MASSAGE THERAPY

MASSAGE THERAPY

Various forms of massage, traction, and manipulation have been used in medicine throughout the world for several thousand years. Each modality represents an approach to treatment of the musculoskeletal and other systems sought by a steadily increasing number of people. 

While there is no consensus on the complete physiology of massage, traction, or manipulation, it is generally accepted that there is more to these treatment approaches than just the interaction of mechanical forces and human anatomy.  There is a long history of touch as a natural, essential component to healing and health maintenance.

Throughout history, massage has been woven into the cultural context of medicine. Massage may be the earliest and most primitive tool to treat pain.

Massage consists of Eastern and Western variants. In the West, the practice and popularity of massage has varied over time. In recent years, a previous decline in popularity of massage, probably related to technological advancements in medicine, has been reversed into a resurgence of interest.

         The American people are pursuing massage in increasing numbers for various reasons (eg, relief of pain, relaxation, and conditioning). While little doubt exists that massage is beneficial for certain conditions, additional research is needed to establish its profile of efficacy.

BASIC MASSAGE CONCEPTS

Massage is a therapeutic manipulation of the soft tissues of the body with the goal of achieving normalization of those tissues.

Massage can have mechanical, neurological, psychological, and reflexive effects.

Massage can be used to reduce pain or adhesions, promote sedation, mobilize fluids, increase muscular relaxation, and facilitate vasodilation. Massage easily can be a preliminary treatment to manipulation; however, it clearly targets the health of soft tissues, while manipulation largely targets joint segments.

Massage consists primarily of hand movements, some of which may be traction based. Traction is defined as the act of drawing or pulling or as the application of a pulling force. Traction sometimes involves equipment but also can be applied manually.

In addition, traction affects changes in the spinal column itself, with soft tissues only secondarily changed. Effects of massage, like those of traction, tend to be fairly nonspecific.

                     TYPES OF MASSAGE 

WESTERN MASSAGE

Western massage is the chief type of massage practiced in the United States today. Among the most common types of massage therapy are acupressure (Shiatsu), Rolfing, Swedish massage, reflexology, and myofascial release. 

Western massage organizes variations of soft-tissue manual therapy into several categories. Pare of France introduced the basic terminology for Western massage to the United States. The essence of Western massage is use of the hands to apply mechanical forces to the skeletal muscles and skin, although the intent may be to affect either the more superficial tissues or the deeper ones.

     Types of basic Western massage are characterized by whether

1)     The focus of pressure is moved by the hands gliding over the skin (ie, effleurage),

2)     Soft tissue is compressed between the hands or fingers and thumb (ie, pétrissage),

3)     The skin or muscle is impacted with repetitive, compressive blows (ie, tapotement), or

4)     (Shearing stresses are created at tissue interfaces below the skin (ie, deep friction massage).

 FORMS OF WESTERN MASSAGE

• EFFLEURAGE

  • In this approach, the practitioner's hands glide across the skin overlying the skeletal muscle being treated.

  • Oil or powder is incorporated to reduce friction; hand-to-skin contact is maintained throughout the massage strokes.

  • Effleurage can be superficial or deep.

  • Light strokes energize cutaneous receptors and act by neuroreflexive or vascular reflexive mechanisms, whereas deep stroke techniques mechanically mobilize fluids in the deeper soft-tissue structures.

  • Deep stroking massage is performed in the direction of venous or lymphatic flow, whereas light stroking can be in any direction desired.

  • Effleurage may be used to gain initial relaxation and patient confidence, occasionally to diagnose muscle spasm and tightness, and to provide contact of the practitioner's hands from one area of the body to another.

  • The main mechanical effect of effleurage is to apply sequential pressure over contiguous soft tissues so that fluid is displaced ahead of the hands as tissue compression is accomplished.

• PÉTRISSAGE

  • Pétrissage involves compression of underlying skin and muscle between the fingers and thumb of 1 hand or between the 2 hands.

  • Tissue is squeezed gently as the hands move in a circular motion perpendicular to the direction of compression.

  • The main mechanical effects are compression and subsequent release of soft tissues, reactive blood flow, and neuroreflexive response to flow.

  • Lymphatic pump is a type of pétrissage done to the chest and rib cage of persons with respiratory compromise in order to draw lymph into the thoracic duct and venous circulation as a result of an alternating increase and decrease of pressure on the chest cavity.

• TAPOTEMENT

  • This percussion-oriented massage involves striking soft tissue with repetitive blows, using both hands in a rhythmic, gentle, and rapid fashion.

  • Numerous variations can be defined by the part of the hands making an impact with the body.

  • The therapeutic effect of tapotement may result from compression of trapped air that occurs on impact.

  • The overall effect of tapotement may be stimulatory; therefore, healthy persons with increased tolerance for this approach are more likely to find this type of massage useful.

• DEEP FRICTION

  • Pressure is applied with the ball of the practitioner's thumb or fingers to the patient's skin and muscle.

  • The main effect of deep friction massage is to apply shear forces to underlying tissues, particularly at the interface between 2 tissue types (eg, dermis-fascia, fascia-muscle, muscle-bone).

  • Deep pressure keeps superficial tissues from shearing so that shear and force are directed at the deeper tissue surface interface.

  • Deep friction massage frequently is used to prevent or slow adhesions of scar tissue

 EASTERN MASSAGE 

                            Over the centuries, Eastern massage systems has been an integral part of the cultures where they are practiced. Systems for evaluation, diagnosis, and treatment generally are not grounded in conventional Western neurophysiology.

Eastern massage includes, among other approaches, Shiatsu, a Japanese system based on traditional Chinese meridian theory with principles of Western science.

The theory of Shiatsu is based upon the system of the 12 traditional Chinese meridians (ie, major channels) of the body in which the energy, life force, or Chi, circulates.

Acupressure pressure points, situated along the course of channels, allow access to these channels. Acupressure applies massage forces, largely through digital pressure, to the same points treated with acupuncture needles.

        Imbalances of energy along the meridians are believed to cause disease and can be rectified by localized finger pressure.

REFLEXOLOGY AND AURICULOTHERAPY

• These systems of massage share the meridian concept with Shiatsu.

• In these approaches, the meridians are believed to have whole body representations on the extremities (similar to the homunculus of the brain).

• The feet (in reflexology) and the ear (in Auriculotherapy) have been mapped in detail.

DECONGESTIVE LYMPHATIC THERAPY

Decongestive lymphatic therapy is the complex massage approach that includes manual lymphatic drainage (MLD) in addition to compressive bandages, exercises, and skin care.

Manual lymphatic drainage consists of gentle massage in the treatment of lymphedema. Proximal areas are treated first to prevent a damming effect; the treatment is thought to stretch the lymphatic collectors and to stimulate the drainage system.

The massage is followed by the application of compressive bandages and is incorporated into a complete self-care program.

MASSAGE TECHNIQUE

             The practitioner controls several variables of massage, including milieu. Actual application of treatment includes rhythm, rate, pressure, direction, and duration.

Most massage approaches involve a friction-reducing medium, so that the hands of the practitioner move along the patient's skin with minimal friction. Powders or oils often are used.

Massage strokes also should be regular and cyclic. The rate of application for massage varies with the type of technique. In some approaches (eg, tapotement, percussion), the rate is several times per second, while in others it is much slower.

The amount of pressure depends upon technique and desired results. Light pressure may produce relaxation and relative sedation and may decrease spasm; breakdown of adhesions and intervention at a deeper tissue level may require heavier pressure.

Treatment of edema and stretching of connective tissue generally requires intermediate amounts of pressure. Direction of massage often is centripetal to provide better mobilization of fluids toward the central circulation. The sequence of tissues treated often is performed in a centripetal fashion.

When muscles are treated, motions generally are kept parallel to muscle fibers. If the treatment goal is to reduce adhesions, shearing forces are circular or at least include cross-fiber components. The area to be treated with massage depends upon the condition being treated and may vary from a well-circumscribed area to treatment of contiguous areas.

Duration of treatment depends upon the area being treated, desired therapeutic goals, and patient tolerance. Wide variation exists regarding treatment duration, which often is guided by changes occurring to tissue during massage application. If massage is performed before other treatments, duration may be determined by the result needed in order to optimize the next treatment step.

Duration of a massage therapy program can range from 1 week to months and depends upon verifiable therapeutic goals. Patients must be reexamined from time to time, depending upon diagnosis and therapeutic goals, to insure satisfactory progress.

PHYSIOLOGIC EFFECTS OF MASSAGE

Massage produces some mechanical effects on the body. Mechanical pressure on soft tissue displaces fluids. Fluid moves in the direction of lower resistance under the static forces of the practitioner's hands, but a moving locus of pressure creates a pressure gradient.

Assuming no significant resistance, pressure is lower proximal to the practitioner's advancing hand. Once mobilized fluid leaves the soft tissues, it enters the venous or lymphatic low-pressure systems. The amount of fluid mobilized in any single treatment is likely to be quite small; however, the physiatrist needs to be aware of this physiologic effect in patients with significantly compromised cardiovascular or renal function.

When treating lymphedema, massage is performed more proximally and then moves distally, based upon the premise that proximal blockage in the lymph channels must be opened first to allow for subsequent distal mobilization of fluid and protein.

Kneading and stroking massage decreases edema; compression converts nonpitting to pitting edema. In addition to strictly mechanical effects, these massage approaches release histamine, causing superficial vasodilation to assist in washing out metabolic waste products. Venous return increases, which subsequently increases stroke volume.

Some evidence suggests that massage increases blood flow contralaterally; however, the mechanism of this postulated action has not been well established.

These effects on mobilization of fluids are more important in flaccid or inactivated limbs, because normal compression supplied by skeletal muscle contraction usually is not present in those cases.

Studies suggest that massage may decrease blood viscosity and hematocrit and increase circulating fibrinolytic compounds. Preliminary data suggest an explanation for the success of massage in decreasing deep vein thrombosis (DVT). Massage may be contraindicated in the presence of existing thrombosis.

Other blood compounds that show massage-related increases include myoglobin, creatinekinase, lactate dehydrogenase, and glutamicoxaloacetictransaminase. Temporary increases in these substances represent local muscle cell leakage from applied pressure.

Lactate decreases in massaged muscles as well.

Massage may decrease muscle spasm and increase force of contraction of skeletal muscle. Decreased spasm and increased endurance may result from wash out of metabolic waste products by fluid mobilization and increased blood flow.

Decreased muscle soreness probably results from metabolic wash out.

REFLEXIVE CHANGES

Massage can stimulate cutaneous receptors, spindle receptors, and superficial skeletal muscle as well. These structures produce impulses that reach the spinal cord, producing various effects, including moderation of the facilitated segment. Somatovisceral reflex changes to the viscera are possible in this model.

PSYCHOLOGICAL EFFECTS OF MASSAGE

Massage generally increases feelings of relaxation and well-being in patients. Whether this is from placebo effect or the result of some previously undiscovered reflex is not fully understood.  Practitioners often incorporate a variety of psychophysical techniques, such as guided imagery, into massage treatment. 

A prospective, nonrandomized trial of massage therapy at a major US cancer center sought to examine massage therapy outcome in a large group of patients.  Over a 3-year period, 1290 patients were treated with regular ("Swedish"), light touch, or foot massage, based on the request of the patient. 

The patients filled out symptom cards before and after a 20-minute (average) massage session. Symptom scores were reduced by approximately 50%, with outpatients demonstrating about 10% greater benefit than did inpatients. Anxiety, nausea, depression and pain demonstrated the greatest improvement in symptom score.

Several studies have investigated the role and potential benefits of massage during pregnancy.  A study by Field and colleagues found such a benefit not only in the recipient of the massage, but also in the patient's spouse. 

In this study, self-reported leg pain, back pain, depression, anxiety, and anger were reduced to a greater extent in pregnant women who underwent massage than in women in the control group.

In addition, the women's partners, who performed the massages, reported feeling less depression, anxiety, and anger over the course of the massage therapy period than did partners in the control group. Moreover, the pregnant women and their partners showed improved scores on a relationship questionnaire.  

THERAPEUTIC GOALS & INDICATIONS - MASSAGE THERAPY

Massage may be used as primary therapeutic intervention or as an adjunct to other therapeutic techniques. Uses can include, but are not limited to,

1)     Mobilization of intertissue fluids,

2)     Reduction or modification of edema,

3)     Increase of local blood flow,

4)     Decrease of muscle soreness and stiffness,

5)     Moderation of pain,

6)     Facilitation of relaxation, and

7)     Prevention or elimination of adhesions. Massage may be used to alter pathophysiology of a primary condition (eg, contracture) or to prevent or modify deleterious effects of a previously used treatment modality.

Many studies have focused on the utility of massage to treat low back pain. The authors of one literature review concluded that strong evidence exists for the efficacy of massage in relieving chronic, nonspecific low back pain; they also found "moderate evidence that massage provides short- and longer-term follow-up relief of symptoms." 

Moreover, the authors determined there to be "moderate evidence that acupressure may be better than Swedish massage" for chronic low back pain, "especially if combined with exercise."

Hospitalized patients who receive massage express improvements in mood, body image, self-esteem, and perceived levels of anxiety. This phenomenon is facilitated by reduction in physical symptoms and distress and may be accompanied by decreased tension, anxiety, and pain perception.

Another therapeutic effect derived from massage is muscle relaxation. Massage appears to reduce tone and enhance circulation to the area. Muscle relaxation also may result from increased sensory stimulation caused directly by massage. This increased sensory input to the spinal cord may result in changes in reflex pathways, leading to central modulatory decreases of muscle tone.

Other effects of massage are enkephalin release, endorphin production, promotion or absorption of fibrous tissue, restoration of connective tissue pliability, improvement of lymphatic flow (in some studies, up to 7-9 times), and increased levels of natural killer (NK) cells. 

Tanabe and Nakayama provided data that suggest that mechanical stimuli, such as massage, to adipocytes may inhibit expression of adipogenic transcription factor peroxisome proliferator-activated receptor, which is independent of systemic energy consumption. They postulate that such stimuli can assist in reducing the body's fat stores, and may help to decrease obesity.

CONTRAINDICATIONS FOR MASSAGE

Massage is contraindicated when it could cause worsening of a particular condition, unwanted tissue destruction, or spread of disease.

Malignancy, thrombi, atherosclerotic plaques, and infected tissue could be spread by massage.

               Absolute contraindications to massage include  

1)     DVT, because increased blood flow in a limb could cause a thrombus to detach from the vessel wall, creating an embolism;

2)     Acute infection;

3)     Bleeding; and

4)     A new open wound.

              Relative contraindications include    

1)     Incompletely healed scar tissue,

2)     Fragile skin,

3)     Calcified soft tissue,

4)     Skin grafts,

5)     Atrophic skin,

6)     Inflamed tissue,

7)     Malignancy,

8)     Inflammatory muscle disease, and

9)     Pregnancy.

The physiatrist should be aware that massage must be used very carefully in chronic pain patients.