Massage for Therapists. A Guide to Soft Tissue Therapy 3rd Ed

Massage for Therapists Massage for Therapists: A guide to soft tissue therapy , Third edition By Margaret Hollis, Edited by Elisabeth Jones © 2009 Blackwell Publishing Ltd ISBN: 978-1-405-15916-6

Massage for Therapists A guide to soft tissue therapy Third edition Margaret Hollis Edited by Elisabeth Jones A John Wiley & Sons, Ltd., Publication

This edition first published 2009 © 2009 by Blackwell Publishing Ltd Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell. Registered office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom Editorial offices 9600 Garsington Road, Oxford, OX4 2DQ, United Kingdom 2121 State Avenue, Ames, Iowa 50014-8300, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell. The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Whilst every attempt has been made to provide accurate and useful information, neither the Editor, Contributing Authors, Publishers nor any other persons contributing to the formation of this publication assume any liability with respect to the use or any injury and/or damage resulting to persons or property from any use of the information contained in this publication. Library of Congress Cataloging-in-Publication Data Massage for therapists : a guide to soft tissue therapy. – 3rd ed. / edited by Elisabeth Jones. p. ; cm. Rev. ed. of: Massage for therapists / Margaret Hollis. 2nd ed. 1998. Includes bibliographical references and index. ISBN 978-1-4051-5916-6 (pbk. : alk. paper) 1. Massage therapy. I. Jones, Elisabeth, 1939– II. Hollis, Margaret. Massage for therapists. [DNLM: 1. Massage–methods. WB 537 M4146 2009] RM721.H58 2009 615.8′22–dc22 2009005287 A catalogue record for this book is available from the British Library. Set in 9.5/11.5pt Sabon by SNP Best-set Typesetter Ltd., Hong Kong Printed in Singapore 1 2009

Contents Foreword xi Trigger points 14 Preface Contributors xii Nerve impingement 14 Acknowledgements xiii The nervous system 14 I The basis for massage xvi The CNS 14 1 Introduction to massage The PNS 14 Elisabeth Jones 1 Basic structure of the nervous system 17 Western forms of massage Eastern forms of massage The neuro-endocrine mechanism 17 Globalisation Entrainment 17 2 Relevant anatomy and physiology: an overview 3 The circulatory system 17 Elisabeth Jones The cardiovascular system 17 The skin 3 Function 17 Function 4 Structure 17 Structure 4 Blood pressure 18 Appendages of the skin The lymphatic system 18 Connective tissues Piezo-electricity Function 18 Fluid balances of the skin 5 Structure 18 The musculoskeletal system The cerebrospinal fluid system 19 The skeleton Function 19 Function Muscles 5 Structure 19 Function 5 Fluid balances 20 Structure Definitions associated with 6 The endocrine/hormonal system muscle action 7 (ductless glands) 20 Reflexes Common terms 8 Function 20 Anatomical position Common terms 8 Structure 20 8 The effects of stress on the 8 endocrine system 20 8 The respiratory system 20 10 Function 20 10 Structure 20 10 External respiration 21 10 Internal respiration 21 Nervous and chemical control 13 of respiration 21 13 The digestive system 21 13 Function 21 14 Structure 21 14 The energy system 21

vi Contents 3 Evidence-based effects, risk 23 Palpation and skill 58 awareness and contraindications Specific soft tissue mobilisations for massage 24 (SSTMs) 59 24 Dr David Lee and Carol Young* 5 Preparation for massage 60 24 Mechanical effects Margaret Hollis and Elisabeth Jones 60 Physiological effects 27 62 27 Self preparation 62 Physiological effects on the 28 Hand exercises 63 circulatory system Relaxation 63 30 The environment 63 Physiological effects on the 32 Contact mediums 63 nervous system 63 36 Powder 63 Alpha motoneuron excitability Oils 64 Pain 37 Liquid oils 64 Physiological effects on the 37 Creams 64 Water-based lubricants 64 musculoskeletal system Soap and water Psychological effects Allergic reactions 65 Summary of the mechanisms of massage Preparation of the patient 66 Palpation and developing sensory 66 therapy Massage in vulnerable groups – risk awareness 67 Examination of the part awareness and contraindications Ticklish subjects 67 Contraindications for massage therapy 68 6 Massage manipulations 69 II The application of massage 43 69 Margaret Hollis and Elisabeth Jones 73 4 Examination and assessment 45 74 Effleurage 75 Ann Thomson Stroking 77 Petrissage 77 Treatment planning 45 77 Examination of patients 45 Kneading 77 Assessing findings 46 Picking up 78 Clinical reasoning 46 Wringing 79 Rolling 79 Clinical features that may guide the 47 Muscle shaking 80 therapist towards the possible 49 Frictions 80 sources/causes of patients’ 49 Circular frictions 80 problems (the ‘genics’) Transverse frictions 81 49 Tapôtement (percussion) Determining the indications for massage Hacking 82 Aspects of examination and 54 Clapping assessment that relate to massage 55 Vibrations 82 Observation and palpation using 55 Beating 82 massage strokes to identify Pounding indications Tapping Observation and palpation using massage strokes to identify 7 Massage to the upper limb contraindications Margaret Hollis and Elisabeth Jones Measuring change and outcome measures Preparation of the patient For a treatment in sitting position Examination and assessment recording * From the chapter by Janice M. Warriner and the late Alison M. Walker in the second edition of this book (Hollis 1998).

Contents vii For a treatment in lying position 82 Wringing 102 To elevate the arm 82 The thigh 102 Effleurage 83 The calf 102 To the whole limb 83 102 Part strokes 83 Muscle shaking 102 Kneading 85 The thigh 103 Double-handed alternate kneading 85 The calf 103 Single-handed kneading 86 103 Finger kneading 87 Skin rolling and skin wringing 103 Thumb kneading 87 The knee 104 Picking up 88 104 Wringing 90 Hacking and clapping Muscle shaking 91 The thigh 105 Muscle rolling 91 The calf Hacking and clapping 91 The anterior tibial and peroneal muscles 8 Massage to the lower limb 93 9 Massage to the back, gluteal 106 region and neck Margaret Hollis and Elisabeth Jones 93 106 93 Margaret Hollis and Elisabeth Jones 106 Preparation of the patient 106 Preparation of the treatment couch 93 The thoracolumbar region 106 Treatment of the lower limb with the Preparation of the patient 106 93 Preparation of the treatment couch 107 patient supine 94 Treatment of the patient in prone lying 108 Treatment of the lower limb with the 94 Effleurage 109 96 Kneading 109 patient prone 97 109 Effleurage 97 Alternate, double-handed kneading 110 98 Single-handed kneading 110 To the whole limb 98 Superimposed kneading 111 Part strokes 98 Thumb kneading 111 Kneading 98 Finger kneading 112 The thigh Skin rolling 112 Round the knee 99 Wringing 112 Thumb kneading round the patella 99 Muscle rolling 113 Finger kneading the knee 99 Hacking and clapping 113 The calf muscles The gluteal region 113 Palmar kneading the anterior 99 Preparation of the patient 113 Effleurage 113 tibial muscles 99 Kneading 114 Palmar kneading the peronei Superimposed kneading 114 The foot 100 Frictions 114 Thumb kneading the anterior 100 Circular frictions 115 Picking up 115 tibial muscles 100 Wringing 115 Thumb kneading the peroneal 100 Hacking and clapping 115 100 The neck 115 muscles 100 Client in prone lying 116 Thumb kneading the dorsum of 102 Client in lying 116 Client in side lying 117 the foot Client in forward lean sitting Thumb kneading the sole of the foot Effleurage Thumb kneading the interosseous Kneading Picking up spaces Thumb and finger kneading the toes Picking up The thigh The calf

viii Contents Muscle rolling 118 Occupational situations 131 Hacking and clapping 118 Pre natal, labour and post natal 132 Babies 132 10 Massage to the face and scalp 119 Children 133 The older population 133 Margaret Hollis and Elisabeth Jones 119 Learning disabilities 133 119 Mental health 134 Preparation of the patient 119 Physical disabilities 134 Face massage 121 134 Effleurage 121 Neuromuscular-skeletal conditions 135 Kneading 121 Neurological conditions 135 Wringing 122 Cancer care 135 Plucking 122 Contraindications/precautions 136 Tapping 122 HIV/AIDS 136 Vibrations 123 Pain 136 123 Respiratory conditions 137 Exit foramina of the trigeminal nerve 123 Reconstructive surgery 137 Over the sinuses 123 Scar management 137 Muscle stretching 123 Desensitisation 137 Occipitofrontalis 124 Oedema management Clapping 124 To the platysma 124 III Some specialised techniques 139 Scalp massage 124 Effleurage/stroking 13 Some types of massage and soft Kneading tissue therapies Vibrations Elisabeth Jones 11 Massage to the abdomen 125 141 Active release technique (ART) Margaret Hollis and Elisabeth Jones 125 Acupressure 141 125 Animal massage 141 Preparation of the patient 126 Aromatherapy 141 Palpation 126 Ayurvedic massage 142 Effleurage 126 Bio-energy therapies 142 Kneading 126 Bowen therapy 142 Vibrations 127 Classical massage 142 Brisk lift stroking and shaking 127 Connective tissue manipulation (CTM) 143 Stroking 127 Craniosacral therapy 143 127 Heller work 143 The ascending colon 127 Indian head massage 143 The transverse colon 127 Lomi lomi 143 The descending colon 128 Manual lymph drainage (MLD) 144 Kneading 128 Muscle energy technique (MET) 144 The ascending colon 128 Myofascial release (MFR) 144 The descending colon 128 Neuromuscular therapy 144 Rolling Periosteal massage 145 Skin wringing Pin and stretch 145 Points to be observed Polarity therapy 145 Positional release 145 12 Uses of classical massage in some Proprioceptive neuromuscular 145 health care settings: an overview 130 facilitation (PNF) 145 Elisabeth Jones Hold relax (HR) (contract relax) 146 Stress 130 Depression 131 Anxiety 131

Contents ix Auto hold relax 146 Post-competition massage 157 Repeated contractions (RC) 158 Combining repeated contractions 146 Post-travel massage 159 159 with soft tissue techniques Non-specific sports massage 160 Slow reversals (SR) 160 Stabilisations 146 General body massage 161 Reflexology Rolfing (structural integration) 146 Specific areas of massage 163 Segment massage Shiatsu 146 Summary 163 Soft tissue release (STR) 163 Specific soft tissue mobilisations 147 Case study 163 163 (SSTMs) 147 163 Specific stretch 164 Sports massage 147 15 Aromatherapy 164 Swedish massage 147 164 Thai massage (Thai yoga massage) 147 Elisabeth Jones 165 Therapeutic touch Trager Introduction 165 Transcadence massage Trigger point release 147 Historical uses of essential oils 166 Tuina/tui na (pronounced tweena) 166 Vibrational therapy (VT) 148 Egyptians: 3000–1500 BC 166 Zero balancing 167 148 Greeks: 500–40 BC 168 14 Massage in sport 148 Europeans 168 Joan M. Watt 148 Essential oils 168 Basic rules of sports massage 168 Diagnosis 148 Basic chemistry 168 History 168 Contraindications 148 Mind and body 168 Aims of treatment 170 Position 149 Extraction methods 170 Materials 171 Skin preparation 149 A working knowledge of 171 Joint position Technique 149 essential oils 171 Check with the participant 171 Clean up 149 Methods of administering 171 Warn the participant 171 150 essential oils 171 Massage manipulations in sports 171 massage Olfaction 171 171 Acupressure 151 Inhalation 171 Trigger pointing Skin absorption 172 Ice massage Specific sports massage Ingestion Massage in conditioning Massage as a treatment 151 Glossary of terms and properties of Pre-competition massage Inter-competition massage 151 some essential oils 151 The practical application of 151 essential oils 151 Olfaction/inhalation 152 Skin absorption 152 Ingestion 152 The holistic approach 152 Aromatherapy massage 152 Lymphatic drainage 152 Neuromuscular massage 152 Acupressure 152 Effects and uses of aromatherapy massage 152 Muscle tension 152 Blood circulation 153 Pain 153 Fatigue 153 Infection 153 Relaxation 154 One-to-one care 155 Support for staff and carers 156 Sleep

x Contents General wellbeing 172 How to apply pressure 187 Pregnancy/childbirth/baby care 172 The elderly 172 Professional development of the therapist 188 Consultation procedures 172 Verbal 172 Conclusions 188 Visual 173 Tactile 173 Glossary 188 Personality type 173 Other information 173 17 Myofascial release and beyond 190 Oils 173 Contraindications 174 Ann Childs and Stuart Robinson 190 Hazards 174 190 Oils not to be used at all in therapy 174 Introduction to the fascial matrix Oils never to be used on the skin 175 Aims of the MFR approach 191 Oils not to be used with patients Palpation philosophy and possible 191 175 who have epilepsy 175 barriers to effectiveness 191 Pregnancy 175 Exercises to enhance palpatory skills Precautions 176 192 Blending of oils and formulation 176 Exercise 1: Attuning whole and 192 Basic formula 176 bilateral hand sensitivity Preparation of the patient 177 192 Treatment by aromatherapy massage 177 Exercise 2: Enhancing palpatory Case study 177 sensitivity 192 Purity of essential oils 177 Storage 178 Exercise 3: Palpating fascial glide 192 Conclusion Exercise 4: Influence of palpation 192 16 Shiatsu – the Japanese healing 179 and body tension 193 art of touch Exercise 5: Palpation changes 193 179 193 Andrea Battermann 179 with different states of mind 193 179 Exercise 6: Identification and 193 Introduction 180 What is shiatsu? 180 documentation of fascial 194 History 180 restrictions 194 Introduction to oriental medicine 181 Exercise 7: Identification of the 194 Diagnostic methods dominant holding pattern in 194 181 the body 194 Four forms of diagnosis 182 Myofascial release techniques 195 Shiatsu theory 183 A sustained stretch technique 183 Contraindications 195 Basic principles and techniques Beyond the anatomy 196 of shiatsu 183 Involving the mind and feelings 196 183 An exploration of suggested rationale Clinical indications 184 and their clinical implications Contraindications Responsive biomechanical model Cautions Neural-mechanoreceptor model Physiological effects associated Gel-to-sol model Piezo-electric model with shiatsu Trauma release model Case study: self-shiatsu massage Evidence of effectiveness in clinical The self-shiatsu routine practice So what do we feel with our hands? Future implications Index 199

Foreword Congratulations! You are reading a book which has My hope for you as a reader of this book is that the potential to educate your hands, improve your you will come to understand the three basic princi- massage techniques and increase your understand- ples of massage as a touch therapy. First, as a ing of touch and its related therapies. therapist you will be acquiring, through your hands, an in-depth knowledge of your patients and their As someone who has taught massage, I know tissues. You will then use this knowledge to apply how immensely useful the book Massage for the procedures correctly and in such a way that you Therapists can be, and I am delighted that this latest help the body to heal. Relief from pain and discom- edition is going to give a new generation the oppor- fort through touch is an instinctive human reaction, tunity to benefit from Margaret Hollis’s knowledge but it has to be sensitively and thoughtfully admin- and expertise. When Margaret initially wrote this istered to achieve its full potential. You use your book it was aimed particularly at physiotherapy educated hands! students, as she had taught many in her capacity as Head of the Bradford School of Physiotherapy, but Second, from the patient’s perspective there must what she has to say is just as important and relevant be a feeling of trust in the therapist. This stems to anyone embarking on a career involving massage initially from the two-way exchange of information and soft tissue therapies. It is testament to the during the assessment, followed by the receiving of appeal of the earlier editions that this book has the right depth and presssure of touch, and an been translated into many languages, and I well explanation of the particular techniques. This remember Margaret’s delight that her book was then allows the patient to react positively to the helping students throughout the world to improve treatment. their knowledge of how to massage safely and effectively, and understand the reasons for the Third, this book should provide a realisation that treatment. this basic knowledge is the ground rock on which all other therapies are based, giving you the key In this updated version we are indebted to to much greater understanding and ability to Elisabeth Jones and her eminent band of co- improve the human condition. contributors for the excellent additions to Margaret’s earlier work. Their contributions provide an I wish you good luck in your quest, sensitivity in updated evidence base for massage, a comprehen- your fingertips and a focused mind to absorb the sive guide to assessing patients, and an insight into knowledge within. the many branches that have ‘sprouted’ from the massage ‘root’. These have led to the numerous soft Tessa Campbell MCSP, HPS, MIFPA tissue therapies that are so important in health and Chairman of the Chartered Physiotherapists in well-being today. Massage and Soft Tissue Therapies (CPMaSTT)

Preface to the third edition This third edition of Massage for Therapists is a ᭿ Chapter 4 shows how to gather information, follow-up to the first and second editions conceived vital to the proper application of techniques. and written by Margaret Hollis, MBE, MSc, FCSP, who was founding Principal of the Bradford School ᭿ Chapter 12 revises some of the uses for classi- of Physiotherapy, and published by Blackwell cal massage techniques. Science, Oxford, in 1987 and 1998 respectively. Sadly Margaret died some years ago and I was ᭿ Chapter 13 outlines some different techniques. invited by Amy Brown, Commissioning Editor, ᭿ Chapters 16 and 17 offer insight into two more Physiotherapy Professional Division, to edit and write in this edition. specialised techniques. The new, enlarged book is aimed at providing There has been huge renewed interest in massage, students and therapists in the orthodox, integrated partly due to further evidence-based research into and complementary sectors with a textbook that its effectiveness and partly due to public awareness describes, in detail, techniques that offer models of of its therapeutic value and therefore demand for good practice for the reader to follow. treatment. The chapters are written by different authors The contributors to this book are all health- because of the need to be scientifically based and care professionals and experts in their field. The also in the interests of accuracy and validity of the majority are Members of the Chartered Society techniques. The new chapters expand on, and are of Physiotherapy, UK, (MCSP) and in their curricu- relevant to, the practice of massage as follows: lum of study one of the core subjects is massage. (Physiotherapists are often termed Physical ᭿ Chapter 2 outlines the systems of the body that Therapists in other parts of the world.) I am may be affected. extremely grateful to them all. ᭿ Chapter 3 further reviews literature on the I hope Margaret Hollis would have been proud evidence base in relation to effects achieved, of this third edition. It is dedicated to her as well as awareness of risk and memory. contraindications. Elisabeth Jones

Contributors Andrea Battermann MCSP, HPC, MRSS (T) chairperson for ACPEM, the Association of Andrea Battermann first qualified with a diploma Physiotherapists in Energy Medicine. in social work in Germany in 1985. She is a char- tered physiotherapist and a registered practitioner Margaret Hollis MBE, Hon MSc, Hon DSc and teacher with the Shiatsu Society UK and quali- (Brad), FCSP, DipTP fied in physiotherapy in Germany in 1992. Andrea Margaret Hollis trained as a physiotherapist and worked for several years within various specialities teacher of physiotherapy at the Swedish Institute at in the NHS including neurology rehabilitation, St Mary’s Hospital, London, before teaching in chronic pain management and out-patient clinics. New Zealand from 1946. She returned to the UK She has built up a successful private practice in 1950 to become the founding Principal of the incorporating physiotherapy, shiatsu, acupuncture, Bradford Hospital School of Physiotherapy. The counselling and supervision for colleagues and stu- lack of definitive textbooks prompted Margaret to dents. Andrea authored a chapter in Complementary write, and she published several works on massage, Therapies for Physical Therapists (ed. R.A. exercise therapy, assessment and manual handling. Charman). Her main interest is to link Oriental and The volume and diversity of her work was acknowl- Western medicine with psychology to create a more edged in 1974 with the award of an MBE, and in holistic model of health care. 1984 the Chartered Society of Physiotherapy hon- oured her with a fellowship. Now at peace, we Ann Childs MSc, MCSP recognise her unique contribution to physiotherapy Ann Childs currently works as a lecturer and prac- and to life. titioner physiotherapist in mental health for the Nottinghamshire NHS Healthcare Trust and the Uni- Elisabeth Jones CBE, MCSP, MBABTAC, versity of Nottingham, Division of Physiotherapy. MIFPA Her primary interests include touch and movement- Elisabeth Jones is a chartered physiotherapist who based therapies in relation to working with trauma, has lectured and taught massage and aromatherapy and moving towards an integrated approach to worldwide and run a training centre for massage, physical/mental health delivery in the NHS. Ann’s aromatherapy and reflexology for 25 years. She lifetime interest and enthusiasm in complementary has worked in the NHS and nursing homes, and medicine is expressed in her current role as currently has her own private practice. She is a

xiv Contributors member of two clinical interest groups: Chartered Ann Thomson FCSP, MSc, M Univ, FMACP, Physiotherapists in Massage and Soft Tissue BA, Dip TP Therapies (CPMaSTT) and the Association of Ann Thomson was a teacher, Vice Principal and Physiotherapists in Energy Medicine (ACPEM). Head of School at the Middlesex Hospital School Elisabeth is a former Chairman of two organisa- of Physiotherapy until its closure in 1997. She tions: the British Association of Beauty Therapy joined the Manipulation Association of Chartered and Cosmetology (BABTAC) and the Aromatherapy Physiotherapists (MACP) in 1970. In 1998 Ann Organisations Council (AOC). became Director of Physiotherapy Studies, University College London, to continue the delivery of the Dr David Lee BSc (Hons), PhD, PGCHEP MSc programme for physiotherapists. The philoso- Dr David Lee originally trained as a human biolo- phy of the programme is that quality, highly edu- gist, qualifying with a BSc in 1999. Thereafter he cated expertise must be developed in physiotherapists completed a psychobehavioural PhD in sleep who transfer the best scientific and clinical evidence research at the University of Loughborough in into the treatment and management of patients. 2005, before commencing work as a Research Massage and soft tissue therapy have always been Associate in the Division of Nursing at the University an integral part of Ann’s teaching. She is a member of Bradford, School of Health Studies. David then of the Chartered Physiotherapists in Massage and moved on to lectureships at Bradford in the Division Soft Tissue Therapy (CPMaSTT) team developing of Rehabilitation and the Graduate School, and is the Fundamentals of Massage and Soft Tissue now working as a research fellow at the University Therapy course that is piloting an endorsement of Newcastle-upon-Tyne in the Division of Clinical scheme with the Chartered Society of Physiotherapy Psychology. His primary interests include sleep (CSP). She has been honoured with a Fellowship research, NHS service delivery and evaluation, the award by both the CSP and the MACP. health and wellbeing of older people and quantita- tive research methodologies. He is also director of Joan M. Watt MA, MCSP, MSMA a company offering consultancy for individuals Joan Watt is a chartered physiotherapist who has with sleeping problems and companies with shift- worked in private practice since 1981, specialising working employees whose performance may be in musculoskeletal problems, sports medicine and affected by sleep disruption. massage. As team physiotherapist and team manager, she has attended many sporting events Stuart Robertson MSc, BSc Physiotherapy, including Olympic Games, Commonwealth Games BEd (Hons) and World Championships, and is Honorary Stuart Robertson is both a qualified teacher and Medical Advisor to the Scottish Commonwealth chartered physiotherapist. He has spent over a Games. She was lead physiotherapist to GB Athletics decade teaching nationally and internationally, pre- from 1984 to 1996 and is currently lead physio- dominantly on the integrative role of the fascial therapist for British Shooting. She was Chair of system and its importance in dysfunction and CPMaSTT, the CSP specific interest group for disease. This work has acted as an integral bridge Massage and Soft Tissue Therapy; she is Honorary between the clinical development and integration of President, First Chair person and founder of the mind–body techniques as well as energy medicine Sports Massage Association; and a Member of the into the teaching of manual therapy skills. His back- United Kingdom Athletics Anti-Doping Panel. In ground in physical education has also led him to 1999 Joan authored Massage for Sport. Joan was develop a series of exciting physical exercises linked President of Scottish athletics from 1999 to 2003, to the senses, which can be used in the clinical and received the CSP Distinguished Service Award setting for specific injuries or simply for proactive in 2002. health. His clinical experience has involved him working as a clinical specialist in an NHS chronic Carol Young MRes, DipRG&RT, Dip pain department through to working with interna- Aromatherapy, MCSP tional sportsmen and women. He is currently Carol Young qualified as a remedial gymnast and working towards an MEd, with the aim of introduc- recreational therapist in 1979 and became a char- ing his stress reduction programmes into schools. tered physiotherapist in 1985. She worked in clini-

Contributors xv cal posts specialising in older person rehabilitation Carol’s interest in massage which she is now teach- and stroke rehabilitation in the community. Carol ing in the undergraduate physiotherapy programme. joined the Bradford School of Physiotherapy team She has trained in connective tissue massage and in 1990 as a clinical supervisor and made the transi- shiatsu and gained a Diploma in Aromatherapy in tion to lecturer in 1993. The School has since 1998, continuing to practice in her spare time. become the Division of Rehabilitation within the Carol is committed to the continuation of massage School of Health Studies at the University of as a core physiotherapy skill and has a keen interest Bradford. Experience in teaching neuromusculo- in the various branches of massage and seeking skeletal anatomy and physiotherapy treatment, evidence to support its use. research and reflective practice has complemented

Acknowledgements So many people have helped me with this new ᭿ Bruce Aitkin MCSP edition either by help and advice or through per- ᭿ Andrea Battermann MCSP sonal experience. My grateful thanks to everyone. ᭿ Mary Bromily MCSP ᭿ Ann Childs MCSP For encouragement at an early stage: Bob Chapman ᭿ Suzanne Evans MCSP FCSP, MCSP, DipTP ᭿ Mark Fairclough MCSP ᭿ Ley Finlayson MCSP For encouragement at later stages: Tessa Campbell ᭿ Donna Gurr MCSP MCSP; Ann Thomson FCSP; Joan Watt MCSP ᭿ Liz Holey MCSP ᭿ Viv Lancey MCSP For encouragement throughout: Amy Brown, ᭿ Jill Mintz MCSP Commissioning Editor, Professional Division, ᭿ Penny Nisbet MCSP Wiley-Blackwell, Oxford. ᭿ Erica Nix MCSP ᭿ Clare Phillips MCSP To the authors of the following chapters: ᭿ Stuart Robertson MCSP ᭿ Ann Thomson FCSP ᭿ Chapter 3: Dr David Lee, Carol Young MCSP, ᭿ Joan Watt MCSP Janice M. Warriner MCSP and the late Alison M. Walker MCSP To everyone at the University of Bradford School of Physiotherapy, and in particular: ᭿ Chapter 4: Ann Thomson FCSP ᭿ Chapter 14: Joan Watt MCSP ᭿ Bryan Walkden MCSP who took all the pho- ᭿ Chapter 16: Andrea Battermann MCSP tographs and reproduced the line drawings for ᭿ Chapter 17: Ann Childs MCSP and Stuart this new edition. Robertson MCSP ᭿ The models, both physiotherapy students at the time: Danielle O’Neill and Laura Robinson. To those who contributed ideas for Chapter 12: ᭿ Jan Warriner and all the staff, for their hospi- ᭿ Robyn Grieg MCSP tality and for the photo-shoot in the precincts ᭿ Caroline Griffiths MCSP of the University of Bradford Physiotherapy ᭿ Pauline Melody BA, RGN School – where Margaret Hollis first set up ᭿ Katy Mitchell MCSP ᭿ Jac Tambellina MSc, RMN To those who contributed ideas for Chapter 13:

Acknowledgements xvii photographic pictures to illustrate her original this book, and without whom this edition could not edition of Massage for Therapists, of which have been put together. Chapters 5–11 are the central core. To the students and patients I have had the good To the International Federation of Aromather- fortune to be involved with and from whom I have apists and the International Federation of learnt so much about the therapeutic value of Professional Aromatherapists. massage and soft tissue therapies. To the indefatigable work of John Perrott AFC Finally to my daughters, Felicity and Lucy, who who set up and who copied all the contributions in have listened to and supported me throughout the editing of this book.

IThe basis for massage Massage for Therapists: A guide to soft tissue therapy , Third edition By Margaret Hollis, Edited by Elisabeth Jones © 2009 Blackwell Publishing Ltd ISBN: 978-1-405-15916-6

1Introduction to massage Elisabeth Jones Massage is an ancient art and modern clinical Prosser in 1941 gave another: ‘The scientific research has provided increasing scientific evidence manipulation of the soft tissues of the body as apart for its therapeutic use. Since time immemorial ‘the from mere rubbing’. Vickers in 1996 offered: laying on of hands’ has been known to have benefi- ‘Technically it can be described as the therapeutic cial effects, not only on the body but also on the manipulation of soft tissue’. mind. Its value as a therapy has been utilised through- Think of a small child who has just had a tumble. out history by primitive peoples and by many civi- The reaction of the worried parent is to hold her/ lizations, from the Chinese almost 5000 years ago him with a loving touch. Similarly, if we hurt our- to the Hindus of India, the Japanese, the Thai and selves, our instinct, more often than not, is to press the ancient Egyptians, some time later. The Greeks and/or rub the affected part. Such gestures seem to and the Romans were also proponents of massage. be rooted deep in the psyche. The comfort that may Hippocrates (460–377 bc) described its medical be gained by such touch brings with it one of the uses. The Roman Bath concept, where massage fundamentals of healing, namely transference of played an important part, was preserved in Turkey caring energy to the traumatised person, wholly or long after the fall of the Roman Empire. Not much in part. documentary evidence is available on the use of massage in the Middle Ages. It was not until French The word ‘massage’ comes from ‘mass’ the missionaries returned in the early nineteenth century Arabic term denoting ‘to press’. There are many from China, carrying information from ancient definitions of massage. Early in the twentieth Chinese manuscripts on massage, that its use as a century, Araminta Ross, Principal of the Dublin therapy became popular in Europe and in the School of Massage, wrote in her book The USA. Masseuse’s Pocketbook (1907) the following: Western forms of massage ‘Massage is the term used to express certain sci- entific manipulations, which are performed by Per Henrik Ling (1776–1839) of Sweden founded the hands of the operator upon the body of the an Institute in Stockholm in 1813 and promoted patient. It is a means used for creating energy, the therapeutic use of techniques termed ‘Swedish where such has become exhausted, from whatso- ever cause and is a natural method of restoring the part either locally or generally injured, to its normal condition’. Massage for Therapists: A guide to soft tissue therapy , Third edition By Margaret Hollis, Edited by Elisabeth Jones © 2009 Blackwell Publishing Ltd ISBN: 978-1-405-15916-6

4 Massage for Therapists massage and gymnastics’. In 1856 the Taylor broth- Globalisation ers (Charles and George) brought Swedish Massage to the USA. In 1894 the Society of Trained With ‘globalisation’, many techniques are being Masseuses was formed (later incorporated into the incorporated within the modern practitioner’s port- Chartered Society of Physiotherapy) in the UK. folio. Public awareness of the benefits of massage has grown and with it an ever-increasing demand In 1932 Mary McMillan of Harvard Medical for safe and effective treatment. It is therefore very School, USA, was responsible for more advanced important to have a knowledge of human anatomy techniques in massage. In 1943 the American and physiology, and the next chapter is written Association of Masseurs and Masseuses was formed with the intention of providing an outline of and in the 1950s Gertrude Beard of North Western the body systems relevant to the practice of University, Evanston, Illinois, together with Francis massage. Tappen, wrote a number of influential books on massage. Also in the 1940s and 1950s James Cyriax Further reading of St Thomas’s Hospital, London, UK, developed transverse friction massage techniques. Many other practitioners offered their ideas, too numerous to mention here. Eastern forms of massage Beard, G. and Wood, E.C. (1965) Massage Principles and Techniques. W.B. Saunders, Philadelphia. As mentioned above, the Chinese, the Japanese, the Hindus of India and the Thais had developed their Benjamin, P.J. and Tappan, F.M. (2005) Tappan’s Handbook own types of massage centuries ago. The Yellow of Healing Massage Techniques: Classic, Holistic and Emperor’s Classic of Internal Medicine (c. 500 bc) Emerging Methods. Pearson Prentice Hall, Upper Saddle was a book on Chinese medicine that provided a River, New Jersey. foundation for traditional medicine, practised in many Asian countries. Tui-na – a form of acupres- Cyriax, J.H. and Cyriax, P.J. (1993) Illustrated Manual of sure – originated in China. Anma (amma), a type Orthopaedic Medicine, 2nd edn. Butterworth Heinemann, of Japanese massage, came from China, whilst Oxford. Shiatsu, a modern form of acupressure, was devel- oped in the twentieth century ad. In India the Fritz, S. (2004) Fundamentals of Therapeutic Massage, 3rd ‘Ayurvedic’ massage techniques were based on the edn. Mosby, St Louis. ‘Vedas’ which were ancient books written centuries before the birth of Christ, defining spiritual and Holey, E. and Cook, E. (2003) Evidence Based Massage, a philosophical beliefs. Practical Guide for Therapists. Churchill Livingstone, Edinburgh. Hollis, M. (1998) Massage for Therapists, 2nd edn. Blackwell Science, Oxford. Prosser, E.M. (1941) A Manual of Massage and Movements, 2nd edn. Faber and Faber, London. Ross, A. (1907) The Masseuse’s Pocketbook. Scientific Press, London. Vickers, A. (1996) Massage and Aromatherapy, a Guide for Health Professionals. Chapman and Hall, London.

Relevant anatomy and physiology: 2an overview Elisabeth Jones This chapter gives an overview of the anatomy capillary network in its tissues, together with and physiology that is relevant, in this book, for the evaporation of sweat. the practice of massage, in particular classical ᭿ Maintains heat levels in the body, via regula- massage. tion of circulation and therefore its capillary network, by virtue of the insulating effect of THE SKIN the adipose tissue below the skin and by the hair on the surface of the skin. The skin is the outer covering of the body (Fig. 2.1). Sensation: the skin provides sensory nerve endings which conduct pain, touch, vibration, pres- Function sure, cold and heat. Some areas of the body have more neural receptors than others, e.g. the fingers Protection: due to its structure it is a strong tensile have more than the back. Examples are as barrier which protects the underlying tissues: follows: ᭿ From dehydration and from externally applied ᭿ Nociceptors: pain, temperature, itch, stretch, entry of fluids. discriminatory touch, mechanical stimuli. ᭿ From most chemicals and micro-organisms. ᭿ From ultraviolet (UV) rays. ᭿ Ruffini’s corpuscles: tactile (crude pressure). ᭿ From trauma. ᭿ Pacini’s corpuscles: deep pressure, stretch, Regulation of temperature: through conduc- vibratory sensation, mechanical stimuli. tion, convection, radiation and evaporation, the ᭿ Merkel’s discs: light pressure, shear forces, skin: ᭿ Helps to remove excess heat in the body, via vertical pressures, discriminatory touch. ᭿ Meissner’s discs: tactile, discriminatory touch, regulation of the circulation and thence the mechanical stimuli, vibration. Excretion: excess fluid as well as waste products are excreted through the sweat glands. Production of vitamin D: when UV rays are absorbed by the skin, they act on a chemical called 7-dehydrocholesterol, which is converted ultimately into vitamin D. Massage for Therapists: A guide to soft tissue therapy , Third edition By Margaret Hollis, Edited by Elisabeth Jones © 2009 Blackwell Publishing Ltd ISBN: 978-1-405-15916-6

6 Massage for Therapists Hair Hair follicle Stratum corneum Merkel’s Stratum lucidum discs Stratum granulosum Epidermis Meissner’s disc Stratum spinosum Capillaries Stratum basalum Capillaries Free nerve ending Sweat Sebaceous gland gland Pacini’s corpuscle Dermis Figure 2.1 The skin. Erector pili muscle Ruffini’s corpuscle Capillaries Hypodermis Adipose tissue Absorption: drugs and some other substances, much friction, e.g. soles of the feet and palms of the such as essential oils, can be absorbed through the hands. skin. ᭿ Stratum basalum: the deepest layer of the epi- Immunity: specialised cells destroy pathogenic dermis. It consists of a layer of column-shaped, organisms, and Langerhans’ cells function with T hydrated cells that contain nuclei and are cells to provide immune reactions to some diseases. mitotically active. This layer also contains melanocytes (melanin pigment cells), the To convey emotions: reddening of the skin number of which account for variations in skin may convey anger or embarrassment. Blanching of colour as well as helping to protect from exces- the skin can show anger or fear. Even tiny hairs sive UV rays. may become erect in frightening situations. ᭿ Stratum spinosum: this layer of irregularly Structure shaped cells lies on top of the stratum basalum. There are intercellular bridges between the cells, Epidermis giving a prickly or spiny appearance. Ribonucleic acid (RNA) is present and initiates the produc- This is made up of five layers or strata. The cells tion of keratin, a water-repellent protein. The are mitotically active (i.e. they reproduce by split- stratum basalum together with the stratum spi- ting in two) in the lowest zone. As they work nosum form the germinativum layer. through the layers, they change, gradually harden- ing and drying until they become keratinised dried ᭿ Stratum granulosum: this layer lies on top of cells in the topmost layer, the stratum corneum. the stratum spinosum and has spindle-shaped Here they desquamate (fall off). This process takes cells. The nuclei of the cells are missing or dis- about 35 days under normal circumstances, which integrating. This layer together with the stratum maintains the constant thickness of the epidermis. lucidum, the next layer above, may be missing ‘Thin’ skin covers most of the body surfaces, ‘thick’ in ‘thin’ skin. The process of keratinisation skin being found where there is a likelihood of starts here due to the presence of kerato-hyaline.

Relevant anatomy and physiology: an overview 7 ᭿ Stratum lucidum: this appears as a clear layer Function of closely packed cells with no nuclei. The cells ᭿ To pack and support blood vessels, lymphatic have a soft substance called eleidin, which is gradually being turned into keratin. and nerve fibres and some organs. ᭿ To bind the skin to underlying layers. ᭿ Stratum corneum: this is the most superficial ᭿ To store fat in the body, act as an insulator and layer and acts as a barrier and a protection against trauma to the skin due to its many play a part in heat regulation. layers of horny epithelial scales, containing ᭿ To protect the organs. keratin, in which no nuclei are discernible. This ᭿ To give mobility to the skin. is particularly evident in ‘thick’ skin. It is the only completely keratinised layer, and is where Skin thickness varies. It is 5 mm in some places, desquamation continually takes place. such as the back, and 0.5 mm in others, such as in the eyelids. Dermal–epidermal junction Appendages of the skin This cements the epidermis and dermis together, Nails provides support for the epidermis and acts as a partial barrier to certain cells and large molecules. These are formed by cells, which originally devel- oped in the stratum basalum and have become Dermis (corium) keratinised. Although nails do not have sensory nerve endings, pressure on them can cause sensa- The dermis lies below the epidermis and the tion in surrounding tissues, and can help with the dermal–epidermal junction. It consists of two sense of touch. parts: Hair ᭿ Papillary layer: this is the upper layer. It has fibrous and connective material which forms Hair grows on most parts of the body, but not on ‘convex humps’ into the epidermis called papil- the palms or the soles of the feet, lips and some lae. Sensory nerve endings and capillary and genitalia. The hair is a keratinised structure with no lymphatic vessels project into the papillae. sensory endings and arises from the base of the hair follicle, which is a deep indentation in the skin. The ᭿ Reticular layer: this has a much more dense erector pili muscle is attached to the follicle and, network of fibres than in the papillary layer. when required, it makes the hair erect, e.g. in cold Collagen and elastic fibres are present, helping or in fear. to give structure, support and elasticity to the skin. Sweat glands (sudoriferous glands) Sensory nerve fibres and receptors, capillaries There are two types: and lymph vessels as well as sweat glands and hair follicles are to be found in the dermis. Voluntary ᭿ Eccrine: these are the most numerous, to be muscles such as the facial and scalp muscles are found over almost all the body surface other attached to the dermis, and involuntary muscles than the lips, nails, ears and glans penis. They such as the erector pili, which cause the hair to arise from the subcutaneous tissue and are become erect, are also attached to the dermis. simple tubes, coiled at the base, secreting sweat which contains salts and waste products. As a Subcutaneous adipose layer (superficial fascia) result they help to regulate temperature and (hypodermis) waste excretion. Below the skin proper lies the subcutaneous adipose ᭿ Apocrine: these are found in the axilla (armpit), layer. This is made up of areolar tissue (loose con- the areola of the breast and around the anus. nective cells, rather like bubble wrap) and adipose They arise from the subcutaneous tissue and tissue (fat cells) with capillaries and lymphatic and are larger than the eccrine glands. They are nerve fibres passing through. associated with hair follicles and are simple

8 Massage for Therapists branching tubes. They have a viscous secretion, Piezo-electricity begin to function at puberty and appear to have a sexual function, possibly exuding a sub- Physicists have found that electric fields are gener- liminal scent. ated when pressure or stretch is applied to certain crystals (piezo-electric effect). Living crystals are Sebaceous glands soft and flexible, and crystalline arrangements are the rule, not the exception, in living systems. These are usually associated with hair follicles. Connective tissue is considered by many to be They are simple branching structures, situated in piezo-electric. When bone and cartilage is com- the dermis, other than on the palms and the soles pressed or when tendons, ligaments or skin are of the feet. Some glands open directly onto the skin, stretched, minute electrical pulsations are set up namely those around the glans penis, eyelids and (Oschman 2000). This has led to the possibility that lips. They secrete sebum, an oily fluid which main- connective tissue may have energy-related proper- tains the suppleness of skin and hair and has anti- ties which can be used in certain forms of therapy fungal properties. In adolescence they can be such as massage. overactive. Fluid balances of the skin Ceruminous glands The fluid within the systemic circulatory system is These are a special type of apocrine gland, which a transport mechanism which carries oxygen, carbon are simple coiled tubes, opening into the ear and dioxide, nutrients, electrolytes, hormones, chemi- secreting a waxy substance. cals and many other substances, including waste products, to and from all parts of the body via arter- Connective tissues ies, arterioles, capillaries, venules and veins. Connective tissue is composed of fibres, cells and The lymphatic system primarily carries away sometimes fluids, in varying amounts, according to excess fluids and waste products from different its purpose, together with a ground substance. parts of the body. It produces antibodies in the Collagen and reticulin fibres give support, and lymph nodes to fight infection. There are capillary elastin fibres offer elasticity. Among some of the loops and lymphatic vessels passing up through the cells are fibroblasts which help repair tissue, mast dermis into the papillary layer and it is vital that cells which are involved in inflammatory changes, they function normally, so as to maintain the correct and plasma cells which produce antibodies. The fluid balance not only in the skin but also in the skin is a major connective tissue; others include body. bone, cartilage, ligaments and tendons, as well as blood. THE MUSCULOSKELETAL SYSTEM Function The skeleton Connective tissue supports, transports, connects The skeleton (Fig. 2.2) is the framework of the body and protects the body. Damaged tissue requires and is composed of two types of tissue: healing by the formation of connective tissue. Adhesions occur when fibrous tissue becomes ᭿ Bone proper adhered to structures that have been traumatised. ᭿ Cartilage Overuse in a structure may cause extra fibrous tissue to be laid down in the musculoskeletal frame- Both these are forms of connective tissue. Bone work and it may become fibrosed, causing is a rigid non-elastic tissue. There are 206 separate dysfunction. bones. Movement of the body is possible because

Relevant anatomy and physiology: an overview 9 Publisher's Note: Image not available in the electronic edition Figure 2.2 The skeleton. Reproduced from Thibodeau, G.A. and Patton, K.T. (2003) Anatomy and Physiology, 5th edn. Mosby, St Louis, copyright 2003 with permission of Elsevier.

10 Massage for Therapists when bones come together at joints, the skeletal ᭿ Voluntary muscles (skeletal) muscles attached to the bones either side can by These are under the control of the will and virtue of contraction and relaxation move them. the central nervous system (CNS). The fibres Stimulation of the nerve endings in the muscles are long and striped. They are attached to allows this to take place. the skeleton and are responsible for body movement. Cartilage is softer than bone, slightly elastic and less rigid. It forms the temporary skeleton in the ᭿ Involuntary muscles (visceral) developing fetus but is gradually almost entirely These are not under the control of the will but replaced by bone. It remains on most bone ends under the autonomic nervous system (ANS). forming part of the joint and also in part of the rib The fibres are short and unstriped, lie in the cage and the respiratory tract. visceral walls and move on the contents. Function ᭿ Cardiac muscle This is a form of involuntary muscle, found ᭿ Support: it provides the framework, position only in the heart, not being under the control and shape of the body. of the will but under the ANS. It also has its own nerve supply, and the fibres are short and ᭿ Protection: it provides a protecting environ- striped. They create a wave of contraction ment for the structures within, e.g. ribs for the which pumps the blood onwards through the lungs and skull for the brain. heart, to the blood vessels. ᭿ Movement: the muscles attached to bone at There are over 600 voluntary muscles. The con- joints, by virtue of their contraction and relax- traction of these muscles creates purposeful move- ation, provide movement for the body. ment. Each muscle cell or fibre is roughly cylindrical in shape and consists of tiny parallel subunits called ᭿ Storage: bones provide storage for minerals myofibrils. Different structures help protect the such as calcium and phosphorus. individual elements that compose muscle and are as follows: ᭿ Blood cell formation: red bone marrow inside the ends of long bones such as the ᭿ Endomysium: this is a delicate membrane of humerus and the femur, and flat bones of the connective tissue covering the muscle fibres. skull, etc., provide blood cells. ᭿ Perimysium: this is a stronger connective Muscles tissue membrane which covers the groups of fibres. The muscles are soft tissue structures responsible for movement (see Figs. 2.3 and 2.4). ᭿ Epimysium: this is the coarser connective membrane sheath which covers the whole Function muscle formed by a collection of the groups of fibres. Contraction: muscles have contractile tissue, which when activated facilitate movement, produce Associated with muscles are the following: heat and maintain posture. tendons, aponeurosis, ligaments and fascia. Tendons The fibrous tissues that attach muscles to bone are called tendons. Structure Aponeurosis The muscular system is under the control of the This is a flat band of connective tissue which con- nervous system. It can be divided into the following nects one muscle to others by merging with the muscle types: sheaths of these other muscles.

Relevant anatomy and physiology: an overview 11 Publisher's Note: Image not available in the electronic edition Figure 2.3 Skeletal muscles of the body (anterior view). Reproduced from Thibodeau, G.A. and Patton, K.T. (2003) Anatomy and Physiology, 5th edn. Mosby, St Louis, copyright 2003 with permission of Elsevier.

12 Massage for Therapists Publisher's Note: Image not available in the electronic edition Figure 2.4 Skeletal muscles of the body (posterior view). Reproduced from Thibodeau, G.A. and Patton, K.T. (2003) Anatomy and Physiology, 5th edn. Mosby, St Louis, copyright 2003 with permission of Elsevier.

Relevant anatomy and physiology: an overview 13 Ligaments muscle tension, muscle tone, stretch, speed, direction of movement and body position. These are strong bands of fibrous connective tissue which hold bones together at a joint and also Reflexes protect it. Reflexes are automatic motor responses to sensory Fascia stimuli. Nervous system receptors when stimulated are interpreted and conducted through ‘somatic’ This is a structure that covers the whole body, lies reflex arcs in the spinal cord. below the skin and is made up of two layers of connective tissue. ᭿ Stretch reflex: this is a ‘feedback’ mechanism controlling muscle length by causing contrac- ᭿ Deep: this surrounds the muscles, bone and tion of muscle. The sensitivity of the muscle deep organs. spindles to stretch has an effect on muscle tone throughout the body. Hyperactivity of these ᭿ Superficial: this is the layer just under the stretch reflexes causes increased tensions in skin. muscle. Definitions associated with ᭿ Tendon reflex (Golgi receptors): this is a feed- muscle action back mechanism whereby tendons react to the pull of a muscle contraction and respond by ‘Neuro’ refers to ‘nerves’ and ‘muscular’ refers to setting up muscle relaxation, to protect the ‘muscles’. muscle from excessive tension which might tear it from the tendon. ᭿ Motor unit: a muscle and the nerve supplying it make up a ‘motor unit’. ᭿ Flexor and crossed extensor reflexes: the flexor reflex is elicited when an unpleasant sensation ᭿ Motor neuron: a muscle cannot contract is received in one part of the body and other unless it is stimulated by a nerve (motor parts of the body go into action with the inten- neuron). tion of withdrawing from the pain or noxious stimuli, (e.g. if the right foot stands on a ᭿ Neuromuscular junction: a motor nerve (action drawing pin, the reflex action withdraws the nerve) stimulates a muscle through a motor end- foot and the individual rebalances, and possi- plate at the ‘neuromuscular junction’. bly shouts). ᭿ Neurotransmitter: a chemical such as acetyl- Reciprocal innervation choline, which transmits signals across a gap (between two neurons) called a synapse. This occurs when one muscle contracts and its opposite muscle relaxes, e.g. when the biceps con- ᭿ All-or-none law: muscle fibres obey the ‘all or tracts, the triceps reciprocally relaxes. none law’, i.e. each muscle fibre contracts maximally. Common terms ᭿ Aerobic respiration: muscles get their potential Origin: this is the point from which a muscle energy from reactions between glucose mole- arises. cules and adenosine triphosphate (ATP) in the presence of oxygen. Insertion: this is the point at which the muscle is finally attached. The origin is usually the ‘fixed’ ᭿ Anaerobic respiration: if the oxygen supply to point and the insertion is the ‘moveable’ point. a muscle is reduced, as in high-intensity exer- Sometimes muscles do work from a reversed origin. cise, then the ATP is provided by ‘glycolysis’, a process that can proceed in the absence of Action: this is the movement that occurs as a oxygen, using glycogen stores in the muscle. result of muscle contraction. Lactic acid is an end product of this process and causes temporary aches in muscle. ᭿ Proprioceptors (mechanoreceptors): these are specialised nerve receptors which receive and transmit information about joint position,

14 Massage for Therapists Tone: continuous partial contraction of some of fascial trigger points, or MTPs). MTPs are sensitive the muscle fibres causes tautness in a muscle but to pressure and can feel tight (taut bands) and very not movement. For example, the postural muscles tender. Pain is often referred from these points else- that keep us upright in standing or sitting are where. The local circulation is altered due to many constantly finely adjusting their contractions to different factors (metabolic, stress, nutrition, counteract gravity. mechanical, posture, etc.). A ‘twitch’ response may occur when points are palpated. The painful points Anatomical position and areas are often found in similar zones in differ- ent individuals. Fig. 2.5 shows what is termed the anatomical posi- Nerve impingement tion of the human body. Movement of the head, trunk and limbs, and position of these parts, is Soft tissues may cause compression or entrapment given particular terminology in relation to the ana- of a nerve, causing altered sensation or pain. tomical position (Fig. 2.6). THE NERVOUS SYSTEM Common terms The nervous system is divided into the central Anterior: to the front. nervous system (CNS) and the peripheral nervous Posterior: to the back. system (PNS). Medial: nearest to the midline. Lateral: furthest from the midline. The CNS Proximal: nearest to the trunk. Distal: furthest from the trunk. The CNS is composed of the brain within the skull, Abduction: away from midline. i.e. the cerebrum, the cerebellum, the midbrain, the Adduction: towards midline. pons, the medulla oblongata, the hypothalamus, Flexion: bending. the ventricles, the pineal body, the thalamus and Extension: straightening. the basal ganglia. Covering the brain are the menin- Lateral rotation: turn outwards. ges and the cerebrospinal fluid (CSF). The spinal Medial rotation: turn inwards. cord within the vertebrae, and its coverings, the Circumduction: abduct, adduct, flex, extend, meninges and the CSF are also part of the CNS. rotate outwardly and rotate inwardly, all in one The PNS full movement. Pronation: to place the anterior aspect face down. Supination: to place the anterior aspect face upwards. Opposition: to pull across (the thumb across the palm). Dorsum: anterior aspect of the foot or hand. Plantar: underside of the foot (sole). Palmar: palm aspect of the hand. Trigger points The PNS is composed of nerves and ganglia: These are small areas of tension or micro spasms ᭿ Cranial nerves (12 pairs) originate in the brain in muscle or connective tissue (also known as myo- but go beyond the anatomical boundaries of the brain and the spinal cord.

Relevant anatomy and physiology: an overview 15 Skull Cervical spine − midline Clavicle Scapula Humerus Rib cage The trunk Innominate Spine Olecranon process bone midline Palm facing forward Thumb Sacrum Ulna Radius 8 Carpal bones Palm facing forward − 5 metacarpals Coccyx Thumb 14 phalanges Patella Fibula Tibia 7 Tarsal bones Dorsum 5 metatarsal bones of foot 14 phalanges Big Big toe toe Figure 2.5 Anatomical position (anterior aspect). Palms of hands and dorsum of feet face forward.

16 Massage for Therapists Fingers abducted Forearm pronated Arm Elbow flexed adducted Arm abducted and laterally rotated Elbow extended Median Sagittal plane planes Forearm supinated Coronal plane Fingers adducted Lateral side Proximal Leg laterally rotated Medial Leg medially Foot extended side rotated (dorsiflexed) Distal Foot flexed (plantar flexed) Figure 2.6 Some anatomical terminology. Reproduced from Faiz O. and Moffat D. (2006) Anatomy at a Glance, 2nd edn., copyright 2006 with permission of Blackwell Publishing Ltd. ᭿ Spinal nerves (31 pairs) pass from the spinal efferent nerves and sensory (sensation) afferent cord to its periphery (anterior motor roots) and nerves and a combination of these called mixed from its periphery back to the spinal cord (pos- nerves. terior sensory roots). ᭿ Autonomic spinal nerves (ANS) which inner- vate the viscera. There are two types of auto- There are two types of spinal nerves: nomic nerves: ᭿ Sympathetic nerves which have an ᭿ Spinal nerves which innervate muscles, joints and other structures, namely motor (action) excitory stimulating role (fight or flight syndrome).

Relevant anatomy and physiology: an overview 17 ᭿ Parasympathetic nerves which have the guide for other rhythms (McCraty et al. 1995). an inhibitory role (rest and repair The synchronisation of the rhythms of the heart, syndrome). respiration and digestion promotes body balance or homeostasis to create a healthy body. Basic structure of the nervous system THE CIRCULATORY SYSTEM ᭿ Neurons: a neuron is made up of a nerve cell, with its receiving processes, the dendrites, and This is composed of two main parts, the cardiovas- its transmitting processes, the axon fibre and cular system and the lymphatic system. its nerve endings. White nerve fibres are medul- lated (covered in a fatty sheath called myelin). The cardiovascular system Grey fibres have no such myelin sheath. ᭿ Neuroglia (glia): this is the supporting struc- ture around the neurons. The neuro-endocrine mechanism This consists of the heart, the arteries, the arteri- oles, the capillary network, venules and veins, Many cells have receptors for neurotransmitters which form a closed system (Fig. 2.7). and hormones and can therefore be influenced by both types of chemicals. The endocrine system Function influences the nervous system and likewise the nervous system influences the endocrine system – a Transport: it carries oxygen, nutrients, salts, hor- feedback loop. mones, leucocytes to fight infection, clotting factors and other substances to the tissues, and returns The neuro-endocrine content regulates physio- waste products, carbon dioxide, water, dead cells, logical function. In an ever-changing chemical etc. back to the excretory organs of the body, as well mixture there are fluctuations depending on body as regulating temperature by movement of fluids. demands. Mood and perceptions of pain and stress can be affected by the variations in proportion of Structure these chemicals. The heart is the centre of this system, being a mus- For example, Dr Candace Pert and others discov- cular organ which pumps blood out through the ered endorphin and non-endorphin pain-inhibiting arteries and arterioles into a capillary network sur- hormones associated with activity of the CNS (Fritz rounding tissue cells, and back through venules and 2004). Moreover, the body produces several opiate- veins (which have valves to prevent backflow) to like compounds such as enkephalin and beta endor- the heart (which also has valves to prevent back- phins. These help to relieve particularly chronic flow). The contracting period of the heart is called pain and produce euphoria. The body also pro- ‘systole’ and the resting period is called ‘diastole’. duces cortisol hormone, which is at high levels The blood itself is an alkaline fluid, total volume when the nervous system is under stress. approximately 5–6 litres (10 pints) and consists of plasma and blood cells. Entrainment Plasma This is an important reflex action which appears to be processed through the ANS and is the co-ordina- Plasma is the liquid part, clear and straw coloured, tion of a synchronisation of various system rhythms. containing various substances including salts, In the body, biological oscillators such as the thala- hormones, plasma proteins, sugars, urea and amino mus of the brain and the heart set this pattern of acids. rhythm. Research at the Institute of HeartMath in California, USA, indicates that the heart rhythm is

18 Massage for Therapists Blood pressure Publisher's Note: This is the force or pressure exerted on the walls of Image not available an artery by the blood contained within it. It is in the electronic edition influenced by age, exercise, rest, emotion, haemor- rhage, arteriosclerosis (or hardening of the arteries by deposits of certain salts) and atherosclerosis (furring up of the arteries by certain types of cho- lesterol deposits). Variations in blood pressure are considerable, but approximate readings in normo-tensive indi- viduals should be, at rest, below 140 mm of mercury (or electric reading) for systole and below 90 mm of mercury (or electric reading) for diastole. The lymphatic system Figure 2.7 The cardiovascular system. Adapted from The lymphatic system is shown in Fig. 2.8. Thibodeau, G.A. and Patton, K.T. (2003) Anatomy and Physiology, 5th edn. Mosby, St Louis, copyright 2003 with Function permission of Elsevier. Drainage: of excess tissue fluids, maintaining fluid Blood cells balances via lymph and blood capillary vessels. ᭿ Red cells or corpuscles (erythrocytes) (RBCs). Immunity responsibility: via lymphocytes There are approximately 5 million per cubic manufactured in the lymph nodes. millimetre (mm) of blood, and they are bi- concave with no nucleus. They are very small Absorption: of fats and other nutrients via the and so can pass through a capillary wall. They lacteals which carry ‘chyle’, a specialised type of contain a substance called haemoglobin which lymph, from the villi projections of the small intes- carries oxygen to all parts and takes away tine into the cisterna chyli, a chamber at the base of carbon dioxide. They are manufactured in the the thoracic duct in the thorax. Ultimately the con- red bone marrow. tents of the duct flow into the cardiovascular system, where the duct joins the left subclavian vein. ᭿ White cells or corpuscles (leucocytes or phago- cytes) (WBCs). There are approximately 8000 Structure per cubic mm of blood, and there are different types. Larger than RBCs, they have a nucleus The lymphatic system is not a closed circulatory generally irregular in shape. They are produced system like the cardiovascular system. It consists of in bone marrow. They help with the defence of lymph capillaries (starting with blind-ended ducts the body, being part of the immune system. in the tissues), lymph vessels, lymph nodes and two ducts, the right lymphatic duct and the thoracic ᭿ Platelets (thrombocytes). There are approxi- duct, both found in the trunk. Tonsils, Peyer’s mately 250,000 per cubic mm of blood. They patches, the spleen and the thymus gland are also are minute spherical structures produced in part of the lymphatic system. red bone marrow. They are essential for clotting. Lymph Lymph (which closely resembles blood plasma and intercellular fluids) is the liquid that is absorbed by the lymph capillaries and is then carried through

Relevant anatomy and physiology: an overview 19 Upper cervical glands Submandibular glands Right lymphatic Lower cervical glands duct Thoracic duct Left subclavian vein Right subclavian Axillary glands vein Thoracic duct Cysterna chyli Supratrochlear glands Abdomenal glands Iliac glands Inguinal glands Lymphatic Popliteal glands glands Figure 2.8 The lymphatic system. Adapted from Faiz O. and Moffat D., Anatomy at a Glance, Lymphatic copyright 2006 with permission of Blackwell vessel flow Publishing Ltd. Area drained by right lymphatic duct lymph vessels and nodes, to be drained via the two breathing through its carbon dioxide levels. The ducts into the cardiovascular system at their junc- movement of CSF has a pumping rhythm that some tion with the right and left subclavian veins. contend can be palpated. This rhythm seems to affect the phenomenon of fascial movement and is Lymphatic pump independent of other body rhythms. The lymph flows steadily through the lymphatic system to the right lymphatic duct and the thoracic Structure duct and thence into the two subclavian veins. The pumping action of contracting muscles and respira- The brain and spinal cord have three coverings, and tion aids this, together with the valves in the vessels a cushion of fluid. The coverings are: which prevent backflow of the liquid. ᭿ The outer dura mater ᭿ The middle arachnoid mater THE CEREBROSPINAL FLUID ᭿ The inner pia mater SYSTEM The fluid is: Function ᭿ The cerebrospinal fluid (CSF) Cerebrospinal fluid (CSF) nourishes, cools and pro- In the subarachnoid space around the brain and the tects the brain and spinal cord and influences spinal cord, and within the canals and cavities of the brain and spinal cord, there is CSF. It is sepa-

20 Massage for Therapists rated from the blood in the choroid plexuses which The effects of stress on the are networks of capillaries in the brain. It circulates endocrine system in the subarachnoid space and is reabsorbed into the venous blood through fingerlike projections Although difficult to define, stress can be anything (villi) of the arachnoid membrane. to disturb a person’s sense of wellbeing. What may for one person be an enjoyable challenge, to another Fluid balances may be a stressful situation. In particular will be those times when there are major life changes. If we did not maintain the chemical nature and There are obvious events that are considered to be other characteristics of our internal body environ- stressful for nearly everyone: divorce, separation, ment, we could not survive. Circulatory fluid in bereavement, moving house, injury or illness, and the cardiovascular system, the lymphatic system job loss are examples. and indeed the CSF system shifts chemical products from place to place, and redistributes heat, The body’s natural response to stress is to produce pressure, nutrition and waste, etc. and helps to keep extra adrenaline, noradrenaline and corticosteroids. this environment normal. These increase heart rate and respiration as well as blood flow to muscles, so we are better equipped This balance of fluids is a vital part of homeosta- to run away from the event or stay and fight it. sis balance which keeps the body healthy. Selye researched these phenomena and termed it the ‘fight or flight’ reaction to stress (Antony and THE ENDOCRINE/HORMONAL Thibodeau 1979). SYSTEM (DUCTLESS GLANDS) Over a period of time, if unrelieved, stress may Function lead to conditions such as undue anxiety, insomnia and depression, as well as symptoms such as head- The nervous system and the endocrine system work aches, fatigue and digestive upsets. on their own or together as the neuro-endocrine system, to help maintain communication, integra- Chronic stress where pressures are relentless, tion and control. Both perform their function via unmanageable or overwhelming is acknowledged chemical messages sent to specific cells. as a risk for serious illness, hypertension, heart disease and mental illness. Structure THE RESPIRATORY SYSTEM There are glands in different parts of the body which perform specific functions via ‘hormones’, Function types of chemical messenger secreted by each gland and sent not through an opening (duct) but directly Inspiration: the respiratory system is responsible into the bloodstream. for taking in oxygen, which is vital for all living cells as they require a constant supply in order to The following constitute the main glands: carry out their energy processes (metabolism). This is called inspiration. ᭿ Pituitary (anterior and posterior) ᭿ Pineal Expiration: the respiratory system also gives up ᭿ Thyroid carbon dioxide and water vapour, which occurs as ᭿ Parathyroids a waste product of the metabolism. This is called ᭿ Adrenals (cortex and medulla) expiration. ᭿ Pancreas ᭿ Gonads (ovaries in the female and testes in Structure the male) The organs of respiration are:

᭿ The upper respiratory tract: which comprises Relevant anatomy and physiology: an overview 21 the nose, the mouth, the throat, the larynx, the sinus cavities and the Eustachian tubes. THE DIGESTIVE SYSTEM ᭿ The lower respiratory tract: which comprises Function the trachea (windpipe), the bronchi, and bron- chioles and alveoli (air cells) of the two lungs. Absorption of nutrition: the main function of the The two lungs (right and left) lie in the thorax digestive system is to change nutrition taken via the (chest) and either side of the heart. They are mouth into a suitable form so that it can be easily inert organs, meaning they work by a variation absorbed into the body and utilised for growth, in the atmospheric pressure, caused by the repair, heat and energy, with the waste products of work of the intercostal muscles and diaphragm these metabolic processes excreted at the anus, and muscle, to which they are attached. These by the urinary system, and sweat glands. muscles are themselves attached to the ribs (intercostals) and the vertebrae behind Structure (diaphragm). The digestive system proper is in essence a long tube External respiration stretching from mouth to anus with vital digestive structures incorporated along its route. These are Inspiration occurs when these muscles contract and the mouth, oesophagus, stomach, small intes- expand the thorax, sucking air through the upper tine and large intestine (Fig. 2.9). and lower respiratory tracts into the alveoli of the lungs. Expiration occurs when these muscles relax, The digestive contents, once they leave the mouth the ribs revert to their original position and the and upper part of the oesophagus, are moved by lungs recoil, driving air out through the lower and the action of the involuntary muscles of the diges- the upper respiratory tracts and expelling it through tive tract, by a wave-like phenomenon called the mouth. ‘peristalsis’. Internal respiration Accessory organs of digestion The inspired air containing oxygen passes through Liver: which produces bile to emulsify fats in the millions of air cells (alveoli) which have very thin digestive tract and stores products of digestion, walls. Oxygen is absorbed through these walls into among other important functions. the blood capillary networks surrounding the alveoli and travels via the cardiovascular system to Gallbladder: which stores bile from the liver, to all the tissues of the body. Carbon dioxide and be used when there is more fat than usual in the water vapour pass out from the blood capillaries digestive tract. back into the alveoli during expiration. Pancreas: which produces enzymes used to act on fats, carbohydrates and proteins in the digestive tract, as well as producing insulin for sugar metabolism. Nervous and chemical control THE ENERGY SYSTEM of respiration Technology is beginning to enable researchers to The carbon dioxide and hydrogen ion content of measure this subtle body system, to show that these arterial blood influences respiration by stimulation electrical fields exist. Animal studies show, for of chemo-receptors within the brain (medulla example, that the platypus detects its living food oblongata). Above-normal levels of these chemicals source by sensing the electrical field around its prey will promote faster breathing and a greater volume of air passing out in expiration.

22 Massage for Therapists Parotid gland Mouth Pharynx Tongue Larynx Sublingual gland Trachea (windpipe) Submandibular gland Oesophagus Lung Lung (gullet) Stomach Diaphragm Spleen Pancreas Liver Gall bladder Descending colon Transverse colon (of large intestine) (of large intestine) Ascending colon Small intestine (of large intestine) Sigmoid colon (of large intestine) Appendix Rectum Anus Figure 2.9 The digestive organs. (Alcock 1989). There is considerable scientific Faiz, O. and Moffat, D. (2006) Anatomy at a Glance, 2nd debate, however, on the truth of the effectiveness edn. Blackwell, Oxford. of therapies based on such piezo-electric compo- nents of the body. Connective tissue, as already Fritz, S. (2004) Fundamentals of Therapeutic Massage, 3rd noted, is piezo-electric, and it extends throughout edn. Mosby, St Louis. the body even to the innermost parts of each cell (Oschman 2000). Stimulation of a piezo-material McCraty, R., Tiller, W.A. and Atkinson, M. (1995) Head– causes either generation of an electric current or a Heart Entrainment – A Preliminary Survey. Institute of vibration. Kirlian photography demonstrates the HeartMath, Boulders Creek. electromagnetic aura of energy which emanates from the body. Oschman, J.L. (2000) Energy medicine – the new paradigm. In: Complementary Therapies for Physical Therapists (ed. Dr Candace Pert theorises that energy healers R.A. Chapman), Part 1, pp 3–36. Butterworth-Heinemann, may use their own energy fields to enhance the Oxford. energy in their patients (Pert 1999). Massage by application of pressure has an effect on connective Pert, C.B. (1999) Molecules of Emotion; Why You Feel the tissue which may enable it to conduct piezo- Way You Feel. Simon & Schuster, London. electricity. Further reading References Field, T. (2006) Massage Therapy Research. Churchill Alcock, J. (1989) Animal Behaviour: An Evaluatory Livingstone, Edinburgh. Approach. Sinawar, Sunderland, Massachusetts. Guyton, A.C. (1991) Textbook of Medical Physiology. W.B. Antony, C.P. and Thibodeau, G.A. (1979) Anatomy and Saunders, Philadelphia. physiology. In: Selye’s Concept of Stress (ed. H. Selye), p. 664. Mosby, St. Louis. Rowett, H.G.Q. (1999) Basic Anatomy and Physiology, 4th edn. John Murray, London. Thibodeau, G.A. and Patton, K.T. (2002) Anatomy and Physiology, 5th edn. Mosby, St Louis. Thomson, A., Skinner, A. and Piercey, J. (1991) Tidy’s Physiotherapy, 12th edn. Butterworth-Heinemann, Oxford.

Evidence-based effects, risk awareness 3and contraindications for massage Dr David Lee and Carol Young* Observation of the animal kingdom suggests that The potential effects of massage are many and ‘rubbing’ of different types is useful to deal with the variations in technique introduce yet another array various discomforts of living. We have all observed of variables. Replication of studies is hindered by domesticated animals ‘licking’ and ‘stroking’ such subtleties as changes in rhythm or depth of wounded areas. Puppies and kittens are licked to technique and the length of application of massage. facilitate digestive functions. Some primates rub Many studies report misleading findings due to each other to assist toleration of or to relieve a methodological inadequacy and inconsistency disorder. Every one of us has been rubbed or patted between studies. in infancy to assist voiding of wind and also to comfort and induce sleep in the fretful. Most of us Despite the problems with some of the research will have held and then rubbed our bumps and into the effects of massage, there would seem to be painful areas such as disordered joints and muscles. reasonable consensus with subjectively claimed These are subjective glimpses of some of the per- benefits as to the systems and areas of the body ceived benefits that massage may provide. affected by massage. Massage has effects that have been described traditionally under the following Massage has been regarded for a long time as main headings: having a variety of physiological and psychological effects (if from a largely empirical base). In recent ᭿ Mechanical years the therapeutic trend is ever more towards ᭿ Physiological evidence-based practice and this has led to an ever- growing body of research seeking to establish sci- ᭿ on the circulatory system entifically the effects of massage. The research ᭿ on the nervous system investigating the effects of massage, as with many ᭿ on the musculoskeletal system areas of medicine, has produced evidence that is ᭿ Psychological incomplete and often contradictory. There is some difficulty in completely separating *From the chapter by Janice M. Warriner and the late Alison the effects under these individual headings as it M. Walker in the second edition of this book (Hollis would seem some effects could have appeared under 1998). at least two headings; for example, circulatory effects on the skin may be viewed as both mechani- cal and physiological. Part of the problem arises from the fact that massage is a system of mechani- cal techniques and when applied to living tissues Massage for Therapists: A guide to soft tissue therapy , Third edition By Margaret Hollis, Edited by Elisabeth Jones © 2009 Blackwell Publishing Ltd ISBN: 978-1-405-15916-6

24 Massage for Therapists subsequent effects are usually physiological – if at The stretching effects of carefully selected times bordering on the pathophysiological. Few massage manipulations can help in promoting or effects would seem to be mechanical only. retaining mobility of new ‘skin’ tissue relative to Subdivision of physiological effects into circulatory underlying tissue layers. The mechanical stresses of and neurological may also be problematic as not all massage are useful to attempt to counter the ten- of the reported effects fit neatly into these dency for repair scar tissue to shrink and shorten. subheadings. Massage is often very successful in maintaining scar length while contributing to the strength of the The effects of massage will be discussed under repair and maybe assisting with other changes in these main headings, while acknowledging seman- the surrounding area, even if they are more through tic variations. Following this description of the circulatory effects. effects of massage under these broad headings an examination of the issues surrounding the efficacy There is good reason to believe these positive of massage therapy in vulnerable groups will be influences on superficial scar tissue can be repeated presented along with situations where massage at deeper tissue levels. Mobility between tissue therapy might be contraindicated or even ill interfaces occurs normally unless fibrous adhesions advised. are present, when massage may stretch the tissues on one another. Appropriately timed massage inter- Mechanical effects vention to encourage strength and alignment of repair fibres can enhance the natural process of Massage may have a number of effects on the skin. healing in the tissues. The constant passage of the hands over the skin will remove dead surface cells and allow the sweat The percussive manipulations performed over glands, the hair follicles and the sebaceous glands the lungs have the mechanical effect of jerking to be free of obstruction and to function better. The adherent mucus free from the bronchial tree and, increased lubricant effect is seen especially when aided by gravity, assisting the removal of sputum desquamation is a problem. The circulatory effects towards the upper respiratory passages. The jarring on the skin are exhibited in some subjects by effect and the vibratory effect probably cause some obvious reddening and by an increase in warmth mixing of respiratory gases, while vibrations per- often commented on by the patient. formed on the distended, wind-laden abdomen cause movement of the wind and relief of discom- Mobilisation of the skin and tissues at deeper fort, whether in the infant after a feed or patients levels is possible through the mechanical influence in the post-operative abdominal recovery stage. The of the massage. The lightest massage will cause mechanical effects of massage have for a long time movement of the epidermis by the movement of the been reported to be effective in terms of encourag- hand over the skin. In turn the epidermis moves on ing hyperaemia (resulting from histamine release), the underlying tissues and the dermis on deeper increasing the suppleness of tissues and parasympa- tissues. thetic activity, relaxing muscle tone, reducing oedema, activating mast cells and relieving subcu- Therapeutically, massage has been used widely in taneous scar tissue (Ironson et al. 1996; Duimel- the management of scar tissue, the benefits of which Peeters et al. 2005). can be observed most readily when healing of the skin is involved. Approximately 5 days after any Physiological effects damage has been sustained the weaker type III col- lagen is laid down as part of the repair process and Physiological effects on the begins to be converted to the stronger type I colla- circulatory system gen (Lakhani et al. 1993). Massage may provide externally applied stresses that can influence the When massage is applied to the skin there is quite conversion of one type of collagen to another as often an observable change of colour in the area. well as the alignment of fibres which tends to be This change has been attributed most usually to the along lines of stress.

Evidence-based effects, risk awareness and contraindications for massage 25 massage having an effect on the circulatory system. from increased limb volume following venous It has been reasonable to consider that massage occlusion. Following the application of vigorous, applied to deeper structures would have similar stimulating massage to normal subjects, average effects on the blood vessels within such structures. increases in blood flow of 57% and 42% for upper Research papers have attempted to explore many (n = 12) and lower (n = 14) extremities respectively aspects of the circulatory effects achieved by were found. Even greater increases averaging 103% massage. Circulatory flow (venous, lymphatic, arte- were shown following massage of limbs (n = 7) that rial), blood velocity and blood viscosity have were flaccidly paralysed following poliomyelitis. all been areas of investigation during the last However, Wakim states that this massage is more 50 years. forceful than that normally used by therapists and suggests that such pressure could be damaging to The squeezing, compressive and pushing ele- flaccid limbs. No evidence is provided for these ments of the massage manipulation carried out with assumptions and the sample sizes reported in this centripetal pressure are widely considered to bring study are obviously small, limiting the generalis- about drainage of venous blood and lymph. This ability of these findings. was a view held by Scull (1945) who considered that venous and lymphatic flow could be mechani- In the same paper Wakim also reports findings cally enhanced in this way by ‘displacement of their on blood flow alterations using a less vigorous contents into regions subjected to lesser pressure’. ‘modified Hoffa type of deep stroking and knead- Scull hypothesised further that such changes in cir- ing’. In one ‘normal’ subject no significant increases culatory flow may have occurred due to neurovas- in blood flow were found. Taking a 15% or above cular adjustments. increase as clinically significant Wakim reported significant increases in four out of six observations A more recent study by Mortimer et al. (1990) of massage to flaccidly paralysed limbs, with an looked at skin lymph flow in anaesthetised pigs average increase of 22% over the six readings. using a ‘hand-held’ massager. The researchers found significantly increased (p < 0.005) isotope clearance Similarly, Severini and Venerando (1967) found rates in the massaged leg compared with the con- significant increases in blood flow with deep tralateral leg. massage. Only insignificant changes were noted with superficial massage. It is difficult to relate these findings directly to the effects of manual massage on the conscious In 1952 Ebel and Wisham, using sodium radio- human, but it does encourage speculation as to how isotope clearance procedures, found no increase in changes in venous and lymphatic flow may be calf muscle blood flow after 10 minutes’ massage achieved. in comparison with a control test the previous day (n = 7). Hansen and Kristensen (1973), using 133 The drainage of venous blood can be observed if xenon isotope clearance, found a significant increase a dependent hand in which the superficial veins are (p < 0.01) in muscle blood flow during 5 minutes’ easily observed is stroked firmly. The soft-walled effleurage. This was followed by a significant veins are compressed and the blood within them decrease (p < 0.05) for 2 minutes post massage flows onward or centripetally. Its return is stopped before returning to baseline values. The authors by the presence of valves, which prevent backflow, hypothesise that increases in blood flow during and by the blood behind waiting to take its place. massage may be due to emptying of the capillary Lymph vessels are also thin walled and affected in bed, leading to a decrease in blood flow post the same way. All the minute drainage vessels must massage as the capillary bed refills. The authors be equally affected so that as blood and lymph also comment that the increases are relatively small, flows onwards more rapidly due to the massage, the even less than in light exercise. replacing blood moves more quickly. In this way the drainage of treated tissues is enhanced, allowing Also using 133 xenon clearance as an indicator fresh blood an unimpeded flow. of muscle blood flow, Hovind and Nielsen (1974) compared the effects of 2 minutes’ petrissage to the A number of studies have attempted to investi- thigh and forearm with 2 minutes’ tapotement to gate changes in blood flow and have produced vari- the contralateral thigh and forearm (n = 9). Resting able findings. Wakim et al. (1949) examined blood values were recorded prior to the intervention. flow using venous occlusion plethysmography, a Blood flow significantly increased (p < 0.01) fol- technique whereby the arterial flow is calculated

26 Massage for Therapists lowing tapotement, but no significant change was state that they had studied these effects previously noted following petrissage. The researchers suggest and found only small, insignificant falls in viscosity. that tapotement might cause repeated muscular In opposition to the findings of Ernst, Arkko et al. contractions, precipitating increased blood flow. (1983) had previously found no change in haema- tocrit values following a 1-hour whole body In a more recent study Tiidus and Shoemaker massage. (1995) measured muscle blood velocity using ultra- sound velocimetry (n = 9). Arterial blood velocity On a cautionary note, when studying both was measured before and during a 10-minute humans (n = 6) and dogs (n = 8), Eliska and massage comprising deep and superficial effleurage, Eliskova (1995) found that massage applied at pres- at 1 hour and 72 hours post treatment. Venous sures of 70–100 mmHg caused damage to lymphatic blood velocity was measured at 72 hours post treat- vessels. The damage was greater if oedema was ment. No significant differences were noted between present. the rest and massage conditions for either arterial or venous velocities. Further investigation using Blood pressure, heart rate, skin temperature and Doppler ultrasound to assess blood flow in the conductivity, and oxygen consumption are among lower limbs was conducted by Shoemaker et al. the factors researched. The findings of these studies (1997). These authors reported that manual massage into the effects of massage on these parameters are did not elevate muscle blood flow in any of the inconsistent. Comparison of studies is fraught with muscle groups massaged, nor did the type of massage difficulties: study groups vary from the healthy to used impact on muscle blood flow. They concluded the critically ill, and the massage applied varies that if increased blood flow is the desired therapeu- from a 1-minute back rub to a 1-hour whole body tic outcome, then light exercise would be beneficial, massage. whereas massage would not (Shoemaker et al. 1997). These findings contradict those described by A number of well-designed studies failed to find Hovind and Nielsen (1974) who reported a 35% significant differences in a variety of physiological increase in blood flow in skeletal muscle following measures as a result of massage. However, many of massage using the tapotement technique. However, these studies had very small sample sizes. Some these authors report that the technique is rather studies found significant increases while others painful and contraindicated for older people with found significant decreases as a result of massage. thin skin/underlying tissue damage. A number of studies continued measurements for some minutes after massage with variable findings All these studies are hampered by small sample as to the persistence of the effect. Until large-scale sizes and the gross nature of the measurements. well-controlled studies using similar massage inter- Studies of the minute circulation to specific areas vention have been conducted the picture will remain where the blood flow was compromised by trauma unclear. or disease might prove a more useful source of information. Comparison of these findings is diffi- However, it appears unlikely that the changes in cult due to variations in massage applications and blood pressure or heart rate will be great enough study designs. to be of danger to patients. The benefits of any decrease in blood pressure would only be of clinical Ernst et al. (1987) explored the effects of massage usefulness if any carryover effects persist. Further on blood viscosity. Using 12 healthy adults, blood studies into this aspect are required. viscosities were measured before and after a 20- minute whole body massage. A significant fall The observable effects in the human are cutane- (p < 0.05) in native blood viscosity, haematocrit ous circulatory responses occurring in the following and plasma viscosity was noted. The researchers order: concluded that such viscosity changes suggest an inflow into the general circulation of low viscosity ᭿ A transient white line appears in response to fluid derived either from stagnant microvessels or light pressure and is the result of an initial from interstitial fluid. Either of these could have capillary constriction. therapeutic benefits. However, no control group was included in this study to compare the effects of ᭿ Because the tissues are slightly traumatised by rest and postural changes alone. The authors do most massage manipulations and more so by those such as skin rolling and percussive manipulations, a histamine-related substance is released.

Evidence-based effects, risk awareness and contraindications for massage 27 Histamine is stored in mast cells in the connective ‘Hoffman’ or ‘H-reflex’ excitability. The ‘H-reflex’ tissues, and in the basophil cells and platelets of represents an indirect measure of spinal motor blood, all of which may be disturbed or traumatised neurone excitability and therefore the excitability by the various massage manipulations. The release of the spinal reflex pathway. All these studies, pub- of this substance initiates the following triple lished between 1990 and 1994, have consistently response involving three reactions which follow shown a decrease in the H-reflex amplitudes during each other rapidly. A red line appears and is caused massage. This denoted a decrease or inhibitory by dilatation of the minute blood vessels indepen- influence on alpha motoneuron excitability. A dent of the somatic supply of the skin area. A flare similar experimental design was used for all the of redness often described as a ‘flush’ then appears studies: pre-treatment, baseline control readings around the area and is due to a widespread dilata- followed by a few minutes’ massage with readings tion of skin arterioles. This is brought about by the (individual studies used 3-, 4- and 6-minute timings), axon reflex. The third feature of the triple response terminating with post-treatment readings. The is slight swelling, usually described as a wheal. The triceps surae muscle group was used on each increased permeability of the capillary walls allows occasion. escape of more tissue fluid so that the area becomes slightly swollen. This fluid is almost identical to Morelli et al. (1990), by studying nine healthy lymph. subjects, were able to demonstrate a 71% decrease in H-reflex amplitude during a 3-minute applica- Physiological effects on the tion of petrissage to the ipsilateral triceps surae, but nervous system this amplitude reverted to normal levels when the massage was terminated. This suggests that reduced Massage is recognised as having an effect on the motoneuron excitability occurs only when the nervous system. Different methods of application massage is being applied and there is no apparent will provide subtle variations of afferent input carryover effect. A further study demonstrated that which, in turn, may cause a number of possible this inhibitory effect is only achieved in the muscle effects. Practice suggests that manipulations need to group receiving the petrissage and not in other be selected for the specific effects that they may muscle groups (Sullivan et al. 1991). cause. It is believed that the diametrically opposite effects of sedation or stimulation of a patient may The study by Morelli et al. (1991) using more be achieved by selection of appropriate tempo, subjects (n = 20) and a 6-minute period of petris- degree of pressure and length of continuity of each sage confirmed the decreased amplitude of the H- manipulation and the massage as a whole. It is reflex in the triceps surae with still no carryover noticeable that the sedative effect appears to require effects noticeable in the post-massage period. longer to achieve than the stimulatory effect, However, these authors went on to exclude factors whether applied to the patient as a whole or to such as changes in skin temperature, nerve conduc- individual parts of the body. tion velocity and antagonist activity as being responsible for the decrease in H-reflex excitability. In recent years researchers have begun to turn Rapidly adapting cutaneous and/or muscle recep- their attention to proving some of the claimed tors along with inhibitory polysynaptic, non- effects. An ever-increasing knowledge of the mecha- segmental pathways were proposed by the authors nisms operating within the nervous system has as possible mediators of these change(s) because of encouraged this research, along with a revival of the immediacy of the noted response(s). interest in massage as a therapy and the develop- ment of suitable means of measurement. In 1992 Goldberg et al. reported that reduction of H-reflex excitability occurred with both light Alpha motoneuron excitability petrissage (pressure = 1.25 kPa) and deep petrissage (pressure = 2.5 kPa). A greater effect was noted A team of researchers from Montreal conducted a with deep massage and this research team suggested series of studies on the effect of massage on the that pressure-sensitive receptors must be implicated in the mechanisms bringing about the inhibition. Sullivan et al. (1993) went on to report that H- reflex excitability could also be decreased during effleurage.

28 Massage for Therapists Goldberg et al. (1994) reported a similar reduc- Hernandez-Reif et al. (2001) reported significantly tion in H-reflex amplitude during petrissage of the increased serotonin levels in their massage treat- triceps surae in eight out of ten subjects with spinal ment group after intervention (p = 0.05) and cord injuries. The sample included both complete describe this finding as important as chronic pain and incomplete lesions. One patient with complete patients have been shown to have depleted sero- and one patient with incomplete lesions failed to tonin levels. show the reduced H-reflex amplitude. Despite this the main effects of the massage treatment were The spinal cord is taken to be the next point at statistically significant (p = 0.008). The decrease in which pain may be blocked before signals ascend H-reflex amplitude was not as great and was con- to the cerebrum for conscious appreciation of the sidered to be less uniform than noted in the partici- sensation. Since the presentation of the pain gate pants of previous studies. This study did indicate a theory of Melzack and Wall in 1965 and subse- tendency to some carry-over effects post massage. quent modifications to this, there has been a basis Although the sample population was small and this for believing that sensory traffic, into the dorsal might detract from the potency of the reported find- grey areas of spinal cord segments, is sifted and ings, it was felt to be ‘encouraging’ with possible sorted. This is performed by complex neuronal cir- clinical implications if future research could further cuitry including that within the substantia gelati- delineate the potential effects of massage therapy nosa. Signals from different sources are carried on H-reflex amplitude. Sustained decrease in H- along fibres of different diameters and compete reflex amplitude was not noticed in this particular across the synapses of the circuitry for which signals study (Goldberg et al. 1994). will have the right to further transmission. Input of signals along large-diameter fibre pathways com- Pain petes with pain signals along smaller diameter fibre pathways and can close the ‘pain’ gate. This occurs Pain is a complex phenomenon of many compo- via various influences on synapses – preventing pain nents and at the very least encompasses physical signals from further transmission to conscious level. and emotional elements. There are different types Higher levels of the CNS are considered to be of pain: acute, sharp, fast pain, which is carried to involved in pain control, most probably involving the central nervous system (CNS) along ‘A delta’ descending pathways and release of endogenous nerve fibres; and chronic, aching, slow pain, which opiate substances (endorphins). is served by the so-called C fibres. Sensitivity to pain is perceived individually and perception thresholds Some of the descending fibres are thought to seem to be variable. This variability appears to be emanate from areas such as the reticular formation demonstrable both between individuals and even of the brainstem and are triggered by certain within a given individual at different times. Pain pain signals reaching that level within the CNS. perception is thought to be influenced by many Some of the subsequent endogenous opiate release factors, one of these being afferent input to the will be at the reticular formation and at higher CNS, and this may be where massage is able to levels, but also at the spinal cord level. It has been exert its effects. suggested that this will result in the suppression of pain signals entering at these sites (Holey and Cook Control or suppression of pain is deemed to 1997). occur at different levels within the nervous system, although these mechanisms are still more hypo- It has been put forward that the setting of the thetical than fully proven (Carreck 1994). Critical pain gate is controlled by higher centres and this key sites for influencing pain are: (1) peripheral can dominate neural activity at the spinal cord level areas where there is presence of tissue damage; (Melzack and Wall 1988, cited in Carreck 1994). and (2), chemical substances such as bradykinin, It is difficult to define with certainty exactly which serotonin and substance P which are released higher centres may be involved, but parts of the and stimulate the free pain receptors (nociceptors) cerebral cortex and limbic system have been impli- commonly producing the characteristics of cated (Holey and Cook 1997). slow pain previously described (Guyton 1992). Massage may contribute in some way to pain control at all the indicated levels and therefore may influence pain perception and its threshold. Pain receptors are not readily adaptive (Guyton 1992)

Evidence-based effects, risk awareness and contraindications for massage 29 so if harmful chemicals are present as a result of study using subjects with acute and chronic back injury, pain signals are likely to be triggered and pain might give different results. Massage and carried to the CNS. Massage, used appropriately in endogenous opiate release was still considered as accessible peripheral areas of damage, has been the possible mechanism of pain relief. observed as having a positive effect in reducing pain. It is speculated that under these circumstances Weinrich and Weinrich (1990) investigated the the massage may have altered the local circulation effect of massage on patients with cancer pain. The in such a way as to reduce or remove noxious sub- main significant positive finding was a decrease of stances, thereby reducing or removing stimuli, pain immediately post massage, but only for the reflected in a corresponding reduction of response male subjects. There were a number of problems by the pain receptors. with this study. Only 10 minutes’ back massage was performed by student nurses after a minimal Massage can provide the CNS with afferent training period of 1 hour. The control group sub- inputs, some along the larger diameter ‘A beta’ jects were simply visited by the data collector for fibres, that will compete with incoming pain signals 10 minutes. The researchers felt that where there to the spinal cord. This input (if of adequate level) was significant pain reduction this had tended to may block pain signals by a process of presynaptic occur in male subjects already experiencing higher inhibition and may reduce or prevent transmission levels of pain than the female subjects, and males to conscious level. within the control group. Pain levels were self reported. This pilot study posed many questions, Massage input, relative to the higher centres and which have largely remained unanswered. It was the release of endorphins, is a somewhat hypotheti- considered that massage may be a useful option for cal area. It may be possible that sensory signals short-term pain relief. triggered by certain massage techniques stimulate higher levels of the CNS. These areas may be those Puustjarvi et al. (1990) investigated 21 female capable of sending descending signals and this may subjects with chronic tension headaches. Each result in opiate release; some in turn afford pain subject received 10 sessions of upper body massage control through post-synaptic inhibition at spinal – kneading and stroking, with prolonged work over level. Quite how the highest levels of the CNS are trigger points. Pain measured by questionnaire and involved is hard to assess. Can they influence brain- visual analogue scale decreased and the number of stem areas or other areas within the cerebrum? days with neck pain decreased in the follow-up How is this influence exerted via opiate release? period at 3 and 6 months. Additionally cervical Can these areas be affected by sensory input from movements improved, and reduced electromyo- massage, and is this the cross-over point with what gram (EMG) activity was shown in the frontalis has been labelled the ‘psychological effect’ in times muscle. The researchers felt the study confirmed past? positive clinical and physiological effects of massage. Research studies into the relationship between massage and pain control have produced some very Carreck (1994) explored the pain perception mixed results. Some of the studies have examined threshold of 40 healthy subjects, using 15 minutes’ normals, i.e. subjects without pain, and lead one to lower limb massage with 20 subjects and wonder if responses are inclined to be different in 15 minutes’ rest with the other 20 subjects. normals compared with those found in subjects Transcutaneous electrical stimulation was used to already experiencing pain. elicit the point at which the participants first per- ceived pain. The results showed increased pain per- Day et al. (1987) chose to investigate the effect ception thresholds in the group who had received of massage on endogenous opiates within the massage and it was concluded that massage is a peripheral venous blood. The study consisted of 21 valuable option in the management of pain. healthy adult volunteers. One group rested for 40 minutes and the other group received 30 minutes’ Mancinelli et al. (2006) described a significant back massage using mineral oil. Venous beta endor- decrease in perceived muscle soreness after 17 phin and beta lipotropin were measured pre and minutes’ massage (including effleurage, petrissage post treatment. Massage in this set of circumstances and vibration techniques) applied to the thighs did not change the levels of the endogenous opiates. of 11 sportswomen (p < 0.0011). However, the The researchers recommended that a follow-up reported findings were derived from a small sample

30 Massage for Therapists size and only from fit and healthy women, and how especially if combined with exercise and acupunc- these findings may extend into other populations is ture (Furlan et al. 2002). not known. Ernst (2004) reviewed six randomised controlled Hasson et al. (2004) reported a large, randomised, trials and seven clinical trials of the effectiveness of 3-month follow-up design study into the effective- massage therapy for relieving lower back pain and ness of massage on diffuse chronic pain patients management of delayed onset muscle soreness (n = 129). They described an initial effectiveness of (DOMS) within a systematic review of chiropractic massage therapy (n = 62) in the chronic pain and massage manual therapies for pain control. He patients compared with a relaxation control group described ‘serious methodological flaws’ in many of (n = 55) on functional pain outcomes assessed using these studies which described ‘often contradictory’ a questionnaire at baseline, immediately following findings. Further examination of these studies iden- intervention and at 3 months follow-up. These tified: small sample sizes; no blinding; inadequate authors described a significant improvement in outcome measurements; short follow-up periods; muscle pain immediately post intervention in their and low volumes of data, as reasons for these con- treatment group (Fischer’s F ratio (F) (48.2) = 5.8; tradictory findings and weak evidence of the effec- p < 0.01), with no such improvements described by tiveness of manual therapies for the treatment of the control participants. However, these positive pain (Ernst 2004). effects of massage were not noticed at the 3-month follow-up; some of the treated patients even Massage and pain will be reviewed further under described more pain at 3-months than at baseline, the musculoskeletal and psychological headings. and the authors commented that the reasons for this deterioration were not known (Hasson et al. Physiological effects on the 2004). musculoskeletal system A randomised controlled trial of massage therapy The focus in this section is on the possible effects for low back pain reported by Preyde (2000) massage may have on muscles. Inevitably there will described improvements in pain outcomes in a be some reference again to pain, as muscular pain treatment group (comprehensive massage n = 25 and soreness are not uncommon. and soft-tissue manipulation n = 25] compared to exercise (n = 22) and sham laser (n = 26) control In a 1989 study by Balke et al. researchers inves- groups after 1 month of intervention and at 1 month tigated how massage might affect muscle fatigue. subsequent follow-up. Significant improvements Subjects performed a gradual exercise test on a were also reported in the comprehensive massage treadmill and this was then followed by either rest group compared to the soft-tissue manipulation or manual or mechanical massage of the legs for group in measurements of function (p < 0.00 1), about 15 minutes. Exercise performance was pain intensity (p < 0.001) and pain quality (p = retested and this improved in both the manual and 0.001), although the author stated that these mechanical massage groups. The sample group was improvements were modest (Preyde 2000). very small, but the researchers considered that massage assisted recuperation from fatigue ‘more Hernandez-Reif et al. (2001) reported improved effectively than total rest alone’. This finding is pain outcome measurements as assessed using the reinforced in a small way by another study investi- Short-Form McGill Pain Questionnaire (Melzack gating a number of modalities with respect to treat- 1987). Group by time analyses identified reduced ment of subacute low back pain. Incorporated in pain in both groups, but effects only persevered in their procedures was the Sorensen fatigue test, the massage treatment group and not in the relax- which examined trunk extension and how long this ation group at 1 month follow-up. might be maintained in seconds to the point of fatigue. Subjects in the massage grouping received Another review into the effectiveness of massage 15 minutes’ back massage three times a week over for low back pain conducted in 2002 identified nine a period of 3 weeks. The massage group showed studies (eight of which were randomised trials) and the greatest improvement in best extension effort showed variable effectiveness of massage in patients and fatigue time when compared with the other with lower back pain. The authors concluded that massage might be of benefit to patients with sub- acute and chronic non-specific lower back pain,

Evidence-based effects, risk awareness and contraindications for massage 31 modalities used such as corset, spinal manipulation massage applied 2 hours after exercise could hinder (Pope et al. 1994). the delivery of neutrophils to the ‘injury site’, i.e. the exercised muscle, and so reduce the inflamma- A 1990 study investigated percussive vibratory tory response and resultant soreness. Fourteen massage on short-term recovery from muscle untrained male subjects exercised elbow flexors and fatigue. The experimental group received 4 minutes’ extensors isokinetically and eccentrically. The percussive vibratory massage and 1 minutes’ rest experimental group was given 30 minutes’ ‘athletic’ compared with 5 minutes’ rest only for the control massage 2 hours post exercise. The control group group. The procedures for the two groups were was rested. DOMS, creatine kinase and neutrophil interspersed between three periods of exercise and levels were assessed before exercise and at intervals rate of fatigue measurements. It was found that up to 120 hours post exercise. It appeared that there was no significant benefit from massage in the massage reduced DOMS and creatine kinase levels. terms of these study conditions. The length of It produced prolonged elevation of circulating neu- massage time, the type of massage and the timing trophils, leading to the assumption that these had of the intervention could all be questioned; however, not accumulated in the muscle so the inflammatory it does not convincingly negate the use of massage response and subsequent soreness were reduced for the effects on muscle under different circum- (Smith et al. 1994). stances (Cafarelli et al. 1990). The second study by Weber et al. (1994) exam- A 1995 cross-over study (Rinder and Sutherland ined DOMS from a slightly different perspective. 1995) was more positive about the effect of massage Muscle soreness and force deficits following high- on muscle fatigue. Subjects were exercised to the intensity eccentric exercise were investigated using point of fatigue and on one occasion allotted to the 40 untrained female subjects. These were randomly massage group and on the next occasion to the rest assigned to one of four groups – therapeutic group. Massage in the form of effleurage and petris- massage, upper body ergonomics, micro current sage was applied for 3 minutes to this fatigued electrical stimulation and control which took the quadriceps muscle. Other subjects rested for 6 form of 8 minutes’ rest. Soreness was measured minutes. Following immediately after either massage using a visual analogue scale. Maximum voluntary or rest, subjects were asked to complete as many isometric contraction (at 90 ° elbow flexion) and leg extensions as possible against their individual peak torque were assessed using a Cybex isokinetic half load maximum. The results showed that dynometer. Readings were taken before exercise massage had significantly improved quadriceps per- and at 24 and 48 hours post exercise. The elbow formance compared to rest. The discussion of this flexors were eccentrically exercised to exhaustion. study points out that even where no significant The massage group was given 2 minutes’ light effect of massage was elicited, no study has found effleurage, 5 minutes’ petrissage followed by 1 min- detrimental effects of massage on muscle fatigue. It ute’s effleurage immediately after exercise and after also considered that not all effects might be of a 24 hours at reassessment. No differences were purely physical nature and psychological factors noted between the massage and other groups. The could not be ruled out. results from this study do not support the use of massage immediately post exercise or 24 hours DOMS can occur in any individual who per- after exercise to relieve DOMS or the force deficits forms some unaccustomed exercise. It is considered associated with it. to appear 8–24 hours post exercise, building to its height of discomfort at about 48 hours post exer- Some earlier research studies have also produced cise and resolving over a few days (Smith et al. contradictory findings but often studies are not 1994). DOMS may present as slight discomfort comparing like with like. There are great variations localised to myotendinous areas, to stiffness and in types of massage used and the length of time it extreme pain throughout the muscle. It commonly is applied. There is much work to be done to refine occurs in association with eccentric muscle activity. study design and consistency. Maybe then tangible It is thought that such activity sets up an acute proof of the effects of massage will be found. inflammatory reaction in the muscle and massage intervention may be able to moderate the injury Muscle tension can lead to pain and soreness. response. Two 1994 studies examined this area, Massage has been used to promote relaxation of producing variable findings. Smith believed that muscle and is a means of dealing with or offsetting

32 Massage for Therapists the development of such discomfort. An early tissue massage of the shoulder (n = 15). Although study postulated that tension in muscles on the their various outcome measurements reached statis- posterior aspect of the trunk and lower limbs tical significance (all at p < 0.05) these authors would limit trunk forward flexion. The flexion was concluded that ‘the mechanisms behind these measured on a ‘fingers to floor’ basis. Measurements effects remain unclear’ (Van Dolder and Roberts were taken before and after a 30-minute rest 2003). period, and before and after a 30-minute massage. The massage was to the whole of the back and Hernandez-Reif et al. (2001) reported improved lower limbs. All 25 study subjects showed gain in pain outcomes (as measured using the Short-Form trunk flexibility after undergoing massage com- Pain Questionnaire (Melzack 1987)) in their pared to the pre- and post-rest readings. It was massage treatment group and in their relaxation concluded that massage can create relaxation in control group (p < 0.001). However, pain reduc- voluntary muscles, although mechanisms were not tion was reported to be maintained in the treatment clear. Comment was made that almost all subjects group, but not in the relaxation control group, sug- reported a feeling of relaxation and this may impli- gesting that massage therapy may be more effective cate higher centre nervous activity relative to spinal at reducing pain than relaxation over time. circuitry. Local vascular metabolic changes were also proposed as possible contributors (Nordschav A very recent review of the literature regarding and Bierman 1962). the effectiveness of massage therapy on musculo- skeletal pain conducted by Lewis and Johnson Hopper et al. (2005) reported significantly (2006) examined the quality and findings of some increased hamstring muscle lengths (p < 0.001) in 20 studies. Their conclusions were equivocal in 36 female hockey players following classic massage describing 9 out of the 20 massage therapy studies (n = 19) and following dynamic soft tissue mobili- reviewed as being effective in reducing musculo- sation (n = 16) techniques. However, 24 hours later skeletal pain, whereas 11 of the 20 studies reviewed the significant lengthening of the hamstrings of were reported as being ineffective. these hockey players was no longer demonstrable in either of the treatment groups (p > 0.160). This brief survey of some of the available research on the effects of massage on muscles has identified Danneskiold-Samsoe et al. (1982) studied 13 both positive and negative findings. women with regional back and shoulder(s) muscle pain and tension. Subjects were given a course of Psychological effects 10 massage treatments each lasting between 30 and 45 minutes. After each massage, plasma myoglobin A question that comes to mind under this heading and the extent of the area of muscle tension were is, does this warrant a separate section or are the measured. Plasma myoglobin levels rose following effects to be discussed just an extension of physiol- the early massage treatments, reaching a peak some ogy? Much debate is possible, but the contents of 3 hours after the treatment. It was noted that as this chapter are considered to be either psychologi- muscle tension declined with further treatments, so cal or psychophysiological. Research papers to date did the plasma myoglobin levels. The researchers have not been very successful in clarifying such concluded that release of plasma myoglobin occurs matters as it is suggested that much evidence is from muscles that exhibit tension and that massage based on ‘anecdotal testimony and practical field assists in the normalisation of muscle tension. experiences’ as to the ‘positive effects of massage Plasma myoglobin showed no change from normal on psychological wellbeing’ (Cafarelli and Flint levels when muscles without pain or tenderness 1992). were massaged. This suggests that regional muscle tension and pain may be due to disorders of muscle An interesting study by Weinberg and Kolodny fibres rather than involvement of connective tissue. (1988) investigated the relationship between exer- Proposed mechanisms for these findings were not cise, massage and mood enhancement. The subjects forthcoming. were 183 students of physical education and they were divided into six groups. These groups were Van Dolder and Roberts (2003) reported swimming, jogging, racquetball, tennis, a control improved range of motion (ROM), pain and function in patients with shoulder pain using soft

Evidence-based effects, risk awareness and contraindications for massage 33 rest condition and a massage (full body) condition assess mood psychological state changes by the dif- group. The psychological measurement tools used ferent, available inventories than to predict physi- were the profile of mood states (POMS) after ological responses relative to those changes in McNair (1971), the state anxiety inventory (SAI) of psychological dynamics. Spielberger (1970), and the Thayer adjective check- list (1967), all cited in Weinberg and Kolodny Different markers are used to monitor physiolog- (1988). ical changes. These are commonly blood pressure (systolic and diastolic), heart rate, skin temperature The POMS questionnaire is used to measure (often of the fingers), galvanic skin response, respi- mood fluctuations. It contains six subscales: ratory rate, saliva composition and somatic electro- tension–anxiety (somatic tension), depression– myography (EMG) on muscles like the masseter dejection (feelings of personal inadequacy), anger– and trapezius, which are often identified as having hostility (feelings of intense overt anger), high levels of tension. There is thought to be much vigour–activity (mood of high energy), fatigue– interrelationship between the continuum of arousal– inertia (mood of weariness and low energy) and relaxation and levels of anxiety. High levels of confusion–bewilderment (cognitive inefficiency). arousal may occur in emotionally stressful situa- The SAI questionnaire is designed to assess the state tions, and often, but not always, this manifests as of anxiety. Thayer’s adjective checklist is used to raised levels of blood pressure, heart rate, EMG examine anxiety and activation, these recognised activity and constriction of blood vessels in periph- respectively through the subscales of high activa- eral circulation as demonstrated by reduction of tion (feelings of tension and anxiety) and general temperature in the fingers (Longworth 1982). Some activation (feelings of calm and relaxation). of these physiological changes will undoubtedly involve adjustments via the autonomic nervous Each subject completed these questionnaires system (ANS). prior to and immediately after their 30-minute period of either exercise, Swedish massage or rest. The following is a brief sampling of studies that The results showed that the massage and the have dealt with psychophysiological effects and running groups were consistently more related to massage. positive mood states and psychological wellbeing immediately after the ‘activity’. However it was Longworth (1982) investigated the effects of noted that the benefits were much more marked in slow stroke back massage (SSBM) in ‘normo-tensive the post-massage group. females’ who were nursing students and staff with an age range from 19 to 52 years. This quite Results from the other groupings generally did complex study attempted to monitor many changes. not produce significant change. All the subscales of Anxiety was assessed by use of the state (trait) the POMS questionnaire, except the vigour sub- anxiety inventory of Spielberger, as mentioned pre- scale, showed a positive relationship to massage. viously. A number of physiological readings were The beneficial relationship was also demonstrated taken. Six minutes of uninterrupted slow stroke with regard to the high activation and general acti- massage were administered during the approxi- vation subscales of Thayer’s adjective checklist. The mately 27-minute experimental period, which also researchers concluded that massage was ‘consis- contained baseline rest and final rest periods. At the tently related to transitory positive mood enhance- end of the experimental period subjects generally ment’ and psychological wellbeing even if only stated they felt rested and relaxed. The researcher demonstrated in the setting of the study. It would believed that the SSBM had been successful in low- seem to go part way to justifying subjective com- ering the psycho-emotional and somatic arousal ments often made post massage on its use in the level of subjects into the rest period post massage. sports context as well as in many other areas of This finding was reinforced by significant decreases life. in SAI scores, demonstrating a reduction in anxiety state. It was also noted during the period that EMG The tension–anxiety part of mood states has been levels were reduced, indicating lower levels of investigated in a number of studies. Some studies muscle tension. have also attempted to link changes in psychologi- cal state to altered physiology. Many different Changes in other physiological markers were subject groups have been used and findings have more difficult to explain. No significant differences been of infinite variety. It appears almost easier to were noted for systolic/diastolic blood pressure or

34 Massage for Therapists heart rate between the baseline rest and final rest ception (mean 60%) and anxiety (mean 24%) periods of experimental time. It was assumed the levels. Feelings of relaxation were enhanced. In this massage between the rest periods produced no pro- study the physiological measures tended to decrease longed effect on the ANS even though changes had following massage. occurred during the experimental time, e.g. an initial rise in systolic blood pressure during the first Meek (1993) working with 30 hospice clients 3 minutes of massage, and increased heart rate in used SSBM to achieve relaxation. The duration of the last 3 minutes of the 6-minute massage. the massage was only 3 minutes. Modest but not very prolonged decreases took place in blood pres- A study by Barr and Taslitz (1970) examined sure and heart rate along with a rise in skin tem- the effects of back massage on autonomic functions perature. The researcher took these to be indicative in 19 college students aged 19–21 years. Each of increased relaxation, which usually means a low student underwent three massage sessions of 20 arousal level and this suggests a low anxiety state minutes with pre- and post-massage rest periods (Longworth 1982; Meek 1993). and three separate control periods of correspond- ing duration. Some of the physiological findings Groer et al. (1994) studied anxiety levels and correspond to those of the Longworth study and took post-massage saliva samples in a group of 18 others do not. Heart rate did tend to increase well, older adults. The control group underwent a during massage; however, systolic and diastolic 10-minute period of relaxed lying and the experi- blood pressure decreased during the initial period mental group had a 10-minute back rub. SAI ques- of massage, the latter apparently conflicting with tionnaires were completed before and after the the Longworth findings. Barr considered that back intervention. Anxiety levels went down for both the massage did have an influence on autonomic func- experimental and the control group but not to sig- tions, mainly an increase on sympathetic activity nificant levels. The saliva in the post-massage group and a smaller effect on parasympathetic action. It showed increased levels of immunoglobulin A. This was speculated further whether the changes were finding is part of a claim that massage can have primarily as a result of the massage or the mental beneficial effects on the body’s immune system. It state of the subjects. This highlights again the mys- is not clear why reduction in anxiety did not reach terious interrelationships of higher centre activity significant levels on this occasion. in the CNS to autonomic adjustments and pain control. What influence do changes of mood or Fraser and Ross (1993) also looked at the effect emotions play in physiological adjustments? Does of back massage on elderly residents in institution- the afferent input of massage change activity in the alised care. A similar format of monitoring physio- limbic system, the subcortical and even the cortical logical markers, blood pressure, etc. and anxiety areas and do they in turn instigate changes within levels via Spielberger’s self-evaluation questionnaire body systems? Some consistency does appear to be were used pre and post intervention. Three experi- present in the literature regarding the positive mental subject groups were given either back effects of massage on mood-anxiety levels in a massage with normal conversation, conversation range of people. only or no intervention. Post-test scores were all lower in the massage group although not statisti- Ferrell-Torry and Glick (1993) investigated cally significant; however, there was a statistically whether massage could modify anxiety and the per- significant difference in mean anxiety score between ception of cancer pain as well as monitoring other the massage group and the no intervention group. physiological changes. The study group comprised Verbally subjects reported the back massage to be nine hospitalised males all experiencing cancer relaxing. It was felt massage as a form of touch was pain. Pain was measured by visual analogue scale valuable in the care of the elderly person and and anxiety by Spielberger’s SAI, these being used perhaps assisted communication. before and immediately ‘after massage. Thirty minutes’ effleurage, petrissage and myofascial Corley et al. (1995) also looked at the effect of trigger point massage therapy was applied to the back rubs on elderly residents in care. Mood was neck, back and shoulders. Respiratory and heart found to improve in both massage and rest control rates and blood pressure were measured. Massage groups but not to significant levels. Subjectively the produced significant reductions in both pain per- residents commented positively on the back rub. Little of significance was found in physiological measures.