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

188 Massage for Therapists You may feel a dull ache or pleasant tingling Do-In (literally ‘leading and guiding’) Ki through- if you are on the tsubo with the right angle and out the body is a system of working on the whole depth of penetration. The anatomical location body with self-shiatsu techniques or exercises. of the acupuncture points will describe only the Specific Makkho-Ho stretches are recommended by area where you have to touch in order to find practitioners to support the outcome effects between the location of the tsubo. treatments. The student is taught how to keep a ᭿ If you feel increasing pain or discomfort by healthy lifestyle using the principles of a Chinese pressing a tsubo, gradually decrease the pres- medicine diet, general exercise to keep flexibility sure until you find a more tolerable sensation, and strength, and maintaining the balance between which is called ‘sweet pain’ in shiatsu. rest and activity. ᭿ Do not continue to press a tsubo that is excru- ciatingly painful. Conclusions ᭿ Approximately 2 minutes should decrease pain of the tsubo with firm pressure; if not, stop This chapter has provided an introduction to shiatsu pressing this tsubo. with some practical applications. Due to the popu- ᭿ If you feel pain in another part of your body larity of complementary therapies (CT) in the UK (referred pain), press the points in these related and patients frequently using CT beside or instead areas as well. Each tsubo belongs to a merid- of Western medicine, it is important that health ian. Sometimes the next point or more distant care professionals know what most CT entail in points on the same meridian are activated. order to converse with patients. Nowadays CT is ᭿ Avoid self-shiatsu during pregnancy unless an more integrated within the medical system. experienced practitioner has supervised your Acupuncture is one of the most frequently used CT treatment. by doctors and physiotherapists. Shiatsu is recog- nised as the manual treatment of acupuncture by Professional development of the Acupuncture Association of Chartered the therapist Physiotherapists (AACP) and the Chartered Society of Physiotherapy in the UK. Shiatsu requires long and complex training over a period of years involving an immense amount of Physiotherapists can use shiatsu as it is a recog- practice and theoretical study in order to master nised practice. There is no doubt about the clinical this skill and gain an understanding of it. The per- effectiveness of shiatsu. The problem is more how ception of Ki in the patient’s body and our own is it can be integrated partially and effectively into developed by practising Qi-Gong and meditation, physiotherapy treatments. It is unrealistic due to the receiving treatments and working on the teacher’s constraints of time to aim to carry out a full-length body. shiatsu treatment. Over many years the author has used physiotherapy techniques with an energetic In a tutorial lesson, the teacher will give direct awareness of Ki movement and has achieved very feedback on how to sense and direct Ki in the good clinical outcomes with long-lasting effects. body while the student is working. In shiatsu the emphasis in training is on the development of Glossary Hara, from which all movements originate and physical stamina and relaxation are gained. A prac- Anmo: a traditional form of Chinese massage, lit- titioner with a strong Hara is able to sense, transmit erally translated as ‘pressing and rubbing’. and manipulate Ki more effectively and keeps the awareness in the Hara throughout the whole Blood: with a capital ‘B’ indicates Blood in the treatment. sense of Oriental medicine, which represents more than it does in Western medicine. For Makko-Ho meridian stretches (similar to yoga) example, in Oriental medicine, poor memory are taught to students; this is a simple workout for indicates deficient Heart Blood and the lustre of the whole body and meridian system.

Shiatsu – the Japanese healing art of touch 189 the head hair depends upon the Liver Blood. act in a never-ending flow. This theory is used to categorise various symptoms of the body and Where Ki goes, Blood goes and Ki also follows mental states. Zen: an Eastern philosophy, a form of Buddhism, Blood. The function is to moisten, nourish and which encourages spontaneity and living in the present moment. It is used in shiatsu to still the relax on the physical and psychological level. mind and create an atmosphere of heightened Bo and Yu points: diagnostic acupuncture points awareness. in the front and back of the body. Acknowledgements Ch’i or Qi: Chinese word for energy (Ki in I would like to thank Aliki Sapountzi for the pho- Japanese). tography, Mark Wright, Clifford Andrews, Sensei Do-In: self-shiatsu includes percussion or tapping Akinobu Kishi and many other teachers, colleagues, students and patients for their encouragement and techniques, meridian stretching and breathing inspiration. exercises for guiding and leading the Ki through- References out the body. For clarification the terminology Beresford-Cooke, C. (1996) Shiatsu Theory and Practice. Churchill Livingstone, Edinburgh. self-shiatsu is used in the text when massage tech- Harris, P.E. and Pooley, N. (1998) What do shiatsu practi- niques are described to work on oneself. tioners treat? A nationwide survey. Complementary Eight principles: ways of categorising various Therapies in Medicine, 6(1), 30–35. symptoms into recognisable patterns to deter- Masunaga, S. and Ohashi, W. (1977) Zen Shiatsu. Japan Publications, Tokyo. mine the extent and seriousness of the illness and Further reading which points to use, e.g. cold and hot, interior or Charman, R.A. (2000) Complementary Therapies for exterior causes of disease. Physical Therapists. Butterworth-Heinemann, Oxford. Five elements or five phases: used in Chinese Deadman, P., Mazin, A. and Baker, K.(1998) A Manual of medicine and shiatsu. Organs are characterized Acupuncture Point Cards. Journal of Chinese Medicine Publications, Hove. by the elements metal, water, wood, fire and Ferguson, P. (1995) Self-Shiatsu Handbook. New Leaf earth and the relationship between them. Publishing, Houston. Hara: Japanese word for the abdomen, acknowl- Kaptchuk, T.J. (1983) Chinese Medicine. Rider, London. edged as the centre of physical and spiritual Liechti, E. (1998) The Complete Illustrated Guide to Shiatsu. strength. Element Books, Shaftesbury. Hara diagnosis: zones on the abdomen where the Lundberg, P. (2002) The Book of Shiatsu. Gala Books, practitioner feels the state of Ki in the meridian London. Masunaga, S. (1987) Zen Imager! Exercises. Japan and the body. Ki: Japanese word for energy. Publications, Tokyo. Kyo: a deficient or empty meridian, which responds Useful websites slowly to treatment. Kyo–jitsu: the theory used in Zen shiatsu describ- http://www.holisticphysiotherapy.org. http://www.shiatsu.org. ing the dynamic relationship between a more kyo and a jitsu meridian (full or overactive) and their physical manifestations. Makko-Ho: meridian stretches (similar to yoga), a simple workout for the whole body and each meridian. Meridian: an energy pathway in the body where Ki flows more strongly. Moxa: a treatment warming the body by burning the herb Mugwort (Artemisia vulgaris leaf) on or over specific acupuncture points. Qi (or Ch’i): Chinese word for energy. T’ai Chi and Ch’i Kung: Chinese therapeutic exercises for building and circulating the Qi in the body using the breath. Tsubo: Japanese word for acupuncture point. Yin Yang: the dynamic relationship of all forms in which complementary and opposing forces inter-

17Myofascial release and beyond Ann Childs and Stuart Robertson Introduction to the fascial matrix fascia for the purposes of this chapter are inter- changeable. Fascia is composed of the proteins col- There are many types of massage/bodywork tech- lagen, providing strength, and elastin, providing niques focusing more specifically on the fascial flexibility, and the ground substance, a polysac- component of tissues (rather than muscle or bone) charide gel complex surrounding every cell (Gray to effect a global, whole body response, for example and Williams 1995; LeMoon 2008). connective tissue massage, structural integration, rolfing, trager, shiatsu, positional release and cra- The fascia surrounds, supports and give struc- niosacral therapy. Rather than become embroiled tural integrity and interconnectivity to all the in semantics, or in the classification of techniques systems of the body (Stecco et al. 2008), down to identified by goals of treatment or clinical effects cellular and nuclear level (Chaitow 2006). (Sherman et al. 2006), this chapter broadly looks at the underlying approach widely termed myofas- The muscular and fascial systems are both derived cial release (MFR) currently gaining much popular- from the mesoderm and known together as the ity in both traditional and complementary medicine. myofascial system. On a gross level, individual Although muscle is implicated, the salient feature muscles are enveloped in a fascial matrix, the endo-, that loosely distinguishes this approach from ‘tra- peri- and epimysium, interconnecting not only ditional’ massage is the interconnectivity of the muscles, but also all the functional body systems fascial system, subtlety of palpation and a gentle (Juhan 1987; Gray and Williams 1995). Body (low load) sustained stretch. The approach is driven movements either tension or slacken some part of more by perception, palpation and the patient’s this three-dimensional fascial matrix providing a tissue response rather than following a structured key component to movement and structure. The framework based on symptom-driven techniques. nervous system receives the greatest amount of afferent sensory nerves from the muscles and related There has been a tendency to identify muscles in fascia, potentially forming the largest sensory organ terms of anatomical structure and functional isola- (Schleip 2003, part 1). tion, yet other body systems are identified in rela- tion to their total anatomical and functional Aims of the MFR approach continuity through connective tissue, for example the vascular, lymphatic, osseous, respiratory and ᭿ Identify and palpate subtle, discrete areas of neural systems. The term connective tissue and restriction within the fascial matrix. 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

Myofascial release and beyond 191 ᭿ Apply a gentle sustained three-dimensional receivers; if they only tune into one frequency they stretch for approximately 90–120 s. will only receive one radio station, but if free to scan all the different frequencies then potentially all ᭿ Facilitating with hands, follow and allow this radio stations may be received. If some of those restriction to elongate and ‘unwind’ as a spon- stations are in a foreign language, to filter them out taneous (not preconceived) release of the myo- would diminish the bigger picture. If the mind fascial tissue. intention is to feel solely for myofascial restrictions (tuning into the myofascial station), this will be the ᭿ Acknowledge and encourage changed aware- station received. As this becomes more accom- ness of any somatic, postural, emotional or plished other stations can be received at the same mental changes in a supportive, trusting time; for instance, tuning into emotions that may environment. be related to the palpated area. ᭿ Maintain improved range of movement and resulting new ways of moving with home exercises. Palpation philosophy and possible Exercises to enhance palpatory skills barriers to effectiveness The space apportioned here to palpatory skill In order to locate these fascial restrictions, the prac- description is indicative of the importance and rel- titioner needs to relax, let go of expectation and evance to the MFR technique. pay attention to the tactile and proprioceptive information received through the hands. During Exercise 1: Attuning whole MFR teaching sessions students tend to focus on and bilateral hand sensitivity what they think they are supposed to be feeling, rather than what they are actually feeling in their During palpation we may become aware of being hands. This has led to the following response: able to feel more easily with the right or left hand or with only part of that hand. The following exer- ᭿ ‘This is a waste of time, how can palpating so cise helps to develop feeling with the whole of one lightly tell us anything?’ – the more effort hand and then bilateral sensitivity. required the more out of touch you seem to be (Blackburn 2004, part 3). ᭿ Place your flat hands palm down on a table surface as lightly as possible. Become aware of ᭿ ‘I’m never going to get this.’ – this may become which areas you can feel in contact with the a self-fulfilling prophecy. surface. Do both hands feel equally relaxed? ᭿ ‘What exactly is it I’m supposed to be feeling?’ ᭿ Allow the hands to rest fully on the surface of – needing to fulfill an expectation. the table. Does one hand melt and mould (meld) into the table surface more than the ᭿ ‘I really, really, really, want to be able to do other? Bring awareness into each finger, thumb this.’ – the practitioner is trying too hard and and palm of the hand. Avoid pushing the hands is too tense to feel any subtle tensions in the into the surface; simply allow the weight of just body. the hands to sink into the table. As these undermining thoughts, beliefs and atti- ᭿ Notice what has to shift in you, for your sen- tudes arise in our mind, palpating at a subtle level sitivity and awareness to develop more fully becomes more difficult to the point where the ana- throughout the whole hand. lytical, right-brained thinking process may inhibit the more left-brained palpatory sensitivity (Payne ᭿ Then notice what has to change in order for 2000). you to be able to feel more equally with both left and right hand. The mind needs to be free to explore, in a non- judgemental way, an appreciation of incoming ᭿ Identify in your own body areas of tension and information, rather than analysing and referencing how that may affect your ability to palpate. each thought. Imagine our hands working as radio

192 Massage for Therapists Exercise 2: Enhancing palpatory Exercise 5: Palpation changes with sensitivity different states of mind ᭿ Repeat the above exercise with your hands ᭿ Ask a consenting colleague/friend to bring to lightly resting on your thighs. mind one negative and one positive thought they have on a regular or daily basis, then ᭿ Having paid attention to what is happening in forget the thoughts and focus on the present. your hands start to notice what is actually underneath your hands. Does one hand sink ᭿ Place your hands over the person’s diaphrag- into the tissues more freely? Develop a sense of matic area (anterior hand over the xiphoid density of the thigh tissue. process, posterior hand over the T10 area). Observe the feelings in your hands and then ᭿ Change hands in order to feel the left leg with beyond into the tissues. the right hand and right leg with the left hand. How deeply into the tissues can you feel with ᭿ Once you have a clear feeling of the tissues, ask either hand? Is there a difference? Change over the person to take a deep breath in, and when hands to see if the difference is consistent. he/she breathes out, to bring the positive thought to the forefront of his/her mind. Notice ᭿ Return the right hand to the right leg and left what happens at the interface of your hands hand to the left leg. If there is asymmetry in and beyond into the person’s body. perception between your hands, what needs to shift in you or where do you need to release ᭿ After approximately 20 s, ask the person to tension in order for the hands to feel more take another deep breath in, and on breathing equal? out to bring his/her focus into the negative thought and notice changes. ᭿ Repeat the above with hands on the right and left side of the abdomen and thorax to develop ᭿ Notice how with the different mind states there this symmetry in hand perception. may be a change in feeling between your hands. Exercise 3: Palpating fascial glide Exercise 6: Identification and ᭿ Placing your hands on your thighs, imagine documentation of fascial restrictions that your hands are part of the thighs (light touch as in Exercise 2). ᭿ A body chart may document the hand place- ment for assessing the whole of the fascial ᭿ Now traction away from the hip (south), then matrix. With light touch learnt from the palpa- away from the knee (north), then back to the tion exercises previously, glide the tissues in the starting position, then to the left and the right. north, south, east and west directions as in Describe how the tissues felt in each leg and Exercise 3. the amount of excursion from the starting position. ᭿ Mark on a body chart areas of tissue restric- tion, i.e. where you feel the tissues move freely ᭿ Repeat this whilst extending your awareness and where they are restricted. beyond the surface to engage all the tissues of the thigh. Exercise 7: Identification of the dominant holding pattern in the body ᭿ Repeat with the hands placed on the abdomen and thorax. ᭿ Having assessed areas of tension/restriction throughout the body, each of these restrictions Exercise 4: Influence of palpation and are prioritised (explained on training courses) body tension in a similar manner to prioritising primary over secondary trigger points. ᭿ Now you have greater awareness in your hands, notice how your palpatory sensitivity is influ- enced by your own body tension and posture. ᭿ If unsure continue to practise Exercises 1–3.

Myofascial release and beyond 193 Myofascial release techniques as in all massage therapy. The following are abso- lute contraindications (J. Annan, teaching material There are many ways of releasing perceived myo- 2006; see ‘Course information’): fascial restrictions. The two most basic techniques are recoil stretch (direct technique) and positional ᭿ Malignancy. release (indirect technique). The recoil stretch takes ᭿ Aneurysm. tension up in the tissues and the positional release ᭿ Acute circulatory conditions. relaxes tension in the tissues. For the purpose of ᭿ Acute rheumatoid arthritis. this text, focus will be on the direct stretch tech- ᭿ Cellulitis. nique as it is the safest to learn from text. ᭿ Febrile state. ᭿ Advanced osteoporosis. A sustained stretch technique ᭿ Obstructive oedema. ᭿ Anticoagulants. Conventionally, tissue has been stretched from a ᭿ Severe hyperalgesia. two-dimensional perspective in many therapeutic ᭿ Advanced diabetes. interventions; however, the body functions three ᭿ Systemic infection. dimensionally, and hence assessment, treatment ᭿ Healing fracture sites, haematoma and open and functional change is three dimensional. wounds (use clinical judgement). ᭿ Place your hands either side of the restriction, and engage the fascia by taking up the slack in Beyond the anatomy the tissues. Involving the mind and feelings ᭿ Gently stretch (a few grams) by increasing the tension three dimensionally until you feel the It is of great importance for the therapist and tissues ‘lock’ under your hands and hold. patient to be equally ‘present’, that is to have a Imagine you have an elastic cord between your shared awareness of the physical and mental experi- hands and wind the tension up. This tension is ence of the patient to facilitate the patient’s thera- developed between the hands without pushing peutic process (Blackburn 2004; Blackburn and down into the body excessively; more a sense of Price 2006). King (2002) suggests a deeper interac- pulling the tissues apart three dimensionally. tive tissue engagement is facilitated between patient and therapist by the patient focusing his/her breath- ᭿ Hold this gentle stretch (sustained low load ing into the fascial restriction. pressure) for a minimum of 90–120 s (Barnes 1997). As the restriction eases, warmth, motion The concept of the mind and body being inextri- and softening of the tissues is often palpated. cably linked is now taken as a given. The growing integration of mind, body and feelings demon- ᭿ Follow this release, holding the gentle pressure strated in cognitive behavioural therapy (CBT), against any new restriction/barrier. Repeat psychoneuroimmunology (PNI) and mindfulness in until the tissues are softened and pliable. the practice of manual therapy are testament to the growing interest and significance of mental and Often there is no clear distinction between assess- emotional stresses in relation to the presentation of ment and treatment as the gentle kinaesthetic per- symptoms. Our posture can be seen as a reflection ception of a fascial restriction initiates a physiological of our mental and emotional states becoming habit- stretch (unwinding). ual over time. Latey (1996) describes in depth how the somatic body encapsulates mind and feelings at Contraindications different levels, enabling exploration, understand- ing and the potential for therapeutic change. The same subjective and objective assessment pre- Therapeutic rapport facilitates personal meaning of ceding treatment and clinical judgement is applied these bodily responses to stress, enabling the

194 Massage for Therapists patient’s insight and motivation to change previous mechanoreceptors in the thoracolumbar fascia may habitual physical and mental responses to stress. relate to chronic low back ache and be possibly implicated in the ageing process (Schleip et al. An exploration of suggested rationale 2005). Considering the possibility that MFR’s spe- and their clinical implications cific sensory input might activate the central nervous system, thus eliciting neural reactions, Bertolucci Responsive biomechanical model (2008) suggests that EMG activity could objectively measure simultaneous subjective palpatory Fascia has tended to be considered as an inert con- phenomena. tainer and passive contributor to biomechanics. However, immunohistological analysis has demon- Gel-to-sol model strated the presence of contractile smooth muscle- type features in cells called myofibroblasts, in Thixotrophy is the gel-to-sol (dense to more fluid normal fascia occurring particularly in the fascia state) transformation confirmed to occur after lata, plantar and lumbar fascia (Schleip et al. 2005). mechanical pressure to connective tissue (Twomey An increasing body of evidence is demonstrating and Taylor 1982). how physical manipulation may potentially influ- ence profound and rapid structural, functional and The extracellular ground substance of fascia is a mechanical interactions between fibroblasts and the viscous colloidal semi-liquid in the immediate envi- extracellular matrix, resulting in fascial changes ronment of every cell in the body, bathing the col- (Grinnell 2008). These fascial contraction proper- lagen fibres and composed of water-binding complex ties may be actively influencing biomechanical sugar mucopolysaccharides. As a general process, behaviour, enabling an active temporary adjust- stress, disuse and lack of movement cause the gel to ment of passive muscle stiffness in response to dehydrate, contract and harden. Dehydrated tissue increased mechanical and/or emotional tensional feels gnarled and stringy (King 2002). demands (Schleip et al. 2006). This may have an impact on fascial proprioception where an altera- The application of pressure or stretch brings tion of fascial tone may contribute to sacro-iliac about a rapid rehydration and change to sol, yet instability and spinal segmental instability (Schleip removal of pressure allows the system to rapidly et al. 2005) in a similar way that stiffness in plantar re-gel. However, during the ‘sol’ phase, the ground fascia contributes to stability of the foot (Cheung substance becomes more porous, providing an et al. 2004). improved medium for the diffusing entry and exit of nutrients, oxygen, waste products of metabolism Neural-mechanoreceptor model and enzymes. If the stretch is gentle and sustained (less is more) and the following rest period suffi- Schleip (2003, part 2) discuses how Ruffini sensory ciently long enough, more water soaks into the mechanoreceptors in the broad fascial sheaths give ground substance than before the stretch. This sensory and proprioceptive feedback to the central water content then increases to a higher level than nervous system when stimulated by slow deep before the stretch. This increased hydration could steady manual pressure involving lateral stretch. account for the palpable tissue changes after long- The Ruffini mechanoreceptors and other interstitial duration MFR but not below 2 minutes (Barnes fascial mechanoreceptors (types III and IV) when 1997; Oschman 1997, part 5; Schleip 2003, part stimulated can also affect autonomic function by 1). However, this still does not account for the increasing vagal activity (increased parasympathetic therapist’s experience of tissue change after a few response), promoting global muscle relaxation and seconds. less emotional arousal. Increased vagal activity also changes local fluid dynamics and tissue metabolism Piezo-electric model (Schleip 2003, part 2). A diminished number of The structure and architecture of each cell consists of connective tissue, called the cytoskeleton, having the ability to communicate and process electrome-

Myofascial release and beyond 195 chanical and electrochemical signals. On a more loskeletal improvements in mobility, pain and dys- subtle scale, fascia may act as a liquid crystal. When function to wider holistic mind–body responses. fibroblasts are distorted by movement, pressure, The individualised nature and diverse responsive- compression or tension, piezo-electrical fields spread ness of MFR together with the varied outcomes throughout the body. The strength of these fields poses complex methodological issues for research depends on the angle with which the pressure is design, resulting in few rigorous studies. However, applied (Oschman 1997, part 5; Schleip 2003, the following descriptions give a flavour of clinical part 1). potential: Oschman (2005) discusses how the reliable detec- ᭿ Barnes et al. (1997) demonstrated the effect of tion of extremely low-frequency, non-thermal and a myofascial release treatment technique on non-ionising energy fields, as experienced in gentle obtaining pelvic symmetry. Acknowledging the sensitive manual touch, can potentially have impor- small sample size (n = 10), the results indicated tant biological effects which optimise rapid cellular that the treatment had the potential to be effec- communication. These may be partially explained tive in facilitating a change in asymmetric by emerging concepts of semiconduction, quantum pelvic position toward symmetry. Limitations mechanics, liquid crystals and biological coherence. of the study described subjects already under- In practical terms, this may be explained as less going MFR and the questionable reliability of input producing greater clinical outcomes with the measurements. possibility of a physical intervention being directed some distance from the presenting symptoms, yet ᭿ Davis et al. (2005) compared MFR and exer- still clinically affecting the symptoms. Clinical evi- cise to exercise alone in two case studies involv- dence is discussed in Oschman (1997, part 5) and ing two older people with severe kyphoscoliosis Schleip (2003, part 1). from osteoporosis and pain that necessitated walking with a rolling walker. Subjective and Trauma release model objective measures were taken pre and post MFR/exercise compared with exercise alone. In a positive context, just as myofascial tissue After MFR, both cases reported improved feel- appears to be therapeutically responsive to manual ings of energy, improved posture and greater therapy, equally, within a negative context, for ease in reaching and walking. Objectively there example, physical trauma or poor posture, the was improved balance, height, walking speed myofascial tissue change may appear to support (timed-up-and-go or function) and pain reduc- dysfunction, as seen in adhesions and scar tissue. tion compared with exercise only. Oschman (2006) hypothesises how the fascial matrix extending into every cell and nucleus in the ᭿ A single case study describing MFR in the body senses and absorbs the physical and emotional treatment of a chronic thoracic outlet syn- impact in traumatic experiences. As these ‘struc- drome with nerve root irritation and gross pos- tural memories’ are laid down in the fascia at an tural asymmetry fully explained the treatment unconscious, non-verbal level, it is suggested that rational. The successful outcome of 2 weeks of the non-verbal subtle MFR may release and resolve intensive daily treatment described clinically this ‘tissue–held’ trauma (Blackburn 2003; Oschman significant changes in function, ROM, pain and 2006). postural symmetry (Barnes 1996). Evidence of effectiveness in clinical ᭿ A single case study of amyotrophic lateral scle- practice rosis showed improvements in range of move- ment, vagal tone, self report and timed-up-and-go There is much positive anecdotal evidence arising at 12 weeks follow-up (Cottingham and from MFR ranging from objective specific muscu- Maitland 2000). The following suggest potential clinical applications: ᭿ Myofibroblast-facilitated contraction in the intramuscular perimysium fascia will influence passive muscle stiffness in conditions such as

196 Massage for Therapists torticollis, Parkinson’s rigor, ankylosing spon- change the perception of this ‘alternative therapy’ dylitis, shortened soleus in muscular dystrophy towards an accepted integrated clinical practice. and chronic muscle tension, e.g. of the upper trapezius. It is suggested that very slow, sensi- The work of Myers (2004, part 13) in metaphori- tive manual deep tissue techniques may target cally describing the functional, articulated chains of and release these particular restrictions (Schleip myofascial structures as train lines dovetails well et al. 2006). into Langevin et al.’s (2001) parallel concept of ᭿ Increased alkalinity of blood in hyperventila- how the interconnected myofascial network appears tion may cause contraction of intrafascial to relate to the acupuncture meridian network, acu- smooth muscle, increasing overall fascial puncture points and myofascial trigger points. The tension. This may have implications in fibro- propagation and amplification of cellular signals, myalgia and chronic fatigue syndrome (Schleip from mechanical pressure/stretch, through the 2003, part 2). fascial network, may potentially further our under- ᭿ Post mastectomy and reconstruction, fibrous standing of the integrative communication and scar tissue and adhesions are eased and func- function of the whole body. tion improved (Hobden 2006). This described ability to sensitively palpate and So what do we feel with our hands? therapeutically respond to changes in the myofas- cial tissues to affect the whole body may enhance If MFR affects local blood supply and local tissue (and change) our clinical practice, regardless of the viscosity, it is conceivable that these tissue changes specific manual therapy technique or discipline of could be rapid and significant enough to be felt by the therapist (Myers 2004, part 1; Bertolucci the ‘listening’ hand of the practitioner (Schleip 2008). 2003, part 2). The tissue responses our hands expe- rience could be related to the sponge-like squeezing References and refilling in the semi-liquid ground substance. Manual stimulation of fascia leads to tonus changes Barnes, J. (1996) Myofascial release in treatment of thoracic in the motor units which are mechanically linked outlet syndrome. Journal of Bodywork and Movement to the tissue under the therapist’s hand, enabling Therapies, 1(1), 53–7. the hand to feel local specific changes in tone (Schleip 2003, part 1). It would seem that our Barnes, M.F. (1997) The basic science of myofascial release: understanding of the traditionally passive contain- morphological changes in connective tissue. Journal of ing role of fascia is moving towards an adaptable Bodywork and Movement Therapies, 1(4), 231–8. and sensitive organ, responsive to the human hand. Barnes, M.F., Gronlund, R.T., Little, M.F. and Personius, W.J. (1997) Efficacy study of the effect of a myofascial Future implications release treatment technique on obtaining pelvic symmetry. Journal of Bodywork and Movement Therapies, 1(5), In the past, many therapies without an acceptable 289–96. biomedical explanation were seen as alternative to the orthodox health care system of that time. Bertolucci, L.F. (2008) Muscle repositioning: a new verifiable Ongoing research and emerging concepts briefly approach to neuro-myofascial release. Journal of Bodywork addressed in this chapter are beginning to give some and Movement Therapies, 12, 213–24. explanation of how the gentle sustained touch and global clinical changes observed in MFR may Blackburn, J. (2003) Trager: psychophysical integration – an overview. Journal of Bodywork and Movement Therapies, 7(4), 233–9. Blackburn, J. (2004) Trager part 2, 3, 4: Hooking up: the power of presence in bodywork. Journal of Bodywork and Movement Therapies, 8, 114–21, 171–88, 265–77. Blackburn, J. and Price, C. (2006) Implications of presence in manual therapy. Journal of Bodywork and Movement Therapies, 2(1), 68–77. Chaitow, L. (2006) Fascia 2007 Congress. Journal of Bodywork and Movement Therapies, doi:10.1016/j. jbmt.2006.07.004. Cheung, J.T.K., Zhang, M. and An, K.N. (2004) Effects of plantar fascia stiffness on the biomechanical responses of

Myofascial release and beyond 197 the ankle–foot complex. Journal of Clinical Biomechanics, muscular connective tissue. Medical Hypotheses, 66, 19, 839–46. 66–71. Cottingham, J. and Maitland, J. (2000) Integrating manual Sherman, K., Dixon, M., Thompson, D. and Cherkin, D. and movement therapy with philosophical counselling for (2006) Development of taxonomy to describe massage treatment of a patient with amytropic lateral sclerosis: a treatments for musculoskeletal pain. BMC Complementary case study that explores the principles of holistic interven- and Alternative Medicine, 6, 24. Available from http:// tion. Alternative Therapies, 6(2), 120–28. www.biomedcentral.com/1472-6882/6/24 (open access Davis, C.M., Doerger, C., Rowland, J., Sauber, C. and Enton, article). T. (2005) Myofascial release as complementary to exercise Stecco, A., Masiero, S., Macchi, V., Stecco, C., Porzionato, in physical therapy for two elderly patients with osteopo- A. and De Caro, R. (2008) The pectoral fascia: anatomical rosis and kyphoscoliosis: two case studies. Australian and histological study. Journal of Bodywork and Movement Journal of Physiotherapy, 51(Suppl 4), S15. Therapies, 12, doi:10.1016/j.jbmt.2008.04.036. Gray, H. and Williams, P.L. (1995) Gray’s Anatomy, 38th Twomey, L. and Taylor, J. (1982) Flexion, creep, dysfunction edn. Churchill Livingstone, Edinburgh. and hysteresis in the lumbar vertebral column. Spine, 7(2), Grinnell, F. (2008) Fibroblasts mechanics in 3-dimensional 116–22. collagen matrices. Journal of Bodywork and Movement Therapies, 12, 191–3. Further reading Hobden, J. (2006) Ties that bind. Frontline, January, p. 31. Juhan, D. (1987) Handbook for bodyworkers: Job’s body. Andrade, C.K. and Clifford, P. (2001) Outcome-based Station Hill Press, Barrytown, New Jersey. massage, In: Connective Tissue Techniques. Lippincott King, K. (2002) Myofascial breathwork: a regenerative body- Williams and Wilkins, Philadelphia, pp. 244–74. work approach. Journal of Bodywork and Movement Therapies, 6(4), 224–5. Barnes, J.F. (2004) Myofascial release: the missing link in Langevin, H.M., Churchill, D.L. and Cipolla, M.J. (2001) traditional treatment. In: Complementary Therapies in Mechanical signalling through connective tissue: a mecha- Rehabilitation (ed. C.M. Davis). Slack Incorporated, nism for the therapeutic effect of acupuncture. FASEB Thorofare, New Jersey, pp. 59–81. Journal, 15, 2275–81. Latey, P. (1996) Feelings, muscles and movement. Journal of Oschman, J. (2003) Energy Medicine in Therapeutics and Bodywork and Movement Therapies, 1(1), 44–52. Human Performance. Butterworth Heinemann, Oxford. LeMoon, K. (2008) Terminology used in fascial research. Journal of Bodywork and Movement Therapies, 12, Useful websites 204–212. Myers, T.W. (2004) Structural integration – developments in http://www.fasciaresearch.com. Ida Rolf’s recipe. Journal of Bodywork and Movement http://www.i-sis.org/brainde.shtm (articles by M.W. Ho). Therapies, 8; Part 1, 131–42; Part 2, 189–98; Part 3, http://www.johnlatz.com/keyelements_article.html. 249–64. http://www.rolf.org/about/research.htm. Oschman, J.L. (1997) What is healing energy? Journal of http://www.sciencedirect.com/science/journal/13608592. Bodywork and Movement Therapies, 1(2–5). Part 2, 117– http://www.softtissuetherapy.com.au. 22; Part 3, 179–94; Part 4, 239–47; Part 5, 179–94. http://www.somatics.de/fasciaresearch/innervation.htm. Oschman, J.L. (2005) Energy and the healing response. Journal of Bodywork and Movement Therapies, 9, 3–15. Course information Oschman, J.L. (2006) Hypothesis: trauma energetics. Journal of Bodywork and Movement Therapies, 10, 21–34. http://www.dmbem.com/mfrb.htm (Stuart Robertson). Payne, R. (2000) Relaxation Techniques – A Practical http://www.physiouk.co.uk/html/courses/fascial.htm (John Handbook for the Health Care Professional, 2nd edn. Churchill Livingstone, London. Annan). Acknowledgements to John Annan for kindly pro- Schleip, R. (2003) Fascial plasticity – a new neurobiological viding information regarding contraindications, as taught explanation. Journal of Bodywork and Movement in his courses. Therapies, 7(1–2), Part1, 11–19; Part 2, 104–16. Schleip, R., Klinger, W. and Lehmann-Horn, F. (2005) Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence muscu- loskeletal dynamics. Medical Hypotheses, 65, 273–7. Schleip, R., Naylor, I., Ursu, D., et al. (2006) Passive muscle stiffness may be influenced by active contractility of intra-

Index abdominal massage 125 inhalation 166–7, 168 brisk lift stroking and shaking 126–7 olfaction 166, 168 constipation 129 precautions 175–6 depth 128–9 purity 177 effleurage 126 skin absorption 167–8 kneading 126, 127–8 storage 177–8 palpation 125–6 working knowledge 165–6 patient preparation 125 holistic approach 168, 172 rolling 128 massage 171, 177 skin wringing 128 acupressure 171 stroking 127 blood circulation 171 vibrations 126 elderly patients 172 fatigue 171 active release technique (ART) 141 general wellbeing 172 acupressure 141 infection 171 lymphatic drainage 170 aromatherapy 170 muscle tension 171 sports massage 152–3 neuromuscular 171 acute inflammation of joints 55 one-to-one care 171 AIDS 136 pain 171 allergic reactions 64 pregnancy/childbirth/baby care 172 alpha motoneuron excitability 27–8 relaxation 171 anatomical position 14, 15, 16 sleep 172 animal massage 141–2 support for staff and carers 171 Anma (Amma) 4 personality type 173 ANS (autonomic spinal nerves) 16, 17 preparation of patient 176–7 anterior tibial muscles 99, 105 arthrogenic joint related problems 47, 135 anxiety 34, 35, 131 ascending colon 127, 128 aponeurosis 10 assessment 49–50 arm see upper limb massage abnormal and normal responses 50, 51 aromatherapy 142 contraindications 37–8, 54–5, 135–6 case study 177 see also contraindications consultation procedures 172–3 measuring change and outcome 55 essential oils 173 body chart 55–6 body image drawings 56 blending and formulation 176 SOAP notes 56–8 chemistry 164 muscles and fascia 52–3 contraindications 174–5 nerve tissue 53–4 extraction methods 165 oedema 54 glossary of terms and properties pain and soreness 54 168–70 historical uses 163–4 ingestion 168 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

200 Index palpation circular frictions 77 descriptors 50, 51 gluteal region 113–14 skill 58–9 circulatory system scar tissue 51–2 cardiovascular system 17–18 skin 50–1 cerebrospinal fluid system 19–20 tendons 53 endocrine system 20 see also clinical features fluid balances 20 autonomic spinal nerves (ANS) 16, 17 lymphatic system 18–19 ayurvedic massage 4, 142 physiological effects of massage 24–7 respiratory system 20–1 baby massage 37, 132–3 aromatherapy 171 clapping 79–80 back massage 112 back massage 106 facial massage 123–4 clapping 112 gluteal region 114–15 effleurage 106–7 lower limb 103–5 hacking 112 neck massage 118 kneading 107–8 upper limb 91–2 alternate, double-handed 108–9 finger kneading 110 classical massage 143 single-handed 109 clinical features superimposed kneading 109 thumb kneading 109–10 arthrogenic joint related 47 muscle rolling 111–12 cardiovasculogenic 48 preparation of patient 106 endocrine 48–9 prone patient 106 ergogenic 49 skin rolling 110 gastrointestinal 48–9 treatment couch 106 genitourinary 48–9 wringing 111 myogenic fasciogenic 47–8 neurogenic 48 Beard, Gertrude 4 osteogenic 48 beating 80 psychogenic 49 biceps 85, 86, 89, 90, 91 pulmonary 48–9 bio-energy therapies 142 sociogenic-socioeconomic 49 blood cells 18 viscerogenic 48–9 blood flow 25–6 clinical reasoning 46 blood pressure 18, 26, 33, 34 CNS (central nervous system) 14 body chart 55–6 pain 28–9 body image drawings 56 colon 127–8 Bowen therapy 142–3 complementary therapies 171, 188 brachioradialis 89, 90, 91 connective tissue manipulation (CTM) 143 bruising 54 connective tissues 8 buttocks see gluteal region constipation 129 contact mediums 63–4 calf muscles 98, 102, 103, 104–5 sports massage 154, 156, 157, 158, 159 cancer 34, 135–6 contraindications 37–8, 54–5, 135–6 aromatherapy 174–5 malignant tumours 54 myofascial release 193 cardiovascular system 17–18 pregnancy 175 cardiovasculogenic problems 48 shiatsu 183 central nervous system (CNS) 14 sports massage 151, 154, 155, 156, 157, 158, pain 28–9 159, 160 cerebrospinal fluid (CSF) 19–20 corium 7 ceruminous glands 8 couch 63, 93, 106 children 35, 133 craniosacral therapy 143 Chinese medicine 141, 147, 149, 179, 180, 181, 184 creams 63–4

CSF (cerebrospinal fluid) 19–20 Index 201 Cyriax, James 4, 135 working knowledge 165–6 delayed onset muscle soreness (DOMS) 31, 31, 153 see also aromatherapy deltoid 85, 86, 88–9, 90, 91 evidence-based practice 23 depression 35, 36, 131 myofascial release 195–6 dermal-epidermal junction 7 examination of patients 45–6, 66 dermis 7 see also assessment descending colon 127, 128 digestive system 21–2 facial massage 119 digits see fingers clapping 123–4 disabilities 133–5 effleurage 119–20 disease 135 exit foramina of the trigeminal nerve 122 DOMS (delayed onset muscle soreness) 31, 31, 153 kneading 121 muscle stretching 123 effleurage 67–8 occipitofrontalis 123 abdomen 126 patient preparation 119 back massage 106–7 platysma 123–4 facial massage 119–20 plucking 121–2 gluteal region 113 sinuses 123 lower limb tapping 122 part strokes 96–7 vibrations 122–3 whole limb 94–6 wringing 121, 122 neck massage 116 scalp 124 fascia 13 upper limb assessment 52–3 part strokes 83–5 whole limb 83 fasciogenic problems 47–8 finger kneading 70–1 elderly patients 34–5, 133 aromatherapy 172 back massage 110 lower limb 98, 100 endocrine problems 48–9 upper limb 87 endocrine system 20 fingers 84–5, 88 energy system 21–2 fluid balances entrainment 17 circulatory system 20 environment 63 skin 8 epidermis 6–7 foot 96, 99, 100 epilepsy 175 forearm 84, 86, 87, 89–90, 91 ergogenic problems 49, 131–2 fractures 54 essential oils 173 frictions 77 circular 77, 113–14 blending and formulation 176 gluteal region 113–14 cancer care 136 transverse 77–8 chemistry 164 contraindications 174–5 gastrointestinal problems 48–9 extraction methods 165 gel-to-sol 194 glossary of terms and properties 168–70 genics 47 historical uses 163–4 genitourinary problems 48–9 ingestion 168 gluteal region 112 inhalation 166–7, 168 olfaction 166, 168 clapping 114–15 precautions 175 effleurage 113 purity 177 frictions 113–14 skin absorption 167–8 hacking 114–15 storage 177 kneading 113 patient preparation 112 picking up 114 wringing 114

202 Index knee 98 peroneal muscles 99, 100 hacking 79 sole of the foot 100 back massage 112 thigh 97 gluteal region 114–15 toes 100 lower limb 103–5 neck massage 116–17 neck massage 118 palmar 70 upper limb 91–2 scalp 124 superimposed (reinforced) 72–3 hair 7 thumb pad 71–2 hand exercises 62 thumb tip 72 hand massage 84, 87, 90–1 upper limb 85 head massage 124 double-handed alternate kneading 85–6 finger kneading 87 Indian head massage 143 single-handed kneading 86–7 patient preparation 119 thumb kneading 87–8 headaches 123, 183–4 whole hand 70 Heller work 143 knee 96, 98, 103 histamine 26–7 HIV 136 learning disabilities 133–4 holistic medicine 168, 172 leg see lower limb massage hormones 17, 20 ligaments 13 hypertrophic scars 137 Ling, Per Henrik 3, 148 hypodermis 7 Linn transcadence (LTC) massage 149 liquid oils 63 ice massage 153 lomi lomi 144 immune system 35 lower limb massage Indian head massage 143 infection 171 clapping 103–5 inflamed joints 55 effleurage interosseous spaces part strokes 96–7 lower limb 96, 100 whole limb 94–6 upper limb 84, 87 hacking 103–5 kneading 97 joint inflammation 55 anterior tibial muscles 99 calf muscles 98 Ki 180, 181, 188 dorsum of the foot 100 see also Qi foot 99, 100 interosseous spaces 100 kneading 69–70 knee 98 abdomen 126, 127–8 peroneal muscles 99, 100 back massage 107–8 sole of the foot 100 alternate, double-handed kneading 108–9 thigh 97 finger kneading 110 toes 100 single-handed kneading 109 muscle shaking 102–3 superimposed kneading 109 picking up thumb kneading 109–10 calf 102 facial massage 121 double-handed, simultaneous 101 finger pad 71 singe-handed to double-handed alternate finger tip 71 flat finger 70–1 101 gluteal region 113 thigh 100–1 heel of hand 73 preparation of patient 93 lower limb 97 prone patient 93–4 anterior tibial muscles 99 skin rolling and skin wringing 103 calf muscles 98 supine patient 93 dorsum of the foot 100 foot 99, 100 interosseous spaces 100

treatment couch 93 Index 203 wringing 102, 103 lumbar region 107 neck massage 118 see also back massage upper limb 91 lunge standing 61 muscle shaking 77 lymphatic drainage 136, 144, 170 lower limb 102–3 lymphatic system 18–19 upper limb 91 lymphoedema 136 muscle stretching 123 muscles malignant tumours 54 action 13 manual lymph drainage (MLD) 136, 144 anterior view 11 massage assessment 52–3 function 10 contraindications see contraindications insertion 13 Eastern forms 4 origin 13 evidence-based practice 23, 36–7 posterior view 12 history 3 reciprocal innervation 13 mechanical effects 24 reflexes 13 origin of the term 3 structure 10 physiological effects aponeurosis 10 alpha motoneuron excitability 27–8 fascia 13 circulatory system 24–7 ligaments 13 musculoskeletal system 30–2 tendons 10 nervous system 27 tone 14 pain 28–30 musculoskeletal system preparation see preparation anatomical position 14, 15, 16 psychological effects 32–6 nerve impingement 14 standing positions 60, 61 physiological effects of massage 30–2 vulnerable patients 37 skeleton 8–10 Western forms 3–4 trigger points 14 massage manipulations 67 see also muscles beating 80 myofascial release (MFR) 144, 190–1 clapping see clapping barriers to effectiveness 191 effleurage see effleurage contraindications 193 frictions see frictions evidence of effectiveness in clinical practice 195–6 hacking see hacking fascial matrix 190 kneading see kneading future implications 196 muscle shaking see muscle shaking gel-to-sol model 194 petrissage see petrissage mind and feelings 193–4 picking up see picking up neural-mechanoreceptor model 194 pounding 80–1 palpation 191–2 rolling see rolling piezo-electric model 194–5 sports massage see sports massage responsive biomechanical model 194 stroking see stroking sustained stretch techniques 193 tapôtement see tapôtement techniques 193 tapping see tapping tissue responses 196 vibrations see vibrations trauma release model 195 wringing see wringing myofascial trigger points 14 McMillan, Mary 4 myogenic problems 47–8 mechanopostural defects 134 mental health 134 nails 7 motor neurone excitability 27–8 neck massage muscle energy technique (MET) 144 muscle rolling 76–7 clapping 118 back massage 111–12 effleurage 116 hacking 118 kneading 116–17

204 Index lower limb calf 102 lying 115 double-handed, simultaneous 101 muscle rolling 118 single-handed to double-handed alternate 101 picking up 117–18 thigh 100–1 sitting 115–16 nerve impingement 14 neck massage 117–18 nerve tissue 53–4 upper limb 88 nervous system CNS 14 biceps 89 entrainment 17 brachioradialis 89–90 neuro-endocrine mechanism 17 deltoid 88–9 physiological effects of massage 27 forearm flexors 89 PNS 14, 17 triceps 89 structure 17 piezo-electricity 8 neuro-endocrine mechanisms 17 myofascial release 194–5 neurogenic problems 48 pin and stretch 145 neurological conditions 135 plasma 17 neuromuscular massage 170 platysma 123–4 neuromuscular-skeletal conditions 134 plucking 121–2 neuromuscular therapy 145 PNF (proprioceptive neuromuscular facilitation) observation see assessment 145–6 occipitofrontalis 123 PNS (peripheral nervous system) 14, 17 occupational stress 131–2 polarity therapy 145 oedema 54, 137 positional release 145 oils 63 post natal massage 132 oriental medicine 180 pounding 80–1 powder 63 see also Chinese medicine pre-natal massage 132 osteogenic problems 48 pregnancy 132 pain 28–30, 54, 136, 171 aromatherapy 172 palmar kneading 70 contraindications 175 preparation lower limb 99 contact mediums 63–4 palpation environment 63 examination 45–6, 66 abdomen 125–6 hand exercises 62 descriptors 50, 51 palpation and sensory awareness 65–6 myofascial release 191–2 patient 64 sensory awareness 65–6 relaxation 62–3 skill 58–9 self preparation 60, 61 see also assessment proprioceptive neuromuscular facilitation (PNF) 145–6 patella 98 psychogenic problems 49 percussion see tapôtement see also anxiety; depression; stress periostial massage 145 psychological wellbeing 32–6 peripheral nervous system (PNS) 14, 17 sports massage 154, 155, 158 peroneal muscles 99, 100, 105 pulmonary problems 48–9 petrissage 69 kneading see kneading Qi 149, 180 muscle shaking see muscle shaking see also Ki picking up see picking up rolling see rolling recent fractures 54 wringing see wringing reconstructive surgery 137 physical disabilities 134–5 reflexes 13 picking up 73–4 reflexology 147 gluteal region 114

relaxed hand contact 62–3 Index 205 repetitive strain injury (RSI) 131 respiratory conditions 136–7 dermal-epidermal junction 7 respiratory system 20–1 dermis (corium) 7 Rolfing 147 disorders 54 rolling epidermis 6–7 fluid balances 8 abdominal massage 128 function 5–6 muscle rolling 76–7 hair 7 nails 7 upper limb 91 piezo-electricity 8 skin rolling 75–6 sebaceous glands 8 subcutaneous adipose layer (superficial fascia/ back massage 110 knee 103 hypodermis) 7 Ross, Araminta 3 sweat glands (sudoriferous glands) 7–8 skin rolling 75–6 sacrospinalis 110, 111 back massage 110 scalp massage 124 knee 103 skin wringing: abdomen 128 patient preparation 119 sleep scapula 110 aromatherapy 172 scar tissue soap and water 64 SOAP notes 56–8 assessment 51–2 sociogenic-socieconomic problems 49 benefits of massage 24 soft tissue release (STR) 147 desensitisation 137 soreness 54 hypertrophic scars 137 specific soft tissue mobilisations (SSTMs) 59, 147–8 tethering 137 specific stretch 148 sebaceous glands 8 sports massage 148, 151, 153, 159 segment massage 147 acupressure 152–3 self-massage 183–7 aims of treatment 151 self preparation 60, 61 case study 161–2 shiatsu 4, 147, 179 clean up 152 applying pressure 187–8 conditioning 153–4 cautions 183 contact materials 154, 156, 157, 158, 159 clinical indications 182 contraindications 151, 154, 155, 156, 157, 158, contraindications 183 diagnostic methods 180–1 159, 160 do-in 188 depth 152 glossary 188–9 diagnosis 151 history 179–80 duration 154, 155, 156, 157, 158, 159, 160 makkho-ho 188 full body massage 159–60 oriental medicine 180 history taking 151 physiological effects 183 ice massage 153 principles and techniques 181–2 inter-competition 156–7 professional development 188 joint position 152 self-massage 183–7 materials 152 theory 181 position 151 tsubos 179, 184, 187–8 post-competition 157–8 shoulder 83–4 post-travel 158–9 sinuses 123 pre-competition 155–6 skeleton 8–10 psychological effect 154, 155, 158 skin skin preparation 152 assessment 50–1 specific areas of massage 160 sport specific 160 sports massage 152 treatment for injuries 154–5 ceruminous glands 8 connective tissues 8

206 Index triceps 85, 86, 89, 90, 91 trigeminal nerve 122 trigger pointing 153 trigger point release 149 warm-up and 152, 156 standing positions 60, 61 sports massage 153 stress 20, 130–1 trigger points 14 occupational 131–2 Tuina 4, 149 stroking 68–9 tumours 54 abdomen 127 scalp 124 upper limb disorders 131 see also effleurage upper limb massage 82 structural integration 147 subcutaneous adipose layer 7 clapping 91–2 sudoriferous glands 7–8 effleurage superficial fascia 7 surgery 134–5 part strokes 83–5 reconstructive 137 whole limb 83 sweat glands 7–8 elevating the arm 82–3 Swedish massage 3–4, 143, 148 hacking 91–2 swellings 55 kneading 85 double-handed alternate kneading 85–6 tapôtement 78–9 finger kneading 87 beating 80 single-handed kneading 86–7 clapping see clapping thumb kneading 87–8 hacking see hacking muscle rolling 91 pounding 80–1 muscle shaking 91 tapping see tapping picking up 88 vibrations see vibrations biceps 89 brachioradialis 89–90 Tappen, Francis 4 deltoid 88–9 tapping 81 forearm flexors 89 triceps 89 facial massage 122 preparation of patient 82–3 Taylor, Charles and George 4 sitting position 82 tendocalcaneous 102 wringing 90–1 tendons 10 vibrational therapy (VT) 149–50 assessment 53 vibrations 80 Thai massage 148 therapeutic touch 148 abdominal massage 126 thigh 96, 97, 100–1, 102–3, 104 facial massage 122–3 thixotrophy 194 scalp 124 thoracolumbar region see back massage viscerogenic problems 48–9 thumb kneading 71–2 vulnerable patients 37 lower limb 98, 99–100 walk standing 61 upper limb 87–8 water-based lubricants 64 tibial muscles 99, 105 work-related upper limb disorders (WRULDs) 131 ticklish subjects 66 wringing 74–5 toes 96, 100 Trager 148–9 abdominal massage 128 transverse frictions 77–8 back massage 111 trapezius 117, 118 facial massage 121, 122 trauma 134–5 gluteal region 114 trauma release 195 lower limb 102, 103 transcadence massage 149 upper limb 90–1 transverse colon 127 treatment couch 63, 93, 106 zero balancing 150 treatment planning 45