Massage Flashcards
General Effects of Massage: Cardiovascular System
Circulation
- Dilation of superficial vessels via local reflexes
- Increase in stroke volume via promotion of venous return (for some pt’s. this may not be good because the heart would be able to handle the increased blood volume).
- Decrease incidence of DVT via decrease in blood viscosity and hematocrit.
Edema
- Increases lymph flow via mechanical pressure.
Massage has 3 effects
- Psychological
- Physiological
- Mechanical
General Effects of Massage: Connective Tissue
Decreases pain and improves tissue mobility (Mechanical)
Cyriax Friction (for injury only)
- Traumatic hyperemia
- Prevents/Disrupts adhesion
- Temporary analgesia
General Effects of Massage: Muscle Tissue & Nervous System
Muscle Tissue
- Decreases muscle spasm
- Decreases muscle hypertension
- Increases muscle extensibility
Nervous System
- Decreases pain, possibly via the Gate Theory of Pain and via an increase an opiate production.
Indication for Massage
Pain Edema Muscle Spasms Trigger Points Inefficiencies of Circulation Contracted Tissue Specific or General Tension
Contraindication for Massage
For this course:
Severe Distress (severe pain, febrile state) Systemic Edema Acute Conditions (0-48 hrs, minimum) Over Recent Surgery Increased Circulation is not Desired Contagious Skin Conditions Over Foreign Bodies or Sharp Bony Prominence Over Areas of Active Bone Growth Over Areas of Decreased Sensation Tuberculosis Diagnosis Over the Pregnant Abdomen
What is the Role of Touch (How Does Touch Effect)
Interaction is both physical and physiological (gets the pt. used to you and visa versa)
Helps you identify the pt’s. state
Touch can communicate your state of being
How are your hands? (how do they feel)
How are your hands?
Always wash your hands before and after a treatment (H2O and Soap).
Hot Water, 15+ seconds.
Hands warm and dry prior to touching the pt.
Always consider short finger nails and rings.
Positioning of the Patient
Support should be given to natural joint curvatures.
Pt. Limbs should be elevated to allow gravity to assist (when possible) with circulation.
Patient should not be holding /supporting any part of themselves
Above all else, the pt. should be comfortable.
Draping
You want to expose the area that you will be treating.
Parts not treated should be covered by a towel or a sheet.
Draping should be tight.
The Drape Line - The line of the drape you DO NOT cross.
Massage Media (lotion/creams)
The purpose for massage media is to avoid uncomfortable friction between the clinicians hands and the pt’s skin.
It is best if it is unscented, hypo allergenic.
Avoid lotions: Many absorb too quickly into the skin requiring repeated pauses/interruptions to the massage.
Positioning the Therapist
Always monitor your own body mechanics.
Shift your weight.
When possible, face the pt. when performing massage (this allows you to monitor non-verbal cues, and gives them more assurance if they can see you and what you are doing).
Where should the table be for the Therapist?
The table height is usually between the therapist’s wrist and the ends of the fingers.
This may vary though; therapist may need to use a step.
Effleurage Massage
A rhythmic, consistent, stroking
This can be superficial or deep.
Superficial effects - reflex effect and is calming.
Deep effects - reflex and mechanical effect
Effleurage also helps with:
Information gathering
Calming/Focusing
Warming of superficial tissues (skin and fascia).
Petrissage and Compression
This is intermittent Kneading
This can be done unilaterally, bilaterally, or digitally (by the therapist)
Petrissage helps to:
Increase circulation
Softens and lengthens tissue
Friction Massage
This type of massage is sustained pressure with movement.
Friction massage may be done linear, cross fiber and circular.
Cyriax Cross Fiber is a particular technique.
Jostling
Is a rhythmic shaking of tissue or a limb.
This helps to:
Decrease muscle guarding.
Helps the pt. to relax.
Percussion/Tapotement
This includes: Hacking* Slapping* Cupping* Gorilla Punching* Beating Punching
Direct Pressure (Type of Massage)
This is a sustained pressure without movement. (One point)
Myofacial Release
Look Up
Trigger Point Technique
Look Up
Principles Regarding Massage Strokes (Consider?)
Direction - linear, cross fibers, digital, proximal (Always distal to proximal or end that way, towards the direction of the heart).
Duration - Take adequate time to achieve goal
Pressure - this varies based on intent, body region, pathology and pt. tolerance.
Rate & Rhythm - This should be purposeful and consistent (like massage should)
Principles regarding Stokes
Work broad and light - specific and deep
Mold your hands to the pt’s body.
Deep pressure: always distal to proximal
Address the entire length of the muscle of interest.
Minimize interruptions (lifting hands, stopping abruptly, taking phone calls etc)
Pain
Massage helps painful musculoskeletal conditions
Massage may be potentially beneficial for:
Back pain
General orthopedic conditions
Post-operative conditions
Fibromyalgia
Degenerative joint conditions
Edema
Edema is swelling caused by an increase in fluid in the interstitial, intra-articular, or intracellular space.
Massage is proposed as a treatment for helping to reduce edema caused by injury, illness or surgery.
Types of Edema
Local: Edema is confined to an area ex. ligament sprain
Systemic Edema: Occurs throughout the body ex. Congestive Heart Failure
Lymphedema: Edema resulting from compromise of lymphatic system ex. Removal of cancerous lymph nodes
The Lymphatic System
The lymph system is comprised of: Lymph fluid/Interstitial fluid Lymph Nodes Lymph Ducts Associated lymph tissues, capillaries and vessels that produce and transport lymph fluid
Tissues –> Circulatory system
Functions of the Lymphatic System
- Remove excess fluids from tissues
- Absorption of fatty acids and subsequent transport of fat to the circulatory system.
- Production of immune cells
Side note: There are no pumps in the lymphatic system. Lymphatic fluid is moved by muscular contraction (body movements) through one way valves.
Lymphatic System: Lymphedema
Lymphedema is an accumulation of high-protein fluid that can collect in any body part, but most typically in arms or legs. It usually occurs when the lymph vessels or lymph nodes are blocked or removed.
There is two types:
Primary Lymphedema
Secondary Lymphedema
Primary Lyphedema
This is rare and congenital. Caused by poor development of lymph vessels. Ex. Milroy’s Disease.
Massage is not indicated for primary lymphedema.
Secondary Lymphedema
This is caused by damage to lymph vessels or nodes. May result from surgery, radiation or infection.
Lymphedema Massage or Manual Lymphatic Drainage
This is a form of massage utilizing light pressure (30-40 mmHg) and brush like strokes to encourage the movement of lymph through lymphatic vessels and lymph nodes
Contracted Tissue and Massage
After injury or surgery, adhesions may develop.
Specific techniques may help to prevent or release adhesions ex. Scar Tissue
After neurological injury, muscle tonicity may change.
Massage helps to lengthen muscles.
Muscle Spasms
Muscle spasms are involuntary contractions due to inflammation and irritation. Often to protect the body.
Massage and Muscle Spasms
Massage helps to relax muscle spasms by helping local blood flow which then reduces pain associated with spasm.
Massage can also help to break the pain-spasm cycle.
Trigger Points
TrP definition from Travell and Simons (1983)
“…a focus of irritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive gives rise to referred pain and tenderness, and sometimes are referred to autonomic phenomena and distortion of proprioception.”
TrPs “feel” like taut bands and are tender when palpated.
Relaxation
Relaxation is a nice side effect which can enable us to carry out other treatments.
When Increased Circulation is not Desired (Contraindication)
Since massage increases circulation there are instances when we dont want to do that such as:
Systemic Edema: Occurs throughout the body. ex. Congestive Heart Failure. The pt’s heart cannot take the increased blood volume.
Primary Lyphedema: Edema resulting from compromise of lymphatic system.
Infections: infections may be spread by blood or pymph ex: osteomyelitis (bone), septic arthritis, dermatitis, cellulities, myositis.
Deep Vein Thrombosis: Mechanical stimulation can break off a thrombus (symptoms of DVT, redness, temperature, redness, painful upon palpation).
Severe Distress (Contraindication)
Do not perform massage when the patient is in severe distress or febrile condition.
When the pt. feels physically ill or nauseated
Is in severe pain
Has a fever -> systemic problem occuring
Skin Conditions (Contraindication)
Avoid massage in areas where a condition may be contagious or worsen or spread by applying pressure or rubbing.
Rashes Boils
Athlete’s foot Ringworm
Alleregies (certain oils or lotions, pts. are often aware of their alleregies, double check).
Skin Conditions (Contraindication)
Impetigo
Cellulitis
Dermatitis
Over Foreign Bodies or Sharp Bony Prominence’s (Contraindication)
Massage can shear and compress tissues
Massaging over foreign bodies (nails, screws, shrapnel) or over sharp bony prominence’s may lead to tissue damage.
(Screws or metal, always go around the area or over superficially).
Massage Too Soon: Acute Conditions (Contraindication)
Massage damaged or leaking blood vessels will increase bleeding.
-should wait a minimum of 48 hours after acute episode.
(its okay to work above the site though)
Massage too early in the healing process will damage the delicate cellular and fibrous network, possibly delaying healing.
Avoid massaging conditions in the “itis” ex.)
Appendisitis - may spread inflammation through abdomen.
Rheumatoid Arthritis - avoid over acutely inflammed joints, use caution when not acute.
Plebitis - vein inflammation, completely avoid site (usually the legs) and distal to site.
Areas of Decreased Sensation (Contraindication)
Pts. can not give proper feedback. If they cannot give proper feedback you could be further injuring the pt.
ex. Stroke, diabetes, spinal cord injury, frostbite.
Over Recent Surgery or Loss of Structural Integrity (Contraindication)
Over Recent Surgery: Must know your MD’s protocol, special care taken with scar massage techniques. (also depends on the type of surgery)
Skin Grafts: Tissue may not accommodate shearing forces.
Over Areas of Active Bone Growth
Healing Fracture Sites
Myositis Ossificans
Osgood-Schlatter Disease
Tuberculosis (Contraindication)
Highly contagious bacterial infection that usually begins in the lungs.
Massage can spread it to:
Lymph nodes
Kidneys
Bones
Active Symptoms include: Coughing Blood in sputum Fatigue Weight loss Night sweats
The goal is to avoid disturbing or spreading the infection.
Pregnancy (Contraindication)
- Contraindications include increased blood volume
- Increased DVT risk
- Increased soft tissue laxity
- Positioning considerations for comfort and circulation
- Increased training needed to perform massage over the abdomen
Precautions
May need to reduce pressure, avoid certain regions or perform a shorter massage.
-Continually monitor patient for negative side effects.
Hematoma - May be able to help with re absorption, but do not perform too early
Non-Union Fracture
Herniated Disc
Debilitated Pts. - Children, elderly, fragile skin
Malignancies - Pallative Care
Conditions w/ collagen weakening - long term use of steroids, diabetes or advanced RA
Friction Massage
Is a non-gliding technique where contact is not superficial.
Friction massage is always applied with specificity.
Types of Friction Massage
Cross Fiber Friction
Circular Friction
Linear/Parallel Friction
Cryiax Friction
Tools:
Finger tips, thumb pad, pain, forearm, or elbow
Friction Massage: Inteneded Purpose
To mobilize adherent tissue/Reduce scar tissue
Reduce/mobilize Trigger Points
Increase Local Circulation
Decrease Paina
Cross Fiber
Depp friction applied perpendicular to the direction of the fibers.
Parallel
Deep Friction applied in the same direction as the fibers.
Circular
Repeated circular motion, distal to proximal considered.
Deep Transverse Friction Massage (DTFM)
Also known as Cyriax Friction is a technique popularized by Dr. James Cyriax for pain and inflammation relief in musculoskeletal conditions
Deep Transverse Friction Massage (Continued)
This technique attempts to reduce abnormal fibrous adhesions and make scar tissue more mobile in sub-acute and chronic inflammatory stages by realigning normal soft tissue fibers.
It has been proposed that DTFM also enhances normal healing conditions by preventing abnormal scarring.
Effects of Deep Transverse Friction Massage
Mechanical
- Mobilization
- Elongation of tissue fibers
Physiological
-Localized Hyperemia
Histological
- Prevents or slows scar formation
- Stimulates collagen orientation along lines of stress
Neurological
-Pain inhibition via stimulation of mechanoreceptors
Indications for Deep Transverse Friction Massage
Promote healing of connective and contractile tissue.
To retain or regain mobility.
Pain modulation.
Contraindications for Deep Transverse Friction Massage
Acute inflammation
Hematoma
Conditions that increase bleeding
- Hemophilia
- Pts. on anti-coagulants
- Pts. on steroids
Debilitated/Open Skin
Positioning For DTFM
Muscles supported in a position of relaxation or reduced muscle tone.
Tendons: position of tension.
Ligaments: taunt, as far as the ROM allows.
DTFM Treatment Protocol
Initial treatment: 5 to 6 minutes
The 1st one to two minutes the patient may feel mild to moderate tenderness, within two minutes the pain should subside considerably.
Once pain subsides, gradually increase the pressure; check every 1-2 minutes
Increased by 3 minutes each session, 12 to 15 minute max (others recommend 10 to 20 min max)
Wait 48 hours between treatment sessions.
Trigger Points Definition
Tender area in a muscle and its fascia
Can cause referred pain - referral patterns are different than nerves (they don’t usually make sense)
Upon palpation, feels like a taut band with a nodule.
Techniques to Treat Trigger Points
Ice Massage Digitil or ischemic Compression PNF TPPR
Characteristics of Trigger Points
Consistent referred pain pattern upon compression of the TrP.
Local twitch response elicited by palpation (or by kneading).
Possible Restricted ROM.
Muscle weakness with no appreciable atrophy
Possible autonomic phenomena including vasomotor and pilomotor responses.
Active Trigger Points
Always tender, produce referred pain.
Associated muscle may be weak and present with decreased motion/flexibility
When palpated, present with a localized twitch response (an involuntary contraction)
Latent Trigger Point
Painful only when palpated
Potential TrP Causes
Acute conditions
-Fractures, sprains, dislocations, muscle impact injuries.
Stress from excessive or unusual exercise
Articular Dysfunctions
Overload on the muscle from prolonged stationary posture or prolonged muscle immobilization in a shortened position.
Nerve Compressions
Motor End Plate Hypothesis
Dysfunction (presynaptic, synaptic or postsynaptic) may be acquired or genetic.
Leads to continued release of Ach
Causing spontaneous electrical activity or muscle contraction.
Trigger Point Pressure Realease
Gentle digital pressure; aim to reduce ischemic effect to the injured tissue
One Finger palpating the TrP while the muscle is passively lengthened to the point of tissue resistance.
At tissue resistance, pressure on the TrP is slowly increased.
Digital Compression TrP
Should be applied to tone point for a prolonged period (10-45) seconds) and pressure released with resolution of pain.
Suggested Treatment Approach
- Perform effleurage/petrissage techniques to “warm” the tissues.
- Digital Compression
- Follow compression techniques with effleurage/petrissage techniques to “move out metabolic waste”.
- Either manual stretch or instruct the pt. to stretch the involved tissue.
Hypothesis for Compression
Pressure and stretching help to restore contracted sarcomeres to normal resting length.
Mechanical pressure helps to separate myosin and actin.
