressure. To increase pressure into the client’s tissue while performing massage, put body weight into the back foot through ground reaction force. The weight of the body is distributed to the full foot of the weight-bearing leg, not just the toes.

Perpendicularity is an important concept that ensures that the pressure is sinking 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.

Stacking the joints one on top of another is essential to the concepts of perpendicularity and weight transfer. The practitioner’s body must be a straight line from the feet and through the shoulder to the forearm, or through the elbow acting as an extension of the shoulder, to the heels of the hands. The ankle, knee, hip of the back leg, and spine are stacked. The shoulder is stacked over the elbow, which in turn is stacked over the wrist. Stacking the joints in this way allows the pressure to go straight into the client’s body effortlessly as the center of gravity moves forward.

A straight back and a pressure-bearing leg are other essential components of body mechanics. If the back is not straight, the practitioner often ends up pushing with the upper body instead of using the more effortless feeling of transferred weight. The practitioner’s weight should be held on the back leg and on the heel of the foot. At first, this may feel uncomfortable; however, some of the biggest and strongest muscles in the body are those in the legs. If you carry the weight on the back, fatigue sets in more quickly, and eventually, the pain can become debilitating. The core muscles and associated connective tissues of the posterior, lateral, and anterior torso are considered the core. The core includes large connective tissue structures such as the lumbar dorsal fascial and the abdominal fascia. The core muscles contract, pulling the connective tissues taut, and make a girdle-like structure to maintain upright posture. Massage therapists need core stability to maintain a straight back, stack joints, and shift the body’s center of gravity forward to apply pressure (Figures 3-2 and 3-3).

Figure 3-2 Fundamentals of body mechanics. A, Begin. B, Lean, weight shift, stabilization, joint stacking. C, Glide: When weight from your back foot moves forward, from the heel to the ball of your foot and your toes, it is time to reposition by taking a step. D, After taking the step, reestablish core stabilization and the leaning posture. E, Example of body mechanics. F, Pressure of foot into floor results in arm glide. G, Compression down at 90 degrees. H, Example of application principles when kneeling.

Pressure has been defined in numerous ways: compressive force; force application depth; light, medium, and deep depth; and so forth. Drag is the resistance to glide. Glide moves horizontal to the tissues. If you combine pressure with drag, you create a multitude of intensities. For example, light pressure with extensive drag would significantly stretch the skin. Increase the pressure slightly and maintain significant drag, and the superficial fascia is stretched (tension force applied).

If you alter the duration (how long the technique is applied), the intensity can be modified. Generally, long duration is more intense and short duration is less intense. For specific application, short duration is 10 seconds, moderate duration 30 seconds, and long duration 60 seconds. For a whole session, short duration is 5 to 15 minutes, moderate duration 15 to 30 minutes, and long duration 45 to 60 minutes.

Another factor is the size of the point of contact. A large contact area is less intense than a small contact point. More pressure can be applied safely with a broad base of contact such as the forearm or full hand, rather than with a small point of contact such as when thumb pressure is used. Therefore, the factors that gauge the intensity of massage applications are compressive force, drag, duration, and size of the contact point. In addition, a fast rhythmic application is more intense than a slow rhythmic application. Determining “the right pressure” is sometimes more difficult than it appears.

Beginning with compressive force, we consider that increasing force is necessary to influence various layers of soft tissue from surface to deep, as well as physiologic factors (Figure 3-4 and Table 3-1).

TABLE 3-1

General Guidelines for Pressure, Drag, Speed, and Duration in Massage Applications for Various Conditions

Desired Outcome	Pressure	Drag	Speed	Duration
Fragile patient (to provide comfort and to soothe)	1 to 2	0	Slow	Short to moderate
Palliative, pleasure-based (nonfragile patient, to stimulate parasympathetic dominance)	2, 3, or 4	1	Slow	Moderate
Lymphatic drainage, surface	2 to 3	2	Slow	Moderate to long
Lymphatic drainage, deep	4 to 5	2	Slow	Moderate
Myofascial release (superficial fascia)	3	3	Slow	Long
General relaxation (to inhibit sympathetic arousal)	4 to 5	2	Slow	Moderate
Trigger point inhibition	4 to 6 (depending on location)	0	Moderate	Moderate
Scar tissue surface (mature scar)	2 to 3	2 to 3	Slow	Moderate
Adhesion of muscle layer or layers	4 to 6	3	Slow	Moderate
Arterial support	4 to 5	0	Moderate to fast at location over artery	Short to moderate
Venous return support	3	1	Slow	Moderate
Anticoagulant use	1 to 2	0 to start (monitor results)	Varies	Varies
Fragile bones (osteoporosis)	1 to 4 (depending on muscle bulk and density)	0 to 3	Varies	Varies
Stimulation of sympathetic autonomic nervous system (ANS) dominance	2 to 5	0 to 1	Moderate to fast	Short to moderate

Massage equipment

Massage table

The massage table must be set at a comfortable height, which depends on the body size and style of the practitioner. An individual with long arms may need a shorter table than a person with short arms. A person with a short torso, short arms, and long legs often needs a taller table.

A general rule is that the table height should be half the practitioner’s height (i.e., if a person is 5 feet 6 inches [66 inches] tall, then the table is 33 inches high). Based on torso, arm, and leg ratios, the correct height for the table is 2 to 3 inches higher or lower. Experiment with what feels best. If one has a tendency to bend at the waist and curl the back when applying massage, the table may be too short, and raising the table will help. These recommendations represent only a starting point, and each practitioner must experiment to determine the most comfortable table height.

A table that is 24 to 28 inches wide provides adequate space for the client to lie down comfortably but is not so wide that the practitioner is reaching for the client in the middle of the table.

Floor mats

If the massage professional chooses to work on a mat on the floor, the same body mechanics principles apply. The weight-bearing balance points on the floor are then set from the knees instead of the feet.

Stools and chairs

A low stool or chair is helpful when one is working on the face, neck, and feet. It is appropriate for the practitioner to sit while doing massage as long as the practitioner is comfortable, relaxed, and can obtain the appropriate leverage for the pressure the client needs. It is important that the stool or chair does not slip or roll while the practitioner is applying pressure.

Body supports

The body position of the client should be adjusted as necessary. For the most part, clients should be in a comfortable, nonharmful position. Body supports are used to bolster the body during the massage and give contour to the flat working surface (Figures 3-5 and 3-6).

Figure 3-5 Equipment and supplies: table, chair, mat, and bolsters.

Draping

Draping is the process of moving sheets and towels over the client to maintain warmth, modesty, and professional boundaries. The draping materials need to be laundered in an approved sanitary fashion. Typically the draping materials are washed in hot, soapy water with bleach (Figure 3-7).

Figure 3-7 Draping examples. A-B, Prone. C–D, Side-lying. E, Supine.

Massage methodology

The infinite variations of massage application are derived not from many different methods but from skilled use of the fundamental application of depth, pressure, drag, direction, speed, rhythm, frequency, and duration for variation in the quality of touch.

All massage manipulations introduce mechanical forces into the soft tissues. These forces, which are set in the soft tissue, stimulate various physiologic responses.

Application of force

The five kinds of force that can affect the tissues of the body are compression, tension, bending, shear, and torsion.

Compression

Compressive forces occur when two structures are pressed together; the force is applied perpendicularly. Compressive force is a component of massage application and is described as depth of pressure. Compressive force is used therapeutically to affect circulation, sensory and autonomic nerve stimulation, nerve chemicals, and connective tissue pliability.

Tension

Tension forces (also called tensile forces) occur when two ends of a structure are pulled apart from one another; the force is applied perpendicularly. Tension force is used during massage with applications that drag, glide, lengthen, and stretch tissue to elongate connective tissues and lengthen short muscles.

Bending

Bending forces represent a combination of compression and tension. One side of a structure is exposed to compressive forces, while the other side is exposed to tensile forces. Bending occurs during many massage applications. Force is applied across the fiber or across the direction of the muscles, tendons or ligaments, and fascial sheaths.

Shear

Shear force is applied parallel to the structure (unlike compressive force and tensile force, which are applied perpendicularly) in a back-and-forth manner. Massage methods that create friction use shear force.

Torsion

Torsion forces are best understood as twisting forces. Massage methods that use kneading introduce torsion forces and target connective tissue changes and fluid movement (Figure 3-8).

Figure 3-8 A, Compression. B, Tension. C, Bending. D, Shear. E, Torsion.

Massage manipulations

The methods of massage described next introduce one or a combination of these forces to the body for therapeutic benefit. This process is influenced by the quality of application, depth of pressure, drag, duration, speed, rhythm, and frequency.

Holding/resting position

When the massage begins, it is very important for this initial contact to be made with respect and a client-centered focus, as well as with the intention to meet client goals. With the holding/resting position, we enter the client’s personal boundary space. When application of the holding position has been mastered, it is easy to flow into the other methods, and gliding is often next in sequence (Figure 3-9).

Figure 3-9 Holding position.

Gliding strokes

Gliding strokes are historically known as effleurage, which originates from the French verb meaning “to skim” and “to touch lightly on.” The most superficial applications of this stroke do this, but the full spectrum is determined by pressure, drag, speed, direction, and rhythm, making this manipulation one of the most versatile. The forces most commonly introduced by gliding are tension force, bending force, and compression force. The distinguishing characteristic of gliding strokes is that they are applied horizontally in relation to the tissue fibers, generating a tensile force. Gliding strokes also can be applied across fibers to create a bending force. During a gliding stroke, light pressure remains on the skin, and moderate pressure extends through the subcutaneous layer of the skin to reach muscle tissue, but not so deep as to compress the tissue against the underlying bony structure (Figure 3-10).

Figure 3-10 Gliding creates tension force. Gliding historically has been termed effleurage.

Kneading

Because the skin and the underlying muscles cannot be lifted (kneaded) without first pressing into them, compression (with the gliding stroke) should be done before kneading begins. Pétrissage, the historical term for kneading, is derived from the French verb petrir, meaning “to knead.” The soft tissue is lifted, rolled, and squeezed during application. Just as gliding focuses horizontally on the body, kneading focuses vertically and twists. The main purpose of this manipulation is to lift tissue, while applying bend, shear, and torsion forces (Figure 3-11).

Figure 3-11 Kneading creates torsion force. Kneading historically has been called pétrissage.

Skin rolling

A variation of the lifting manipulation is skin rolling. 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. Skin rolling is one of the very few massage methods that is safe to use directly over the spine. Because only the skin and superficial fascia are accessed and the direction of pull to the tissue is up and away from the underlying bones, the spine risks no injury, unlike when any type of downward pressure is used (Figure 3-12).

Figure 3-12 Skin rolling creates bending force.

Compression

Compression moves down into the tissue at a 90-degree angle. It can be a specific method that uses a lift and compress approach. Compressive force is an aspect of gliding and kneading, and 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 client’s body is (Figure 3-13).

Figure 3-13 Compression creates compressive force.

Vibrations

The correct technique for producing manual vibrations is to set up a small amount of alternating contraction and relaxation in some of the muscles of the forearm with those of the upper arm and the shoulder kept passive (unless required for fixation purposes) (Figure 3-14).

Figure 3-14 Vibration.

Shaking

Shaking is a massage method that is effective in relaxing muscle groups or an entire limb. Shaking manipulations 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 (Figures 3-15 and 3-16).

Figure 3-15 Hip joint jostling vibration with client prone.

Rocking

Rocking is a soothing, rhythmic method that is used for calming. Rocking is both reflexive and chemical in its effects. For rocking to be most effective, the client’s body must move so that the fluid in the semicircular canals of the inner ear is affected, thereby initiating parasympathetic mechanisms (Figure 3-17).

Figure 3-17 Rocking.

Percussion or tapotement

Percussion moves up and down on the tissue. The term tapotement comes from the French verb tapoter, which means “to rap, smack, drum, or pat.” Percussion techniques require that the hands or parts of the hand administer springy blows to the body at a fast rate. These blows are directed downward to create a rhythmic compression of the tissue.

Hacking. This method is applied with both wrists relaxed and the fingers spread, with only the little finger or the ulnar side of the hand striking the surface. The other fingers hit each other with a springy touch. Point hacking can be done by using the fingertips in the same way.

Tapping. The fingertips are used to apply targeted gentle stimulation.

Cupping. Fingers and thumbs are placed as if making a cup. The hands are turned over, and the same action used in hacking is performed. When performed on the anterior and posterior thorax, cupping is good for stimulating the respiratory system and for loosening mucus.

Slapping (splatting). The whole palm of a flattened hand makes contact with the body. This is a good method for releasing histamine to increase vasodilation and its effects on the skin.

Beating and pounding. These moves are performed by using a soft fist with knuckles down, or vertically with the ulnar side of the palm (Figure 3-18).

Figure 3-18 Percussion/tapotement. A, Hacking. B, Tapping. C, Cupping. D, Slapping. E, Beating.

Friction

Friction manipulations are brisk concentrated strokes the generate heat and are thought to prevent and break up local adhesions in connective tissue, especially over tendons, ligaments, and scars, by creating therapeutic inflammation . The direction and depth can vary. One method of friction consists of small, deep movements performed on a local area. It provides shear force to the tissue. (Figure 3-19).

Figure 3-19 Friction creates shear force.

Joint movement/range of motion

Joint movements are methods that move each joint through various positions within the normal range of motion (ROM). These movements, which are never forced, can be active (AROM), when only the client moves; active assisted (AAROM), when the massage therapist helps the client move; active resisted (ARROM), when the massage therapist resists movement of the client; and passive (PROM), when the massage therapist provides movement (Figures 3-20 and 3-21).

Figure 3-20 Joint movement.

Muscle energy methods

Muscle energy methods use a controlled muscle contraction to support stretching of short tissues by increasing the client’s tolerance to the stretch sensation.

Contract –relax

This method causes isometric action in the target muscle tissue to support stretching.

Combined methods: Contract-relax-antagonist-contract

Contract and relax and antagonist-contract can be combined to enhance lengthening effects. This method can be called contract-relax-antagonist-contract (CRAC) (Figures 3-22 and 3-23).

Figure 3-22 Muscle energy methods increase tolerance to stretch. A, Contract relax. B, Antagonist contract.

Stretching

Stretching is a mechanical method of introducing various forces into connective tissue to elongate areas of connective tissue shortening. Muscle energy techniques are used to prepare muscles to stretch by activating lengthening responses. Longitudinal stretching pulls connective tissue in the direction of the fiber configuration. Cross-directional stretching pulls the connective tissue against the fiber direction. Both accomplish the same thing, but longitudinal stretching is done in conjunction with movement at the joint. If longitudinal stretching is not advisable, if it is ineffective in situations of hypermobility of a joint, or if the area to be stretched is not effectively stretched longitudinally, cross-directional stretching is a better choice. Cross-directional stretching focuses on the tissue itself and does not depend on joint movement (Figures 3-24 and 3-25).

Figure 3-24 Stretching. A, Begin. B, Stretch.

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Jun 22, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

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