Chapter04_Therapeutic_Massage_Techniques_

73 C h a p t e r 4 Therapeutic Massage Techniques Learning Outcomes After completing this chapter, you will be able to: ■ Identify conditions under which massage is and is not performed, known as indications and contraindications. ■ Identify areas of endangerment that are beyond the scope of the entry-level massage therapist. ■ Describe the basic anatomical and directional terms in order to begin work on the body. ■ Describe the basic Swedish massage strokes that form the foundation of therapeutic massage. ■ Outline and begin to incorporate all six considerations of application into the massage strokes. ■ Understand and perform skeletal muscle palpation to identify spasms. ■ Recognize the difference between massage sequence and flow, and begin to choreograph a massage routine. ■ Discuss and demonstrate proper body mechanics for massage and bodywork. ■ Practice a full massage routine for both table and chair. Indications and Contraindications 74 Part I Basic Concepts of Therapeutic Massage and Bodywork www.mhhe.com INTRODUCTION All Western-oriented massage, whether it focuses on relaxation or more highly skilled work, is based on Swedish massage and the strokes first formulated by a Swedish fencing master. The term Swedish is often used to refer to a “light” or “relaxation” massage, whereas the term therapeutic massage denotes a more contemporary massage that is corrective or rehabilitative. Certain considerations or elements dictate the specifics of each stroke, such as amount of pressure, the speed with which it is applied, and the length of time the stroke lasts. Your ability as a massage thera- pist to blend these considerations (or mechanics) with fluid movements creates a complete and fully sat- isfying massage that will appeal to a variety of clients. For the entry-level massage therapist, general guidelines specify conditions where massage is and is not warranted, commonly known as indications and contraindications. Further, there are areas of the body known as areas of endangerment that require advanced training and are, therefore, not within the scope of this text. For safety reasons, these precautions must be understood early on in the therapist’s training. However, all massage therapists should follow the old adage, “When in doubt, don’t” and the medical credo “Do no harm.” Key Terms areas of endangerment (p. 76) compression (p. 86) considerations (p. 74) contusion (p. 79) cramps (p. 79) cross-stretch (p. 86) depth or depth of pressure (p. 80) direction (p. 81) duration (p. 81) effleurage (p. 81) fine tremulous (p. 86) frequency (p. 81) friction (p. 84) hypertrophy (p. 79) indications and contraindications (p. 74) massage flow (p. 88) massage sequence (p. 88) massage therapist’s intent (p. 89) Meissner’s corpuscles (p. 80) muscle atrophy (p. 79) nerve stroke (p. 86) palpation (p. 76) petrissage (p. 83) prone (p. 88) rhythm (p. 81) rocking (p. 86) shaking (p. 86) skin rolling (p. 86) spasm (p. 78) speed of the stroke (p. 81) strains (p. 79) supine (p. 88) tapotement (p. 85) thumb presses (p. 88) vibration (p. 85) wringing (p. 86) Massage therapists often find themselves in situations where they must ask the seem- ingly simple question: “Can this person receive a massage at this time?” There are a few guidelines to follow that clearly state instances in which, or conditions where, massage is recommended (indicated) and instances in which, or conditions where, massage is not recommended (contraindicated). T E C H N I Q U E E M P H A S I S To complicate matters further, some conditions are local contraindications (so the rest of the body may receive massage), while some conditions may require a different massage modality. Below are basic guidelines that will aid you in your decision. For an in-depth look at possible ramifications of working with clients taking medications, see chapter 22. Indications As mentioned in the Introduction and Overview, there are numerous benefits to receiv- ing a massage and just as many conditions for which massage is indicated. First and www.mhhe.com Chapter 4 Therapeutic Massage Techniques 75 foremost, circulatory massage, such as Swedish massage, increases circulation. The in- dividual cells of the body depend on an abundant supply of blood and lymph. These fluids supply nutrients and oxygen to the body as well as carry away wastes and toxins. So, massage simply helps promote overall good health. Massage facilitates the smooth flow of energy and communication among the car- diovascular, digestive, urinary, respiratory, lymphatic, and nervous systems—creating homeostasis (constancy and balance in the body). With reference to the integumentary system, massage can often enhance skin condition. Massage directly improves the func- tion of the oil and sweat glands that keep the skin lubricated, clean, and cooled. Tough, inflexible skin can become softer and more supple following massage. A healthier, more youthful appearance may be the result. Massage also aids recovery from soft tissue injuries, such as sprains and strains. The growth and repair of tissues are accelerated by efficient circulation in the injured areas and appropriate stimulation of the healing tissues. Therefore, massage therapy can of- ten help accelerate and improve recovery as well as reduce discomfort from such in- juries (see chapter 13). Finally, massage can have a calming effect on people who are high-strung (“Type A” personalities) and people who have become dependent on pharmaceuticals or alco- hol for rest and relaxation (although it should never replace physician-prescribed med- ications for diagnosed mental or emotional disorders). Massage balances the nervous system by soothing or stimulating nerves and neural pathways, depending on which ef- fect is needed by the individual at the time of the massage. Common afflictions such as muscle tightness and tension, insomnia, and tension headache caused by stress; spasms and cramps (charley horses) resulting from sports activities; digestive disorders (including constipation and spastic colon) encouraged by a hectic lifestyle; arthritis, asthma, fibromyalgia, sinusitis, and temporomandibular joint dysfunction caused by certain pathologies; carpal tunnel syndrome and thoracic outlet syndrome caused by repetitive motions; and postural imbalances caused by tem- porary conditions such as pregnancy or genetic conditions such as scoliosis all warrant massage (see Introduction and Overview, and chapter 5). Generally, anytime a massage will be beneficial to the person and no underlying causes of concern such as disease or circulatory problems exist, it is considered an indication. Contraindications Contraindications may be general or local, specific to certain modalities, or determined by medication use. Circulatory massage is considered a total contraindication in situa- tions in which any modification, modality, or location would result in unsafe condi- tions. A circulatory massage is defined as any massage modality, such as Swedish, that directly moves blood and lymph through the body, as opposed to an acupressure mas- sage that works on meridians, and indirectly affects the blood and lymph system. Anytime a client has a severe condition (e.g., severe insulin-dependent diabetes or high blood pressure), total or full-body circulatory massage is contraindicated. Edema due to any heart, lung, liver, or kidney dysfunction is a contraindication for massage. The response to touch (reflex effect on nervous system) could make the disease worse. In car- diovascular diseases, massage could dislodge a thrombus (blood clot), resulting in an embolus (floating blood clot) and causing heart attack or stroke. Abnormally high body temperature, often an indication of acute infection, is a contraindication for massage. Modifications to massage such as refraining from working on a certain area (local) can be made to allow massage to the rest of the body. For example, you should not mas- sage distal to (or below) varicose veins so you do not further damage already compro- mised veins, but you may proceed with massage on the rest of the body (or massage proximal to, above, the veins). Never perform massage over open wounds, lesions, or other potentially infectious sores. Many grey areas exist in which the therapist must draw on training and practical experience to make an educated decision as to whether or not the client may receive a The Art of Skeletal Muscle Palpation Directional Terms Areas of Endangerment 76 Part I Basic Concepts of Therapeutic Massage and Bodywork www.mhhe.com massage. In some cases, it might be a quality of life issue. A terminally ill client, as in the case of a cancer or AIDS patient, would benefit from the touch of a skilled and compas- sionate therapist. In other cases, under a doctor’s guidance, a client may receive a spot— or area-specific—massage to alleviate pain. If you question whether or not you should massage a client or specific area, do not do so until you have further clarification from another health care professional. It is far better to lose one massage than cause harm to a client. If your gut says no, listen! Depending on the situation, you may be able to switch to another modality, such as Thai massage or Reiki. For example women who are breast cancer survivors may ben- efit from Thai massage or shiatsu. A small amount of localized acupressure massage and gentle stretching can be both relaxing and balancing for women emerging from a very difficult time. Further, energy work can be an excellent alternative to circulatory mas- sage. Again, conditions that are contraindicated for circulatory full-body massage (such as lupus) may not be compromised by other modalities. A client on anti-inflammatories (ibuprofen) or analgesics (aspirin and acetamino- phen) may not be able to accurately assess pain levels during a massage. A client taking muscle relaxants will have an altered sense of stretch response, prohibiting very deep work. Circulatory massage is contraindicated for any client on an anticoagulant. Med- ications that slow the clotting process would be compromised by massage that increases blood flow. Areas of endangerment are areas of the body where no pressure or no deep application of pressure is recommended because of underlying structures such as nerves, arteries, veins, and vital organs. Most areas of endangerment are located at joints, such as the back of the knee (popliteal region) or inside of the elbow (cubital region). There are a few instances where application of pressure to these areas is acceptable; however, this application requires highly specific training that does not fall within the entry-level massage therapist’s scope of practice. The Think About It in this chapter lists areas of endangerment on the body. Figure 4.1 illustrates the location of these sites. Before working on the body, a complete understanding of body regions and directional terms is necessary. The body is discussed as it is held in anatomical position: standing erect with head and feet forward, arms at sides with palms facing forward. The extrem- ities refer to the hands, arms, feet, and legs. The torso (or trunk) is the body from the chest cavity to the abdominal cavity, minus the head and neck. Medial refers to toward the midline of the body, while lateral refers to away from the midline. In any circulatory massage, work is done centripetally, which means toward the heart. See chapter 6 for a detailed discussion of directional terms. Also, begin to familiarize yourself with the muscles and their location and bony landmarks by reading chapters 8 and 9. Simply stated, palpation is the art of observing with your eyes, touching with your hands, and identifying with your eyes and hands. When you palpate, you are using the art of touch to evaluate the body. Although there are many types of body palpation, we will focus on accessing the skeletal muscle structure and function. The purpose of the massage therapist’s initial palpation evaluation is to determine whether skeletal mus- cles and their connective tissue coverings are functioning normally or abnormally. This will greatly assist you in determining the type of massage strokes—as well as the amount of pressure applied with the strokes—that are best suited to your client. Detailed discussions of anatomy, physiology, and kinesiology can be found in part 2 of this text, but for our purposes here, a brief overview of anatomy and physiology re- www.mhhe.com Chapter 4 Therapeutic Massage Techniques 77 3 endangerment areas of the neck 1 Inferior to ear 2 Anterior 3 Posterior Abdominal aorta Axilla (armpit) Femoral triangle Figure 4.1 (a) Areas of endangerment in the supine position. (b) Areas of endangerment in the prone position. 2 endangerment areas of the elbow 1 Cubital (anterior) 2 Ulnar notch (funny bone) Popliteal fossa (Back) kidneys Medial brachium (a) (b) 78 Part I Basic Concepts of Therapeutic Massage and Bodywork www.mhhe.com Think About It Areas of Endangerment 1. Inferior to the ear Location: notch posterior to the ramus of the mandible Structure of concern: facial nerve, external carotid artery, styloid process 2. Anterior triangle of the neck Location: borders formed by SCM, trachea, and mandible Structures of concern: carotid artery, jugular vein, vagus nerve 3. Posterior triangle of the neck Location: borders formed by SCM, trapezius, and clavicle Structures of concern: brachial plexus, subclavian artery, jugular, brachiocephalic vein 4. Axilla Location: armpit Structures of concern: axillary, median, musculocutaneous, and ulnar nerves; axillary artery 5. Medial brachium Location: upper inner arm between biceps and triceps Structures of concern: ulnar, musculocutaneous, and median nerves; superior ulnar artery, brachial artery, basilic vein 6. Cubital area of the elbow Location: anterior bend of the elbow Structures of concern: median nerve, radial and ulnar arteries, median cubital vein 7. Ulnar notch of the elbow Location: “funny bone” between the medial epicondyle of the humerus and the olecranon process of the ulna Structures of concern: ulnar nerve 8. Femoral triangle Location: bordered by the sartorius muscle, adductor longus, and inguinal ligament Structures of concern: femoral nerve, femoral artery, femoral vein, great saphenous vein 9. Popliteal fossa Location: posterior aspect of the knee bordered by gastrocnemius and hamstring Structures of concern: tibial nerve, common peroneal nerve, popliteal vein 10. Abdomen Location: midabdomen Structures of concern: aorta 11. Back (Kidneys) Location: against the posterior abdominal wall at the level of T-12 to L-3 (under the twelfth rib); the right kidney is slightly lower than the left Structure of concern: kidney veals that skeletal striated muscles are voluntary and controlled by conscious action of the central nervous system. They are named for the action they do, the region of the body they are found in, and their attachment sites to the skeleton. Skeletal muscles pro- duce movement of body levers. Most massage procedures primarily affect skeletal mus- cles and their connective tissue coverings. E X A M P O I N T Normal muscle contraction is palpated as a slight increase in tension as the muscle shortens. The most commonly palpated muscle dysfunction is a spasm. Spasms are palpated as an increase in muscle tension due to increased shortening (hypertonicity), which the www.mhhe.com Chapter 4 Therapeutic Massage Techniques 79 client cannot release voluntarily. This muscle tension prevents lengthening of the mus- cles involved. Injury, disease, or emotional stress are the usual causes of muscle spasms. Cramps are involuntary muscle twitches; they are palpable as muscle swelling and usually observable as quivering or palpitating of the muscle tissue. Convulsions are also involuntary spasms of a muscle that usually present a series of jerking movements in the muscle. Minor trauma to the body may cause a contusion or muscle bruise. E X A M P O I N T Internal bleeding caused by the contusion will be palpable as swelling due to inflammation. Tetonic contracture of muscle tissue results in continuous muscular contractions due to tonic or sustained spasm or fibrosis. It will palpate as a “hardening” of the muscle tis- sue and is usually observable as persistent twitching or a quick jerking of the muscle. The most common injuries to muscle tissue are strains (torn, overstretched, or hy- potonicity) of muscles. Strains are palpated by the degree or grade of strain. Grade I is an overstretching of only a few muscle fibers with minimal or no tearing of the fibers. Grade I may or may not be palpable or visually observable. Grade II consists of a partial tear in less than half of the muscle. Grade II strains show a thickening of the muscle tis- sue (which is palpable), and there may be some bleeding where the overlying skin may be discolored. Grade III presents tearing of up to 100% of the muscle. It is palpable by a depression or “bunching” of the muscle with very observable skin discoloration. E X A M P O I N T Strains occur mostly in the belly of the muscle or at musculotendinous junctions. Muscle atrophy is a wasting away of the tissue and is palpable by a decrease in the overall width of the muscle. Hypertrophy is an increase or broadening of the muscle due to vigorous activity or exercise. It is palpable by an enlargement of the muscle fibers. Flaccid muscles diminish in breadth due to a lack of muscle activity or exercise. They palpate as being very relaxed or without normal muscle tone. The art of muscle palpation is a very important skill to develop as a massage ther- apist. It requires an understanding of the anatomy and physiology of the “instruments” used in palpation. Recall that these instruments are your eyes and hands (primarily the fingertips). In the clinical artistry of palpation, you must also be aware of how the act of observation and touch may change the anatomy and physiology of the muscle tissue. Methodology Many methods of muscle palpation are available to the massage practitioner. They range from intrusive to nonintrusive, active to passive, and very firm contact to little or almost no pressure at all. Firm or heavy pressure may cause muscles to tighten as the body responds to the force of the massage therapist’s hand. The information gathered from forceful palpation may indicate more about the body’s defense mechanisms than the actual condition of the muscle tissue and its connective tissue coverings. Noninvasive, light palpation elicits no resistance from the body and more accu- rately detects the condition of the muscle tissue. T E C H N I Q U E E M P H A S I S When you palpate, remember the acronym PALPATE, or “P ress Always Lightly, Perceive At T he Exterior.” To accurately detect the condition of a muscle, you use the encapsulated nerve end- ings in your fingertips and pads to relay the information gathered to the brain. When 80 Part I Basic Concepts of Therapeutic Massage and Bodywork www.mhhe.com you palpate nonintrusively, you use Meissner’s corpuscles for fine touch (see chapter 9). These corpuscles are located at the papillae of the dermis right underneath the epi- dermis (or outer covering of the skin). Your goal in muscle palpation is to be like a dry sponge placed in a pool of water where information is “absorbed” through your hands. You can then accurately and pre- cisely access the condition of your client’s skeletal muscular system and proceed to mas- sage using the most beneficial and effective routine for that individual. E X A M P O I N T Swedish massage was first formulated by Per Henrik Ling, a Swedish gymnastic instructor and fencing master, in the early 1800s. Ling’s program provided the foundation for modern-day therapeutic massage and physical therapy. Extensive travel through Asia gave Ling