Massage

Question 1

General Effects of Massage: Cardiovascular System

Answer 1

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.

Question 2

Massage has 3 effects

Answer 2

1. Psychological
2. Physiological
3. Mechanical

Question 3

General Effects of Massage: Connective Tissue

Answer 3

Decreases pain and improves tissue mobility (Mechanical)

Cyriax Friction (for injury only)

• Traumatic hyperemia
• Prevents/Disrupts adhesion
• Temporary analgesia

Question 4

General Effects of Massage: Muscle Tissue & Nervous System

Answer 4

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.

Question 5

Indication for Massage

Answer 5

Pain
Edema
Muscle Spasms
Trigger Points
Inefficiencies of Circulation
Contracted Tissue
Specific or General Tension

Question 6

Contraindication for Massage

Answer 6

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

Question 7

What is the Role of Touch (How Does Touch Effect)

Answer 7

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)

Question 8

How are your hands?

Answer 8

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.

Question 9

Positioning of the Patient

Answer 9

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.

Question 10

Draping

Answer 10

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.

Question 11

Massage Media (lotion/creams)

Answer 11

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.

Question 12

Positioning the Therapist

Answer 12

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).

Question 13

Where should the table be for the Therapist?

Answer 13

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.

Question 14

Effleurage Massage

Answer 14

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).

Question 15

Petrissage and Compression

Answer 15

This is intermittent Kneading

This can be done unilaterally, bilaterally, or digitally (by the therapist)

Petrissage helps to:
Increase circulation
Softens and lengthens tissue

Question 16

Friction Massage

Answer 16

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.

Question 17

Jostling

Answer 17

Is a rhythmic shaking of tissue or a limb.

This helps to:
Decrease muscle guarding.
Helps the pt. to relax.

Question 18

Percussion/Tapotement

Answer 18

This includes:
Hacking*
Slapping*
Cupping*
Gorilla Punching*
Beating
Punching

Question 19

Direct Pressure (Type of Massage)

Answer 19

This is a sustained pressure without movement. (One point)

Question 20

Myofacial Release

Answer 20

Look Up

Question 21

Trigger Point Technique

Answer 21

Look Up

Question 22

Principles Regarding Massage Strokes (Consider?)

Answer 22

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)

Question 23

Principles regarding Stokes

Answer 23

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)

Question 24

Pain

Answer 24

Massage helps painful musculoskeletal conditions
Massage may be potentially beneficial for:
Back pain
General orthopedic conditions
Post-operative conditions
Fibromyalgia
Degenerative joint conditions

Question 25

Edema

Answer 25

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.

Question 26

Types of Edema

Answer 26

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

Question 27

The Lymphatic System

Answer 27

``` 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

Question 28

Functions of the Lymphatic System

Answer 28

1. Remove excess fluids from tissues 2. Absorption of fatty acids and subsequent transport of fat to the circulatory system. 3. 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.

Question 29

Lymphatic System: Lymphedema

Answer 29

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

Question 30

Primary Lyphedema

Answer 30

This is rare and congenital. Caused by poor development of lymph vessels. Ex. Milroy's Disease. Massage is not indicated for primary lymphedema.

Question 31

Secondary Lymphedema

Answer 31

This is caused by damage to lymph vessels or nodes. May result from surgery, radiation or infection.

Question 32

Lymphedema Massage or Manual Lymphatic Drainage

Answer 32

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

Question 33

Contracted Tissue and Massage

Answer 33

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.

Question 34

Muscle Spasms

Answer 34

Muscle spasms are involuntary contractions due to inflammation and irritation. Often to protect the body.

Question 35

Massage and Muscle Spasms

Answer 35

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.

Question 36

Trigger Points

Answer 36

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.

Question 37

Relaxation

Answer 37

Relaxation is a nice side effect which can enable us to carry out other treatments.

Question 38

When Increased Circulation is not Desired (Contraindication)

Answer 38

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).

Question 39

Severe Distress (Contraindication)

Answer 39

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

Question 40

Skin Conditions (Contraindication)

Answer 40

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).

Question 41

Skin Conditions (Contraindication)

Answer 41

Impetigo Cellulitis Dermatitis

Question 42

Over Foreign Bodies or Sharp Bony Prominence's (Contraindication)

Answer 42

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).

Question 43

Massage Too Soon: Acute Conditions (Contraindication)

Answer 43

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.

Question 44

Areas of Decreased Sensation (Contraindication)

Answer 44

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.

Question 45

Over Recent Surgery or Loss of Structural Integrity (Contraindication)

Answer 45

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.

Question 46

Over Areas of Active Bone Growth

Answer 46

Healing Fracture Sites Myositis Ossificans Osgood-Schlatter Disease

Question 47

Tuberculosis (Contraindication)

Answer 47

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.

Question 48

Pregnancy (Contraindication)

Answer 48

- 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

Question 49

Precautions

Answer 49

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

Question 50

Friction Massage

Answer 50

Is a non-gliding technique where contact is not superficial. Friction massage is always applied with specificity.

Question 51

Types of Friction Massage

Answer 51

Cross Fiber Friction Circular Friction Linear/Parallel Friction Cryiax Friction Tools: Finger tips, thumb pad, pain, forearm, or elbow

Question 52

Friction Massage: Inteneded Purpose

Answer 52

To mobilize adherent tissue/Reduce scar tissue Reduce/mobilize Trigger Points Increase Local Circulation Decrease Paina

Question 53

Cross Fiber

Answer 53

Depp friction applied perpendicular to the direction of the fibers.

Question 54

Parallel

Answer 54

Deep Friction applied in the same direction as the fibers.

Question 55

Circular

Answer 55

Repeated circular motion, distal to proximal considered.

Question 56

Deep Transverse Friction Massage (DTFM)

Answer 56

Also known as Cyriax Friction is a technique popularized by Dr. James Cyriax for pain and inflammation relief in musculoskeletal conditions

Question 57

Deep Transverse Friction Massage (Continued)

Answer 57

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.

Question 58

Effects of Deep Transverse Friction Massage

Answer 58

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

Question 59

Indications for Deep Transverse Friction Massage

Answer 59

Promote healing of connective and contractile tissue. To retain or regain mobility. Pain modulation.

Question 60

Contraindications for Deep Transverse Friction Massage

Answer 60

Acute inflammation Hematoma Conditions that increase bleeding - Hemophilia - Pts. on anti-coagulants - Pts. on steroids Debilitated/Open Skin

Question 61

Positioning For DTFM

Answer 61

Muscles supported in a position of relaxation or reduced muscle tone. Tendons: position of tension. Ligaments: taunt, as far as the ROM allows.

Question 62

DTFM Treatment Protocol

Answer 62

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.

Question 63

Trigger Points Definition

Answer 63

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.

Question 64

Techniques to Treat Trigger Points

Answer 64

``` Ice Massage Digitil or ischemic Compression PNF TPPR ```

Question 65

Characteristics of Trigger Points

Answer 65

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.

Question 66

Active Trigger Points

Answer 66

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)

Question 67

Latent Trigger Point

Answer 67

Painful only when palpated

Question 68

Potential TrP Causes

Answer 68

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

Question 69

Motor End Plate Hypothesis

Answer 69

Dysfunction (presynaptic, synaptic or postsynaptic) may be acquired or genetic. Leads to continued release of Ach Causing spontaneous electrical activity or muscle contraction.

Question 70

Trigger Point Pressure Realease

Answer 70

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.

Question 71

Digital Compression TrP

Answer 71

Should be applied to tone point for a prolonged period (10-45) seconds) and pressure released with resolution of pain. Suggested Treatment Approach 1. Perform effleurage/petrissage techniques to "warm" the tissues. 2. Digital Compression 3. Follow compression techniques with effleurage/petrissage techniques to "move out metabolic waste". 4. Either manual stretch or instruct the pt. to stretch the involved tissue.

Question 72

Hypothesis for Compression

Answer 72

Pressure and stretching help to restore contracted sarcomeres to normal resting length. Mechanical pressure helps to separate myosin and actin.