Massage_connection

Chapter 1—Introduction 27 codes that give the sequence of arrangement of Cell Membrane (Plasma Membrane) amino acids needed to form a specific protein. The lineup of bases that code for a specific protein is The cell membrane (see Figures 1.17and 1.18) is a known as a gene, and a gene exists for every type of thin, delicate layer that is made up of lipids, carbo- protein manufactured in the body. hydrates, and proteins. It is referred to as a phos- pholipid bilayer because it is made up of two layers When the gene is activated, it begins to manufac- of phospholipids. The phospholipids are lined in such ture proteins with the help of the ribosomes and a way that the end of the molecules containing the RNA. The RNA carries the template of the genetic phosphate group that have an affinity for water— code to the cytoplasm and assures the amino acids hydrophilic end—faces the outside of the cell mem- are in the right sequence to form the protein. brane. The hydrophobic ends that contain the fatty acids face each other in the middle of the cell mem- Protein Synthesis brane. This arrangement of the cell membrane pre- vents water and water-soluble substances from cross- It should be noted that the proteins determine the ing the lipid portion of the cell membrane. This characteristics of the cells, tissues, and the organism arrangement is used because the composition of the itself. Therefore, a large part of cellular activity is cytoplasm of the cell is different from that of the fluid synthesizing different proteins; the instructions for around it. These differences have to be maintained if the sequence of amino acids in the proteins are car- the cell is to survive. ried by the DNA. The phospholipid bilayer is interrupted in certain The genetic code for a specific protein, present in areas by proteins that go completely through the wall the DNA, is used as a template to copy the sequence of or are integrated into the wall with part of the protein amino acids for that protein. The copy is in the form molecule projecting into or out of the cell. These are of RNA. This process is called transcription. The RNA known as membrane proteins. Because of the pres- moves out of the nucleus into the cytoplasm. In the cy- ence of a large number of different proteins (mosaic) toplasm, with the help of ribosomes and using the in the “sea” of phospholipids, the structure of the cell template on the RNA, amino acids are lined and membrane is referred to as the fluid mosaic model. bonded in the right sequence to form the specific pro- tein needed. This process is known as translation. The membrane proteins that go through and through are referred to as integral proteins. The Extracellular fluid Cell identity Ligand marker Linker Hydrophobic end Transporter Receptor Cell membrane Pore Enzyme (phospholipid bilayer) Hydrophilic end Cytoplasm FIGURE 1.17. The Cell Membrane. A, a semipermeable membrane separates two solutions with unequal concentration of solutes; B, water moves to the solution of higher concentration, until the concentrations in the two solutions become equal; C, pressure is applied to equal volume of both solutions; this pressure is equivalent to the osmotic pressure.

28 The Massage Connection: Anatomy and Physiology FIGURE 1.18. Diffusion meability, the cell can maintain a different concen- tration of substances inside the cell than outside the others are referred to as peripheral proteins. The cell. For example, there are more sodium ions out- membrane proteins have many functions. Some pro- side the cell compared with inside. This difference in teins serve as anchors or linkers and connect the cell chemical concentration is known as the chemical membrane to surrounding structures to stabilize the gradient. If the inside and outside electrical charges cell. Others serve as recognition proteins, or identi- are compared, the inside of the cell is more negative fiers, or cell identity markers. These are usually gly- than the outside. This is known as the electrical gra- coproteins that project out of the membrane and help dient. Many factors determine whether a substance the immune cells identify the cell as self or nonself. can pass through and the direction of movement. Some of the peripheral proteins are enzymes and fa- cilitate chemical reactions inside or outside the cell, Factors Affecting Transport depending on their position; others are receptors. To some extent, the size of the substance plays a part, Receptor proteins are specific and have an affinity with the membrane being less permeable to those for specific hormones and other substances. The spe- substances that are larger. The electrical charge of cific extracellular molecules that stimulate the recep- the substance has an effect on whether it is trans- tors are referred to as ligands. Each cell may have re- ported. At rest, the inside of the cell is more negative ceptors for more than one ligand, and the receptors than the outside. Substances that carry negative vary from cell to cell. In this way, hormones, which charges, therefore, find it more difficult to pass. The are carried throughout the body by the blood, affect molecular shape of the substance also has an effect. only cells that have receptors for the specific hor- Substances that are lipid-soluble pass through the mone. membrane easily because the membrane is made up of phospholipids. The direction of movement is de- Certain proteins located in the cell membrane may termined by the electrical and chemical gradients serve as carriers or transporters. If a specific solute (electrochemical gradient). Transport may be af- becomes attached to the carrier, the protein carrier fected by a combination of one or more factors. changes shape and transports the solute across the cell membrane. This may occur with or without the The transport across the membrane may occur use of active energy. Certain integral proteins work as with or without the use of energy. Transport without channels or gates; forming small paths across the use of energy is referred to as passive transport. For cell membrane and allowing water and specific ions the transport of some substances, energy in the form to pass through. The channels may be opened by of ATP must be used. This is known as active trans- changes in potential or by binding of ligands. port. In both of these transport types, transporters may or may not be involved—known as mediated or The carbohydrates in the membrane, although unmediated transport, respectively. There are many only contributing about 3% of the weight of the cell mechanisms by which passive transport occurs. membrane, project outward and help form a layer that protects the cell membrane. Passive Transport Membrane Transport Five mechanisms are used for passive transport— diffusion, osmosis, filtration, carrier-mediated The cell membrane determines which substances en- transport, and vesicular transport. ter or leave the cell and is said to be impermeable if it does not allow any substance to pass through. A Diffusion cell membrane can also be selectively permeable. It may be impermeable to one substance and freely al- Diffusion (see Figure 1.18) is the movement of ions low another to pass through. A typical cell membrane and molecules from an area of higher concentration is selectively permeable. Because of its selective per- to one of lower concentration. This difference in con- centration is known as the concentration gradient. Substances that are lipid-soluble diffuse directly through the phospholipid bilayer. Other substances, such as ions, diffuse through specific channels, if the channels are open. This passive process—diffusion— is important in the body. When the blood reaches the tissue, nutrients move from inside the blood vessels into the interstitial fluid by diffusion. The opposite also occurs by diffusion. Waste products from the cell

Chapter 1—Introduction 29 move along the concentration gradient into the across a semipermeable membrane. Conversely, the blood. Similarly, carbon dioxide and oxygen between movement of water from a region of higher concentra- the air and blood move by diffusion. tion (of water) to a region of lower concentration. The rate of diffusion depends on the distance that Three important characteristics of osmosis are: separates the two solutions. To increase efficiency in the body, the distance of the cells from the blood is • Osmosis is the diffusion of water molecules only about 125 micrometers (␮m). The difference be- across a membrane. tween the concentrations of the two solutions also plays an important part. Oxygen in the body moves • Osmosis occurs across a selectively permeable more rapidly into the tissue when the tissue has been membrane that allows water to freely move active and the concentration of oxygen is much lower through it; not the solutes. than in the blood. • The movement of water is toward the solution Molecule size affects diffusion. Smaller particles with the higher concentration of solutes. tend to move at a faster pace than larger particles. Other than distance and concentration gradient and In the body, the fluid inside the cell (intracellular size, the electrical charges on the two substances af- fluid) and the fluid outside the cell (extracellular fect diffusion, as the interior of the cell is negative. fluid) have dissolved substances. Each of these sub- Even if a concentration gradient exists, a negatively stances tend to diffuse as if they were the only sub- charged substance finds it more difficult to enter the stance in the solution. For example, if sodium and negatively charged cell. Temperature is another fac- chloride are present, they each move along their own tor that affects diffusion. Higher temperatures in- concentration gradient. The changes in the concen- crease the diffusion rate. tration gradient of chloride do not affect the move- ment of sodium. Substances that are lipid-soluble, such as alcohol, fatty acids, and steroids, enter the cell easily through In general, the total concentration remains the the lipid cell membrane if there is a concentration same on both sides. If the concentration of ions and gradient. Substances that are water-soluble, however, molecules vary between the inside and outside of the must rely on the presence of channels to pass cell, water is drawn by osmosis to the side that has through, even if a concentration gradient exists. The more ions and molecules and less water. surface area available for diffusion also determines the rate of movement. Because channels occupy only Red blood cells can be used to illustrate osmosis. a small percentage of the cell membrane, diffusion When placed in a glass of water, water rushes (by os- through channels is comparatively slower than direct mosis) into the red blood cells because they have diffusion across the phospholipid bilayer. more particles inside. The cells swell and immedi- ately rupture. If the cells are placed in a glass of wa- Osmosis ter into which two spoonsful of table salt was mixed, water from the cell moves out and the cells shrink. Osmosis (see Figure 1.19) is the net diffusion of water Osmotic pressure of a solution is an indication of from a region of lower concentration of solute (parti- the force of water movement into that solution as a cles) to a region of higher concentration of solute result of its solute concentration. High solute concentration, Low solute concentration, ISOTONICITY, HYPERTONICITY, AND low fluid concentration high fluid concentration HYPOTONICITY and high osmotic pressure and low osmotic pressure A solution that has exactly the same osmotic pressure as the intracellular fluid does not allow osmosis through the FLUID cell membrane in either direction when placed on the outside of cells. Such a solution is said to be isotonic with Semipermeable the body fluids. The number of particles present in 0.9% membrane solution (0.9 g/dL) of sodium chloride is the same as that in blood. If a person is transfused with this concentration FIGURE 1.19. Osmosis of sodium chloride, the cells are not affected. This solu- tion, normal saline, is used in persons who are dehy- drated or with low blood volume. A solution that causes osmosis of fluid out of the cell and into the solution is said to be hypertonic. A solution that allows osmosis into cells is hypotonic. Care must be taken that transfused solutions are of the right concentrations and that they do not affect movement of fluid in and out of cells by osmosis.

30 The Massage Connection: Anatomy and Physiology Filtration the processes fuse with each other to form a vesicle inside the cytoplasm (see Figure 1.20A). In some In filtration, water is forced across a semipermeable types of endocytosis, the substance initially binds to membrane as a result of hydrostatic pressure. For receptor proteins before a vesicle is formed. example, it is equivalent to the pressure that pushes water out of a nick in a garden hose through which After endocytosis, at times, the contents are di- water is flowing. By filtration, fluid moves out of cap- gested by enzymes (stored in vesicles) present in the illaries. Similarly, fluid filtered from the blood into cytoplasm. This process is known as phagocytosis the renal tubules of the kidney finally form urine. The (cell eating). Most defense cells kill microorganisms movement of larger particles, along with water, by fil- by phagocytosis. tration depends on the size of the pores present in the membrane. Exocytosis Carrier-Mediated Transport Exocytosis is the opposite of endocytosis (see Fig- ure 1.20B). Here, vesicles floating in the cytoplasm In this method of transport, integral proteins bind to fuse with the cell membrane and extrude their con- specific ions, or other substances, and carry them tents into the extracellular fluid. Mucus secretion, se- across the cell membrane into the cell. Each carrier cretory products of certain glands, and nerve endings on the cell membrane is specific (i.e., it binds to only extrude the contents of vesicles in this way. one specific substance). The amount of substance carried into the cell depends on the number of carri- Active Transport ers present for that substance. Some carriers can carry two different substances. Both substances may Active transport (Figure 1.19) is the transport of sub- be carried in the same direction or one substance stances into or out of the cell using energy. Energy is may be carried out of the cell while the other is si- needed for this kind of transport because it occurs multaneously brought into the cell. against the concentration gradient, unlike diffusion. The carriers involved in this transport are referred to Substances, such as glucose and amino acids, are as ion pumps. All cells have specific ion pumps that transported by carriers because they are insoluble in transport sodium, potassium, calcium, and magne- lipids and are too large to be transported through sium. Ion pumps are specific (i.e., a pump is specific channels. Carriers specific for these substances bind for one ion). There are certain pumps that transport to them and move them into the cell along the con- one ion inside as another is sent outside. These spe- centration gradient. Here, no energy is used. It cial carrier proteins are known as exchange pumps. should be noted that it is a diffusion process, except The most common exchange pump is the sodium– that it is facilitated by carriers. This type of transport potassium exchange pump, or sodium–potassium is referred to as facilitated diffusion. The rate at ATPase. which they move into the cell depends on the number of carriers present on the cell membrane. Normally, the extracellular fluid has more sodium than the inside of the cell; potassium is the opposite. A unique property of carriers is that hormones can Sodium tends to diffuse in slowly along its concen- regulate them. Certain carrier activity is facilitated by tration gradient, while potassium moves out. To the binding of hormones. In this way, hormones reg- maintain homeostasis, the sodium–potassium pump ulate the movement of specific substances into the uses energy to pump out sodium and pump in potas- cell. For example, the hormone insulin facilitates the sium. This pump uses energy by consuming about movement of glucose into the cell. 40% of the ATP produced in a resting cell. Vesicular Transport Transmembrane Potential With vesicular transport, vesicles or small mem- All cells have more negative charges inside as com- brane-lined sacs are used to bring substances into or pared with the outside. This difference in charges is out of the cell. The process of bringing substances in maintained by the presence of a cell membrane that by forming vesicles is known as endocytosis. Trans- is selectively permeable and ionic pumps that move port of substances out of the cell in this manner is re- substances by active transport. This difference in ferred to as exocytosis. electrical charge is known as the transmembrane potential. Transmembrane potential is measured in Endocytosis millivolts (mV). The membrane potential of a neuron, for example, is Ϫ70 mV. The maintenance of trans- Substances outside the cell that are too large to enter membrane potential is important, as it is required for via channels are “engulfed” by a depression in the cell many functions, such as transmission of nerve im- membrane. The cell membrane folds to form two pulses, muscle contraction, and gland secretion. processes, similar to two arms in an embrace, and

Chapter 1—Introduction 31 Cell membrane Golgi apparatus Bacterium A Endocytosis Lysosomes Phagosome Exocytosis B Phagosome fuses with lysosome Secondary lysosome Cytoplasm FIGURE 1.20. Vesicular Transport. A, Endocytosis; B, Exocytosis The Cell Life Cycle Specific genes, known as repressor genes, op- pose,cell division. When the rate of growth exceeds From fertilization to physical maturity, the cells un- that of inhibition, the tissue enlarges. If uncontrolled dergo many divisions. When a single cell divides, it cell growth occurs, a tumor or neoplasm results. forms two daughter cells that are identical to the original cell. A cell may live from a few days to many TISSUE LEVEL OF ORGANIZATION years, depending on the cell type. Most cells have a gene, which is triggered to self-destruct at a specific Because of the complexity of the human body, it is time. not possible for every cell to do all the functions re- quired. Instead, some cells become specialized to do Cells divide in two ways: mitosis and meiosis. Mi- specific functions. Together, all these differentiated tosis is common and is the process of division seen in cells are able to fulfill the needs of the body. As a re- somatic cells, involving the separation of the dupli- sult of specialization, the cells, although they have cated chromosome into two identical nuclei. The cy- the basic organelles, appear different, taking on dif- toplasm and the nucleus then separate into two new ferent sizes and shapes with modifications according cells. to function. A collection of cells that does the same function is known as tissue. Meiosis can be seen in the testis and ovary during the formation of sperm and ova, in which the daugh- The body basically consists of four main tissue ter cells end up with half the number of chromo- types—epithelial tissue, connective tissue, muscle somes found in somatic cells. When the ovum and tissue, and neural tissue. Muscle tissue is described sperm fuse during fertilization, the fused cell then in Section XX; neural tissue in Section XX. The ep- has the right number of chromosomes. ithelial and connective tissues are described below. When cells are not dividing, they continue to func- Epithelial Tissue tion fully. This phase is known as the interphase. Cells that do not multiply after birth, such as neu- Epithelial tissues cover surfaces that are exposed to rons, are said to be in the interphase. the environment, line internal passages and cham- bers, and form glands. They are found in the skin, lin- Cell division is regulated by peptides known as ing the respiratory, reproductive, digestive, and uri- growth factors, which are present in the extracellular nary tracts. They also line the inner walls of the blood fluid. Growth factors bind to receptors in the cell membrane and trigger cell division. Growth hormone, nerve growth factor, epidermal growth factor, and ery- thropoietin are a few of the growth factors identified.

32 The Massage Connection: Anatomy and Physiology vessels and heart. Epithelia are found lining the vari- dehydration, injury, and destruction by chemicals ous body cavities, such as the cerebral, spinal, peri- and foreign agents. Because the epithelia are selec- cardial, pleural, and peritoneal cavities. tively permeable to substances, they control the entry of substances into the body. Structure Almost all epithelia have a good nerve supply, As the major function of epithelia is to form a barrier, which enables them to sense changes in the environ- they are found in layers, with individual cells bound ment and convey that information to the brain for to adjacent cells, unlike other tissues that may be suitable action. Some epithelia have a secretory func- found scattered individually in the extracellular ma- tion and form the glandular epithelium. terial. Cells may be bound to each other by fusion of cell membranes to form tight junctions. Tight junc- Epithelia Classification tions prevent movement of water and other sub- stances between the cells. In some epithelia, the bind- As epithelia have common features as mentioned ing between the cells may be in the form of gap above, they are subtly modified to suit specific func- junctions. Gap junctions have small passages that al- tions. Epithelia have been classified in accordance low movement of substances between adjacent cells. with the modifications in numbers of layers and with Other cells, such as those in the skin, are bound to- the shape of cell. gether by desmosomes. These connections are strong and help to maintain the cell layers in sheets. According to the number of layers, they are classi- fied as simple epithelium (one layer) or stratified One surface of epithelial cells is exposed to the ex- epithelium (multilayered). According to cell shape, ternal surface, such as the atmosphere or passage epithelia are classified as squamous, cuboidal, tran- they line (lumen). This surface is the apical surface. sitional, and columnar. The other surface faces the inside of the body and is known as the basal surface. The basal surface of the Simple Epithelium epithelia is attached to a thin, fibrous membrane known as the basement membrane. Simple epithelium has only one layer of cells over the basement membrane. Being thin, epithelia are fragile As the cells of the epithelia are closely packed, they and found only in areas inside the body that are rela- do not have blood vessels supplying them. Instead, tively protected, such as the lining of the heart and they rely on nutrients brought by diffusion from ad- blood vessels and the lining of body cavities. They are jacent blood vessels. The cells closer to the lumen also found lining the digestive tract and in the ex- may obtain nutrients by diffusion from the lumen. change surfaces of the lungs, where their thinness is Being exposed to the environment, epithelial cells are an advantage for speedy absorption. constantly being damaged and lost; however, the stem cells located in the epithelia multiply rapidly Stratified Epithelium and replace these cells constantly. A stratified epithelium has many layers and forms an The epithelia located in areas of absorption or secre- effective protection from mechanical and chemical tion, are modified to increase the surface area for this stress. They are found in the skin and lining the open- function. The modification is in the form of microvilli. ings of lumens such as the mouth, anus, vagina, and Such epithelia are found in the digestive and urinary urethra. The squamous, cuboidal, and columnar ep- tract. Certain epithelia have cilia, which enables them ithelium may be simple or stratified. to move secretions and other fluid over the surface. Cil- iated epithelia are found in the respiratory tract. Squamous Epithelium Functions The squamous epithelium consists of cells that are flat and thin and somewhat irregular in shape. Sim- As previously mentioned, a major function of the ep- ple squamous epithelium (see Figure 1.21A) is ithelia is to form a barrier and protect the body from found in protected regions (being thin and delicate) where absorption takes place or where friction must EXAMINATION OF EPITHELIA be minimal. A specific name is given to the epithe- lium that lines body cavities—mesothelium. The Bits of epithelia are often used for investigations. For ex- simple epithelium lining blood vessels and heart are ample, scrapings from unusual looking epithelia are exam- called endothelium. ined for cancerous changes. Epithelia shed into the amni- otic fluid are studied for genetic abnormalities in the fetus. A stratified squamous epithelium has many lay- ers. The skin is a good example. In areas such as the skin, where the barrier formed by the epithelium also

Chapter 1—Introduction 33 Simple cuboidal Simple squamous Simple squamous cell A Basement membrane Simple columnar Connective tissue B Stratified squamous C Basement membrane Transitional Connective tissue D Pseudostratified ciliated columnar Cilia Basement membrane Goblet cell Connective tissue Basement membrane EF Connective tissue Simple ciliated columnar epithelium Microvilli Goblet cell FIGURE 1.21. Epithelial Cells. A, Simple squamous epithelium; B, simple cuboidal epithelium; C, simple Absorptive cell columnar epithelium; D, stratified squamous epithelium; Basement E, transitional epithelium; F, pseudostratified ciliated membrane columnar epithelium; G, simple ciliated columnar epithelium Connective G tissue protects the body from dehydration, the most super- place, such as the pancreas, salivary glands, and thy- ficial layers are packed with a protein known as ker- roid glands. Stratified cuboidal epithelia are rare atin. Such epithelia are referred to as keratinized; and found in the large ducts of the mammary glands those without keratin are said to be nonkeratinized. and sweat glands. Cuboidal Epithelium Transitional Epithelium Cuboidal epithelium (see Figure 1.21B), as the name Transitional epithelium (see Figure 1.21E) is the type suggests, appear like a cube in section. They are of epithelium in which the cells seem to change found in areas where absorption or secretion takes shape. They are found in the lining of the urinary

34 The Massage Connection: Anatomy and Physiology bladder. When the bladder is full, the cells are secretion is the most common. Apocrine secretion is stretched and appear flat. When the bladder is empty, found in sweat glands in the armpit. Holocrine secre- the cells appear multilayered. tion is used by sebaceous glands near the hair folli- cles. Columnar Epithelium Exocrine glands are classified according to the The cells of columnar epithelium (see Figure 1.21C) type of secretion they produce. They are classified as appear as if they are columns—long and slender. serous glands if they secrete a watery secretion con- These cells are found in regions where absorption or taining enzymes and mucous glands if they secrete secretion occurs. Some columnar epithelia, such as the slippery, lubricating, glycoprotein—mucus. those in the respiratory tract, appear to be in layers, Some glands are mixed and secrete both serous and but they actually are not. These are referred to as mucus secretions. pseudostratified columnar epithelium (see Figure 1.21F). In the respiratory tract, these epithelia also The glands may be either unicellular—just one se- have cilia and are an example of ciliated epithe- cretory cell in the epithelia or multicellular, forming lium. simple or more complex tubes that secrete. Glandular Epithelium The endocrine glands secrete their products di- rectly into the blood. The thyroid gland, pituitary Many epithelia that have cells that produce secre- gland, adrenal glands are a few examples of en- tions are known as glandular epithelium (see Figure docrine glands. 1.22). The structures lined with glandular epithelium are known as glands. Two types of glands—the exo- Connective Tissue crine and endocrine—exist in the body. Structure The exocrine glands release secretions on the ep- ithelial surface. Tubes, known as ducts, usually con- Connective tissue is the most abundant of all tissue, vey the secretions to the surface. Tear glands, sweat forming a continuous network thoughout the body. If glands, and salivary glands are a few examples. The all other tissue was removed, connective tissue would secretions may be released from the cell by exocyto- form the three-dimensional framework of the body, sis (merocrine secretion); by the apical region of the much like cellulose in plants. Connective tissue, such cell, packed with vesicles being detached (apocrine as bone, blood and fat, appear to be different from secretion); or by the entire cell rupturing and releas- each other, but they have some common features that ing the contents (holocrine secretion). Merocrine place them under this classification. All connective tissue have three characteristics—they have special- ized cells; protein fibers that are present outside the Hormone-producing Blood vessel Skin Blood vessel (epithelial) cell Sweat gland Thyroid follicle Stored hormone Lumen of duct precursor Exocrine gland (sweat gland) A Endocrine gland (thyroid) B FIGURE 1.22. Glandular Epithelium

Chapter 1—Introduction 35 Tendons, Ligaments, and Healing Connective Tissue Proper Remember that collagen fibers are not actually living tis- This type of connective tissue (see Figure 1.23) has sue. They are protein fibers secreted by fibroblasts into the many different types of cells suspended in the matrix. ground substance. This implies that where there is a large The properties and proportions of fibers also vary. proportion of collagen in tissue, there is not much de- mand for blood supply (as the fibers are just secretions). Cells Unfortunately, areas with less blood supply take Connective tissue proper has cells that help with repair, longer to heal. That is why injured tendons and liga- healing, and storage, as well as other cells that help ments heal slowly. Because cartilage does not have a di- with defense. Fibroblasts and mesenchymal cells re- rect blood supply, it also heals slowly. pair injured tissue; adipocytes store fat. Other cells in connective tissue proper that have the capability of mi- Connective Tissue—Like Marmalade? grating to injured areas are macrophages, mi- crophages, mast cells, lymphocytes, and platelets. An apt analogy of connective tissue is marmalade. The thick translucent base of marmalade is similar to ground Fibroblasts substance. The orange peel and other ingredients floating in the base are similar to the protein fibers and cells Fibroblasts are the most abundant cells. They secrete found in connective tissue. Like marmalade, connective a polysaccharide known as hyaluronic acid and pro- tissue becomes thicker in consistency when cooled and teins into the ground substance, which gives connec- becomes more fluid when warmed or when more water tive tissue its thick consistency. Fibroblasts also se- is present. crete proteins that interact and form the protein fibers in the ground substance that is responsible for cells; and a fluid known as ground substance, in the strength, flexibility, and elasticity of connective which the fibers and cells are suspended. The fibers tissue. and the ground substance combined are referred to as the matrix that surrounds the cells. Mesenchymal Cells Unlike epithelia, the cells in connective tissue are Mesenchymal cells are the mother cells that differen- scattered. Connective tissue is not exposed to the ex- tiate into fibroblasts and other cells when there is in- terior and most connective tissue is vascularized (i.e., jury. they have a good supply of blood vessels). Many types of connective tissue have nerve endings that respond Adipocytes to various sensations, such as touch, pressure, pain, and temperature changes. Adipocytes (see Figure 1.24) are fat cells in which the cytoplasm is filled with a huge, fat droplet. The num- Function ber of adipocytes varies from region to region and from one person to another. Connective tissue has many functions. It forms the structural framework for the body and helps support, Connective Tissue and Hormones surround, and interconnect various organs and tis- sues. It also helps transport fluid and substances Growth hormone secreted by the pituitary gland stimu- from one region to the other (e.g., blood). Certain lates fibroblasts and other cells. As a result, it increases connective tissue protects the organs and certain tis- the formation of ground substance and protein fibers. sue has special cells scattered in them that help kill Cortisone secreted by the adrenal cortex has an in- invading organisms. Connective tissue may serve as a hibitory effect in the formation of connective tissue. For storage sites for nutrients (e.g., fat). this reason, cortisone (steroids) is used to reduce inflam- mation and adhesion formation in injured tissue. Classification Contractures Connective tissue may be classified as connective tissue proper, fluid connective tissue, and sup- When muscles are not used, they are replaced by con- porting connective tissue. The three types differ in nective tissue, making the muscles stiff. Contractures are the type of cells, fibers, and ground substance. The observed in people who are paralyzed because their proportions also vary, altering the consistency. muscles and joints have been in a fixed position for a long time.

36 The Massage Connection: Anatomy and Physiology Collagen fiber Elastic fiber Fibroblast Adipocyte Neutrophil Reticular fiber Eosinophil Macrophage Blood vessel Mast cell Plasma cell FIGURE 1.23. Connective Tissue Proper Macrophages sites of injury and inflammation. They, too, help with defense. Macrophages are defense cells that have wandered into the connective tissue from the blood. Scavenger Mast cells cells, they remove dead cells and foreign agents. Cer- tain macrophages may be fixed to a site (fixed Mast cells are small, connective tissue cells usually macrophages), as found in the liver and spleen. Oth- found near blood vessels. Mast cell cytoplasm con- ers are wanderers, attracted to injured areas by tains the chemicals histamine and heparin. When in- chemicals liberated by injured tissue. These are the jury occurs or when stimulated by allergic sub- free macrophages. stances, mast cells liberate chemicals into the surrounding tissue, producing the typical reactions Microphages observed in inflammation. Microphages are other types of white blood cells Lymphocytes (neutrophils and eosinophils) that are attracted to Lymphocytes are white blood cells that wander in tis- Cytoplasm sue and function as defense cells. Nucleus of Platelets adipocyte Blood vessel Platelets are the smallest cells present in the blood; they help stop bleeding at the time of injury. Connective Tissue Fibers Connective tissue has three different types of fibers, which vary in proportion. The fibers may be colla- Fat-storage area CAPSULES of adipocyte The body defends itself from disease and microorganisms Plasma by forming a connective tissue capsule around infected membrane areas. A pustule or abscess is a typical example. The mi- FIGURE 1.24. Loose Connective Tissue—Adipose tissue croorganisms, defense cells (both dead and alive), to- gether with secretions, are cordoned off by a connective tissue capsule, which contains the infection to the local area and prevents it from spreading.

Chapter 1—Introduction 37 Superficial and Deep Fascia withstand a lot of force if applied from both ends. Ten- dons and ligaments, which withstand a lot of force as The superficial fascia, also known as subcutaneous tis- muscle contracts, are made up almost entirely of colla- sue, is made up of fat and connective tissue. Its main gen. The flexibility of collagen also allows joints to function is to reduce heat loss from the body. Superficial move as the tendons and ligaments go across them. veins, lymph glands, and cutaneous nerves are found in this region. In some areas of the body—especially over Collagen fibers can be arranged in different ways to bony prominences—the superficial fascia is modified alter the property of the tissue, dictated by the ground into subcutaneous synovial bursae. For example, bursae substance and the local tissue. They may be arranged may be found over the bony prominence in the posterior randomly, forming sheets (e.g., fascia); systematically aspect of the elbow or over the knee joint. In certain ar- stacked (e.g., aponeurosis); spun loosely (e.g., subcu- eas where the skin is moved, cutaneous muscles are taneous tissue); or arranged in parallel (e.g., tendon). present in the fascia. The facial muscles, the superficial muscle in the scrotum (dartos), the neck and facial mus- Reticular Fibers cle (platysma) are examples of these muscles. Reticular fibers are also proteins, but they are much The deep fascia is a tough layer of connective tissue thinner, forming branching networks. This gives the that lies over the muscles and attaches to bony promi- connective tissue flexibility. At the same time, these nences that are subcutaneous by fusing with the outer fibers are tough and can resist force applied in differ- layer of the bone. In some regions, skeletal muscle is ent directions. Because of these properties, reticular partly or fully inserted into the deep fascia. For example, fibers are more abundant in areas where cells and or- the gluteal muscle (gluteus maximus) inserts into a thick gans must be kept together. Reticular fibers hold fascia in the lateral part of the leg (the iliotibial tract). blood vessels and nerves in place. Sheets of deep fascia often pass between groups of Elastic Fibers muscles before they blend with the periosteum (outer covering) of the underlying bone. These intermuscular Elastic fibers are branched, wavy fibers containing septa divide the limb into different compartments, apart the protein elastin. The special characteristic of from providing a larger surface area for the attachment of elastin is that it can be stretched and it will return to muscles. its original size when released. In regions over joints, the deep fascia forms tough Ground Substance sheets that hold tendons in place. For example, such sheets (e.g., flexor retinacula) are found anterior to the The ground substance is the medium in which the wrist joint. cells and protein fibers are suspended. Usually clear and colorless, it has the consistency of thick syrup. Deep fascia plays an important role in blood circula- Proteoglycan, which gives ground substance its vis- tion. Because of the effect of gravity, blood in the veins cous property, is formed by the interaction of poly- tends to pool in dependent parts. The deep fascia is par- saccharides and proteins secreted by fibroblasts into ticularly tough in these regions, preventing muscle mass the extracellular fluid. distention. Substances moving in and out of cells have to pass Rolfing through the ground substance before they enter blood vessels. The consistency of ground substance The techniques used by this method of manipulation varies from region to region. In tissue where mobility have an effect on the body by exerting pressure and var- is required, the major component of ground sub- ied forces on the connective tissue. stance is hyaluronic acid. In tissues where support is the major function, chondroitin sulfate is the major gen fibers, reticular fibers, or elastic fibers. The component. proportion of different fibers in the ground sub- stance is responsible for the different texture and Depending on how loose or dense they appear, property. connective tissue proper can be classified as loose connective tissue or dense connective tissue. Collagen Fibers Loose connective tissue has more ground sub- Collagen fibers are the most common type. They are stance and less protein fibers and cells. It is the “pack- long, straight, and unbranched. They are made up of ing material” that fills the space between organs, pro- protein strands tightly wound together like rope and viding support and absorbing shock. For example, it is held together by hydrogen bonds, giving connective tis- the presence of loose connective tissue that keeps the sue flexibility. Collagen, however, is strong and can skin in place. At the same time, it allows the skin to be pinched up and separated to some extent from the un- derlying tissue. Along with the adipose tissue, this

38 The Massage Connection: Anatomy and Physiology layer of loose connective tissue present under the skin Cartilage forms the subcutaneous layer or the superficial fas- cia. Adipose tissue is a special type of loose connective Cartilage matrix (see Figure 1.26) is made up of a tissue (see Figure 1.24). It acts as a shock absorber and special polysaccharide known as chondroitin sul- insulator to slowdown loss of heat. fate, which interacts with the proteins in the ground substance to form proteoglycans. Cartilage cells Dense connective tissue has much more protein known as chondrocytes are found in the matrix. fiber—predominantly collagen—than loose connective These cells are located in cavities known as lacunae. tissue. The collagen fibers may be arranged regularly Unlike other connective tissue, cartilage does not or irregularly, giving the tissue variable flexibility and have blood vessels and must rely on diffusion of nu- strength. Dense connective tissue has a shiny, white trients from surrounding areas. appearance. Tendons, ligaments, aponeurosis, the cap- sule of joints, the outer layer of bones (periosteum), The property of cartilage depends on the type and the outer layer of cartilage (perichondrium), are all ex- proportion of protein fibers scattered in the matrix. amples of this type of tissue (see Figure 1.25). Depending on its property, cartilage may be classified as hyaline cartilage, elastic cartilage, or fibrocar- Fluid Connective Tissue tilage. Hyaline cartilage has closely packed collagen fibers, making it tough and flexible. The most com- Blood and lymph are examples of fluid connective tis- mon cartilage type, it is found in joints covering the sue. The liquid matrix of blood is the plasma. Blood ends of the bones. It is also found in the epiphyseal cells are suspended in the plasma. Proteins, nutrients, plate (the region where bone growth occurs). Elastic waste products, hormones, and electrolytes are dis- cartilage has more elastic fibers, making the cartilage solved in the plasma. Lymph is the fluid flowing inside more “springy.” It is found in regions such as the ex- lymphatic vessels, varying in composition according ternal ear. Fibrocartilage has little ground substance to the site they drain. The structure, composition, and and more collagen fibers, making the cartilage tough, function of blood and lymph are described in Chap- helping it resist compression and absorb shock. It is ters XX and XX, respectively. found in the intervertebral disks (the cartilage be- tween two vertebrae). Supporting Connective Tissue Connective Tissue—the Fluid Crystal Supporting connective tissue provides a strong, solid framework; cartilage and bone are typical examples. From the description of the various types of connective Strength is provided by the presence of numerous tissue, it can be observed that by varying the propor- fibers in the ground substance. In bone, in addition to tion of the three components—ground substance, pro- the fibers, insoluble calcium salts are deposited in the tein fibers, and cells—the property of the tissue can be ground substance. The structure of bone is described changed significantly. By having a watery ground sub- in Section XX. stance, fluid connective tissue, such as blood, is formed. By introducing more protein fiber, less fluid Nucleus of Ground substance Nucleus of fibroblast chondrocyte Collagen Lacuna containing fiber chondrocyte FIGURE 1.25. Dense Connective Tissue—Tendon FIGURE 1.26. Supporting Connective Tissue—Cartilage

Chapter 1—Introduction 39 but tougher tissue is formed. By altering the propor- connective tissue. Four such membranes exist in the tion of collagen, elastic, and reticular fibers, the tissue body—mucous membrane, serous membrane, cu- can be as tough as tendons that withstand more force taneous membrane, and synovial membrane. or flexible (but tough) tissue, such as tissue that covers muscles. With the introduction of specialized proteins Examples of mucous membrane are the lining of and cells, such as chondrocytes, the connective tissue is digestive, respiratory, urinary, and reproductive transformed into solid, flexible cartilage. With the in- tracts. The epithelium secretes mucous in these re- troduction of insoluble calcium salts into the ground gions. Serous membrane lines the peritoneal, pleural, substance, the tissue becomes rigid—bone. and pericardial cavities and secretes a watery fluid. The body’s outer surface is covered by skin, a cuta- The remarkable properties of connective tissue neous membrane. The synovial membrane, which se- make it comparable to fluid crystal—a type of sub- cretes the synovial fluid, lines all synovial joints. stance that can be transformed from one state to an- other. As it is largely made up of nonliving material, Effects of Age on Tissue its fluid crystal state can be manipulated to a large ex- tent by application of heat, cold, stretch, and activity. Connective Tissue Thixotropic Properties With age, many tissue changes occur. With connec- tive tissue, the collagen and elastic fibers change in Connective tissue, such as gels, has the property of quality, making tissue less flexible. Healing of tissue thixotropy. This phenomenon solidifies substances, takes longer in older persons than in younger indi- such as gelatin, when cold or left undisturbed and liq- viduals. uefies substances when warmed or stirred. With aging, the water content in ground substance Connective tissue, if not stretched and warmed by decreases and the density of fibers increases. As a re- muscular activity, tends to stiffen and become less sult, diffusion of substances, as well as movement of flexible. This is one of the reasons why early mobility cells through the ground substance, is impaired with is emphasized after injury. Stiff, less mobile joints are age. These changes impact the supply of nutrients to more common in sedentary individuals. tissue and the rate of healing. Massage therapy has a tremendous impact on con- As tissue ages, collagen fibers increase in number nective tissue. The stretches, strokes, movement, and and size. They also develop cross-linkages, making heat make connective tissue more fluid, allowing them less flexible. Elastic fibers undergo such greater movement and flow, encouraging better blood changes, making them more rigid, with a tendency to flow and speedy removal of pain producing toxins fray and fragment. from the area. As a person ages, hyaline cartilage loses water and Connective Tissue and Adhesive Properties is slowly converted to fibrocartilage. Elasticity of the cartilage is lost and certain regions, such as the artic- Unfortunately, with disuse and chronic pressure, the ular cartilage, become thinner. The increase in fiber collagen fibers of connective tissue tend to pack to- density encourages deposition of calcium, and calci- gether by hydrogen bonding. In areas that are chron- fication may be seen in cartilage and around major ically stressed, inflamed, or that have not been used blood vessels. (For age-related changes: in bone, see for a long time, the connective tissue layers, which page XX; nervous tissue, see page XX; and muscle separate organs, bind together, preventing easy tissue, see page XX). movement and gliding of the organs over each other. This is known as adhesions. Nerves and blood ves- The tissue changes reflect as loss of skin elasticity; sels may get caught in these adhesions, causing com- wrinkle formation; joint stiffness; lung elastic recoil plications. Reduced range of motion, ischemic pain, loss; costal cartilage rigidity; intervertebral disk and loss of sensation and voluntary control are some shrinkage; height loss; heart chamber elasticity loss of the negative outcome of adhesions. and less forceful contraction; valve stiffening, leading to valvular dysfunction; and less extensible blood ves- Manipulation helps prevent adhesions in those sit- sels, predisposing elderly persons to hypertension. uations or slow it down. It also helps align the colla- gen fibers in a way to better reduce friction and allow Implications for Bodyworkers movement. Membranes The manual techniques used by bodyworkers have a significant effect on underlying tissue. Strokes, such Membranes, which cover and protect other struc- as effleurage, kneading, and petrissage, affect the tures, are formed by the combination of epithelia and fluid component of tissue by increasing blood and

40 The Massage Connection: Anatomy and Physiology lymph flow and reducing edema. Friction strokes are and increase mobility. Special training is required to particularly useful in the treatment of adherent con- perform these techniques, as the effects may be both nective tissue, as they help to realign collagen fibers localized and generalized. during the remodeling phase of healing. The effects of massage on organs and specific sys- Connective tissue technique is a term given to tems are discussed in the respective chapters. those techniques that specifically affect the underly- ing connective tissue. Skin rolling, friction, myo- Make Sense of This fascial release, and direct fascial technique are some techniques in this category. This was Mr. Myer’s first visit to the massage clinic, and the therapist tried to take a quick history. Mr. Myer seemed In skin rolling techniques, the skin and the tissue knowledgeable about his medical condition and pro- overlying the deep fascia are lifted and rolled over the ceeded to describe all of his lifelong medical problems. He underlying tissue. This stroke is useful in individuals explained that his mother had osteoporosis and he sus- where adhesions are present between the skin and pects he has it too. The year before, the doctor had de- the deep fascia, as seen in burns, after healing of tected a swelling in his buccal region. It turned out to be a wounds, and surgery. Loosening such adhesions over neuroma. A biopsy was done and surgery was advised. joints may improve joint mobility. The reactive hy- peremia that results also has beneficial effects. This Mr. Myer had to have a tracheostomy while the technique is contraindicated in those persons with lumpectomy was performed. Unfortunately, he had systemic connective tissue disorders and inflamed phlebitis as a complication. He read that phlebitis could skin and fragile skin. lead to thrombosis and thrombosis could result in hemi- plegia. Fortunately, he recovered without many compli- The repetitive strokes of friction produce move- cations. “Do you notice that some of my facial muscles ment between individual fibers located in dense con- have atrophied? That’s why my grin is lopsided,” he said, nective tissue, reducing adhesions and promoting re- grinning at the therapist. alignment of collagen fibers. In myofascial/fascial techniques, sustained force is applied to the superfi- cial or deep fascia and muscle to lengthen the fascia Table 1.2 Anatomic Terminology To understand health-related literature and to converse knowledgeably with other health professionals, the bodyworker must be familiar with anatomic terms. It becomes easier to learn these terms when the derivation is known. Most terms are of Greek or Latin origin; more re- cently, German or French. Some terms (eponyms) have been given to honor individual anatomists or physicians. Medical terms are usually comprised of two or more parts. A root is the essential component of the word. It may represent a disease, a procedure, or body part. A pre- fix is one or more letters attached to the beginning of a root, and a suffix is one or more letters attached to the end of a root. With the basic knowledge of root, prefix, and suffix and some practice, it is easy to interpret the meaning, or definition, of a term. The meaning of some of the common prefixes, suffixes and roots are given below. In the last column, give your own example for each of the word components. Prefix/Suffix Meaning Example Prefix/Suffix Meaning Example A absent, without aᎏnesthesia alb- white aᎏᎏlᎏbumin a-; an- away from aᎏᎏbnormal -alg pain myaᎏlᎏgᎏia ab- abdomen aᎏbᎏᎏdᎏoᎏmᎏinᎏoᎏpelvic ambi- both aᎏᎏmbᎏiᎏdextrous abdomino- pertaining to iliaᎏᎏc; abdominaᎏᎏl; an- without aᎏᎏnencephaly -ac; -al; -ar; -ary andr(o)- male aᎏᎏnᎏdᎏroᎏgen relating to hearing oculaᎏᎏr; coronaᎏrᎏyᎏ angi- pertaining to blood aᎏnᎏgᎏᎏina acou- extremity aᎏcᎏoᎏuᎏstic meatus acr(o)- hearing condition aᎏᎏcᎏrᎏomegaly ankylo- vessels aᎏnᎏkᎏᎏyᎏlᎏosing -acusis toward presbycᎏuᎏsᎏᎏiᎏs crooked spondylitis ad- gland aᎏdᎏhesion ante- aden(o)- fat aᎏdᎏeᎏnᎏoᎏcarcinoma anti- in front of aᎏᎏnᎏteᎏbrachial adipo- air aᎏdᎏiᎏpᎏᎏocytes aque- against aᎏᎏntᎏᎏigen aero- moving towards a aᎏᎏerᎏᎏosol -arche water aᎏqᎏᎏueᎏous humor af- aᎏfᎏferent arthr- beginning menaᎏrᎏᎏchᎏᎏe central point pertaining to joint aᎏrᎏtᎏhᎏᎏritis

Chapter 1—Introduction 41 Table 1.2 Anatomic Terminology (Continued) Prefix/Suffix Meaning Example Prefix/Suffix Meaning Example -ase an enzyme proteaᎏᎏseᎏ crani(o) skull cᎏrᎏaᎏᎏniᎏosacral -asthenia weakness myaᎏᎏsᎏtᎏheᎏᎏniᎏᎏa gravis crin(o) secrete endocᎏrᎏiᎏᎏne auto- self aᎏᎏuᎏtᎏonomic crypt- hidden cᎏᎏrᎏypᎏᎏtorchidism B cutane(o)- skin subcᎏuᎏtᎏaᎏᎏneᎏᎏous bi- two bᎏiᎏlateral cyan- blue cᎏᎏyᎏaᎏnosis bili- bile bᎏiᎏᎏlᎏirubin cysti- sac or bladder cᎏyᎏᎏstᎏiᎏtis bio- life bᎏᎏiᎏology cyt(o)- cell cᎏyᎏtᎏᎏoplasm blast-/-blast embryonic state erythrobᎏᎏlᎏaᎏsᎏt D blephar(o)- eyelid bᎏᎏlᎏeᎏphᎏaᎏrᎏitis dactyl- digit (finger or toe) polydᎏaᎏᎏcᎏtᎏylᎏy brachi- arm bᎏᎏrᎏacᎏhᎏiᎏal plexus de- down dᎏᎏescend brachy- short bᎏrᎏᎏaᎏcᎏhᎏycephalic derm- relating to skin dᎏeᎏrᎏᎏmatitis brady- slow bᎏᎏrᎏaᎏdyᎏcardia dextr(o) right dᎏeᎏᎏxᎏtrᎏose bucc- pertaining to the bᎏuᎏcᎏᎏcinator di- two dᎏiᎏchotomy dia- across or through dᎏiᎏᎏaphragm C cheek diplo- double dᎏᎏipᎏlᎏᎏopia cac- dips- thirst polydᎏᎏipᎏᎏsia calc- bad cᎏaᎏᎏchexia dis- apart dᎏᎏisᎏlocate capit- stone cᎏᎏaᎏlcᎏulus dors(i)(o)- back latissimus dᎏoᎏrᎏsᎏᎏi pertaining to the cᎏaᎏpᎏᎏiᎏtulum duct- conduct dᎏᎏuᎏcᎏtus arteriosus capn-; carb- dur- hard dᎏuᎏᎏra mater carcin- head hypercᎏaᎏᎏpᎏnea dys- bad, difficult dᎏyᎏsᎏuria cardi- carbon dioxide cᎏaᎏᎏrᎏcᎏinᎏoma E cata- cancer cᎏᎏaᎏrᎏdiᎏology e- out eᎏpithelium caud- heart cᎏᎏaᎏtaᎏbolism -eal pertaining to peritoneᎏᎏalᎏ dialysis cephal- down cᎏaᎏᎏudᎏal ecto- outside eᎏᎏcᎏtᎏopic -cele tail encᎏeᎏᎏphᎏᎏalᎏitis -ectomy removal appendeᎏcᎏtᎏoᎏᎏmᎏy celi- head varicocᎏeᎏlᎏeᎏ ede- swelling eᎏdᎏᎏema -centesis pouching or hernia cᎏᎏeᎏliᎏac artery -emia pertaining to blood aneᎏmᎏiᎏᎏa abdomen amniocᎏeᎏnᎏtᎏᎏesᎏiᎏᎏs en- within eᎏᎏnema cerebro- puncture for end- within eᎏnᎏdᎏoscopy cervic- cᎏᎏerᎏeᎏbᎏrᎏoᎏspinal fluid enter(o)- pertaining to eᎏnᎏᎏtᎏeᎏroᎏcolitis chol- aspiration cᎏᎏeᎏrᎏviᎏx chondr- brain cᎏᎏhoᎏᎏlecystectomy epi- the gut eᎏᎏpᎏidermis chrom- neck hypocᎏhᎏoᎏᎏnᎏdrᎏiac region erythro- above eᎏrᎏyᎏᎏtᎏhᎏroᎏcyte -cide bile monocᎏhᎏᎏrᎏomᎏatic eu- red eᎏuᎏthyroid circum- cartilage suicᎏᎏiᎏdᎏe ex- normal eᎏxᎏtremity co-; con- color cᎏiᎏᎏrᎏcᎏuᎏmference exo- out of eᎏᎏxoᎏcytosis col(i)(o)- destroy cᎏᎏoenzyme; cᎏoᎏnᎏjoint extra- outside eᎏᎏxtᎏᎏrᎏacellular contra- around cᎏoᎏlᎏonoscopy F outside of coron(o) together cᎏoᎏnᎏtᎏᎏraᎏlateral fasci- corp- colon cᎏᎏoᎏrᎏoᎏnary artery febri- band; bundle fᎏᎏaᎏsᎏcᎏia cost(o)- against cᎏᎏorᎏᎏpus callosum fever fᎏeᎏᎏbrᎏᎏile crown or circle cᎏᎏoᎏsᎏtᎏochondral body Continued rib

42 The Massage Connection: Anatomy and Physiology Table 1.2 Anatomic Terminology (Continued) Prefix/Suffix Meaning Example Prefix/Suffix Meaning Example among -ferent carry affᎏᎏeᎏreᎏᎏnᎏt inter- inside iᎏᎏntᎏeᎏᎏrstitial fil- threadlike fᎏᎏilᎏament intra- hip iᎏnᎏᎏtᎏraᎏcellular fiss- split fᎏiᎏsᎏsᎏure ischi(o)- condition iᎏᎏsᎏchᎏiᎏum for- opening fᎏᎏorᎏamen -ism equal hyperthyroidiᎏᎏsᎏm -form shape cuneifᎏoᎏᎏrᎏm iso- one who iᎏsᎏoᎏmetric G -ist optometriᎏsᎏᎏt galact(o)- milk gᎏaᎏᎏlᎏacᎏtᎏose specializes in gastro- related to gᎏᎏasᎏtᎏrᎏoᎏintestinal -itis inflammation pleuriᎏtᎏiᎏᎏs J -gen the stomach fibrinogᎏeᎏᎏn jejun(o)- jejunum (empty) jᎏᎏejᎏᎏunᎏᎏoplasty an agent which juxta- adjacent to; near jᎏᎏuᎏxᎏtaᎏglomerular -genic osteogᎏeᎏᎏniᎏᎏc K gest- produces gᎏᎏeᎏsᎏtation kerat(o)- cornea; scarred kᎏeᎏrᎏaᎏtᎏitis gli- originating from neurogᎏlᎏiᎏoma tissue gloss- carry hypogᎏlᎏoᎏᎏssᎏus kine(t)(o)- kᎏiᎏᎏneᎏsiology glue L movement glott- related to epigᎏlᎏoᎏᎏttᎏis labi- lᎏᎏaᎏbiᎏa majora glyco- gᎏlᎏᎏyᎏcᎏolysis lacri- lip lᎏᎏaᎏcrᎏiᎏmal gland gnos(o) the tongue diagᎏᎏnoᎏᎏsis lact- tears lᎏᎏacᎏtᎏose -gram opening electrocardiogᎏrᎏaᎏᎏm lapar(o)- milk lᎏaᎏpᎏᎏaᎏroᎏscope gran- sugar; sweet gᎏrᎏᎏaᎏnulocyte laryn(o)- abdomen lᎏaᎏrᎏᎏyᎏngectomy -graph knowing polygᎏrᎏaᎏpᎏᎏh later- larynx lᎏᎏatᎏeᎏrᎏal record of -lepsy side epilᎏᎏeᎏpsᎏᎏy gravi- particulates prima gᎏrᎏᎏaᎏviᎏda leuk- seizure lᎏeᎏᎏuᎏkocyte gyn(o)- instrument for gᎏyᎏnᎏecology lex(o)- white dyslᎏeᎏᎏxia H lip- word, phrase lᎏiᎏpᎏosuction hema- recording hᎏᎏemᎏᎏatology lith(o)- fat lᎏᎏiᎏthᎏᎏotripsy hemi- heavy hᎏᎏemᎏiᎏsphere -logy stone biolᎏᎏogᎏyᎏ hepat- woman hᎏeᎏpᎏaᎏᎏtitis lord(o)- science of lᎏoᎏᎏrᎏdoᎏsis hetero- hᎏᎏetᎏᎏeᎏrᎏogenicity lymph(o)- bent lᎏyᎏᎏmpᎏᎏhoᎏcyte histo- blood hᎏiᎏᎏstᎏoᎏlogy -lysis clear fluid hemolᎏyᎏᎏsiᎏsᎏ holo- half hᎏoᎏlᎏᎏocrine M dissolve homo- liver hᎏoᎏᎏmᎏosexual macro- mᎏᎏacᎏrᎏᎏophage hydro- other hᎏyᎏdᎏᎏrᎏocephalus mal- big mᎏaᎏᎏlnutrition hyper- tissue hᎏᎏypᎏeᎏᎏrventilation -malacia bad osteomᎏaᎏᎏlaᎏᎏciᎏᎏa hypo- whole hᎏᎏypᎏᎏothyroidism mamm(o)- softening mᎏaᎏmᎏᎏmᎏogram hyster- same hᎏyᎏsᎏtᎏᎏeᎏrectomy mast(o)- breast mᎏaᎏsᎏᎏtectomy I water meat(o)- breast mᎏeᎏaᎏᎏtus -ia excessive anemiᎏᎏa medi- opening mᎏeᎏᎏdᎏiastinum idio- less iᎏᎏdᎏioᎏpathic mega- middle acromᎏᎏeᎏgaᎏly ile(o)- uterus iᎏlᎏiᎏacus melan(o)- big mᎏᎏelᎏaᎏᎏnocyte infra- iᎏᎏnfᎏrᎏaᎏred black condition self ileum beneath

Chapter 1—Introduction 43 Table 1.2 Anatomic Terminology (Continued) Prefix/Suffix Meaning Example Prefix/Suffix Meaning Example meno- menstruation mᎏeᎏnᎏoᎏpause P thick pᎏᎏaᎏcᎏhᎏyderma ment- mind mᎏᎏenᎏᎏtal pachy- give birth to multipᎏaᎏᎏra meso- middle mᎏeᎏᎏsᎏothelium par- near or abnormal pᎏaᎏᎏrᎏaplegia meta- after mᎏᎏetᎏaᎏstasis para- disease pᎏᎏaᎏthᎏology -meter measuring device manomᎏeᎏᎏteᎏᎏr path(o)- abnormality encephalopᎏᎏaᎏthᎏᎏy micro- small mᎏiᎏᎏcᎏrᎏoorganism -pathy children pᎏeᎏdᎏiatrics mio- less, smaller mᎏᎏiᎏosis ped- lack of neutropᎏᎏeᎏniᎏᎏa mito- threadlike mᎏiᎏᎏtoᎏchondria -penia around pᎏeᎏᎏrᎏicardium mono- single mᎏᎏonᎏᎏocyte peri- to eat macropᎏᎏhᎏagᎏes morph- shape mᎏᎏorᎏpᎏhᎏology phag- medicine pᎏᎏhᎏaᎏrᎏmᎏacᎏᎏology multi- many mᎏᎏulᎏᎏtᎏimedia pharmac(o)- pharynx pᎏhᎏaᎏᎏrᎏynᎏgᎏitis myc(o)- fungus mᎏᎏyᎏcoᎏplasma pharyng(o)- an affinity for eosinopᎏᎏhiᎏᎏl myel(o)- marrow; spinal mᎏᎏyᎏelᎏitis -phil vein pᎏhᎏlᎏᎏeᎏbitis phleb(o)- dread pᎏhᎏoᎏbᎏia myo- cord mᎏyᎏoᎏmetrium -phobe light pᎏhᎏoᎏtᎏography myx- muscle mᎏyᎏᎏxedema phot(o)- growth hyperpᎏlᎏᎏasᎏᎏiᎏa N mucus -plasia reconstruction of angiopᎏᎏlaᎏᎏstᎏyᎏ narc- nᎏaᎏᎏrcᎏolepsy -plasty flat pᎏlᎏaᎏᎏtyᎏsma naso- numb nᎏaᎏsᎏoᎏpharyngeal platy- paralysis hemipᎏᎏlᎏegᎏᎏiᎏa necro- nose nᎏᎏeᎏcrᎏᎏosis -plegia rib; side; pleura pᎏᎏleᎏᎏuᎏral cavity neo- dead nᎏeᎏoᎏplasm pleur(o)- to breathe dyspᎏnᎏᎏeaᎏ nephro- new nᎏᎏeᎏphᎏrᎏoᎏlogy -pnea air or lung pᎏᎏnᎏeuᎏmᎏoᎏnᎏia neuro- kidney nᎏeᎏuᎏᎏrᎏology pneumon(o)- foot pᎏoᎏᎏdiatrist O nerve pod- formation of erythropᎏᎏoᎏieᎏᎏsiᎏᎏs oc- oᎏᎏcclusion -poiesis many pᎏᎏoᎏlᎏymorphs ocul(o)- against oᎏcᎏuᎏᎏloᎏmotor poly- after pᎏoᎏᎏsᎏtpartum -oid eye androᎏiᎏᎏd post- movement apᎏrᎏᎏaxᎏiᎏᎏa -ole resembling centrioᎏᎏleᎏ -praxia before pᎏrᎏᎏenatal oligo- small oᎏlᎏᎏigᎏoᎏdendrocyte pre- favoring; supporting pᎏrᎏᎏognosis -oma small myoᎏᎏmᎏa pro- anus pᎏᎏrᎏoᎏctᎏology oo- tumor oᎏᎏocyte proct- protein pᎏrᎏᎏotᎏᎏeoᎏlysis ophthalm- egg oᎏᎏpᎏhᎏtᎏhaᎏlᎏmᎏology prote(o)- false pᎏsᎏeᎏᎏudᎏoᎏstratified or- eye oᎏᎏral pseudo- mental pᎏsᎏᎏycᎏᎏhᎏology orchi- mouth oᎏrᎏcᎏᎏhiᎏtis psych(o)- lung pᎏᎏuᎏlmᎏᎏoᎏnary ortho- testes oᎏrᎏᎏthᎏoᎏstatic pulmo(n)- kidney pᎏyᎏeᎏᎏloᎏnephritis -ory normal coronoᎏrᎏᎏy pyel(o)- pus pᎏyᎏᎏoderma -ose pertaining to glucoᎏᎏsᎏe py(o)- heat pᎏᎏyrᎏexia -osis full of arthroᎏsᎏiᎏsᎏ pyr(o)- oste(o)- condition oᎏsᎏᎏtᎏeoᎏmyelitis Q four qᎏuᎏᎏadᎏriplegia ot(o)- bone oᎏtᎏitis quad- ovo- ear oᎏvᎏary ox(o)- egg oᎏᎏxidation oxygen Continued

44 The Massage Connection: Anatomy and Physiology Table 1.2 Anatomic Terminology (Continued) Prefix/Suffix Meaning Example Prefix/Suffix Meaning Example above R again rᎏᎏecurrent super- above sᎏuᎏᎏpᎏeᎏrior re- straight rᎏeᎏcᎏᎏtus supra- joined sᎏuᎏpᎏᎏraᎏorbital rect- kidney adrᎏᎏenᎏal gland sym-; syn- sᎏᎏymᎏphysis; sᎏᎏynᎏthesis ren(o)- network rᎏᎏeᎏtiᎏculum T fast rete- behind rᎏᎏetᎏrᎏᎏopharyngeal tachy- movement tᎏᎏaᎏchᎏᎏycardia retro- nose rᎏhᎏiᎏnᎏitis -taxis far chemotᎏaᎏᎏxiᎏᎏs rhin- excessive flow hemorᎏrᎏhᎏᎏagᎏᎏe tele- stretch tᎏeᎏᎏleᎏhealth -rrhage suture herniorᎏrᎏᎏhᎏaᎏphᎏᎏy tens- four tᎏᎏeᎏnᎏsor -rrhaphy flow diarᎏrᎏᎏheᎏaᎏ tetra- heat tᎏᎏetᎏrᎏalogy -rrhea red rᎏᎏubᎏor therm- chest tᎏhᎏᎏerᎏᎏmometer rub(r)- thorac- clot tᎏhᎏoᎏrᎏᎏacᎏic S flesh sᎏᎏarᎏcᎏoma thrombo- cut tᎏhᎏrᎏᎏomᎏbᎏoᎏphlebitis sarc- blood serosᎏaᎏnᎏᎏgᎏuᎏinous fluid -tomy poison mastectᎏoᎏmᎏᎏy sangui- split sᎏᎏcᎏhᎏizᎏoᎏphrenia tox- trachea cytotᎏᎏoᎏxic schiz(o)- hard sᎏᎏcᎏlᎏerᎏᎏoderma trache(o)- across tᎏrᎏᎏacᎏᎏhᎏeoᎏstomy scler(o)- crooked sᎏcᎏᎏolᎏiᎏᎏosis trans- three tᎏrᎏaᎏᎏnᎏscutaneous scolio- instrument to endosᎏcᎏᎏoᎏpeᎏ tri- hair tᎏᎏrᎏiceps -scope trich- crushing tᎏrᎏᎏicᎏᎏhosis examine a part dissᎏeᎏᎏctᎏ -tripsy state relating lithotᎏᎏriᎏᎏpsᎏyᎏ -sect to cut sᎏᎏeᎏmᎏipermeable -trophy hypertᎏᎏrᎏoᎏphᎏᎏy semi- partly sᎏᎏeᎏnsᎏation to size sensi- feeling; perception sᎏeᎏᎏpticemia U linguᎏᎏlᎏa; noduᎏlᎏᎏe sep- decay sᎏᎏerᎏrᎏᎏaᎏtus anterior -ula; -ule small uᎏlᎏᎏtᎏrᎏasonogram serrate- saw-tooth erythropoiesᎏiᎏsᎏ ultra- excess uᎏᎏniᎏlateral -sis process sᎏᎏomᎏᎏatic uni- one polyuᎏᎏrᎏiᎏa soma- body insᎏoᎏmᎏᎏnia -uria urine uᎏrᎏᎏology somn(i) (o) sleep sᎏᎏpᎏhᎏygᎏᎏmoᎏmanometer uro- pertaining to sphygm(o)- pulse ankylosing sᎏpᎏoᎏnᎏdᎏᎏyᎏlitis vᎏaᎏsᎏ deferens spondyl(o)- vertebra sᎏqᎏᎏuaᎏmᎏous epithelium V urine vᎏeᎏnᎏᎏipuncture squam(o)- scale homeosᎏᎏtᎏaᎏsᎏiᎏs vas- vᎏᎏerᎏᎏmᎏicularis -stasis stop or stand sᎏᎏteᎏaᎏtᎏorrhea ven(i)(o)- vessel vᎏᎏesᎏiᎏcᎏoᎏureteral steat(o)- fat sᎏᎏteᎏᎏnoᎏsis vermi- vein vᎏiᎏtᎏamin steno- narrow sᎏᎏtᎏerᎏeᎏᎏognosis vesic(o)- worm stere(o)- three dimensional sᎏtᎏᎏeᎏthᎏᎏoscope vit- bladder steth(o)- chest ileosᎏᎏtᎏoᎏmᎏy Z life -stomy surgical opening sᎏᎏuᎏblingual zygo- join sub- below zᎏᎏygᎏoᎏmatic bone

Chapter 1—Introduction 45 SUGGESTED READINGS Fill in the Blank Andrade CK, Clifford P. Outcome-Based Massage. Baltimore: 1. The levels of organization from larger to smaller Lippincott Williams & Wilkins, 2001. are: Goats GCK. Connective tissue massage. Br J Sports Med 1991; Organism ________________ → ________________ → 25(3):131–133. ________________ → ________________ → Chemicals Goats GC. Massage—the scientific basis of an ancient art: Part 1, 2. In each situation, determine if water would Part 2. Br J Sports Med 1994;28(3):149–155. move into the cell (I); out of the cell (O); or nei- ther (N). Mark each situation with I, O, or N. Juhan D. A Handbook for Bodywork: Job’s Body. New York: Sta- tion Hill Press, 1987. Solute (chemical substance dissolved in water) more concentrated around the cell Kenney RA. Physiology of Aging: A Synopsis. 2nd Ed. Chicago: ________________ Year Book Medical, 1989. Solute less concentrated around the cell Kotzsch RE. Restructure the body with rolfing: deep massage that re- ________________ aligns the human form. East West Nat Health 1992;22(6):35–38. Solute concentration is the same as in the cell Premkumar K. Pathology A to Z. 2nd Ed. Calgary: VanPub Books, ________________ 1999. 3. Completion Sandler S. The physiology of soft tissue massage. J Bodywork Movement Ther 1999;3(2):118–122. a. Within the nucleus of the atom, there are positively charged particles called Review Questions ________________ and uncharged particles called ________________. Multiple Choice b. If you subtract the atomic number from the 1. Which structure separates the thoracic cavity mass number, you will identify the number of from the abdominopelvic cavity? ________________. A. Diaphragm B. Visceral peritoneum c. In the ________________ bond, a pair of elec- C. Liver trons is shared. D. Parietal pleura E. Rib cage d. In the ________________ type bond, a weak link between a hydrogen atom and another 2. Which of the following is NOT a characteristic atom, such as oxygen or nitrogen, is formed. of a person in anatomic position? A. Feet together e. The ratio of hydrogen to oxygen in all carbo- B. Arms at sides hydrates is ________________: ________________. C. Body erect D. Eyes directed forward f. Carbohydrates, lipids, and proteins all con- E. Palms facing posteriorly tain carbon, hydrogen, and oxygen. A fourth element, ________________, makes up a sub- 3. To the ankle, the knee is stantial portion of protein. A. intermediate. B. lateral. g. An increase in tissue or organ size by in- C. distal. crease in cell size (not number) is known as D. inferior. ________________. E. proximal. 4. Fill in the blanks, using the appropriate 4. Superior is to cranial as posterior is to anatomic terms: A. external. B. ventral. a. The ears are ________________ to the nose. C. caudal. D. dorsal. b. The elbow is ________________ to the fingers. E. internal. c. The heart is located ________________ to the 5. Of the existing chemical elements, four elements vertebral column. make up 96% of the human body. These elements follow, EXCEPT d. The muscles of the abdomen are A. carbon. ________________ to the skin over the abdomi- B. sulphur. nal wall. C. nitrogen. D. oxygen. E. hydrogen.

46 The Massage Connection: Anatomy and Physiology 5. Fill in the blanks with the appropriate muscle tis- 4. There are about four different kinds of amino sue type: cardiac muscle, smooth muscle, or acids found in human proteins. skeletal muscle. (More than one type may be ap- propriate for certain statements.) 5. When a stimulus response results in an en- hancement of the initial stimulus, it is a nega- a. Striations when viewed under the microscope tive feedback mechanism. ________________ 6. Negative feedback mechanisms are more com- b. Controlled by the autonomic nerves mon than positive feedback mechanisms. ________________ 7. Of the three major components of the mecha- c. Intercalated disks ________________ nisms that help to maintain homeostasis, the ef- fectors sense the changes in the environment. d. Diaphragm is an example of ________________ 8. Mitosis is a type of cell division in which a cell e. The muscle found in the uterus is an example divides into two new cells with the same num- of ________________ ber of chromosomes as the original cell. f. Branched appearance ________________ 9. The pH of the body is 6.5. 10. A pH of 9.0 is considered acidic. 6. Fill in the blanks, using the appropriate mem- brane type: mucous, serous, cutaneous, and sy- Matching 1. This plane divides the novial. A. body into superior and inferior parts. a. Membrane found in joints, such the knees a. _____ parasagittal and shoulders plane; 2. This plane divides the body into equal right b. Membrane that lines the mouth b. _____ midsagittal and left portions. plane; c. Membrane lining of the thoracic cavity 3. This plane divides the c. _____ transverse body into anterior and d. The skin is considered to be this type mem- plane posterior portions. brane d. _____ frontal plane 4. This plane divides the 7. Below is a classification of connective tissue. Fill body into unequal right in the blanks with the appropriate type. B. and left portions. a. _____ lateral True or False 1. Toward or near the sur- b. _____ medial face of a structure or (Answer the following questions T, for true; or F, body. for false): c. _____ superficial 2. Away from the midline 1. Diffusion, osmosis, and facilitated diffusion are d. _____ inferior of a structure or body. all passive transport processes. e. _____ anterior 3. Toward the front of a 2. Plasma membranes consist of a double layer of structure or body. carbohydrate molecules with proteins embedded in the bilayer. 4. Toward the lower part of a structure or body. 3. Oxygen, water, NaCl and glucose are inorganic compounds. 5. Toward the midline of a structure or body. Connective tissue Connective tissue proper a. b. Loose connective tissue c. Eg. Blood d. Eg. Bone e. Eg. Eg. Tendon Eg. Ligament

Chapter 1—Introduction 47 C. 1. Contains the heart. 6. _____ homeostasis f. study of external and a. _____ pleural cavity 2. Contains the spinal 7. _____ atom internal structures of b. _____ pericardial 8. _____ isotope the body cavity. cord. 9. _____ ion c. _____ abdominal 3. Contains the bladder g. includes all the chemi- cavity 10. _____ metabolism cal reactions in the body d. _____ vertebral and rectum. 11. _____ buffer cavity 4. Contains the lungs. h. collection of different e. _____ pelvic cavity types of tissues having f. _____ cranial cavity 5. Contains the brain. the same function 6. Contains the liver and i. atoms of an element stomach. that have the same atomic number but dif- D. Match the function (a, b, c, d, or e) to the follow- ferent mass number ing list of systems: j. study of changes that occur during develop- 1. _____ Cardiovascular a. removes nitrogenous ment in the womb system waste products k. compounds that prevent rapid changes in pH 2. _____ Lymphatic b. involves defense system mechanisms and removal of excess fluid F. Match the organelle with the function mentioned: from the interstitial 1. _____ endoplasmic a. plays an active part fluid compartment reticulum during cell division 3. _____ Respiratory c. manufactures blood 2. _____ lysosome b. manufactures proteins system cells; provides surface 3. _____ mitochondria c. contains destructive for muscle attachment enzymes 4. _____ Nervous d. removes carbon 4. _____ microvilli d. manufactures ATP system dioxide from blood and 5. _____ centriole e. increases surface area helps maintain pH for absorption 5. _____ Muscular e. propagates species system G. Match the word with the type of chemical 6. _____ Urinary f. perceives changes in reaction: system the external environ- 1. _____ Exchange a. A ϩ B ↔ AB ment and reacts reaction 7. _____ Skeletal g. helps absorb nutrients 2. _____ Decomposition b. AB ϩ CD ↔ AD ϩ CB system reaction 8. _____ Digestive h. helps with movement; 3. _____ Synthesis c. AB ↔ A ϩ B system produces heat reaction 9. _____ Endocrine i. carries nutrients system H. Match the following types of bonds with their de- scriptions: 10. _____ Reproductive j. manufactures 1. _____ In this type of bond, a. ionic bond system vitamin D an atom looses its electrons to another 11. _____ Integumentary k. regulates body function atom. system by secreting chemicals 2. _____ In this type of bond, b. hydrogen bond the atoms share their into the blood electrons. E. Match the following words with their definitions: 3. _____ In this type of bond, c. covalent bond atoms share their 1. _____ anatomy a. condition of constancy electrons unequally. in the internal environment 2. _____ physiology b. study of the functions of the structures of the body I. Match the following tissue types with the 3. _____ embryology c. atoms that carry posi- descriptions: tive or negative charges 1. _____ helps the heart pump a. connective 4. _____ tissue d. smallest unit of matter out blood tissue 5. _____ organ e. collection of cells hav- 2. _____ forms the inner lining b. muscle tissue ing the same function of blood vessels

48 The Massage Connection: Anatomy and Physiology 3. _____ forms the major c. epithelial tissue Short Answer Questions component of the d. nervous tissue spinal cord 1. Name the different systems of the body. 4. _____ forms the most 2. Give the functions of each system. abundant type of tissue in the body 3. Locate, on your body, the sacral, popliteal, frontal, umbilical, and brachial regions. 5. _____ transmits electrochemical 4. Define the term homeostasis. impulses 5. List the major chemicals that make up the body. 6. _____ forms an abundance of nonliving fibers 6. Name the different ways transport can occur across the cell membrane. 7. _____ forms the surface of the skin 7. Describe the special characteristics of epithelial tissue. J. Match the type of epithelium with the location. 8. Locate squamous, cuboidal, and columnar ep- 1. _____ most of the a. cuboidal ithelium in the body. respiratory tract epithelium 9. Describe the characteristics of connective tissue. lining has this 10. Explain why cartilage and dense connective tis- sue take longer to heal. type of epithelium 11. Name the positive effects of massage on connec- 2. _____ specific to the lining b. ciliated tive tissue. of the urinary bladder columnar 12. Name a few connective tissue techniques and identify the conditions where they are particu- epithelium larly useful. 3. _____ lines ducts c. stratified 13. Define thixotropy. squamous Prefixes/Suffixes/Terms epithelium Identify the meaning of the underlined prefixes/ suffixes/terms in the following text: 4. _____ found where there is d. transitional Mrs. Goldsmith slipped on ice and fractured her a lot of friction epithelium hip. Even the short period she was immobilized led to atrophy of her leg muscles. But this was K. Match the following types of transport across the not her only problem. Her intraocular pressure was high. Just a month prior to her fall, en- cell membrane with the description: doscopy was performed to rule out gastric ulcer when she developed severe epigastric pain. 1. _____ requires the use of ATP a. simple Later, she found out that she had cholelithiasis for which cholecystectomy seemed to be the diffusion only solution. 2. _____ the water moves from b. endocytosis Case Study Mrs. Simon, a 45-year-old lawyer, filed claims an area of high with her insurance agent for damages that she had incurred in an accident 6 months ago. She concentration of solutes had been receiving treatment for whiplash from her massage therapist for more than 4 months. (particles in the water) to Mrs. Simon requests a written report of the therapist’s assessment of her injury and progress an area of low with treatment. As a health professional, what knowledge do concentration of solutes you think a bodyworker needs to complete this report? 3. _____ transport is driven by c. active hydrostatic pressure transport 4. _____ large particles are taken d. osmosis from the exterior by indentation of the plasma membrane 5. _____ movement of the solutes e. filtration is driven by the difference in concentration gradient of the solutes L. Match the following roots/suffixes/prefixes with the correct meaning: 1. _____ short a. tachy 2. _____ bad b. caud 3. _____ tail c. adipo 4. _____ fat d. brachy 5. _____ fast e. crypt 6. _____ hidden f. dys 7. _____ band g. fasci

Chapter 1—Introduction 49 Coloring Exercise a. Color each of the abdominal areas in the given diagram, using a different color and fill- ing in the color code. O lumbar regions O umbilical region O epigastric region O hypogastric region O iliac region O hypochondriac region Liver Stomach Spleen Small intestine Appendix Urinary bladder Large intestine

50 The Massage Connection: Anatomy and Physiology b. Color each of the labeled areas in the given diagram, using a different color and filling in the color code. O cranial region O pubic area O deltoid region O popliteal fossa O cubital region O crural region O sternal region O gluteal region Pelvis AB

Chapter 1—Introduction 51 c. Color each of the labeled structures in the given diagram, using a different color and fill- ing in the color code. O mitochondria O nucleus O cytoplasm O cell membrane O centriole O nucleus O endoplasmic reticulum O Golgi apparatus

52 The Massage Connection: Anatomy and Physiology absorption of nutrients; eliminates waste. Ner- vous—detects, interprets and reacts to changes Answers to Review Questions in the internal and external environment. Respi- ratory—exchange of gases, maintains pH; helps Multiple Choice produce sound. Cardiovascular—carries oxygen and nutrients to tissues, removes wastes from 1. A; 2. E; 3. E; 4. D; 5. B tissues, maintains temperature; helps with de- fense; helps maintain the internal environment. Completion Endocrine—regulates body activities by secret- ing hormones. Reproductive—helps propagate 1. systems; organs; tissues; cells; chemicals species. Lymphatic—returns protein and fluid 2. a. O; b. I; c. N to blood from the interstitial compartment; par- 3. a. protons, neutrons; b. neutrons; c. covalent; ticipates in defense. Urinary—helps eliminate nitrogenous waste; helps maintain pH. d. hydrogen bond; e. 2:1; f. nitrogen; g. hypertrophy Skeletal—manufactures blood cells in marrow; 4. a. posterior or lateral; b. proximal or superior; supports body; protects organs; helps with movement; stores minerals. Muscular—helps c. anterior; d. superficial with movement; generates heat. 5. a. a and c; b. a and b; c. a; d. c; e. b; f. a 3. Refer to Figure 1. 7. 6. a. d; b. a; c. b; d. c 4. It is the condition of constancy in the internal 7. a. fluid connective tissue; b. supporting connec- environment 5. Oxygen, carbon, hydrogen, nitrogen, calcium, tive tissue; c. dense connective tissue; d. lymph and phosphorus 6. Diffusion, osmosis, filtration, carrier-mediated; True–False vesicular transport; active transport 7. Cover surfaces; line internal passages and cham- 1. true bers; found in layers; are not supplied by blood 2. false, it is a phospholipid bilayer vessels; multiply rapidly; form a barrier and pro- 3. false, glucose is organic tect; have a good nerve supply 4. false, there are about 20 significant amino acids 8. Squamous epithelium can be found in the peri- toneum; endothelium lining heart and blood in the body vessels; alveoli of lungs; some parts of kidney 5. false, it is a positive feedback mechanism tubules; Cuboidal epithelium can be found in 6. true glands; ducts; and some parts of kidney tubules; 7. False, it is the receptors, effectors produce the Columnar epithelium can be found lining the stomach; intestines; gall bladder; uterine tubes; effect some parts of kidney tubules 7. true 9. Connective tissue has specialized cells, protein 8. true fibers, and ground substance; the cells are scat- 9. false, it is 7.35–7.45 tered; they are not exposed to the exterior; most 10. false, pH below 7.0 would be acidic connective tissue are vascularized; most have nerve ending that respond to sensations Matching 10. They have a poor blood supply and are mostly made up of nonliving matter (matrix) A. 1. c; 2. b; 3. d; 4. a 11. The stretches, strokes, movement and heat make B. 1. c; 2. a; 3. e; 4. d; 5. b connective tissue more fluid, allowing greater C. 1. b; 2. d; 3. e; 4. a; 5. f; 6. c movement and flow, encouraging blood flow, D. 1. i; 2. b; 3. d; 4. f; 5. h; 6. a; 7. c; 8. g; 9. k; 10. e; and speedy removal of pain producing toxins from the area. It can help prevent or slow adhe- 11. j sions; it also helps to better align collagen fibers, E. 1. f; 2. b; 3. j; 4. e; 5. h; 6. a; 7. d; 8. i; 9. c; 10. g; reducing friction and allowing movement. 12. Skin rolling—This stroke is useful when adhe- 11. k sions are present between the skin and the deep F. 1. b; 2. c; 3. d; 4. e; 5. a fascia, as seen in burns, after healing of G. 1. b; 2. c; 3. a wounds, and surgery; friction—repetitive H. 1. a; 2. c; 3. b strokes of friction produce movement between I. 1. b; 2. c; 3. d; 4. a; 5. d; 6. a; 7. c J. 1. b; 2. d; 3. a; 4. c K. 1. c; 2. d; 3. e; 4. b; 5. a L. 1. d; 2. f; 3. b; 4. c; 5. a; 6. e; 7. g Short-Answer Questions 1. and 2. Integumentary—protects body; temper- ature regulation; production of vitamin D; per- ceives sensation. Digestive—breaks down food;

Chapter 1—Introduction 53 individual fibers located in dense connective tis- Prefixes/Suffixes/Terms sue, reducing adhesions and promoting realign- ment of collagen fibers; myofascial/fascial Intraocular, inside eye; endoscopy, examination techniques—sustained force is applied to the of the inside; epigastric, pain over the stomach superficial or deep fascia and muscle to region; cholelithiasis, stone in the gallbladder; lengthen the fascia and increase mobility. cholecystectomy, removal or excision of the gall- 13. It is the phenomenon that solidifies substances bladder. when cold or left undisturbed and liquefies sub- stances when warmed or stirred. Case Study To begin with, an understanding of medical ter- minology.



CHAPTER 2 Integumentary System Objectives On completion of this chapter, the reader should be able to: • List the functions of the integumentary system. • Identify the layers of the skin and the accessory structures. • Describe the various factors that determine skin color. • Describe the effects of ultraviolet radiation on the skin. • Explain the role of skin in temperature control. • Explain how different sensations, such as touch, pressure, pain, and temperature change, are “sensed” by the skin and conveyed to the central nervous system. • Define dermatome. • Explain the role of the accessory structures in maintaining skin functions. • Identify the location of superficial and deep fascia. • Identify substances that may be absorbed through the skin. • Describe the role of microorganisms that inhabit normal skin and mucous membrane. • Define inflammation. • Explain the purpose of inflammation. • List the common causes of inflammation. • State the cardinal signs of acute inflammation and explain the underlying mechanisms. • Explain the various ways inflammation may resolve. • Compare and contrast acute and chronic inflammation. • Describe the mechanisms involved in skin healing. • Describe the effects of aging on the components of the integumentary system. • Describe the possible effects of massage on the integumentary system. • Compare the effects of various massage techniques on the skin. • Describe the effects of heat application on the skin. • Describe the effects of cold application on the skin. • Explain the unique properties of water that make it suitable for use by bodyworkers. • Define macule, wheal, papule, nodule, vesicle, pustule, ulcer, crust, scale, and fissure and identify the anatomic structure of skin affected by each of these skin lesions. A lthough massage and other complementary ther- complex mechanical, physiologic, and psychological responses are produced in the deeper structures. A apies affect many systems, the organ system or struc- thorough knowledge of structure and function will ture that is physically handled by the therapist is the help therapists treat clients more effectively. For ex- integumentary system. Therapists use their sense of ample, some areas of the skin are more sensitive to touch to assess their clients’ temperature, texture, touch than others and less pressure is sufficient. The and tension of soft tissue. The client perceives the type of technique used and the rate, vigor, and manipulation by the therapist through the skin and 55

56 The Massage Connection: Anatomy and Physiology rhythm determine the effect on the client. Because Its vast surface area helps store nutrients. The skin client satisfaction largely relies on the sensations also serves as a reservoir of blood, as the volume of evoked, knowledge of how the brain perceives sensa- blood flowing in its extensive network of blood vessels tion gains importance. Heat and cold may be used for can be altered according to systemic needs. therapy and questions, such as what effect they have on the body, arise. Diseases of the body are often reflected in the skin. Many internal disorders are outwardly presented as Manipulation of the skin often causes visible skin lesions. However, the most important function changes in color or color changes may be already of the skin that is recognized by society is the skin’s present. An understanding of why this happens may ability to reflect emotional states, regardless of dis- be beneficial to the therapist. If clients with allergies ease. Warmth and human affection are given and re- inadvertently contact certain chemicals in the clinic, ceived through the skin. To a large extent, human edema, itching, and redness may be produced. beauty is related to the structure of the skin. As soci- Knowledge of why and how this happens can help ety gives importance to the color, texture, and tone of the therapist avoid these situations. In aromatherapy, skin, even slight skin imperfections evoke a variety of essential oils are used on the skin and an under- individual responses. standing is needed of what can and cannot be ab- sorbed through the skin. To understand the clinical Structure of the Skin conditions that produce skin problems and take suit- able precautions, the therapist needs to know the The integument consists of the cutaneous membrane, structure of normal skin. or skin, and the accessory structures, such as hair, nails, glands, muscles, and nerves (see Figure 2.1). The Chapter 2 details the functions and structure of the skin covers an area of approximately 1.5–2 m2 (59–78.7 skin and the effects of aging and massage on the in- sq in) and is responsible for about 16% of body weight. tegumentary system. The superficial part of the skin is the epithelium, or epidermis. Deep to the epithelium is a layer of con- The integumentary (inte, whole ϩ gument, body nective tissue, the dermis, in which the glands, hair, covering) system consists of skin, together with ac- and nails are located. Deep to the dermis is the subcu- cessory structures, such as glands, hair, nails, muscle, taneous layer, or hypodermis, which consists of loose and nerves. Skin is made up of different types of tis- connective tissue and adipose tissue. This layer sepa- sue that perform specific functions and is considered rates the skin from the underlying muscle, bone, and an organ. The skin is the heaviest organ and has the other structures. largest surface area. Functions of the Skin The skin has many functions. It protects the underly- THE EPIDERMIS ing organs and tissues from abrasion, irradiation from sunlight, and attack by pathogens and other The epidermis (see Figures 2.2 and 2.3) is the most harmful agents. Salt, water, and certain organic superficial layer of the skin and is composed of strat- wastes are lost through sweat and, thus, the skin has ified squamous epithelium. The epidermis is sepa- excretory functions. The skin plays an important role rated from the dermis—the deeper layer—by the in maintenance of body temperature. It prevents loss basement membrane. Not having a direct blood sup- of heat when the atmosphere is cold and facilitates ply, the epidermis relies on nutrients in the intersti- loss of heat when the body gets hot. The skin detects tial fluid that have diffused from the capillaries lo- changes in the surrounding environment by its ability cated in the dermis. to sense touch, pressure, pain, and temperature and relays this information to the central nervous system. ASTOUNDING FACTS The skin participates in the synthesis of vitamin D, which plays an important role in calcium metabolism. • The skin weighs about 8 pounds (3.63 kilograms). • The skin has approximately 640,000 sensory receptors DERMATOLOGY connected to the spinal cord by more than a half mil- Dermatology is the branch of medicine concerned with lion nerve fibers. the study of skin and skin diseases. • An area of skin the size of a quarter contains about 3 million cells, 100 sweat glands, 50 nerve endings, and 3 feet of blood vessels.

Chapter 2—Integumentary System 57 Stratum corneum Epidermis Stratum lucidum Epidermal ridge Capillary loop Stratum granulosum Stratum spinosum Hair Stratum germinativum Dermis Epidermis Nerve ending Sebaceous gland Epidermis lifted to reveal papillae of the dermis Dermis Arrector pili muscle of hair Dermal papillae Blood vessels Sweat pore Papillary layer of dermis Nerve endings Retricular layer of dermis Hypodermis (subcutaneous tissue) Hair root Sweat glands Nerve to hair follicle Adipose tissue FIGURE 2.1. Structure and Components of the Skin There are four types of skin cells: • stratum granulosum • stratum lucidum • keratinocytes • stratum corneum. • melanocytes • Merkel cells In areas where skin is exposed to friction, such as • Langerhans cells (Figure 2.2). the palm of the hand, sole of the foot, and fingertips, the skin is thick and consists of all five layers. In Keratinocytes make up 90% of the epidermis; they other areas, such as the eyelids, the skin is thin and lie in many distinct layers and produce a tough fi- stratum lucidum is absent. brous protein called keratin. Keratin helps protect the skin from heat, microorganisms, and chemicals The Stratum Germinativum in the environment. This single-celled layer, consisting of cuboidal or The layers of the epidermis can be identified by ex- columnar epithelium, is attached to the basement amining a section under the microscope. Beginning membrane. It is thrown into folds known as epider- with the basement membrane, which separates the mal ridges that extend into the dermis (Figure 2.2). epidermis from the dermis, the following layers can The projections of the dermis adjacent to the ridges be identified: are known as the dermal papillae. The surface of the skin follows the ridge pattern. This pattern, referred • stratum germinativum, or stratum basale • stratum spinosum

58 The Massage Connection: Anatomy and Physiology Langerhans cell Superficial Dead keratinocytes Lamellar granules Stratum corneum Stratum lucidum (found only in palm, “sole,” and fingertips) Stratum granulosum Stratum spinosum Stratum FIGURE 2.3. A Photomicrograph of the Epidermis germinativum sponsible for the color of the skin. Melanocytes are Basement scattered throughout this layer and their processes membrane extend to the more superficial layers of the skin. Dermis Melanocytes Melanocytes form 8% of all skin cells and manufac- Keratinocyte Tactile disk ture the pigment melanin. Melanocytes contain the Melanocyte Merkel cell enzymes required for converting the amino acid tyro- sine into melanin. The melanin pigment, packaged in- Sensory neuron Skin Cancer Deep FIGURE 2.2. Layers of the Epidermis Excessive exposure to ultraviolet radiation can predis- pose a person to skin cancer. There are three common to as whorls, is especially obvious in the palms and types of skin cancers: basal cell carcinoma, squamous soles. These ridges increase friction and surface area, cell carcinoma, and malignant melanoma. Basal cell providing a better, more secure grip of objects. The carcinoma arises from the germinativum layer and is the shapes of the ridges are genetically determined and most common; like squamous cell carcinoma, it does unique to an individual; they do not change with not metastasize easily. Malignant melanomas arise from time. For this reason, fingerprints can be used for melanocytes, grow rapidly, metastasize via the lymphat- identification. ics, and have the poorest prognosis. Abnormal growths that are asymmetrical and have irregular borders, vary- As its name suggests, this layer contains germina- ing colors, and are larger than 0.5 mm may be indica- tive, or basal cells, that multiply rapidly and replace tive of malignant melanoma. cells in the superficial layer that have been lost or shed. The keratinocytes are large and contain keratin filaments in the cytoskeleton. The keratin filaments attach the cells to each other and to the basement membrane. Areas of skin that lack hair contain spe- cialized cells known as Merkel cells. These cells are in close contact with touch receptors and stimulate these sensory nerve endings. Pigment cells, known as melanocytes, are also located in this layer and are re-

Chapter 2—Integumentary System 59 side the cell in small vesicles called melanosomes, is SUNBLOCKS transferred along the processes that extend into the su- perficial layers of skin. In the superficial layers, the Commercial sunblocks are rated on their ability to oc- vesicles are transferred into other cells, coloring them clude UV rays. The ratings are generally on a scale of temporarily, until they fuse with lysosomes and are 1–35, with 1 being least occlusive. Sunblocks with ratings then destroyed. In individuals with light skin, less of 35 are total sunblocking agents. Although UV rays are transfer of melanosomes occurs among cells, and the less harmful early in the morning and late in the after- superficial layers lose their pigments faster. In individ- noon, they have also been implicated in skin cancer. It is uals with dark skin, the melanosomes are larger and estimated that there would be a decrease of about 78% of transfer occurs in many of the superficial layers. In- skin cancers if children younger than 18 used sunscreen terestingly, the number of melanocytes per square mil- with a blocking agent of at least 15. limeter of skin is the same for both dark- and light- skinned individuals. It is the melanin synthesis rate The cumulative effects of UV radiation exposure that is different. The number of melanocytes is in- can damage fibroblasts located in the dermis, leading creased in some areas of the body, such as the penis, to faulty manufacture of connective tissue and wrin- nipples, areolae (area around the nipple), face, and kling of the skin. UV rays also stimulate the produc- limbs. tion of oxygen free radicals that disrupt collagen and elastic fibers in the extracellular regions. Although a The melanin pigment protects the skin from the small amount of UV radiation is beneficial, larger harmful effects of ultraviolet (UV) radiation. Expo- amounts may cause alterations in the genetic mater- sure to UV rays stimulates those enzymes that pro- ial in the nucleus of cells—especially the rapidly mul- duce melanin and produces a “tan” skin. The tan tiplying cells in the stratum germinativum, increas- fades when the keratinocytes containing melanin are ing the risk of cancer. Depletion of the ozone layer lost. Melanin production is also increased by secre- and overexposure to the sun may be responsible for tion of melanocyte-stimulating hormones by the an- increased incidence of skin cancer. terior pituitary gland. Synthesis of Vitamin D Because melanin pigment is concentrated around the nucleus, it works like an umbrella, absorbing UV Excessive exposure to sunlight is harmful; however, rays and shielding the nucleus and its high deoxyri- some exposure to sunlight is useful and needed by bonucleic acid (DNA) content. Melanin also protects the body. The cells in the stratum germinativum and the skin from sunburn. However, the rate of melanin stratum spinosum convert the compound 7-dehydro- synthesis is not rapid enough to provide complete cholesterol into a precursor of vitamin D. Vitamin D protection; it is possible to get a sunburn easily, espe- is a group of closely related steroids produced by the cially in the first few days of prolonged sun exposure. action of ultraviolet light on 7-dehydrocholesterol. Mild sunburn consists of varying degrees of redness Vitamin D synthesized in the skin is transported to that appear 2–12 hours after exposure to the sun. the liver and then to the kidneys where it is converted Scaling and peeling follow any overexposure to sun- into a more potent form (see Figure 2.4). Vitamin D light. Dark skin also burns and may appear grayish or increases calcium absorption in the intestines and is gray–black. an important hormone in calcium metabolism. Lack of vitamin D can lead to improper bone mineraliza- Albinism and Vitiligo tion and a disease called rickets (in children) and os- teomalacia (in adults). Albinism is caused by a congenital inability to synthe- size melanin as a result of genetic defects in the bio- Stratum Spinosum chemical pathway that manufactures melanin. Vitiligo is a result of melanin loss in patchy areas of the skin. It Stratum spinosum consists of 8–10 layers of cells lo- develops after birth and is progressive. cated immediately above the stratum germinativum. As the cells multiply in the stratum germinativum, Freckles they are pushed upward into the stratum spinosum. Observed under the microscope, these cells have a Freckles are small, pigmented spots on the skin, in spiny appearance, hence, their name. This layer of which the melanocytes in the area have produced more cells, in addition to keratinocytes, contains Langer- than normal levels of melanin pigment. hans cells, which are involved in defense mecha- nisms. Langerhans cells protect the skin from

60 The Massage Connection: Anatomy and Physiology pathogens and destroy abnormal cells, such as cancer Ultraviolet light cells, that may be present. Skin 7-dehydrocholesterol Stratum Granulosum Vitamin D3 (cholecalciferol) Stratum granulosum consists of 3–5 layers. By the Liver Vitamin D3 (cholecalciferol) time the keratinocytes reach this layer from the lay- Kidney 25-hydroxcholecalciferol ers below, they have flattened and stopped dividing. The cells have a granular appearance when viewed 25-hydroxcholecalciferol under the microscope and contain a granular protein 1,25 dihydroxycholecalciferol (calcitriol) known as keratohyalin, which organizes keratin into thicker bundles. The cells also contain lamellar Intestines 1,25 dihydroxycholecalciferol granules, which release a lipid-rich secretion into (calcitriol) the spaces between the cells. These lipid-rich secre- Calcium tions work as a sealant and slow the loss of body flu- phosphate Calcium and phosphate ids. As the cells manufacture keratohyalin, they be- absorption come flatter and thinner and the cell membranes become thicker and impermeable to water. With FIGURE 2.4. Synthesis of Vitamin D and the Role of Various Or- time, a thick layer of interlocking keratin fibers sur- gans in its Formation rounded by keratohyalin may be seen within the cell membrane of the original cells, which have now lost STRATEGY TO PREVENT VITAMIN D their organelles. These structural changes provide DEFICIENCY protection against pathogens and are responsible for the impermeability of skin to water. The next time you buy milk in the grocery store, look at the label. Many dairy companies add cholecalciferol Stratum Lucidum (identified as Vitamin D) to the milk. Cholecalciferol has drastically reduced vitamin D deficiency in the population. Stratum lucidum, as its name indicates, is translu- cent and consists of densely packed, flat cells that are filled with keratin. This layer is more prominent in the palms of the hands and soles of the feet. Stratum Corneum Stratum corneum is the most superficial layer and mostly consists of dead cells and keratin. The trans- formation from live cells to the dead cells in this layer is known as keratinization, or cornification (corne, hard or hooflike). There are about 15–30 layers of these cells, which are periodically shed individually or in sheets. It usually takes about 15–30 days for the cells to reach this layer from the stratum germina- tivum. The cells then remain in the stratum corneum for about 14 days before they are shed. The dryness of this superficial layer, together with the coating of lipid secretions from sebaceous and sweat glands, makes the skin unsuitable for growth of microorgan- isms. If the skin is exposed to excessive friction, the layer abnormally thickens and forms a callus. Although dead cells make the skin resistant to wa- ter, it does not prevent the loss of water by evapora- tion from the interstitial tissue. About 500 mL of wa- ter per day is lost via the skin. This loss of water is known as insensible perspiration, which is different from that actively lost by sweating, called sensible perspiration.

Chapter 2—Integumentary System 61 Promotion of Epidermal Growth elastic fibers in the dermis. The water content helps maintain the flexible and resilient properties of the Epidermal growth is promoted by a peptide known skin, or the skin turgor. The collagen and elastic as epidermal growth factor (EGF). EGF is secreted fibers are arranged in parallel bundles. The orienta- by various tissues, such as the salivary gland and tion of the bundles allows the skin to resist the stress glands in the duodenum. This factor combines with placed on it during movement. Although the elastic receptors on the cell membrane of multiplying cells fibers stretch and come back to their original length, in the epidermis and promotes cell division, produc- the collagen fibers are tough, resisting stretch but al- tion of keratin, and development and repair after in- lowing twisting and bending. jury. So potent, a small sample of EGF from a per- son’s tissue has been used outside the body to form Figure 2.5 shows the lines of cleavage of skin. sheets of epidermal cells to cover severe burns. This is the pattern of collagen and elastic fiber bun- dles established in the dermis that follow the lines of THE DERMIS tension in the skin. The lines of cleavage are of im- portance, as injuries to the skin that are at right an- The dermis is the connective tissue layer that lies gles to these lines tend to gap because the cut elastic deep to the epidermis. It contains protein fibers and fibers recoil and tend to pull the wound apart. Heal- all the cells in the connective tissue proper, such as fi- broblasts, macrophages, adipose cells, and mast cells. Skin Grafts It supports the epidermis and is the primary source of its nutrients. The dermis contains loose connective If the stratum basale has been destroyed over a wide tissue that lies closer to the epidermis (papillary area of skin, as may happen in severe burns or frostbite, layer, or pars papillaris) and dense irregular con- skin grafts may be used to speed healing and prevent nective tissue deep to the papillary layer (reticular infection and scarring. In a skin graft, a segment of the layer, or pars reticularis). Collagen and elastic fibers skin from a donor site is transplanted to the recipient impart strength, elasticity, and extensibility of the site. The skin may be transplanted from another area of skin. The dermis is vascular and contains a network the body of the injured individual (autograft), taken of blood vessels. Lymphatic vessels are also present in from a donor or cadaver (allograft), or taken from an- abundance in this layer. Accessory structures, such as other species (heterograft). At times, epidermal culturing sweat glands and hair follicles, are located in the der- may be used. mis. In addition, the dermis contains numerous nerve endings and nerves that convey various sensa- In epidermal culturing, a sample of the epidermis is tions from the skin to the central nervous system. taken from the injured individual and cultured in a con- trolled environment that contains growth factors and The consistency and texture of skin is largely de- other stimulatory chemicals. This artificially produced termined by the water content and the collagen and epidermis is then used to cover the injured area. Newer procedures include use of special synthetic skin com- Psoriasis posed of a plastic “epidermis,” a dermis made from col- lagen fibers (obtained from cow skin), and ground carti- This condition, the cause of which is unknown, charac- lage (obtained from sharks). These materials serve as teristically presents as scaly patches on the skin. The models for dermal repair and are used as a temporary thickened, scaly patches are a result of the increased cover. rate at which keratinocytes migrate from the stratum germinativum to the surface. STRETCH MARKS Burns and Dehydration Stretch marks (also called striae or lineae albicantes) are produced when the skin is stretched so much that the When the epidermis of the skin is damaged by a burn elastin and collagen fibers in the dermis are damaged. injury, water from the interstitial fluid can be more easily This prevents the skin from recoiling to its original size, lost by evaporation and dehydration can quickly ensue. with resultant creases and wrinkles commonly referred to The loss of the protective barrier makes the person more as stretch marks. They appear as red or silver-white vulnerable to invasion by pathogens. Dehydration and streaks on the surface of the skin. Stretch marks are com- infection are the major complications of burn injury. mon in the abdomen after pregnancy. They are also seen in previously obese individuals who have lost a lot of weight.

62 The Massage Connection: Anatomy and Physiology Anterior Posterior histamine from mast cells, and vasodilator metabo- lites from injured cells, have a direct effect on the cal- FIGURE 2.5. Lines of Cleavage iber of blood vessels. ing is slower and there is more scarring in this type In addition to the autonomic nerves, there are nu- of injury compared with those injuries parallel to the merous sensory receptors, which respond to sensa- lines of cleavage. tions such as touch, pressure, pain, cold, and warmth. Mild stimulations, especially if produced by some- NERVE SUPPLY TO THE SKIN thing that moves across the skin, cause itching and tickling sensations (see page XX for additional infor- The skin is supplied by autonomic nerves, which in- mation on cutaneous receptors). Any given receptor nervate the blood vessels and glands in the skin. See signals or responds to only one kind of cutaneous sen- page XX for details of autonomic nerves. Briefly, au- sation. The receptors may be free nerve endings or tonomic nerves supply glands, blood vessels, and in- modified to form special structures that have a sur- ternal organs. There are two types: sympathetic and rounding capsule or expanded tips. Some are found parasympathetic. wound around hair follicles. The number of sensory receptors per unit area varies from region to region. Sympathetic stimulation and circulating epineph- More receptors are present in areas, such as the face, rine and norepinephrine produce vasoconstriction. lips, and fingers, that are more sensitive to sensations. There are no known vasodilator fibers to the cuta- neous blood vessels; dilation is caused by a decrease The receptors are continuous with sensory nerves. in the constrictor tone of the sympathetic nerves. Sensory nerves from the skin take the impulses gen- Chemicals, such as bradykinin from sweat glands, erated in the receptors to the central nervous system. The sensory nerves from a specific area of the skin en- ter a particular segment of the spinal cord. The area of skin supplied by the nerves from a particular spinal segment is known as the dermatome. The der- matomes of the different spinal nerves throughout the surface of the body have been traced (see Figure 2.6). These patterns are of clinical importance as damage to a spinal nerve results in loss of sensation in the specific dermatome. The intimate association between the skin and the brain can be appreciated by the fact that the brain has a map, representing the entire body, in the area that perceives sensations. There is a larger represen- tation for regions that are more sensitive than others (see Figure 2.7). The pathway taken by impulses gen- erated by the sensory receptors of the skin is also very specific. This is why we are able to locate exactly—up to a few millimeters—where we have been touched on the skin. Many consider the skin an extension of the brain through which interactions between the mind and body can be made by touch. It is interest- ing to note that during prenatal development, both the skin and the nervous system are derived from the same embryonic layer, the ectoderm (in the embryo, all the structures of the body are derived from three layers—ectoderm, mesoderm, and endoderm). Shingles Shingles is a viral infection that infects the dorsal root ganglia; it tends to affect one or more dermatomes and produces a painful rash along its distribution. Massage is contraindicated when rashes are present.

Chapter 2—Integumentary System 63 T1 C2 T1 C2 T2 C3 T2 T4 C4 C3 T6 C5 T4 C4 T8 T6 C5 T10 C6 T8 C6 T3 T10 C7 S2 T12 C8 S3 T5 T3 L2 T5 T7 T7 L4 T9 T9 T11 T11 S1 L1 L1 S3 L3 T12 S5 L2 L5 C8 S2 L3 S4 C7 C8 L5 C7 L2 L4 L5 L3 L4 L5 S1 FIGURE 2.6. Distribution of Dermatomes on the Skin BLOOD CIRCULATION IN THE SKIN illaries at this junction join and rejoin to form venules and veins. In many regions, such as the fin- The skin has an extensive blood supply; 8–10% of the gers, palms, toes, and ear lobes, direct connections, total blood flow in the body can be found in the skin. known as arteriovenous anastomoses, link arteri- The heat lost from the body is regulated by altering oles and venules. These links allow blood diversion, the volume of blood flowing through the skin. without it entering the superficial capillaries from which heat dissipates. The arteries supplying the skin form a network at the junction of the subcutaneous layer with the der- The blood vessels to the skin are well innervated by mis. This junction is known as the cutaneous the autonomic nervous system. Blood flow can vary plexus. Branches from these arteries supply the adi- widely in response to changing temperatures, from as pose tissue located in the subcutaneous layer. Other little as 1 mL to 150 mL/100 g of skin per minute. The branches supply the accessory structures as they plexuses in the skin, to some extent, serve as blood travel toward the epidermis. These branches form an- reservoirs. When blood is lost, these vessels constrict, other network at the junction of the dermis and epi- propelling blood into the systemic circulation to dermis that follows the contours of the papilla. This maintain blood flow to the vital organs. junction is known as the papillary plexus. The cap-

64 The Massage Connection: Anatomy and Physiology Primary somato- sensory area of cerebral cortex Thalamus Dorsal column nuclei Medial lemniscus Medulla Dorsal column Receptors for touch, stereognosis, proprioception, weight discrimination and vibration Spinal cord Dorsal column- medial lemniscus pathway Anterolateral (spinothalamic pathway) Receptors for pain, cold, warmth, crude touch, pressure, tickle or itch FIGURE 2.7. An Overview of the Pathway Taken by Sensory Impulses and the Representation of the Body in the Sensory Area of the Cerebral Cortex

Chapter 2—Integumentary System 65 Hemangiomas It is because of radiation that a person can feel cold in a warm room with cold walls. As the name suggests, hemangiomas are abnormal growths of the dermal blood vessels. They may be tem- Because heat is conducted from an object’s surface porary or permanent. In infants, temporary, bright, to the surrounding environment, the amount of body raised and rounded lesions, known as strawberry he- heat lost is largely determined by skin temperature. mangiomas or capillary hemangiomas, may be seen on The temperature of the skin, in turn, depends on the the skin. They tend to disappear by 5–7 years of age. amount of blood that reaches the skin from the skin’s deeper layers. Body temperature can be controlled by Permanent, flat, reddish-purple, disfiguring lesions altering the amount of warm blood reaching the skin. are known as port-wine stains or cavernous heman- Hair traps some of the heat lost from the skin to the giomas. These affect the larger, deeper vessels of the air. When the outside environment is cold, the dermis and are usually seen on the face. They do not smooth muscles attached to the individual hairs con- disappear with age. tract and make the hairs stand on end, trapping a layer of air between the hairs. This layer slows down Shock the loss of heat. In man, clothes supplement the layer of hair. Therefore, the amount of heat lost across the Circulatory shock is more pronounced in people with clothing depends on the texture and thickness of the elevated temperature resulting from the dilation of cuta- clothing. Dark clothing absorbs radiated heat, while neous blood vessels. People in shock should, therefore, light clothing reflects heat. not be warmed to the extent of increasing their body temperature because this can worsen the situation. Transfer of heat causes another mechanism—the evaporation of sweat. Vaporization of 1 gram of wa- Skin and Temperature Control ter removes approximately 0.6 kcal of heat. During heavy exercise in a hot environment, sweat secretion The normal oral temperature is 37°C (98.6°F), which may be as high as 1,600 mL/hour. Heat loss by va- is .5 degrees (32.9°F) lower than the rectal tempera- porization can then be as high as 900 kcal/hour. The ture representative of core body temperature. Tem- rate of vaporization depends on the humidity of the peratures vary at different parts of the body. In gen- environment and the movement of air around the eral, the extremities are cooler than the rest of the body. body. Body temperature must be maintained within a narrow range despite wide temperature fluctuations The body’s adjustment to the changing environ- in the environment. The rate of chemical reactions mental temperature is largely controlled by the hypo- varies with temperature and enzymes function only thalamus and is a result of autonomic, somatic, en- properly within a narrow temperature range. docrine, and behavioral changes. Local reflex responses also contribute. For example, when cuta- The major processes by which heat is lost from the neous blood vessels are cooled, they become more body are conduction and radiation (70%), sweat va- sensitive to circulating catecholamines (e.g., epineph- porization (27%), respiration (2%), and urination rine) and the arterioles and venules constrict. Other and defecation (1%). Conduction is the heat ex- adjustments include shivering, hunger, increased vol- change between two objects in contact with each untary activity, increased secretion of norepinephrine other. The amount of heat lost in this way depends on and epinephrine, and hair “standing on end.” When the temperature difference between the objects. Con- hot, cutaneous vasodilation, sweating, increased res- duction is helped by convection. Convection is the piration, anorexia, apathy, and inertia (to decrease movement of molecules away from the area of con- heat production), are some of the adjustments. tact. For example, if the air is cool and it comes in contact with warm skin, the air around the body is The signals that activate the hypothalamus come warmed; this warm air rises and fresh cool air from temperature-sensitive cells in the hypothalamus reaches the skin. Heat can be lost by convection and cutaneous temperature receptors. whether the object moves through the medium (e.g., swimming in cold water) or the medium moves over Jaundice object (e.g., a cool breeze moving over the skin). Ra- diation is transfer of heat by high frequency waves In the condition jaundice, the skin has a yellowish tinge, from one object of a higher temperature to another. resulting from the accumulation of bilirubin in body flu- ids. Bilirubin is a breakdown product of hemoglobin. Its levels increase above the normal range if there is rapid and abnormal breakdown of hemoglobin, liver dysfunc- tion, or blockage of the bile duct (see page XX).

66 The Massage Connection: Anatomy and Physiology Variation in Skin Color occur around the stroke line. The red reaction is caused by dilation of capillaries as a result of the BLOOD FLOW AND SKIN COLOR CHANGES stroke pressure. The wheal is a result of the increase in permeability of the capillaries and movement of Because blood vessels to the skin are extensive and lo- fluid into the interstitial tissue caused by the release cated close to the surface, alterations in blood flow can of histamine from mast cells located in the region. be visually observed as changes in skin color. Color The flare is a result of arteriolar dilation. Together, changes are better observed in those persons with the three responses are known as the triple response light-colored skin and may not be as distinct in those and are part of the normal response to injury. persons with dark-colored skin. You can experiment on yourself or your colleagues and observe these changes. Reactive Hyperemia The characteristic pink color or reddish tint of the skin is a result of the oxygenated hemoglobin in the red Tie a piece of string (or you may use a rubber band) blood cells. When blood flow is reduced temporarily, firmly around your finger. Leave it in place for one the skin becomes pale. If pressure is applied to the skin, minute and then remove it and observe what hap- the blood in the vessels of the skin, stagnates. Oxygen pens. The skin turns fiery red soon after the occlusion in the hemoglobin is quickly used by the tissue in the is removed. This is known as reactive hyperemia. area, and the hemoglobin becomes darker as a result of When blood flow to an area is restricted, the arteri- deoxyhemoglobin formation. When observed through oles in that area dilate as a result of the release of the skin, this reaction gives a bluish hue, termed chemicals (products of metabolism) by the oxygen- cyanosis. The bluish discoloration is more prominent deprived cells. When blood flow is no longer re- in areas where the epithelium is thin, such as the lips, stricted, blood rushes into the dilated blood vessels. tongue, beneath the nails, and conjunctiva. Watch the color change when you obstruct blood flow by tying a Erythema string or rubber band around a finger. At times, the skin appears red after injury, inflamma- When a person is exposed to a cold environment, tion, or exposure to heat. This redness is a result of the blood vessels to the skin constrict to conserve dilatation of capillaries in the dermis and is termed heat and the person appears pale. If the temperature erythema. is low, however, cell injury occurs in exposed areas such as the tip of the nose or ear. The metabolites lib- PIGMENTATION OF SKIN BY CAROTENE erated by the injured cells cause the smooth muscle of the of blood vessel walls to dilate, producing the Carotene is an orange-yellow pigment that tends to typical redness seen after frostbite. accumulate in epidermal cells and the fat cells of the dermis. It is found in abundance in orange-colored During exercise, blood vessels in the skin dilate to vegetables, such as carrots and squash. Light-skinned dissipate heat, while blood vessels in most other parts individuals who eat a lot of these vegetables, can have of the body constrict. This is in response to the hypo- an orange hue to their skin as a result of the accu- thalamus, which monitors temperature changes. This mulation of this pigment. In darker-skinned individ- reflex response overrides all other reflex responses uals, the hue does not show up as well. Carotene is an that may be triggered in the blood vessels in the skin. important pigment that can be converted to vitamin A, which plays a role in the growth and maintenance White Reaction of epithelia and synthesis of light receptor pigments of the eye. Draw a pointed object lightly over your skin and ob- serve what happens. The stroke line becomes pale— Pituitary Tumors and Skin Color the white line. The mechanical stimulus causes the smooth muscle guarding blood flow through the cap- Certain tumors of the pituitary gland increase secretion illaries, called the precapillary sphincter, to contract. of melanocyte stimulating hormone (MSH) and produce As a result, blood drains out of the capillaries and darkening of the skin similar to a deep tan. Increased small veins and the skin turns pale. secretion of adrenocorticotropic hormone (ACTH), which is structurally similar to MSH, from the anterior The Triple Response pituitary gland may also cause similar changes in skin coloration (e.g., as in Addison disease). Now, draw a pointed object more firmly across the skin and observe. The stroke line turns red in about 10 seconds. This is called the red reaction. In a few minutes, swelling (wheal) and diffuse redness (flare)

Chapter 2—Integumentary System 67 SUBCUTANEOUS INJECTIONS reduce the body temperature. The secretory activity of merocrine glands is controlled by the autonomic Injections are often given in the subcutaneous layer be- nerves and circulating hormones. When these glands cause of its relatively scarce blood supply and distance are secreting at their maximal rate, such as during from vital organs. Other than safety, drugs are more heavy exercise, up to a gallon of water may be lost in slowly absorbed from this layer, prolonging their duration one hour. of action. The acidic pH of sweat, to some extent, deters SUBCUTANEOUS LAYER, OR HYPODERMIS growth of harmful microorganisms on the surface of the skin. The sweat glands may be considered to have The subcutaneous layer, although not actually part of an excretory function as water; electrolytes; and cer- the skin, is an important layer that lies deep to the tain organic wastes, such as urea, are lost in sweat. dermis. It is largely composed of connective tissue, Certain drugs are also excreted through sweat. which is interwoven with the connective tissue of the dermis. This layer stabilizes the skin, connecting it to Compared with merocrine glands, there are few underlying structures, while allowing some indepen- apocrine sweat glands, which are located in the dent movement. At the same time, the subcutaneous armpits, around the nipples, in a bearded region (in tissue separates the deep fascia that surrounds mus- men), and in the groin area. They start to secrete at cles and organs from the skin. Therefore, this layer is puberty and produce a cloudy, sticky secretion, with also known as the superficial fascia. The subcuta- a characteristic odor. This secretion contains lipids neous layer has a deposit of adipose (fat) tissue and and proteins, in addition to the components of sweat serves as an energy reservoir and insulator. The adi- produced by merocrine sweat glands. The apocrine pose tissue also protects the underlying structures by glands are surrounded by myoepithelial cells, which, serving as shock absorbers. The distribution of fat in on contraction, discharge the apocrine secretions the subcutaneous layer changes in adulthood. In into hair follicles. This secretion is a potential nutri- men, it tends to accumulate in the neck, arms, along ent for microorganisms and the action of bacteria on the lower back, and buttocks; in women, it accumu- this secretion tends to intensify the odor. The apoc- lates primarily in the breasts, buttocks, hips, and rine glands change in size during the menstrual cy- thighs. cle—increasing during ovulation and shrinking at the time of menstruation. ACCESSORY STRUCTURES Sebaceous Glands The accessory structures of the skin include the sweat glands, sebaceous glands, hair, and nails. They lie pri- The sebaceous glands are located close to the hair fol- marily in the dermis and project onto the surface licles and discharge their secretions into the hair fol- through the epidermis. licles. In other areas, such as the lips, glans penis, and labia minora, they discharge directly on to the Sweat Glands skin surface. There are no sebaceous glands in the palms and soles. The size of the glands varies from The sweat glands, also known as sudoriferous or ec- region to region. Large glands are present in the crine glands (see Figure 2.1), are coiled tubular breasts, face, neck, and upper part of the chest. They glands that are surrounded by a network of capillar- secrete an oily substance and are sometimes referred ies. Located in the dermis, they discharge secretions to as the oil glands. The secretion, called sebum, is a directly onto the surface of the skin or the hair folli- mixture of lipids, proteins, and electrolytes. Sebum cles. There are two types of sweat glands: eccrine/ provides lubrication, protects the keratin of the hair, merocrine and apocrine. Eccrine sweat glands are conditions skin, and prevents excess evaporation of located over the entire body. There are approximately water. These glands are sensitive to sex hormones, 2–5 million of these glands, with the forehead, palms, and the increase in activity at puberty makes a per- and soles having the highest number. son more prone to acne. Acne is a result of blockage of the sebaceous ducts and inflammation of the seba- Sweat is 99% water. The remaining 1% consists of ceous glands and surrounding area. sodium chloride (responsible for sweat’s salty taste); other electrolytes; lactic acid; some nutrients, such as Other Glands of the Skin glucose and amino acid; and waste products, such as urea, uric acid, and ammonia. The main function of The skin also contains other specialized glands found sweat is to cool the surface of the skin and, thereby, in specific regions. The mammary glands of the breast, related to the apocrine sweat glands, secrete milk. The regulation of milk secretion and ejection is

68 The Massage Connection: Anatomy and Physiology complex and controlled by hormones and nerves (see Nails page XX for details). Nails protect the tips of the fingers and toes and limit Specialized glands, known as ceruminous glands, the distortion when exposed to excess stress. Nails are present in the external auditory canal. These are formed at the nail root, an epithelial fold deeply glands are modified sweat glands that secrete ceru- located near the periosteum of the bone. The body of men or earwax. This sticky secretion protects the ear the nail is composed of dead cells that are packed from foreign particles. with keratin. Nail growth can be altered by body me- tabolism. Changes in structure, thickness, and shape Hair can indicate different systemic conditions. Hair, or pili, is seen in almost all parts of the body. It Absorption Through the Skin originates from structures known as hair follicles, which are found in the dermis. Hair is formed in the Substances that are lipid-soluble can penetrate the follicles by a specialized cornification process and is epidermis, although rather slowly. On reaching the made up of soft and hard keratin, which gives it its dermis, the substance is absorbed into the circulation. characteristic texture and color. The deepest part of Administering a brief pulse of electricity can speed the hair follicle enlarges slightly to form the hair bulb penetration. The electrical pulse creates channels in and encloses a network of capillaries and nerves. A the stratum corneum by changing the position of cells. strip of smooth muscle, known as the arrector pili muscle, extends from the upper part of the dermis to As a result of slow absorption, drugs are often ad- connective tissue surrounding the hair. Stimulation ministered via the skin, producing slow and pro- of this muscle makes the hair stand on end (goose longed action over several days. Nicotine patches, an pimples, gooseflesh, or goose bumps) and traps a aid used by smokers to quit smoking, use this type of layer of air next to the skin, further helping to insu- transdermal administration. By slow and continuous late the body. administration of nicotine, the craving for smoking is reduced. Gradually, the dosage of nicotine in the There are two types of hair. Fine, fuzzy hair is patch can be tapered. Dimethyl sulfoxide (DMSO) is known as vellus hair. The heavy, deeply pigmented a drug given for treatment of joint and muscle in- hair, as found in the head and eyebrow, is known as juries. Other drugs dissolved in DMSO are easily ab- terminal hair. The growth of hair is greatly influ- sorbed through the skin. Estrogen, for the treatment enced by circulating hormones. of menopause, and vasodilator drugs, for increasing the coronary blood flow, are examples of transder- Hair has many functions. Scalp hair protects the mally administered drugs. head from UV rays and serves as insulation. Hair found in the nose, ears, and eyelashes helps prevent Systemic adverse effects can be produced if drugs entry of larger particles and insects. The nerve plexus are administered transdermally for prolonged periods. surrounding the follicle detects small hair move- For example, corticosteroids used to treat chronic in- ments and senses imminent injury. flammation can be absorbed through the skin and pro- duce symptoms of corticosteroid excess or Cushing’s Hair color reflects the pigment differences pro- syndrome. duced by melanocytes in the hair papilla. Although genetics play an important part, hormones and nutri- Microorganisms on the Skin tion have an important role too. With age, as pigment production decreases, hair appears gray. This chapter on the integumentary system would not be complete without considering the invisible layer of Hair grows and sheds according to a hair growth microorganisms that inhabit the surface of the skin. cycle. Hair in the scalp may grow for 2–5 years at the This huge colony of organisms is the “normal mi- rate of about .33 mm per day. The rate varies from in- crobial flora.” Similar to residents and tourists in a dividual to individual. As the hair grows, the nutri- city, there are resident microorganisms (resident ents required for hair formation are absorbed from flora) that are regularly found in a specific area at a the blood. Heavy metals may also be absorbed, and specific age and transient flora that inhabit the skin hair samples can be used for identifying lead poison- for hours, days, or weeks. The resident flora play an ing. Hair is, therefore, one of the important speci- important part in maintaining health and normal mens analyzed in forensic medicine. As a hair function. reaches the end of the growth cycle, the attachment to the hair follicle weakens and the follicle becomes inactive. Eventually, the hair is shed and a new hair begins to form. Hair loss can be affected by such fac- tors as drugs, diet, radiation, excess vitamin A, stress, and hormonal levels.

Chapter 2—Integumentary System 69 Resident flora prevent harmful bacteria from pendicitis, inflammation of the appendix; and neuri- thriving on the skin by directly inhibiting them or tis, inflammation of the nerve. competing with them for nutrients. However, resi- dent bacteria can be infective and harmful if they are CARDINAL SIGNS OF INFLAMMATION introduced in large amounts into the bloodstream, which can occur when the skin is injured or when Despite the many causes of inflammation (see Figure surgery is performed without adequately cleansing 2.8), the sequence of physiologic changes that occur the skin surface before incision. They may also be in the body are the same. If you scratch your forearm harmful in individuals whose immunity has been sig- and observe the changes that occur, you will see the nificantly suppressed. cardinal signs of inflammation, including redness, heat, swelling, pain, and loss of function. It may be surprising to learn that profuse sweat- ing, washing, and bathing cannot significantly alter These signs are caused by changes that occur at normal flora. The skin must be treated with special the microscopic level. When you scratch your fore- solutions to make it sterile. This should not deter arm, you may notice immediate whitening of the hand washing before and after treating clients, how- skin. This reaction is a result of the constriction of ever. Potential pathogens are easily removed by water blood vessels lying under the skin. Soon, the area ap- and scrubbing with soap containing disinfectants has pears red (hyperemia). The blood vessels in the area an even greater effect. dilate as a result of the liberation of chemicals by the injured tissue. If touched, the area feels warm. The Inflammation and Healing warmth is a result of increased blood flow. Within minutes, swelling occurs along the line of injury (ex- Inflammation—the reaction of living tissue to in- udation). This swelling is a result of the fluid leakage jury—is easily visualized on the surface of the skin. from the capillaries, which have become more per- Inflammation and healing are detailed under this sys- meable. The contents of the injured cells leak out and tem, although these processes occur throughout the stimulate pain receptors in the vicinity, causing pain. body. Although inflammation produces discomfort, it The injured tissue may be unable to function prop- is beneficial and helps the body adapt to everyday erly, partly because of pain. stress. Inflammation helps heal wounds and prevents and combats infection. Inflammation depends on a These signs help control the effects of the injurious healthy immune system. agent. The fluid that leaks out and the increased blood flow dilute the toxins that are produced. The COMMON CAUSES OF INFLAMMATION pain alerts the individual to take remedial measures. The changes that occur with injury also stimulate Some common causes of inflammation are physical clotting, reducing blood loss and containing the tox- (burns; extreme cold, such as frostbite; trauma); ins within the local area. chemical (chemical poisons, such as acid or organic poisons); infection (bacteria, viruses, fungi, or para- Role of White Blood Cells sites); and immunologic and other circumstances that lead to tissue damage, such as vascular or hor- In inflammation, together with changes in the blood monal disturbances. It is important to note that in- vessels, the white blood cells are triggered into ac- flammation is not always a result of infection. Condi- tion. Immediately after the injury, the white blood tions producing inflammation are denoted by adding cells accumulate along the blood vessel walls, re- the suffix, itis. For example, arthritis, inflammation ferred to as margination or pavementing of white of the joint; bursitis, inflammation of the bursa; ap- blood cells. Attracted by the chemicals liberated by the injured tissue, they squeeze through the widened Dermatitis and Cellulitis gap between the cells of the capillary wall. This stage is known as the emigration of white blood cells. The Dermatitis is an inflammation of the skin that involves white cells then move to the injured region. The the dermis. There are many forms of dermatitis, such as process by which the white cells are attracted to the contact dermatitis and eczema. If the inflammation tissue is called chemotaxis. On reaching the tissue, spreads along the connective tissue of the skin, it is they destroy cells and other structures that they per- known as cellulitis. ceive as nonself (see page XX). This process is called phagocytosis. Of the white blood cells, neutrophils and monocytes are most capable of phagocytosis. They do so by extending two arms of the cell mem- brane around the foreign or dead tissue. The two ex- tensions then fuse, engulfing the foreign tissue into

70 The Massage Connection: Anatomy and Physiology Leukocytes move to site of injury Skin Injury Red blood cells in tissue space Arteriole Closed Open Precapillary Many blood cells sphincter in capillaries (Hyperemia) Red blood cells Capillaries with few or no blood cells Venule White blood cell in tissue space Normal Inflamed Protein, water, and Increased capillary electrolytes leave permeability capillary to form exudate FIGURE 2.8. Vascular Changes in Acute Inflammation the cytoplasm, forming what is called a phagosome. mor necrosis factor, and complement fractions (see Lysosomes, vesicles containing digestive enzymes page XX). that are present in the cytoplasm of the white cell, fuse with the phagosome and kill and digest the en- SYMPTOMS ACCOMPANYING gulfed debris. INFLAMMATION Chemical Mediators Whatever the cause, inflammation produces symp- toms that may last for only a few hours or for days. Alhough the process of inflammation is initiated by Remember a time when you had an injury or infec- injury and death of cells, the signs and symptoms tion. Fever, loss of appetite, lethargy, and sleepiness that accompany it are a result of locally liberated are some symptoms that you may have noticed. chemicals—the chemical mediators. These mediators These responses are mainly a result of the chemical are secreted in many ways. Some are secreted by mediators. An increased number of white blood cells, white blood cells or by cells, such as mast cells, lo- an increased liver activity, and a decreased iron level cated in the connective tissue. Some of the mediators in the blood (which results in anemia) are some un- are formed by chemical reactions triggered locally by seen responses that occur during the inflammatory tissue injury. Some chemical mediators are hista- process. Amino acids, the building blocks of protein, mines, prostaglandins, leukotrienes, bradykinin, tu- are used up to make new cells and form collagen for

Chapter 2—Integumentary System 71 repair. This increase in energy usage, along with loss curs, and if there is an abundance of fibroblasts in the of appetite, is responsible for weight loss often seen area. Usually inflammation becomes chronic when with inflammation. the initial injury or irritant persists. For example, people working with asbestos can have chronic in- RESOLUTION OF INFLAMMATION flammation in the lungs resulting from inhaled as- bestos, a condition called asbestosis. Many bacteria, Inflammation can resolve in three ways: (1) it can fungi, viruses, and parasites can also produce chronic slowly disappear, with the tissue appearing normal or inflammation. For example, tubercle bacillus, en- close to normal (heal); (2) it can progress, with much gulfed by macrophages, remains alive and produces fluid collecting in the area (exudative inflammation); chronic inflammatory changes in the lung. Chronic or, (3) it can become chronic. inflammation may present as fibrosis, ulcer, sinus, or fistula. EXUDATIVE INFLAMMATION Fibrosis is a reaction caused by fibroblasts that Inflammation invariably results in different types of produce collagen and fibrous tissue. Fibrosis results fluid collecting outside the cells in the injured area. in the formation of scar tissue and adhesions. This fluid is called an exudate. Exudates vary in composition of protein, fluid, and cell content. For In some cases, chronic inflammation may lead to example, after a small area of your skin is burned, a ulcer formation. An ulcer is formed when an organ blister forms. This blister is filled with a clear exu- or tissue surface is lost as a result of the death of cells date, which indicates low protein content. This is and is replaced by inflammatory tissue. Usually, ul- known as serous exudate. cers are found in the gut and the skin. Inflammation sometimes results in a thick and A sinus is another presentation of chronic inflam- sticky exudate that contains fibrous tissue. The fibers mation. A sinus is a tract leading from a cavity to the are actually a meshwork of proteins. When this type surface. For example, sinuses may be associated with of inflammation resolves, increased adhesion and osteomyelitis, in which, as the bone cells die, they scar tissue often occurs in the area. This type of re- form an artificial tract leading from the bone to the action is beneficial, however, as it causes the adjacent surface of the skin through which the dead tissue ex- tissue to stick to each other and prevents spread of in- udes. fection to surrounding areas. This exudate is known as fibrinous exudate. A fistula is a tract that is open at both ends and through which abnormal communication is estab- The white fluid that collects in an inflamed area lished between two surfaces. For example, when cells especially if it is infected, is pus, or purulent exu- die while receiving radiotherapy for treatment of cer- date. The yellowish-white color of pus is actually vical cancer, a fistula may develop between the blad- caused by dead tissue, white blood cells, cellular de- der and the vagina. bris, and protein. Purulent exudate may collect in dif- ferent ways. It may be collected within a capsule to HEALING AND REPAIR form an abscess. If immunity is low, purulent exu- date may spread over a large surface of tissue. The outcome of inflammation depends on many is- sues. Other than the extent of the injury to the spe- Occasionally, the fluid that collects is blood-tinged. cific tissue, repair and healing depend on the proper- This is hemorrhagic exudate. In this case, the blood ties of the cells in the tissue. The cells of the body can vessels are injured or the tissue is crushed. Inflam- be divided into three groups, based on their capacity mation may result in a membranous exudate, in to regenerate—labile cells, stable cells, and perma- which a membrane or sheet is formed on tissue sur- nent cells. face. The membrane is a result of dead tissue caught up in the fibrous secretions. Cells with the capacity to regenerate throughout life quickly multiply and produce new cells to take CHRONIC INFLAMMATION the place of injured or dead tissue. These are known as labile cells. Examples are epidermal cells, geni- An inflammation is considered chronic when it per- sists over a long period. In some cases, it may persist Keloids and Scars for months and years. As a general rule, however, a chronic inflammation is one that lasts for longer than A keloid, an abnormal nodular mass formed at the site six weeks. Medically, inflammation is considered of skin injury, is a result of excessive collagen synthesis. chronic if the area is infiltrated by many lymphocytes A scar is a mass of collagen that is the end result of re- and macrophages, if growth of new capillaries oc- pair by fibrosis.

72 The Massage Connection: Anatomy and Physiology tourinary tract cells, cells lining the gut, hair follicle (e.g., liver spots or senile lentigo). The skin becomes cells, and epithelial cells of ducts. more vulnerable to injury from sun exposure. Another groups of cells, known as stable cells, The dermis thins and the number of elastin fibers have a low rate of division, but are able to regenerate decreases. The ground substance tends to become de- if injured. Examples are liver cells, pancreatic cells, hydrated. An elderly person’s skin is, therefore, fibroblasts, and endothelial cells. To regenerate, these weaker, with a tendency to wrinkle and sag. The me- cells require the presence of a connective tissue chanical strength of the junction between the epider- framework. Also, a sufficient number of live cells mis and dermis diminishes, which may account for must be present for regeneration to occur. For exam- the ease with which blisters form in elderly persons. ple, if extensive injury occurs in the liver, the connec- The glandular secretions decrease, resulting in dry tive tissue framework is lost and the liver only heals skin that is prone to infection. The reduction in by fibrosis, with liver failure as the outcome. How- sweat production; loss of subcutaneous adipose tis- ever, the liver can recover fully after minimal injury. sue in many parts of the body, especially the limbs; and feeble skin circulation affects thermoregulation. Cells of the nervous system, cardiac muscle, and As a result, elderly persons are more easily affected skeletal muscle are referred to as permanent cells. by changes in environmental temperature. These cells cannot divide, and the injured and dead cells are replaced by fibrous tissue and scar formation. The formation of hair slows down in the hair folli- cles, resulting in finer hair. Reduced melanocyte activ- Study of the mechanisms involved in the healing ity results in gray or white hair. Both sexes experience of skin wounds gives insight into healing in general. hair loss, with the onset at about age 30 in men and af- Figures 2.9 and 2.10 show the mechanism involved in ter menopause in women. Loss of axillary hair and pu- the healing of superficial (healing by first or primary bic hair is slower than that of scalp hair. In men, hair intention) and deep (healing by second intention) growth may increase in the nostrils and ears. skin wounds. Nail growth is also slower as one ages. Changes in Effects of Aging on the the nail components result in a dull, yellowish ap- Integumentary System pearance. The nails tend to thicken, especially in the toes where toenails may become curved and hooked. All components of the integumentary system are af- fected by aging. The skin changes that develop with Age does not seem to affect the skin’s ability to age must be considered by the therapist when plan- serve as a barrier to water vapor loss. The cutaneous ning treatment for clients in an older age-group. The nerves also do not significantly change with age. epidermis becomes thinner as a result of a significant decrease in the activity of the stratum germinativum, Integumentary System and which makes older persons more prone to infection, Bodyworkers injury, and delayed healing. The number of Langer- hans cells decreases, increasing the risk of infection. The importance of touch as an avenue for healing of The decrease in the production of vitamin D3 results in the mind and body cannot be underestimated. Studies reduction in calcium and phosphate absorption from of healthy, preterm infants have shown that massage the gut, leading to fragile bones. Melanocytes decrease facilitates growth and development.1 The internal state in number with resultant pigment changes in the skin of mind directly affects the surface of the skin, evi- denced by blushing when embarrassed or turning pale when frightened. Often, diseases of the mind and body FACTORS THAT AFFECT HEALING HELP FOR WRINKLES? One method that speeds healing is to remove foreign ma- Tretinoin (Retin-A TM) is a drug in the form of a gel or terial by cleansing the wound. In surgery, healing is cream that is derived from Vitamin A. It increases blood speeded by using sutures to bring the edges of the wound flow to the dermis and speeds dermal repair, decreasing together. However, suture material is foreign and can de- the rate of wrinkle formation and reducing the appear- ter healing when it remains in place for too long. Sutures ance of already existing wrinkles. To reduce wrinkles in are removed a few days after surgery or are made of ab- the skin, some persons resort to botulism toxin injection sorbable materials. To prevent infection, antibiotic creams into facial muscles. By paralyzing the muscles, the pull on or liquids are used to cleanse wounds. If a large area has the skin is reduced and wrinkles disappear. been injured, skin grafts are used to speed healing.

Chapter 2—Integumentary System 73 Blood clot Basal epithelial cells migrate around wound Immediately: Blood clot and debris fill the cut Fibroblasts Neutrophil Collagen fibers Dilated blood vessels 2-3 hours: Early inflammation closes the edges Epithelial Fibroblastic Scab growth activity Thickening of epidermis 2-3 days: Macrophages remove 10-14 days: Scab formation: blood clot. Increased fibroblastic epithelial covering is complete activity and epithelial growth and edges of wound unite by close gap fibrous tissue; however, the wound is still weak Weeks: The scar tissue is still Months-Years: Very little or hyperemic; union of edges is no scars; collagen tissue good but not full strength remodelled by enzymes; normal blood flow FIGURE 2.9. Healing of Skin Wounds by First Intention present as changes in color, tone, or even abnormal le- flexes, involve both the autonomic nerves and the sions on the skin. Because the skin is the largest sensor rich sensory plexuses in the skin. Some examples of that informs the mind about the external environment, cutaneovisceral reflexes are the abdominal reflex it is conceivable for techniques used on the skin to af- (contraction of the abdominal muscles on stroking fect the mind and internal organs in various ways. the skin over the abdomen), the plantar reflex (con- traction of the muscles of the foot on stroking the It is well known that skin stimulation can trigger sole of the foot), and the gag reflex (emptying of the various reflexes. Some of the therapeutic effects of stomach on tickling the back of the throat). massage seem to arise from altered blood flow and pain suppression in deeper structures by such re- Massage has the ability to mechanically change flexes. These reflexes, known as cutaneovisceral re- the texture and consistency of skin. For example, the

74 The Massage Connection: Anatomy and Physiology Early skin wounds. Fibrous scar tissue can potentially trap nerves, blood vessels, and lymphatics. By realigning Wound filled with collagen fibers and facilitating the movement of skin blood clot over other superficial structures, massage can help Location of acute prevent problems caused by this entrapment. inflammation One of the physiologic effects of massage is the ca- Subcutaneous pacity to increase local blood and lymph flow, im- tissue proving the nutritive status, facilitating the removal of toxins released by injured tissue, and quickening A few days later healing. The increase in blood and lymph flow may be a result of direct mechanical displacement, as well Scab as reflex nervous responses of blood and lymph chan- Contraction of nels walls induced by application of pressure to cuta- wound size due to neous areas. In addition, release of vasodilator sub- action of fibroblasts stances, such as histamine from mast cells, is linked to local increase in blood flow. It should be remem- Mitotic activity bered that massage can quicken drug absorption in of epithelium injection sites secondary to the increase in blood New capillary flow. Other physiologic effects include an increase in loops insensible perspiration and facilitation of sebaceous secretion. Approximately 1 week later Undoubtedly, massage can reduce the pain per- ceived by the brain, as explained by the gate-control Scab shed mechanism (page •• reference). The therapeutic ef- fect may be a result of both a psychological and phys- Loose connective iologic phenomenon. Even without scientific expla- tissue formed by nation, most persons automatically knead or touch fibroblasts or massage a painful area and find relief. Massage, in general, produces a sense of well-being and renewed A few weeks later vigor. Evidence also suggests that it reduces stress, anxiety, and pain perception and has a positive effect Epithelium covers on immune function.3,4 wound site Scar tissue MASSAGE TECHNIQUES AND THE EFFECTS ON THE BODY After a month The mechanical, reflex, physiologic, psychological, Collagen fibers and psychoneuroimmunologic effects of massage are relaid related to the technique used. Mechanical effects are those caused by physically moving the tissues (e.g., FIGURE 2.10. Healing of Skin Wounds by Second Intention compression, stretch, etc.) Reflex effects are changes in function caused by the nervous system. Physio- skin becomes softer and suppler when massaged. logic effects involve changes in body processes With recurrent and prolonged manipulation, the skin caused by nerves, hormones, and chemicals. Psycho- can become more resilient, flexible, and elastic. At logical effects are emotional or behavioral changes. the superficial level, massage helps to remove dry, Psychoneuroimmunologic effects are those that alter scaly skin. At a deeper level, important effects of mas- hormone levels and function through stimulation of sage include the ability to help realign collagen fibers the neurohormonal system. in the dermis during and after the healing of deep The techniques used in the manipulation of skin and underlying tissue can be categorized as: • superficial reflex techniques • superficial fluid techniques • neuromuscular techniques • connective tissue techniques • passive movement techniques.

Chapter 2—Integumentary System 75 Superficial Reflex Techniques creased relaxation, reduced muscle excitability, and increased intestinal movement. When superficial reflex techniques are used, the re- flexes produce changes . No mechanical effects are The superficial lymph drainage technique uses produced. Therefore, the direction of the stroke is short, rhythmic, nongliding strokes in the direction unimportant. These techniques primarily affect the of lymph flow. The strokes result in gentle stretching level of arousal, perception of pain, or autonomic bal- of the skin and superficial fascia, together with the ance and have been shown to have positive effects on stimulation of contraction of lymph vessels. If per- the physiologic and psychological development of formed over a large surface area of the body, it effec- premature infants.1 Examples of superficial reflex tively increases lymph return to the veins. In addi- techniques include static contact, superficial stroking, tion, these techniques reduce anxiety and pain, and fine vibration. produce sedation, and improve immune function. Static contact is synonymous with a resting posi- Neuromuscular Techniques tion, passive touch, superficial touch, light touch, maintained touch, or stationary hold. In this tech- Neuromuscular techniques include broad contact nique, minimal force is used and the therapist’s compression (compression, pressure, pressing), petris- hands are still. This technique produces sedative ef- sage (kneading), stripping (stripping massage, deep fects and reduces anxiety. It is often used at the be- stroking massage), and specific compression (focal ginning and end of massage. compression, ischemic compression, digital compres- sion, digital pressure, direct pressure, static friction, Superficial stroking is also known as light stroking, and deep touch). These techniques affect both superfi- feather stroking, or nerve stroking. In this technique, cial and deeper tissues, such as muscle. Broad contact the therapist’s hands glide over the skin with little compression has been shown to increase blood and pressure on the subcutaneous tissue. It is used to alter lymph flow.6 It may increase or decrease muscle rest- arousal levels and to reduce pain. Pain is reduced by ing tension and have a stimulating or sedative effect, stimulation of large diameter touch nerve fibers, depending on the rate and pressure of strokes. Hence, which, in turn, reduce the transmission of pain im- it is commonly used in sports massage. pulses to the brain. Local reflexes triggered by the strokes reduce muscle spasm and tension. In petrissage, the tissue is repetitively compressed, dragged, lifted, and released against underlying struc- Fine vibration, also known as vibration, cutaneous tures. These strokes relieve anxiety, improve immune vibration, transcutaneous vibration, mechanical vi- function, and positively alter allergic responses. In ad- bration, and vibratory stimulation, is a technique in dition, petrissage has been shown to increase mobility which rapid, trembling movement with minimal pres- of connective tissue and extensibility of muscle, reduce sure is produced by the therapist on the client’s skin. muscle tension, enhance muscle performance, and in- Studies of the effects of vibration using mechanical vi- crease joint motion.7 These effects may be caused by bration have shown that the pain threshold increases, cutaneovisceral reflexes and mechanical compression. causing reduction in pain.5 Such an effect is produced even if the stimulation is given at different sites— In stripping, slow, gliding strokes are applied from proximal to, distal to, or on the site of pain or in the one attachment of muscle to the other. It may be used contralateral region. An increase in muscular tone to reduce the activity of myofascial trigger points may be seen below the site of stimulation. (points on the surface of the body that are sensitive to touch and cause pain that travels or spreads when Superficial Fluid Techniques palpated). In addition to affecting trigger points, stripping may have the same effects as petrissage. Superficial fluid techniques are those that effect Strokes performed in the direction of the natural flow structures in the dermis and subcutaneous tissue. Su- result in emptying of veins and lymphatics. For this perficial effleurage and superficial lymph drainage effect to occur, the muscles must be totally relaxed techniques are in this category. In superficial ef- and the effects of gravity must be employed (e.g., fleurage—also known as effleurage—gliding, limb elevation, recumbent position). It is important stroking, or deep stroking, gliding movements are for proximal muscles to be relaxed while working on used. In addition to producing reflex effects similar to distal areas. If the pressure exerted is excessive, the those of superficial stroking techniques, these move- arterial blood flow that occurs in the opposite direc- ments affect lymphatic and venous return in skin and tion of veins and lymphatics may be impeded. Heavy deeper structures by mechanical compression. They pressure may also result in a protective reflex con- are, therefore, particularly effective in reducing traction of muscles. edema. These techniques also have psychological and other physiologic effects, such as reduced anxiety, in- In specific compression, pressure is applied to a specific muscle, tendon, or connective tissue in a

76 The Massage Connection: Anatomy and Physiology Foot Reflexology lar friction, transverse friction, deep friction, deep transverse friction, cross-fiber friction, and Cyriax Foot reflexology is based on the belief that a reflex rela- friction), skin rolling (tissue rolling, rolling), myofas- tionship exists between specific areas on the feet and cial release (myofascial stretching), and direct fascial body segments and organs. Thickening, pain, and tender- techniques (connective tissue technique, bindegeweb- ness of certain areas of the foot may reflect dysfunction smassage, myofascial massage, deep tissue massage, of the related organ. In order to normalize the dysfunc- deep stroking, strumming, ironing, myofascial ma- tion, specific compression is applied to the reflex points nipulation, and soft-tissue mobilization) are some of on the foot. The mechanism by which this technique the methods used. This technique is accompanied by produces its effects is not known. General outcomes of reactive hyperemia and local increase in temperature. reflexology include reduced anxiety, improved mood and Hyperemia may result from release of histamine from energy, and increased relaxation. mast cells and autonomic reflexes. It is claimed9 that these effects may last for several hours following ma- Specific Compression and Acupoints nipulation. Connective tissue techniques may have a powerful analgesic action that may be explained by Chinese medicine believes that energy travels through the gate-control theory (page reference) and release the body in channels called meridians. There are 12 of natural painkillers. paired bilateral meridians and 2 median sagittal meridi- ans. Each meridian is associated with a specific organ Friction massage frees adherent skin, loosens scars and its physiologic functions and has a basic quality of and adhesions of deeper tissues, and reduces local energy (yin or yang), which may not coincide with func- edema. Repetitive, nongliding techniques are used in tions identified by Western medicine. Small points, friction massage to produce movement between the called acupoints, have been identified along each merid- fibers of connective tissue. In skin rolling, the tissue ian. Acupoints may be located close to the surface or superficial to the deep fascia (the connective tissue deep to it and show altered sensitivity in diseased states. layer investing muscles) is grasped and, using gliding Stimulation of acupoints affects the related organs and strokes, lifted and rolled over in a wavelike motion. physiologic functions at remote sites. This stroke results in mechanical stretch of the con- nective tissue, releasing adhesions that may restrict Acupoints may be stimulated by acupuncture, mas- mobility. In myofascial stretching or release, nonglid- sage, electrical current, laser, and moxibustion (dried ing traction is applied to muscle and the associated herbal agents, such as mugwort leaves, are formed into a fascia. This technique, similar to direct fascial tech- cone and ignited over the acupoint). Acupressure and niques, also results in mechanical lengthening of the shiatsu use techniques such as compression to stimulate fascia and is widely used in musculoskeletal condi- the points. Research shows that stimulating acupoints tions to increase mobility. may reduce nausea and vomiting during and after surgery and may have a positive effect in sleep disorders Passive Movement Techniques and other disorders. Passive movement techniques use passive motion to If acupoints are inadvertantly activated when treating treat various conditions. They include shaking (mus- trigger points, unexpected results may sometimes be ob- cle shaking, course vibration, rolling friction, and served in remote areas. jostling), rhythmic mobilization, and rocking (pelvic rocking, rocking vibration). These techniques have direction perpendicular to the tissue in question. greater effects on muscles and joints. They produce This technique is used extensively by bodyworkers, sedation (possibly by stimulating vestibular reflexes) either alone or in combination with other tech- and decrease anxiety and pain perception. niques (e.g., shiatsu, acupressure, and reflexology). It may help soften adhesions and fibrosis. The fact Percussive Techniques that it is used to reduce pain and produce physio- logic effects in regions far from the site of appli- Percussive techniques alternatively deform and re- cation suggests that it works by triggering complex lease tissue at varying rhythms and pressure. Clap- somatovisceral reflexes.8 ping or cupping, tapping, hacking, pounding, and tapotement are some examples. These strokes result Connective Tissue Technique in initial skin blanching as a result of contraction of arterioles from mechanical stimulation. Blanching is Connective tissue technique uses palpation to help re- followed by redness brought about by vasodilation model and lengthen connective tissue. Friction (circu- from overstimulation. The effects of this technique