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

Uses of classical massage in some health care settings: an overview 137 In the cystic fibrosis patient group more emphasis Some useful massage manipulations are described is being placed on moving away from ‘passive’ ses- below. sions and allowing more self-directed treatments. This includes the use of hand-held positive pressure Scar management and vibratory devices, to aid clearance of secretions and the use of ‘autogenic’ breathing techniques. Massage may be used on scar tissue. It is usually started 2 weeks or more following suture removal Tapôtement may still be the treatment of choice or over soluble sutures when the wound has with some patients, especially during a chest infec- healed. tion requiring admission to hospital for intravenous antibiotics. In such circumstances secretions may be Tethering especially difficult to clear and the addition of manual techniques may aid expectoration. The thumb can be applied gliding deeply over the tissues. The patient is then taught how to do this Some useful massage manipulations are: technique three or four times daily. This will help not only to untether a scar but also to prevent ᭿ Tapôtement further adherence and improve blood supply to the ᭿ Vibration area. Creams must not be coloured or perfumed, to ᭿ Shaking prevent allergic reaction. E45 cream is an example of a cream often used. Note: as always, care must be taken to ensure the correct patient groups are treated with the above, Hypertrophic scars being aware of any contraindications expressed by the patient’s consultant. A more superficial thumb pressure is used with an E45-type cream. The cream may then be removed For those patients who suffer from musculoskel- and a deeper thumb kneading applied. Silicone gel etal pain associated with tension in the respiratory and compression are also utilised. muscles (typically in the thoracic area and often in the neck and shoulders), massage that helps to relax Desensitisation these muscles can be usefully employed. Any scar that is not massaged can become hyper- Those people who suffer from anxiety due to sensitive. Gentle thumb pressure may be applied ‘breathlessness’ may be helped by ‘stress’ massage early and may be very effective in helping to desen- techniques described earlier in this chapter. sitise the scar area, in particular those areas follow- ing limb or finger amputation or after nerve Some useful massage manipulations are described injury. in the section on ‘Stress’. See sections on ‘Stress’ and ‘Physical disabilities’ in this chapter. Reconstructive surgery Massage is used as part of treatment following Oedema management trauma/reconstructive surgery to the body. It has a particularly important role in therapy following Post-traumatic and surgical oedema is a problem hand injury. that needs to be treated early, namely in the first 2–3 weeks following injury. Thereafter its presence It has three main uses: prolongs the inflammatory stage of healing, leading possibly to chronic fibrotic oedema. Massage is ᭿ Scar management given with thumb pressure distal to proximal ᭿ for tethering with the use of an E45-type cream. This is then ᭿ for hypertrophic scars followed with compression, active exercises and ᭿ for desensitisation elevation. ᭿ Desensitisation ᭿ Oedema management

138 Massage for Therapists Reference Holey, E. and Cook, E. (2003) Evidence Based Therapeutic Massage and Practical Guide for Therapists, 2nd edn. Cyriax, J.H. and Cyriax, P.J. (1993) Cyriax’s Illustrated Churchill Livingstone, Edinburgh. Manual of Orthopaedic Medicine, 2nd edn. Butterworth Heinemann, Oxford. Hollis, M. (1998) Massage for Therapists, 2nd edn. Blackwell Science, Oxford. Further reading Lewis, M. and Johnson, M.I. (2006) The clinical effectiveness Auckett, A.D. (2004) Baby Massage: Parent–Child Bonding of therapeutic massage for musculo-skeletal pain; a sys- Through Touch. Newmarket Press, New York. temic review. Physiotherapy, 92, 146–58. Charman, R.A. (2000) (ed.) Complementary Therapies for McNamara, P. (2004) Massage for People with Cancer (ed. Physical Therapists. Butterworth Heinemann, Oxford. V. Speechley). Cancer Research Centre, London. Field, T. (2006) Massage Therapy Research. Churchill Mustoe, T.A., Cooter, D., Gold, M.H., et al. (2002) Livingstone, Edinburgh. International clinical recommendations on scar manage- ment. Plastic and Reconstructive Surgery, 110(2), Fritz, S. (2004) Fundamentals of Therapeutic Massage, 3rd 560–71. edn. Mosby, St Louis. Price, S. and Price, L. (1995) Aromatherapy for Health Hess, D.R. (2002) Evidence for secretion clearance tech- Professionals. Churchill Livingstone, Edinburgh. niques. Cardiopulmonary Physical Therapy Journal, December. Tappan, F.M. and Benjamin, P.J. (2004) Tappan’s Handbook of Healing Massage Techniques; Classic, Holistic and Emerging Methods. Prentice-Hall, New Jersey. Thomson, A., Skinner, A. and Peircey, J. (1991) Tidy’s Physiotherapy, 12th edn. Butterworth Heinemann, Oxford. Vickers, A. (1996) Massage and Aromatherapy, a Guide for Health Professionals. Chapman and Hall, London.

IIISome specialised techniques 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

Some types of massage and 13soft tissue therapies Elisabeth Jones This chapter gives a brief overview of the wide Acupressure variety of massage types that may be used in therapy. Each method, if it is to be safe and effec- Acupressure incorporates the concept of energy tive, needs to be learnt from a competent and expe- pathways and specific points, as in acupuncture, on rienced tutor who has attained well-recognised parts of the body, but uses thumbs, fingers, some- qualifications. Do not work in these fields without times even elbows, to apply pressure on the points such training. instead of needles. Some sources consider this therapy to be older in origin than acupuncture, The descriptions in this chapter are a ‘taster’ of originating probably from China. the different ways in which the ‘laying on of hands’ can help to promote healing. The subsequent chap- Other similar therapies such as tuina and shiatsu ters give a fuller explanation of some of the spe- (see later) also come from the East. Stimulating cialised techniques that have a particularly wide such points may trigger the release of endorphins, use. the hormones that help to reduce pain and tension in the musculoskeletal system. Circulation and Active release technique (ART) energy flow may also be improved. Developed and patented by P. Micheal Leary DC, Balance of activity throughout all the body CCSP, this is a state-of-the-art soft tissue system/ systems is aimed for and this promotes a feeling of movement-based massage technique that treats ‘wellness’. muscles, tendons, ligaments, fascia and nerves. There are over 50 specific moves, unique to ART. Animal massage Headaches, back pain, carpal tunnel syndrome, shin splints, shoulder pain, plantar fascilitis, knee Unlike working in the human field, direct referrals problems and tennis elbow are just a few of the are not permitted; the Veterinary Act requires many conditions that may be helped by ART. They that any person working on an animal must have got one thing in common, namely they are have obtained permission from the veterinary often the result of overused muscles. surgeon employed by the owner. Animals respond 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

142 Massage for Therapists remarkably well to massage, and in 1984, when a therapy massage can offer a valuable contribution specific interest group, the Association of Chartered towards ‘wellbeing’. Physiotherapists in Animal Therapy, was formed, the veterinary profession accepted the undoubted Ayurvedic massage benefits of massage offered by professionals, particularly for small animals in post-operative Ayurvedic massage utilises the concepts of Ayurveda situations. (an ancient practice from India which balances three life forces – energy, movement and digestion) The dog and cat can usually be persuaded to lie together with warm oils and massage techniques on recumbent, and relaxation follows acceptance of a certain energy points. The aim is to create a sense stranger’s hands. The masseur/euse needs to adapt of harmony of body and mind. It may be used for when working with horses, as the animal is neither stress-related conditions to help achieve relaxation recumbent nor relaxed due to effects from gravity, and increase vitality. and because the stay system of the appendicular skeleton remains in a state of constant tension, to Bio-energy therapies ensure the animal is in readiness to flee from a predator. The masseur/euse is working with the Massage is considered by many practitioners to be subject, not below but in front of the animal, and one of the bio-energy therapies, which are gaining adaptation of the use of body weight and arm posi- greater credence following new research. Many sci- tion is required. entists, including James Oschman PhD in the USA, consider that connective tissues which extend A knowledge of surface anatomy is essential. throughout the body form a semiconducting elec- Swedish massage techniques have proved the most tronic network. Pressure from massage techniques beneficial when dealing with animals; effleurage, may stimulate the conduction of ‘piezo-electricity’ compression, skin rolling and cross fibre friction through this energy system (see Chapter 2). being those of choice. It is well known and accepted that humans have Aromatherapy energy fields and the interaction of the practitio- ner’s magnetic and electrical patterns with those of Aromatherapy is a therapeutic procedure which the patient may influence the treatment. Positive utilises the fragrant components extracted from ‘intention’ may therefore create positive energy aromatic plants. The aromatic substances are those effects, which together with massage techniques essential oils of certain plants that are considered gives beneficial outcomes. to promote health and wellbeing. The combination of the beneficial effects of essential oils, together Bowen therapy with the healing results of appropriate massage techniques, provides a ‘natural’ treatment of con- The Bowen method, also known as Bowen therapy, siderable value. is a gentle hands-on, soft tissue mobilisation tech- nique. Light rolling moves of skin over underlying Aromatherapy massage probably creates the tissues are made at specific sites, grounded in an most diffuse therapeutic effect, if compared with understanding of anatomy. This is followed by the other methods of use of essential oils. The oils are therapist leaving the treatment room at intervals utilised not only by skin absorption, but also by during the session. Specific conditions are not olfaction and inhalation, when applied by treated. However, there is no situation where it massage. Aromatherapy massage may be used for many client groups. Mental health settings; pre-natal, labour, and post-natal events; stressed, anxious and/or depressed individuals; musculoskeletal dis- orders; those in terminal care; and the elderly are a few examples of the situations in which aroma-

Some types of massage and soft tissue therapies 143 cannot be used safely. It has had beneficial effects personality. The craniosacral system is composed on organic conditions and the whole range of mus- of the membranes and cerebrospinal fluid that sur- culoskeletal problems. round and protect the brain and spinal cord. There is a mild cranial pulse that can be felt at 8–12 beats Classical massage per minute, which can vary in volume and range and variations in this pulse may signify restrictions Classical massage is based on Swedish massage in the body systems. The treatment is gentle and techniques, and comprises four main types of relaxing. movement: ᭿ Effleurage/stroking Heller work ᭿ Petrissage ᭿ Tapôtement/percussion Developed by Joseph Heller, the soft tissue manipu- ᭿ Friction lation and body movement re-education are similar to Rolfing (see later), yet acknowledge the relation- It is the most frequently used technique, either in ship between body and mind, using guided verbal its own right or in combination with other tech- dialogue to address emotions that lock muscles and niques (see Chapter 6). affect breathing. There are typically eleven sessions working to bring consciousness into the body, to Connective tissue manipulation (CTM) bring choice and empowerment and awareness. There is a focus on balance at all levels, especially Connective tissue manipulation (CTM) is the the deep core musculature. German Bindegewebsmassage technique which was developed in the 1930s by Elisabeth Dicke. It is a Heller work can help: muscle pain, especially in highly specific technique which targets the inter- the neck, shoulder and back; stress-related condi- faces within the skin and connective tissue. By tions; sports injuries; and conditions related to poor working on connective tissue reflex zones (after the posture. head), powerful autonomic reactions are induced through the somatovisceral reflexes. Indian head massage Therapeutic effects include stimulation of the Indian head massage has been practised among parasympathetic nervous system, inducing relax- families in India for many centuries, mainly by ation in sympathetic activity and the physical symp- women, with the use of oils to improve the condi- toms of anxiety. Enhanced peripheral circulation tion of their hair. Known as ‘champi’ from which and autonomic and hormonal balance are also the word ‘shampoo’ is derived, it is still practised induced (Holey 1995). by barbers in India as part of their routine, and it is often carried out in public places. Craniosacral therapy The Western version includes not only the scalp Craniosacral therapy uses a light touch to uncover, but also the neck, shoulders and upper back, where evaluate and facilitate the release of subtle causes we hold tension, using both soothing and invigorat- of ill health and dysfunction in the neuromuscular- ing strokes, as well as pressure on acupoints. skeletal and fascial systems. It addresses the entire physiology, right down to cellular level, embracing The use of oils on the scalp is optional, as the the emotional, energetic and spiritual dimensions of main benefit these days comes from relief of tension and pain in the muscles over which the hands are worked, and therefore a reduction of feelings of stress.

144 Massage for Therapists Lomi lomi Muscle energy technique (MET) This is a type of Hawaiian technique, based on the Muscle energy technique (MET) is an adaptation of Hawaiian Huna philosophy that there can be another type of soft tissue manipulation called pro- balance achieved between mind and body. It is an prioceptive neuromuscular facilitation (see later), intuitive form of massage using the hands and arms initially developed in the 1950s and which has seen of the healer on the person’s physique, utilising long a resurgence since the late 1970s, particularly in the gliding strokes. A prayer may begin the session, and osteopathy profession. sometimes a number of healers may apply the massage at the same time. It is used to facilitate joint mobilisation and release of muscle shortness. It has been described Manual lymph drainage (MLD) as a ‘highly sophisticated system of manipulative methods in which the patient uses her/his muscles, This is a massage technique used to treat lymphoe- on request, from a precisely controlled position in dema, i.e. a condition of the lymphatic system which a specific direction, against a distinctly executed arises as a result of damage or disease. The swelling counter force’. can affect the limbs, trunk and head. The lymph collects in the tissues under the skin, causing the There are all sorts of variations of this basic skin to stretch and the tissues to become congested principle which involve post-isometric relaxation, and painful, resulting in stiffness of the joints. reciprocal inhibition, variations in the effort of the patient, variations in the counterforce by the prac- The massage is extremely gentle and is performed titioner, subsequent stretch, variation in contrac- using the palm of the hand and the flat of the tion, time of contraction, rhythm of contraction, fingers, in direct contact with the skin, and is com- and combination with pressure techniques. Often posed of small circular movements, working in the the variety of methods within MET are described direction of the flow of the lymph. as positional release techniques or strain counterstrain. The treatment session is in three parts: Myofascial release (MFR) (1) In order to improve the lymph flow through the body, the main groups of lymph nodes are Myofascial release (MFR) techniques deal predomi- stimulated; these are in the axilla, the groin and nantly with the fascial (connective tissue) system, the base of the skull and neck. Gentle pressure although muscle is implicated. The fascia supports is used on these nodes in the direction of the and gives structural integrity and interconnectivity heart. to all systems of the body. When there is emotional and physical trauma, the myofascial tissue may (2) The area of the trunk closest to the swelling is tighten in response, in certain areas. This can cause cleared, and the fluid is directed towards the restricted movement and pain. cisterna chyli, thence to the thoracic duct, emp- tying into the left subclavian vein, and leaving Torticollis, chronic muscle tension (e.g. upper space for the fluid to drain from the limb. fibres of the trapezius), fibrous scar tissue, adhe- sions, fibromyalgia and chronic fatigue syndrome (3) Only then in the third phase is the affected limb are among some of the conditions that it is sug- touched. Treatment always starts at the top gested may be helped by MFR. and progresses slowly down to include the fingers and toes, then up the trunk. The flat of After subtle palpation, gentle pressure and then the hand is used to guide the fluid up the limb; gentle stretch are applied to the affected area which pressure is gentle and the skin is never allows this restriction to elongate (‘unwind’) as a dragged. spontaneous release of myofascial tissue. Somato- emotional changes may happen and the patient will The technique should never produce pain, and need to feel the therapist is supportive and that he/ a sound knowledge of the lymphatic system is she is in a trusting environment. (See Chapter 17.) essential.

Some types of massage and soft tissue therapies 145 Neuromuscular therapy Positional release Neuromuscular therapy is sometimes called ‘trigger This non-invasive technique to release muscular point therapy’ or ‘myotherapy’. Local soft tissue contraction, tension or spasm was first discovered dysfunction sometimes presents as local specific by Lawrence Jones, DO who found that placing a spots of pain or tenderness, often referred to as patient in a position of ease, for a period of time, ‘trigger points’. The pain produced in these areas released tension. of dysfunction often radiates away from the tender spot. Thumb and/or finger pressure is used to The method has been likened to untangling a release spasms, interrupt the pain cycle and help knotted jewellery chain instead of pulling it apart; return tissues to normal function. pushing the links together releases the chain very effectively. The practitioner achieves this by pas- Periosteal massage sively placing a person’s body or body part into a position that brings the origin and insertion of Periosteal massage involves small circular move- the muscle or muscle group together. Fine tuning ments which are often conducted with the thera- of position is administered until the patient is at pist’s knuckle on the superficial aspects of bone. It his or her most comfy state. This position is held is thought to have a reflex effect, but can be rather by the therapist for 90 seconds which facilitates uncomfortable, although it has been widely used in muscle spindle resetting. The patient then must Europe. It is used to help reduce pain. be slowly and passively returned to the neutral position. Pin and stretch All these methods are used to increase flexibility, to loosen muscles and to reduce pain in a muscle prior to deep massage and trigger point work, as may be used, for example, with sports problems or occupational stress. This is an American version of soft tissue release Proprioceptive neuromuscular (STR) and specific stretch (SS) (see later). It relies facilitation (PNF) on pressure being applied to an area of muscle and stretch being combined to produce change in the Proprioceptive stimuli are applied for processing in resting length of the muscle/group of muscles being the spinal cord or brain, to modulate the output of worked upon. The aim is to ‘re-set’ muscle fibres to motor neurones and recruitment of motor units. their resting length. Activity of the motor neuromuscular system is altered for therapeutic effect. Polarity therapy Proprioceptive stimuli are applied as: Devised by Dr Randolph Stone, polarity therapy employs a blend of both Eastern and Western con- ᭿ Touch – manual contact (guiding strength of cepts of health, working with the human energy contraction and direction of movement). field. Using light touch, bodywork, diet, exercise and self awareness, the therapist aims to restore ᭿ Verbal – explanation, commands, tone of optimum energy flow, therefore enabling the body voice. to heal itself naturally on emotional, mental and spiritual levels. Polarity therapy forms part of the ᭿ Visual – demonstration. foundation of craniosacral therapy and myofascial ᭿ Patterns of movement – functional combined release. movements. ᭿ Compression/distraction of joint surfaces – stimulates mechanoreceptors. ᭿ Pressure – recruits motor units to produce the appropriate response for the patient’s thera- peutic needs.

146 Massage for Therapists PNF techniques involve the patient actively con- resist the agonists of the movement. An isomet- tributing to the therapy. Developed in the USA in ric hold is maintained. This phase is followed the 1950s, variations have evolved, but the funda- by an isotonic contraction of the agonists mental principles remain the same. PNF may be against the therapist’s pressure until a new used for relaxation/lengthening of muscles, regain- motion barrier is reached. There is no relax- ing joint movement, rebalancing muscle activity, ation phase; the agonists are working all the and restoring postural reflexes and stability. time. The length of hold is typically 10–15 seconds and repetitions are typically 3–6. Important philosophical principles are: a positive ᭿ Stretch reflex (repeated stretch) – this may be approach, no pain and achievable tasks set up for used to enhance the contraction of the agonists. success (Adler et al. 2008). As the instruction is given to move into new range the therapist applies a short sharp stretch Techniques of PNF used by chartered physio- to the agonists. The spinal reflex kicks in and therapists are: hold relax, repeated contractions, the agonist contraction is stronger due to combining repeated contractions with soft tissue greater recruitment of the motor units. techniques, slow reversals and stabilisations. ᭿ To strengthen muscle – this technique is applied from the full length of the muscle to fully Hold relax (HR) (contract relax) shortened. HR aims to improve the range of movement at Combining repeated contractions with joints, limit factors of muscle spasm, increase tone soft tissue techniques and improve ‘muscle tightness’. The patient moves the joint to resistance (motion barrier). The short- During the hold, palpation of the antagonist muscle ened muscles (antagonists to the movement to be may identify deep scarring. This then may respond gained) are held contracted isotonically against the to specific soft tissue mobilisations (SSTM). The therapist’s manual pressure, followed by a relax- reasoning therapist will apply a combination of ation phase. The patient is asked to move the joint active work for the contractile elements and passive into the new range gained by the lengthening effect holds to allow creep and viscoelastic changes in the on the shortened muscle. non-contractile elements of muscle tissue. Repetitions are carried out until no further move- Slow reversals (SR) ment is gained – typically 3–6 repetitions. There is no consensus in the literature regarding the length This involves continuous activity from one direc- of time for HR phases – the minimum is 15 seconds tion of movement to the opposite in a diagonal and maximum 30 seconds. The relaxation phase is pattern. Greater motor recruitment leads to stron- in the order of 15 seconds. ger contraction, increasing range of movement and co-ordination. Auto hold relax Stabilisations A patient may perform hold relax to lengthen muscles on his/her own. This requires special tuition The patient is positioned in a functional position to make sure that the exercise is performed cor- and manual pressure is applied to the muscles until rectly, but it is very much in keeping with the they are all working. This facilitates stability and patient being involved actively in his/her rehabilita- co-ordination. tion from an early stage. Repeated contractions (RC) ᭿ To gain joint range – the joint is moved to the motion barrier. Manual pressure is applied to

Some types of massage and soft tissue therapies 147 Reflexology Shiatsu Reflexology originates from ancient traditions of Shiatsu literally means ‘finger pressure’ when trans- working on the hands and feet for health. This lated from Japanese. It is the manual part of acu- concept is based on the hypothesis that the whole puncture and part of Japanese traditional medicine. body is reflected in miniature on the hands and feet. Mainly fingers, thumbs and palms of the hands Reflex points correspond to specific areas of the apply different depths of pressure over all the body, body. When pressure is applied to these points there stimulating acupuncture points known as tsubos in is a change in the corresponding area of the body, Japanese. It is more than a mechanical stimulation helping to enhance the healing process. This of the points – it is an oriental healing art based on approach works with whole body systems rather an energetic medical model. than a separate body part, influencing both body and mind. Shiatsu is based on Chinese medicine and uses Eastern philosophy as its theoretical framework. Reflextherapy is an umbrella term that includes Traditionally treatment is carried out on a cotton reflexology, incorporating a subtle, gentle touch, to layer mat (futon) at floor level, with the body include the head and the ear, and works holistically remaining fully and comfortably clothed. Nowadays relating to the needs of the individual. some practitioners use a wide table, which is height adjustable. Shiatsu aims to maintain wellbeing and Areas of experienced clinical benefits include: health, as well as treat specific conditions such as musculoskeletal, respiratory, digestive, reproduc- musculoskeletal disorders, pain, psychosomatic tive, neurological and endocrine disorders as well problems and stress-related symptoms, among as relaxation, pain reduction, improved mobility, others. (See Chapter 16.) palliative care and chronic illness. Rolfing (structural integration) Soft tissue release (STR) Ida Rolf developed a protocol of series of hands-on STR is a hybrid technique, combining movement soft tissue techniques, giving a fundamental frame- and manipulation of soft tissues, particularly fascia work for unraveling and stretching the myofascial and muscle, with elements of neuromuscular system. This allows patients to become aware of therapy (NMT) as well as connective tissue massage and therefore change their inhibiting movement frictions and stretch. The technique is administered patterns, which are manifested structurally in their by applying and maintaining pressure or ‘locking’ body, and functionally as realignment alongside the into the relevant tissues, whilst simultaneously forces of gravity. stretching away aligned fibres, through passive or active movement of the associated joint. This can Health benefits include improved mobility and produce a quick and effective ‘release’ in local areas function in musculoskeletal conditions, feelings of of soft tissue tension. It is often used as a form of fitness and a reduction of tension patterns. sports massage. Segment massage Specific soft tissue mobilisations (SSTMs) The practitioner targets the fascia under the skin. Small movements are made according to the seg- These are oscillatory manual techniques applied to mental pattern of skin innervation. This East soft tissue. The techniques are graded. Pressure is German technique gently stimulates the autonomic applied to the structure at right angles to the lon- nervous system and is therefore used for a range of gitudinal axis of the structure to be treated, in such disorders

148 Massage for Therapists a way as to create a bowing and therefore lengthen- worldwide. Classical massage is based on Swedish ing effect. massage but is more expansive in its manipulation techniques (see Chapter 6). These techniques are very effective for lengthen- ing and releasing scar-type collagen in healed, tight Thai massage (Thai yoga massage) or adherent structures such as muscles, tendons and ligaments. Effectiveness is dependent on thorough This technique is a combination of acupressure, examination to identify the problem structure, gentle stretches and applied yoga, to assist energy requiring the therapist to have a sound in-depth flows around the body, and thus help the body’s knowledge of applied anatomy and sensitivity in self-healing properties. The therapist uses hands, palpation. thumbs, elbows, knees or feet to apply pressure to energy lines along the body, using gentle stretches Specific stretch and applied yoga to enhance the benefits. The patient remains fully clothed, and the massage takes Specific stretch is similar to STR in that pressure is place on a mattress on the floor. A typical massage applied at the same time that a muscle is stretched. lasts at least 90 minutes and always treats the whole Variations of active and passive stretch are intro- body, though specific attention can be paid to duced and the pressure applied must be graded to problem areas. influence/affect muscle and connective tissues at various depths. Sports massage Therapeutic touch The massage manipulations used in sports massage Therapeutic touch is a contemporary approach to are as described in Chapter 6 and also involve acu- an ancient and traditional form of healing practice. pressure, trigger pointing and ice massage. Sports Although there is a loose structural and philosophi- massage can be divided into: cal framework to the clinical practice, therapeutic touch is not part of any religious doctrine, but is ᭿ Specific sports massage. seen more as a natural human potential. In practical ᭿ Non-specific sports massage. terms the therapist’s hands may be working on the skin, through clothes or in the space around the Any therapist involved in sports massage must subject’s body. The therapist’s mind intention and know and understand the principles of the sport ‘centering’ (a form of focusing and meditation) are (see Chapter 14). pivotal to the technique. The technique has been shown to reduce anxiety, improve mood, reduce Swedish massage pain (including phantom limb pain after amputa- tion) and facilitate wound healing, and potentially Per Henrik Ling (1776–1839) of Sweden is credited could be of benefit in improving wellbeing and with the development of Swedish massage. He relaxation across all health care and patient explored massage techniques from different sources groups. and co-ordinated some of them into a rationalised method, now termed Swedish massage. He founded Trager the Royal Gymnastic Central Institute, where for the treatment of disease he advocated active and This technique was developed and trademarked by passive movements and massage. By the time of his Milton Trager in the USA. He describes it as psy- death in 1839 his system had become recognised

Some types of massage and soft tissue therapies 149 chophysical integration, as it involves a combina- The patient is assessed objectively using palpa- tion of ‘tablework’, which includes large passive tion of suspected muscle areas as well as testing for movements, and rocking and mentastics, active joint range and muscle strength. Widely recognised movements performed after treatment. Trager diagnostic criteria for identification of TrPs include therapy is said to induce a feeling of relaxation, ease a taut palpable band; exquisite spot tenderness of of movement and reduced physical tension. a nodule within the taut band; a recognisable (familiar to the patient) referred pattern of pain on Transcadence massage pressure of the tender nodule; and full stretch of the affected muscle being limited by pain. Properly called Linn transcadence massage (LTC) because it was devised by Denise Linn (of Cherokee Careful treatment of TrPs using a variety of Indian heritage), transcadence massage is a com- approaches often brings about relief of painful plete body system that blends the most potent symptoms – some conditions requiring an extremely aspects of Native American healing philosophy light touch and some responding to firmer treat- with altered states of conscious, through percussion ment. Comparative research has listed the follow- massage movements. It is useful for dealing with ing methods as being amongst the most effective for deep-seated tension associated with old trauma, producing immediate benefits from the treatment of both physical and psychological. identified TrPs: ice spray and stretch; application of superficial local heat; and deep inhibitory pressure soft tissue massage. Tuina/tui na (pronounced tweena) Trigger point release Tuina is the ancient art of Chinese massage, using the operator’s fingers, hands, arms, elbows and A feature common to many, if not all chronic pain knees. It is based on the traditional Chinese medi- conditions, is the presence of localised areas of soft cine theory of balancing the flow of Qi (energy) tissue dysfunction which promote pain and distress throughout the body along certain lines called in distant structures. These localised areas are meridians. The methods used include the hand tech- known as trigger points. niques of massage for the soft tissues of the body, acupuncture points to directly increase the flow of The phenomenon of trigger points (commonly Qi, and manipulation to help realign the tissues. abbreviated as TrPs) is often overlooked in medical diagnosis and treatment of painful conditions. A Conditions for use are similar to some of those sufferer may have been presented with an X-ray where classical massage may be utilised, e.g. allevi- diagnosis of ‘normal wear and tear’ in a dysfunc- ating chronic pain, particularly in the musculoskel- tional joint, and it is the bones, joints, bursae and etal system. The techniques are practised either on nerves where physicians usually concentrate their a couch or on a mat on the floor. attention. It is thought that TrPs are caused by dysfunction at the site of the motor endplates of The Chinese tradition is not to take the clothes skeletal muscle fibres. off, but they are loosened, and the shoes are removed. It is one of the three main components of The author’s personal approach when assessing Chinese medicine, the other two being acupuncture a patient with painful symptoms is to always include and herbal medicine. questions in the subjective assessment that enquire about a history of sudden contraction or stretch of Vibrational therapy (VT) muscles such as in a heavy fall or a history of pro- longed overuse of a group of muscles such as in a This is also called vibrational medicine and energy heavy task or activity. The author has also found medicine. It is based on the scientific principles that that TrPs are present in related muscle tissue fol- lowing joint replacement surgery.

150 Massage for Therapists all matter vibrates to a precise frequency, and that Further reading by using resonant vibration, balance of matter can be restored. Trauma may disrupt the normal rhyth- Cash, M. (1996) Sport and Remedial Massage Therapy. mic movements of tissue molecules and VT is Ebury Press, London. directed at restoring the natural rhythm. All the senses may be stimulated to try to achieve this, Chaitow, L. and DeLany, J. (2000) Clinical Application of including touch. Neuromuscular Techniques. Churchill Livingstone, Edinburgh. Zero balancing Holey, E.A. and Cook, E.M. (1997) Evidence Based The person’s energy field is accessed by taking up Therapeutic Massage. Churchill Livingstone, Edinburgh. the slack from the physical body (often with gentle traction and stretch), so that the hand acts as a Oschman, J.L. (2002) Energy medicine: the new paradigm. fulcrum or balance point. Any additional pressure In: Complementary Therapies for Physical Therapists will then allow movement to orient around the (ed. R.A. Charman), pp. 2–33. Butterworth-Heinemann, hand and be felt as an energetic change at the inter- Oxford. face of the ‘physical and energetic’. The internal perceptions of elongation may take the person onto Pert, C.B. (1999) Molecules of Emotion. Why You Feel the deeper states of relaxation and awareness. The Way You Feel. Simon and Schuster, New York. normal flow of energy that permeates the bones is restored and realigned with the physical structure Simons, D.G., Travell, J.G., Simons, L.S. and Cummings, to optimise function. Energy balancing effects are B.D. (1999) Travell & Simons’ Myofascial Pain and of a holistic nature, reducing pain and stress, dealing Disfunction: The Trigger Point Manual, Vol 2, 2nd edn. with past trauma and enabling the person to develop Lippincott Williams and Wilkins, Philadelphia. his or her life potential. Watt, J. (1999) Massage for Sport. Crowood Press, References Marlborough. Adler, S., Beckers, D. and Buck, M. (2008) PNF in Practice: Useful websites An Illustrated Guide, 3rd edn. Springer, Heidelberg. http://www.activerelease.com/about.asp Holey, L.A. (1995) Connective tissue massage: towards a http://www.bowen-technique.co.uk scientific rationale. Physiotherapy, 81(12), 730–39. http://www.energysearch.us http://www.hellerwork.com/ http://www.luminati.com/vibration.html http://www.massagetoday.com/aboutmt http://www.mic.ki.se/diseases/alphalist.html http://www.noetic.org http://www.reflexologyforum.org http://www.reflextherapy.org.uk http://www.rolfing.org/indexuk/htm http://www.thaiyogamassage.co.uk http://www.touch.org.uk/ http://www.zerobalancinguk.org

14Massage in sport Joan M. Watt Massage has been used in sport from time immemo- Diagnosis rial. Athletes have resorted to massage since the days of the first Olympic Games, and the ancient Diagnosis will only apply if massage is being used athletes developed a special tool, the strygil, to to treat a sports injury. Many sports massages are scrape the masseur’s oil from the skin (Williams classified as specific, i.e. not only to treat a particu- 1974). lar problem but also to help prepare prior to activ- ity, between bouts of activity or after activity. Sports massage can be divided into: Non-specific sports massage is also used to help keep the body in tune. ᭿ Specific sports massage ᭿ Non-specific sports massage Basic rules of sports massage History Before embarking on any sports massage, the basic It is always good practice to gain a full history, either rules of such a regime must be addressed: relevant to a particular problem or concerning previ- ous experience of and reaction to massage. ᭿ Diagnosis ᭿ History Contraindications ᭿ Contraindications ᭿ Aims of treatment Contraindications are listed in Chapter 3. It is ᭿ Position vitally important when dealing with sports people ᭿ Materials to remember the great risk of recent injury being ᭿ Skin preparation present. ᭿ Joint position ᭿ Technique Aims of treatment ᭿ Check with the participant ᭿ Clean up Is the massage to be stimulating or sedative? The ᭿ Warn the participant aim of treatment will depend on when massage is to be administered, e.g. pre or post event. 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

152 Massage for Therapists Position results. Soap and water are available in the treat- ment room but not necessarily at pitch side. In that It cannot be guaranteed that there will always be a situation wet-wipes or an astringent lotion should treatment couch available when using massage in be available for use. sport. Always ensure that the therapist is going to be able to perform all the necessary techniques with Warn the participant the greatest ease and that the recipient is at all times warm and comfortable. Even if the participant has frequent massages, always warn what to expect as a result of this Materials session, e.g. pre-competition stimulating massage may induce a feeling of warmth but the rules of Various oils may be used, most commonly vegeta- warm-up must still be observed. ble based, ice, non-steroidal anti-inflammatory gel, towels, ranging from small to very large, and inflat- Massage manipulations in able pillows. sports massage Skin preparation The massage manipulations used in sports massage are as described in Chapter 6, plus acupressure, Many sports people shave their legs before competi- trigger pointing and ice massage. tion and small nicks are not unusual. Aseptic condi- tions should apply, with absolute cleanliness Acupressure essential. Acupressure/acupuncture (‘acu’ is Chinese for Joint position needle) points are stimulated by finger or thumb pressure. There is a complete therapy using the In the treatment rooms, positioning as described in ‘tsubos’-specific sensitive points used in acupressure previous chapters should be adhered to. At track or and also shiatsu (in Japanese ‘shi’ is finger, ‘atsu’ is pitch side be prepared to be innovative and use pressure) where whole hands, elbows, feet and whatever is available and suitable to obtain the best knees may be used to massage the body (Jarmey joint position. and Tindall 1991). Technique In sports massage acupressure tends to be to specific trigger points. These points are identified as This will be addressed later in the chapter. tense, sometimes hard, and always producing pain in the muscle/connective tissue. Check with the participant Once the point to be treated has been identified, Always ask the participant if the massage is deep the finger or thumb is used to apply pressure to that enough, too deep or as he/she wants it. specific point. The technique is similar to that used in circular frictions but only one finger or the thumb Clean up tip is used. There are many different opinions as to the length of time the pressure should be held. A Participants cannot enter the competition arena firm pressure accompanied by a slight circular covered in oil. A basketball player with oil on his motion applied for a maximum of 1 minute, relaxed thighs can get this onto his hands with disastrous and reapplied three or four times, gives good results. The object is to try to get muscle relaxation in as short a time as possible, thus making this technique very useful immediately prior to activity by remov-

Massage in sport 153 ing particular spots of muscle/tissue tension. The the most advantageous way to aid the participant use of both acupressure and shiatsu in sport is in his/her chosen event. growing and there are many varying theories on the subjects, from basic applications to reduced muscle Massage in conditioning tensions right up to the complete science of the full holistic concept of Oriental medicine (Downer The conditioning time of year for any sports person 1992). will depend entirely on what his or her goals are for that particular year. The actual time of year will Trigger pointing vary from sport to sport, dependent on the competi- tive season and major event(s). The object involves Trigger pointing as first addressed by Travell and the SAID principle: specific adaptation imposed Simons in Travell & Simons’ Myofascial Pain and demands (Wallis and Logan 1964). This principle Dysfunction: The Trigger Point Manual is an puts the body through safe and intense develop- extremely efficient method of treatment in sport. ment, to achieve peak condition at the time of This is particularly good pre and inter competition, major competition. There may have to be more when specific tight spots and tension are identified. than one time of ‘peaking’ in each year, e.g. to As always with this technique it is vital to treat all qualify for Olympic selection in June and then to areas and ensure you do not leave the point too compete in the Olympic Games in September. soon. Massage at the time of conditioning plays a very important part in the training regime. Ice massage Objects The most convenient method of application of ice massage is to use a polystyrene cup which has been ᭿ To promote recovery from a hard training filled with water and then frozen. Cut a 1.25-cm session. It is to be expected after a hard bout ring from the top edge of the cup and then massage of exercise that the sports person will experi- the injured area with the ice until an erythema is ence various aches, pains and a feeling of tired achieved. If dealing with tendinous or small areas and heavy limbs. Massage can be invaluable in an ice cube held in a tissue is best. speeding up recovery at this time. Specific sports massage ᭿ To aid cool-down. The object of cool-down is to return the body to its pre-exercise state as Specific sports massage is given for a particular quickly and painlessly as possible. Massage at reason and can be used in six different situations: this time can be used to aid circulation, assist in the removal of waste products and enable ᭿ Massage in conditioning the participant to perform his or her cool-down ᭿ Massage as treatment regimes more effectively. ᭿ Pre-competition massage ᭿ Inter-competition massage ᭿ To prevent delayed onset muscle soreness ᭿ Post-competition massage (DOMS). It is widely appreciated that intense ᭿ Post-travel massage bouts of exercise will produce varying degrees of muscle soreness after the event. This sore- These six specific sports massages may have to ness may not be noticed for up to 24 hours be carried out at pitch or track side and it may not after cessation of the activity. Many learned always be possible to follow to the letter the manip- sources will insist that there is no specific proof ulations, routines and methods suggested. The that massage will, in any way, prevent the therapist must be prepared to be adaptable and use occurrence of DOMS. On the other hand the manipulations and skills at his/her command in observation and anecdotal evidence lead those who are actively engaged in the field of sport massage to feel DOMS can be, and is, influ- enced positively by the application of the correct massage techniques.

154 Massage for Therapists ᭿ Psychological effect. The importance of the ing any micro trauma that may have been occa- psychological effect of touch has never been sioned by a particularly hard training session. fully quantified. At this hard time of training for the sports person a massage performed by Massage as a treatment a good knowledgeable practitioner can make a vast difference to his or her continued wellbe- Massage as a treatment for sports injuries can be ing and can enhance the benefits of the condi- used after 48 hours if all bleeding and tissue swell- tioning period. ing has ceased, or, in the case of haematoma, after 4 days or dependent on the patient’s tolerance. Contact materials Objects Oils and mild warming rubs. ᭿ To stimulate circulation. Forty eight hours Routine and manipulations used after trauma it is important to clear away the debris of the incident and remove the excess ᭿ Light effleurage to accustom the person to tissue fluid. Massage can play a useful part in touch; also to test to see if there has been any reaching these goals. micro trauma to soft tissue as a result of hard training. ᭿ To promote recovery from injury. As stated above, to stimulate circulation and also to ᭿ Deep effleurage to promote venous and lym- ensure the continued good state of surrounding phatic drainage. tissues. ᭿ Petrissage to mobilise the soft tissues. ᭿ To break down adhesions. The most impor- ᭿ Deep effleurage as above. tant result after injury in sport must be that the ᭿ Acupressure to address any specific tension or individual has not been left with a tight short- ened scar in any soft tissue. Adhesions and scar trigger spots identified. tissue are sources of trouble and can result in ᭿ Stroking to provide relaxation and aid venous further trauma producing bigger and thicker areas of adherent tissue. Massage can play a return. very important part in the recovery. ᭿ Tapôtement/shaking/vibrations to stimulate ᭿ To promote flexibility. It is essential that and give a feeling of wellbeing. all participants have returned at least to ᭿ Effleurage to aid venous and lymphatic return, their previous level of flexibility after injury. Massage can provide a useful adjunct to the and to assess the final state of the tissues. essential stretch routines performed by the patient. Method ᭿ To improve the range of movement. Most Start with the back, then the limbs, concentrating types of injury, both soft tissue and bony, on the muscles most used in the training session. may well necessitate periods of strapping Often finish with a foot massage. and/or immobilisation. A return to full range movement is necessary prior to return to full Duration training and competition. Massage is used extensively to facilitate achieving a full range Whole body: 1–1.5 hours; half body: 30–45 minutes. of movement. This massage can be given on a daily basis through- out the conditioning period, with the first massage being given the day before the first day of hard training. Contraindications Contact materials Contraindications are as described in Chapter 3, Oil, cream, heat rub, ice, anti-inflammatory gel or paying particular attention to identifying and avoid- cream.

Massage in sport 155 Routine and manipulations used Pre-competition massage ᭿ Stroking to accustom the sports person to Massage prior to competition is to many sports touch and discover any areas of sensitivity. people part of the ritual carried out before their sporting endeavour. The time of this massage as ᭿ Effleurage to promote venous and lymphatic part of the adjunct to performance must be care- return; depth will depend on injury. fully planned. If dealing with a team sport and all players require a massage, there must be adequate ᭿ Petrissage to mobilise soft tissue and induce staff so that massages are not carried out many slight stretch on those tissues; also to reduce hours before the actual physical warm-up. In the muscle spasm. case of individual performance, the report time and/ or start time will decide the time of the pre-competi- ᭿ Effleurage as above. tion massage: for example, start time 10.30 a.m., ᭿ Frictions – to produce a counter-irritant effect report time 10.10 a.m., warm-up 1 hour, therefore the pre-competition massage must start at 8.40 a.m. as described in Chapter 6, to mobilise and at the latest. break down scar tissue. ᭿ Tapôtement to produce an excitation effect as Warm-up is the preparation of the body for phys- described in Chapter 6, plus a feeling of ical activity. It is divided into three components: wellbeing. ᭿ Effleurage as above. ᭿ Raising body temperature and increasing car- ᭿ Shaking applied both locally and to a total limb diovascular activity. to aid relaxation and relief of muscle tension and cramp. ᭿ Putting all joints through a full range of move- ᭿ Acupressure – by stimulating trigger points it ment and all muscles into their greatest length is possible to gain muscle relaxation or an of flexibility. increase in muscle tone, dependent on depth and length of pressure applied. ᭿ Sport-specific warm-up by practising the activi- ᭿ Connective tissue massage to mobilise the deep ties to be carried out. reticular layers of the dermis. ᭿ Rolling as described in Chapter 6. Thus, a rugby player will end his/her warm-up with ᭿ Effleurage as above and to assess the final state ball skills, passing and tackling; a hurdler will of the tissues. hurdle; and a discus thrower will practise the move- ments required to throw the discus. Method This massage cannot be used instead of the par- Always massage proximal and then distal areas of ticipant’s own physical warm-up but definitely can the body before concentrating on the treatment be used to enhance the preparation. area proper. Objects Duration ᭿ To prepare muscles for exertion. By increas- Dependent on area and sensitivity of the area to ing the circulation to specific areas and mobilis- be treated the duration of massage may be 10– ing soft tissues. Massage prior to activity will 30 minutes. The treatment can be used daily depend- make it easier to carry out the specific stretches ing on the patient’s level of discomfort and needed for any performance. training/competition schedule. ᭿ To aid warm-up effect. As the term implies, Contraindications warm-up is about warming the body prior to activity. The vasodilatation caused by Contraindications are as described in Chapter 3. massage will enhance this phase of physical Also it is advisable not to massage within 3 days of preparation. training or competition if the methods are used to treat scar tissue or adhesions, and never if the ᭿ Psychological effect. The time spent on the patient cannot tolerate treatment. massage couch is often used by participants to prepare mentally for the forthcoming action. This may be done in conversation with the therapist or may be inward and silent. There is

156 Massage for Therapists a great advantage if the therapist knows the 5 minutes of acupressure can be used. It is best competitor well and knows whether or not he/ performed immediately prior to warm-up and it she likes to talk at this stage. It is also a good may well be followed by particular muscle stretch time to reinforce positive messages and allay techniques such as contract/relax or stretch/relax as fears about injury worries and the state of the used in progressive neuromuscular facilitation tech- opposition. niques. Do not use hot rubs. Contact materials Contraindications These must be carefully selected dependent on the Contraindications are as stated in Chapter 3. Also activity about to take place and great care must be it is advisable not to massage if the competitor has taken to clean the area well after the massage. Oils, not used massage prior to competition on previous creams and talcum powder are all appropriate, but occasions. do not use any heating agent. All rubefacients will cause vasodilatation of the skin and this will prove Inter-competition massage to be detrimental to the warm-up. The vasodilata- tion needs to be greatest below the dermis to aid When there is prolonged competition it will be nec- warm-up. essary to provide inter-competition massage. During a competition that has several rounds such as quali- Routine and manipulations used fying, quarter-final, semi-final and perhaps even finals on the same day, there are periods of rest in ᭿ Stroking to accustom the person to touch. between. This is when massage can be very useful ᭿ Effleurage to promote venous and lymphatic to the participant; also in multi-events at track and field, when the men do ten events over 2 days and return, and discover any area that is particu- the women seven. In this circumstance, if the ath- larly tight, tense or giving pain. letes spent their normal time before and after each ᭿ Petrissage to increase mobility of the soft tissues discipline doing warm-up and cool-down, they and stimulate circulation. would be too tired to compete. Cool-down is the ᭿ Tapôtement/shaking/vibration – all or one or time immediately after training or competition two to promote a feeling of wellbeing and give when the participant will jog and perform specific relief from muscle tension. exercises all aimed at returning the body to its ᭿ Effleurage to finish massage and ascertain that resting state. Massage is extremely useful to com- the desired effects have been produced. plement a shortened warm-up and cool-down, but ᭿ Trigger point and acupressure may be needed again cannot replace these essential activities. The if there are specific areas of muscle spasm, only time massage can replace cool-down is if the tension or increased tone. participant is too exhausted to perform an active cool-down or if injury precludes activity. Massage Method can never replace active warm-up. Massage as requested by the participant. Many Objects sports people only want/need massage to a particu- lar area, e.g. hamstrings or calf, while others request ᭿ To promote recovery. After a bout of exer- a full body massage. cise there will be waste products in the tissues. Massage, by stimulating venous and lymphatic Duration return, aids the process of elimination of such products. Duration of the massage is dependent on the area to be covered and length of time to achieve the ᭿ To refresh the competitor. In a prolonged desired effect of stimulation and to decrease any competition it is not unusual to experience spasm or increase tone. Usually 20–30 minutes to muscle fatigue and general tiredness. Stimulating a maximum time of 1 hour is best. As a last-minute massage can be advantageous to combat both attempt to decrease specific muscle tension, feelings.

Massage in sport 157 ᭿ To work out niggles. After hard exercise Method there may well be a feeling of tightness in certain muscle groups, which will not respond Massage as needed by the competitor. Early on in to the competitor’s normal series of stretching the day the request may be to address one specific exercises. Massage can be used to help physi- area that is bothering the competitor. However, as cally and also to reassure the participant that the competition continues and usually before and/ there is no major problem developing. or after the last event of the day, it may be necessary to cover the full body. ᭿ To prevent muscle cramps and spasms. It is not unusual, especially if the competition is Duration taking place in a situation where dehydration can occur, to be presented with cramps. While Massage as time allows; this may be for only several the competitor rehydrates with the correct minutes or up to an hour. It is best to perform fluids, massage can be used to help increase the inter-competition massage immediately after cool- circulation to the affected part. down and/or prior to the next warm-up. Contact materials Contraindications Be careful to select the correct medium. If the area Contraindications are as stated in Chapter 3. Also is sweaty or has sand or chalk on it, it must first be any area of recent trauma must be avoided. cleansed. The pores will be open and you do not want to clog these with any medium which will Post-competition massage impede heat loss. A very light oil or soapy water is best. Never use any hot rubs at this stage. It may At the cessation of activity the competitor will do be necessary to use ice massage if there is an area cool-down. Massage can be used to enhance the where there could be actual tissue damage. effects of this procedure. On certain occasions it may be necessary to replace active cool-down with Routine and manipulations used massage and passive movements, e.g. after a mara- thon, long-distance event, or when the competitor ᭿ Stroking to accustom the person to touch and has sustained an injury that precludes active to assess the temperature and state of the area cool-down. to be massaged. Objects ᭿ Effleurage to promote venous and lymphatic return and discover any particularly tense ᭿ To carry away waste products (see ‘Inter- spot(s). competition massage’ above). ᭿ Petrissage to help remove the waste products ᭿ To allow body functions to return to and mobilise the soft tissues. The rolling normal. At the end of any period of physical manipulations described in Chapter 6 are par- activity the cardiovascular system may be ticularly useful here. working excessively hard, or as a result of the cessation of activity the blood pressure ᭿ Acupressure to any area that is excessively can suddenly drop. Massage, especially cen- tense or tending to cramp. tripetal effleurage, is very useful in restoring normality. ᭿ Vibrations and shaking – whole-limb shaking and vibration are very good towards the end ᭿ To prevent post-exercise pain (as previously of this massage to ensure the limb is ready for described in ‘Massage in conditioning’). the next bout of exercise and unlikely to go into cramp. ᭿ To work out niggles. Frequently after activ- ity the participant may complain of certain ᭿ Trigger pointing and acupressure – always be specific areas of pain or tension. If any tissue sure there is no underlying soft tissue damage is suspected, ice massage can be damage. ᭿ Effleurage to complete the session and prepare the competitor for warm-up.

158 Massage for Therapists applied. If the cause is purely exercise induced, which might well be caused by micro trauma, in then massage is beneficial to remove the which case only ice massage should be applied. tightness. ᭿ Psychological effect. As previously described Post-travel massage this can be very important if the competitor is either on a ‘high’ after competing success- It is very common for all types of sports people to fully or, conversely, ‘down’ after a poor have to travel varying distances to participate in performance. competition all over the world. Wherever possible sufficient time should be allowed to permit ade- Contact materials quate acclimatisation both to time change and cli- matic conditions. In reality the competitors may not Ice, soapy water or light oil, but not any hot rubs be able to allow this time to adjust. The length of or talcum powder. time spent travelling and the frequency of this travel can adversely affect performance. Travel problems Routine and manipulations used highlighted in sport are: All manipulations should be slow and rhythmic. ᭿ A general feeling of stiffness. ᭿ A feeling of lassitude. ᭿ Stroking to assess the area and accustom the ᭿ Aches, especially in the lower back, neck and sports person to touch. shoulders. ᭿ Effleurage – at first light and centripetal, then ᭿ Swelling of lower legs and feet. deeper if there is no tension or pain. It can be performed in all directions, to increase circula- Solutions are: tion and remove waste products. ᭿ Light exercise ᭿ Petrissage – starting fairly light and deepening ᭿ Shower to a level the participant can tolerate. ᭿ Jacuzzi ᭿ Massage ᭿ Effleurage interspersed between all other strokes and for at least 5 minutes at the end of Objects the massage to enhance tissue drainage. ᭿ To increase venous and lymphatic flow, Method thus removing swelling and stiffness. Massage as requested by the competitor. This may ᭿ To remove aches and increase flexibility by be to one specific area only or to the whole body gently and deeply stretching the soft tissues. area and in some instances may be used in place of active cool-down. ᭿ To remove any residual stiffness without tiring the competitor with exercise. Duration ᭿ To restore normal balance of the body. Duration is dependent on the area to be covered; it ᭿ To create a feeling of wellbeing. may last 15–30 minutes or may take a full hour. This massage is best performed after the active Contact materials cool-down and preceded by a tepid shower. When taking the place of an active cool-down it is essen- Oil or creams. Do not use talcum powder or hot tial to ensure that the participant is adequately rubs as there may well be some dehydration rehydrating as well as receiving massage. present. Contraindications Routine and manipulations used Again contraindications are as described in Chapter ᭿ Stroking to assess the condition of the skin and 3. Also be very circumspect around painful areas accustom the participant to touch.

Massage in sport 159 ᭿ Effleurage – first centripetal to aid tissue drain- Basically we are referring to a massage that is given age and increase venous and lymphatic return, for no specific treatment purpose, and is not before, then multidirectional to promote tissue between or after competition or travel. Non-specific stretching. sports massage can be divided into two applications: ᭿ Petrissage – especially kneading, wringing, picking up and rolling techniques to assist ᭿ General body massage drainage and stretch the soft tissues. ᭿ Specific areas of massage ᭿ Effleurage should be interspersed regularly General body massage with all other strokes. Sports people spend a large part of their lives con- ᭿ Tapôtement, vibration and shaking to aid ditioning and preparing their bodies for the rigours venous and lymphatic return and to promote a of their particular sport. Many of them firmly feeling of wellbeing. believe that regular full body massage will aid them in their pursuit of excellence. Method Objects Start with the back and neck, then the legs and if necessary the arms as well. Finish with assisted ᭿ To enhance a general feeling of wellbeing. stretches to the major muscle groups used in the ᭿ To promote relaxation, if this is desired by participant’s activity. the participant. Duration ᭿ To stimulate, if requested by the participant. ᭿ To monitor condition of the musculature Duration is dependent on the areas to be covered but should be a minimum of 30 minutes and may and soft tissues. last over an hour. Best results are gained if the ᭿ To highlight and deal with any area that participant has already carried out some gentle activity, such as a jog and gentle stretches, and then could develop into a problem. had a tepid shower prior to massage. Contraindications Contact materials Contraindications are as described in Chapter 3, Oils. If knowledgeable, aromatherapy can be used paying particular attention to the effects of (see Chapter 15), creams, mild warming rub or dehydration. talcum powder. Non-specific sports massage Routine and manipulations used There are times in the competitor’s year when there For objects 1 and 2: is no competition or conditioning taking place. At those times the athlete will still be maintaining his/ ᭿ Stroking to accustom to touch. her body in a state of preparedness for the activities ᭿ Effleurage – long slow manipulations used of the future. Massage can play a very important and helpful part at those times and is referred to as continuously. non-specific massage. This term also applies to ᭿ Kneading deep enough not to tickle, slow and massage given when the competitor has arrived at the competition site ahead of the event by at least rhythmical. 2 days, or finished competition and is still present ᭿ Effleurage – slow to end the session. at the competition site, waiting for the rest of the team to complete competition and return home. For objects 1 and 3: ᭿ As described in ‘Pre-competition massage’. For object 4: ᭿ Deep effleurage.

160 Massage for Therapists For object 5: Method ᭿ Trigger pointing and friction may be added and Concentrate on the area highlighted by the partici- in this case the non-specific massage will change pant, but do not forget to clear the surrounding to a treatment massage if specific problem area. areas are highlighted. Method Duration ᭿ For objects 1 and 2, as described in Chapter 2, Massage for as long as is needed to gain the desired starting with the back and neck, then each limb effects. in turn, foot massage as opposed to facial massage and, if deemed necessary, finish by Contraindications returning to the back. Contraindications are as described in Chapter 3. ᭿ For objects 1 and 3, as described in ‘Pre-com- petition massage’. Summary ᭿ For object 4, extra effleurage at the start and ᭿ Never give a first massage to a participant finish of the session. within 48 hours of competition. ᭿ For object 5, as described in ‘Massage as a ᭿ Arrange for the first massage to take place treatment’. when there is plenty of time for any adverse effects to be worked off. Duration ᭿ Adverse effects may be: For objects 1 and 2, massage as long as is needed ᭿ producing too much relaxation; to gain the desired relaxation, usually 1–1.5 hours. ᭿ stirring up old problems such as scar It is important that the competitor can lie and relax tissue. for at least half an hour after completion of the massage. Sports massage may be sport specific and any therapist involved must know and understand the For objects 1 and 3, it is as described in ‘Pre- principles of that sport. Most importantly, the rules competition massage’. and call-up times of the sport must be understood. As already stated, there will not always be time to For object 4, a few extra moments at the end of perform the beginning, middle and end of a massage each session are required. as you might wish. The most important issue in a situation where time is of the essence is to be abso- For object 5, duration is as your findings lutely clear about the main object of this massage. necessitate. It may be to eliminate a particular point of tension or increase range of movement. Having identified Contraindications the object, choose which of the techniques can best deliver the desired effect and use them. If the sport Contraindications are as described in Chapter 3. is an outdoor activity it may not even be possible to remove clothing, e.g. skiing, orienteering, dis- Specific areas of massage tance running – participants frequently wear tights or jogging bottoms to protect their legs. In instances Dependent on the muscle groups most used in a par- like these whole limb shaking, vibration or trigger ticular event, the competitor may request an area of pointing through the clothing will be the best body to receive massage, rather than a full body massage techniques to use. massage, e.g. a thrower’s back and/or shoulders; a sprinter’s hamstrings, quadriceps and calf muscles; a distance eventer’s and soccer player’s calf muscles. Objects, contact materials and manipulations These are as described in ‘General body massage’.

Massage in sport 161 Case study ity. All other ranges of movement could be improved by stretching. Medial rotation of This case study by Joan M. Watt originally appeared both hip joints was reduced by 20%. in Sportex Dynamics and is reproduced with per- ᭿ Palpation – sensation was normal, no lower mission of Centaur Publishing. back problems, skin temperature normal, no evidence of skin abrasions, cuts or rashes. What is sports massage? Sports massage is apply- ing massage modalities for the specific benefit of Treatment plan and outcome: sports and exercise participants and can be applied to any active person. It covers the manipulation and ᭿ Considerations – this young man did not stay management of the soft tissues of the body. Sports in the area of the competition and was only massage can address specific muscle, ligament, going to be present for the 2 days of tendon or fascia problems or be used to enhance competition. the activity of healthy tissue. This type of massage should be administered to positively enhance each ᭿ Aims and objectives – it was agreed that we person’s ability to move, exercise and compete. should try to get enough relaxation into the affected muscle tissue to allow safe participa- Event information: decathlon is a track and field tion. It was explained that long term the athletics event and is only for male competitors. damaged area would need to receive intensive There are ten events in all which take place over care with correct soft tissue mobilisation, 2 days. Day one consists of 100 m, long jump, shot passive and active stretching and conditioning. put, high jump and 400 m. On day two the events The competitor was advised to seek profes- are 110 m hurdles, discus, pole vault, javelin and sional help at home, and contact details of a 1500 m. practitioner in his home area were supplied. Scenario: a 20-year-old student who is about to ᭿ Treatment pre-event – general massage to compete in the decathlon for his university team posterior aspect of right thigh and calf using presents with limited range of movement in his stroking, effleurage, grades 1 to 2, petrissage, right hamstring 30 minutes prior to his first event. specific kneading, picking up, wringing and rolling grades 1 to 3. This was then followed General health: excellent, very fit, no known ill- by trigger pointing and acupressure grades 1 to nesses, current injuries or allergies. 2 on specific areas, and ended with myofascial release and proprioceptive neuromuscular Previous history: originally tore his right ham- facilitation. string at age 17 and has had no problems since. Range increased following treatment to allow a Previous treatment: physiotherapy at time of good pattern of movement with no pain. injury, ice strapping, exercise and stretching. No follow-up or advice. Massage was administered before each of the events on day one, with ice massage being intro- Medication: none. duced between events four and five. Surgery: none. Post-event massage concentrated on gently loos- ening the tightest area and consisted mainly of Assessment: effleurage, myofascial release, rolling, wringing and muscle energy technique. Ice was applied for ᭿ Questioning – this revealed previous injury 10 minutes at the end of massage and the athlete history, a dislike of doing flexibility exercises was advised to do gentle non-weight-bearing and only paying lip service to warm-up and stretches for 5–10 minutes every hour awake and cool-down. stretching to be held for 30–40 seconds. ᭿ Observation and movement – very fit, well- Day two started with slightly increased range, muscled young man but exhibits slightly stiff but pain was experienced from mid to end of range movement patterns. Right hip flexion was 20 of movement. degrees less than left and lower musculotendi- nous junction of the right biceps femoris was Massage as on day one was administered before scarred and showing evidence of loss of elastic- each event and post competition, with ice being used on each occasion.

162 Massage for Therapists By the end of day two the musculotendinous Further reading junction was slightly slacker but showing active trigger points with very noticeable attachment to Andrade, C.K. and Clifford, P. (2001) Outcome Based good tissue. Range of movement was almost full Massage. Lippincott Williams and Wilkins, Philadelphia. and the athlete experienced slight tightness and occasional twinging. Cafarelli, E. and Flint, F. (1992) The role of massage in preparation for and recovery from exercise. Sports Since this event the competitor has received treat- Medicine, 14(1), 1–9. ment from a sports-specific physiotherapist and sports massage practitioner in his home area. He Hilbert, J.E., Sforzo, G.A. and Swensen, T. (2003) The effects now has equal pain-free range of movement in right of massage on delayed onset muscle soreness. British and left hamstrings, strength is equal and he is Journal of Sports Medicine, 37, 72–5. training and competing fully. On palpation of the original problem area there is a small but mobile Holey, E.A. and Cook, E.M. (2003) Evidence-Based area of scar tissue. Ongoing it is vital that the Therapeutic Massage. Churchill Livingstone, Edinburgh. athlete continues all stretching and strength work and attends for regular assessment of the scar Robertson, A. Watt, J.M. and Galloway, S.D.R. (2004) tissue. Effects of leg massage on recovery from high intensity cycling exercise. British Journal of Sports Medicine, 38, References 173–6. Downer, J. (1992) Shiatsu (Headway Lifeguides). Hodder Simons, D.G., Travell, J.G., Simons, L.S. and Cummings, and Stoughton, London. B.D. (1999) Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 2, 2nd edn. Jarmey, C. and Tindall, J. (1991) Acupressure for Common Lippincott Williams and Wilkins, Philadelphia. Ailments. Gaia Books, London. Watt, J. (1999) Massage for Sport. Crowood Press, Wallis, E.L. and Logan, G.A. (1964) Figure Improvement Marlborough. and Body Conditioning Through Exercise. Prentice Hall, New York. Weerapong, P., Hume, P.A. and Kolt, G.S. (2005) The mech- anisms of massage and effects on performance, muscle Williams, J. (1974) Massage and Sport. Bayer, Switzerland. recovery and injury. Sports Medicine, 35(3), 235–56.

15Aromatherapy Elisabeth Jones Introduction in the perfume Kyphi ‘lulled one to sleep, allayed anxieties and brightened dreams’ (Genders 1972). Aromatherapy may be defined as a therapeutic treatment that utilises the fragrant components Greeks: 500–40 BC extracted from aromatic plants. The aromatic sub- stances generally used by aromatherapists are the The Greeks also used aromatics for medicinal as essential oils of these plants. Aromatherapy massage well as body-enhancing purposes. A famous Greek must only be practised by those therapists who have perfume ‘Megaleion’, named after its Greek creator nationally recognised qualifications. Megallus, was used not only for its scent but also for healing wounds and reducing inflammation. Historical uses of essential oils Europeans Since time immemorial aromatic plants and their Twelfth century extracts have been used for religious, medicinal and cosmetic purposes. Many monasteries had their own aromatic herb gardens and used the plants and extracts to heal the Egyptians: 3000–1500 BC sick who came to their doors. Abbess Hildegard of Bingen is known to have utilised both the plant and The ancient Egyptians used them not only for reli- the essential oil of lavender. gious rites (embalming of bodies, using in particular cedarwood oil), but also for their therapeutic effects Sixteenth century (scented unguents on sun-baked skin to soothe and maintain elasticity). A famous perfume, ‘Kyphi’, To ward off the plague, according to a book written was made of a mixture of fragrant herbs and resins. in French, Les Secrets de Maître Alexis de Piedmont, Plutarch said that the aromatic substances included the house should be fumigated with all manner of fragrant substances including rosemary, cloves, 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

164 Massage for Therapists nutmeg, sage, aloes and juniper wood (Genders it is not practicable, or is too expensive, to isolate 1972). it. Essential oils are not confined to flowers. They may be found in leaves, grasses, seeds, roots, rhi- Seventeenth century zomes and fruits as well as woods and resins. By the beginning of the 17th century approximately When essential oils are produced in more than 60 oils were being used for their perfume and one part of a plant, the individual oils will differ in medicinal effects (Valnet 1980). composition and fragrance, e.g. the bitter orange tree gives bitter orange oil from the rind of the Nineteenth century orange, petitgrain oil from the leaves and the green twigs, and neroli oil from its freshly picked ‘The first research into the antiseptic powers of flowers. essential oils was undertaken by Chamberland in 1887 in his work on the anthrax bacillus. He noted Basic chemistry the active properties of origanum, Chinese cinna- mon, Singhalese cinnamon, angelica and Algerian A typical essential oil is a complex mixture of chem- geranium’ (Valnet 1980). ical compounds, each of which possesses its own individual properties (Williams 1989). Twentieth century ‘All of the constituents of an essential oil are Cavel’s research on microbial cultures in sewage organic; that is, their molecular structures are based has shown many essences to have the power to upon arrangements of carbon atoms blended into render inactive 1000 cc of culture at considerable one another and to atoms of hydrogen. Oxygen dilutions (Valnet 1980). Cavel in fact researched 35 atoms are present in many of the constituents of oils, finding thyme, origanum and sweet orange the essential oils and sometimes atoms of nitrogen and/ most effective (Cavel 1918). or sulphur’ (Williams 1989). Gattefosse, a French chemist, was the first to coin The constituents that have molecules containing the term ‘aromatherapy’, having during and after carbon and hydrogen only are called hydrocarbons. World War I made an extensive study of the The number of constituents in an essential oil varies, uses of plants, and published a book termed and an oil may have 100 or more when analysed. ‘Aromatherapy’ in 1937. The contribution of any one constituent to the unique scent of an essential oil depends on: During World War II, Dr Jean Valnet, another Frenchman, inspired by Gattefosse’s work, started ᭿ The proportion of the constituent. to use essential oils in his clinical practice. His ᭿ The volatility of the constituent. medication included both internal and external use ᭿ The quality of the constituent. of essential oils. ᭿ The strength of odour of the constituent. By the 1960s a small band of enthusiasts (the The varying evaporation rates of the individual foremost being Madame Maury, a French biochem- constituents will affect the fragrance of the essential ist) began to incorporate essential oils into massage oil over the passage of time. ‘It is the odours of the treatments. This use of essential oils has grown oxygenated constituents and to a secondary degree steadily and aromatherapy massage, when given by the odours of their sesquiterpenes which determine properly qualified practitioners, is now widely used the odours of almost all the essential oils’ (Williams in hospitals, hospices and clinics. 1989). Essential oils Mind and body An essential oil may be defined as an odorous, vola- A perfume uses natural and synthetic materials to tile substance, present within all aromatic plant combine odour and volatility to give the wearer matter. In many cases the amount is so minute that maximum psychological pleasure from the fra- grance that he/she has chosen. This pleasure results

Aromatherapy 165 from the stimulation of the olfactory (smell) nerve ᭿ Distillation: this is the method usually employed endings in the nose. An aromatherapist combines for extracting the essential oil from a plant. psychological with physiological effects to gain The plant material is heated either in boiling maximum therapeutic value from the essential water or in steam and the essential oil mole- oils. cules are released and are ultimately distilled. Aromatherapists remain firmly committed to ᭿ Expression: the expression technique is reserved using only natural essential oils from aromatic for citrus oils because they are unable to with- plants. stand the rigours of distillation. Hand or mechanical pressure is applied to the rinds of ‘It has been demonstrated that the anti-inflam- citrus fruits, thereby expressing their essential matory and other medicinal properties of some oils. natural oils, some of which have been used since Biblical times, are gentler and less toxic than the ᭿ Solvent extraction: aromatic extracts such as pure active drugs isolated from the oil’ (van concretes and absolutes and resinoids contain Toller and Dodd 1988). considerable amounts of non-volatile matter and cannot therefore be truly termed essential These essential oils offer a state of wellbeing not oils. They are removed by chemical solvents only for the mind but also for the body. from the plant matter that stores them. They are sometimes used by aromatherapists. Extraction methods ᭿ Enfleurage: this method used to be used to Figure 15.1 describes methods of extraction and the extract absolutes for perfumery. Glass plates aromatic derivatives from plants. Essential oils used were covered with a film of cold fat on which in aromatherapy may be extracted from plant mate- fragrant flower petals were laid, their essential rials in the following ways: oils being absorbed by the fat. ᭿ Hydrofusion/percolation: this is the newest method of extraction and though it uses steam as in distillation it is considered to be a faster process. ᭿ Maceration: some essential oils are too difficult or too costly to distil and are therefore extracted by a method called maceration. Plants such as calendula, lime blossom and Melissa are cut up and placed in a vat of vegetable oil, e.g. almond or sunflower, and agitated for some days. The molecules of the essential oils are absorbed by the vegetable oil, and the liquid is filtered and then bottled. ᭿ Carbon dioxide extraction: this method was introduced in the 1980s for the perfumery trade, but it remains an expensive method. The oils are supposed to be more like the ‘natural’ oil. Figure 15.1 Aromatic derivatives from plants. A working knowledge of essential oils It is important that an aromatherapist has a working knowledge of the traditional uses of at least 40 dif- ferent oils, and a list of the most commonly used is given below:

166 Massage for Therapists Basil (Ocimum basilicum) Olfaction Benzoin (Styrax benzoin) Bergamot (Citrus bergamia) Olfaction occurs when the sense of smell is inter- Cajaput (Melaleuca cajaputi) preted by the olfactory apparatus. This starts in the Cedarwood (Cedrus virginia) nose where the olfactory receptors are situated, and Chamomile – Moroccan (Ormenis multicaulis) spreads via impulses along the olfactory nerve (C1) Chamomile – Roman (Chamaemelum nobile) to the olfactory bulbs on the underside of the brain. Clary sage (Salvia sclarea) There are two groups of receptors of about 25 Cypress (Cupressus sempervirens) million cells each of which lie in a small area at the Eucalyptus (Eucalyptus globulus) top of the nose. Fennel (sweet) (Foeniculum vulgaris) Frankincense (Boswellia carteri) Protruding from the cells are olfactory hairs Geranium (Pelargonium graveolens) which are so small as to be visible only when very Ginger (Zingiber officinalis) highly magnified by the electron microscope; they Grapefruit (Citrus paradisi) lie immersed in the thin watery secretion of the Hyssop (Hyssopus officinalis) mucus which covers the surfaces of the nasal cavi- Jasmine (Jasminum officinale) ties (Williams 1989). Juniper (Juniper communis) Lavender (Lavender angustifolia) Odour molecules from the essential oils are vola- Lemon (Citrus limon) tile and fat and water soluble. Lemongrass (Cymbopogon citratus) Mandarin (Citrus reticulata) ‘As a result when we breathe in these molecules Marjoram (sweet) (Origanum marjorana) they easily penetrate the mucus layer and come into Melissa (lemon balm) (Melissa officinalis) contact with the olfactory cilia. The incoming mol- Myrrh (Commiphora myrrha) ecules fit into the receptor sites and initiate an elec- Neroli (Citrus aurantium) trochemical reaction in a “lock and key” action’ Niaouli (Melaleuca viridiflora) (Vickers 1996). Palmarosa (Cybopogon martinii) Patchouli (Pogostemon cablin) The olfactory apparatus is closely associated Pepper (black) (Piper nigrum) with the limbic system (hippocampus and amyg- Peppermint (Mentha piperita) dala), once known as the rhinencephalen or ‘nose- Petitgrain (Citrus aurantium bigaradia) brain’. The limbic system is that part of the brain Pine (Pinus sylvestris) that is concerned with feelings, emotions, moods Rose (Rosa centrifolia/Rosa damascena) and motivation. It influences eating, aggressive Rosemary (Rosmarinus officinalis) action and sexual activity and controls certain hor- Sandalwood (Spanish) (Santalum album) mones and the autonomic nervous system. There is Sweet orange (Citrus aurentium/Citrus vulgaris) quite a lot of observational evidence that shows Teatree (Melaleuca alternifolia) that odours influence mind and body, e.g. Thyme (Thymus vulgaris) Ylang ylang (Cananga odorata, var. genuina) (1) Menstrual synchrony in female humans is an example thought to be due to odour (Schwartz Methods of administering essential oils and Natyncuk 1990). Figure 15.2 illustrates methods of use and the (2) Communication in the insect world by the passage of essential oils into the body. volatile chemical pheromones is often cited in support of this theory. Aromatherapists generally administer essential oils therapeutically via olfaction, inhalation or skin The fragrance of essential oils transmitted via the absorption. olfactory system to specialised areas of the brain undoubtedly creates psychological effects which in turn may achieve physical effects of a therapeutic nature. Inhalation Inhalation occurs when we breathe air into the lungs. When the vapour from an essential oil con-

Aromatherapy 167 Figure 15.2 The practical application of essential oils: methods of use, and passage of essential oils in the body. taining aromatic molecules passes into the respira- Skin absorption tory system it can have an effect throughout the system. Many traditional remedies advocate the use Until relatively recently it was thought that the skin of essential oils in boiling water and vaporising was virtually impermeable, but it is now known chest rubs to improve respiratory function. A that the skin and mucous membranes are able to number of clinical tests have been done that support absorb lipophilic substances (Brun 1952). the use of such inhalations (Berger et al. 1978; Traditionally, the action of oils when they are Saller et al. 1990). absorbed through the skin is considered to be similar to when they are absorbed into the capillary The aromatic molecules also pass through the network around the alveoli of the lungs. They enter walls of the alveoli in the lungs and enter the blood- the bloodstream and are transported round the stream. Again, clinical research has shown this to body until naturally eliminated. happen (e.g. Kovar et al. 1987; Buchbauer et al. 1993; Falk-Filipsson et al. 1993).

168 Massage for Therapists Whether absorbed by the lungs or the skin it is ᭿ Tissues possible they influence the body processes. Some ᭿ Perfumes may stimulate the release of endorphins – the body’s ᭿ Burners own chemicals which can have an analgesic or anti- ᭿ Steamers depressant effect. Others appear to have a diuretic effect, whilst yet more may be able to help with Skin absorption hormonal balances of the body or support the immune system. ᭿ Massage ᭿ Compresses Just as the oils work on the respiratory tissue ᭿ Creams itself during inhalation, so essences can have an ᭿ Lotions effect on the skin during skin absorption. Essential ᭿ Perfumes oils therefore not only provide pleasing fragrances, ᭿ Baths which have an effect on the mind, but also can have beneficial effects on the body. Ingestion Ingestion Essential oils may be administered orally or via the ᭿ Drops anus or vagina. However, ingestion as a method of ᭿ Food treatment should only be undertaken by those qual- ᭿ Gargles ified, for instance in phytotherapy. The reason for ᭿ Capsules this is that this method has the greatest risks of ᭿ Pessaries adverse effects. Though some doctors in France ᭿ Douches specialise in treatment by ingestion, it is rarely used ᭿ Suppositories in the UK or the USA. Glossary of terms and properties of The holistic approach some essential oils There are various ways of viewing the cause and The terminology applied to the uses of essential oils treatment of disease. It is held that conventional has been borrowed from herbal medicine. Table medicine locates all disease in the physical body, 15.1 shows a list of such terms (with explanations), and even emotional distress is viewed as a biochemi- together with some essential oils that offer these cal disorder that requires biochemical intervention. properties. Holistic medicine seeks the roots and treatment of disease not just in the individual’s body but also in The practical application of the mind, family, environment and community. In essential oils cancer, for instance, it has been claimed that an individual’s temperament (Eysenck 1988) and social Figure 15.2 illustrates the different methods by and family links (Reynolds et al. 1994) affect the which essential oils may be utilised for therapeutic onset cause of disease (Vickers 1996). purposes, and their passage in the body. The practical application of essential oils for Olfaction/inhalation therapeutic purposes uses the holistic approach both during consultation and in treatment. ᭿ Vaporised oils Aromatherapy is considered to be one of the ᭿ Sprays complementary therapies, but its usefulness in the treatment of many conditions is now widely appre- ciated by those working in orthodox medicine. Consequently an ever-increasing number of doctors, nurses, physiotherapists and other paramedical

Aromatherapy 169 Table 15.1 Glossary of terms and properties of some essential oils. Term Property Essential oil Analgesic gives pain relief basil, benzoin, bergamot, cajaput, chamomile, clary sage, coriander, cypress, eucalyptus, geranium, ginger, juniper, lavender, lemon, Anticontusive prevents bruises lemongrass, marjoram, melissa, orange, pepper (black), peppermint, Antidepressant counters low spirits pine, rosemary, thyme Antifungal inhibits growth of fungi geranium, ginger, hyssop Antiphlogistic reduces inflammation and bergamot, chamomile, clary sage, coriander, geranium, jasmine, Antiseptic vasoconstricts lavender, melissa, neroli, orange, patchouli, pine, rose, Antispasmodic sandalwood, thyme, ylang ylang inhibits growth of bacteria myrrh, tea-tree relieves smooth muscle spasm benzoin, chamomile, clary sage, cypress, geranium, jasmine, lavender, myrrh, neroli, niaouli, peppermint, rose, sandalwood Antiviral inhibits replication of viruses Aphrodisiac increases sexual desire almost all oils Astringent tightens tissues basil, bergamot, cajaput, chamomile, coriander, cypress, eucalyptus, fennel (sweet), frankincense, geranium, hyssop, jasmine, juniper, Carminative eases bowel pain and expels lavender, mandarin, marjoram, melissa, pepper (black), wind peppermint, rose, rosemary, sandalwood, thyme Cordial acts as a tonic for the heart niaouli, tea-tree Cytophylactic Depurative stimulates cell regeneration clary sage, jasmine, neroli, patchouli, pepper (black), rose, sandalwood, ylang ylang Digestive purifies the blood of toxins and waste bergamot, cedarwood, frankincense, geranium, grapefruit, juniper, lemon, patchouli, rose, rosemary, sandalwood aids digestion basil, bergamot, chamomile, coriander, fennel (sweet), ginger, Diuretic removes fluid from the body hyssop, juniper, lavender, mandarin, melissa, myrrh, neroli, through the kidneys pepper (black), peppermint, rosemary, sandalwood, thyme Emmenagogue aids menstrual problems benzoin, lavender, lemon, mandarin, rosemary Euphoric uplifts into an excitory state almost all oils Expectorant expels mucus from the chest eucalyptus, hyssop, jasmine, juniper, rose Febrifuge reduces fever basil, bergamot, cajaput, chamomile, geranium, ginger, hyssop, lemongrass, marjoram, myrrh, orange, thyme cedarwood, chamomile, cypress, eucalyptus, fennel (sweet), frankincense, geranium, juniper, lavender, lemon, marjoram, orange, patchouli, pepper (black), pine, rosemary, sandalwood, thyme basil, cajaput, chamomile, clary sage, cypress, fennel (sweet), ginger, hyssop, jasmine, juniper, lavender, marjoram, melissa, myrrh, peppermint, rose, rosemary, sandalwood, thyme, ylang ylang clary sage, ylang ylang basil, benzoin, cedarwood, cypress, eucalyptus, frankincense, hyssop, lemon, myrrh, niaouli, peppermint, sandalwood, thyme chamomile, cypress, eucalyptus, hyssop, lemongrass, melissa, orange, pepper (black), peppermint continued

170 Massage for Therapists Table 15.1 Glossary of terms and properties of some essential oils (continued ). Term Property Essential oil Haemostatic helps to arrest bleeding geranium, rose Hepatic helps with liver problems Hyperpnoea Reduce abnormally fast chamomile, mandarin, peppermint, rose, rosemary Hypertensor Hypotensor breathing ylang ylang Laxative raises blood pressure Nervine Reduces blood pressure mandarin, rosemary, thyme helps to evacuate bowels Rubefacient clary sage, hyssop, lavender, lemon, marjoram, melissa, ylang ylang Sedative useful for nervous disorders in general camphor, fennel (sweet), ginger, hyssop, mandarin, orange, pepper Stimulant (black), rose Tonic stimulates circulation Vulnerary basil, cedarwood, chamomile, coriander, cypress, hyssop, juniper, soothes the nervous system lavender, lemon, lemongrass, mandarin, melissa, orange, peppermint, rosemary, thyme has a tonic action on mind and body benzoin, coriander, eucalyptus, juniper, lemon, pepper (black), peppermint, pine, rosemary, thyme acts as a mild astringent heals sores and wounds benzoin, bergamot, cedarwood, chamomile, clary sage, cypress, frankincense, geranium, hyssop, jasmine, juniper, lavender, marjoram, melissa, neroli, patchouli, peppermint, rose, sandalwood, ylang ylang coriander, eucalyptus, grapefruit, hyssop, lemon, niaouli, orange, pepper (black), pine, rosemary grapefruit, lemon, mandarin benzoin, cajaput, chamomile, eucalyptus, frankincense, geranium, hyssop, jasmine, juniper, lavender, lemon, orange, patchouli, rosemary, sandalwood, thyme workers are including aromatherapy as part of the massage techniques described in this book that ‘care package’ they offer in hospitals, hospices and would be the most appropriate would be: clinics. ᭿ Effleurage/stroking Aromatherapy massage ᭿ Petrissage/kneading The combination of the therapeutic effects of essen- Many aromatherapists, myself included, use further tial oils with the therapeutic effects of the ‘laying techniques such as lymphatic drainage, neuromus- on’ of hands, namely massage, provides a ‘natural’ cular massage and acupressure manipulations of treatment of considerable value. The oils are utilised the soft tissue. not only by skin absorption but also by olfaction and inhalation when applied by massage. Lymphatic drainage Aromatherapy massage probably creates the These manipulations involve short or long, light or most diffuse therapeutic effect if compared with deep stroking movements which help move on other methods of use of essential oils. It is also a excess fluids, waste matter and toxins, through the very safe treatment when practised by a competent lymphatic system, towards the heart and into the and well-trained, qualified aromatherapist. The general circulation, and thence to the excretory organs of the body.

Aromatherapy 171 Neuromuscular massage Pain The manipulations involve a knowledge of the rela- Aromatherapy is reported to have a short-term tionship between the cutaneous sensory zones of effect on pain. This is of particular importance in the body, the autonomic nervous system and the physical disability, cancer care, hospice care, internal organs. Movements include deep palmar primary care and AIDS. kneadings and deep finger kneadings in the zones. Acupressure Fatigue These manipulations include a knowledge of the Certain essential oils are said to act as stimulants. philosophies of acupuncture and shiatsu. The move- Aromatherapy treatment of fatigue is reportedly of ments include working with the thumbs on meridi- benefit in cancer, AIDS, mental health and primary ans (energy lines) and tsubo points (areas where care in particular. energy blockages may be released) of the body. Effects and uses of Infection aromatherapy massage Essential oils are known to be antimicrobial. More My personal experience (and that reported by many controversially, aromatherapy is claimed to stimu- aromatherapists) has shown me that aromatherapy late the immune system. Complementary treatment massage is the most popular form of treatment with of infection is an issue of particular interest in the essential oils. There are a number of consistent treatment of disabled children and people with themes in different patient groups’ experience of AIDS. and response to massage and aromatherapy. (Vickers, who has been a member of the Research Relaxation Council for Complementary Medicine, in his book Massage and Aromatherapy – A Guide for Healthy Aromatherapy can be a relaxing experience. Patients Professionals (1996), supports these findings.) may also undertake self-help with essential oils, as inhalations or in baths. Relaxation is generally ben- Muscle tension eficial, especially where patients are anxious, such as in cancer care, disabled children, hospice care, It is claimed that massage and aromatherapy can mental health, HIV and AIDS. relieve muscle tension. This can sometimes lead to short-term improvements in mobility. Muscle One-to-one care tension and mobility is said to be a particular issue in physical disability, AIDS and primary care. One-to-one care and attention associated with massage or aromatherapy treatment is not common Blood circulation in health care. This has been found to be important in physical disability, primary care, mental health, Aromatherapists say that essential oils can also HIV, AIDS, hospice care and cancer care. stimulate local blood flow. This is reportedly of value in physical disability, cancer care and where Support for staff and carers patients spend significant periods of time in bed or in a wheelchair, e.g. in intensive care units and Massage and aromatherapy can be an important AIDS in some cases. means of providing support to staff and carers.

172 Massage for Therapists Sleep professionals will seek to discover a complete picture of the events leading to the patient’s condi- Aromatherapy is reported to improve sleep. tion. This will include such areas as the patient’s medical, social and family background. General wellbeing The patient consultation is a vital prelude to a Most people report feeling generally better in them- session of treatments. It is this that leads to correct selves after massage or aromatherapy treatment assessment of the patient, both physical and psy- (Vickers 1996). Aromatherapy is useful at all stages chological, and therefore to correct treatment. My of life. approach is shown below. A Consultation Card/ Sheet is required and on which the results of three Pregnancy/childbirth/baby care major techniques are recorded: Aromatherapy massage can help pain and insomnia ᭿ Verbal and give a sense of deep relaxation. It is therefore ᭿ Visual of considerable benefit to those who are pregnant, ᭿ Tactile in labour or have post-natal depression. Verbal Massage for babies is common in certain coun- tries and the use of essential oils with massage for This is the first very important point of communica- babies is becoming widespread in Western coun- tion. The patient may make a booking by telephone tries. It helps the ‘bonding’ process between parent or come to your clinic. Either way, it is very impor- and child, and may increase the child’s resistance tant that he/she is made to feel relaxed and at ease to infection, improve weight gain and help general and that the person to whom he/she talks has a mental and physical development. detailed knowledge of aromatherapy. If the patient decides to come for treatment then the consultation The elderly procedure will begin. Aromatherapy massage is being used more widely First, ensure that the treatment room is warm in the care of the elderly. This is a time of life when and quiet and gives the atmosphere of peace. The people may feel especially alone, depressed and treatment couch needs to be firm and comfortable fearful. Aromatherapy massage to hands, feet, neck with suitable drapes. and shoulders can help to break the sense of isola- tion and inspire calm and peace. Let the patient undress and lie down, well covered and warm. Sit beside the patient and begin quietly Problems that may be helped are: to discuss the points outlined on the Consultation Sheet. Take a name, address and telephone number, ᭿ Pain in the musculoskeletal system and also that of the patient’s doctor. ᭿ Constipation ᭿ Dyspepsia One cannot, unfortunately, rely entirely on verbal ᭿ Insomnia communication alone, for a variety of reasons. First, ᭿ Pressure sores a patient who has come for treatment for the first time might feel shy or even embarrassed and there- Consultation procedures fore be very non-committal in some areas. Second, the patient may genuinely have forgotten past prob- As aromatherapy is an holistic therapy, the consul- lems which in fact may have a bearing on his or her tation procedure should take a full 25–30 minutes. present state of mental and physical health. Different aromatherapists will approach a consulta- tion in a variety of ways, but all well-qualified There are three areas that need to be covered: ᭿ Medical ᭿ Social ᭿ Family history The pattern of events leading up to the consulta- tion session will have a profound influence on the

Aromatherapy 173 patient’s current wellbeing. Needless to say, prob- Foot reflexology lems that have a genuine medical significance must The following point needs to be noted: be referred to the GP before undertaking a treat- ᭿ Reflex pain areas on either foot ment programme for such a condition. Visual Personality type This is a second technique that is vital for obtaining The temperament of the patient is taken into a correct assessment of the patient’s condition. account and it is noted whether he/she is Yin More often than not it is combined with another (passive, lacking in energy, debilitated) or Yang technique, namely tactile. (active, hypertensive, often irritable and nervous and certainly prone to stress symptoms). Depending Tactile on the personality type, the acupressure techniques are also varied, so it is important to know the tem- Tactile adds a third dimension to assessment and is peramental characteristics of the patient. a final ‘back up’ to the information already gained. The areas examined by visual and tactile means Other information are: ᭿ The back ᭿ It is important to know whether the patient is on ᭿ The face drugs, medicinal or otherwise, and to find out if ᭿ The abdominal area there are any other items of medical information ᭿ The feet (reflexology) that have not been listed on the chart. The back ᭿ Precautions – contraindications. It is vitally ᭿ Spinal alignment important to find out if there are problem areas ᭿ Colour before treatment. This way, the appropriate ᭿ Texture oils and massage can be given. ᭿ Connective tissue massage tension areas of ᭿ The GP’s name, telephone number and permis- fascia sion. Should there be a medical problem that ᭿ Pain should be referred to the doctor before treat- ᭿ Flare reaction by stimulation to circulation ment, ensure permission is given in writing. The face ᭿ Facts, full and true. This ensures that the The following points need to be noted: patient signs to say that he/she has given you ᭿ Colour full and true facts before you give treatment. ᭿ Skin type (sensitive, dry, oily, combination) ᭿ Tone ᭿ Oil blends and home care. For each treatment, ᭿ Expression mark the date of treatment and fill in details of oil blends and home care advice and whenever Abdominal this changes according to new patient needs. The following points need to be noted: ᭿ Pain Oils ᭿ Tension Once all the previous facts have been correlated, an assessment may be made as to which essential oils and base oils are suitable for the patient’s condi- tion. Usually no more than three different oils are required to cope with most of the problems the therapist can deal with, and these are blended care- fully to produce a therapeutic, individual blend suitable for that patient alone.

174 Massage for Therapists It is important to identify whether it is necessary depending on where the essential oil is applied. to have a special facial blend as well as a body Respiratory conditions should be treated with blend, so ensure that at the consultation, accurate care when using essential oils. The amount of formulae are given. oil(s) chosen, the medium in which it/they are carried and the length of time of inhalation Contraindications must be safely controlled. ᭿ Sensitisation: here there is an allergic response Aromatherapy massage is an extremely safe treat- to an essential oil. Only small amounts are ment when given by a competent, well-trained, required to trigger a reaction. Photosensitisation qualified aromatherapist (Price and Price 1995; occurs when the sun shines on the skin on Tisserand and Balacs 1995). The very small per- which certain oils have been applied. A photo- centage of essential oils in relation to the carrier oil chemical reaction takes place, causing pigmen- when blended (i.e. a maximum of 0.5–2% essential tation. Bergamot is one of the best known oils oils, namely 3–12 drops, to a maximum of 30 ml that can produce this effect. of carrier oil) ensures this is the case. Certain oils present risks either of toxicity, skin Such a treatment means that there is a ‘con- irritation or skin sensitisation and are not consid- trolled’ use of essential oils. Only ‘gross misuse’ ered safe in general use. Below is a list of oils that would cause problems. However, because of the should not be used in aromatherapy. media attention focused on certain oils mentioned in some books on aromatherapy it is probably sen- Oils not to be used at all in therapy sible for an aromatherapist generally to avoid certain oils for particular conditions, mainly because According to the International Federation of a perception has been created in the popular mind Aromatherapists (2008), the following oils should that there is ‘something wrong’ with them. This is not be used: particularly true of certain oils that some literature claims may have adverse effects in the first 3 months Almond (bitter) Prunus amygdalus of pregnancy. Those aromatherapists who have Boldo leaf Peumus boldus gone on courses of a high standard of training will Calamus Acorus calmus be fully aware of which oils are safe to use for dif- Camphor (brown) Cinnamomum camphora ferent conditions. Camphor (yellow) Cinnamomum camphora Cassia Cinnamomum cassia Hazards Cinnamon (bark) Cinnamomum Certain hazards are associated with some oils, Costus zeylancium namely the possible problems of toxicity, irritation Elecampane Saussurea lappa or sensitisation. Fennel (bitter) Inula helenium Horseradish Foeniculum vulgare ᭿ Toxicity: this is commonly called poisoning Jaborandi (leaf) Amoracia rusticana and at a certain level becomes fatal whether Mugwort (armoise) Pilocarpus jaborandi applied to the skin or taken orally. Toxicity is Mustard Artemisia vulgaris dose dependent – the greater the amount of Pine (dwarf) Brassica nigra essential oil, the greater the hazard. The very Rue Pinus mugo small amounts of essential oil put into a carrier Sassafras Ruta graveolens oil for an aromatherapy massage by a well- Sassafras (Brazilian) Sassafras albidum trained professional would not present a Savine Ocotea cymbarum problem in any way. Southernwood Juniperus sabina Tansy Artemisia abrotanum ᭿ Irritation: here there is a localised inflamma- Thuja (cedarleaf) Tanacetum vulgare tion affecting the skin or mucous membranes, Thuja (Western Thuja occidentalis Thuja plicata red/Washington)

Aromatherapy 175 Wintergreen Gaultheria procumbens pregnancy. If there is a history of miscarriage, do Wormseed Chenopodium not use at all. Wormwood anthelminticum Precautions Artemisia absinthium Apart from these contraindications, there are certain Oils never to be used on the skin basic precautions to be taken when using essential oils: Clove bud Eugenia caryophyllata Clove leaf Eugenia caryophyllata ᭿ They should not be taken internally unless pre- Clove stem Eugenia caryophyllata scribed by a suitable qualified medical Origanum Origanum vulgare practitioner. Origanum (Spanish) Thymus capitatus ᭿ Although the majority of essential oils do not In the author’s experience also sage, either harm the skin, if there is sensitisation or irrita- Dalmation (Salvia officinalis) or Spanish (Salvia tion, wash off with mild soap and water. lavandulifolia) should not be used for aromather- apy treatments. ᭿ If an essential oil gets into the eye it may cause pain and distilled water is best for washing it Oils not to be used with patients who out. have epilepsy ᭿ Essential oils in most circumstances should be According to Epilepsy Action/British Epilepsy diluted in some carrier medium (vegetable oil, Association (2007) the following oils should not be water, cream). used on patients who have epilepsy: ᭿ When making up a massage oil, the dilution is Fennel (sweet) Foeniculum vulgare 0.5–2% (3–12 drops) per 30 ml of carrier oil. Hyssop Hyssopus officinalis Sensitive skins should only have 3 drops of Rosemary Rosmarinus officinalis essential oil in 30 ml of carrier oil. Sage Salvia officinalis and Salvia ᭿ Avoid giving essential oil massage to skin with Wormwood lavandulifolia acne as the passing of the hands may spread Artemisia absinthium infection. Other useful methods utilising essen- tial oils may be used instead, namely com- Pregnancy presses and vaporisers. Regarding pregnancy, where there is controversy ᭿ Essential oils that are rubifacient in effect over which oils to use or not to use, particularly should not be used on dry, sensitive or vasodi- in the first trimester, it is vital that the therapist lated skin. has a nationally recognised qualification in aroma- therapy, from which he/she will obtain information ᭿ Essential oils should be kept away from flame to help make safe choices. A midwife needs to have as they are flammable. up-to-date knowledge of the United Kingdom Central Council (UKCC) Rules for Midwives, ᭿ Babies and children need to have much less the Standards for Administration of Medicines percentage essential oils to a carrier oil than an and the Code of Practice as applicable to aroma- adult because of their relatively smaller body therapy as well as locally agreed protocols drawn area. Usually this would be about 25% of the up by various midwifery and gynecological normal adult dose, and the treatments should services. be of less duration, and less frequent. Only 1%, i.e. a small amount of essential oil, is ᭿ Medical conditions, if presented on consulta- the maximum one would use in a carrier oil for tion, should be discussed (with the patient’s permission) with his or her medical practitio- ner and a written letter of approval received from the medical practitioner before aroma- therapy massage is given. In particular the treatment of a patient with cancer must only be carried out with the approval of the patient’s

176 Massage for Therapists consultant. Some consultants are quite happy ᭿ Fragrance appreciation by the patient of the to give this approval, others are not, whether essential oils that the therapist intends to put the patient is on chemotherapy/radiation together in the special blend. therapy or whether without medication at all. As yet there is no complete knowledge of the Basic formula effects of essential oils combined with massage when a patient is undergoing medical treat- There can be anything from one to five oils in a ment involving drugs. It is imperative therefore blend with a carrier oil, but it is usual to have three. that an aromatherapist has the agreement of This is so that it is possible to cover most problems the patient’s medical practitioner before and at the same time be able to appreciate the sub- embarking on treatment. tlety of different essences without finding that they have been swamped. It is usual to put approxi- Blending of oils and formulation mately 0.5–2% (3–12 drops) of essential oils (in total) to 1 oz (30 ml) of carrier oil. Fewer drops are When the aromatherapist decides after consultation required for strong-scented oils and more drops for with the patient to make up a special blend for that the gentle fragrances. Each essential oil has many patient’s aromatherapy massage, two separate com- therapeutic values. In making up the special blend ponents are used: it is sensible to write down the problems that you want to treat, and against each write a list of the ᭿ A vegetable carrier oil. oils that can be helpful in each case. Often it will ᭿ An essential oil or oils incorporated in the be seen that a number of oils will be helpful with each of the problems. Provided the fragrances carrier oil. appeal to the patient and blend well together it is sensible to aim for maximum benefit by choosing Many types of carrier oil are available, each to put these together. Otherwise one can choose an useful and having its own properties; these oil suitable for each problem, ensuring that the include: patient likes each fragrance and that each will blend well, one with the other. ᭿ Almond: softening, soothing to the skin, a light oil suitable for face and body. The blend needs to be built up carefully, a drop of each oil at a time. It is wise not to overpower ᭿ Avocado: deeply penetrating and very nourish- gentle scents such as rose with, for instance, too ing. Contains vitamins A and B and is good for much eucalyptus. If one wishes to ‘fix’ the blend it dry, mature skin. is sensible to incorporate a base note such as patchouli. Sometimes one is asked if there are essen- ᭿ Grapeseed: a light oil, good for body and tial oils that will not combine. The answer is that face. one can combine any essential oil with any other essential oil, but that some oils blend better with ᭿ Jojoba: a very nourishing oil, which is particu- each other than others. It takes time and consider- larly recommended for dry, mature skins. able practice to achieve blends that have a harmony of fragrance. ᭿ Safflower: light and nourishing, recommended for body and face treatments. Finally it is important to remember that the patient’s needs may change over successive treat- Many hundreds of essential oils are available for ments and that one may have to reformulate the use, but it is more practical to utilise the better blend accordingly. known ones. Preparation of the patient The decision on how to blend the oils depends on the information gained from the patient during After consultation: the consultation. The important factors are: ᭿ The problems discerned during the consulta- tion, which can safely be treated by the aromatherapist.

Aromatherapy 177 (1) The patient lies supine, warm, comfortable and was added as it would aid the reduction of the vis- well covered. ceral muscle spasm and because of its calming and uplifting effects. Total drops of essential oils were (2) A headband is placed on the head to protect 12–30 ml of almond carrier oil (i.e. 2% essential hair from creams and oils. oils to 100% carrier oil). (3) The face and neck are deep cleansed with On the next session, a week later, she reported a herbal products. reduction in pain in the head, neck and shoulders and in her abdominal area, but still felt anxious and (4) The aromatherapy oil is lightly massaged low. Clary sage, a euphoric, was added, reducing over the face for 1 minute, with stroking the sandalwood amount so that the percentage of movements. essential oils (2%), i.e. 12 drops, to 30 ml carrier oil (100%) remained the same. (5) The patient is then asked to move into the prone position, the head supported by the This new combination turned out to be very suc- patient’s own hands or a small roll of towel- cessful and after four weekly sessions the patient ling, and a roll of towelling under the ankles. reported that she felt very much better in every way. Thereafter she had monthly sessions for a total of Treatment by aromatherapy massage 6 months and professed to feel well again at that time. Whenever she feels stressed she returns for As stated before, the effleurage (stroking) and petris- treatment. sage (kneading) movements described earlier in this book are techniques often employed by aromather- Purity of essential oils apists during an aromatherapy massage treatment. In addition I use lymphatic drainage, neuromuscu- Essential oils used by aromatherapists for therapeu- lar massage and acupressure techniques. tic massage should be of the highest quality, and of natural and not synthetic origin. The quality of the I first work on the back; then the backs of the oil will depend on the good reputation of a high- legs; then turn the patient into supine again and grade supplier. commence with the front of the legs, the arms, the abdomen and finish with the scalp, neck, face and Storage shoulders. It must be emphasised that an aroma- therapist adapts his/her massage techniques and Essential oils can deteriorate rapidly. It is very the areas treated according to the patient’s needs important therefore that they are stored under the and any precautions noted in the consultation following conditions: procedures. ᭿ They should be in containers that will not Case study interact with the oil. Glass is usual for small amounts. Over 10 kg, then internally lacquered A 55-year-old woman, recently divorced, came to steel drums are used. Plastic containers are no have aromatherapy because she had been told it was good as the plastic and oil interact. very helpful in stress situations. She was suffering from severe tension headaches, pain in the neck and ᭿ They should be sealed very well. shoulders and bloating in her colon area. It was ᭿ They should be protected from light, particu- decided on her first session that she would like to have a full body treatment, with head, neck, shoul- larly from strong sunlight, because it has a ders and abdomen to be given extra attention. chemical catalytic effect (photocatalytic) which precipitates chemical changes in the oil. Lavender was chosen to have an analgesic, seda- Artificial light is not so damaging. tive and uplifting effect. Bergamot was also chosen ᭿ They should be kept in cool conditions. Almost for the above effects and because of its usefulness all oils can be kept in a refrigerator at 5°C. in helping digestive upsets. Finally, sandalwood Vetivert, sandalwood, cedarwood and patchouli

178 Massage for Therapists should be kept at a room temperature of 15°C. Genders, R. (1972) A History of Scent. Hamish Hamilton, Rose oil, rose absolute and some other oils will London, pp. 20, 126. solidify, but this is no problem as they will remelt at room temperature. Under no circum- International Federation of Aromatherapists (2008) IFA stances should they be heated. Cautionary Essential Oils List. IFA, London. ᭿ For the therapist running a clinic it is sensible to order only small quantities, to avoid Kovar, K.A., Gropper, B., Freiss, D. and Ammon, H.P.T. deterioration. (1987) Blood 1evels of 1,8 cineol and locomotor activity of mice after inhalation and oral administration of rose- Conclusion mary oil. Planta Medica, 53(4), 315–18. It may be concluded that aromatherapy massage is Price, S. and Price, L. (1995) Aromatherapy for Health a safe, useful and effective treatment for a wide Professionals. Churchill Livingstone, Edinburgh. variety of conditions, when given by a properly trained therapist. As a result its role in the health Reynolds, P., Boyd, P.T., Blacklow, R.S., et al. (1994) The care setting, both in the UK and worldwide, has relationship between social ties and survival among black expanded enormously in recent years. It is therefore and white breast cancer patients. National Cancer Institute most welcome to see that the orthodox and comple- Black/White Cancer Survival Study Group. Cancer mentary medicine practitioners can work harmoni- Epidemiology, Biomarkers and Prevention, 3(3), 253–9. ously together in the further interest of patient care and treatment. Saller, R., Beschomer, M., Hellenbrecht, D. and Buhrimg, M. (1990) Dose dependency of symptomatic relief of com- References plaints by chamomile steam inhalation in patients with common cold. European Journal of Pharmacology, 183, Berger, H., Jarosch, E. and Madreiter, W. (1978) Effects of 728–9. Vapourub and petrolatum on frequency and amplitude of breathing in children with acute bronchitis. Journal of Schwartz, D. and Natyncuk, S. (eds) (1990) Chemical Signals International Medicine Research, 6, 483–6. in Vertebrates. Oxford University Press, Oxford. Buchbauer, G., Jirovitz, L., Jager, W., et al. (1993) Fragrance Tisserand, R. and Balacs, T. (1995) Essential Oil Safety, A compounds and essential oils with sedative effects upon Guide for Health Professionals. Churchill Livingstone, inhalation. Journal of Pharmaceutical Science, 82(6), Edinburgh. 660–64. Valnet, Dr. Jean (1980) The Practise of Aromatherapy. Brun, K. (1952) Les essences vegetales en tant qu’agent de Daniel, Saffron Walden, pp. 28, 33, 34. penetration tissulaire. These Pharmacie, Strasbourg. van Toller, S. and Dodd, G.H. (1988) Perfumery, the Cavel, L. (1918) Sur la valeur antiseptique de quelques huiles Psychology and Biology of Fragrance. Chapman and Hall, essentielles. Comptes Rendus (Academie des Sciences), London, p. 29. 166, 827. Vickers, A. (1996) Massage and Aromatherapy – A Guide Epilepsy Action/British Epilepsy Association (2007) Leaflet, for Health Professionals. Chapman and Hall, London, pp. July 2007. Epilepsy Action/British Epilepsy Association, 33, 174–6. Leeds. Williams, D. (1989) Lecture 1, p. 7. In: Lecture Notes on Eysenck, H.J. (1988) Personality, stress and cancer protec- Essential Oils. Eve Taylor, London. tion and prophylaxis. British Journal of Medical Psychology, 61, 57–75. Further reading Falk-Filipsson, A., Löf, A., Hagberg, M., Hjelm, E.W. and Campbell, T. and Jones, E. (2000) Aromatherapy. In: Wang, Z. (1993) d-limonene exposure to humans by inha- Complementary Therapies for Physical Therapists (ed. R. lation; uptake, distribution, elimination and effects on the A. Charman) pp. 231–46. Butterworth-Heineman, pulmonary function. Journal of Toxicology and Oxford. Environmental Health, 38(1), 77–88. Davis, P. (2005) Aromatherapy A–Z. Vermilion. Ebury Gattefosse, R.M. (1937) Aromatherapy (translated 1993). Publishing, London. Daniel, Saffron Walden, p.87. Useful websites http://www.ifaroma.org – International Federation of Aroma- therapists. http://www.ifparoma.org – International Federation of Pro- fessional Aromatherapists.

Shiatsu – the Japanese healing 16art of touch Andrea Battermann Introduction puncture and moxibustion (application of heat), acupressure, herbalism, diet and therapeutic exer- This chapter opens with a description of the history, cises known as T’ai Chi and Ch’i-Kung (breathing theory and practice of shiatsu. The photography exercises). demonstrates some of the basic shiatsu techniques and principles and an example of self-shiatsu Traditionally, treatment is carried out on a cotton massage shows the manual stimulation of acupunc- layer mat (futon) at floor level with the body ture points for relieving headaches. The chapter remaining fully and comfortably clothed. Nowadays, ends with an outline of the professional develop- some practitioners use a wide table, which is height ment of shiatsu practitioners. It is beyond the scope adjustable. Shiatsu aims to maintain good health of this chapter to explain shiatsu theory and termi- and wellbeing, as well as to treat specific nology in detail; interested readers are referred to conditions. the Further reading. History What is shiatsu? Shiatsu has its roots in Chinese medicine and devel- Shiatsu literally translated means ‘finger pressure’. oped about 5000 years ago. It evolved over centu- It is the manual therapy of acupuncture and part of ries and was practised by people who developed a traditional Japanese medicine. Mainly fingers, high sensitivity of touch and body awareness. They thumbs and palms of the hands apply different were able to localise points and areas on the body depths of pressure over the whole body, stimulating that relieved pain and stiffness, locally and distally. acupuncture points known as tsubos in Japanese. It Simultaneously, shiatsu influenced the function of is more than a mechanical stimulation of points – it internal organs; headaches, for example, are relieved is an oriental healing art based on an energetic by pressing specific points on the hands and feet. medical model. Shiatsu is based on Chinese medi- Manual techniques like pressing and rubbing cine and uses Eastern philosophy as its theoretical (Anmo) were used long before stimulating acupunc- framework. Chinese medicine incorporates acu- ture points with fish bones, stones and later needles. Massage techniques remained an important prereq- 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

180 Massage for Therapists uisite of the physician’s training before he/she was in the body and at the same time strengthen the allowed to progress to needles (Beresford-Cooke body’s general constitution. In disease and illness, 1996). Chinese doctors observed the effects on the Ki energy becomes deficient or excessive in the body and categorised the points that treat certain meridians and moves into a state of imbalance conditions, as well as developing an holistic diag- (Masunaga and Ohashi 1977). nostic medical model and treatment. Diagnostic methods Chinese medicine started to appear in Japan in the 5th century ad, in fragmented form, in the A detailed examination of all physical, emotional hands of Japanese warlords returning from incur- and mental expressions and symptoms is carried sions in Korea. It was not until the 8th century ad out by the practitioner using different forms of when a Buddhist monk named Jian Zhen brought diagnostic methods in Chinese medicine. a systematic corpus of written texts into Japan. The materials introduced by Jian Zhen mostly derived Four forms of diagnosis from the Han dynasty, dating to about 200 ad, and contained many herbal prescriptions of ‘Han Fang’ ᭿ Asking questions: present and past medical which is pronounced ‘Kam Po’ (also Kan Po) in and social history, appetite and digestion, Japanese. Over the following centuries in Japan, stools and urination, taste and thirst, body various schools of Japanese acupuncture arose, and temperature and perspiration, eyes and ears, variations in diagnostic approaches appeared. For menstruation. example, whereas in China more emphasis was placed upon diagnosis from the pulse in the wrists, ᭿ Observing: noting posture, colours of clothes in Japan more emphasis was accorded to diagnosis and facial skin, and condition of hair and nails. by palpation of the abdomen, or ‘Hara’ in Japanese. This process of evolution of Kam Po and Japanese ᭿ Hearing and smelling: listening to the tone acupuncture continued. At the beginning of the of the voice and noting any body smell. 20th century acupressure massage developed into a medical form of treatment, changed its name to ᭿ Touching: this is the most important diag- shiatsu and was legally recognised in 1950 in Japan. nostic and treatment method in shiatsu. The A well-known shiatsu practitioner, Shizuto practitioner feels the quality of Ki with the Masunaga, created a unique system incorporating fingers in defined zones in the abdomen, merid- four paradigms into shiatsu: Chinese medicine, ians and tsubos of the patient’s body. Each Western physiology, psychology and oriental phi- zone in the Hara, as well as the diagnostic Bo losophy (Daoism and Zen). His style and approach and Yu points (in the front and back of the are now used worldwide. Masunaga developed the body), mirror the state of Ki in the associated abdominal (Hara) diagnosis and extended the meridian. The Hara diagnosis is used before length and location of the traditional energy path- and after the treatment (see Fig. 16.1). The ways, known as meridians, throughout the whole Hara is defined in zones that are related to body. He also developed techniques to work with individual meridians. Figure 16.2 shows Hara one meridian in the entire body. diagnostic zones in the abdomen (after Masunaga and Ohashi 1977). The quality of Introduction to oriental medicine each zone indicates how the Ki circulates in the meridian. The palpation of the Hara, Yu and Shiatsu is based on an energetic concept of Ki (the Bo points, together with all the other diagnos- body’s vital energy, known as Qi in Chinese). It is tic signs and symptoms, determines which essential to understand this concept in order to meridian and points are treated. The practitio- grasp Chinese medicine theory and its practical ner diagnoses states and patterns of disharmo- application. Chinese medicine, as well as shiatsu, nies in the Ki, Blood, Yin and Yang long before aims to stimulate a free flow of Ki in the meridians they manifest physically in the body or develop into a disease; for that reason traditional Chinese medicine (TCM) plays a major role in

Shiatsu – the Japanese healing art of touch 181 Yin and Yang, the five phases or elements, the eight principles and the kyo–jitsu theory. Kyo and jitsu are interdependent and cannot be separated. Kyo is the condition of deficient energy which manifests itself as weakness or stiffness. The shiatsu technique for treating a kyo condition is called tonification, which requires a holding touch to encourage Ki flow. Jitsu is the condition of most concentrated energy (excess) which manifests in hard but elastic and more resistant body tissue. The jitsu is worked with a sedating technique and requires a more active technique to disperse the excess energy. Either one meridian, part of a meridian or any body part or Hara zone can be described as having a degree of kyo or jitsu quality. Throughout the shiatsu treatment the practitioner diagnoses and treats kyo and jitsu areas either in the meridian, tsubos or body parts and aims to balance the Ki in the whole body. Figure 16.1 Hara palpation. Key to the Hara zones 1 Basic principles and techniques of 25 shiatsu 1 Heart 3 76 2 Gall bladder 44 The following principles are relevant in giving a 3 Liver treatment: 4 Lung 8 5 Stomach ᭿ Controlled body weight and relaxation are 6 Triple heater 11 9 11 used when pressure is applied; no muscular 7 Heart protector 12 12 power is used. Figure 16.3 shows controlled 8 Spleen 10 body weight. 9 Kidney 10 Bladder ᭿ Stationary and perpendicular pressure is 11 Large intestine applied in order to access and sense the Ki in 12 Small intestine the meridians and points. Figure 16.4 shows stationary and perpendicular pressure. Figure 16.2 The Hara diagnostic zones in the abdomen (after Masunaga and Ohashi 1977). ᭿ Two-hand connection is maintained in which there is a stationary, listening hand called a preventative medicine and complements the ‘mother hand’, which gives support, stability Western medical model. A treatment method is and stillness, as well as an active hand, called chosen according to the results of all diagnostic a ‘child hand’, which works with a penetrative rnethods and follows a phenomenological technique. The practitioner holds awareness in approach. both hands as well as the interaction between them. Figure 16.5 shows the two-handed Shiatsu theory technique. There are several models in Chinese medicine ᭿ Meridian continuity is used, in which the prac- explaining the Ki circulation throughout the body: titioner works along the whole length of any chosen meridian to find points of deepest pen- etration in order to access the Ki and manipu- late it.

182 Massage for Therapists Figure 16.3 Elbow technique. Photograph ©ALIKI Figure 16.5 Two-hand technique. Photograph ©ALIKI SAPOUNTZI www.aliki.co.uk. SAPOUNTZI www.aliki.co.uk. able position with an aligned and open posture. ᭿ There is a reciprocity of process, involving a constant inner listening and responding to the patient’s needs and expressions. It is like a non- verbal dialogue through touch between thera- pist and patient, affecting the patient’s whole wellbeing. Each shiatsu treatment is unique and cannot be precisely repeated. The external techniques can be reproduced, but the internal dialogue as well as the proprioception-sense is unique and personal to that moment between patient and therapist. Clinical indications Figure 16.4 Stationary and perpendicular pressure. Shiatsu can be used for many conditions. It is espe- Photograph ©ALIKI SAPOUNTZI www.aliki.co.uk. cially effective for musculoskeletal disorders, arthri- tis, respiratory conditions, immunodeficiency ᭿ An holistic approach of treatment is followed, problems, psychosomatic conditions, hormonal in which the client’s emotional, mental, spiri- imbalances, digestive problems, headaches and tual and physical states are considered. migraine, childbirth and pregnancy, anxiety and depression, as well as stress-related symptoms. A ᭿ Use of a steady rhythm throughout the treat- national survey carried out by Harris and Pooley ment enhances the patient’s deep relaxation, (1998) discovered that musculoskeletal and psycho- physically and mentally. logical disorders are the most common conditions treated by shiatsu practitioners. Most treatments ᭿ A relaxed manner of the therapist is important are given for neck/shoulder problems, followed by as he/she needs to work in the most comfort- lower back problems and arthritis (see Fig. 16.6). The main psychological disorder treated is depres- sion, followed by stress and anxiety.

Shiatsu – the Japanese healing art of touch 183 Physiological effects associated with shiatsu Figure 16.6 Neck release. Photograph ©ALIKI SAPOUNTZI ᭿ Drowsiness. Some patients relax very deeply www.aliki.co.uk. and it can take some time until they sit up and their reaction response can be delayed, e.g. Contraindications driving or walking in traffic. It is advisable to sit for some time after the treatment. Shiatsu is contraindicated in the following conditions: ᭿ Low muscle tone and sweating can appear in areas of hypertonicity. ᭿ Cerebrovascular accident (not yet stabilised). ᭿ Fever. ᭿ Stress response: hyperventilation, dry mouth ᭿ Systemic/contagious infections. and light headedness. ᭿ Any acute inflammations. ᭿ Thrombosis. ᭿ Temporary aggravation of symptoms and ᭿ Haemophiliac patients or patients on antico- increased pain for a maximum of 2 days fol- lowing the treatment. Clients should be agulant medication. informed about this possible effect and reas- ᭿ Varicose veins. sured that this is a normal response. Cautions ᭿ Improvement of lymphatic and general circula- tion of body fluids. ᭿ Light touch should be used on lymphatic areas below the ears, throat area and groin. ᭿ Strong analgesia due to an increase of opioid- like hormones and other neurohormones, ᭿ Treatment of the abdominal area should be which is noticeable after a short treatment careful, with a light touch and for a short time. time. The patient tolerates a much stronger and more penetrative touch towards the end of the ᭿ Ulcerous conditions and open wounds or treatment. serious burns should not be worked upon. ᭿ Increased peristaltic sounds, which can be ᭿ New scar tissue or skin rashes should not be noticeably loud, with embarrassment for the worked on directly. patient. Reassurance of the patient is needed that the autonomic nervous system is strongly ᭿ A patient who is very hungry and weak should activated. not be worked on, because he/she may faint after the treatment. ᭿ Reduced heartbeat. ᭿ Strong stimulation of the autonomic nervous ᭿ Special care should be taken in pregnancy in the first 3 months. Gentle work is recom- system. mended avoiding the following points: GB-21, ᭿ Stimulation of the neuropathways from muscles SP-6, BL-60, Li-4 and LiV-3. to the brain, e.g. flaccid muscles increase in ᭿ Light touch should be used for patients with muscle power and tone. hypertension. ᭿ Increase of sensation of areas that were numb due to scars or neurological causes. ᭿ Improvement of proprioception sense. Case study: self-shiatsu massage The following case study describes a treatment that can be applied to oneself to relieve headaches and migraines. It is easy to use and to teach to patients as a self-help method. The author has given this treatment to many patients and students.

184 Massage for Therapists BL-2 GB-20 ST-3 BL-10 LI-4 GB-21 Figure 16.8 Point LI-4. Figure 16.7 Acupuncture points for relief of headaches. A neurological consultant once referred a patient GB-41 with persistent unilateral headaches which could not be clearly diagnosed and no treatment had been LIV-3 effective. The patient’s signs and symptoms were assessed with Chinese medicine methods. The loca- Figure 16.9 Points LIV-3 and GB-41. tion and symptoms of his headaches corresponded precisely with the bladder meridian and its pathway ᭿ LIV-3 (Taichong Great Rushing): on the on the skull. He was taught the following treatment dorsum of the foot, in the hollow distal to the and advised to practise twice daily and write a pain junction of the first and second toe (Fig. diary. His second session focused on supervision of 16.9). point locations and treatment techniques. After the third session, the patient reported relief from head- ᭿ GB-41 Zulinqi (Foot Governor of Tears): in the aches after each self-shiatsu massage. depression distal to the junction of the 4th and 5th metatarsal bones, on the lateral side of the The following point locations were taught (see tendon muscle extensor digitorum longus (Fig. Fig. 16.7): 16.9). ᭿ BL2 Zanzhu (Gathered Bamboo): in a depres- The self-shiatsu routine sion on the medial end of the eyebrows. Self-shiatsu massage can be practised sitting com- ᭿ M-HN-3 Yintang (Hall of Impression): at the fortably in an upright position. midpoint between the medial ends of the eyebrows. Press the inside corners of each eye. You will find the points if you pinch the bridge of the nose (Fig. ᭿ GB-20 Fengchi (Windpond): below the occiput, 16.10). in the hollow between the origins of the ster- nomastoid and trapezius muscles. Press the points under the eyebrows. Rest your head heavy and relaxed on your fingertips (Fig. ᭿ BL-10 Tianzhu (Celestial Pillar): on the midline 16.11). of the neck, in a depression directly below the occipital protuberance, on the lateral side of the trapezius muscles. ᭿ GB-21 Jianjing (Shoulder Well): midway between the occiput of the neck and the tip of the acromion, at the highest point of the shoulder. ᭿ ST-3 Juliao (Great Crevice): eyes look straight forwards, below the pupil, level with the border of the ala nasi, on the lateral side of the naso- labial groove. ᭿ LI-4 Hegu (Joining Valley): on the dorsum of the hand, between the thumb and index finger, at the midpoint of the second metacarpal bone, close to its radial side (Fig. 16.8).

Shiatsu – the Japanese healing art of touch 185 Figure 16.10 Working on BL-2. Photograph ©ALIKI Figure 16.12 Pressure in between the eyebrows. Photograph SAPOUNTZI www.aliki.co.uk. ©ALIKI SAPOUNTZI www.aliki.co.uk. Figure 16.11 Pressure underneath the eyebrows. Photograph Figure 16.13 Massage of the eyebrows. Photograph ©ALIKI ©ALIKI SAPOUNTZI www.aliki.co.uk. SAPOUNTZI www.aliki.co.uk. Lightly press the point M-HN-3 with the palm Pinch and massage your eyebrows from the inside of the hands together. Let your head tilt forwards to the lateral ends several times (Fig. 16.13). and position your middle fingers in between the eyebrows. Hold the point for 2 minutes as you relax Grip your head with fingers apart. and breathe deeply (Fig. 16.12). Work along parallel lines extending over the top of your head towards your neck. Then circle around

186 Massage for Therapists Figure 16.14 Working on the meridian on the head. Photograph ©ALIKI SAPOUNTZI www.aliki.co.uk. Figure 16.16 Self-massage technique on the neck. Photograph ©ALIKI SAPOUNTZI www.aliki.co.uk. Figure 16.15 Working on BL-10 underneath the occipital the neck on the left side. Simply relax the weight of line. Photograph ©ALIKI SAPOUNTZI www.aliki.co.uk. your arm in front of your chest. Keep your fingers curled like a hook. Sink deeper into the muscles as your ears and temples with the palm of your hands, they soften and relax. Hold for 1 minute and take pressing towards the centre of your head (Fig. a few, long, deep breaths. Repeat on the other side 16.14). (Fig. 16.17). Firmly press the point GB-20: place your thumbs Press the point ST-3: use your thumbs to gently underneath the base of your skull in the hollows press upwards underneath the cheekbones directly between the origins of the sternomastoid and tra- below the centre of your eyes. Tilt your head for- pezius muscles. Apply the pressure gradually under- wards and relax, taking a couple of deep breaths neath the base of your skull as you slowly tilt your (Fig. 16.18). head backwards. Take a deep breath and hold the point for 1 minute. Then work the point BL-10 as Firmly press the point LI-4: relax your left arm you direct the pressure towards the opposite eye. and hand on your thigh. Place your right thumb on You can work other tight points under the occipital the webbing between your thumb and index finger ridge on the hairline (Fig. 16.15). of your left hand. The pressure is directed towards the base of the left index finger at the highest point Press the back of your neck with both thumbs of the bulge of the muscle. Repeat on the other lateral to the cervical spine from the top to the base hand. You will feel a dull ache if you are on the of the neck (Fig. 16.16). point (Fig. 16.19). Curl your fingers and place them on the highest Stimulate the points LIV-3 and GB-41: take off point of your shoulder muscles at GB-21 close to your shoes and sit comfortably. Place your left heel on top of your right foot between the first and second toe for 1 minute. You can also rub this area gently. Stimulate the point GB-41: place your heel between your fourth and fifth toe and work as above. Repeat on the other foot (Fig. 16.20).

Shiatsu – the Japanese healing art of touch 187 Figure 16.17 Working on GB-21. Photograph ©ALIKI Figure 16.19 Working on LI-4. Photograph ©ALIKI SAPOUNTZI www.aliki.co.uk. SAPOUNTZI www.aliki.co.uk. Figure 16.20 Working on LIV-3. Photograph ©ALIKI SAPOUNTZI www.aliki.co.uk. How to apply pressure Figure 16.18 Working on ST-3 with the thumb. Photograph ᭿ Use your body weight to lean into the tsubo. ©ALIKI SAPOUNTZI www.aliki.co.uk. ᭿ Apply finger pressure gradually and then hold the tsubo deeply with a firm and steady pene- tration for up to 3 minutes. ᭿ Never press a tsubo with an abrupt, forceful or jarring technique. ᭿ Most tsubos and meridians appear bilateral on the body. The tsubos are like coin-size areas.