Principles and Practice

of
Therapeutic Massage
 Principles and Practice
of
Therapeutic Massage
Second Edition

Akhoury Gourang Sinha

BPT (NIRTAR) MSPT, PhD
Reader
Department of Physiotherapy
Punjabi University
Patiala (Punjab), India

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Principles and Practice of Therapeutic Massage
© 2010, Akhoury Gourang Sinha
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted
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First Edition: 2001
Reprint 2002
Reprint 2004
Second Edition: 2010
ISBN 978-81-8448-831-9
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 To
Ma, Papa, Uru Didi
and
Babuji
 Foreword
It is my proud privilege to write the Foreword to this edition of Principles and Practice of
Therapeutic Massage by AG Sinha.
Massage or manipulation of soft tissues is the oldest form of physical therapy mentioned
in ancient medical records. Of late due to several reasons Physiotherapists started paying it
least attention. However, learning the skills of massage is the basic step to achieve success in
specialised manual therapy techniques, as this is one of the main techniques that helps
Physiotherapists to develop the palpatory skills and sensory awareness.
Most of the books available for Physiotherapists are by the overseas authors and often
present diversified explanation of techniques, uses and applications. This always confuses a
learner as well as teacher and Mr Sinha, after performing an extensive search of literature, has
written this comprehensive book. I strongly feel that this would be of help very much not only
to the students but also to the teachers.
This book is a great boon for everyone concerned, as this is the first book on massage
written by an Indian Physiotherapist. In a situation, where massage as a therapeutic modality
is neglected or given least priority, I appreciate the author for his boldness to bring out this
book. This may catalyse others to write books on physiotherapy field.
I pray His almighty for the success of Mr Sinha in this endeavor.

AG Dhandapani
Additional Professor of Physiotherapy
SRMC and RI (Deemed University)
Porur, Chennai (TN), India

Formerly
Head of the Department of Physiotherapy
National Institute of Rehabilitation Training and Research
Cuttack (Orissa), India
 Preface to the Second Edition

I am overwhelmed by the response I got for the first edition of the book. The second edition
contains several new information and discussion on the recent uses of massage. In the first
edition I mentioned that the subject of massage has always gone through the phases of
advocacy and denigration. The current phase is one that of resurgent advocacy. The advanced
technology is increasingly being used world over to examine its effects and uses. These research
on one hand are establishing the basis of its uses in several of the conditions where massage
have traditionally not been used by the established practitioners. On the other hand the risk
for the misuse/use of the modality is also fast increasing. The second edition of this book
examines these issue from closer quarters especially with regards to the uses of massage in
AIDS, cancer, hypertension, obesity etc. Information emerged from the recent researches have
been incorporated. Black and white photographs have been replaced by the new ones. However
the basic structure of the book has not been altered though minor errors of typography are
corrected.
I hope that the revised edition would be able to satisfy the inquisitiveness of both the
students and researchers.
AG Sinha
 Preface to the First Edition

This book has been written for all those who are interested in the scientific use of massage—
an ancient mode of treatment for painful muscles. Information on various aspects of massage
is scattered throughout the literature. The available texts on massage, mostly written by western
authors, focus usually on specific dimension of massage. In those places where enough books
are not available, it often becomes a problem for a new teacher to collect the teaching material.
As a result of this the teaching of massage is often neglected. These problems, which I
experienced both as a student and a teacher, have stimulated me to work on this text. In
nutshell, it is an attempt to collect the scattered knowledge and present it in a form of systematic
and comprehensive exposition of principles, techniques and clinical uses of massage.
Divided into 11 chapters, this book attempts to critically evaluate the different aspects of
massage. It includes detailed discussions on the general physiological effects of massage, its
uses in different conditions and the contraindications.
The Chapter on Definition and Classification of Massage assimilates the similarity and
dissimilarity of different techniques and classify them accordingly. Different techniques of
massage are described in detail along with their specific effects on the body tissue.
A Chapter on the Practical Aspect of Massage explains the rationales behind the use of
different sequence of techniques and mentions the points to be considered while administering
massage. This intends to cater to the practical examination requirement of the students. These
two Chapters contain several photographs/illustrations to simplify the subject.
The essential features of the application of massage in different pathological conditions
are explained in a chapter, which intends to serve as guideline for the beginners.
The features of lymphatic system, quite essential for the scientific practice of massage
have been presented in a separate chapter. This chapter includes four charts showing
schematically the distribution of lymph node and the direction of lymphatic flow in the
different parts of body.
The important landmarks and milestones in the development of this modality are described
under the history of massage, while the Chapter on New Systems of Massage gives a brief
introduction of some specific forms of massage which are widely used in different parts of the
world.
Sports massage has emerged as an important modality in the field of athletic and sports
world. A separate chapter presents a detailed account of the various theoretical and practical
aspects of this advancing area of massage.
While working on this text, I came across a volume of literature on the topic. Out of which,
however, I could refer only a portion. These titles are listed out in References. The remaining
titles which are not quoted in this book, but I feel, can be of immense help to anyone who
wishes to know more about this modality, are listed in Bibliography.
 Preface to the First Edition xi
Given at the end, these up-to-date lists might help those who are interested to take up this
modality as a special interest subject in postgraduate classes and research.
The main aim of this book is to make the subject matter more meaningful and realistic
from the academic point of view. I am aware, that curriculum in many physiotherapy
programme may not permit as comprehensive a study on massage as this book may entail. For
this reason each chapter has been written as a fairly independent entity relatively independent
from rest of the book.
Although, primarily written for physiotherapy undergraduate students who have to
study this subject as part of the curriculum, I earnestly hope that it would also serve as a
useful reference to the members and students of other disciplines like naturopathy, ayurveda,
physical education, sports medicine, etc.
Every attempt has been made to avoid errors though some might have crept in inadvertently.
I shall be obliged if any such error is brought to my notice. I further solicit suggestions and
criticism from learned teachers for further improvement.
AG Sinha
 Acknowledgments

I take this opportunity to express my gratitude to all those who have helped in the preparation
of this book. In particular my thanks are due to my Guru Mr AG Dhandapani, Additional
Professor of Physiotherapy, SRMC and RI, Chennai, who not only read my manuscript and
gave valuable suggestions but also kindly wrote the Foreword. I express my sincere thanks to
Dr PK Nishank (PT), Dr Saibal Bose (PT), Dr Anupam Bhunia (PT), all my former colleagues
at Srinivas College of Physiotherapy, Mangalore and my friends Dr Shiv Kumar (PT) and Dr
Raju Sharma (PT), whose constructive criticism helped me a lot in drafting this book in its
present form. Thanks are also due to Dr GS Kang, Dr S Koley and Dr Amarjeet Singh (PT) my
colleagues at GNDU, Amritsar, for their help in many ways in preparation of the manuscript.
I fall short of words to express my feeling to Prof. JS Sandhu MS (Ortho) DSM, Dean
Faculty of Sports Medicine and Physiotherapy, GNDU who not only encouraged me to go
ahead with all my endeavors, but also stood behind me like a rock on the occasions when I
was sinking deep into solitude and dejection.
I am also indebted to my friends Dr Deepak Kumar for sparing his valuable hours to take
photographs and Mr Digvijay Srivastava of INTACH, Lucknow for drawing all the diagrams
of this book. Thanks are also due to my friends Dr Jitender Sharma (PT) and Dr R Thangaraj
for helping me with the manuscript. I express my gratitude to Mrs S Kalai Selvi and Miss
Suman Makkar for converting my illegible handwriting into beautiful letters.
I would be failing in my duties if I do not acknowledge my thanks to all those authors
whose works have been consulted and quoted in this book.
Thanks are also due to my publisher M/s Jaypee Brothers Medical Publishers (P) Ltd,
New Delhi for making efforts in bringing out this book.
Last but not the least, I wish to put on the record my deep sense of gratitude to my brother
Hemant Sinha (Munnu) without whose support and encouragement, it would not have been
possible for me to reach at this destination.
 Contents

1. Definition and Classification of Massage ................................................................. 1

2. Physiological Effects .................................................................................................... 8
3. Therapeutic Uses .......................................................................................................... 24
4. Contraindications ........................................................................................................ 33
5. Techniques .................................................................................................................... 41
6. Practical Aspects of Massage ...................................................................................... 80
7. Therapeutic Applications of Massage ....................................................................... 101
8. History of Massage ....................................................................................................... 115
9. New Systems of Massage ............................................................................................ 120
10. Sports Massage ............................................................................................................. 135
11. Outlines of the Lymphatic System .............................................................................. 158
Glossary .......................................................................................................................... 167
References ........................................................................................................................ 171
Bibliography ................................................................................................................... 181
Index ............................................................................................................................... 185
 Definition
Definition and Classification
and Classification of Massage1 1
of Massage

1 Definition and
Classification of Massage

DEFINITION
What is massage? No uniform answer seems to exist to this question. Massage is
one of those terms, which are easily understood than expressed. People find it
difficult to define massage, although they are confident of its meaning. Many
definitions of massage have been offered from time-to-time. Given below are some
of the definitions.
• Massage is the scientific mode of curing certain forms of disease by systematic
manipulations. – Murrel
• Massage refers to all mechanical procedures that can cure illness. – Hoffa
• Massage signifies a group of procedures, which are usually done with hand on
the external tissue of the body in a variety of ways either with a curative, palliative
or hygienic point in view. – Graham
• Massage is the scientific manipulation of the soft tissues of body with the palmar
aspect of hand(s) and or fingers.
• Massage can be defined as the hand motions practiced on the surface of body
with a therapeutic goal.
• Massage is the application of force to the soft tissue without producing any
movement or change in the position of joints.
• Massage is a term applied to certain manipulations of the soft tissues. These
manipulations are most efficiently performed with the palmar aspect of hand
and administered for the purpose of producing effects on the nervous system,
muscular system as well as on the local and general circulation of the blood and
lymph. – Beard
• Massage is the mechanical stimulation of soft tissues of the body by rhythmically
applied pressure and stretching.
• Massage is a healing art.
Most of these definitions are inadequate because neither do they include the
complete dimension of massage nor do they offer any criteria to decide whether a
given technique can be included in massage or not.
2 Principles and Practice of Therapeutic Massage
Definitions of Murrel and Hoffa restrict the application of massage to sick
people. Though, throughout the history massage has been used not only by sick
but also by the healthy people for therapeutic, restorative as well as preventive
purposes. Moreover, these definitions do not address the technical specifications
of massage.
Few definitions emphasise that manipulation of soft tissue should be performed
by hand. While this is true for most of the techniques, it cannot be considered as
a criteria for defining massage, because in some methods of massage parts of
body other than the hands are also being used during manipulation. For example,
in tread massage there is predominance of leg work. Besides, according to this
criteria several mechanical devices like vibrator, percussor, pneumatic massage,
etc. which essentially have the similar mechanism of action and physiological
effects cannot be included in massage despite the fact that these machines were
primarily devised to save the time and energy of the therapist.
If the techniques of massage are analysed carefully, it becomes obvious that
mere rubbing or handling of the skin by hand does not produce the desired effects.
Rather it is the variable amount of mechanical energy imparted to the body tissue
during various manoeuvres, which accounts for the effects of massage. These
mechanical forces may be generated by hand or by any other mechanical device
and can be a criteria for defining massage and classifying its various techniques.
This concept has been dealt with in the definitions of massage given by Graham
and Beard. These definitions while acknowledging the predominance of hand works
in massage also hint at the possibilities of other ways of manipulating the tissues.
However, transmission of mechanical energy is also involved in the various
joint mobilisation and manipulative procedures which also use the therapist’s hand
as a major tool. Therefore, it is imperative that these two major categories of manual
therapy should be distinguished from each other. While the joint mobilisation
and manipulation procedures achieve their aim by producing movement (either
physiological or accessory) of the joint, massage manipulates the soft tissue and
essentially does not produce any change in the position of the joint during
manipulations.
These facts can be assimilated to outline the essential features of massage
technique which may then form the criteria to decide whether a given technique
can be included in the category of massage or not.

FEATURES OF MASSAGE TECHNIQUE

Essential features of massage technique can be listed as follows:
1. Technique should apply mechanical force to the soft tissue of the body.
2. These forces must not produce any change in the position of the joint.
3. The technique must evoke some physiological and/or psychological effect
which serve to achieve the therapeutic, restorative or, the preventive goal.
 Definition
Definition and Classification
and Classification of Massage3 3
of Massage
Considering these features, any technique, be it manual or mechanical, which
imparts mechanical energy to the soft tissue of body through the skin without
producing any change in the position of joint, in order to elicit certain physiological
or psychological effect which can be utilised for therapeutic, restorative or preventive
purposes either on sick or a healthy individual can be defined as massage.

CLASSIFICATION OF TECHNIQUES
Basis of Classification
Application of touch and pressure in various manners constitute the manoeuvres
of massage. The effects produced by a technique entirely depend upon the type of
tissue approached during a particular technique and the character of the technique
governs this. Any given technique can be analysed and compared with other
techniques of massage in terms of:
• Magnitude of applied force
• Direction of force
• Duration of force
• Means of application of force.
So, the characters of technique could be one of the bases of classification.
Massage can also be classified on the basis of depth of tissue approached during
a technique. The region of body, to which massage is given, has also been used to
classify massage. Massage manoeuvres can be done either by hands of the therapist
or by various mechanical devices. This can be another basis of classifying massage
(Fig. 1.1).

CLASSIFICATION OF MASSAGE
On the Basis of Character of Technique
According to the nature of character of technique classical/manual massage
techniques are classified into following 4 basic groups. Each group has more
than one subgroup (Fig. 1.2).

Fig. 1.1: Basis of classification of massage

4 Principles and Practice of Therapeutic Massage

Fig. 1.2: Classification of massage techniques on the basis of character of techniques

1. Stroking manipulations: Superficial stroking, effleurage

2. Pressure manipulations: Kneading, petrissage, friction
3. Tapotement/percussion manipulations
4. Vibratory manipulations.

Stroking Manipulations
The technique of this group consists of linear movements of relaxed hand along
the whole length of segment known as “Strokes”, which usually cover one aspect
of the entire segment of the body at a time. An even pressure is applied throughout
the strokes, which are repeated in rhythmical way. According to the amount
and direction of applied pressure, it is divided into two techniques.
Superficial stroking: It is the rhythmical linear movement of hand or a part
thereof over the skin in either direction, i.e. proximal to distal or vice versa, without
any pressure.
Effleurage: It is the linear movement of hand, over the external surface of
body in the direction of venous and lymphatic drainage, with moderate pressure.

Pressure Manipulations
In this group of techniques, the hand of the therapist and skin of the patient
move together as one and fairly deep localised pressure is applied to the body.
The techniques are directed towards the deeper tissue. The aim is to achieve the
maximal mechanical movement of different fibres with the application of that
maximum pressure, which a patient/subject can tolerate comfortably.
Depending upon the type and direction of applied pressure it can be divided
into following three major subgroups. Each subgroup consists of more than one
technique.
 Definition
Definition and Classification
and Classification of Massage5 5
of Massage
— Kneading
— Petrissage
— Friction.
Kneading: In this group of techniques, the tissues are pressed down on to the
underlying- firm-structure and intermittent pressure is applied in circular direction,
parallel to the long axis of bone. The applied pressure increases and decreases in a
gradual manner but the contact of the therapist’s hand(s) with the patients body is
never interrupted. Different techniques of this group are:
— Digital kneading: Pressure is applied with the fingers (finger kneading) or
thumb (thumb kneading).
— Palmar kneading: Pressure is applied with the palm.
— Reinforced kneading/ironing: Both the hands, placed over one another, are
used to apply pressure. The lower hand, which is in contact with the patient’s
skin, receives reinforcement from the other hand.
Petrissage: In this category of massage, the tissues are grasped and lifted
away from the underlying structures and intermittent pressure is applied to the
tissue in the direction that is perpendicular to the long axis of bone. Different
techniques of this group are:
i. Picking up: Tissues are lifted away from underlying structures, squeezed and
then released using one or both the hands.
ii. Wringing: Using both the hands, tissues are lifted away from the underlying
structures, squeezed, twisted and then released.
iii. Skin rolling: The skin and fascia are lifted up with both the hands and moved
over the subcutaneous tissues by keeping a roll of lifted tissue continuously
ahead of the moving thumb.
Friction: In this group of technique the tissue are subjected to small range of
to and fro movement performed with constant deep pressure of the finger or
thumb. Different techniques of this group are:
— Circular friction: Direction of movement is circular.
— Transverse friction to and fro movement is performed across the length of
structure. It is also called cross-fibre massage.

Vibratory Manipulations
In this group of techniques, the mechanical energy is transmitted to the body by
the vibrations of the distal part of upper limb, i.e. hand and/or fingers, which are
in constant contact with the subjects skin, using the body weight and generalised
cocontraction of the upper limb muscles. This technique is mainly directed towards
the lung and other hollow cavities.
Depending upon the direction and frequency of vibration it is divided into
two techniques:
6 Principles and Practice of Therapeutic Massage
Vibration: In this technique, the fine vibrations are produced, which tend to
produce fine movement of hand in upwards and downward direction.
Shaking: In this technique, coarse vibrations are produced, which tend to
produce fine movement of hand in sideway direction.

Percussion/tapotement manipulations
In this group of techniques, a succession of soft, gentle blows are applied over the
body, which produce a characteristic sound. The striking hands are not in constant
contact with the skin and strike the body part at regular interval. This results in the
application of an intermittent touch and pressure to the body during these
manipulations.
The different parts of hand are used to strike the subject’s skin and accordingly
the techniques are named:
Technique Administered with
Clapping Cupped palm
Hacking Ulnar border of the 5th, 4th and 3rd digits
Beating Anterior aspect of the clenched fist
Tapping Pulp of the fingers
Pounding Medial aspect of the clenched fist
The features of various techniques of classical massage is given in table 1.1.

Table 1.1: Features of various techniques of classical massage

Technique Salient Features
Stroking Linear movements of hand or parts thereof, along the entire length of segment,
with the lightest pressure and constant touch.
Effleurage Linear movement of hand or a part thereof, along the entire length of segment,
with moderate pressure and constant touch.
Kneading Circular movements of soft tissue, parallel to the long axis of underlying bone,
with constant touch and intermittent pressure.
Petrissage Circular movements of soft tissue, perpendicular to the long axis of underlying
bone, with constant touch and intermittent pressure.
Friction Small range to and fro movement of soft tissue with constant touch and
constant deep pressure.
Percussion Oscillatory movement of hand or a part thereof with intermittent touch and
pressure.
Vibration Small range oscillatory movement of hand in upward, downward, directions
with constant touch.
Shaking Small range oscillatory movement of hands in sideways direction with constant
touch.

On the Basis of Depth of Tissue Approached

Depending upon the depth of tissue approached during manipulations, massage
techniques can be classified as:
 Definition
Definition and Classification
and Classification of Massage7 7
of Massage
Light Massage Techniques
The force applied during the manoeuvre are light, so that the effect of massage is
confined to the superficial tissue only. e.g. stroking, tapping, etc.

Deep Massage Techniques

The forces applied during the massage are moderate to deep so that the effect of
massage reaches to the deeper tissues like muscle. e.g. friction, kneading, etc.

On the Basis of Region Massaged

Massage can also be classified as below, according to the region to which it is
given.

General Massage
Massage applied to the entire body is usually termed as general massage. However,
massage administered to a large body segment like the back, lower limb, etc. can
also be included in this category. It is usually administered in debilitated persons
following prolonged recumbency and on athletes after exhaustive physical work
to bring a sense of well-being and comfort.

Local Massage
When massage is administered in a particular area of the body segment it is
termed as local massage. This is used in the treatment of the local pathological
conditions. For example, massage of wrist in tenosynovitis, friction to lateral
ligament of ankle following sprain, etc. can be considered as local massage.

On the Basis of Means of Administration of Technique

On this basis, the massage can be classified into the following two categories.

Manual Massage
The word “manual” refers to the ‘lying on’ of hand over the subject’s body. The
massage administered with the hand or other body part of the therapist is called
manual massage. e.g. technique of classical massage, connective tissue massage,
trigger point massage, accupressure massage, etc.

Mechanical Massage
When the mechanical devices based on the principles of massage, administer the
mechanical energy to the patient’s body, in order to manipulate soft tissue, it
may be termed as mechanical massage. e.g. vibrator, compression devices,
pneumatic massage, etc.
8 Principles and Practice of Therapeutic Massage

2
Physiological Effects

As a therapeutic modality, massage is being used for the relief of pain, swelling,
muscle sprain, restricted movement, tension and anxiety associated with a large
number of a disorders, afflicting muscular, nervous, cardiorespiratory and other
systems.
The therapeutic value of massage lies in its numerous and combined
physiological effects. The effect of massage of the body is very much technique
dependent. Massage, be it manual or mechanical, imparts pressure and stimulates
mechanically the various tissue approached at the time of application of a particular
technique. It is the magnitude, duration, and the direction of force applied during
a particular technique that determines the effects, produced by that technique on
the body.
Various authors have described the effects of massage in various ways. Hollis
(1987) classified the effects of massage into two groups—mechanical and
physiological, whereas Lehn and Prentice (1995) talked about reflex and mechanical
effects of massage. However, during massage treatment, the effects produced are
the combination of various mechanical, physiological, reflex and psychological
consequences of massage and in one way or the other are pronounced on some
tissue system of the body. Thus it is much rational to study the effects of this modality
in reference to a specific system. This chapter discusses the effects of massage on
the body as a whole. The effects associated with specific individual techniques are
listed in Chapter 5, which presents a complete discussion on the individual
techniques.
This chapter presents physiological effects of this modality on different system
of the body. The effect of massage on respiratory system is the specific effect of
percussion and vibration, though they are included in this chapter in order to
complete the discussion.
The physiological effects of massage can be discussed under the following
headings:
 Physiological
Definition and Classification Effects9 9
of Massage
1. Effects on the circulatory system
• On the venous and the lymphatic flow
• On the arterial flow.
2. Effects on blood
3. Effects on the exchange of nutritive elements
4. Effects on metabolism
5. Effects on the nervous system
• On sensory nervous system
• On motor nervous system
• On autonomic nervous system.
6. Effects on the mobility of the soft tissue
7. Effects on the respiratory system
8. Effects on the skin
9. Effects on the adipose tissue
10. Psychological effects
11. Effects on immune system.

EFFECTS OF MASSAGE ON THE CIRCULATORY SYSTEM

On the Venous and the Lymphatic Flow
Massage aids in the mechanical emptying of the veins and the lymphatics. It
facilitates the forward movement of the venous blood and the lymph and thereby
reduces the chance of stagnation of the blood and the lymph in the tissue space.
The flow of the venous and the lymphatic channels from the extremities mainly
depends on the activity of the smooth muscles, present in the walls of the vessels.
The contraction of these small muscles in conjunction with the valves present in
the vessels acts as a strong pumping mechanism, which keeps the tissue space
clear from the free fluid. Other factors such as the skeletal muscle pump, thoracic
pump, (i.e. Aspiration of the lymph into the thorax during the inspiration), arterial
pulsation adjacent to the lymphatics and the force of gravity have a minor role in
the normal circumstances but under the conditions where the normal lymph
mechanism does not function properly, these factors become more important.
The contraction of the skeletal muscles compresses the blood vessels and exerts
a pressure on the fluid present inside. This increase in intravascular pressure stimu-
lates the contraction of the smooth muscles present in the wall of the vessels. Cont-
raction of smooth muscles further increases the pressure inside the vessels. When
this pressure increases beyond the threshold, the valves open up and the fluid
moves onto the next segments. As the valves provide only unidirectional flow, the
fluid cannot come back to the empty segment. When the muscles relax, the segment
is refilled by the fluid from the distal segments. This way the venous and the
lymphatic fluids are allowed to move only in one direction.
10 Principles and Practice of Therapeutic Massage
The mechanical action of massage resembles with that of normal muscular
contraction. The different techniques of massage alternately compress and release
the soft tissue. This facilitates the venous and lymphatic flow. The effleurage,
kneading and petrissage squeeze the veins and the lymphatic vessels and force the
venous blood and the lymph towards the heart, causing an increased drainage of
the blood and lymph from the massaged part/segment.
In case of fluid stagnation due to mechanical factors, the flow of venous and
lymphatic fluid is obstructed. Massage facilitates the drainage, and reduces the
stagnation of fluids and also speeds up the removal of waste products. According
to Paikov (1986) the body contains 1200-1500 mm of lymph moving at the speed of
4 mm/sec and massage increases the speed eight folds.

On the Arterial Flow

Massage improves the blood supply of the area being massaged. A definite vaso-
dilation along with an increase in the peripheral blood flow is usually observed
after massage. This moderate, consistent and definite increase in the arterial flow
may be attributed to the following events happening during massage.
• Release of vasodilators
• Activation of axon reflex
• Decrease of venous congestion.

Release of Vasodilators
Massage acts as a succession of mild traumatisation. It provokes and brings about
the release of histamine and other substances by the stimulation of mast cells. This
liberation of histamine plays an important role in the vasodilation produced during
massage (Hollis, 1987). These substances increase the arterial diameter and are
partially responsible for the axon reflex. The patent capillaries open up under the
influence of these chemicals and bring about an increase in the blood flow to the
part massaged.

Activation of Axon Reflex

Massage activates the axon reflex, which produces cutaneous vasodilation. When
an area of the skin is firmly stroked, the sensory nerve ending are stimulated. The
impulse is carried to the spinal cord by the peripheral nerves. In the way itself, a
branch of the nerves may be stimulated and instead of going to the spinal cord,
impulses return back to the periphery to produce its effects on the cutaneous vessels
which are supplied by the branch of the same peripheral nerve (Fig. 2.1). The effect
is the relaxation of the smooth muscles of the arterial wall and the vasodilation
(Chatterjee, 1985).
So the reflex arc of the axon reflex is completed by the two branches of the same
sensory fibres. Through one branch, the impulse is received and through the other
 Physiological
Definition and Classification Effects11 11
of Massage

Fig. 2.1: Axon reflex

it is transmitted back of the peripheral vessels, causing vasodilation. This type of

impulse is known as antidromic impulse. In fact, axon reflex is the only reflex that
does not involve the CNS (Choudhary, 1993).

Decrease of Venous Congestion

If any portion of the vessel is dilated, then the neighbouring vessels also become
constricted (Avon Reflex) (Chatterjee, 1985). The arterioles become compressed if
the venous congestion is increased. The congested venous and lymphatic fluid exerts
a compressive force on the arterioles. The lumen of the arterioles becomes narrow
and so the blood supply to the part is reduced. It is a physiological process, which
the body adopts in order to relieve the congestion. As a result of this, the outflow
from the veins exceeds the inflow to the constricted arterioles and the congestion is
reduced.
Massage promotes the forward movement of lymph and blood and indirectly
helps in restoring the arterial flow.

Research on the Circulatory Effects of Massage

Wolfson (1931) examined the effect of deep kneading massage on the venous blood
on an animal model (Dog). The venous blood flow was measured by anaesthe-
sising the dog and by cannulation of the femoral vein. He found that massage caused
a great initial increase with a fairly rapid decrease in the flow of blood to a rate less
than normal. Immediately following massage blood flow slowly returned to normal.
He concluded that the decrease in the blood flow is due to a more complete emptying
of venous blood for a short period of time. Wakim (1949) used plethosmography
technique to measure the flow of blood, observed that deep stroking and kneading
produced a consistent increase in the flow of blood of extremities in the subjects
with flaccid paralysis. No such increase was found in the normal subjects, patients
of rheumatoid arthritis and subjects with spastic paralysis.
12 Principles and Practice of Therapeutic Massage
With the advent of new techniques of measuring the blood flow, several studies
have been carried out to determine the efficacy of massage on the blood flow. The
results of these reports are at best conflicting at the moment.
Dubrovsky (1982) and Hensen and Kristensen (1973) used radioisotope of Xe133
to determine the flow of blood reported an increased clearance rate of Xe133 after
massage and attributed it to the increase in the blood flow. However, Hovind and
Neilsen (1974) founded that no net increase in the blood flow though the increase
clearance rate of Xe133 was observed in their study, which they attributed to the
mechanical emptying and refilling of vascular bed.
Bell (1964) conducted Plethysmographic studies and reported that the rate of
blood flow was doubled during massage, which lasted for about 40 minutes after
the termination of massage. Sereveni and Venerando (1967) even reported an
increased blood flow in the nontreated homologous limb in response to deep
massage in adults.
Recent studies with ultrasound Dopplerography, however, do not support the
notion that massage leads to increase in the blood flow. Harichaux and Viel (1987)
noted that slower massage was more beneficial for venous return than massage
repeated at high frequency. Though the studies performed by Ek et al (1985), Linde
(1986), Shoemaker et al (1997) and Tidus and Shoemaker (1995) could not
demonstrate any increase in blood flow of muscle and skin following massage.
However Ek et al (1985) noted the individual and sexual variation in the effect of
massage and reported that woman, more than men, increased their skin blood flow
bilaterally after massage.
Hinds et al. (2004) compared the effects of massage against a resting control
condition upon femoral artery blood flow, skin blood flow, skin and muscle
temperature after dynamic quadriceps exercise. Thirteen male volunteers
participated in 3 × 2 min bouts of concentric quadriceps exercise followed by 2 × 6
min bouts of deep effleurage and petrissage massage or a control (rest) period of
similar duration in a counterbalanced fashion. Blood flow and temperature, blood
lactate concentration, heart rate and blood pressure were taken at baseline,
immediately after exercise, as well as at the midpoint and end of the massage/rest
periods. They observed that massage to the quadriceps did not significantly elevate
femoral artery blood flow but the skin blood flow and temperature was found
elevated which was not accompanied by any significant deviation of other
parameters as compared to the resting control. Similar increase in the skin blood
flow confined to the local massaged area has also been reported by Mori et al (2004).
Definitely more well-controlled and defined studies are required before we
approve or disapprove the circulatory effects of massage. For the time being clinical
as well as experimental result in terms of decrease in oedema and increased muscle
clearance rate following massage are beyond doubt (Kresge, 1988). Though much
needs to be done to pin point whether these are due to increased blood flow,
 Physiological
Definition and Classification Effects13 13
of Massage
increased lymphatic drainage or due to more complete emptying and refilling of
the vessels.

EFFECTS ON BLOOD
Few studies are available on the effect of massage on the blood cells. Wood and
Becker (1981) quoted Mitchell to state that RBC count increased after massage both
in health and in anaemia. Schneider and Havens (1915) also reported an increase in
red blood cells and haemoglobin count following abdominal massage. This increase
in RBC and haemoglobin count may increase the oxygen carrying capacity of blood.
Increase in the platelets count after massage has been reported in an animal
model (Lucia and Rickards, 1933). They performed massage on the ear of 5 rabbits
in gentle but firm manner for 5 minutes. The ear was then punctured and the first
drop of blood was studied. They found an increase in the blood platelets count of
the massaged ear, but found no change on the opposite unmassaged ear.
Smith et al (1994) have demonstrated an increase in the neutrophil count
following 30 minutes of massage performed 2 hours after intense exercise. However,
Viitaslo et al. (1995) found no effects of 20 minutes under water jet massage, after
exercises, on the circulating lymphocytes, neutrophils or monocytes.
Hilbert et al. (2003)also did not observe any change in the neutrophil count
following 20 minutes of massage .Though of late a number of studies have reported
alteration in the leucocyte counts following massage in patients afflicted with AIDS
and cancer patients (Hernandez-Reif et al.,2005; Zeitlin et al.,2000).
No satisfactory explanation is available in the literature as to why these changes
occur after massage. According to Kresge (1989) massage raises the RBC count by
mobilising stagnant blood cells in the splanchnic circulation rather than by increased
production. Malone (1990) is of opinion that secondary to mechanical stimulation
the body reacts by increasing the cellular component in the blood. Smith et al (1994)
have postulated that increase in neutrophil count may have the potential to retard
the inflammatory changes associated with strenuous exercises which may be of
some use in the management of delayed onset muscle soreness.
More studies with proper design and statistical analysis are required to explore
the effect of massage on blood cells in both healthy and diseased subjects.

EFFECTS ON THE EXCHANGE OF METABOLITES

Massage promotes rapid disposal of waste products and the replenishment of the
nutritive elements. Massage also increases the movement of liquids and gases in
the body (Hollis, 1987). The increased arterial blood flow following massage brings
more oxygen and nutritive elements and also causes more rapid oxygenation of
the blood. Massage speeds up the lymphatic and venous flow, which promotes
rapid disposal of the waste products of metabolism. These changes make the
exchange of waste products between the blood and the tissue at cellular level more
14 Principles and Practice of Therapeutic Massage
efficiently. This may overall improve the trophic condition of the part being
massaged. However, Gupta et al (1996) did not find any difference in the rate of
lactate removal between massage assisted recovery and simple passive recovery
from a supramaximal exercise bout in 10 male athletes. Their subject received 10
minute of massage consisting of kneading and stroking of upper and lower limbs.
They concluded that short-term massage is ineffective in enhancing lactate removal
following supramaximal exercise.
Detailed discussion on the effect of massage on lactate removal is presented in
the chapter 10.

EFFECTS ON METABOLISM
Traditionally massage has been applied for the purpose of promoting the general
status of well-being. By virtue of increasing arterial blood flow and venous lymphatic
drainage theoretically massage may accelerate the various metabolic process of the
body. However, very little research has been done in this area with conflicting
reports. Some 70 years ago Cuthbertson (1933) in a review article summarised the
various studies and reported an increase in the output of urine, increase rate of
excretion of nitrogen, inorganic phosphorus and sodium chloride following
massage. He reported no effect either on the acid-base balance of the blood, or on
the basal consumption of O2.
Recently, Boone and Cooper (1995), while investigating the effect of massage
on oxygen consumption at rest on 10 healthy adult male also observed no significant
change in O2 consumption, heart rate, stroke volume, cardiac output and A-VO2
difference during the massage.
Zelikovski (1993) using a pneumatic sequential device found no difference in
the blood level of lactate, pyruvate, ammonia, bicarbonate and pH before and after
massage. However, Flore et al (1998) reported a slight increase in maximum O2
consumption after a special massage protocol called biokingeriga (BK).
Danskiold et al (1983) stated that massage performed in the area of regional
muscle tension and pain, increased muscle myoglobin and this increase is
proportional to the degree of muscle tension. They suggested this could be related
to the loss of oxidative metabolic capacity within the muscle. The increase in serum
myoglobin was also reported by Viitaslo et al (1995). However, Rodenburg et al
(1994) could not find any change in the myoglobin concentration in the blood of the
subjects who received massage after an extensive eccentric exercise programme,
although they have found a significant change in the creatine kinase activity in the
blood.
Smith et al (1994) also reported a significant decrease in the rise of plasma creatine
in massaged subject compared to the control group.
 Physiological
Definition and Classification Effects15 15
of Massage
EFFECTS ON THE NERVOUS SYSTEM
The nervous system consists of sensory, motor and autonomic component. Different
techniques of massage produce effects on all these components.

Sensory System
Massage has a sedative effect on the central nervous system which can be easily
demonstrated if applied monotonously with slow rhythm (Knapp, 1990). The use
of massage for the relief of pain of various origins is an age old practice. However,
exact mechanism by which massage brings about pain relief was not understood
until Melzack and Wall (1965) put forward their famous theory of pain gate. The
cognisance that the various sensory inputs, that are carried over by afferents fibres,
can significantly affect the perception of pain has provided a rationalised scientific
basis to the use of massage as a therapeutic modality for pain relief.
The different manoeuvres of massage imparts an array of sensory experience
by stimulating the peripheral sensory receptor, mainly touch and pressure receptors,
present in the skin and soft tissue. These sensations are carried by the large diameter
A β (beta) fibres, which play an important role in inhibition of the perception of
pain, carried by A δ (delta) and C fibres.
The stimulation of low threshold mechanoreceptor blocks the pathway of pain
sensation by presynaptic inhibition at the level of substantia gelatinosa of spinal
cord. This could be the mechanism by which light pressure manoeuvres massage
like effleurage, stroking, hacking, tapping, beating, etc. reduce the pain.
Some massage manoeuvres also produce mild to moderate pain by stimulation
of painful areas of the body. It is said to facilitate the secretion of certain antipain
substances, such as β endorphin and enkephaline, in the periaqueductal gray matter
(PAG) at the level of midbrain. From there, these substances descend to the dorsal
horn of spinal cord, and suppress the release of substance P (neurotransmitter of
pain). This blocks the transmission of pain impulses to the higher pain perception
area of brain.
This effect is otherwise also known as counter irritant effect. It is attributed to
the pain relief obtained by acupuncture and acupressure, which also relieves pain
by producing localised pain. This could be one of the mechanism responsible for
the pain relief obtained by heavy pressure manoeuvres like kneading, friction,
petrissage, connective tissue massage, etc.
Kaada and Tersteinbo (1989) have reported a moderate mean increase of 10 per
cent in β endorphin level, lasting for about one hour with a maximum effect after 5
minutes, after termination of connective tissue massage in 12 volunteers. They linked
the release of β endorphin with the pain relief, feeling of warmth and well-being
associated with massage.
16 Principles and Practice of Therapeutic Massage
Motor System
According to Kuprian (1982) the physiological effects of classical massage lies
primarily in its ability to exert regulatory influences on the muscle tone. It is generally
agreed that massage can elicit facilitating and inhibiting responses in neuromuscular
excitability (Hollis, 1987; Wood and Beaker, 1981). This seemingly paradoxical claims
may be attributable to the difference in the rate of application and the degree of
pressure applied during various massage manoeuvres (Sullivan, 1993).

Facilitatory Effects of Massage on Motor System

It is said that massage can reflexly increase the muscle tone by stimulation of the
skin receptor or stretch of the muscle spindle (Hollis, 1987). Superficial stroking,
taping, hacking, etc. are commonly used for this purpose.
The tone of muscle is maintained by the activity of muscle spindle. Muscle
spindle contains the intrafusal fibres supplied by gamma motoneuron and lies
parallel to the extrafusal fibres of the muscles that are supplied by alpha motoneuron.
The capsule of muscle spindle is attached with the extrafusal fibres. Any stretch to
the muscle spindle, either by activation of gamma motoneuron or by passive
mechanical procedures, activates the reflex arc. The impulse travels via the afferent
nerve fibres and propagates toward the spinal cord. Some impulses are
monosynaptically transmitted to the alpha motoneuron of the same muscle. The
activation of alpha motoneuron produces contraction of the extrafusal fibres of the
muscle.
Various massage manoeuvres stretch the muscle fibre which may facilitate the
muscle contraction. However, according to Lehn and Prentice (1994) massage does
not increase muscle tone. Wood and Backer (1981) also commented that the notion
that massage causes increase in muscle tone has not been substantiated by
experimental scientific research.
Nevertheless, in various facilitation techniques, different massage manoeuvres
are used for the purpose of increasing the tone of hypotonic muscles, the mechanism
of which is not yet understood. It is claimed that most facilitation techniques are
directed at stretch reflex with a view of controlling them more efficiently by having
an inhibitory or excitatory effect on motoneuron pool. The basis of this assumption
is the observation that factors creating abnormalities in the stretch reflex mechanism
have a devastating effects on the production of normal movement (Atkinson, 1986).
Following are the few of the facilitation techniques, which utilise massage
manoeuvres.
• Touch, applied over the working muscles and/or the surface against which the
movement has to occur, supplies skin stimulation which acts as a guidance to
the movement and facilitates the activities in the motoneuron pool.
• Pressure over the muscle belly has the effect of activating the muscle spindle,
probably by distorting the shape of muscle fibres and creating a stretch stimulus.
 Physiological
Definition and Classification Effects17 17
of Massage
• Cutaneous stimulation by quick light brushing, stroking, clapping and pressure
over the relevant dermatone is being used as a preparatory facilitation to increase
the excitability of motoneurons which supply the inhibited muscle.
(a) For the skin supplied by anterior primary rami, the excitatory effect is local
and is mainly confined to superficial muscles.
(b) For the skin supplied by posterior primary rami, the excitatory effect is on
deep muscles.
It is postulated that cutaneous stimulation causes rapid and large modulation
of muscle spindle sensitivity presumably through complex gamma motoneuron
fibres (Atkinson, 1986).

Inhibitory Effects of Massage on Motor System

Massage techniques can also reduce the tone of muscle. It has been claimed that
petrissage or massage in which muscles are kneaded can exert an inhibitory effect
on motoneuron (Hollis, 1987; Tapan, 1988). It is said that effleurage is capable of
producing both stimulating and relaxing effects (Wood and Backer, 1981; Hollis,
1987).
According to Rood, slow stroking if carried out from neck to sacrum over the
centre of back will reduce fluctuating muscle tone. Deep rhythmic massage with
pressure over the insertion of muscle has been proved effective in some cases of
spasticity.
Activation of tension dependent Golgi tendon organ, which has an inhibitory
effect on the stretch reflex mechanism, has been postulated as a mechanism of these
effects.
Recently, studies have been conducted to substantiate these claims by providing
scientifically documented evidence. These rigorously designed experiments have
shown that some techniques of massage (petrissage, kneading and effleurage) exert
an inhibitory effect on the spinal alpha motoneuronal excitability. This inhibitory
effect is transient (Sullivan et al., 1992), directly related to the pressure applied
during massage (Goldberg et al., 1992) and is not only restricted to homonymous
motoneuron pool (Sullivan, 1991), but could also be demonstrated for a close
synergistic muscle uninvolved in the massage (Morelli et al., 1998).
Efficacy of massage on motoneuronal excitability was objectively examined in
all these studies using the amplitude of H(Hoffmann) reflex which is an indirect,
but reliable measure of motoneuron excitability.
Sullivan et al. (1992) recorded H-reflex from the distal aspect of right triceps
surae muscle in a controlled experiment where 4 minutes massage of ipsilateral
and contralateral triceps surae, and hamstrings muscle group was used as the
technique of intervention. They observed that massage of ipsilateral triceps surae
resulted in a reduction of H-reflex amplitude (0.83 mV) in comparison with the
pretest control condition and remaining experimental condition (range 1.77-2.33
18 Principles and Practice of Therapeutic Massage
mV). They concluded that the stimulus and receptor activated during massage are
specific to the muscle being massaged.
Similar reduction in H-reflex amplitude has also been reported during 3 minute
petrissage (Morelli et al., 1990) and 6 minute petrissage (Morelli et al., 1991) who
concluded that reduction of H-reflex amplitude were observed only during the
period of tissue manipulation regardless of the duration of massage.
Sullivan et al., (1993) reported a mean reduction of 25 per cent in amplitude of
H-reflex recorded from ipsilateral triceps surae of 16 healthy subjects, during 3
minutes of effleurage. In all these studies, the reduction was sustained only for the
duration of massage. Immediately after the massage H-reflex returned to the
pretreatment control level with a tendency for the amplitude to increase with each
successive trial.
Goldberg et al (1992) compared the effects of two intensities of massage (light
massage (5 mm H2O) and deep massage (10 mm H2O)) and found that though the
H-reflex was reduced in both intensities of massage, the deep massage produced
greater reduction than the light massage procedure.
It is suggested that H-reflex modulation results under the influence of rapidly
adopting receptors or centrally mediated pathways via polysynaptic and non-
segmental projections specific to the motoneuron pool (Morelli et al., 1991).
The attenuation in motoneuron excitability is manifested in the reduction of
muscle tone and can form the plausible explanation of the efficacy of massage in
the treatment of spasm and other condition associated with increased muscle tone
such as psychological stress, precompetition anxiety, etc. in neurologically healthy
individual.
However, these results cannot be extrapolated to the neurologically impaired
people as these were obtained with neurologically healthy subjects (Sullivan, 1991).
There is a need to examine the application of massage on the neurological disorders,
especially on the upper motorneuron lesion.
In an attempt to investigate the effect of massage in person with neurological
impairment Goldberg et al. ( 1994) examined the effect of 3 minute petrissage on 10
spinal cord injured individuals and observed a 27 per cent mean group decrease in
the peak-to-peak amplitude of H-reflex during the 3 minute massage (petrissage)
as compared to premassage and postmassage condition. However the response
was not uniform in all the subjects. in some subjects the H reflex amplitude increased
by 20 per cent whereas in some in decreased up to 80 per cent. Moreover the response
was not associated with any long-term effects.

On Autonomic Nervous System

Several authors have hypothesised that massage has definite reflex effect and it
can influence the functioning of visceral organ by modulating the autonomic nervous
system through peripheral sensory stimulation. (Ebner, 1975; Mennell, 1945; Hollis,
1987; Lahn and Prentice, 1995).
 Physiological
Definition and Classification Effects19 19
of Massage
Physiological responses associated with autonomic nervous system, such as
heart rate, cardiac output, blood pressure, respiratory rate, skin temperature, skin
conductance, activity of sweat gland, etc. are claimed to be influenced by massage.
However, in the absence of conclusive experimental evidence, it becomes difficult
to substantiate or refute these claims. In general it is accepted that massage increases
the temperature of skin, activates the sweat gland and increases the skin conductance
(electrodermal response). The reports on the effect of massage on other parameters,
such as cardiac output, blood pressure, respiratory rate, etc. are conflicting. Some
studies reported an increase in all these parameters whereas other reported either
decrease or no change.
Ebner (1975) reported the investigation of skin temperature of three patients
after connective tissue massage. An increase in skin temperature (1-2°C) of the foot
was observed following 20 minutes of connective tissue massage on lumbosacral
segment of back.
Connective tissue massage improves the blood supply of target organ by
balancing the sympathetic and parasympathetic component of autonomic nervous
system (Thompson et al., 1991). It is claimed that when soft tissue mobilisation is
performed for autonomic or reflex effects, sensory receptors in skin and superficial
fascia are stimulated. The stimulus passes through afferent pathways to the spinal
cord and may be channelled through autonomic pathways producing effects in the
area corresponding to the dermatomal zone being massaged.
Barr and Taslitz (1970) examined the effect of back massage on autonomic
function on 10 normal female subjects. They reported that an increase in sympathetic
activity occurred during the massaged period in experimental group as evident by
a delayed increase in systolic blood pressure, increased heart rate, increased sweat
gland activity, and increased body temperature. However, they had not subjected
their data to statistical analysis. Peshkov (1981) also found a marked increase in the
electrodermal response (EDR/GSR) in young gymnasts following massage.
The electrodermal response (or GSR) is a reflection of variation of the sweat
gland activity and pore size, both of which are controlled by the sympathetic nervous
system. Barr and Taslitz (1970) reported an increase in heart rate after 20 minutes
of back massage. However, Boone and Cooper (1998) could not found any change
in heart rate after 30 minutes massage of lower extremity.

EFFECTS ON THE SOFT TISSUE

Massage has significant effect on certain properties of the soft tissues like elasticity,
plasticity and mobility. The tissues which can be affected by massage include
muscles, sheath, ligaments, tendons, aponeurosis, joint capsules and superficial as
well as deep fascia. Different manoeuvres of massage stretches the constituent
collagen fibres of these tissues in different directions. The adhesions present between
fibres are broken and maximum mobility between fibres and adjacent structures is
20 Principles and Practice of Therapeutic Massage
ensured. Cyriax (1998) stated that transverse friction restores the mobility of muscles
in the same way as mobilisation frees the joint.
The main function of a muscle is to contract. When a muscle contracts, not only
its length reduces but the width of muscle also increases. Cyriax refers this
phenomenon as the broadening out of muscle and states that the full mobility of
muscle in broadening out must be maintained in order to achieve adequate
shortening of muscles. Different massage manoeuvres especially transverse friction
mechanically separate the glued muscle fibres and restores the mobility.
The fibrin formed within the chronic endurated structures following chronic or
subacute inflammation can effectively be stretched and mobilised during pressure
manipulations. This way massage maintains and restores the mobility of soft tissues
as well as prevents adhesion formation, joint stiffness, contracture, etc.

MUSCLE STRENGTH
Massage is capable of increasing muscular strength, is one of the most persistent
and widespread belief in both professional and lay medical circle (Kuprian, 1982).
Most authorities on the subjects are of unanimous opinion that massage does not
increase the strength of muscle (Lahn and Prentice, 1995; Wood and Backer, 1981;
Knapp, 1990). Strengthening of a muscle can only be achieved by the active
contraction of a muscle. Massage, at best, can prepare the muscle for contraction by
increasing the circulation and facilitating the removal of metabolic waste.
Massage is used for facilitating the recovery of muscle function following
exhaustive exercises. The experimental evidences with regards to this use of
massage are equivocal. A detailed discussion on this topic is presented in Chapter
10.

EFFECTS ON THE RESPIRATORY SYSTEM

Percussion and vibration techniques of massage assist the removal of secretion
from the larger airways, though their effect on the smaller airway is controversial
(Imle, 1989). Increased secretion clearance, after chest physiotherapy, both in adult
and in paediatric group can be the result of percussion and vibration loosening and
advancing secretions from the airways more centrally. After the removal of secretion
gas exchange becomes more efficient. An increase in PaO2 have been frequently
reported after respiratory massage manoeuvres in patients suffering from chronic
obstructive pulmonary disease (Bateman et al., 1981), postoperative and post-
traumatic patients (Ciesla et al., 1981; Mackenzie et al., 1978) and in neonatal patients
suffering with respiratory distress (Finer et al., 1979). Significant decrease in partial
pressure of oxygen has been reported in critically ill patients receiving chest
physiotherapy in the form of postural drainage and percussion. However,
percussion and vibration alone not proven to contribute to hypoxaemia, though
postural drainage which is often employed with these techniques does cause
alteration in cardiorespiratory functions.
 Physiological
Definition and Classification Effects21 21
of Massage
Efficacy of each treatment method is difficult to assess as in most of the chest
physiotherapy research along with these manual techniques postural drainage,
cough, suction and breathing exercises are also included. The attempts to evaluate
the specific contribution of percussion or vibration to the total therapy programme
are both rare and conflicting. Percussion is shown to effect intrathoracic pressure
change of 5-15 cm of H2O (Imle, 1989).
Percussion is thought to cause bronchospasm which is evident by a fall in FEV1
in some patients of chronic lung disease (Campbell et al, 1975) which is small and
short lived in the most of these cases. However, other studies have either reported
no change or increase in FEV1. It is often stated that vibration dislodges the most
stubborn secretion in larger as well as smaller airways. Hyperinflation with vibration
is associated with significant and deleterious increase in intracranial pressure
(Garradd and Bullock, 1986) and fluctuation in cardiac output (Laws and Mclntygre,
1969).
Efficacy of these techniques is dependent on the skill of the clinician and
complications have been reported mostly due to poor technique administration.

EFFECTS ON THE SKIN

Massage in general improves the nutritive status of skin. Following massage the
temperature of skin rises. Massage facilitates the movement of skin over the
subcutaneous structures. As a result skin becomes soften, more supple and finer.
Furthermore, after prolonged massage the skin also becomes tough, more flexible,
elastic and its sensitivity is reduced so that it can be handled fairly roughly without
causing much discomfort. It has a soothing effect on the highly sensitive and vascular
papillae, over which deeper layers of the culticle fits.
The dead cells are removed by the constant contact of the hand over the skin.
The sweat glands, hair follicles and the sebaceous glands, thus, become free from
obstruction and can function more effectively (Hollis, 1987). Massage, by activating
the sweat glands, increases perspiration, so that the heat dissipation is increased. It
also facilitates the sebaceous secretions from exocrine glands of skin and thus,
improves the lubrication and appearance of skin.

EFFECT ON ADIPOSE TISSUE

Massage was found responsible for activation of lipolysis. The release of
catecholamine by the tissue nerve ending was particularly stressed as the cause.
This was confirmed when activation of lypolysis was depressed by beta blockers
(Wakim, 1985).
Similar claims have been made that massage can remove the deposits of adipose
tissue in the various layers of the body.
22 Principles and Practice of Therapeutic Massage
However, experimental studies by Wright (1946), Kalb (1944), etc. do not support
this notion. Knapp (1990) has also stated that massage is ineffective in weight
reduction. Though massage is widely used in various obesity reduction programmes
both manually and in the form of vibratory belt, lack of literature on this topic
makes it difficult to justify this claim. However, it may be hypothesised that since
massage improves the function of muscle and helps reduction of fatigue, the subject
may perform vigorous exercises with little more intensity after massage which
ultimately burns the calories. So at the best massage can work only as an adjunct to
weight reduction programmes.

PSYCHOLOGICAL EFFECTS
Massage can lower the psychoemotional and somatic arousal such as anxiety and
tension.
During massage treatment, a close contact is established between therapist and
patient, which help to overcome the feeling of strangeness and anxiety. The
surrounding equipments, treatment area and the assured way in which therapist
handles the patient, all exert a strong placebo effect. It helps to reduce tension and
anxiety and induces relaxation. This effect is more pronounced when massage is
used for the purpose of general relaxation.

IMMUNOLOGICAL EFFECTS OF MASSAGE

In recent times several research groups started postulating that massage as a useful
stress-reduction tool may be capable of inhibiting, or even reversing, potentially
detrimental immunological effects associated with AIDS and cancers. On the basis
of this postulation lies the studies that showed associations between stress and
immune suppression (Glaser, 1984), and between stress-reduction interventions
and immune enhancement (Kiecolt-Glaser, 1985). Since ages the role of massage in
inducing relaxation and combating the stress-related symptoms has been advocated.
It is now believed that massage may exert some effect in modifying the immune
system activities. Recent research focus is directed towards the investigation into
the immunological effects of massage therapy in an attempt to provide rationales
for its use in combating some late stage complications associated with AIDS and
cancer.
Ironson et al. (1996) reported significant increases in natural killer (NK) cell
number and function with HIV positive and HIV negative men following massage.
Similar finding on the normal subjects undergoing a stressful situation has also
been reported by Zeitlin et al. ( 2000) who examined the immunological effects of
massage therapy as a stress-reduction intervention a sample of nine medically
healthy subjects. All the subjects were first- and second-year female medical students
(age range 21-25) who received a 1-hour full body massage 1 day before an academic
examination that was causing them considerable anxiety. The massage protocol
was developed to encourage relaxation and increase circulation and included the
 Physiological
Definition and Classification Effects23 23
of Massage
application of effleurage, petrissage, and friction strokes of Swedish massage. Blood
samples, self-report psychosocial data, and vital signs were obtained immediately
before and immediately after the massage treatment. Cell phenotypes of the major
cells of the immune system, natural killer cell activity (NKCA) and mitogen-induced
lymphocyte stimulation were also assessed. The results showed a significant
reduction in respiratory rate, stress scores, and a decrease in the percentage of T
cells postmassage. Though no significant differences between pre- and postmeasures
of blood pressure, pulse, or temperature were found. An increase in the total number
of peripheral WBCs postmassage was observed which was not associated with the
increase in the absolute number of T cells. Analysis of NKCA data revealed a
significant time (pre-post) effect indicating a significant increase in killing activity
after the massage. The authors suggested that massage may have health benefits
beyond and unrelated to its stress-reduction potential.
However Birk et al. ( 2000) could not observe any significant ( p < 0.05) changes
in peripheral blood levels of CD4+ lymphocytes, CD8+ lymphocytes, CD4+/CD8+
lymphocyte ratio and natural killer cells following a 45-minute overall body massage
once per week on a sample of forty-two subjects with HIV infection.

Table 2.1: Physiological effects of massage at a glance

• ↑Venous and lymphatic flow.1

• ↑Arterial blood flow to the muscle and skin.2
• ↓Stagnation of fluid in tissue space.1
• ↑Removal of waste products of metabolism.2
• ↑WBC, RBC and platelets count in circulating blood.2
• ↑Nutritive exchange between blood and cells.3
• ↑Trophic status of the part massaged.3
• Induce sedation.
• ↓Pain.3
• Facilitate contraction in hypotonic muscle.3
• ↓Excitability of motoneuronal pool in neurologically healthy person.1
• Modulate autonomic response.2
• ↑Electroderma response or GSR.1
• ↑Removal of secretion from lung.1
• ↑Gaseous exchanges across pulmonary capillaries.1
• ↑Removal of dead cells from skin.3
• ↑Activity of sweat and sebaceous gland.1
• Modulate psychosomatic arousal.1
• Mobilise soft tissue.1
• Break the soft tissue adhesions.1
• Accelerate various metabolic processes.2
• Promote lypolysis.3
1 = experimentally proved 2 = conflicting claims 3 = no experimental evidence
24 Principles and Practice of Therapeutic Massage

3
Therapeutic Uses

Massage is one of the oldest form of treatment for human ills. It has been used as a
therapeutic modality in various conditions since ancient times. However, often
without rationalisation and scientific evidence. In ancient Syria, massage was
believed to be capable of expelling spirits from a person’s body. It was also advocated
in conditions like syphilis and intestinal obstructions (Kellogg, 1919). In ancient
Rome and China it was used extensively. It continues to be used in most of the
traditional Indian systems of medicine till today, where its utility is claimed in
almost every clinical condition. However, like any other form of treatment massage
cannot be beneficial in all the diseases or injuries (Wood and Becker, 1981). Rather,
if the physiological effect of massage is analysed carefully, it becomes clear that
quite a few conditions are amenable to massage. In physiotherapy, massage is used
for the following purposes:
• To improve the mobility of the soft tissues
• To reduce muscle spasm and pain
• To reduce oedema
• To increase circulation
• To mobilise secretions in the lung
• To induce local and general relaxations.

Mobility of Soft Tissue

The skin, fat, fascia, muscle and the ligament are the soft tissues of the body. Any
injury or inflammation to these soft tissues leads to adhesion formation, which
decreases their mobility and causes pain. After inflammation, the new granulation
tissue formed during the process of healing is usually oedematous. This is due to
the presence of a protein rich fluid which leaks into the tissue space from the
capillaries in the process of neovascularisation. This oedema in the soft tissue persists
long after the inflammatory response is over. It consolidates and binds the newly
laid collagen fibres to each other and to the surrounding structures. This causes
adhesion formation, extensive scarring, soft tissue tightness and contracture which
are the common causes of pain and dysfunction of the moving part of the body, i.e.
the musculoskeletal system.
 Therapeutic
Definition and Classification of MassageUses25 25
The to and fro movement of massage mechanically breaks down the adhesion
and facilitates the free movement of the adherent structure. The aim of massage is
to prevent the adherence of recently formed soft tissue and also to break the adherent
scar tissue established in the long-standing cases. The different massage manoeuvres
roll the individual fibres of the soft tissue. This breaks the adhesion and aids in the
facilitation of movement. Increased scar pliability and decreased scar bonding with
the use of massage have been reported. Bodian (1969) founded that massage useful
in treating thick scar and keloid formation around eyelid. In an animal model (rat),
Gahlsen et al (1999), induced tendinitis in Achilles tendon using the enzyme
collagenase and treated it with soft tissue mobilisation of various pressure. They
reported a statistically significant increase in the number of fibroblasts, determined
by the use of light microscope and electron microscope, in cases treated with heavy
pressure mobilisation. They observed that the application of heavy pressure
promotes the healing process to a greater degree than the light or moderate pressure.
However, Patino et al. (1999) failed to demonstrate any appreciable effect of
massage therapy on the vascularity, pliability and height of hypertrophic scar in 30
paediatric patients.
Nevertheless, massage has an important role in the mobilisation of soft tissue
and its uses are advocated in conditions where adhesion and restricted mobility
are the causative factors of pain and limitation of motion. It’s role in prevention of
the adherent tendon and skin, a common complication in all microsurgical
procedures, has now gained universal acceptance. The various conditions in which
massage is used for mobilisation of soft tissue are listed below:
— Tendinitis
— Tenosynovitis
— Fibrositis
— Muscular injury
— Ligament sprain
— Postsurgical scar
— Postburns contracture
— Pre-and postoperative cases in plastic, and reconstructive surgery.

Muscle Spasm and Pain

Spasm is the increased muscle tone in a localised area. It is one of the primary
responses of body to pain or injury. The increase in muscle tone is a protective
mechanism which helps to prevent further damage by restricting the movement.
Often, this contracted state of the muscle is maintained for long periods and itself
becomes the cause for pain. Physiologically, in presence of spasm there occurs
capillary constriction which reduces the blood flow. Circulatory restriction results
in limitation of the flow of nutrients and oxygen to the area and retention of waste
product. More spasm leads to more ischaemic pain and less flexible tissue. This
26 Principles and Practice of Therapeutic Massage
vicious cycle of pain-spasm-pain is advanced and spasm persists. This, vicious
cycle can be broken by massage (Liston, 1997). Massage interferes with this cycle
by reducing the pain. It thus prevents the further occurrence of spasm.
Pain is reduced or minimised following massage which can be explained by
following hypothesis:
1. By the stimulation of sensory nerve endings and production of mild pain,
massage blocks the pathway of pain in accordance with the Melzack and Wall’s
theory of pain gate.
2. The mechanical movement of massage stretches the individual fibres of soft
tissue and reduces their tension.
3. Removal of metabolic waste products results due to increased drainage of the
massaged area. This results in reduction of pain, as these substances are noxious
to the tissue and irritate the free nerve endings.
4. Increased blood flow following massage reduces the anoxic condition present
in the tissue due to the compression of the blood vessels produced by the
sustained muscular contraction. Thus, it reduces the danger of increased tissue
damage.
5. The stimulation of the peripheral sensory receptors is said to have an effect on
the general level of excitation and inhibition in the region of the anterior horn
cells. This effect is utilised in massage to reduce the tone of muscles in
neurologically healthy individuals.
All these factors together aid to reduce the spasm. For this purpose massage is
employed in the following conditions.
— Unspecified back pain
— Fibrositis
— Postexercise muscle soreness, etc.

Reduction of Oedema
Oedema is the accumulation of tissue fluid in the extracellular space. Untreated
oedema is an established causative factor for delayed healing, pain as well as for
decreased mobility with subsequent compromised functional use of the afflicted
part. Massage is an important aspect of oedema reduction programme (Mager and
McCue, 1995). Massage reduces oedema utilising its mechanical effect of forcing
the fluid into the drainage channels. When the oedema is due to mechanical factors
such as muscle inactivity as in paralysis, valve insufficiency, lymph node blockage,
etc. massage procedures are helpful in the reduction of swelling. For the same
purpose, it is also used in the management of venous ulcer, lymphoedema following
radical mastectomy, etc. However, it should be supplemented with, active exercises,
elastic bandages and elevation to offer better and sustained effects.
 Therapeutic
Definition and Classification of MassageUses27 27
Enhancement of Circulation
Massage has been used throughout the ages as a treatment for cold extremities,
where the blood supply is decreased due to the vasoconstriction in response to the
cold. The rubbing activity causes vasodilation and thus increases the temperature
of the affected part of the body.
Massage is prescribed in nerve palsies, and in various lower motor neuron
lesions. The purpose of this is to maintain the trophic condition of the paralysed
part, utilising the circulatory effects of massage.
Massage becomes an important substitute for muscle activity in conditions when
the body parts cannot be moved due to various reasons including severe exhaustion
following intense physical works, old age, prolonged recumbency, generalised
paresis, etc. The mechanical compression and relaxation of massage creates a
pumping effect and improves the lymphatic and venous drainage. This hastens
absorption of fluid and reduces stagnation. The improved arterial circulation
following massage facilitates the exchange of nutritive elements into the paralysed
extremities. In this way the nourishment of the paralysed muscle is maintained to
a certain extent.
For this effect only massage is advised in all type of flaccid paralyses, i.e. Bell’s
palsy, poliomyelitis, neurotmesis, Guillain-Barré syndrome, etc.
In these cases, however, the purpose of massage is only to maintain the nutrition
of the muscle. It does not have any affect on the strength of the muscle, which can
only be increased by active exercises.
The increased circulation following massage is also utilised in the management
of sports specific conditions. Preactivity massage brings more blood and oxygen to
the massaged part and thus helps in warming up of the muscles. Postactivity
massage removes excess of lactic acid and other metabolites accumulated in the
muscle and is said to decrease the severity of delayed onset muscle soreness.
However, massage cannot increase strength of the muscle nevertheless it can prepare
the muscle for high intensity activity/exercise for a longer duration, which
ultimately leads to increase in muscle strength.

Mobilise Secretions in the Lungs

Certain techniques of massage (i.e. clapping, vibration and shaking) are exclusively
used for the management of chest disorders. Massage finds a major role in the
treatment of those chest disorders where increased and viscid secretions are the
source of problem. In diseases like chronic bronchitis, emphysema, cystic fibrosis,
bronchiectasis, etc. there occurs increased production of sputum which accumulates,
stagnates, dries up and blocks the small respiratory pathways.
The gaseous exchange of the part distal to the block, becomes restricted and
gradually that segment of lung collapses. Similar increases of sputum production
is seen in postoperative periods of cardiothoracic and abdominal operations. The
28 Principles and Practice of Therapeutic Massage
various manual and mechanical respiratory techniques of massage, i.e. vibration,
shaking, percussion, etc. produce a jarring effect on the lung tissue. The mechanical
energy transmitted to the lung tissue through the chest walls leads to the loosening
up of the viscid secretions. Massage also moves the sputum up in the bronchial
tree. Drainage of the sputum is facilitated by postural drainage. Once the secretions
loosen up and go up in the upper respiratory tract, they can be removed by coughing.
Doering et al (1999) examined the influence of manual vibratory massage on
the pulmonary function of postoperative patients of heart and lung transplant. The
vibratory massage was performed with a frequency of 8-10 vibrations per second
for 7.5 minute on each side of thorax, starting from the lower costal arch and
progressing to the upper thoracic aperture. They found during the vibratory
massage, a significant increase (p < .05) in mean tidal volume by 30 per cent and in
the percutaneous oxygen saturation. Significant decrements were observed in the
central venous pressure (by 11%), and the pulmonary vessels resistance (by 18.3%).
They found no change in cerebral blood flow velocity. They observed that vibratory
massage, by reducing ventilation perfusion mismatch and by increasing oxygen
saturation, could be a helpful method for improving pulmonary mechanism and
perfusion.

General and Local Relaxation

The importance of touch as a means of communication and its importance in
imparting a sense of well-being and confidence cannot be underestimated.
Psychologically and emotionally, massage has been used since ages to enhance a
feeling of well-being and relaxation. Tiredness after prolonged work, anxiety of a
feverish child as well as pain and apprehension of an arthritic elderly responding
well to massage is a common man’s experience. Therefore, the use of massage for
ensuring comfort and relaxation has remained one of the most common practice in
all cultures and civilisations throughout the world.
Massage has been shown to have a beneficial influence on development,
attitudes and emotional status of a baby (Schneider, 1992). Psychological parameters
associated with tension and anxiety have been shown to decrease significantly with
massage (Makechnic et al., 1983). Crompton and Fox (1987) also observed that
massage techniques promote two to three times faster recovery of psychological
and physiological status of athletes.
Recently several studies have appeared in literature where, the efficacy of
massage in reducing anxiety and stress associated with several clinical conditions
has been examined scientifically. Richards (1998) compared the efficacy of six
minutes of back massage with psychological relaxation technique (muscle relaxation,
mental imagery and music) on the sleep of elderly cardiovascular patients admitted
in critical care unit. He observed that the quality of sleep was improved among the
back massage group whose patients slept one hour longer than the other group.
 Therapeutic
Definition and Classification of MassageUses29 29
Field et al (1998) reported that asthmatic children treated with 20 minutes
massage before bedtime for 30 days showed immediate decrease in behavioural
anxiety. Their attitude toward asthma also improved along with other pulmonary
functions over the period of one month. Similar decrease in anxiety, improved mood
and pulmonary function with massage has also been reported in children with
cystic fibrosis (Hernandez-Reif et al., 1999). Massage was shown to decrease
fidgetting in adolescent with attention deficit hyperactivity disorder (Field et al.,
1998). On their study on pregnant women, Field et al. (1999) founded that 20 minutes
massage session twice a week for 5 weeks resulted in reduced anxiety, improved
mood, better sleep and less low back pain in addition to fewer complications during
labour and postnatal period.
In an interesting study, Hernandez-Re if, et al (1999) taught hand or ear self
massage to smokers (mean age 32.6 years), during 3 craving per day for 1 month
and found that self-massage group smoked few cigarettes by the last week of the
study. They suggested that self-massage may be an effective adjunct to the treatment
for the adults attempting smoking cessation to alleviate smoking related anxiety,
reduce craving and withdrawal symptoms, improve mood and to reduce the number
of cigarettes smoked per day.
Though the role of massage in reducing anxiety and improving mood has long
been accepted, these studies provide an insight into the newer application of this
therapy.
In the recent times the use of massage as a form of complementary therapy has
increased. The following paragraphs presents a brief discussion on these recent
trends on the use of massage.

Massage and Obesity

Deep mechanical massage has been advocated as an alternative or adjunctive
therapy for the contouring of subcutaneous fat and as a treatment for cellulite
(Adcock,2001). However experimental evidence with regard to this effect is scarce
and contradictory. Till today, no controlled clinical trial has established the role of
massage in the reduction of obesity. Though several equipment based on the
principles of vibratory massage is being marketed for this purpose.

Massage and AIDS

Of late a number of studies have appeared in the literature reporting the increasing
use of massage by the AIDS patients (Williams et al. 2005; Mills and Ernst, 2005;
Gore-Felton,2003; Toups,1999). Several articles have also appeared in the literature
that examined the role of massage in the management of AIDS-related problems
(Siegel et al., 2004; Toups, 1999 ). These reports are to be read with caution. Some
studies reported increase in natural killer cell activity after massage in both AIDS
as well in normal individual under stressful condition. In an extensive review on
the use of complementary therapies on the AIDS Mills and Ernst (2005) found only
30 Principles and Practice of Therapeutic Massage
four clinical trial on massage and commented that available data are insufficient
for demonstrating effectiveness of massage therapy in the management of AIDS.
They further commented that notwithstanding the widespread use of
complementary and alternative medicine by people living with HIV/AIDS, the
paucity of clinical trials and their low methodological quality is a matter of concern.
However the most important role of massage in the management of these patient
groups may exist in the area of stress reduction. Several studies have documented
that massage or touch helps alley the anxiety, depression and the other stress related
symptoms in this patient group. According to Müller-Oerlinghausen (2004) slow-
stroke massage is suitable for additional acute treatment of patients with depression
which was very readily accepted also by very ill patients. Birk et al. (2003) in a
controlled clinical trial observed that Massage administered once per week to HIV-
infected persons does not enhance immune measures though massage combined
with stress management favourably alters health perceptions and leads to less
utilisation of health care resources. On the basis of current evidences it can be
suggested that as far management of stress and fatigue related symptoms associated
with AIDS the use of massage may have some role, which need to examined further.
However claims with regards to its role in the cure of the diseases should be
dismissed.

Massage and Cancer

Many people with cancer experience pain, anxiety, and mood disturbance.
Conventional treatments do not always satisfactorily relieve these symptoms, and
some patients may not be able to tolerate their side effects. Complementary therapies
such as acupuncture, mind-body techniques, massage, and other methods are now
increasing being used in providing palliative care to the terminally ill cancer patients
in order to relieve symptoms and improve physical and mental well-being. (Deng
and Cassileth, 2005). It is suggested that patients who receive massage have less
procedural pain, nausea, and anxiety and report improved quality of life. Increase
in the level of dopamine levels, natural killer cells, and lymphocytes following
massage in women diagnosed with breast cancer have been reported by Hernandez-
Reif et al. (2005).However the strongest evidence for benefits of massage is for stress
and anxiety reduction, although research for pain control and management of other
symptoms common to patients with cancer, including pain, is also promising.
(Corbin, 2005).
Manual lymph drainage is a specialised form of massage used in patients with
lymphoedema. Two small trials (Johansson et al., 1998; Johansson et al., 1997)
founded that manual lymph drainage to be an effective adjunct to compression
bandaging or sleeves in patients with arm lymphoedema after surgery for breast
cancer.
 Therapeutic
Definition and Classification of MassageUses31 31
Cassileth and Vickers (2004) studied the patients reported symptom severity
before and after the application of massage therapy in 1290 patients over 3 years
period using 0-10 rating scales of pain, fatigue, stress/anxiety, nausea, depression
etc. They observed that symptom scores were reduced by approximately 50 per
cent, even for patients reporting high baseline scores. These data indicate that
massage therapy is associated with substantive improvement in cancer patients'
symptom scores.
In a Quasiexperimental design on a sample of 41 patients admitted to the
oncology unit at a large urban medical centre in the United States for chemotherapy
or radiation therapy. Smith et al. ( 2002 ) examined the effects of therapeutic massage
on perception of pain,subjective sleep quality, symptom distress, and anxiety in
patients hospitalised for treatment of cancer. Twenty participants received
therapeutic massage and 21 received the control therapy of nurse interaction. It
was observed that mean scores for pain, sleep quality, symptom distress, and anxiety
improved from baseline for the subjects who received therapeutic massage; only
anxiety improved from baseline for participants in the comparison group. Similar
finding have also been reported by Cassileth and Vickers (2004) who in a
randomised clinical trial involving 1290 patients reported about 50 per cent
reduction in symptoms scores of pain, fatigue, stress/anxiety, nausea, depression,
etc. In patients receiving massage therapy and the benefits of massage persisted
throughout the duration of 48-hour follow-up. These studies indicate that massage
therapy has the potential to bring about improvement in the symptoms of the
patients afflicted with cancer and it can used as a palliative therapeutic aid in the
overall care of cancer patients especially at the end of life in an attempt to improve
the quality of life. However the massage therapy is not entirely risk-free and it can
also be associated with increased risks in the oncology population(Corbin, 2005).
Thus it is important that the adverse effects and the contraindications of massage
be kept in mind while using this therapy in terminally ill patients.
The contraindications of the massage which have high degree of possibility of
presence in the cancer patients include thrombosis, and bleeding tendencies owing
to reduced platelets counts. Further care must be taken to avoid injury to tissues
damaged by surgery or radiation therapy. Weiger et al. ( 2002) in a review article on
the use of complementary therapies in cancer observed that though no evidence
indicates that massage promotes tumour metastasis it is prudent to avoid massage
directly over known tumours or even predictable metastasis and special caution
should be exercised in patients with bony metastases as they are prone to fracture.
Likewise, massage should also be avoided over stents or other prosthetic devices
because of obvious danger of displacement (Kerr,1997).
According to Weiger et al. (2002) if the described precautions are observed,
available evidence suggests that it is reasonable to accept the use of massage for
relief of anxiety and as adjunct therapy for lymphoedema.
32 Principles and Practice of Therapeutic Massage
Massage and Hypertension
Long-term unchecked, stress response is implicated as a causative factor for
hypertension. The relaxation response elicited by the massage have been suggested
to aid in the reduction of hypertension. This hypothesis was investigated by Olney
(2005) who examined the effects of a regularly applied back massage on the blood
pressure of patients with clinically diagnosed hypertension. A 10-min back massage
was given to the experimental group (n = 8) three times a week for 10 sessions. The
control group (n = 6) relaxed in the same environment for 10 min, three times a
week for 10 sessions. Statistical analysis showed reduction of both systolic and
diastolic blood pressure in the massage group with effect size 2.25 for systolic
pressure and 1.56 for diastolic pressure (alpha of.05 and power at.80). This
preliminary study suggests that regular massage may lower blood pressure in
hypertensive persons. Holland and Pokorny (2003) also reported a significant
decrease in systolic and diastolic blood pressure after slow stroking back massage
in the adults patients admitted in a rehabilitation setting. In this study a statistically
significant decrease in mean heart rate and mean respiratory rate was also observed.
 Contraindications
Definition and Classification of Massage 33 33

4
Contraindications

Contraindications are the conditions in which one should not administer a particular
therapeutic modality. Before the application of any therapeutic agent its
contraindications must be ruled out scrupulously, otherwise the treatment may
not only be ineffective, it may also be harmful.
Generally, massage is considered as a safe treatment modality. Quite often
laymen who do not have much knowledge of body structure and function practice
it. However, treatment by massage as such is not completely in free from risk.
There are several conditions where application of massage may prove to be
counterproductive. Myositis ossificans after vigorous massage to the fracture around
elbow is a very common occurrence in those areas, where traditionally massage is
used in each and every condition of pain and locomotor dysfunction.
In a literature review Ernst (2003) observed that even though the occurrence of
serious adverse events with massage is not very common, this modality cannot be
considered as entirely risk-free. The review listed about 23 papers that recorded
the adverse events occurred during the execution of massage. These events include
cerebrovascular accidents, displacement of a ureteral stent, embolisation of a kidney,
haematoma, leg ulcers, nerve damage, posterior interosseous syndrome,
pseudoaneurysm, pulmonary embolism, ruptured uterus, strangulation of neck,
thyrotoxicosis and various pain syndromes. Serious adverse effects were associated
mostly with exotic types of manual massage techniques rather than 'Swedish'
massage. The massage delivered by the laymen was also found associated with
majority of the complications.
Therefore, ascertaining that patient/subject is free from any such condition,
where massage may provoke adverse effects should be the first and foremost step
for massage treatment. Several of these contraindications are present in even
otherwise normal adult and babies. So, not only in ailing people but also in normal
persons the contraindications should be ruled out meticulously.
The contraindications of massage can be divided into two broad categories—
general and local. In general contraindications those conditions are included in
34 Principles and Practice of Therapeutic Massage
which massage must not be given to any part of the body. Whereas, in the local
contraindications those conditions are included in which a particular area of the
body affected by a condition must not be massaged, but massage can be done to
other unaffected parts of the body.
This chapter presents a detailed discussion on each contraindication. Most of
these contraindications are based on theoretical assumptions and personal
experience of clinicians. The nature of exact harm caused by application of massage
in many of these conditions, cannot precisely be proved for want of scientific
literature on this topic. Many experienced clinicians may opt to administer massage
in several conditions described as contraindication in this chapter. However, the
purpose of this chapter is not to challenge them, but, only to rationalise the practice
of massage and safeguard the interest of newcomers to the profession.

Table 4.1: Contraindications of massage

General contraindications Local contraindications

High fever Acute inflammation
Severe renal or cardiac diseases Skin diseases
Deep X-ray therapy Recent fractures
Osteoporosis Severe varicose veins
Severe spasticity Atherosclerosis
Very hairy skin Thrombosis
Patient’s preference Myositis ossificans
Malignancy
Open wound
Poisonous foci
Others

GENERAL CONTRAINDICATIONS
These are the conditions where the application of massage to any part of the body
is not without risk. Therefore, even before physical examination and positioning of
patients one should ensure that he/she is not afflicted with any general
contraindication of massage.

High Fever
Fever is the generalised rise of body temperature. It is one of the systemic
manifestations of the inflammation. Massage is not indicated in high fever as it
may increase the overall body temperature (Liston, 1995). This will further increase
the metabolic rate which is already elevated due to fever.
It is, however, seen that during fever, light massage of the hip, back and lower
limbs in the form of squeezing, gentle kneading and superficial stroking have a
relaxing effect and in India this is regularly used in the household practice.
 Contraindications
Definition and Classification of Massage 35 35
Nevertheless, there are certain conditions associated with high fever where the
application of massage produces damage to the underlying tissues. In the acute
stage of poliomyelitis, characterised by high fever and acute tenderness of joints
and muscles, complete rest is required as any trauma to the tender muscle may
result in the complete loss of function in that muscle.
Acute flare up of systemic arthropathies is also characterised by high fever
where massage may accentuate the inflammatory response and lead to exaggeration
of the symptoms.
Therefore, the application of massage in the presence of fever should be judged
meticulously and if at all administered, it should be done very carefully so that it
does not compromise the tissue function.

Severe Renal and Cardiac Diseases

Oedema is a feature of renal and cardiac conditions as evident in cardiac failure
(peripheral oedema) and in nephrotic syndrome (generalised oedema).
Generalised increase in venous pressure is a feature of cardiac failure where
the raised pressure at the venous end of capillaries counteracts the osmotic pressure
of the plasma protein, and impedes the reabsorption of the tissue fluid leading to
the production of oedema. In renal failure, there occurs an increase in the
concentration of sodium ions in tissue fluid owing to increased salt retention by
distal tubules of kidney which increases its osmotic pressure. This interferes with
the reabsorption of fluid and oedema results. Unlike gravitational oedema or
paralytic oedema, in the above mentioned conditions, massage will not be of much
help to decrease the oedema as the cause of oedema is not mechanical, but the
individual pathology of the involved systems.
Further, in terminal stages of these disorders, patient may present with vascular
disorders like thrombosis, atherosclerosis, etc. where massage may provoke serious
consequences like pulmonary embolism. Chest percussion has adverse effects, as
may provoke the onset of cardiac arrhythmia and subsequent fall in cardiac output
and partial pressure of oxygen in blood. These effects may prove to be fatal in
severe cardiac diseases. Moreover, the different positionings adopted during the
massage treatment may also not be suitable for these patients. Therefore, it is not
wise to practice the massage techniques for patients suffering from severe renal
and cardiac disorders.

Deep X-ray Therapy

Deep radiotherapy has a devitalising effect on the body tissues. In all irradiated
tissues, be it normal or abnormal, the vascular changes are prominent. During
immediate postirradiation period, vessels may show only dilation. Later on or with
higher dose immediately after sometime, a variety of regressive changes appear
which range from endothelial cell swelling to the total necrosis of the wall of the
36 Principles and Practice of Therapeutic Massage
small vessels (capillary and venules). Affected vessels may thrombose or even
rupture, leading to haemorrhage (Robbins and Kumar, 1987).
In this stage, tissues will not sustain any kind of mechanical trauma. Since
massage is mechanical in nature, tissues may react abnormally during manipulations
leading to more harmful effects. Therefore, massage should not be given to a patient
who underwent deep X-ray therapy.

Osteoporosis
Osteoporosis is a bone disease characterised by a decrease in the absolute amount
of bone mass sufficient to render the skeleton vulnerable to fractures. The skeleton
becomes fragile and may not tolerate the pressure and force (whatever minimal it
may be to a normal skeleton) applied to body during manoeuvres like kneading,
vibration, tapotement, etc. Due to lack of structural stability of bone, even a minimal
trauma can produce fracture. One must be very cautious while applying massage
to the suspected cases of osteoporosis (e.g. old age group, postmenopausal women,
patient on prolonged steroid therapy, etc.).
In fact, all passive procedures of physiotherapy (mobilisation, massage or
manipulation) should be administered with caution in all the other conditions also
where the bones become fragile (e.g. osteomalacia, Paget’s diseases, osteogenesis
imperfecta, etc.).

Severe Spasticity
Spasticity is the abnormal increased tone of muscles due to lesion of upper motor
neuron. This is the characteristic feature of all UMNL including hemiplegia, cerebral
palsy, spinal cord injury, multiple sclerosis, etc. Massage should not be used in
these conditions.
The muscle tone is maintained by muscle spindles. The sensitivity of muscle
spindles is maintained by alpha and gamma fibres, which keep them sensitive to
stretch. In UMNL, the fusimotor activity is increased and therefore, the threshold
of intrafusal muscle fibre to stretch stimulus is decreased. Even a minimal amount
of stretch (exerted by massage or otherwise) can activate the myotatic reflex arc
and provoke hypertonicity, spasm and flexor withdrawal.
Further the abnormal handling, pain and discomfort have all been found to
increase the spasticity. Massage may provoke all these factors and may increase
the tone of the spastic muscles. Though the studies have shown that massage can
decrease the activity of alpha motoneurons leading to decrease in muscle tone in
healthy subjects (see Chapter 2) these findings cannot be generalised to neurological
patient as the behaviour of neural tissue changes drastically in diseased state and
is not yet properly understood.
The only study that investigated the effect of deep massage on the neurologically
impaired individuals reported an average decrease in the amplitute of H-Reflex
 Contraindications
Definition and Classification of Massage 37 37
though this response was not uniform(Goldberg et al., 1994). In some subjects the
H- reflex was increased even up to 80 per cent. This highlights the need of further
investigation before the massage is considered in the management of UMNL.

Very Hairy Skin

Rubbing the hairy skin, especially opposite to the direction of the hair follicle, is
painful. Usually massage is not administered to a very hairy skin. But it is a relative
contraindication as the excessive hair can be shaved off and the part can be
massaged. Heavy oil lubrication of the area prior to massage can also reduce the
chance of hair pulling.

Patient Preference
On account of social, religious, cultural and personal reasons some people do not
like massage. They also feel embarrassed while exposing the body part during the
massage, especially if the therapist is of the opposite sex. In these situations, as far
as possible, the people’s wish must be respected and they should not be forced to
undertake massage until it is very essential like in tendon adherence, etc.

LOCAL CONTRAINDICATIONS
In presence of these conditions the affected body part should not be massaged.
However, if required, the techniques can be administered to the other parts of the
body. For example, in acute sprain, the ankle should not be approached for massage
immediately after the injury but the thigh and the knee of the athlete can be massaged
to promote relaxation, and recovery. These contraindications should be ruled out
during pretreatment physical examination of the patient.

Acute Inflammation
Acute inflammation is an absolute local contraindication of massage. The reasons
are following:
i. Massage exacerbate the vascular changes taking place during acute
inflammatory period, that is, increased blood flow, vasodilatation as well as
increase in vascular permeability and makes the condition worse. As the effect
of massage on vasculature is very similar to that occurring during acute
inflammation, massage during inflammation (acute phase) will further increase
swelling, pain, tenderness and may lead to more tissue damage.
ii. Granulation tissue (formed 48 to 72 hours after the injury) has a very delicate
blood supply which can easily be damaged by movements and shearing forces
of massage manoeuvres. This interferes with the repair process and delays
the healing.
Therefore, massage must not be administered during acute inflammation of
tissues by any means.
38 Principles and Practice of Therapeutic Massage
Skin Diseases
Massage is contraindicated in the presence of infectious skin diseases (Knapp, 1990)
like eczema and other weeping conditions, characterised by pruritus, oedematous
vesicle, pustules and papules for the following reasons:
i. infection may spread from one part to other
ii. therapist may get cross infection
iii. massage is painful to the patient.
In an interesting study Donoyama et al. (2004) demonstrated that Bacteria from
the client's skin transferred to the therapist's hands during massage therapy. They
obtained medium cultures from the therapist's palms and the client's skin before,
during, and after the massage session.
After each massage session, the therapist washed his or her hands and a bacterial
sample was again taken. It was observed that the bacteria count on the therapist's
palms increased during and after massage whereas the bacteria count on the client's
skin decreased during and after massage. After hand washing with water for 20
seconds after each massage session, bacteria were still present on the therapist's
palms.

Recent Fracture
Fracture is the break in the continuity of the bone. In initial stage, massage should
not be given as it disturbs the healing process (Liston, 1995). The shearing movement
of the massage may retard the organisation of haematoma and callus formation. It
may sever the delicate capillaries as well as the bridging tissues and may damage
the flexible granulation tissues that bridge the fracture at an early stage. This may
lead to nonunion or malunion. Further, it is very painful and uncomfortable to
tolerate massage if administered in the vicinity of a recent fracture.
However, if the fracture is immobilised massage may be administered to the
area proximal to the fracture site. It gives comfort to patient by reducing swelling
and relieving tension and pain in the area, but the fractured site must be avoided
always.

Varicose Vein
This is a condition in which due to incompetency of valves, veins become dilated
and tortuous. This results in the venous congestion and walls of vein become thin.
In this condition, massage may provoke complications like haemorrhage and
phlebitis.
Thin veins may not tolerate even minor trauma. It may rupture and due to high
pressure in congested vessels, profuse bleeding may result. The vein may become
extremely tender and firm. Overlying skin becomes red and oedematous. So, in
severe varicose vein massage is an absolute contraindication (Liston, 1995).
 Contraindications
Definition and Classification of Massage 39 39
Thrombosis and Arteriosclerosis
This condition is characterised by formation of fatty plaque in arterial lumen. This
is known as thrombus. Massage should not be given in the presence of thrombus
as emboli may break off from the wall due to mechanical squeezing of blood vessels.
It may travel to some other part of the body through blood stream and block the
circulation of vital organs, i.e. brain, heart and lungs, giving rise to serious
consequences (pulmonary embolism).

Myositis Ossificans
In this condition there occurs callus formation in the soft tissues. The joint capsule
and periosteum is stripped from the bone by violent displacement. Blood collects
under the stripped soft tissue forming haematoma. The haematoma is invaded by
osteoblasts and becomes ossified. This gives rise to limitation of movement and
pain. The risk of formation of haematoma should be minimised by ensuring
complete rest.
Strain and stretching of soft tissue might provoke further bleeding beneath the
soft tissue and may exaggerate the condition. This condition is more common around
the elbow joint. So massage should not be given around elbow joint after any injury.

Malignancy
Metastasis (spread of tumour cells from one area to the other) is the essential feature
of all malignant tumours. Tumour cells disseminate through lymphatic and
haematogenous pathways. Therefore, anything, which increases the lymphatic flow
also, increases the chance of spread of tumour. In order to avoid the movement of
abnormal cells to other areas, massage is contraindicated in malignant conditions
(Liston, 1995; Knapp, 1990).
Weiger et al. ( 2002) commented that though no evidence indicates that massage
promotes tumour metastasis it is prudent to avoid massage directly over known
tumours or even predictable metastasis and special cautions should be exercised in
patients with bony metastases as they are prone to fracture.

Open Wound
Massage over open wounds, cuts and bruise is not only painful but may further
damage the healing tissue. Mechanical movement to wound, which massage will
produce, is an established causative factor for delayed healing of tissue. Therefore,
over the damaged skin massage is a contraindication (Knapp, 1990).

Poisonous Foci
Massage should not be administered in case of snake bite, stings and insect bite
(Liston, 1995). Massage increases the circulation and may facilitate the release of
poison into the circulation, leading to serious systemic effects.
40 Principles and Practice of Therapeutic Massage
Other Conditions
Specialised massage techniques such as connective tissue massage acupressure,
trigger point massage, etc. can elicit adverse autonomic response in pregnancy,
cardiorespiratory conditions and psychological disorders such as panic attack.
Therefore, the specialised techniques of massage should not be administered in
these conditions.
 Techniques41 41
Definition and Classification of Massage

5
Techniques

The nomenclature of basic techniques of the classical massage have remained

unchanged for centuries though a consensus on the exact way of performing these
techniques is not available in the literature. Various authors have described the
various techniques in different manner. This chapter presents a detailed discussion
on each technique of classical massage which include definition, description,
physiological effects, therapeutic uses, specific contraindications and commonly
used variations. The aim is to present all the relevant information about a technique
in one place.
The basic techniques of classical massage described in this chapter are:
• Stroking
• Pressure manipulation
• Tapotement
• Vibration.
The special techniques of massage such as connective tissue massage, etc. are
not discussed in detail in this book though an outline of these techniques are
presented in a separate chapter.

Stroking Group of Manipulation

This group includes two techniques—superficial stroking and deep stroking or
effleurage. In both the techniques, one uninterrupted linear movement of hand or
its part covers one aspect of a whole segment. The uninterrupted linear movement
of hand along the whole length of a segment is called “stroke”. The essential features
of this group of techniques are even pressure, equal rhythm and constant contact
of therapist’s hand with the patient’s body. On the basis of amount of pressure
applied and the direction of movement of hand, this group consists of two basic
techniques.
• Superficial stroking, and
• Effleurage or deep stroking.
These two techniques can be modified in a number of ways.
42 Principles and Practice of Therapeutic Massage
Superficial Stroking
It is the rhythmic movement of hand or parts thereof over the skin with the lightest
amount of pressure in order to obtain sensory stimulation. The strokes can be applied
from proximal to the distal part or vice versa. The rate of strokes per minute, i.e.
speed can be slow or fast, but the rhythm must be maintained throughout. The
variation in the direction and speed of this technique depends on the desired effect.

Technique
Superficial stroking is best performed with the palm of hand or with the pulp of
fingers. However, the use of heel of hand, edge of hands, ball of thumb and knucles
in stroking have also been mentioned by some authors (Kellong, 1919, Wood and
Becker, 1981).
Therapist should position himself in a comfortable position. Since usually the
strokes cover the entire length of segment in one go, the walk standing or fall out
standing is preferred. In these two positions the most proximal parts of the segment
can be reached with one outstretched upper limb without putting undue strain on
the back of the therapist. Direction of stroking can be centripetal or centrifugal. In
the author’s opinion, for best effects, it should be performed in centrifugal (i.e.
from proximal to distal) direction. Therapist should keep his hand fully relaxed.
The fingers should be kept slightly apart and flexible so that they can be moulded
according to the contour of the body.
At the beginning of technique, the pulp of right hand of therapist should be
placed on the most proximal end of the segment to be massaged, this can be achieved
by flexion of right shoulder and extension of right elbow. The left hand should
remain in air, it should be placed near to the most distal part of the segment. This
can be achieved by flexion of left elbow and extension of left shoulder (Fig. 5.1).

Fig. 5.1: Superficial stroking : starting position

 Techniques43 43
Definition and Classification of Massage
The stroke is initiated by controlled extension of right shoulder so that hand is
gently lower down in order to make contact with skin. The contact should be gentle
and essentially without any pressure. This “just touch no pressure” contact should
be maintained throughout the stroke. Controlled and combined flexion of right
elbow and extension of right shoulder ensure the passage of hand over the skin.
As the right hand moves towards the distal part, the left hand should also move
in the proximal direction by a controlled and combined extension of left elbow and
flexion of left shoulder (Fig. 5.2). This is essential to ensure that at the end of stroke
the position of both the hands is reversed, i.e. left hand assumes the proximal
position and right hand comes near the distal most part, so that when right hand
breaks the contact with the most distal part, left hand immediately establishes the
contact with proximal part and starts the stroke (Fig. 5.3). The stroke should end
with a smooth lift of hand. The movement of two upper extremities should be well
timed and controlled in order to ensure that at no time both the hands neither
make nor break the contact with skin simultaneously. And at a time only one hand
slides over the patient’s skin. Making and breaking of contact should be very gentle
so that patient does not perceive the change of hand.
This alternate movement of right and left hand over the skin must be performed
with a constant rate or rhythm. Mennels recommended a rate of 15 per minute for
stroking from shoulder to hand, whereas Wood and Backer determined that
movement of hand at the rate of seven inches per second produced the desired
effects. However, depending upon the desired effects the rate can be varied. The
slower strokes (12-15 stroke per minute) are more sedative while for stimulating
effects faster strokes (30-40 strokes per minute), should be preferred.

Fig. 5.2: Superficial stroking : while proximal hand goes

down the distal hand moves up but does not touch the skin
44 Principles and Practice of Therapeutic Massage

Fig. 5.3: Superficial stroking: finish: note the complete

reversal of the position of hands of therapist

Variation
The stroking may be performed using
• Entire palm—over the broad and highly muscular areas, i.e. back, thigh.
• Knuckles—seldom used in massage treatment except in stimulating massage
of back. It can be used in sports massage set up.
• Ball of thumb—It can be used over confined area.

Techniques of Thousand Hands

In this technique the entire length or segment is not covered in one stroke. Rather
the technique involves several small and overlapping strokes. Strokes are applied
with both the hands wherein strokes of one hand overlaps with the strokes of other
hand and the strokes moved down to cover the entire length of part. It is used for
relaxation (Hollis, 1987).

Physiological Effects
1. Superficial stroking stimulates the cutaneous touch receptors. It has a sedative
effect on the body and if applied in a proper manner it has soothing and
reposing effect.
2. Superficial stroking also indirectly improves the circulation by activating the
axon reflex.
3. It exerts a facilitatory effect on the motoneuron pool and facilitates the
contraction of the muscles. Superficial stroking, if performed faster can have a
stimulating effect as against the relaxing effect, when it is done slowly.
 Techniques45 45
Definition and Classification of Massage
Therapeutic Uses
a. In patients assessment, information about contour, texture, tone, temperature,
etc. can be obtained by superficial stroking which can be used both to identify
the problem area and to determine the effect of treatment used.
b. It is used owing to it’s sedative effect
1. Prior to any massage procedure, to relax the muscles and to accustom the
patient to manual contact.
2. In sleeplessness, gentle stroking of the forehead and the back offer great
relief.
3. In anxiety, tension and psychological stress, slow rhythmic stroking for a
prolonged period can be very useful.
4. In hypersensitivity, stroking is used to decrease the hypersensitivity of part.
In nerve injuries and after amputation, phantom limb, the patient is asked
to do frequently stroking of the part. This accustoms the part to touch and
desensitises the hypersensitive areas.
c. Owing to its facilitatory stimulating effect, fast stroking is used in all facilitation
techniques to elicit contraction in the hypotonic muscles.

Cautions
This technique is a light and stimulating manoeuvre. This may produce a ticklish
sensation. So, it should not be applied in:
1. a hypersensitive person where this may produce unwanted and excessive
tickling.
2. severe spasticity where superficial stroking may elicit flexor withdrawal.

Effleurage or Deep Stroking

It is the movement of the palmar aspect of hand over the external surface of the
body with constant moderate pressure, in the direction of the venous and lymphatic
drainage.
It is one of the main manoeuvres of massage. In fact every massage begins and
ends with effleurage. It is a manoeuvre in which the relaxed hand of therapist slides
over the patient’s skin with firm pressure, without attempting to move the deep
muscle mass. The strokes are applied in the direction of the lymphatic and venous
drainage. Each stroke begins from the distal end of the segment and is completed
at the proximal end usually at the site of a group of lymph nodes. The direction of
movement of hand in this technique is always from distal to proximal. Contact and
continuity must be even throughout the stroke.

Technique
Depending upon the area being massaged, the effleurage can be performed with
one or both hand(s). Usually the palmar aspects of hand, fingers or thumb are used.
46 Principles and Practice of Therapeutic Massage
The therapist should be positioned in a comfortable stance. Like superficial
stroking, in this technique also, the entire length of segment is covered in one go.
Therefore the walk standing position is preferred. This not only ensures a better
reach of the distal part but also facilitate sufficient and controlled application of
pressure without putting undue strain on the back of therapist.
The hand/hand(s) of therapist should be relaxly placed over the distal most
part of the segment to be massaged. It should be moulded to the contour of the part
so that all parts of hand maintain an even contact with the skin. Stroke is initiated
with the combined and controlled flexion of shoulder and extension of elbow, to
slide the hand forward over the skin in the distal to proximal direction. Pressure is
applied by transfer of the body weight to the subjects skin through the upper
extremity of therapist (Fig. 5.4). At no time, the therapist should use muscle force
from upper extremity to apply pressure. This is tiresome and effleurage cannot be
performed for a longer duration.
The hand of therapist should remain rather relaxed and as the strokes advance
forward, its shape should be moulded to maintain a perfect and even contact with
the skin according to the variation of the shape of body part. As the hand moves
forward, the body weight should also be shifted from rear foot to the front foot in
order to ensure an even application of pressure to the skin. This can be achieved by
either controlled flexion of the knee of forefoot or by lifting the heel of rear foot by
plantar flexion. Towards the end of stroke, weight should be completely transferred
to the front foot from the rear foot (Fig. 5.5). Stroke is terminated with a little over
pressure near the lymph node. After this, the hand is brought back to its starting
position with a returning stroke. Controlled extension of shoulder and flexion of
elbow execute this returning stroke.

Fig. 5.4: Effleurage of back : initial stance

 Techniques47 47
Definition and Classification of Massage

Fig. 5.5: Effleurage of back finish: note that the rear foot is
plantar flexed to apply compression without bending the spine

At the end of restoring stroke, the foreknee comes back in extended position
and the rear heel touches the ground.
This returning stroke is essentially a superficial stroking where no pressure is
applied to the skin. If pressure is applied during returning strokes, it will interfere
with the venous and lymphatic refilling and will decrease the effect of effleurage.
Few authorities also advocate that while returning back to its previous position,
the hand should remain in air. While this ensures no pressure on skin, it can only
be used when one hand is used for stroking. When both the hands are used in same
direction, the lifting of hand while returning will break the continuity of contact.
The pressure applied during each effleurage stroke should be as deep as can be
applied without causing discomfort to the patient. The rate of stroking should
essentially be slow (10-12 stroke/min) in order to allow sufficient time for refilling
of the venous and lymphatic channels.
As the direction of effleurage is similar to that of venous and lymphatic drainage,
the therapist should be thorough with the anatomy of venous and lymphatic system.

Variation
The basic technique of effleurage described above can be modified in the following
ways depending on the area to be treated.
1. Both hands can be used on the opposite aspect of the segment such as medial
and lateral aspects of thigh.
2. One hand may follow the other with both the hands ending stroke within a
short interval of time (Fig. 5.6).
48 Principles and Practice of Therapeutic Massage

Fig. 5.6: Both hand effleurage : right hand follows the left hand

3. Only one hand can be used. The other hand is used to support or change the
position of massaged segment. This variation is suitable for the upper limb
(Fig. 5.7).

Fig. 5.7: Upper limb effleurage : one hand changes the position
of patient’s limb while the other executes stroke
 Techniques49 49
Definition and Classification of Massage
4. Limbs can be held in the first web space between the thumb and other fingers
so that the hand assumes the shape of letter ‘C’ (Fig. 5.8).
5. Indian effleurage: In this variation of effleurage, the direction of stroke is
reversed, the extremity is grasped with C grasp and pressure is applied from
proximal to distal part. It is most commonly used over babies. It is claimed
that this technique improves the flow of arterial blood to the massaged part.
However, this variation of effleurage has no place in the classical therapeutic
massage.
6. Cross-hand effleurage or effleurage of knee: For the drainage of areas
surrounding knee joint special positioning of hands is used. Both the hands
are placed just above patella in such away that they cross each other without
overlapping (Fig. 5.9A). During effleurage both the hands are drawn backward
(Fig. 5.9B) on each side till their heels come in contact with each other just
below patella (Fig. 5.9C). Thereafter, the fingers are moved forward and
posteriorly to terminate the stroke in the popliteal fossa (behind the knee)
(Fig. 5.9D).

Physiological Effects
The effects of effleurage are more pronounced on the circulation to the area and
skin of the massaged area.
1. Effleurage produces squeezing of the veins and lymphatics and forces the
venous and lymphatic fluids towards the heart. As a result of which
a. The chance of accumulation of waste is prevented/minimized

Fig. 5.8: C grasp for forearm effleurage

50 Principles and Practice of Therapeutic Massage

Fig. 5.9A to D: Effleurage to knee (A) initial position of hands (B) movement of hands toward
patella (C) heels of both the hands almost come in contact with each other near the tibial tuberosity
(D) end of the stroke directed at popliteal fossa

b. Stagnation of blood and lymph is reduced

c. Venous and lymphatic drainage improves
d. Oedema reduces.
2. Effleurage has a mild stimulating effect on the vasomotor nerves supplying
the blood vessels and skin and leads to elicitation of axon reflex.
3. Effleurage facilitates the circulation in the capillaries.
4. It brings about the liberation of histamine (substance) due to the stimulation
of mast cells and causes erythema.
(This effect of effleurage varies from individual-to-individual and is maximum
when the therapist’s hands are tense; increasing friction between the hand of
therapist and the skin of patient).
5. Effects 2, 3 and 4 collectively improve arterial circulation which overall
improves the nutrition of the part.
6. Improved lymphatic and venous drainage resulting from effleurage may
increase the venous returns and cardiac output to a slight extent.
 Techniques51 51
Definition and Classification of Massage
7. By exerting a stretching effect on the subcutaneous tissue effleurage improves
the elasticity and the mobility of the skin.
8. Stimulation of touch and pressure receptors during effleurage brings about a
sedative effect which serves to sooth, decrease pain and lessen muscle tension.
9. It facilitates the removal of dead cells of skin and improve the activity of sweat
and sebaceous gland.

Therapeutic Use
1. To search for the area of muscle spasm, soreness and trigger points that help
determine the further management.
2. To reduce oedema in:
• mild varicose ulcer
• gravitational oedema and paralytic oedema associated with paralysis and
muscle weakness
• radical mastectomy, etc.
3. To assist the absorption and removal of metabolites and inflammatory products
in:
• muscle fatigue following severe exercise
• subacute and chronic inflammation
• soft tissue injuries.
4. To accustom the patient to the touch of the therapist and to evenly distribute
the lubricant over skin if used.
5. To link up and join various manipulations during massage.
6. To lessen the negative effects of immobility and lethargy associated with
psychological distress (Liston, 1995).

Specific Contraindications
In conditions where there is a danger of peeling off of the skin effleurage should
not be used, e.g.
• newly healed scar tissues
• recent skin grafts
• open wounds.

Pressure Manipulations
The essential feature of this group of techniques is the application of deep
compression to the body with constant touch. These techniques are directed
particularly towards the muscular tissue. The maximum mechanical movement
between different fibres is achieved in these techniques, by the application of deep
localised pressure. According to the nature and direction of pressure application,
techniques of this group can be divided into three major subgroups.
i. Kneading
52 Principles and Practice of Therapeutic Massage
ii. Petrissage
iii. Friction.
These technique produce almost similar physiological effects on the soft tissue.
Kneading and petrissage, involves application of intermittent pressure whereas in
friction the application of pressure is constant.

Kneading
In this technique, tissues are pressed down on to the underlying structures and
pressure is applied in a circular way along the long axis of the underlying bone, so
that the comparison is vertical. The pressure is increased and decreased in a gradual
manner.
Relaxed hands are placed over the skin. The tissues are compressed against the
bone and the hands are moved in a circular direction so that the deeper tissues are
compressed and moved in a circular way. The hands should be placed firmly on
the skin so that the movement can take place only in the deeper structure and not
over the skin.
The whole manoeuvre consists of several small concentric circles performed
parallel to the body surface and each circle overlaps the previous one. The pressure
is gradually increased during one half of the circle till it reaches to the maximum
level at the top of the circle. Similarly during the other half, pressure is decreased
gradually till it reaches a minimum at the bottom of the circle. Thus each circle has
two phases.
1. Phase of compression
2. Phase of relaxation.
During the phase of relaxation where the pressure reaches the minimum, the
hand slides smoothly to the adjoining next area.
The body weight is used to apply the pressure. The therapist usually adopts a
walk standing stance and applies the pressure by shifting the body weight alternately
on both the legs.
Therapist may begin the kneading either from proximal or distal part of the
segment. But the increasing pressure should always be applied in centripetal (i.e.
proximal to distal) direction (Wood and Becker, 1981). For example in treating an
extremity, the kneading may be started from the proximal part and each succeeding
movement proceeds over the adjacent distal area or vice versa. If kneading starts at
proximal end, pressure should be applied in latter half when hand relaxes to
proximal position. If the kneading starts from distal end, the pressure should be
applied in the initial half when hand moves to the proximal position (Fig. 5.10).
The small circular movement of kneading can be performed with part of fingers,
thumb or palm of one or both the hand(s). When using both hands either both the
hands can make the circle simultaneously or alternately. One hand may support
 Techniques53 53
Definition and Classification of Massage

Fig. 5.10: Circular movement of kneading where pressure increase in one half
and decrease in other half. Direction of the pressure is always centripetal

the tissue while other hand makes the circles. Depending on the size of area to be
massaged either whole finger, thumb or a part thereof can be used to make circles.
According to part of hand used during manoeuvre, the kneading can be classified
in the following three techniques.
1. Palmar kneading
2. Digital kneading
3. Reinforced kneading.
Each technique can be varied in a number of ways.

Palmar Kneading
It is performed with the either whole of palmar or with the heel of hand. It can be
performed with one or both hands and usually used over the large areas such as
thigh, calf, arm, etc.

Technique
Therapist position himself in a comfortable position. Walk standing is preferred.
Both the palms are placed relaxly on the opposite aspect of limb segment (e.g. right
hand on the medial and left hand on the lateral aspect of thigh). The fingers and
thumb are not kept in contact with the skin (Fig. 5.11).
Manipulation is initiated by making a small circle first with one hand than with
other hand without applying any pressure. This no pressure circle helps to
coordinate the action of two hands and to assess the condition of part to be massaged.
Circular movement of palm over skin is produced by the coordinated flexion
and extension of shoulder combined with elevation and depression of scapula. It is
the shoulder girdle where therapist produces the actual movement. Position of
hand over skin should not be changed and throughout the manoeuvre the hand
and skin should move as one.
54 Principles and Practice of Therapeutic Massage

Fig. 5.11: Both hand palmar kneading: fingers and thumb are off contact with thigh

After ensuring that both hands can perform coordinated circular movement
the therapist proceeds to perform actual kneading movement. Both the hands make
circle in opposite direction (i.e. clockwise with right hand, anticlockwise with left
hand). Pressure is applied to the circle by transferring the body weight in such a
way that during one half, the pressure builds up gradually out while in another
half it recedes gradually. When the pressure reaches to it minimum at the bottom
of circle, therapist slides his hand over the skin by gentle flexion or extension of
elbow in order to perform next circle over the adjoining area. He should ensure
that next circle should also overlap at least half area of the previous circle.
This process is repeated and the hand is advanced to cover the entire length of
the segment.
The rate of making circle and application of intermitted pressure should be
kept constant. Slower rates allow better penetration to the deeper tissue.

DIGITAL KNEADING
In this group, the kneading movements are executed either with thumb or fingers
and accordingly there are following two subcategories of this group.
a. Finger kneading
b. Thumb kneading.

Finger Kneading
This technique utilises the contact of palmar aspect of either whole finger or a part
 Techniques55 55
Definition and Classification of Massage
thereof to apply pressure. Only one finger may be utilised or two or three fingers
can be used together to increase the contact area. Little finger is usually not used
considering its short length and inability to apply sufficient pressure. Depending
on the part of finger which remains in contact with skin during kneading, this has
following subgroups.

Whole Finger Kneading

Otherwise also called flat finger kneading, this technique is usually performed with
palmar surface of 2, 3 and 4 digits which are held together to make a broad contact
area. The thumb and palm remain off the contact with skin. This usually applied
over the less muscular or poorly padded area, i.e. mandibles (Fig. 5.12).

Finger Pad Kneading

This technique uses the contact of pulp of finger which is otherwise called finger
pad and more appropriately can be described as the palmar surface of distal phalanx.
Depending upon the area to be massaged either one finger can be used or two or
three can be held together to cover the larger area. During this technique the DIP
and PIP joints of the kneading finger should be kept little flexed in order to allow
adequate contact of pulp with skin and to relieve strain of ligaments of IP joint (Fig.
5.13).
It is used around the joint line, extensive scar, and along the line of ligaments.

Fingertip Kneading
In this technique only tip of the pulp remains in contact with skin. Usually done

Fig. 5.12: Whole finger kneading over mandible: all the fingers
are joined together to increase the contact area
56 Principles and Practice of Therapeutic Massage

Fig. 5.13: Finger pad kneading over paraspinal area

Fig. 5.14: Fingertip kneading over the interosseous space of dorsum of hand
 Techniques57 57
Definition and Classification of Massage
with only one or two fingers this technique is the technique of choice when kneading
need to be performed over a localised area, e.g. long and narrow interosseous space
and over localised thickening fibrocitis nodules (Fig.5.14).

Thumb Kneading
Depending upon the size of area to be treated the pulp or the tip of one or both
thumbs may be used to knead. Alternately, one thumb may be placed over the
other to reinforce the moving in contact thumb, the other finger should either remain
off the contact with skin or be placed on little away from the area to be massaged
(preferably on the opposite side of extremities). Following are the two variations of
this technique.

Thumb Pad Kneading

The whole pulp of thumb, i.e. palmar surface of proximal and distal phalanx of
thumb is kept in contact with the skin. It is used over smaller and muscular area
such as thenar and hypothenar eminences (Fig. 5.15A).

Fig. 5.15(A): Thumb pad

kneading over hypothenar eminence

Fig. 5.15(B): Thumb tip kneading

over interosseous space of foot
58 Principles and Practice of Therapeutic Massage
Thumb Tip Kneading
Usually performed with the side of thumb tip it is used like fingertip kneading
over the long and narrow area such as interosseous spaces (Fig. 5.15B).
During these procedures, the therapist should keep his IP joint little flexed.
This helps to protect the palmar ligaments, which may be injured if kneading is
performed with extended finger for a prolonged duration. Most commonly these
digital kneading techniques are used around the joints, localised areas, face and
the paravertebral area of spine. Digital kneading manoeuvres are the technique of
choice when a localised area is to be mobilised.

Reinforced Kneading
This is also called ironing which utilises both the hands while kneading. It transmits
pressure to the very deep structures and used when greater depth is required. Most
commonly this technique is performed over the back.

Technique
Therapist adopts a walk standing stance. The hands are placed over each other and
lower hand remains in contact with the skin. The hand should be placed that side
of spine, which is nearer to the therapist. Elbow of the therapist is kept in complete
extension (Fig. 5.16). Intermittent circular pressure in increasing and decreasing
order is transmitted to the body through shoulder and elbow by controlled shifting
of the body weight from one leg to the other. The extremity which remains in contact
with skin executes the circular movement while the other hand is used only to
reinforce the contact hand. After one circle the hand slides over to the next area of

Fig. 5.16: Ironing/reinforced kneading of back

 Techniques59 59
Definition and Classification of Massage
the near side of the back. This sliding movement of hand results from controlled
flexion or extension of shoulder. At no time the elbow should be allowed to flex as
this will interfere with the effective transmission of pressure.
The area near side of back is worked in this stance. For other side of back therapist
should shift his position to the other side of couch without losing contact with the
skin. This is important in order to apply equal pressure on both the sides.

Variation

Palmar and Digital Kneading

i. Both the hands can be used simultaneously or alternately one after the other.
ii. One hand makes the circle while other hand only supports the body part.
iii. When both the hands are used simultaneously the direction of their circle can
be same or different, i.e. both the hands move in anticlockwise or clockwise
direction or one hand moves in clockwise circle and the other moves in
anticlockwise direction.
Reinforced Kneading It can be performed in both the near and far side of back
without changing the side. In this case, therapist adopts a walk standing stance
across the back to the circles on the opposite side and a walk standing stance
obliquely to the couch to treat the near side. However in this way, the elbow cannot
be maintained in extended position throughout the manoeuvres and the effective
transmission of pressure to all areas of back cannot be ensured.
The selection of any of these variations is purely based on the comfort of patient
as well as ease and familiarity of the therapist with the technique.

PETRISSAGE
According to chambers dictionary (1983) the word petrissage is derived from the
French word “Petrir” meaning “to knead”. There is no agreement among various
authors in the exact description of the petrissage and often just opposite views
have been expressed regarding this technique. Few authors have described
petrissage as a kneading technique (Lehn and Prentice, 1994) others while describing
the picking up, skin rolling and wringing have omitted the use of word petrissage
(Thompson et al. 1991). Some authors (Kuprian, 1981) have also used the term
“working” for petrissage and kneading. (Hollis 1987) under the heading petrissage
described all deep technique such as wringing, and picking up including kneading.
It is only the direction of application of pressure that differentiates petrissage
from kneading. Mennels states that while in kneading the compression is vertical,
petrissage involves a picking up movement of soft tissues with a lateral compression
(as quoted in Wood and Becker, 1981). In kneading, the tissues are compressed
down on to the underlying bone whereas in skin rolling, picking up and wringing
the tissues are lifted away from the underlying bone. Thus these three techniques
60 Principles and Practice of Therapeutic Massage
have one element in common, i.e. the direction of application of pressure which
differentiate them from kneading manoeuvres. Therefore, it is rational to group
these techniques under petrissage.
Thus in petrissage group of techniques, the tissues are lifted away from the
underlying structures and intermittent pressure is applied at a right angle to the
long axis of the bone. The different techniques of this group are:
• Picking up
• Skin rolling
• Wringing.

Picking up
This technique involves lifting of the tissue up at right angle to the underlying
bone, squeezing and releasing it. It is most commonly performed with one hand
only. It is one of the most difficult technique of massage to master.

Technique
Therapist adopts a walk standing stance. The hand is placed on that body part in
such a way that the web space between thumb and index finger lies across the
central line of the muscle bulk and skin to be lifted. The thumb and thenar eminence
are placed on one side and index middle finger with hypothenar eminence are
placed over the other side of the central line. Arm is kept in a position of slight
abduction and elbow in the semiflexed position. The wrist should remain in slight
extension.
Transfer of body weight to skin through upper extremity to apply compression

Fig. 5.17: Single handed picking up to forearm : note total web space is in the contact of skin
 Techniques61 61
Definition and Classification of Massage
initiates the technique. At the same time the grasp of hand is tightened along with
little extension of wrist. This produces the simultaneous lift and squeeze of the
grasped tissue (Fig. 5.17). Then the grasp is loosened and transfer of body weight
releases the compression again. With the release of compression the relaxed hand
slides over to the next adjacent area without loosing contact and conformation with
the skin and the same manoeuvre is repeated. In this way the sequence of lift,
squeeze and release is performed. During the picking up, the web space between
the thumb and the index finger should always remain in contact with the skin. The
therapist should avoid, the contact between two bony prominences (i.e. antero-
medial aspect of proximal phalanx of thumb and anterolateral aspect of second
metacarpal head). The contact between the bony prominences transmits localised
force to the skin and produces pain. During picking up, the pressure should be
evenly distributed to all the lifted tissue.
If pain is felt during the manoeuvre, then either the pressure should be reduced
or the amount of grasped tissue should be lessened.

Variation
1. On larger areas such as thigh hand may be joined together to produce a larger
grasp. Thumb of left hand lies under the heel of right hand along side the
hypothenar eminence while the thumb of right hand lies alongside the index

Figs 5.18A to C: Both hand picking up (A)

thumb of right hand join the index finger of
left hand to increase the contact area
(B) position of both the hands on thigh
(C) final lift and squeeze
62 Principles and Practice of Therapeutic Massage
finger of left hand. This produces a larger grasp and tissues are lifted and
squeezed between medial part of palm and medial three fingers of both the
hands (Figs 5.18A to C).

Skin Rolling
This technique involves lifting and stretching of the skin between the thumb and
the fingers as well as moving the skin over the subcutaneous tissue. The therapist
lifts up and moves the skin and superficial fascia with both the hands keeping a
roll of the skin raised continuously ahead of the moving thumb.

Technique
Both the hands are placed on the skin with thumb abducted in such a way that tip
of thumb and index finger of both the hands touch each other maintaining a full
palmar contact with the skin (Fig. 5.19A).
The technique is initiated by pulling the finger backwards with sufficient
pressure so that skin is pulled up. If done correctly it lifts up of the skin. At the
same time the thumb is adducted and opposed with downward pressure over the
underlying skin. The coordination of finger and thumb motion lifts off a roll of skin

Figs 5.19A to C: Skin rolling (A) initial complete

contact of palm with skin (B) lifting a roll of skin
with thumb and fingers (C) rolling of skin: note
the centre of palm does not come in contact with
the skin
 Techniques63 63
Definition and Classification of Massage
from the underlying structures (Fig. 5.19B). Next the palm is gradually lifted off
the skin so that the lifted roll of skin remains between the tip of fingers and thumb.
Then the thumbs are moved forward to roll the lifted skin against the fingers (Fig.
5.19C).
More skin can be rolled in one grasp in persons with mobile skin, whereas in
adherent skin only little skin can be lifted up. In the areas where there is excessive
subcutaneous fat deposition such as lateral abdominal wall, the skin rolling is
difficult and produces pain.
The main effect of this technique is to stretch the cutaneous and subcutaneous
tissue and induce relaxation. It is most often performed over the back. It can also be
used around superficial joints and on the thickened and shortened scar tissue in a
modified form.

Variation
1. Skin rolling can be performed by single hand also, over small area such as foot
and wrist.
2. Over arm and calf, thigh, instead of lifting the skin, the whole muscle can be
lifted slightly up between tip of finger and thumb using the similar grasp.
Then by alternately applying and releasing the pressure with thumb and
fingers, the muscle fibres can be rolled from side-to-side. This variation is
called muscle rolling (Hollis, 1987) (Fig. 5.20).

Wringing

Fig. 5.20: Muscle rolling to calf

64 Principles and Practice of Therapeutic Massage
This technique resembles somewhat with the activity of twisting and squeezing a
wet towel. Both the hands are placed on the opposite aspects of the limb and moved
in opposite direction, i.e. one in forward and the other in the backward direction.
This is done so that the tissues are lifted and twisted.

Technique
The grasp and placement of hand are similar to that of picking up with only
difference that in this technique, both the hands are used. Hands are placed on the
skin with abducted thumb in such a way that fingers and thumb of both the hands
face each other but remain slightly apart. The therapist adopts a walk standing
stance and uses the body weight to apply compression. Technique is initiated by
pulling the fingers of right hand to pull and lift the skin from underlying structure.
At the same time left thumb pushes the skin in opposite direction (Fig. 5.21). This
produces the stretching of the lifted tissue. Thereafter the finger of left hand push
and right thumb pulls the tissues. The process is repeated several times before the
hands move over to the next area. It is an extremely useful technique for mobilisation
of the adherent skin.

Physiological Effects of Kneading and Petrissage

Effects of these techniques are more pronounced on the deeper tissues.
• Techniques of this group produce a local increase in the flow of blood due to
the pumping action, liberation of H substance and elicitation of axon reflex.
This also decreases the stagnation of fluid and oedema as well as improves the
nutrition of the area.

Fig. 5.21: Wringing to thigh

 Techniques65 65
Definition and Classification of Massage
• It stretches the tight fascia and helps in restoration of mobility of skin and
subcutaneous fascia.
• Various manoeuvres of this group stretch the constituent fibres of muscle and
other connective tissue in different directions, which help in preventing the
consolidation of oedema fluid and thus adhesion.
• The fibrine formed during chronic oedema gets stretched and softened. This
helps in breaking the adhesion and increasing the mobility of adherent
structures.
• The intermittent pressure may also stimulate tension dependent
mechanoreceptor, i.e. Golgi tendon organ, etc. and decrease the excitability of
motoneuronal pool in neurologically healthy individuals. This helps in
decreasing the tension of muscle.
• Improved mobility of soft tissue, decreased oedema, and muscle tension as
well as stimulation of touch and pressure receptor associated with these
techniques collectively contribute to the reduction of pain.

Therapeutic Use
i. To mobilise adhesion and soft tissue showing adoptive shortening, e.g. chronic
inflammation, organised oedema, traumatic adhesion.
ii. To improve mobility of skin by loosening and softening the scar in:
• Burns
• Postoperative scar
• Fibrosis following soft tissue injury and laceration.
iii. To improve circulation particularly in the muscle in:
• Fatigue following intensive muscular activity
• Disuse atrophy.
iv. To reduce muscle tension in:
• Spasm associated with pain
• Tension headache.

Caution
Deep pressure manoeuvres should be used with caution over the areas afflicted
with flaccid paralysis, because the excessive stretch to flaccid muscle may prove to
be counter productive.

FRICTION
This technique consists of small range oscillatory movement which is applied to
the deeper structures with pressure by thumb or fingers. According to the direction
of movement there are two types of friction.
• Circular friction
66 Principles and Practice of Therapeutic Massage
• Transverse friction.

Circular Friction
This was advocated by Wood in 1974. This resembles the digital kneading with the
only difference that it has no phase of relaxation and a constant deep pressure is
applied to the tissue during the whole procedure. The fingertips are placed over a
localised area and along with the application of little pressure downwards, the
skin and the fingers are moved as one in a circular direction. The amount of pressure
is gradually increased as the superficial structure becomes relaxed.
This technique is applied around localised area, i.e. joints, muscle attachments,
over fibrositic nodules and its vicinity, etc. It is most useful when a nerve trunk is
imbedded in consolidated oedema fluid. It is used to produce localised affect on
muscle which are in a prolonged state of tension, e.g. paravertebral muscle
(Thompson et al., 1991).

Transverse Friction
This technique was advocated and popularised by Dr Cyriax of England in the
early half of this century. Here, the direction of the movement is transverse, i.e.
across the long axis of the structure to be treated. It can be performed with:
• Tip of the thumb (Fig. 5.22)
• Index or middle finger which can be reinforced by placing one over the other
(Fig. 5.23)
• Two or three fingers

Fig. 5.22: Transverse friction at ankle with thumb : note that PIP joint thumb is flexed
 Techniques67 67
Definition and Classification of Massage

Fig. 5.23: Transverse friction of collateral ligaments of knee

with two fingers reinforcing each other

• The opposed finger and thumb.

The other parts of the hand should not come in contact with the skin. The fingers
are placed across the length of the structure. With pressure either forward or
backward, movement is performed in small ranges, so that the patient’s skin and
the therapist’s fingers are moved as one. The movement should take place only
between the affected structures (muscle tendon, ligaments) and the underlying parts.
It should never take place between finger and skin. The direction of the movement
is the single most important factor which decides the efficacy of this manoeuvre.
Before starting the friction, the anatomical structures to be moved are identified
and according to the arrangement of the fibres present in that structure, the fingers
are placed transversely along the long axis of the structure.
While applying friction to the soft tissue, the positioning of the patient should
also be decided carefully to ensure perfect movement. The noncontractile structures,
i.e. ligaments and the tendons are placed in fully taut position whereas the contractile
tissue, i.e. muscles should be fully relaxed. Explaining the importance of positioning,
Cyriax (1998) commented that relaxation of target muscle is paramount. Otherwise
the forces of friction will not penetrate deeply and broadening out of individual
fibres will not be achieved.
The fully stretched position of ligaments and tendon provide an immobile base
against which the ligaments/tendons can be moved effectively. This is a painful
procedure and the patient should be informed about it prior to the application of
the manoeuvre.
68 Principles and Practice of Therapeutic Massage
Technique
In general the digits, hand and forearm should form a straight line, being kept in
parallel to the movement imparted. The DIP joint being slightly flexed, much
extension at wrist or flexion at MP joint reduces the strength and friction and forces
DIP joint into full extension, painfully straining it (Cyriax, 1998).
The forces of friction can be generated by alternate flexion and extension
movement of finger/thumb or by wrist, elbow, shoulder or trunk movement while
keeping the finger/thumb firmly against the structure to be treated unduly strain
the hand muscle and cannot be performed for longer duration. Cyriax advocated
the use of latter as in this method more power is achieved with less effort.

Physiological Effects
1. It forcefully broadens out the structure.
2. It moves the individual collagen fibres over the underlying structure and keep
the structure free from adhesion.
3. It breaks the intrafibrillary adhesions. The to and fro motion helps to smoothen
the rough gliding surfaces and ensures pain-free mobility of the individual
collagen fibre.
4. Pain produced during this technique may facilitate the release of enkephalin/
endorphin.
5. Deep friction results in increase in the local blood supply and induce
hyperaemia. The mild erythema may also be produced.

Use
It is mostly used in the treatment of subacute and chronic lesion of muscles, tendons,
ligaments, capsules, nodules, adhesions, etc. It is much useful in localised pain
(trigger points).
Cyriax has strongly advocated the use of transverse friction in traumatic
muscular lesion, tendonitis, tenosynovitis and ligament sprain. He has listed as
many as 22 soft tissue lesions where he claims that transverse friction is much
more beneficial than other modalities including steroid infiltration. Some of these
sites are, musculotendinous junction of supraspinatus, biceps, psoas, anterior and
posterior tibial muscles, peroneal muscles, muscle belly of brachialis, supinator,
interossei of hand and foot, intercostal muscles, oblique abdominal muscles,
subclavius, ligaments around carpal bones, coronary ligament of knee, posterior
tibiotalar ligament and anterior fascia of ankle joint.

Specific Contraindication
1. Traumatic arthritis at elbow
2. Calcification or ossification in soft tissue
e.g. Calcification at supraspinatus tendon
 Techniques69 69
Definition and Classification of Massage
Calcification at collateral ligament of elbow.
3. Rheumatoid arthritis—to the joint capsule
4. Inflammation due to bacterial infection
5. Bursitis
6. Pressure on nerve.
Clinical presentation of these conditions mimics those soft tissues lesion where
transverse friction is indicated. However, in the above first 3 conditions it is harmful
while in the rest 3, it is not effective.

Caution
1. Vigorous friction may give rise to blister formation.
2. Risk of blister formation is more when the friction is performed on a moist
skin. In order to reduce moisture, the area should be made dry before
application of friction using spirit or powder.

PERCUSSION OR TAPOTEMENT
These are French words which when translated in English mean—the striking of
two objects against each other. Characteristic feature of this group of techniques is
the application of intermittent touch and pressure to the body surface.
All techniques of this group utilise the controlled movement of wrist and forearm
to strike the patient’s body surface rythmically. Mild blows are applied with various
pressures and in different manner.
It must not be confused with the diagnostic percussion in which the fluid
containing cavities of the body (the heart, lung, abdomen) are tapped and the sound
produced is used to diagnose the case.
The essence of these techniques is to use the different parts of the hand to strike
the body. The names of these techniques are given according to the part of the hand
used to strike the surface. Various techniques of this group are:
• Clapping
• Hacking
• Tapping
• Beating and pounding
• Tenting
• Contact heel percussion.

Clapping
It is a very common and useful tapotement technique that finds an important place
in the management of chronic respiratory disorders which often leads to sputum
retention. In this technique the slightly cupped hands strike the chest wall one after
the other in a predetermined rate.
70 Principles and Practice of Therapeutic Massage
Technique
Therapist adopts stride standing stance. Arm is kept at 30° angle of abduction and
elbow kept flexed at 90° angle. The hands are cupped so as to trap air inside the
hollow as it comes in contact with the skin. For this purpose, fingers and thumb are
kept adducted and the MP joint of index, middle and ring finger are kept slightly
flexed. In this position when hand rests over the body the centre of hand does not
come in contact with the body surface and only border of hands, fingers and heel of
hand strike the body surface (Fig. 5.24).
The technique is executed by the controlled and rapid flexion and extension of
wrist. At no time movement at elbow should be allowed. For an effective correct, a
free fall of extended hand is required. This is achieved by actively extending the
wrist and thereafter allowing it drop under the influence of gravity without
attempting to produce active flexion of wrist. Hand should create an air cushion
between the hand and the chest wall on impact. It is performed during both
inspiration and expiration and should not apply undue pressure on the soft tissue
of chest wall. Manual percussion is normally performed at a rate of 100-480 times
per minute and is reported to produce between 58-65 newtons of force on the chest
wall (Mackenzie, 1989). If applied in a proper way it produces a characteristic sound,
which can easily be differentiated from that produced in slapping when the whole
palmar aspect of hand comes in contact with the skin. Production of appropriate
sound is important because it indicate that adequate negative pressure (suctioning)
is achieved which produces the mechanical effect of loosening the secretion.
Clapping is performed over the chest wall. Preferably it should be applied over
the blanket or towel covering the chest. It helps to avoid sharp skin stimulation and

Fig. 5.24: Clapping : see when hand strikes, the centre of hand
does not come in contact with skin
 Techniques71 71
Definition and Classification of Massage
pain. Clapping can be taught to the patients suffering from chronic respiratory
disorders so that they can self percuss and loosen up the vicid secretion.
It should not produce pain to the patient and need not be forceful.

Variation
1. While cupping, some therapists fix the wrist in neutral position and use
alternate flexion and extension of the elbow to perform the technique. However
if not properly controlled, clapping performed in this manner can transmit
excessive force to the chest wall and may traumatise the tissue.
2. It can be performed over the bare chest wall.
3. In children or infants, percussion can also be applied using various cup-shaped
objects such as medicine pot padded with gauge, bell of a stethoscope, infant
facial mask, etc.

Caution
Clapping should not be avoided over the anterior chest wall as it may induce cardiac
arrhythmia. The sensitivity of skin is also more on the anterior aspect, therefore,
caution must be taken.

Hacking
In this percussion technique, only the ulnar border of medial three fingers (little,
ring and middle) are used to strike the skin. The fingers are held loosely apart so
that the ulnar border of middle, ring and little finger come successively in contact
with skin during each strike. This produces a peculiar sound.
Therapist adopts a stride standing stance. He keeps his shoulder at about 30°
angle of abduction and fixes the elbow at 90° angle of flexion. Hand should be

Fig. 5.25: Hacking

72 Principles and Practice of Therapeutic Massage
completely relaxed with fingers held loosely apart. Alternate supination and pronation
of the forearm combined with ulnar and radial deviation of the wrist respectively
produce the hacking. Movement of elbow is not allowed at all (Fig. 5.25).
As the hacking advances, the movement at shoulder moves the hands forward
or backwards or sideways.
This technique is very useful from relaxation point of view and is employed
over larger areas such as back, thigh, etc.

Tapping
This technique is useful when intermittent touch and pressure are to be applied
over a small area. In this technique, only pulp of fingers strike the body part. Either
one or both the hands may be used. Fingers are held loose and are relaxed.
Alternate flexion and extension of the metacarpophalangeal (MP) joints produce
the tapping. The wrist and elbow should be kept fixed and no movement is permitted
in these joints.
Commonly it is used over face, neck and other smaller areas. It can be
conveniently used on children.

Beating and Pounding

In these techniques a loosely clenched fist is used to strike the body part. Either one
or both the hands may be used. Depending on the part of clenched fist striking the
body part. Two techniques are named.
• Beating—the anterior aspect of fist strikes the part
• Pounding—the lateral aspect of fist strikes the part.

Beating
Therapist adopts stride standing stance. He keeps his shoulder in abduction of
about 30° angle and the elbow kept in 90° angle of flexion. In making a fist the
fingers are flexed at PIP and MP joint but the DIP joints are kept extended so that a
flat surface composed of dorsal aspect of two distal phalanx in produced on the
anterior aspect of fist. The beating is produced by the alternate flexion and extension
of wrist as used in clapping. Movement at the elbow is not permitted as it may
transmit excessive force (Fig. 5.26).

Pounding
Therapist adopts stride standing stance. The elbow and shoulder are kept at 90°
angle of flexion and 30° angle of abduction respectively. Here in making the fist all
the finger joints, i.e. MP, PIP including DIP are flexed. Thumb rests over the ring
finger.
Supination and pronation of forearm combined with ulnar and radial deviation
of wrist respectively produce the pounding. The action in pounding is similar to
that used in hacking (Fig. 5.27).
 Techniques73 73
Definition and Classification of Massage

Fig. 5.26: Beating : anterior part of clenched fist comes in contact with skin

Fig. 5.27: Pounding : lateral part of clenched fist strikes the skin

These two techniques are commonly used over the back, thigh and other fleshy
and broad area of body to obtain relaxation.

Tenting
This technique is a modification of clapping. Here, the concavity is produced
between the index and the ring finger with the middle finger is slightly elevated
74 Principles and Practice of Therapeutic Massage

Fig. 5.28: Tenting : position of fingers

and placed over them (Fig. 5.28). Over the smaller chest of the newborn baby or a
premature infant can be struck with this technique is very effective for loosening of
the viscid secretion.

Contact Heel Percussion

This is again a modification of the clapping technique. Here the chest wall is struck
with a concavity produced between thenar and hypothenar eminences.

Physiological Effects of Percussion Techniques

In general, percussion techniques bring about the following effects.
1. Tapotement (Clapping) is thought to create a negative pressure into the lung
through the chest wall. Like suction, which helps to loosen the vicid and
tenantous sputum.
2. After removal of secretion, the gasseous exchange becomes efficient which
improves ventilation and arterial oxygenation.
3. It results in intrathoracic pressure alteration in the range of 5-15 mm of H2O.
(Imle, 1989).
4. In some patients of chronic lung disease, clapping may induce bronchospasm
and a subsequent fall in FEV1.
5. The rhythmic intermittent touch associated with these techniques stimulates
the low threshold mechanoreceptors which help to diminish the perception of
chronic pain.
6. Cutaneous vasodilation is produced by elicitation of axon reflex and the release
 Techniques75 75
Definition and Classification of Massage
of H-substances. The latter effect is more pronounced when the techniques
are not executed properly.
7. Percussion techniques may facilitate the contraction of muscle by decreasing
the threshold of anterior horn cells.
8. Techniques of this group induce relaxation and calm the mental state of the
patient. If applied properly its rhythm and graduated pressure contributes a
lot to induce sleep and relaxation.
If the physiological effects associated with individual percussion techniques
are analysed, the various techniques can be classified under following two
subgroups.
• Respiratory percussion technique
• Stimulating percussion technique.

Respiratory Percussion Technique

These techniques are directed towards lung and utilise the sound energy to dislodge
the sputum from the bronchial tree. Only used over the chest wall these techniques
also have widespread effect on the haemodynamic system. Clapping, tenting,
contact heel percussion can be included in this group.

Stimulating Percussion Technique

Techniques of hacking, beating, tapping and pounding can be included in this group.
These techniques essentially do not have any effect on the respiratory system. Their
main effect is to produce sensory stimulation and induce relaxation. From
therapeutic point of view, these techniques do not offer much. Rather in 1967, the
education committee of Chartered Society of Physiotherapists, London while
investigating the value of different ways of giving massage had recommended to
abandon the technique of beating, hacking and pounding as the examination subjects
of physiotherapy students (Cyriax, 1998).
However, in sports set up, these techniques can be utilised effectively to
rejuvinate an exhausted athlete and to relieve his pre and postcompetitive anxiety
and tension. Even if mere, placebo, the effect associated with these techniques can
be of great help in tackling the psychological problems of the athletes.

SPECIFIC CONTRAINDICATION OF RESPIRATORY

PERCUSSION TECHNIQUES
Specific contraindication of respiratory percussion techniques are the following:
• Haemoptysis
• Pleuritic pain
• Acute pulmonary tuberculosis
• Osteoporosis
76 Principles and Practice of Therapeutic Massage
• Rib fracture
• Over surgical incisions
• Metastatic deposition in ribs and spine.

Caution
1. Indiscriminate use of clapping may provoke
a. Onset of cardiac arrhythmia with a subsequent fall in cardiac output and
partial pressure of oxygen in arterial blood.
b. Bronchospasm which occurs following excessive and rapid clapping.
2. Hacking, beating and pounding may induce flexor withdrawal and aggregate
spasticity in the patients affected with spastic paralysis. Therefore, the
application of these techniques in spasticity should be avoided.

Vibratory Manipulations
In this group of techniques, the vibration of the distal part of upper limb is used to
transmit the mechanical energy to the body. Vibration is produced in hands and
fingers using the generalised co-contraction of the upper limb muscles, which are
in constant contact with the subjects skin. However, it is the position of the forearm
which differentiates its two techniques. The movement of hands during vibration
is in upward and downward directions and forearm is kept in full pronation so
that when complete palmar contact of hand establishes with the patient’s skin the
wrist assumes the position of above 70° to 90° angle of dorsiflexion. Whereas in
shaking, the forearm is kept in midprone position so that the wrist assumes a position
of 0° to 10° angle of dorsiflexion. As a result of which, when vibration is produced
in the upper limb the hand moves relatively in the mediolateral direction. This
technique is mainly directed towards the lung and other hollow cavities.

Vibration
This technique involves, constant touch of therapist hand or a part thereof with the
patient’s skin and the application of rapid intermittent pressure without changing
the position of hand. Most commonly used over the chest wall, where both the
hands of therapist are used, the vibration can also be produced by one fingertip or
palm, though the fingertip vibrations are rarely used in therapeutic massage.

Technique
For chest wall vibration, the therapist adopts a walk standing stance keeping his
elbow completely extended and the shoulder fixed in little flexion. One hand is
placed over the other which remains in contact with the chest wall of patient. To
perform vibration, therapist, transfers his body weight to the patient’s chest through
the extended and stabilised upper extremities and tenses up all the arm and shoulder
muscles in a co-contraction. This produces oscillatory movement of his hand in
upward and downward direction and transmits the mechanical energy to the
patient’s chest (Fig. 5.29). Vibration is always performed during the expiratory phase
 Techniques77 77
Definition and Classification of Massage

Fig. 5.29: Vibration to upper chest wall

of respiration. Patient is asked to inhale deeply and then blow out all the air through
mouth. Vibration is initiated just before the expiratory phase and extended to the
beginning of inspiration phase. Manual vibration operates at the frequency of 20
Hz (Imle, 1989).
Using co-contraction of upper limb muscle vibration can also be produced in
fingertips or single palm.

Physiological effects
1. The transmission of vibration energy helps to dislodge the thick sputum from
the bronchial wall.
2. It has finer action than shaking, therefore it is used in some conditions where
shaking or percussion are contraindications.
3. It may facilitate the movement of liquid and gases in the body cavities.

Therapeutic uses
1. To mobilise the vicid secretion from lung
2. Postoperative sputum retention
3. Chronic obstructive pulmonary disorder
4. Cystic fibrosis
5. Neonatal respiratory distress associated with sputum retention.
In these conditions, vibration is commonly used along with clapping, posteral
drainage, shaking and coughing techniques to clear the lungs.

Caution
78 Principles and Practice of Therapeutic Massage
Chest wall vibration should be administered with caution in:
• Unstable thoracic spine injuries
• Rib and sternal fracture
• Persons receiving prolonged steroid therapy.

Shaking
This technique also transmits oscillatory mechanical energy to the chest wall like
vibration. However, there are two basic features which distinguish this technique
from vibration.
a. Oscillation produced in shaking is coarse as compared to that produced in
vibration.
b. Unlike upwards and downwards movement of hand, in this technique the
direction of oscillation is sideways which may be produced by radial and ulnar
deviation of wrist.

Technique
Therapist adopts either a walk standing or fall out standing stance. Both the hands
are placed over the chest wall over the affected lobe. Shoulder is adducted and
elbow is kept slightly flexed. Placement of hand can be done in one of the following
ways.
a. Patient is positioned in supine lying
1. Place both the hands on each side of anterior chest walls (Fig. 5.30) or
2. Place one hand on anterior and other on the posterior wall of same side.

Fig. 5.30: Shaking on lateral chest wall of a supine patient

 Techniques79 79
Definition and Classification of Massage
b. Patient is positioned in side lying
1. Place both the hands on the upper lateral chest wall, or
2. Place one hand on anterior and the other over posterior chest wall of upper
side.
Shaking is done only during expiration phase. Therapist transfers body weight
to patient’s, chest and tends to produce upward and downward movement of upper
extremity. This shakes the chest wall vigorously.

Physiological effects
1. Shaking produces coarse vibratory movement, thereby transfer thing
mechanical energy to the lungs which helps to dislodge the thick secretion
from the bronchial tree.
2. It mechanically shifts the sputum from the smaller to the larger bronchioles
which can then be cleared off by coughing.
3. Shaking over the sternum during respiration, stimulates a cough.

Therapeutic Use
This technique is used in chest clearance programmes along with all other respiratory
techniques of physiotherapy.

Contraindication
Shaking should not be used in:
• Severe hemoptysis
• Acute pleuritic pain
• Active pulmonary tuberculosis
• Fractured rib
• Osteoporosis.
80 Principles and Practice of Therapeutic Massage

6
Practical Aspects
of Massage

Success of a massage therapy depends upon several factors. Careful selection and
correct application of various techniques no doubt are the most essential factors to
elicit the desired effects. However, several practical points, which are often
ignorantly considered trivial also, influence the outcome of massage therapy. The
position of patient, stance of therapist, proper support to body parts, congenial
environment of treatment room, attitude and appearance of therapist, etc. are not
related to the various techniques of massage, yet play an important role in
determining the efficacy of massage treatment. Position of patient and placement
of pillows significantly influences the amount of muscular relaxation and the depth
of tissue approached during therapy. A congenial atmosphere not only helps to
win the confidence of patient but also exerts a strong placebo effect. If the stance of
therapist is not proper, he may be successful in relieving the symptoms of patient
but he may himself become a victim of postural strain at the end of a prolonged
session. Therefore a thoughtful attention to these so, called trivial but practical
points is essential for the intelligent and successful application of massage.
This chapter deals with some of those practical points which must be given due
consideration during massage therapy session. The flow chart of massage treatment
(flow chart 6.1) and the sequence of different techniques often used in the general
massage of upper limb, lower limb, back and face are given at the end of the chapter.
This aims at helping the beginner to learn the practice of massage.

POSITIONING OF THE PATIENT

Depending upon the age, sex, condition and the part to be treated, patient should
be placed in a suitable and comfortable position. The aim of this positioning is to
ensure the following:
1. The part to be treated should be fully supported to ensure relaxation and to
gain the confidence of patient.
2. The body part should be easily approachable to the therapist so that he does
not face any difficulty in proper administration of the techniques.
3. It should not hamper the continuity of massage.
 Practical Aspects
Definition and Classification of Massage81 81
of Massage
Flow chart 6.1: Steps of massage treatment

Following are the different positions adopted for the therapeutic applications
of massage.
Prone lying : for back and posterior aspect of lower limb.
Supine lying : for anterior aspect of lower limb, upper limb and face.
Half lying : for lower limb, upper limb and chest.
Side lying : for upper limb, chest and lower limb.
Sitting : for upper limb, upper back and face.
Adequate number of pillows should be placed according to body contour to
ensure proper support, complete relaxation and gravity assisted drainage.

Prone Lying (Fig. 6.1)

In this position the patient is placed on a couch or bed with the face down. Most
commonly used in the massage of back, it can also be used for the posterior aspect
of lower limb (Table 6.1).
82 Principles and Practice of Therapeutic Massage

Fig. 6.1: Patient’s positioning in prone lying

Table 6.1: Rationale of pillow placement in prone lying

Support Purposes
One pillow under the abdomen i. To flatten the back and to obliterate the lumbar
lordosis by tilting the pelvis posteriorly. This
helps to relax extensor muscles of the spine.
Pillows under lower legs i. To support the legs and to maintain knee in
flexed position. It relieves the tension of
hamstring muscle
ii. To reduce pressure over the anterior aspect of
ankle and to keep the toes free as well as to
relieve tension of dorsiflexor muscles
Two pillows crossing one another at i. To support the neck in neutral position
90° angle under the forehead ii. To minimise the tension of posterior, neck
muscle
or
Dorsal aspect crossed hands of iii. To ensure the easy access to the posterior neck
patient under the forehead iv. To facilitate easy breathing by not allowing
compression of the nose

Precautions
1. While placing pillows under the abdomen care should be taken to avoid
pressure over the:
• scrotum in male.
• breast in female (pillows are kept little higher up to prevent pressure on
breast).
2. This position should not be used for the people afflicted with heart or
respiratory disorders because in this position the abdomen and the chest are
compressed by the body weight and inspiration is difficult.

Supine Lying (Fig. 6.2)

This position is used for massage of the lower limb, upper limb and face (Table
6.2).
 Practical Aspects
Definition and Classification of Massage83 83
of Massage

Fig. 6.2: Patient’s positioning in supine lying

Table 6.2: Rationale of pillow placement in supine lying

Support Purposes
Pillow under knees
One long pillow across the couch i. To keep hip and the knee in slightly flexed
under both the knees position
or
Two small pillows along the couch under ii. To relieve the tension in the hamstrings, rectus
the knees femoris and iliofemoral ligament
iii. To tilt the pelvis posteriorly to avoid back
hollowing and relax lumbar extensors
iv. To position the thigh in elevation so that the
gravity assists the venous and lymphatic
drainage
Small pillow or a rolled towel under i. To support the cervical lordosis
the neck ii. To maintain neck in neutral position
iii. To relax the muscles around the neck

Precautions
This position is not suitable for those patient’s afflicted with respiratory and cardiac
disorders as they may experience breathlessness (orthopnoea).

Half Lying (Fig. 6.3)

This position is suitable for elderly, cardiac and respiratory patients, as the breathing
becomes easier in this position. It is most commonly used for arm and chest massage.

Fig. 6.3: Patient’s positioning in half lying

84 Principles and Practice of Therapeutic Massage
Patient is positioned in such a way that his trunk is about 45° angle in relation
to lower limbs with pillow under both the knees. In this position the back is
completely supported and the knee and hip are flexed. This helps to achieve
relaxation of the abdominal muscles and makes the respiration easier.

Side Lying (Fig. 6.4)

This position is used for the massage of the upper extremity, chest and the posterior
aspect of the lower limb (Table 6.3).

Table 6.3: Rationale of pillow placement in side lying

Support Purposes
• Pillow under head. • To maintain alignment of neck in neutral
position and to relax the neck muscle.
• 2-3 pillows under the upper most, lower • To completely support the hip in line with
limb: one under thigh, two under legs. the trunk.

Sitting
This position is most commonly used for the massage of the upper extremity and
the posterior neck massage.
a. When used for upper limb massage the limb has to be placed on the plinth
over prearranged pillows to maintain about 90° angle of flexion and abduction
at shoulder joint, with elbow extended and wrist and fingers supported. This
is the position of the ease which also elevates the arm so that gravity assists
the drainage (Fig. 6.5).
b. When used for the posterior aspect of neck and the upper back, the patient
should face the plinth and support is given to the forehead in one of the
following way.
i. Placing the forehead over the dorsum of both hands which are crossed and
kept over the plinth (Fig. 6.6)
ii. Placing the forehead on pillows or (rolled towel) placed over the plinth
(if the shoulder mobility is restricted) (Fig. 6.7)
This serves to obliterate cervical lordosis to relax neck muscles and to give
complete access of the posterior neck to the therapist.
c. For facial massage, the posterior neck can be supported on the head rest
(Fig. 6.8). The face is thus exposed for the therapist to carry out the procedure.

Fig. 6.4: Patient’s positioning in side lying

 Practical Aspects
Definition and Classification of Massage85 85
of Massage

Fig. 6.5: Patient’s positioning Fig. 6.6: Positioning for posterior neck massage,
in sitting for massage of upper limb head is supported on the crossed hands

Fig. 6.7: Positioning for posterior neck massage, Fig. 6.8: Positioning for facial massage
if the patient has shoulder stiffness using head rests in sitting position
86 Principles and Practice of Therapeutic Massage
Note: When elevation of part is required in treatment of oedema, number of pillows
in the distal part should be increased, for example, for lower limb massage in supine
lying the arrangement of pillow could be as follows:
• One pillow under knee
• Two or three pillows under leg and ankle.
Alternatively if patient does not have any complications the foot end of the bed
may be raised.

DRAPPING
The part to be massaged must be fully exposed so that therapist can thoroughly
look over the part and rule out the contraindications. Any adverse effects produced
during manipulation can also be noticed immediately.
However, any undesired exposure of the body parts must be avoided. The other
parts of body must be drapped properly using appropriate drapping material such
as bed sheets, towel, etc. This drapping or covering up of the patient helps.
• to honour the modesty and privacy of the patient
• to keep the patient warm (in winter).
The drapping of patient should not be done in a clumsy way, rather it should
give an aesthetic pleasure, which helps to achieve proper relaxation and to create a
congenial atmosphere (Table 6.4).
Table 6.4: Drapping of various regions during massage therapy

Parts to be massaged Exposed part Drapped part

Back (Fig. 6.9) From occiput to posterior Lower limbs upto gluteal region
superior iliac spine and upper limb upto shoulder joint
Lower limb (Fig. 6.10) From toe to groin Contralateral lower limb, trunk and
genitalia
Upper limb (Fig. 6.11) Tip of finger to axilla and Contralateral upper limb, trunk
supraclavicular fossa below clavicle

Fig. 6.9: Drapping for back massage

 Practical Aspects
Definition and Classification of Massage87 87
of Massage

Fig. 6.10: Drapping for lower limb massage

Fig. 6.11: Drapping for upper limb massage

STANCE OF THE THERAPIST

Economy of muscle work must be considered before starting manipulation so that
fatigue and discomfort for the therapist can be minimised during prolonged session
of therapy. While performing massage, the therapist, should adopt a position which
can provide.
• Wide base to ensure proper stability during manipulations
• Free body movement to have rhythm and maintain the continuity of massage
• Effective use of the body weight to minimise muscle work while applying
pressure.
Flexion attitude of spine during massage strains the back muscles and adds to
the discomfort of therapist. Therefore, it should be avoided as far as possible.
Generally, the therapists during the practice of massage adopt the following
modification of standing.
• Stride standing
• Walk standing
• Fall-out standing.

Stride Standing (Fig. 6.12)

The lower limbs are abducted at hip joint so that feet are placed almost two feet
wide apart.
88 Principles and Practice of Therapeutic Massage

Fig. 6.12: Stride standing stance

In this stance, the base is widened laterally, so that the stability in the frontal
plane is increased. Movement can be carried out effectively in mediolateral direction.
It is an effective stance to perform percussion manoeuvres, skin rolling and
vibration. It is most commonly used for the massage of the back and the face.

Walk Standing (Fig. 6.13)

One leg is placed directly forward to the other leg in such a way that the heels of
both the legs are placed in the same line and are almost two feet length apart.

Fig. 6.13: Walk standing stance

 Practical Aspects
Definition and Classification of Massage89 89
of Massage
In this stance, the base is increased in anteroposterior direction. Pelvis is stabilised
so that the movement of spine can be effectively localised and rotation of spine and
the movement in anteroposterior direction can be carried out efficiently. It is most
suitable and commonly used position for the effleurage and stroking manoeuvres
where whole length of the segment is to be covered in one move.

Fall-out Standing (Fig. 6.14)

One lower limb is placed directly forward by the flexion of hip joint so that the feet
are almost two feet length apart. Knee of the forward leg is slightly flexed while the
other knee remains in extended position. The body is thus inclined forward.
If the arms and shoulders are properly supported, the body weight of the
therapist can be effectively utilised in this position for applying the pressure.

ATTITUDE OF THE THERAPIST

• Therapist should be completely relaxed.
• His/her manners should be pleasant and courteous.
• He/she should be confident and give necessary instructions to the patient in an
effective manner.
• His/her voice should be clear, low pitched and soothing.
• As far as possible he/she should avoid conversations/discussions during the
session.
• The instructions should be given in language which patient can understand.
• These instructions should be simple short and self-explanatory.

APPEARANCE OF THE THERAPIST

• Nails of therapist should be short and clean, as long nails may scratch the body
and creates discomfort during treatment.

Fig. 6.14: Fall-out standing stance

90 Principles and Practice of Therapeutic Massage
• Therapist should also remove all the rings, bangles, watches, etc. for the similar
reason.
• Hair of therapist should be preferably short or it should be properly arranged
so that it does not dangle over the patient’s body and irritate him.
• For the same reason, ornament like necklace, long ear rings, etc. either should
be removed or arranged properly.
• The sleeves of therapist’s apron should be either half or folded upto arms in
order to increase the efficient use of the hand.
• In order to avoid any chance cross infection, the hands should be washed and
dried up before and after massage. If this is done before the patient, it helps to
win the confidence.
• When the climate is cold, therapist’s hands must be warm.
• Therapist should not touch the patient’s skin with cold hands. He should make
them warm by rubbing against each other. This is essential to avoid the
unnecessary stimulation of cold receptors which may produce discomfort and
increase the muscle tension of the patient.
• Therapist should avoid any sort of perfumes as they can have a nauseating
effect on some patients due to allergy.

CONTACT AND CONTINUITY

“The fingers of a good rubber will descend upon an excited and painful nerve as gently as
dew upon the gross, but upon a torpid callocites as heavily as the hoop of an elephant.”
William Beveridge (1774-1839)
Massage at no time should cause pain or discomfort. Even during the friction,
unbearable pain should not be elicited. The hands of the therapist should be relaxed
and moulded to the parts.
The amount of pressure applied during manipulations, need not be the same. It
should be modified accordingly to the condition of the structures being treated.
Initially the massage may start with less pressure and as the superficial tissues
become relaxed, the pressure could be increased gradually in order to approach
the deeper structures.
Massaging a patient is a continuous process. There should not be any break in
the continuity of massage. The change of techniques should not be perceptible to
the patient. Irrespective of the condition of body part, massage should always be
practised in a rhythmic manner. The speed of rhythm may vary according to the
effects desired. For a stimulating effect quicker and stronger strokes should be used
while for a soothing effect, slower and light strokes are applied.
While the contact and continuity should be maintained throughout the session,
there should be no aimless wandering of the hands over any area of patient body.
It is unethical and can seriously endanger the reputation of the therapist.
 Practical Aspects
Definition and Classification of Massage91 91
of Massage
SELECTION OF A TECHNIQUE
Before starting the treatment the technique which are to be used during a session
has to be carefully selected. The technique should be directed towards the condition
in order to achieve only the desired physiological effect. For this purpose patient
should be examined thoroughly. Contraindications should be ruled out and the
aims of treatment should be defined. The technique used during massage session
should, then be selected considering all these factors. Table 6.5 illustrates the
reasoning involved in selection of techniques in some of the conditions.
Table 6.5: Rationale behind the use of techniques in different conditions

Condition Desired effects Techniques to be used

1. Paralytic or gravitational To increase drainage, to Effleurage and kneading
oedema prevent the consolidation of
oedema fluid
2. Adhesion/ Contracture To mobilise the individual Kneading, friction and
fibres of adherent structure wringing
and breakdown the adhesion
3. Bronchiectasis To mobilise the viscid Clapping, vibration and
secretion from the lung shaking
4. Decreased arousal of To induce peripheral Hacking tapping and fast
athlete vasodilatation, and induce speed superficial stroking
psychological stimulation

LUBRICANT
It is a common believe in medical and nonmedical circle that massage with different
oil has some curative value and the effect of massage can be enhanced with the use
of specific medicinal oils. Massage with various oils is a common prescription in
various Indian medicinal systems where it is recommended in several systemic
disease including stroke.
Massaging babies with various types of oils is a common practice in several
communities in the Southeast Asia. The reason for this practice is the presumptions
that oil massage helps prevent hypothermia, increase growth pattern, improve sleep
and in general affect the health of the baby in a positive manner. In the recent years
these practices and claims about the baby oil massage has been investigated
scientifically which lay some credence to this age old practice as far as the baby
massage is concerned. In an interesting study Agrawal et al. (2000) investigated on
a sample of 125 fullterm infants of 6 week of age, whether massage with oils
commonly used in the community for massage in infancy is beneficial. Four groups
of infants were massaged for 4 weeks with herbal oil, sesame oil, mustard oil, and
mineral oil whereas the fifth group did not receive massage and served as control.
The investigators observed that massage improved the weight, length, and mid-
92 Principles and Practice of Therapeutic Massage
arm and mid-leg circumferences as compared to infants without massage. The
femoral artery blood velocity, diameter and flow improved significantly in the group
with sesame oil massage as compared to the control group. The postmassage sleep
of infants was also improved. The study concluded that massage with oil in infancy
improves growth and postmassage sleep.
Soriano et al. (2000) in a trial of 60 preterm neonates reported significantly higher
weight gain over a 30 days period in the oil massage group compared to those who
received routine care (703 + 129 g VS 576 + 140 g; P <0.05). They also demonstrated
a significant increment in length, triceps skinfold thickness and midarm
circumference after 30 days of oil massage in preterm neonates. Field (1980) in a
review of supplemental stimulation of preterm neonates has identified two
controlled trials that had used only tactile stimulation as an intervention. Each of
these studies enrolled 48 subjects. Both had reported greater weight gain in infants
receiving stimulation compared to controls after a 10-day intervention period.
A nonsignificant increase in the body weight of premature infants following
massage with oil as compared to massage without oil was reported by Arora
et al. (2005) who concluded that oil application may have a potential to improve
weight gain among preterm very low birth weight neonates. Solanki et al. (2005)in
a controlled clinical trial of the effect of two kind of oil showed that topically applied
oil can be absorbed in neonates and is probably available for nutritional purposes.
The fatty acid constituents of the oil can influence the changes in the fatty acid
profiles of the massaged babies. In a sample of 120 babies, they observed significant
rise in essential fatty acids (linolenic acid and arachidonic acid) in the blood of
babies massaged with sunflower oil and of saturated fats in babies massaged with
coconut oil group. This study provide some evidence to the believe that the
composition of oil has a role to play in bringing about the cutaneous as well as
systemic effects.
In the study of Satyanarayanan et al ( 2005) coconut oil massage resulted in
significantly greater weight gain velocity in the preterm as well as in the term babies
as compared to mineral oil and placebo (powder). Coconut oil massage group also
showed a greater length gain velocity compared to placebo group.
In addition to the advantage of weight gain it is also assumed that oil massage
may have the potential to prevent nosocomial infection in premature babies by
improving skin barrier. Darmstadt et al (2005) reported that infants treated with
sunflower seed oil were 41 per cent less likely to develop nosocomial infections
than controls. These studies while hinting at the possible benefit of the use of oil
during massage also demand cross validation on a larger sample and further
investigations into the role of oil in massage as far the treatment of various disorders
are concerned.
 Practical Aspects
Definition and Classification of Massage93 93
of Massage
The purpose of using the lubricating contact media during massage is mainly to:
• Make skin soft and smooth
• Reduce friction between therapist’s hand and patient’s skin.
• Gain placebo effect.
The indications for the use of lubricants in massage are the following:
• Presence of excessive sweating either with the patient or with the therapist
• Poor condition of the skin. For example dry, rough, scaly and fragile skin
The commonly used lubricants in the practice of massage are :
• Powder, oils and creams.

Powder
Preferably it should be a nonperfumed one, as many people are allergic to the
fragrance. French chalk or talcum powders are commonly used in the presence of
profused sweating as it very readily absorbs the moisture.

Oils
The oil is helpful when the skin is dry and scaly, for example, after removal of the
plaster cast. Most commonly used oils are edible oils (mustard and coconut oil,
olive oil, etc.), mineral oil, (liquid paraffin) and some medicinal oils. All these oils
exert a drag effect on the skin and provide smooth gliding. For this effect, oils can
also be used in the presence of a very hairy skin. The use of edible oil in therapy is
avoided because they have a peculiar smell, which may be allergic to some people.
They may also attract insects which may produce injuries in persons with anaesthetic
skin such as paraplegic, leprosy patients, etc. Therefore, in these conditions massage
with edible oils should not be considered at all.

Cream
Lanolin or lanolin-based creams are suitable for the mobilisation of scars due to
burns and surgical trauma.

ACCESSORIES
Following accessories are essential in the practice of massage (Fig. 6.15)

Low Stool or Without Arm Support Chair

It is used in positioning of patient in sitting, during the massage of the face and
upper limb and the upper neck.

Couch
It should be well-padded. The top of couch should be covered with washable plastic
or rexine, to facilitate cleaning and disinfection. Height of the couch should be
94 Principles and Practice of Therapeutic Massage

Fig. 6.15: Treatment area and accessories

adequate so that the therapist need not stoop (when the couch is too low) or reach
up (when the couch is too high) to perform the manoeuvres. It should be wide
enough to allow the patient to turn sides. A couch of 6½ feet long, 2½ feet wide and
2½ -3 feet height is adequate for the most therapists of average height. Wider couch
will have a disadvantage that each time patient turns the therapist has to bring him
closer towards the edge. Ideally, the couch should have shelves incorporated into
it where linen, pillows, lubricants, etc. can be stored. Alternatively a movable trolley
can be used to keep the accessories near the couch.

Bed sheet
Six to seven, easily washable large bed sheets are required to drape the patient.
One bed sheet should be placed over the plastic surface of couch to facilitate patient’s
comfort. This also absorbs the perspiration. In winter, the use of one or two large
light blanket over the couch will add to the comfort of the patient.

Towel
Three to four, large size, and 3-4 small size towels are required to drape and provide
support to the patient. The small towels can be used to remove the extra lubricants
from the patient’s skin.

Pillows
Seven to eight soft pillows with washable covers are essential for positioning the
patient.
 Practical Aspects
Definition and Classification of Massage95 95
of Massage
Small Kidney Tray or Bowl
It is used to keep lubricants.

Soap
A nonperfumed soap should be used to wash the hands of therapist before and
after massage.

Water Tap
Therapist should have access to a running water tap to wash the hands. Alternatively
water can be kept in a small plastic container.

SEQUENCE OF THE MASSAGE

Upper Limb (Fig. 6.16)
• Superficial Stroking: From shoulder to fingers 4 to 5 strokes covering all aspects
of the upper limb.
• Effleurage: Performed with only one hand the other hand holds the patient’s
hand and changes the position of patient’s forearm. Consist of 4 to 5 strokes
each ends at axilla. Strokes are performed in following order:

Forearm Pronated
I. Starts from posterolateral border of hand→Ulnar border of forearm→medial,
surface of arm→axilla
II. Dorsum of hand→posterior surface of forearm→posterior aspect of
arm→axilla.

Fig. 6.16: Preparation of patient for upper limb massage

96 Principles and Practice of Therapeutic Massage
Forearm Mid Pronated
I. Lateral border of hand including, thumb→radial border of Forearm→lateral
surface of arm→axilla.

Forearm Supinated
I. Palm of hand→anterior surface of forearm→anterior aspect of arm→axilla
II. Antero-medial border of hand→antero-medial aspect of forearm→medial
surface of arm→axilla.
• Kneading
a. Double handed finger kneading—around shoulder joint
b. Single handed finger kneading over deltoid
c. Alternated handed palmar kneading over—biceps and triceps
d. Palmar kneading—to upper part of forearm
e. Finger tip kneading—on the interosseous space
f. Thumb kneading—over thenar and hypothenar eminences.
• Picking up
To deltoid—triceps—biceps brachii—flexors of forearm and brachioradialis.
• Hacking
It is performed first on one aspect of the upper limb then the position of forearm
altered and other aspect is approached.
i. Forearm pronated: Start from posterior wall of axilla→posterior
deltoid→triceps→forearm extensors.
ii. Forearm supinated: Start from anterior wall of axilla→anterior
deltoid→biceps— forearm flexors—palm (all bony prominences should be
avoided) during hacking.
• Effleurage to whole upper limb again (distal to proximal ending at axilla).

Lower Limb (Fig. 6.17)

• Superficial stroking: From the thigh to toe 3 to 6 strokes, covering all the aspects
of the lower limb.
• Effleurage: Performed with both the hands alternatively or simultaneously,
consists of 3 to 6 strokes each starting from toe and ending at the inguinal lymph
nodes (femoral triangle).

Over Thigh
• Effleurage: Consist of 3 to 6 strokes covering all aspects of thigh. Stroke ends at
inguinal lymph nodes.
• Kneading: Double handed palmar kneading to:
i. Anteroposterior aspect together
ii. Mediolateral aspect together.
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Definition and Classification of Massage97 97
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Fig. 6.17: Preparation of patient for lower limb massage

• Picking up: On quadriceps, adductors and hamstrings.

• Hacking
• Beating
• Effleurage.

Over Knee
• Effleurage: Performed by crossing both the hands above patella, stroke ends at
the popliteal fossa
• Thumb kneading: Around margin of patella
• Finger kneading: Around medial and lateral, collateral ligaments of knee joint
• Effleurage.

Over Leg
• Effleurage: Starts from toe or ankle; stroke ends at popliteal fossa. Rotate the
limb into lateral rotation to approach the posteromedial aspect of leg.

Over Calf Muscles

• Palmar kneading on the upper calf/thumb or finger kneading on the lower calf
• Picking up
• Hacking.
Rotate the leg into medial rotation to approach the posterolateral aspect of leg.

Over Tibial and Peroneal Muscles

• Palmar kneading on the upper half/thumb or finger kneading on the lower
half
• Picking up
• Hacking
98 Principles and Practice of Therapeutic Massage
• Effleurage.

Over Foot
• Effleurage: Stroke ends at ankle
• Fingertip kneading: On the interosseous space and over extensor digitorum
brevis
• Effleurage to whole lower limb.

Back
The back can be divided into 3 areas—thoracolumbar, gluteal region and the neck.
Massage may be performed in the following sequences in the respective areas.

Thoracolumbar Region
1. Superficial stroking: From proximal to distal.
2. Effleurage: Performed with both the hands working together, it consists of 3
strokes executed in the following order (Fig. 6.18).
i. Starts from the most lateral lumbar region—goes upto axilla.
ii. Central lumbar region—up to axilla.
iii. From posterosuperior iliac spine→midline of back→neck →supraclavicular
nodes.
• Ironing: Over the entire back therapist should change his side while
approaching the opposite side.
• Finger kneading: Over paravertebral area both the hands used

Fig. 6.18: Direction of effleurage

strokes in the region of back
 Practical Aspects
Definition and Classification of Massage99 99
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simultaneously preferably starting from lower back and proceeding
gradually toward upper back.
• Hacking: Entire back leaving the spinus processes and scapulae.
• Beating or pounding.
• Skin rolling.
a. From side to midline or vice versa
b. In midline from distal to proximal.
For beginner, respiratory massage techniques, i.e. clapping, vibration and
shaking can be included in massage of upper thoracic region for the sake of
mastering the techniques.

Gluteal Region
• Effleurage: Consists of 3 curved strokes performed with one hand, each stroke
ends at the groin. Direction of strokes is from PSIS to iliac crest upward and
from iliac crest to groin obliquely downward in order to terminate at inguinal
lymph nodes (see Fig. 6.16).
• Palmar kneading: Over gluteal muscles.
• Ironing
• Finger kneading: Over the margin of iliac crest
• Picking up
• Wringing
• Hacking
• Effleurage.

Neck
• Effleurage: Performed with palmar aspect of adducted fingers. It consists of 3
strokes in the following order. The direction of stroke is from upper to lower
neck (see Fig. 6.16).
i. Side of neck→supraclavicular area
ii. Back of neck→supraclavicular area
iii. Midline→side of neck→scapular muscle→axilla
• Finger pulp kneading to–occiput, upper trapezius–midscapular muscles
• Picking up–to upper fibre of trapezius
• Hacking
• Effleurage.

Face
• Effleurage: Consists of 4 strokes directed from midline of face to the
submandibular lymph nodes performed in following order
i. Starts from midline of forehead→downward→below the ear
ii. From nose→cheeks→submandibular nodes
100 Principles and Practice of Therapeutic Massage
iii. From above and below mouth→submandibular gland
iv. From under chin→submandibular gland.
• Finger kneading: In the same line of the stroke of effleurage
• Wringing: Performed with pulp of index finger and thumb over the entire face
• Skin rolling
• Tapping
• Vibration and kneading with one finger over the exit of trigeminal nerve, i.e.
supraorbital submental and infraorbital foramina and facial nerve, i.e.
stylomastoid foramina
• Effleurage.
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7
Therapeutic Applications
of Massage

This chapter deals with the application of massage in pathological conditions. The
different techniques of massage as applied in various conditions, are described.
The emphasis is given on the patient’s positioning, techniques to be used and their
sequences as well as on the aims of treatment. This arrangement is intended to
serve as a guideline to all those who have learned the basic techniques of massage
and now want to apply their knowledge in the treatment of some disorders.
However, one should remember that the techniques mentioned or the massage
itself constitute only an adjunct to the total therapy plans in many conditions. For
example in the treatment of venous ulcer, massage can be effective only if
supplemented with elevation, elastic bandage, dressing and medication.
Therefore while administering massage, this fact should always be kept in mind
and massage should always be supplemented/combined with other physical
modalities as and when required.
The methods of application of massage for the following conditions are described
in this chapter.
• Oedema • Muscle injury
• Radical mastectomy • Traumatic periostitis
• Venous ulcer • Fibrositis
• Lower motor neuron lesion • Painful neuroma
• Bell’s palsy • Engorged breast
• Sprain • Flatulance
• Tenosynovitis • Relaxation
• Tendinitis • Pulmonary conditions

Oedema
When massage is used to reduce oedema, it is often combined with elevation, active
exercises, passive movements and elastic compression to have the lasting effect.
102 Principles and Practice of Therapeutic Massage
Prior to application of massage, all the restrictive clothing such as tight garments,
underwears, etc. should be removed in order to provide a resistance free drainage
pathway.
The oedematous part should be kept in elevated position by pillows placement,
elevating bed ends or by the suspension slings, latter is useful for the heavy limbs.
This position should be maintained for 15–30 minutes before the massage is
administered so that the gravity will assist the drainage.
The patient is instructed to perform deep breathing exercises throughout the
treatment. Deep inspiration decreases the negative pressure of the mediastinum.
This facilitates the flow of lymph and venous blood from the adjacent parts towards
the centre, which is at higher pressure.
The massage is administered in the form of deep effleurage, kneading, picking
up and friction. For soft oedema, the effleurage is used frequently along with light
kneading, while for endurated oedema the emphasis is given to deep kneading
and friction interspersed with effleurage.
The proximal area should be drained first, then the distal area is approached.
To end with, the whole area should be drained once again.
These principles can be utilised in various conditions where reduction of oedema
is the main goal, e.g. arm oedema following radical mastectomy, venous ulcer,
gravitational and paralytic oedema, etc.

Radical Mastectomy
It is the en block resection of breast tissue along with its lymphatic glands. This
surgical procedure is used in the treatment of malignant breast tumours.
The removal of axillary glands destroys the lymphatic channels through which
the lymph returns from the upper extremity. This results in intensive lymphatic
congestion and massive swelling of the arm. The oedema persists until the new
lymphatic channels are formed through axilla to the thoracic duct or the lymphatic
duct.

Aims of Treatment
To facilitate the lymphatic drainage and relieve congestion in the upper limb.
To raise the pressure in the lymphatic vessels in order to assist in the formation
of new drainage pathways.

Position
Patient lies supine or in-side lying with arm in elevation and supported by pillows
or suspension sling. Tight undergarments, brassieres, banians should be removed.
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Techniques used
• Effleurage slow and deep
• Kneading slow and deep
• Friction around the joints.

Sequence
Effleurage is given to the whole upper limb followed by effleurage to the arm to
empty the proximal vessels into the axilla.
At the end of each stroke, the patient is asked to take deep breath. This sequence
should be repeated until the whole length of arm is treated. After 2 to 3 strokes of
effleurage, slow and deep kneading and picking up are given to squeeze out the
oedematous fluid and to make the tissues soft and pliable.
Friction around the shoulder, elbow wrist and the small joints of hand can be
used for the similar purposes.
If the swelling is present, over the chest, back, and the side, similar manipulations
may also be used. In these areas effleurage must accurately follow the direction of
lymphatic drainage of the part.
Care should be taken not to stretch or damage the surgical incision. Medical
advise should always be taken before attempting the massage in the immediate
neighbourhood of scar.

Venous Ulcer
In this condition the chronic venous congestion persists due to incompetency of
the valve and failure of calf muscle pump slows down the blood flow and diminishes
the nutrition of the part. As a result of which, cells necrose; skin breaks down and
ulcer is produced. Later on microorganisms also invade which irritate the normal
tissue and facilitate the spread of ulcer.
The treatment for gravitational venous ulcer by deep massage was first put
forward by Bisgard of Denmark in 1923.

Aims of Treatment
• To reduce oedema and relieve congestion
• To improve circulation of the lower limbs
• To mobilise the soft tissue
• To mobilise the endurated ulcer.

Procedure
Position All bandages and dressings are removed. The wound should be cleaned
scrupulously with an antiseptic solution. It should be covered with sterile gauge
before the application of massage.
104 Principles and Practice of Therapeutic Massage
The lower limb should be well-supported and elevated from the hip by pillows,
suspension sling or by simply raising the foot end of the bed.

Techniques Used
• Effleurage slow and deep
• Kneading slow and deep
• Picking up
• Wringing
• Friction.

Sequence
General massage is given first to the whole lower limb, in the following order to
enhance the circulation.
• Effleurage to whole lower limbs
• Effleurage to thigh
• Effleurage to knee and legs.
Effleurage to thigh, knee and leg draining into deep inguinal lymph nodes and
slow kneading followed by picking up and wringing.
Special attention should be paid to the, dorsum of foot, region of tendo calcaneus
and, behind malleoli.
Then the region of ulcer is treated.
Finger and thumb kneading is given from the periphery to the edge of the ulcer.
The fingers and thumb of the therapist should be placed on the either side of ulcer
and ulcer is moved from side-to-side.
These manipulations soften the enduration and increase the local circulation.

Caution
• Care should be taken if the skin is unhealthy and fragile
• Support the ulcer from one side if kneading is painful
• If the ulcer is infected, manipulations in the region of ulcer should be avoided
as it may spread the infection to the other part of the lower limb.

Lower Motor Neuron Lesion

In the case of flaccid paralysis due to lower motor neuron lesion massage is indicated
with the aim of hastening the absorption of tissue fluid as a substitute for the
pumping action of muscle keeping the muscle/soft tissue supple and adhesion
free and improving nutrition of the part.
Massage should be combined with passive movements of joints and passive
stretching of the tight structures as and when required.
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Procedure
Position The paralysed part should be well-supported. Care should be taken while
positioning to avoid the stretch on the paralysed muscles. For example in flail lower
limbs, the foot must not be left hanging at the edge of bed as in this position gravity
stretches the anterior tibial muscles. Rather in this case the ankle and foot should
be kept in neutral position by proper support with sand bag or foot board.

Techniques Used
Kneading, petrissage, mild percussion, interpersed with effleurage and superficial
stroking.

Sequence
Superficial stroking should be given from proximal to distal area followed by light
effleurage. Direction of effleurage should always be from distal to proximal in the
direction of lymphatic drainage of the part.
Kneading, picking up, wringing, skin rolling should be given thereafter. Care
must be taken not to stretch the atonic muscle and throughout these manoeuvres
the use of deep pressure be avoided.
Tapotement in form of hacking is given after the pressure manoeuvres. Massage
session ends with general effleurage of the affected segment.

Caution
• Sensitive areas like elbow, quadriceps muscle and adductor region of thigh,
should be treated with extra caution as the chances of myositis ossificans is
more in these area.
• Excess pressure and stretch during manipulation must always be avoided.

Bell’s Palsy
It is a condition in which facial nerve is affected and the muscle supplied by it, i.e.
the muscles of facial expression are paralysed. Due to the non-specific inflammation,
the facial nerve becomes swollen within the limited space of facial cannal, which
prevents conduction of the impulses and results in the paralysis of facial muscles.

Aims of Treatment
• To maintain suppleness and elasticity of the skin and muscles
• To improve the circulation
• To reduce the swelling due to inflammatory deposit at the stylomastoid foramen.

Position
Patient sitting on a chair or preferably supine lying with head supported over the
pillows.
106 Principles and Practice of Therapeutic Massage
Techniques Used
Stroking/effleurage, gentle kneading, tapotement, circular friction and petrissage.

Sequence
Stroking is given in the following order:
• From chin upwards to the temple and
• From middle of the forehead downwards to the cheek. It should be gentle but
firm and stimulating.
Effleurage is given considering the lymphatic drainage of different parts of
face. Small circular kneading is given all over the affected side of face but deep
pressure is always avoided.
Tapotement may be administered in the form of quick and light finger tapping.
Over the area of face where only a very thin layer of skin covers the bone, i.e.
forehead and supraciliary ridge, tapotement should be very gentle. Circular friction
and kneading are given at the point where the nerve enters the face (Stylomastoid
foramen), in order to soften any inflammatory deposit present over there, followed
by effleurage to drain them. Gentle picking up and skin rolling can also be practised.
Normal side of the face should be supported with one hand covered with a
layer of cotton. The use of vibration performed with tips of one or two fingers over
the nerve trunk has also been advocated (Wale, 1968).

Caution
• Care should be taken while working in the vicinity of eyes as little neglect or
inattentiveness of therapist may produce serious damage to eyes.

Sprain
It is an injury to a ligament produced by the violent stretching in which some of
ligamentous fibres are ruptured within the outer sheath of the ligament. The post-
traumatic adhesion is formed and if allowed to consolidate, glue the fibres together.
The mobility of ligament is reduced and there occurs chronic pain whenever
ligament is put under stretch.

Aims of Treatment
• To disperse the inflammatory exudate and reduce oedema
• To mobilise the ligament.

Techniques Used
Effleurage, kneading and transverse friction.

Position
Affected ligament should be placed in a slightly stretched position.
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Procedure
Subacute stage Effleurage and kneading are given gently along with the other
modalities to disperse the inflammatory exudate. Gentle friction to the injured
ligament can also be given to maintain the mobility of the ligament.
Chronic stage Transverse friction is the treatment of choice. Chronic sprain results
from scars holding the ligament, abnormally adherent to underlying bone (Cyriax,
1998). Transverse friction is aimed at rupturing the adhesion. Adequate attention
should be given to localise the site of adhesion by careful examination. Direction of
friction should always be at the right angle to the long fibres of the ligament to be
treated.
Duration: 10-15 minutes on alternate days.

Caution
In acute and subacute stage, massage should be used with extreme caution and if
at any time the pain or swelling is found increased, it should be stopped.
In acute and subacute stage massage should be used along with other modalities
such as ice, etc.
In chronic sprain, massage is painful so the patient must be warned before
hand. Ice application over the sore area can be used if the pain is unbearable.

Tenosynovitis
It is the nonspecific inflammation of synovial sheath of a tendon. There occurs
roughening of gliding surface, which produces eruption when the tendon is moved
within its sheath. It is the movement between the close fitting tendon sheath and
the tendon that causes the pain.

Aims of Treatment
• To restore pain-free mobility of tendon within its sheath
• To smooth off the two sliding surface, i.e. inner surface of sheath and outer
surfaces of tendon by breaking down the inflammatory deposition.

Techniques Used
Tranverse friction.

Position
Tendon should be held in a stretched position. When taught, the tendon provides
an immobile base against which the tendon sheath can be moved.

Procedure
Deep transverse friction is applied across the affected tendon. This moves the sheath
repeatedly across the tendon and smoothen the roughness.
108 Principles and Practice of Therapeutic Massage
Caution
Taught position of the tendon should be maintained throughout. Otherwise, sheath
and tendon may be rolled as a one against the underlying surface and no benefit
will occur as the movement will take place at wrong site.

Tendonitis
It is the inflammation of the tendons, which do not have sheath. It is produced due
to trauma, sudden stretch of contracting muscle, or the degenerative changes. Some
of the tendon fibres are torn and a low grade inflammatory change takes place
resulting in adhesion formation and scaring. Painful scar often forms in the substance
of tendon or at the tenoperiosteal junction (Cyriax, 1998) which binds the tendon to
the surrounding structure and every active movement involving that tendon
produces sharp pain.
The tendons that are commonly affected by this condition are supraspinatus,
infraspinatus, common flexor origin, common extensor origin, biceps femoris,
tibialis anterior and posterior and peroneal muscles.

Aims of Treatment
• To regain mobility of the affected tendon by breaking the adherent scar
• To relieve pain.

Techniques Used
Kneading, effleurage and friction.

Procedure
Position The affected tendon should be held in a stretched position with the part to
be treated in a comfortable position.
Gentle circular kneading and effleurage are given in the vicinity of the area to
mobilise the soft tissue and to clear oedema.
Transverse friction at tenoperiosteal junction or over the tendon in the region
of scar adhesion and scarring is administered vigorously.

Caution
Friction must be given to the right spot only otherwise it will cause unnecessary
discomfort without any result.
Pressure of friction must be deep enough to reach the structure.

Muscle Injury/Strain
Scar results following healing process due to muscle strain. The intrafibrillary
adhesions are formed in the muscle which restrict the movement and cause pain
whenever the muscle contracts or put into the stretched position.
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Aims of Treatment
• To prevent adherence of the granulation tissue
• To mobilise the adherent scar tissue
• To relieve pain.

Techniques Used
Friction and kneading.

Position
Patient should be put in a position where the affected muscle remains in fully relaxed
position, otherwise the force of friction will not penetrate deeply.

Procedure
Kneading and effleurage is given to the disperse the oedema if any. Transverse
friction is given perpendicular to the long axis of the adherent muscle fibres. The
muscle fibres must be made to move within themself. Each fibre should be drawn
away from its neighbouring fibre at the site of painful area.
The muscle groups commonly affected and treated by this method are,
supraspinatus belly, brachialis belly, supinator, intercostal muscles, psoas muscles,
oblique muscles of the abdomen, and gastrocsoleus.

Caution
In all soft tissue injuries massage treatment is useful only in subacute and chronic
state. Soon after the injury massage in any form should be avoided, as it may
exaggerate the inflammatory process. Before the application of transverse friction
the site of injury must be localised by proper assessment of the patient. Friction is
often a painful treatment and it should be combined with the other pain relieving
modalities.

Traumatic Periositis
A direct blow to the bone results in painful thickening of the periosteum. This
condition is most often seen with tibia.

Aims of Treatment
To hasten the recovery by dispersing the localised oedema/haematoma of the
periosteal membrane.

Techniques
Effleurage, kneading, circular friction.
110 Principles and Practice of Therapeutic Massage
Sequence
Deep effleurage is given around the peripheri of the lesion and gradually the centre
of lesion is approached.

Caution
In acute stage, massage should not be attempted. The process is painful so patient
should be warned beforehand and ice may be used after the massage manoeuvres
in order to reduce the postmassage soreness.

Fibrositis
Fibrositis is an ambiguous term. It is also known as nonarticular rheumatism or
acute/chronic muscular rheumatism (Wale, 1968). Firm localised tender nodules
are present in the muscle mass. Causes for this condition include any trauma,
exposure to cold, overuse of muscle, poor posture, etc. It is also suggested that
these nodules are produced by local muscle spasm of reflex origin, due to injury of
intervertebral disc or spinal nerve root. Nodules are quite tender and sometimes
also known as trigger points. Though this condition commonly presents in trapezius
muscle, it can affect any muscle of the body.

Aims of Treatment
1. To break the nodules and mobilise the muscle fibres
2. To reduce muscle spasm and associated pain
3. To increase circulation of the part.

Techniques Used
Stroking, effleurage, kneading and friction.

Position
The position of the patient varies according to the muscle affected. Ideally the
position of patient should be such that muscle affected remains completely relaxed
during the treatment.
For trapezius prone position with pillow support to neck and head is ideal.

Sequence
• First massage is given to the area above and below the affected area in the form
of very light rhythmic stroking, gentle kneading and effleurage. This preliminary
massage helps to increase circulation, gain relaxation and to prepare the patient
for more specific friction massage.
• Tender area is approached gradually with care. First light stroking and gentle
kneading is practised over the painful site. Friction is added as soon as the
patient is able to tolerate it. The depth of friction should be increased gradually.
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• Treatment is concluded with a repetition of kneading and effleurage in order to
sooth any soreness produced during the manipulation.

Painful Neuroma
It is a bulbous swelling at the severed end of a nerve. It often gives rise to tender
amputation stump and painful phantom limb. It has been shown that repeated
percussion, in the form of tapping over the neuroma abolishes the symptom
permanently.

Adherent Skin
Any injury to the skin may lead to extensive scarring and subsequent enduration.
Scar formed during the healing of skin wound has a tendency to contract. An
exaggeration of this wound contraction process often results in the formation of
contracture, which restricts the mobility of skin. This situation is commonly
encountered in microsurgical procedure of hand, burns, skin grafting and tendon
repairs. The adherent skin not only restricts the mobility of adjacent joint, but may
also binds the superficial tendons and leads to the insufficient transmission of the
muscle force to its insertion point resulting in mechanical weaknesses of muscle.
The massage techniques in later stage of these conditions are very helpful to prevent
formation of adherent scar by reducing the stagnation of oedematous fluid and to
soften and mobilise the adherent tissue.

Techniques
Effleurage, kneading, skin rolling.

Burns
Procedure Massage should not be given until the tissue can withstand it. Recently
healed skin appears red. It is thin and very delicate which can be easily sloughed
off if shearing forces are applied to it. Therefore, massage procedure should only
be started when healing skin gains considerable strength.
A lubricant is used in early stage to have a smooth sliding of the fingers of
therapist over affected skin. The scar area is mobilised very gently with finger
kneading, first at the periphery then at the centre. There should not be any drag on
the injured part.
As the skin becomes harder, the depth of kneading is increased to treat scar
tissue vigorously.

Skin Graft
Procedure The aim of treatment is to soften and mobilise the grafted tissue and to
improve nutrition.
112 Principles and Practice of Therapeutic Massage
Massage should not be attempted until graft is established, i.e. till 10 to 14 days
after surgery. Otherwise the shearing movements of massage will destroy the newly
formed capillaries in the graft and lead to graft failure. Lubricant is applied at the
edge of the graft. Finger kneading around the edge is used to mobilise the tissue,
effleurage and rolling of grafted structure is also interspersed in between.
Small range of movement is used and pressure is kept superficial, in order to
avoid the sliding of the fingers over the skin while applying pressure as it may
cause blistering. In these cases the overzealous and too early massage should be
avoided as it may encourage the formation of the hypertrophic scars.

Engorged Breast
After the childbirth, once the function of lactation is established the milk may
stagnate inside the breasts. This may be due to presence of some obstructions to
the lactiferous duct, or sometimes the suckling of the child is inadequate enough to
empty the breast properly. This produces considerable pain. In this condition,
massage combined with hot bath may some time offer considerable relief (Wale,
1978).

Aims of the Treatment

• To decrease congestion and reduce pain
• To increase the circulation.

Techniques Used
Kneading, picking up, stroking and friction.

Position
The patient lies on her side warmly covered up. Only the part to be treated should
be exposed. The garment and bed cloth are to be carefully protected by macintosh
and towel. A receiver or kidney tray is placed beneath the breast.

Sequence
Prior to the massage, hot water bath is given to the breast for about 10 minutes.
Lubricant is used in the form of oils.
• Stroking, kneading and picking up manoeuvres are applied from the
circumference of the breast towards the nipple for 3 to 4 times.
• After this friction may be given carefully over any hardened nodules located
during previous manoeuvres.
• Treatment finishes with the repetition of kneading, picking up and stroking
movements.
Lubricants are removed. Hot bathing some time may also be repeated after the
massage to enhance the circulatory effects.
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This procedure can also be applied to increase the flow of milk. But in this
condition instead of hot bath, alternate cold and hot bathing is given in order to
stimulate circulation of gland and massage technique are applied more vigorously.

Flatulence
Massages can be used in the treatment of flatulence which can cause severe
discomfort in postoperative abdominal, gynaecological and urological patients
where the distended abdomen puts strain on scar and produce pain (Hollis, 1987).

Aims of Treatment
To facilitate movement of gases in the abdomen.

Techniques
Vibration.

Position
Patient is positioned in crook lying to relax the abdominal musculature.
Sequence Hand is placed on the side of abdomen and gentle vibration is given with
single hand. Gradually, the hand is moved over the central part of the abdomen.
The depth of the vibration can be increased if the wind is voided or pain
decreases.
• Gentle vibration over the back interspersed with circular kneading with little
upward pressure over the middle back can offer relief in babies with postfeeding
wind (Hollis, 1987).

Relaxation
Massage is most commonly used in the day-to-day life for the purpose of relaxation.
There are various ways in which the technique of massage can be administered for
this purpose. It is the choice of the therapist and preference of the patient which
determines the selection of a particular sequence. The essential principles of massage
in this area of application are as follows:
• The basic technique for relaxation, i.e. comfort, support and restful atmosphere
should always be utilised during treatment session.
• Patient should always be placed in a position of ease.
• Massage technique should be continuously applied without any interruption
or change in the rhythm.
• Each technique should be repeated several times.
Following are the description of some sequence of administration of massage
for the purpose of relaxation:
1. Patient is positioned in either prone or side lying. He is covered from neck to
toe with blanket (in cold weather or bed sheet in warm weather). Stroking is
given to each part of the body so that the body is stroked in following order:
114 Principles and Practice of Therapeutic Massage
[Link] hand each side at the centre of back
[Link] hand each side over the scapula
[Link] hand each side in the midaxillary line
[Link] hand each side down the arm and outer side of leg
[Link] the hands should work together movements should be smooth and of
the same depth
f. Strokes may also be given with single hand alternately, i.e. one stroke to
the right side and then to the left.
2. Patient positioned in the similar way described above. The length of the stroke
is decreased and each hand performs a short stroke. Each hand overlaps the
previously performed stroke. Strokes are repeated quite speedily for a long
duration.
3. General massage of the face, lower limb, upper limb and the back (as mentioned
in Chapter 6) can relax a person considerably.
4. In very tensed persons very slow facial massage (as described in Chapter 6)
with emphasis on the slow and deep kneading over temporal region may be
helpful in inducing relaxation.

Removal of Secretion
For this purpose the respiratory technique of massage are used in cardiothoracic
units of hospitals and in chronic lung diseases such as chronic obstructive pulmonary
diseases, cystic fibrosis, etc.

Procedure
— The patient should be examined properly and the affected lobe should be
localised by the auscultation and percussion.
— Patient should be positioned in postural drainage position so that gravity will
also assist the drainage of secretion.
— Contraindications should be ruled out and techniques are selected accordingly.
— Techniques used for this purpose are vibration, shaking, clapping, tenting and
contact heel percussion. The latter two techniques are much helpful, over the
chest of babies.
— Shaking and vibration should be given during the phase of expiration while
percussion is applied throughout the expiration and inspiration.
— These techniques are supplemented with the huffing and coughing techniques,
breathing exercises and humidifications.
Detailed discussion on the application of these principles in each chest
condition is beyond the scope of this book. The interested readers may refer any
book on chest physiotherapy for this purpose.
 History
Definition and Classification of Massage 115
of Massage 115

8
History of Massage

The French colonists in India first used the term “massage” during 1761-1773, and
included it for the first time in 1812 in a French-German dictionary. This accounts
for the widespread use of French words in massage terminology. However, it’s
uses were known from very ancient times.
Initially there was a dispute regarding the origin of this word. Few authors
claimed it derived from the Arab word—Mass (to touch), others said it was from
the Greek word—Massein (to knead). The Hebrew word—Mashesh (to touch, to
feel, to grasp), and the Sanskrit word—Makesh (to strike, to press) were also said
to have been the original from which the word massage came.
The Arabic and Greek origin proposed by Savery in 1785 and Piory in 1819
respectively has been considered more authentic, due to widespread use of massage
in East and ancient Rome. This word, according to the Oxford dictionary, entered
in the English literature in 1879.
The Practice of massage has been mentioned in all the recorded ancient
civilisations. In Babylon and Assyria, it was used principally to expel the evil spirit
from the body of the patient, while in China it was used in a more scientific way.
The oldest medical work of Chinese ‘Nei-Ching’, written around 1000 BC, mentions
the use of massage in paralysis and in cessation of circulation. In about 619-907 BC,
during Tang Dynasty, massage was recognised as a part of medical practice. The
official repertory of the New Tang Dynasty describes that during those days the
department of massage had one Professor and four masseurs. Degree was conferred
after 3 years of study and a stiff examination. These professionals treated the cases
of fracture, injury, wound, etc. and gave lectures on physical exercises.
However, after Sung Dynasty (960-1279 AD) practice of massage in China
declined, and became the stronghold of the barbers. First in China, then in Japan it
was delegated to the blinds who went about the street soliciting patronage by
shouting Amma-Amma (shampooing or massage).
In India, the uses of massage were well known long before its modern name
came into being. In Sanskrit literature it is known as Champan or Mardan as well as
116 Principles and Practice of Therapeutic Massage
abhyang. It’s mention is found in Ayurveda—the medical part of Atharvaveda,
supposed to have been written around 2nd millennium BC. Megasthenes and
Alexander’s description of India and the Buddhist literature and sculptures also
depicts its widely used status in India. It’s use with different medicinal oils in the
treatment of various disorder is still the mainstay in the practice of Ayurveda,
naturopathy and other traditional forms of Indian medicine system.
The Greeks and Romans were more interested in physical beauty and physical
education than their contemporaries. Massage was very popular among them and
desired by all classes. It was practised by medical practitioners, priests, slaves and
anointers, whose main duty was to anoint the wrestlers before and after their
exercises. Herodius made exercise and massage as a part of medicine while his
pupil Hippocrates, (460-375 B.C.) the father of modern medicine was the first person,
who discussed the qualities and contraindications of massage. He recognised
massage as a therapeutic agent.
Another Greek Physician Asclepedius who was great advocate of massage and
physical therapy, had recommended this technique as the third most important
treatment. It was he, who discovered that sleep might be induced by gentle
‘stroking’. Galen (125-195 AD) the renounced Greek Physician after Hippocrates
wrote about 16 books related to exercise and massage. In these books he discussed
about the massage at length. He also classified this technique into three qualities
and by different combinations he found nine forms of massage, each of which had
its own indications.
Greeks and Romans left behind a lot of literature in which they mentioned the
use of massage in conditions like paralysis, cold extremity, muscle sprain, etc. which
hold good even today. However, they also recommended it in condition like
intestinal obstruction where, now the use of massage is considered inappropriate.
In these literatures, various nonmedical persons also spoke in favour of massage.
This shows the popularity of massage in those days. Cicero (Greek King) considered
his anointer equal to his Physician. He even commented that he owed his good
health as much to his anointer as his Physicians. Julius Caesar had reported to
receive daily massage by a specially trained slave in order to relieve his neuralgic
pain. It is well known that Julius Caesar was a patient of epilepsy.
After the fall of Roman Empire massage and medical gymnastics went back to
the level of folk medicine. There is no mention of massage in medical literature till
fourteenth century. This period during which the progress in almost all branches
of science came to a halt is referred in history books as the Dark Age. Towards the
fifteenth century people again started writing about massage. Antonius, Gazius,
Heronymus, Mercuriaus and Abroise Pare collected the teachings of Hippocrates
and Gelen, and started using massage in the various conditions. Abroise Pare (1510-
1590) who was a great surgeon started the application of massage to surgical patients.
In sixteenth century Fabricus-Ab-Aquapendente who was the tutor of William
 History
Definition and Classification of Massage 117
of Massage 117
Harvey (the discoverer of the blood circulation) wrote a book on massage in which
he warmly recommended the use of massage as a rational therapy for joint affection.
It was he, who used the term ‘Kneading’ for the first time.
Francis Glisson (1597-1677) one of the founders of Royal Society mentioned the
use of massage and exercise in the treatment of rickets. Thomas Sydenhams (1624-
1689) also known as English Hippocrates, was a strong supporter of physical
therapy. During his time several books were published where massage was
mentioned in the care of almost all the diseases including syphilis.
Friedreich Hoffmann first said that human body is a machine which is subjected
to mechanical laws. Nicholas Andry in his L’ Orthopedie published in 1741 described
the effects of massage on the circulation and the skin colour. He used these effects
to soften the tendons and muscles.
In 1780 Joseph Clement Tissot published a book on exercise where he spoke of
‘Alternate Pressure and Relaxation’ on external part which should cause a movement
of the solids and liquids of the body and thus, increase the circulation.
In nineteenth century the person who contributed a lot in this field was Per
Henrik Ling (1776-1839). He was a teacher in Physical Education. He started the
Central Institute of Gymnastics in Stockholm in 1813 where he developed massage
as a part of medical gymnastics and due to his efforts massage gained the attention
of an increasing number of physicians. He classified the techniques of conventional
massage and incorporated the French words such as percussion, tapotement,
effleurage, etc. in his Swedish system of massage. His pupils spread his teachings
in the other European countries. His immediate pupils Augustus George published
Ling’s system in French under the term ‘Kinesitherapy’. By the end of nineteenth
century Swedish massage had received international acclaim.
However Ling did little to distinguish between exercise and massage and his
system though generally known as a massage system also included passive and
active movements. It was left to Dr James B Mennel of England to distinguish
between the massage, movement and exercise during the years 1917 and 1940.
After 1850 the number of books, articles and journals on gymnastics and massage
increased remarkably. During this time two important doctoral thesis on massage
by Estraderf (in 1863) and Mezger (in 1868) were published, where massage was
discussed in a more appropriate manner in the disorders of locomotor system.
Mezger was a Dutch physician and probably it was due to his influence that the
oldest association of Masseur’s was formed in Holland in 1889. The oldest periodical
of this profession was published in 1891.
In the last quarter of the 19th century massage was studied in various research
projects. Following is the list of work done by some researchers:
— Effect of massage on lymphatic flow—Lassar (1887)
— Circulatory effect of vibrations—Hasebrock
— Histological effect of massage on tissue trauma—Caster
— Physiological effects of massage—Piorry.
118 Principles and Practice of Therapeutic Massage
Towards the end of nineteenth century, massage was prescribed in combination
with heat, exercises and electricity. In this century some workers attempted to
establish a solid scientific basis of massage, but unfortunately a few misused and
abused it. Several publications appeared in Germany, France, Italy, Denmark,
England and US reporting on the abuses connected with massage, which ranges
from quackery to prostitution.
History of massage in twentieth century was dominated by the development of
new techniques and new systems namely,
— Sports massage — Connective tissue massage
— Reflex massage — Acupressure
— Periosteal massage — External cardiac massage
Massage was taught in the schools of physiotherapy, medical gymnastics and
the schools of massage. In this century the well known figures in the field of massage
were Rosenthal, Cyriax, Graham and Mennell. Rosenthal gave scientific ground to
massage and manipulation and is accredited for reintroduction of massage into
mainline medical practice. Cyriax advocated the use of deep friction in periarticular
lesions. Terrier combined massage and manipulative therapy more intimately and
termed it as manipulative massage.
While the diversity of technique increased manifold its uses in therapy was
diminished throughout the world in the first half of the twentieth century. In fact
the history of massage has been dominated by a love-hate relationship between
medical establishment and other groups who practice these techniques. Throughout
the world, the so-called fitness centres, health clubs and massage parlours have
been mushrooming up where untrained people unethically practice some of the
technique of massage as a mode of luxurious comfort. These centres have given a
very bad publicity to this ancient mode of treatment. It is due to this, that in the
late 1960s and 1970s, the soft tissue manipulation has been entered in the vocabulary
of some physiotherapists in lieu of the term massage.
Nevertheless, in the late twentieth century, massage again received the attention
of scientific investigators and a number of scientific papers have appeared in the
literature. In most of these works, the effects of massage, established till date by
subjective and observational methods have been subjected to rigorous objective
evaluation. With the advent of sophisticated instruments it became possible to
measure the physiological parameters associated with the effects of massage.
Plethysmography, radioactive isotope clearance rate, Doppler ultrasound, etc. are
now used to examine the effect of massage on the blood flow, whereas the effects
of massage on neuromuscular system are evaluated by Electromyographic
techniques. The discovery of pain gate theory by Melzack and Wall gave a new
credence to the role of massage in pain management. Studies have been conducted
to see the cellular level changes in fibrous tissue after massage manoeuvres using
electron microscope. Several investigators have also attempted to evaluate and
 History
Definition and Classification of Massage 119
of Massage 119
standardise the exact pressure applied during different manoeuvres of massage
using sophisticated pressure monitoring devices.
These studies have been successful in their attempt to reestablish the scientific
value of massage. However, the result of these sporadic studies are conflicting.
Some of them have also challenged the basic circulatory effects of massage. It is
essential that these reports are interpreted with caution in view of small sample
size, nonstandardisation of massage technique used in these studies and more
importantly the lack of cross-validation. There is an urgent need to conduct
multidisciplinary studies, aimed at exploring the various aspects of this ancient
mode of treatment, with the help of all available advanced technology.
Massage therapy has been subjected to alternating period of advocacy and
denigration and current phase is one that of denigration. The development of
pharmacological industries, intervention of new adjuncts in physical therapy, i.e.
SWD, US, traction, IFT, etc. and moreover, the dehumanisation of the patient and
therapist relationship can be enumerated as few factors responsible for this state.
However, in the present era when the technological and pharmacological
advances are fast approaching toward zenith, their limitations and drawbacks have
also become the cause of concern for medical and nonmedical world. An increasing
number of people throughout the world are now moving toward the drugless
approaches of treatment. The trend of disease pattern is also witnessing a rapid
change. Today man is subjected to far greater stress and strain than at any time in
the history. Technological and economic advancement has created a pace and life
style, which an individual often finds difficult to synchronise with. The incidence
of stress, anxiety and psychosomatic diseases are increasing at alarming rates. In
this changing scenario the role of human touch, in combating the dehumanisation
of modernity, is fast receiving attention. The physiological and psychological effects
of massage can offer a solution to majority of these problems, if combined
appropriately with other approaches.
Despite fluctuations in the support of massage, the utility of a few of its
techniques in the management of certain type of soft tissue lesions have always
been acknowledged. In these conditions, their effectiveness has been proved beyond
doubts.
120 Principles and Practice of Therapeutic Massage

9
New Systems
of Massage

Classical massage techniques advocated and standardised by PH Ling, otherwise

called Swedish massage has witnessed a dramatic change in the twentieth century.
Many new techniques have been evolved and are continuing to evolve which though
use the basic principles of classical massage, are essentially different from it.
Although these methods are not very popular, they are widely used in some parts
of the world and form an integral parts of the soft tissue mobilisation. These have
proved effective in certain conditions where classical massage is usually not used.
Many of these techniques elicit vicerocutaneous reflexes and have been proved
effective not only in disorders of locomotion system but also in the dysfunction of
internal organs. This chapter deals with few of those techniques of massage, which
do not fall under the classical massage. The essentials of these techniques are
outlined briefly. For further details, the interested reader is advised to refer to the
literature mentioned in Bibliography.

Connective Tissue Massage

It is a specialised form of massage which utilise vicerocutaneous reflex for diagnosis
and treatment. It was discovered in the 1930s by a German physiotherapist Miss
Elizabeth Dicke. The main effect of this technique is to enhance the blood circulation
of a target area by mobilising the deeper layer of dermis which is said to have
balancing effect on sympathetic and parasympathetic components of autonomic
nervous system (Thompson et al., 1991).
Human embryo is composed of serially arranged several homogenous primitive
segments called metameres. This arrangement is concerned with the mesoderm
and tissue region derived from it, that is, sclerotome, myotome, dermatome,
angiotome and nephrotome. The ectoderm participates in segmentation since in
each of the metamere one spinal nerve enters. The skin over the segment is also
innervated and in this way the segmentation is projected to the skin. This embryonic
connection between metameres and the spinal nerves (dermatome) develops early
and remains unchanged postembryonically. The internal organs that develop from
endoderm correspond to certain spinal cord segments. The relationship between
 New Systems
Definition and Classification of Massage 121
of Massage 121
the functions of internal organs, vessels and nerves as well as the tissue of the
locomotor apparatus which descends from the same metamere is the scientific
foundation of Connective Tissue Massage (Chaitow, 1996).
The proponents of this system emphasise that the surface of body provides
evidence of internal derangements and it is possible to influence the internal organ
reflexly by the application of powerful stimuli to the surface of body. Practitioners
of connective tissue massage have divided the external surface of body into several
reflex connective tissue zones. It is claimed that disturbed organ function gives rise
to altered connective tissue zone. These changes in connective tissue zone are
palpable and may take any of the following forms (Chaitow, 1996).
• Drawn in bands of tissue
• Flattened area of tissue
• Elevated area giving impression of localised swelling
• Muscle atrophy or hypertrophy
• Osseous deformity of spinal column.
The practice of connective tissue massage involves the identification of the
changes in the connective tissue zone related to a specific visceral organ and
treatment of connective tissue zone by special kind of stroking in order to improve
the function of that organ.
Evaluation is the most important part of an effective connective tissue massage
programme. Before the treatment is executed, the patient is examined thoroughly
to find out,
• The affected dermatome
• The mobility of various layers of connective tissue
• The amount of tension present in muscular layers.
Lifting of skin fold, stretching of superficial tissue and skin distraction, are the
three diagnostic techniques used in connective tissue massage.
The technique of massage, consists of a special type of gliding and cutting strokes
(Hollis, 1987), executed mainly with tips or pads of middle and ring finger of either
hand, which are placed at an angle of 30° to 40° from the body surface. Stroke
applies a tangential pull on the skin and subcutaneous fascia, in order to mobilise
the superficial connective tissue (skin and subcutaneous tissue) over the deep
connective tissue (fascia). The strokes are applied in a specific manner. They start
from sacrum and buttock and may progress further upwards up to the neck and
upper limbs or downwards towards the legs. Over the back the strokes are applied
along the dermatome whereas over the peripheral area they are applied along the
muscle fibres. Connective tissue massage stroking elicits a sharp pain and patient
feels a scratching and cutting sensation.
Treatment is carried out two to three times per week and there should be a rest
period of at least one month after fifteen sessions of connective tissue massage.
122 Principles and Practice of Therapeutic Massage
During and after connective tissue massage, a number of reflex reactions occur
which include vasodilatation, diffuse or localised swelling, elevation of skin
temperature, pleasant fatigue, decrement of oedema, increased bowel movement,
diuresis, etc.
Vasodilatation and increase in skin temperature often occur in the area distal to
the massaged site. For example when pelvis is treated with connective tissue
massage, there occurs dilatation of blood vessels of upper extremities. Temperature
of skin has been observed to increase half an hour after the termination of connective
tissue massage, which persists almost for an hour.
It is observed that the vasodilatory effect of connective tissue massage is as
permanent as that of lumbar sympathectomy. It is found very useful in conditions
like varicose veins, thrombophlebitis, thromboangiitis obliterans, Raynold’s disease
and frostbite. Myocardial dysfunction, pulmonary dysfunctions, intestinal disorders,
hepatitis, inflammation of ovary and uterus, menstrual disturbances like
amenorrhoea and dysmenorrhoea are the other indications for connective tissue
massage where it is utilised owing to its autonomic effects.
It is a useful technique in dealing with the consequences of psychiatric
disturbances, anxiety and agitation. It’s effectiveness has been claimed in the
problems involving sleep disturbances, chronic fatigue, and fibromyalgia of
psychosomatic origin.
Since this massage technique provokes widespread autonomic effects, it must
be learned under the direct supervision of a experienced expert.
This revolutionary technique of manual therapy was discovered in a dramatic
way. The therapist, who discovered this technique, was herself suffering from
endarteritis obliterans—a severe circulatory disorder of left leg. She was awaiting
the amputation of her leg, which had the appearance of gangrene.
She was also experiencing severe low back pain after five months of recumbency.
When in order to relieve her pain she palpated her back, she found densely infiltrated
tissue and an increased tension of skin and subcutaneous tissues over ileum and
sacrum. She casually applied some pulling strokes over these hyperaesthetic areas.
Surprisingly, those strokes could not only disperse the dense infiltrated mass and
relieve her backache, but also brought remarkable change in the condition of her
leg. After some trial of these strokes her affected ice cold leg felt warm and superficial
venous circulation was reestablished. After three months the severe manifestation
of her disease dramatically subsided and amputation was avoided. After a year
she could resume her full time duty as Physiotherapist.
The work of Elizabeth Dick was investigated further by Dr Leube and
Dr Kohlrausch, who gave scientific basis to the technique. In 1948 the first book on
connective tissue massage coauthored by Dick and Dr Leube, was published. In
English literature, the technique was fully described by Miss M Ebner in 1955 in
her book “Connective Tissue Manipulations.”
 New Systems
Definition and Classification of Massage 123
of Massage 123
Tread Massage
In this type of massage, the soft tissues are manipulated not by the hand but by the
feet of therapist. It is commonly applied to the back of patient. It can also be used
for lower limbs. The therapist regulates the pressure by utilising his/her body
weight. For the application of maximum pressure, he/she may have to stand on
the patient’s back in order to use the total body weight. It is an ancient technique of
massage most commonly practiced in the eastern countries.

Periosteal Massage
It is a type of reflex-zone massage described by Vogler in 1930s. It is a rhythmic
massage technique applied to the bony prominence of the body by the tip of finger
or thumb. The main effect of this technique, as claimed by Vogler, is to activate the
local and vasomotor reflex by the stimulation of periosteum. The technique
resembles very much with the kneading techniques.
The fingers, thumb, or knuckles are used to apply pressure over the periosteum
near painful areas. Pressure is applied in small circles of 4 to 5 mm diameters. In
half of the cycle, pressure increases and in other half it decreases. Massage progresses
from the periphery towards the centre of periosteal tenderness. The pain relief
obtained by this technique is presumed to be due to the vasomotor reflex changes
and the counter irritant effects.

Stripping Massage
This specific form of massage is employed in the treatment of trigger points. It
consists of specific type of stroking manipulations.
The fingers and thumb apply the slow and deep strokes along the length of
muscle. The muscle to be treated is placed in a comfortably relaxed position but
under moderate stretch. The fingers and thumb of both hands are placed over the
well-lubricated skin at the distal end of the muscle and allowed to slide slowly
towards, the tender point. This is done in order to squeeze out the fluid content of
the muscle.
Initially the pressure is light which increases with the successive strokes. With
the increase of pressure, the stroking fingers of therapists encounter a nodular
obstruction at tender spot, which may be due to stagnation of blood and other
tissue fluids. Repeated strokes of this stripping massage are said to decrease the
nodule and inactivate the trigger point.

Hoffa Massage
Hoffa massage is the classical massage technique using a variety of superficial
strokes including effleurage, petrissage, tapotement and vibration (Lehn and
Prentice, 1994). Alberts Hoffa’s text published in 1900 provides the basis for various
massage techniques that have developed over the years.
124 Principles and Practice of Therapeutic Massage
The primary purpose of this massage is to increase circulation and decrease the
muscle tone. The way of performing effleurage and petrissage of Hoffa massage
has been described by different authors as follows:

Effleurage (by Hoffa)

The hand is applied as closely as possible to the part and glides on it from distal to
proximal. The balls of thumb and little finger are used to stroke the muscle mass
and at the same time slide along the edge of muscle. While the fingertips take care
of the larger muscles the stroke is applied upwardly.

Petrissage (by Tappan)

Apply both hands obliquely to the direction of the muscle fibres. The thumbs are
opposed to the rest of fingers. This manipulation starts peripherally and proceeds
centripetally, following the direction of muscle fibres. The hand goes first and tries
to pick up the muscle from bone, moving back and forth in a zig-zag path.

Rolfing
It is a system devised by Ida Rolf. Rolfing or structural integration is a system used
to correct inefficient posture or to integrate structures. The basic principle of
treatment is that if balanced movement is essential at a particular joint yet nearby
tissue is restrained, both the tissue and the joint will relocate to a position that
accomplishes a more appropriate equilibrium (Lehn and Prentice, 1994).
The technique involves manual manipulation of myofascia with the goal of
balancing the body in the gravitational field. Rolfing is a standardised non-
symptomatic approach to soft tissue manipulation, with a set number of treatment
sessions in basic and advanced sequences. The basic sequence usually involves 10
sessions, each focussing upon a different aspect of postural integration. The advance
sequence that is usually of 2 to 3 sessions followed by tune up sessions as and
when required.
The 10 basic session includes the following:
1. Respiration
2. Balance under the body (legs and feet)
3. Sagittal plane balance—lateral line from front to back
4. Balance left and right—base to body to midline
5. Pelvic balance—rectus abdominis and psoas
6. Weight transfer from head to feet—sacrum
7. Relationship of head to the rest of body—occiput and atlas
8 and 9. Upper half of body to lower half of the body relationship
10. Balance throughout the system.
Once these 10 treatments are completed, advanced session may be performed
in addition to the periodic tone up sessions.
 New Systems
Definition and Classification of Massage 125
of Massage 125
Structural integration of the body’s fascia through deep tissue mobilisation is
used to reduce abnormal stress from postural deviation and restore vertical
alignment. Rolfing is believed to be able to normalise the directional pull of the
fibres within connective tissue and improve muscle tone extensibility and
contractility. Rolfing pressure along the spine of scapula is utilised to realign the
shoulder girdle.

Mechanical Devices of Massage

Usually massage is performed with hands, which consume time and energy.
Moreover, the therapist cannot attend many numbers of patients in a day. Since
ancient times people have constructed many apparatus which can bring about the
same effect, as massage, mechanically and save time and energy for the therapist.
Modern mechanical devices of massage can be grouped under the following two
types according to the effect produced.
1. Vibration devices.
2. Compression devices.

Vibration Devices
These devices provide the oscillation of varying frequency and amplitude to the
body. The effect produced by these devices can be compared with that of vibration
and percussion.
These devices are either electrical or cell-operated. These can be hand-held
devices, which can be used and moved by the therapist, or they can be stationary
devices against which the patient’s body part is held or moved. Basically a vibrating
machine consists of a small motor, an applicator and a control knob. Motor provides
vibrations, the frequency of which can be regulated by the control knob. In hand-
held devices there are several interchangeable applicators of different size, which
are selected according to the need and contour of various part of body.
The frequency and amplitude of vibration produced by these devices varies
from machine-to-machine. Some devices provide oscillation of 100-200 Hz, while
others can only produce oscillation of 10-20 Hz. The devices oscillating at lower
frequency produce the effect of percussion manipulation and known as “percussor”.
By altering the frequency and amplitude one changes into the other. Some devices
incorporate a heating element also, which provides a low degree of heat along with
massage.
Vibration devices find their use in many places. In motor dysfunction of various
different neurological conditions, the vibrators producing fine oscillation have been
used in order to stimulate the voluntary functions of paretic muscles. These vibrators
are also used to induce reflex ejaculation in paraplegic and to assist in bladder
emptying in neurological bladder, etc.
126 Principles and Practice of Therapeutic Massage
Percussor producing coarse vibratory movements are used to dislodge thick
secretions from lungs in pulmonary conditions. For this purpose, vibrating pads
are strapped over the dorsum of hand and therapist places his palm in contact with
patient’s skin. Some vibrating pads can be directly kept over the patient’s chest.
The mechanical oscillation provided by machine is smoothly transmitted to lungs
through the chest wall without exposing the therapist to fatigue.
Vibrators are also used for obtaining general relaxation and relieving pain and
fatigue in upper or lower back. It is for this purpose that these machines are
commonly used nowadays in home and beauty parlours (Fig. 9.1).

Compression Devices
Characteristics of these type of devices are to produce massage of pressure and
release. These machines apply a rhythmic compression to the body segment. The
effect produced by these machines can be compared with that of effleurage.
Basically a compression device has a sealed doubled wall sleeve or hollow tube
which encircles the patient’s limb. The sleeve is attached to a pump, which regulates
the entry of water (in hydraulic devices) or air (in pneumatic devices) into the sleeve.

Fig. 9.1: Vibratory massage

 New Systems
Definition and Classification of Massage 127
of Massage 127
When water or air enters inside, the sleeve inflates and compresses the encircled
segment. This is followed by a phase of deflation in which water/air comes out of
the sleeve. This way the segment is alternatively compressed and released. The
devices have a series of controls which regulates the time ratio of inflation/deflation
(i.e. on/off ratio), the amount of pressure applied, sequence of compression (or
rhythm) and the total duration of treatment.
According to the nature of applied compression, these devices can be grouped
under following two types:
a. Intermittent compression devices
b. Sequential compression devices.
Intermittent compression devices These devices are otherwise known as single cell
compression devices. Here the encircling sleeve has only one continuous
compartment. The sleeve inflates and compresses the limb at chosen pressure and
then deflates. A uniformly distributed pressure is applied to the whole limb at a
time.
Sequential compression devices Unlike the intermittent devices where the whole limb
is compressed at a time, these devices provide a progressive pressure wave to the
body, the encircling sleeve consists of a number of compartments, which can be
inflated and deflated in sequence. As one compartment inflates, other deflates; a
ripple or a pressure wave sets up. It compresses the encircled segment rhythmically.
The overlapping cuffs are inflated sequentially in a centripetal direction. This helps
to enhance the flow of body fluid towards the heart without allowing their back
flow. The sequential devices can produce the milking effect of effleurage, which
cannot be obtained in the intermittent compression devices.
The on/off timings, pressure duration, etc. can be adjusted according to the
diagnosis, the extent of involvement, condition of tissue and to the patient’s comfort.
Some machines provide an electronic control for these purposes while in some
other the rhythm of pressure wave is synchronised with the ECG wave of the patient.
Originally designed in USA for the treatment of lymphoedema following
mastectomy, these devices are employed universally in the treatment of those
conditions, where intermittent pressure helps to alleviate the symptoms. Some of
these conditions are oedema, chronic lymphatic obstruction, arteriosclerosis,
(pressure wave is applied from proximal to distal part), venous pooling, etc. It can
be used for prevention of bedsore, phlebothrombosis and pulmonary embolism. It
is also used for shrinking of the amputation stump.

Digital Ischaemic Pressure

This technique aims at evoking temporary ischaemic reaction within the muscular
tissue by application of a direct pressure. Fingertips are used to apply perpendicular
pressure to the skin towards the centre of a muscle for few seconds. The goal of this
technique is to deactivate the sympathetic trigger points. The direct pressure over
128 Principles and Practice of Therapeutic Massage
the localised painful area stimulates the tension monitoring receptors within muscle
and leads to reduction of muscle tension. The ischaemia also produces pain and
facilitates the release of pain modulating substance. This may give a temporary
analgesia (Bruncker and Khan, 1993).
Primarily used for the management of trigger points, this technique can also be
used to reduce muscle tone and to facilitate proprioception.

Vacuum Cupping
In this technique, a vacuum pump is utilised to create a negative pressure over the
skin. The different sizes of pads connected to the pump and are placed over the
patient’s skin. When the negative pressure (suction) is applied over the body, the
skin and subcutaneous tissues are lifted upwards. This technique is used to release
fascial cross linkage and increase the mobility of the soft tissue restricted due to
fascial tethering.
Initial application should be limited to one to five seconds at a very low negative
pressure during which patient should not perceive a stretch in the tissue. This initial
application serves to assess the tissue response to stretch. In subsequent application
the amount of negative pressure and duration of suction are increased gradually.
The duration of suction can be increased up to 90 second. While the manitude of
negative pressure can be increased upto a level where patient can perceive a
comfortable tissue stretch.
Vacuum cupping is used in the conditions where fascial lengthening is required.
Examples include anterior compartment syndrome of leg, muscle tightness at
iliotibial band, etc. (Bruncker and Khan, 1993). Correct placement of cups and
selection of appropriate suction pressure is paramount as this technique can cause
significant capillary rupture and damage to periosteum if used with excessive
vacuum or with incorrect placement of cups.

Stylus Massage
Unlike all other systems of massage, this method uses a 12 cm long smooth surfaced,
hardwood stick which is similar to a miniature Indian club, in order to intensify the
local mechanical effect of therapist’s finger. The wooden club called stylus has two
ends, narrow and thicker end. Narrow end has a spherical bulge that supports the
tip of therapist’s finger during massage. Narrow end is used to apply deep localised
pressure whereas thicker end is used for mild and gentle treatment.
It is recommended only on particularly hardened area along with other
manoeuvres of classical massage with the aim of breaking the adhesions between
skin, fascia, and capsules. It is claimed that this technique has the advantage of
reaching the areas that would otherwise remain inaccessible to finger such as under
the shoulder blade, and of accurately estimating the location point and size of even
smallest hardening and tissue disorder. It seems that this method relies heavily on
the effects and uses of transverse friction because the only purpose of using a wooden
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stick is to apply more localised pressure without tiring the fingers.
However, this technique is full of hazards. Haematoma can result more easily,
and an injury can aggravate. Inflammatory irritation, myositis ossificans, Sudeck’s
atrophy are the other conditions which may also result after stylus massage.
Therefore majority of therapists and other professional groups outrightly reject
stylus massage. The main contraindications of this technique include, application
over bone spur, spinous process, lymph nodes, veins and breast.
The description of this method is found in the books of German authors.
According to Kuprian (1981), E Densor who was the masseur for many years to
German national soccer team, first made the stylus massage known through his
publication. Densor himself adopted the method from H Schult, an active masseur
in 1936 Berlin Olympic who learned this technique from Japanese (Kuprian, 1981).

Acupressure Massage
Acupressure massage can be considered as a type of reflex zone massage. It’s
principle is very much similar to that of the trigger point. It states that the dysfunction
of internal or external organ is reflected as the alteration in the texture of skin,
which may develop painful nodes. These nodules usually arise at a place distant
from the site of original dysfunction and can be used successfully to alleviate the
symptom.
This massage technique is based on the principles of acupuncture—an ancient
Chinese method that believes that an essential life force exists in everyone, which
control all aspects of life. This life force, called Chi in Chinese, can be considered as
an equivalent of the Indian spiritual terminology Prana, which also describes the
similar concepts. Chinese believe that Chi is governed by two opposing forces,
Yang and Yin. Yang is the positive force whereas Yin denotes the negative force.
These two forces flow through the 26 body line called meridians. There are 12 paired
and 2 unpaired meridians, which are associated with different parts of the body.
An imbalance between these two forces is believed to be the causative factor for
pain and disease.
Whenever such imbalance occurs, certain points along specific meridians
become tender which disappear when the symptoms of disease subside. These
points are called acupressure/acupuncture points. Several acupuncture points have
been mapped out over the surface of body and each has been assigned a name and
special identity in reference to a particular organ. It is claimed that stimulation of a
specific acupuncture point either through needle or deep pressure can dramatically
reduce pain and dysfunction in a distal area of body known to be associated with
that particular point.
In acupressure massage, according to the symptom of patient, specific
acupuncture points are selected. After locating the correct point by palpation or by
electrical resistance testing, massage begins. Heavy pressures are applied using
130 Principles and Practice of Therapeutic Massage
index middle finger, thumb or even elbow in a circular direction over the point.
Applied pressure must be intense and painful to the patient. It is often stated that if
patient can tolerate more pressure the treatment would be more effective.
Usually a single point is massaged for about 1-5 minutes in one session.
In the recent years, this method has gained immense popularity throughout
the world in both medical and nonmedical circles. The effects of this technique can
be explained on the basis of pain gate theory, production of exogenous opioids,
reflex, autonomic response and placebo. Attempts have also been made to establish
a correlation between trigger point and acupressure points.

External Cardiac Massage

Otherwise also known as closed chest cardiac massage, this technique is an essential
component of cardiopulmonary resuscitation programme. It is combined with
mouth-to-mouth ventilation and they together form life saving techniques, which
are simple, effective and can be successfully administered even by a layman with
little training.
It is indicated in sudden and unexpected cessation of effective cardiopulmonary
performance, which is a medical emergency and is often encountered in drowning,
cardiac patient, heat stroke, diabetes, severe road traffic accidents, etc. Any person
can be a candidate for cardiopulmonary resuscitation (CPR) if he/she suddenly
develops the following signs:
• Loss of consciousness
• Loss of carotid and pulmonary pulses
• Loss of respiration
• Loss of heart beat
• Loss of blood pressure.
Unless immediate recognised and properly managed, these conditions can
seriously jeopardise the life by restricted blood flow to brain and other vital organs.
The technique of external cardiac massage aims at forcing the blood out of both
the ventricle by compressing the heart between the sternum and the vertebral
column.

Procedure
Patient position
To effectively compress the heart, the patient should be placed supine, lying on a
firm surface either on the floor or over a hard board placed beneath the mattress.
One hand of the operator should be placed under the neck and other on the forehead
in order to tilt the head backward. This position lifts the tongue from back of throat
and clears the airway. Any foreign body, froth, etc. should be cleared from the nose
and mouth.
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Technique
After proper positioning, mouth-to-mouth ventilation and external cardiac massage
should begin simultaneously.
The best way of doing external cardiac massage is to place the heel of left hand
over the sternum just above the xyphoid. Palm of right hand should placed over
the left hand. Elbow should remain straight. Rhythmic compression should be
applied to the chest wall using the body weight. During compression sternum
should be pushed to a distance of about 1½ -2½ inches. An effective compression
will produce a palpable carotid and femoral pulses. Between compressions the
hand should just leave the chest wall.

Mouth-to-Mouth Breathing
Meanwhile the mouth-to-mouth breathing should also start immediately. For this
purpose it is ideal to have two persons. Alternatively, one operator can also manage
to administer both the procedures. The mouth of the operator should be placed
over the mouth of patient, completely sealing the patient’s mouth. So that there
occurs no leakage of air. Nostrils of patient should be closed by the fingers of
operator. After this, operator should exhale a larger than normal breath into the
patient’s mouth. If the procedure is correct, a rise in the chest wall will be noticed.
In reference to external cardiac massage and CPR, the American Heart
Association has issued the following guidelines for efficient results.
• 80 to 100 external compressions should be applied per minute.
• 50 per cent of each compression-relaxation cycle should be compression.
• If two trained rescuers are performing CPR then for every 5 compressions, one
ventilation should be used.
• If CPR is performed by two lay rescuers or by one trained person, for every
15th chest compression two slow (1 to 1.5 sec) ventilating breath should be
given.
For every half-minute the procedure should be stopped temporarily in order to
ascertain whether spontaneous beating has occurred or not. If there is evidence
that efforts have been successful one may stop and observe the patient for several
seconds. On the other hand, if there is no change in the patient’s status, CPR should
continue till further advanced medical aid arrives. In any circumstances CPR should
not be halted for longer than 5 seconds.
Before starting CPR it is worth trying the following two procedures which may
restore the stopped heart beat.
1. Elevation of legs for 30 seconds—It increases the venous return and if arrest is
due to ineffectual myocardial contraction, it may sufficiently restore the weak
beats and circulation.
132 Principles and Practice of Therapeutic Massage
2. Forceful thumping of the chest wall—A forceful direct blow delivered to the
sternum by the heel of hand may revert the ventricular fibrillation, ventricular
tachycardia and asystole to the normal sinus rhythm. It may be repeated only
once or twice if there is no response.

Commonest Error
The commonest error while carrying out external cardiac massage are the following:
1. Failure to ensure that airway is closed
2. Not occluding the nose during mouth-to-mouth breathing
3. Failure to compress the heart sufficiently
4. Not allowing adequate cardiac filling by using a compression rate which is
too fast
5. By not fully releasing the pressure on the sternum between each compression.

Complication of External Cardiac Massage

Complication which may arise due to external cardiac massage includes, fractured
ribs, haemothorax, pneumothorax, laceration of heart leading to haemoperitoneum,
marrow embolism and laceration of liver and other visceral organs. Many of these
complications are trivial when compared with the seriousness of the emergency,
which if allowed continuing for more than 3 minutes may result in death, or convert
a healthy person to a neurologically vegetable throughout the life.
The practice of external cardiac massage has revolutionised the primary
management of cardiac arrest. Before 30 years the cardiac resuscitation was
performed primarily by thoracotomy and open chest cardiac massage. Now this
kind of massage can successfully save a life even in the hand of a nonmedical layman.
This important life saving technique must be learned not only by the medical and
paramedical persons but also by all the educated persons of a civilised society.

Underwater Massage
Mode of application of pressure in this technique is the pressurised water stream,
which is directed to the body parts submerged in a tub of warm water. This technique
utilises the relaxing effects of warm water combined with the mechanical
compression of high pressure jet of water.
Equipment for this massage consists of a large tub, a pressure pump, a hose
and a set of different diameter nozzles (Fig. 9.2A). Tub has the capacity of 400-600
litre and enough space to allow a subject to lie down comfortably. Pressure pump
is recirculating in nature. It draws the water in, from the tub and returns it back
under high pressure through a movable hose. The variable nozzles can be attached
to the hose according to the amount of pressure required. The narrower nozzle
increases the pressure of water stream and is used to obtain a localised penetrating
and deep effect. The nozzles with medium to large diameter exert relatively less
 New Systems
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Fig. 9.2A: Underwater massage equipment

pressure and cover a wide area. The pressure of water stream may range from 0.5
to 7 bar. A manometer is incorporated in the pump in order to measure and regulate
the amount of pressure.
Along with these essential components, few underwater equipments also have
a heating element which keeps the water of the tub warm. Ideally the temperature
of tub water should be kept between 35°-38°C, i.e. a little above the temperature of
body. The temperature of pressurised water jet can also be regulated and depending
on the requirement it can be kept at either higher or lower temperatures with respect
to the tub water.
Various natural or mineral extracts are usually added to the water with the
intention of promoting relaxation, drainage and rejuvenation.

Technique
Patient is asked to sit, inside the water tub for 5 minutes before the actual underwater
massage to accustom himself to the surrounding. Minimal clothing is allowed.
Massage is administered in half lying, supine lying and side lying position. Prone
position is not used because it interferes with the breathing. Besides, the buoyancy
of water also places the spine in a hyperextended position and increases the lordosis
in prone position. Half and supine lying are used to treat the front aspect of body,
whereas for back and side of body, side lying position is used .
Depending upon the type of treatment, the nozzle size and the pressure of water
jet is adjusted. The movable hose is brought near to the body part to direct the
pressured jet toward the target area. The distance between hose and patient skin
should be 12-15 cm (Fig. 9.2B). Adjusting the angle of water stream can vary the
applied pressure. Stream striking the body at 90° angle applies more pressure than
134 Principles and Practice of Therapeutic Massage

Fig. 9.2B: Underwater massage

that striking at acute angles.

Considering these basic principles, practically effects of all techniques of classical
massage can be produced during underwater massage. For the purpose of enhancing
the lymphatic and venous drainage the stream should be moved from the distal to
the proximal area. It should constantly strike the skin at 50-75° angle. Stream can
be moved in a circular direction with angle of strike, increasing in one half and
decreasing in other half circle. This produces the effects similar to that of kneading
manoeuvres. A high pressure stream striking the skin at 90° angle can be moved to
and fro in small range, to have the effect of transverse friction.
Water jet should never be directed towards sensitive areas like, female breast,
genitals, anus, popliteal fossa, spinus processes, etc. in order to avoid injury.
The advantage of this technique includes preservation of energy of the therapist,
enjoyable atmosphere and facilitation of relaxation.
Routinely recommended to the athletes as an aid to recovery following intense
physical activities, this technique can also be utilised in all other conditions where
manual massage is indicated.
Apart from local and general contraindication of massage adequate caution
should be exercised to exclude the contraindication of hydrotherapy such as cardiac
disease, etc. because position in underwater strains the cardiovascular system.
Athletes are not allowed to participate in intense physical activities for one to two
days after underwater massage.
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10
Sports Massage

INTRODUCTION
Sports massage is routinely recommended as an aid for speedy recovery from
vigorous exercises. It is found useful, when an athlete has to participate in a series
of events, where successive intense muscular activity is required. There are
numerous massage techniques, which are used by sports physiotherapists and
masseurs with the intention of enhancing functional recovery, promoting soft tissue
healing, alleviating tension and stress as well as stimulating the muscles of the
athletes.
The commonly employed massage techniques in the sports setups are effleurage,
superficial stroking, kneading, petrissage, tapotement and friction. While effleurage,
kneading and petrissage are used for restorative effects, the superficial stroking
and tapotements are used for stimulation and maintenance of an optimal arousal
level. The role of friction/cross-fibre massage, in the management of acute and
chronic soft tissue injuries is now well-recognised. Apart from classical manual
massage, specialised massage techniques such as connective tissue massage, trigger
point massage and acupressure massage are also used by those therapists who are
well-trained in these techniques. Other types of massage techniques used in athletic
setting include mechanical vibratory massage and underwater massage.
It is clear that the techniques used in sports massage are not different from
those used in therapeutic massage. In fact the sports massage can be more
appropriately defined as the skillful selection and application of various techniques
of massage on a sports person with the aim of enhancing and prolonging the quality
length of a person’s career in the sports.
Even though the both groups utilise the essential techniques of classical massage
along with few specialised techniques, the aims and objectives of these two setups
are entirely different. Therapeutic massage primarily concerned with aiding the
healing process after an injury or functional disorder, whereas in sports massage
this aim becomes secondary. The primary objective of sports massage is to help
improve performance in those individuals whose physical abilities are far above
136 Principles and Practice of Therapeutic Massage
the average. By ensuring pain-free training and maintaining an appropriate arousal
level it not only prolongs the overall career of an athlete but also enhances the
athletic performance. Apart from promoting quicker recovery from acute and
chronic musculoskeletal injuries, sports massage also address the goal of injury
prevention.

HISTORICAL PERSPECTIVE
The useful role of massage in conjunction with sports activities was well-known in
all the ancient civilisation and it had been very popular among all those interested
in physical beauty and education. In Ancient Greek and Rome, it was practised by
medical practitioners, priest, slaves and anointer, when main duty was to relieve
pain, reduce swelling and refresh the gladiators before and after their exercises.
The use of massage for improving performance of the athlete had been mentioned
in the writing of Hippocrates, Galen and Epictetus. Preparatory and warm down
massage were included in the Galen’s 18 different variants of massage, which he
distinguished by combining the three basic qualities of massage. In those time, the
trainer adjusted his treatment to the needs of athletes. Paintings from ancient Greece
show back rubs and chest massage of Boxers, Achilles tendon massage for runners
and a self massage for the calf muscles (Kuprian, 1981). In those days, massage was
always used in conjunction with active and passive exercises and breathing exercises.
In India the mention of massage as champan and mardan is found in ayurveda,
the medical part of atharvaveda, supposed to have written around second millennium
BC, where its restorative, rejuvenative and soothing effects are described in detail.
Massage was an inseparable part of Indian sports culture. This fact is reflected by
the observation that the traditional masseurs in India are known as Pehalwan
(wrestlers) and athletes massaging each other is still a common sight in all the
traditional akharas (wrestling ground).
In modern times also sports massage, otherwise also called Apotherapy (Liston,
1995) has gained immense popularity and recognition as an important preventive,
restorative and therapeutic modality. The athletes, coaches and those concerned
with sports throughout the world acknowledge that massage is an effective modality
that can enhance the rate of recovery and reduce soreness and discomfort following
intense physical activity.
Massage is an important part of soviet system of athletic training. It is extensively
practised in European countries including those of the former communist block.
Though not taken seriously, before, massage has also reclaimed its important place
in United States athletic world. It was included in 1984 Olympic as a service available
to all athletes (Kresger, 1988). Statistics from Great Britain team in 1996 Olympic
revealed that massage formed 47 per cent of all treatment to the athletes from all
sports (Callaghan, 1998).
 Definition and ClassificationSports Massage 137
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Galloway and Watt (2004) examined the data recorded by the head team
physiotherapist from 12 major national and international athletics events between
1987 and 1998, and observed that a significant proportion of physiotherapists' time
was devoted to the delivery of massage treatment at athletics events which ranged
from 24.0-52.2 per cent of the total number of treatments made. The demand for
massage treatment had been steady over the studied time period of 9 years, which
indicated a consistent use of this treatment modality.
Many claims on the utility of massage in sports setup have not been conclusively
proved. However, sports massage is among many of the methods that follow lack
of experimental verification, yet they have been found to be helpful by clinicians
and coaches who have tried them. The anecdotal evidences favour that it should
continue to be used.

ROLE OF MASSAGE IN ATHLETIC WORLD

It is generally accepted that sports massage, reduces exercise induced muscle
strength loss, reduces muscle soreness, decrease paracompetitive anxiety and
improves mood which ultimately may lead to rapid recovery and enhanced
performance. By decreasing the detrimental effects of training it also helps to
improve training consistency. The value of massage in identification and correction
of the silent (asymptomatic) areas of abnormal biomechanical stress, reflected in
the form of exaggerated muscle tension, also makes it a powerful adjunct to the
prevention programmes of sports injuries.
Table 10.1: Role of massage in sports

• Facilitate recovery following intense exercise

• Relieve discomfort of DOMS
• Lessens fatigue
• Helps identify hidden soft tissue injuries
• Identify abnormal area of biomechanical stress
• Identify and treat old soft tissue lesion
• Enhance psychological recovery
• Modulate psychosomatic arousal during competition.

The role of sports massage in the athletic setting can be discussed under the
following heading:
• DOMS management
• Physiological fatigue and recovery
• Psychological recovery
• Prevention of injuries.

DOMS Management and the Efficacy of Massage

The occurrence of delayed onset muscle soreness (DOMS) can seriously handicap
the athlete. Apart from causing considerable suffering, it can also temporarily
138 Principles and Practice of Therapeutic Massage
impede the performance. It occurs in both trained and untrained individuals in
response to the heavy unaccustomed exercise. In a typical sportsman, it arises when
activity level is increased or when activity begins after a period of relative inactivity.
The pain and stiffness associated with DOMS generally appears between 8-24
hours postexercise, peaks around 48 hours and dissipates over the course of a few
days. The discomfort may range from slight stiffness to extremely disabling pain.
The location of soreness is generally more prominent at the musculotendinous
junction. However in severe cases, pain might be felt throughout the entire muscle
belly.
It is due to the associated reduction in the range of motion (ROM) of involved
joints and the reduction in the force output, this condition not only interferes with
immediate athletic performance, but also limits the activities of daily living. It also
impedes adherence to exercise programme, and may compromise with individual’s
willingness to perform therapeutic exercises during rehabilitation.
Sports massage is routinely recommended as an aid for speedy recovery from
DOMS. No consensus exists about the treatment of this condition and several
methods are being tried with variable results. For this purpose, massage is more
effective if it is administered shortly within 1-2 hours after the strenuous effort
(Kresge, 1988).
The exact cause of DOMS is not known and several hypotheses exist on its
pathophysiology. Ernest (1998), precisely summarised these hypotheses as follows.
• Exercise leads to local accumulation of metabolic waste which in turn sensitise
Aδ and C fibres causing pain.
• Exercises cause muscle ischaemia, which results in the production of pain
substance. Pain in turn produces a reflex spasm which in a vicious cycle prolongs
ischaemia and pain.
• Exercise results in intramuscular oedema, which activates nociceptors causing
pain.
• Eccentric exercises lead to damage of the connective tissue in the area of muscle
and this damage is responsible for the pain.
• Exercise leads to the release of inflammatory by products, which sensitise nerve
fibres causing pain.
• Exercise leads to destruction within muscle fibres liberating creative kinase,
which is the cause of pain.
Massage may positively affect each of these processes by improving the
circulation, as well as the lymph flow and relaxing the muscles. This in turn may
reduce oedema, ischaemia, accumulation of waste substances, and enhance the
regenerative processes. Application of a second sensation such as massage to a
sore muscle could increase discharge from other low threshold sensory fibres and
thereby temporarily, could block soreness sensation (Tiidus, 1997). It is also plausible
that massage disrupts the initial development of inflammatory process by
 Definition and ClassificationSports Massage 139
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preventing the accumulation of neutrophils at the site of microtrauma by increasing
the blood flow and thereby diminishing the muscle damage and affects later
developing muscle soreness (Smith, et al 1994). However, there is limited amount
of research to substantiate these claims and uncertainly exists about the effectiveness
of massage on DOMS.
Bale and James (1991) in their controlled clinical trial included 9 male athletes.
After a maximum run all participants were either rested, or asked to warm down
by exercising at a moderate level or massaged manually for 17 minutes. They
reported that DOMS was less in the massaged group who also showed a more
rapid decline in the lactate level. On the other hand, Wenos et al (1990) found no
effect of massage on DOMS. They induced DOMS in untrained seated subjects by
asking them to lower a weight of 75 per cent of lean body mass from knee extension
to knee flexion. Immediately after eccentric exercises one side of the subjects was
massaged while the other served as control. Soreness perception was evaluated 24,
48 and 72 hours after exercise. Ellison et al (1992) and Drews et al (1990) have also
found no effect of massage on DOMS.
Tiidus and Shoemaker (1995) asked 9 volunteers to perform a bout of bilateral
eccentric quadriceps work. For each volunteer one leg only was randomised to
receive treatment. Massage consisting of superficial and deep effleurage was carried
only daily for 10 minutes. They found a small but significant tendency for massage
to reduce DOMS sensation out after 48 hours postexercise. At other measuring
points during the 96 hours follow-up no such difference occurred.
In a well-designed experiment Smith et al (1994) examined that whether 30
minute massage performed within 2 hours after exercise affect the accumulation of
neutrophils in the muscle. They made 14 healthy untrained males to perform
eccentric isokinetic contraction of elbow flexors and extensor muscles on a kin-com
muscle testing system. At 2 hours following exercise, half of the subjects were given
30 minutes management treatment consisting of effleurage, kneading, friction and
shaking, whereas the control group rested for 30 minutes. They observed that the
massage group had consistently lower DOMS score as compared to the control
group from 24 through 96 hours postexercises. Neutrophil count of massage group
was approximately 15 per cent above baseline at 8 and 24 hours after exercise while
the same for the control group at these same times were approximately 4 per cent
above baseline. This they attributed to the reduced migration of neutrophil into the
tissue space following the massage. In addition, the massage group also
demonstrated a high cortisol level compared to the control. They suggested that
the reduced migration of neutrophil would reduce intensity of the inflammatory
event and reduce the pain and the soreness associated with DOMS.
The varying results observed with the use of massage may be attributed to the
time of massage application and the type of massage technique used. (Cheung et al.
2003). Zainuddin et al. (2005) using an arm-to-arm comparison model concluded
140 Principles and Practice of Therapeutic Massage
that massage was effective in alleviating DOMS by approximately 30 per cent and
reducing swelling, but it had no effects on muscle function. In this study ten healthy
subjects (5 men and 5 women) with no history of upper arm injury and no experience
in resistance training performed 10 sets of 6 maximal isokinetic eccentric actions of
the elbow flexors with each arm on a dynamometer, separated by 2 weeks. One
arm received 10 minutes of massage 3 hours after eccentric exercise while the
contralateral arm received no treatment. Main outcome measures were maximal
voluntary isometric and isokinetic elbow flexor strength, range of motion, upper
arm circumference, plasma creatine kinase activity, and muscle soreness. It was
observed that DOMS was significantly less for the massage condition for peak
soreness in flexing and extending the elbow joint and palpating the brachioradialis
and brachialis muscle. A significantly lower peak value of plasma creatine kinase
activity was observed in the massage group at 4 days postexercise. However,
significant effects of massage on recovery of muscle strength and ROM was not
observed.
Investigating the physiological and psychological effects of massage on DOMS,
Hilbert et al. (2003) concluded that massage administered 2 hour after exercise
induced muscle injury did reduces the intensity of soreness 48 hour after muscle
insult but did not improve the function of exercising muscle. Eighteen volunteers
were randomly assigned to either a massage or control group. DOMS was induced
with six sets of eight maximal eccentric contractions of the right hamstring, which
were followed 2 h later by 20 min of massage or sham massage (control). Peak
torque and mood were assessed at 2, 6, 24, and 48 h postexercise. Range of motion
(ROM) and intensity and unpleasantness of soreness were assessed at 6, 24, and 48
h postexercise. Neutrophil count was assessed at 6 and 24 h postexercise. No
significant differences for peak torque, ROM, neutrophils, unpleasantness of
soreness, and mood were observed between massage and control groups. The
intensity of soreness, however, was significantly lower in the massage group relative
to the control group at 48 h postexercise (p < 0.05).
Farr et al. ( 2002) investigated the effects of a 30-min therapeutic massage on
delayed onset muscle soreness and muscle function following downhill walking.
Eight male subjects performed a 40-min downhill treadmill walk loaded with 10
per cent of their body mass. A qualified masseur performed a 30-min therapeutic
massage to one limb 2 hours postwalk. Muscle soreness, tenderness, isometric
strength, isokinetic strength, and single leg vertical jump height were measured on
two occasions before, and 1, 24, 72 and 120 hours postwalk for both limbs. Subjects
showed significant (p < 0.004) increases in soreness and tenderness for the non-
massaged limb 24 hours postwalk with a significant (p < 0.001) difference between
the two limbs. A significant reduction in isometric strength was recorded for both
limbs compared to baseline 1 hour postwalk. Isokinetic strength at 60 degrees/sec
and vertical jump height were significantly lower for the massaged limb at 1 and
24 hours postwalk. No significant differences were evident in the remaining testing
 Definition and ClassificationSports Massage 141
of Massage 141
variables. They suggested that therapeutic massage may attenuate soreness and
tenderness associated with delayed onset muscle soreness. However it may not be
beneficial in the treatment of strength and functional declines.
Few authors have strongly questioned the use of massage in sports setup (Tidus,
1995) because of the existence of very little evidence which could support the efficacy
of massage on various sports specific problems. However, a consensus about
massage is difficult to obtain from the literature because of wide variation in
parameters, the techniques, time and area of body selected (Callaghan, 1998). (Ernest
1998) suggested that massage may be a promising intervention for reduction of
DOMS and considering the paucity of well-designed studies on this topic, its
effectiveness should be investigated in the vigorous trials with a sufficiently large
sample size.

Efficacy of Massage on Fatigue and Recovery Following Intense Exercises

For a sports person, the recovery from intense physical exercises plays as important
a role for maximising performance as skill acquisition, strength, speed and
endurance training. Postevent massage is widely used world over to facilitate
recovery from physical exertion.
A maximal or submaximal exercise session stresses the body to the maximum.
The demands on cardiovascular, respiratory and neuromuscular system are very
high and in order to meet that, several metabolic and hormonal adjustment occurs
in the internal milieu of the body. With increase in duration or intensity of exercise,
the O2 consumption, heart rate, and cardiac output demonstrates a progressive
increase till a point where the system cannot cope up any further with the increasing
demand. It is at this point that the subject begins to experience the symptom of
general fatigue.
Fatigue is a complex concept, which involves both psychological and
physiological factors. Physiological fatigue can be considered as a warning
mechanism preventing overexertion of individual and as a rule it is always muscular
in nature. Physical fatigue is defined as a state of disturbed homeostasis due to
work and work environment (Christensen, 1960). It gives rise to subjective and
objective symptoms. Subjective feelings may range from slight feeling of tiredness
to complete exhaustion. Objectively it is reflected in the form of decreased work
output.
General physical fatigue is commonly seen in prolonged events such as
marathon, cross country etc. In the intermittent and short duration explosive sports
the local fatigue is commonly experienced. Local fatigue is defined as the failure to
maintain the required expected power output from the muscles. It has been well-
documented that intense unaccustomed exercise or exercises involving a significant
eccentric component will result in reduced muscle strength which lasts upto 5-10
days after the exercises. Similarly, in heavy prolonged exercises, maintained for
142 Principles and Practice of Therapeutic Massage
hours, the energy output during maximal effort gradually decreases. For example,
after one hour of rest, a rate of exercise that normally could be tolerated for 6 minutes
had to be terminated after 4 minutes because of exhaustion.
Therefore, the adequate and speedy recovery is paramount for those athletes
who have to participate in a series of events over a scheduled time frame, because
inadequate recovery during rest day will invariably affect the performance.
The ability of muscle fibres to maintain a high force and the subjective feeling
of fatigue depends on the blood flow through the muscle. During contractions the
intramuscular pressure rises and at a point when it exceeds the arterial blood
pressure it partially or completely occludes the blood flow. Decrease in muscle
blood flow starts at 30 per cent of maximum voluntary contraction and it completely
arrests at about 70-80 per cent of maximum voluntary contraction. This seriously
interferes with the supply of O2 and nutrients and the removal of CO2 and
metabolites resulting in disturbed homeostasis which affect the excitation-
contraction coupling of muscle fibres. Short-term muscle fatigue seen in vigorous
aerobic muscle work, could be a combined effect of exercise induced alteration in
muscle homeostasis including H+ ions accumulation, K+ loss, depletion of high
energy phosphates (ATP + CP), and glycogen, loss of calcium homeostasis, lactate
accumulation and local ischaemia.
A restoration of internal environment after exercise necessitates an adequate
blood supply. Massage by virtue of increasing blood and lymph flow may enhance
the removal of H+ ions and lactic acid from muscle. These substances are known to
interfere with the ability of muscle contractile protein to generate force by either
reduction of the total number of cross bridges formed or by the decreasing the
amount of force generated per cross bridge.
By improving oxygen and nutrient delivery, it may also have a positive effect
on the recovery of lost K+ ions and on the synthesis of ATP and CP.
Apart from affecting the homeostasis process, the intense exercises also cause
excessively prolonged elevation of muscle tone both in resting and in contractile
state (Bruncker and Khan, 1993). This phenomenon of increased muscle tone impairs
the delivery of nutrients and O2 to the cell and slows down the removal of
metabolites, during the recovery. Massage can reduce excessive postexercise muscle
tone, which in turn may enhance the blood flow and facilitate the restoration of
muscle homeostasis.
Research on the effects of massage on physiological recovery following an
exhaustive work out has been focussed on two main area—a) recovery of muscle
function and performance, and b) lactate recovery.

RECOVERY OF MUSCLE FUNCTION

Massage techniques (light after heavy activity and deeper for light activity and
lasting for 30-60 minutes) have been claimed to be two to three times more likely to
 Definition and ClassificationSports Massage 143
of Massage 143
promote recovery than resting alone (Crompton and Fox, 1987). However,
experimental results regarding effects of massage on this area have been
contradictory (Kresge, 1988).
Muller et al. (1966) demonstrated that massage of muscles tired from running
or bicycle riding reduces recovery time as shown by faster decline in pulse rate and
quicker recovery of muscle efficiency.
Balke et al. (1989) examined the effects of massage treatment and reported that
manual massage using percussion techniques have a positive effect on the post-
exercise work performance.
Viitaslo et al. (1995) examined the effects of 20 minutes underwater jet massage
on the recovery from intense physical exercise on 14 junior field and tract athletes.
Each subject spent, in a randomised order, two identical training week engaged in
5 strength/power training sessions lasting for 3 days. Underwater jet massage was
used three times during the treatment week but not during the control week. They
observed that during the treatment week, continuous jumping power decreased
and ground contact time increased significantly less than the control week (P<.05)
along with increase in serum myoglobin. They suggested that underwater jet
massage in connection with intense strength/power training increases the release
of protein from muscle tissue into the blood and enhances the maintenance of
neuromuscular performance capacity.
The hypothesis that expedite removal of fatigue causing metabolites by massage
could improve athletic performance was examined by Zelikovski et al. (1993) using
a pneumatic sequential intermittent device. They conducted trials with 11 men
who exercised at a constant rate on a cycle ergometer until exhaustion. During 20
minutes recovery period mechanical massage was applied to the subject’s leg. The
subjects then performed second constant load exercise. They observed that
mechanical massage brought about a 45 per cent improvement in subject’s ability
to perform subsequent exercise bout. However, they could not observe any
significant difference in the blood level of some fatigue causing metabolites, i.e.
pyruvate, ammonia, bicarbonate and pH during passive recovery and massage
assisted recovery. They suggested that the disappearance of accumulated fluid in
the interstitial space after exercise could be a possible explanation for this result
along with the psychological effects.
Improved muscle function following massage have been reported in other
studies also (Rinder and Sutherland, 1995; Lane and Wenger, 2004, Brooks et al.,
2005). Rinder and Sutherland (1995) investigated the effects of massage on
quadriceps performance after exercise fatigue. Sample consists of 13 male and 7
female. In this randomised, crossover study, the subject completed maximum
number of leg extensions against a half-maximum load. Thereafter they were
exercised to fatigue using an ergometer, to perform ski-squats and leg extensions.
It was followed by either a 6 minutes massage or rest. Thereafter they again
144 Principles and Practice of Therapeutic Massage
completed the maximum number of leg extensions against half-maximum load.
The process was repeated a few days later with the alternative condition (rest or
massage). The result showed that massage after exercise fatigue significantly (p<.
001) improved quadriceps performance compared to rest.
Lane and Wenger (2004), examined the effects of active recovery massage and
cold water immersion (on performance of repeated bouts of high-intensity cycling
separated by 24 hours. For each recovery condition, subjects were asked to take
part in 2 intermittent cycling sessions separated by 24 hours.; One of four 15-minute
recovery conditions immediately followed the first session and included, cycling
at 30 per cent VO2 max;, immersion of legs in a 15 °C water bath; massage of the
legs; and seated rest. A significant decline in the total work completed between the
first and second exercise sessions was observed only in seated rest group.
Brooks et al. (2005) examined the effects of using manual massage to improve
power-grip performance immediately after maximal exercise a sample of 52 healthy
adults. Subjects randomly received either a 5-minute forearm/hand massage of
effleurage and friction, 5 minutes of passive shoulder and elbow range of motion,
or 5 minutes of nonintervention rest following 3 minutes of maximal exercise that
produced fatigue to 60 per cent of baseline strength. They observed that manual
massage to the forearm and hand after maximal exercise was associated with greater
effects than no massage on postexercise grip performance.
However several other investigations have found no effect of massage on the
objective parameters related to the recovery of muscle function on performance
enhancement following an exhaustive work out (Drews et al., 1990; Tidus and
Shoemaker, 1995; Cafarelli et al., 1990, Robertson et al., 2004; Hilbert et al., 2003;
Tanaka et al., 2002; Hemmings et al., 2000; Jonhagen et al., 2004; Farr et al., 2002).
Tidus and Shoemaker (1995) performed 4 days of daily 10 minutes superficial
and deep effleurage on one leg of the subjects following intense eccentric quadriceps
muscle contraction involving both the legs. They demonstrated that for upto 4 days
postexercise, massage did not improve the rate of recovery of quadriceps isokinetic
peak torque (at the speed of 0°, 60° and 180° per second) over that of unmassaged
leg.
Cafarelli et al., (1990) studied the effect of percussive vibratory massage on
recovery from repeated submaximal contractions. 12 male subjects performed
repeated static contractions of the quadriceps at 70 per cent maximal voluntary
contraction (MVC) with periodic MVC performed after every fourth one. This
pattern was continued until the subject could no longer produce 70 per cent MVC.
The entire process was repeated 3 times with rest period between each series. In
the control conditions, the subjects rested for 5 minutes between each of the three
series of contractions. In the experimental condition the subject received 4 minutes
of percussive vibratory massage and 1 minute of rest. The result showed that there
was no significant difference in rate of fatigue between control and experimental
 Definition and ClassificationSports Massage 145
of Massage 145
conditions. It was concluded that short-term recovery from intense muscular activity
is not augmented by percussive vibratory massage.
The aim of the study of Hemmings et al. (2000) was to investigate the effects of
massage on perceived recovery, blood lactate removal and repeated boxing
performance. eight amateur boxers completed two performance bouts on a boxing
ergometer on two occasions in a counter balanced design. After initial completion
of performance, the boxer received a massage or passive rest intervention for 20
minutes. Massage was applied by one sports massage therapist and consisted of
effleurage (30 strokes/min) and petrissage (50-60 strokes/min) techniques,
encompassing the major muscle groups of the legs (8 minutes) back (2 minutes)
and shoulder and arms (10 minutes). Participants received treatment while lying
in the prone position followed by supine position. After the intervention, participants
had a further 35 minutes rest whereupon they completed another self-selected warm
up and a second performance bout. Overall there was one-hour period between
two boxing performances. Each boxer had perceived recovery rating before
completing a second performance. Heart rate, blood lactate and glucose levels were
assessed before, during, and after all the performances. No differences in
performance, blood lactate or glucose were found following massage or passive
rest intervention, though massage intervention significantly increased the perception
of recovery.
Tanaka et al. (2002) investigated the influence of massage application on localised
back muscle fatigue. 29 healthy subjects participated in two experimental sessions
of massage and rest. On each test day, subjects were asked to lie in prone position
on a treatment table and perform sustained back extension for 90 seconds. Subjects
then either received massage on the lumbar region or rested for a 5 minutes duration,
then repeated the back extension movement. The median frequency (MDF), mean
power frequency (MNF) and root mean square (RMS) amplitude of
electromyographic signals during the 90 seconds sustained lumbar muscle
contraction were analysed. The subjective feeling of fatigue was then evaluated
using the visual analogue scale (VAS). MDF and MNF significantly declined with
time under all conditions. There was no significant difference in MDF, MNF or
RMS value between, before and after massage, or between rest and massage
conditions. There was a significant difference in fatigue VAS change between
massage and rest condition. It was suggested that massage application helped
subjects overcome the subjective feeling of the fatigue.
In a prospective randomised clinical trial (Jonhagen et al., 2004) subjects
(n = 16) performed 300 maximal eccentric contractions of the quadriceps muscle
bilaterally. Massage was given to one leg, whereas the other leg served as control.
Subjects were treated once daily for 3 days. Maximal strength was tested on a Kin-
Com dynamometer, and functional tests were based on one-leg long jumps. Pain
was evaluated using a visual analogue scale. Marked loss of strength and function
of the quadriceps directly after exercise and on the third day after exercise was
146 Principles and Practice of Therapeutic Massage
observed. However, the massage treatment did not affect the level or duration of
pain or the loss of strength or function following exercise.
The indicator of altered homeostasis, i.e. increased heart rate, lactic acid,
alteration in serum enzyme and stress hormone level are shown to be related to the
subjective feeling in strenuous prolonged physical effort. However, very little is
known about the nature of this disturbed homeostasis of fatigue (Astrand and
Radolf, 1986). Therefore, it will be improper to assess the effectiveness of any
modality on fatigue on the basis of one or two physiological parameters. Rather the
actual effect of the modality can best be assessed in the actual competitive situation
where both physiological and psychological factors exert a cumulative effect on
the individual.
The research literature to date is insufficient to conclude whether massage
facilitates recovery of muscle function from a fatiguing effort. In a review article
Moraska (2005)noted that most studies on massage have several methodological
limitations including inadequate therapist training, insufficient duration of
treatment, few subjects, or over or under working of muscles that limit a practical
conclusion. The effects of massage depend primarily on the execution of the
technique, which is highly therapist dependent. Unless the execution of the various
techniques is standardised the reports on the efficacy of massage would likely to
remain contradictory and the debate inconclusive.

MASSAGE AND LACTATE REMOVAL

Sports massage is commonly used in an effort to facilitate lactate clearance. Specific
massage techniques are thought to produce local increases in skeletal muscle blood
flow which theoretically, may accelerate the rate at which lactate is shuttled to the
various sites of elimination, thereby promoting its clearance. It is widely believed
that massage by virtue of increasing the blood flow and lymphatic drainage may
enhance the removal of H+ ions and lactate from muscle and facilitate the transport
of lactate into systemic circulation (Lehn and Prentice, 1994). However this notion
does not derive its support from research. The only study which supports the notion
that massage facilitates lactate removal compared to passive rest, is that of Bale
and James (1991). This study, conducted on 9 male athletes, showed lower blood
lactate level following 17 minutes of manual massage compared with passive rest,
though it was higher than that obtained following warm down procedures.
The observation of Bale and James is not in agreement with other studies (Gupta
et al., 1996; Hemmings et al., 2000; Monedero and Donne, 2000; Zelikovsky et al.,
1993; Robertson et al., (2004)). That explored the effect of massage on blood lactate
removal. All these studies have reported that massage has no better effect then the
passive rest as far as the blood lactate removal is concerned. Studies that have
reported no effect of massage on lactate removal used different exercise protocol,
duration and techniques of massage.
 Definition and ClassificationSports Massage 147
of Massage 147
Gupta et al. (1996) used 10 minutes of manual massage of lower limb in sitting
position after exhaustive exercise on bicycle ergometer, and reported no effect on
lactate removal. Martin et al. (1998) compared a 5-minute sports massage routine
for each leg in both the supine and prone positions using the techniques of effleurage,
petrissage, tapotement, (pounding and hacking) and compression with active
recovery and passive rest condition and noted no significant difference between
sports massage and rest for either absolute or relative changes in blood lactate
concentration. In this study the exercise resulted in a 59.38 per cent decrease in
blood lactate concentration, compared with 36.21 per cent and 38.67 per cent for
the sports massage and rest conditions, respectively. Robertson et al. ( 2004) in an
extensively controlled experiment that controlled even the daily routine and dietary
practices of the participants reported that 20 minutes of leg massage consisting of
stroking, effleurage, kneading, picking up, wringing and rolling with all petrissage
techniques interspersed with effleurage in a centripetal direction did not produce
any better reduction in blood lactate concentration when compared with passive
supine rest.
Monedero and Donne (2000) reported no effect of 20 minutes massage, after
exhaustive exercise in bicycle ergometer, consisting of effleurage, tapotement and
stroking in supine position, on lactate removal. Hemmings et al. (2000) used 20
minute whole body massage consisting of effleurage and petrissage after exhaustive
bouts on boxing ergometer and reported no benefit of massage on lactate removal.
Zelikovsky et al. (1993) used 20 minute of pneumatic massage device on lower limb
after bicycle ergometer work outs and reported no effects on lactate removal. Sinha
(2005) used 20 min of manual lower limb massage consisting of effleurage, kneading
and petrissage in supine position with leg slightly elevated, and confirmed the
findings of above studies. These evidences may permit generalisation that
irrespective of the type of strokes, duration of application and the area of body
treated, massage has no effect on lactate removal.
The failure of massage to facilitate lactate clearance may be attributed to the
following two presumptions.
• Massage does not increase the muscular blood flow to the extent sufficient
enough to facilitate translocation of the lactate ( Hemmings et al. ,2000 ; Gupta
et al., 1996).
• Increases in blood flow alone have little or no effect on lactate clearance(Martine
et al., 1998; Sinha, 2005).
The prevailing popular proposition that postevent sports massage promotes
lactate clearance by increasing blood flow through the skeletal muscle bed is at
best can be described as based on conflicting experimental evidences. The effect of
massage on blood flow has been investigated since 1931 yet the evidence that
currently exist is equivocal. Studies performed by Ek et al. (1985), Linde (1986),
Shoemaker et al. (1997) and Tidus and Shoemaker (1995) could not demonstrate an
148 Principles and Practice of Therapeutic Massage
increased blood flow of muscle or skin following massage. Though the enhanced
clearance of isotopes, i.e. insulin (Linde, 1986) and Xe133 (Dubrovsky, 1982; Hovind
and Neilsen, 1974) have been reported, which have been attributed to better venous
emptying following massage rather than increase in the arterial or systemic
circulation.
On the other hand there also exist some evidence to suggest that some massage
techniques increase regional blood flow through skeletal muscle. Studies of Wolfson
(1931), Wakim et al. (1949), Bell (1964), Serveni and Venarando (1967) and Dubrovsky
(1982) reported increased flow of blood following massage. Recently Hinds et al.
(2004)compared the effects of massage against a resting control condition upon
femoral artery blood flow, skin blood flow, skin and muscle temperature after
dynamic quadriceps exercise and observed that following massage the skin blood
flow and temperature was elevated but no significant increase in the femoral artery
blood flow was not observed. They opined that without an increase in arterial blood
flow, any increase in skin blood flow has the potential to divert the blood flow
away from the recovering muscle which puts a question mark on the use of massage
in postexercise recovery session.
In the opinion of the author of this book, the answer of the question that why
massage fails to facilitate lactate clearance lies in understanding the metabolism of
lactate in proper perspective. The hypothesis that increases in skeletal muscle blood
flow may accelerate the rate at which lactate is shuttled to various sites of
elimination, thereby promoting its clearance is based on the circumstantial evidences
that are mostly correlational in nature (Gladden, 2000). There have been only a
couple of studies that attempted to directly evaluate the potential role of blood
flow on lactate removal (Gladden et al., 1992; Watt et al., 1994). These studies suggest
a minor role of blood flow in net lactate exchange in in vitro muscle preparations.
Uncertainty has been expressed on whether these results could be extended to higher
metabolic rates possible in tetanic contraction and asynchronous contraction of
voluntary exercise (Gladden, 2000).
On the other hand, there emerge mounting evidences that suggest that activation
of larger muscle mass during recovery would result in better lactate removal (Thiriet
et al., 1993; Baker and King, 1991). Thiriet et al. (1993) obtained lowest blood lactate
value in active leg recovery, intermediate value in active arm recovery and highest
value in passive recovery following exhaustive bout on bicycle ergometer. Baker
and King (1991) also observed lowest blood lactate value with active leg recovery,
intermediate value in active arm recovery and highest value in passive recovery
following exhaustive bout on canoeing ergometer. In all the studies that compared
massage with active recovery it was observed that the lactate reduction could be
facilitated by the active recovery only and significant differences between massage
and passive rest condition did not exist as far as removal of lactate was concerned.
 Definition and ClassificationSports Massage 149
of Massage 149
The emphasis on the role of blood flow in lactate removal is probably derived
from classical 'O2' debt theory which held lactate as a dead-end metabolite that can
be removed only during recovery by reconversion into glucose via Cori cycle in
liver. Classical 'O2 debt' and 'anaerobic threshold' theories held that lactate is
produced in muscle because of O2 lack and it is a dead end metabolite that could
only be removed during recovery (Hill and Lupton, 1923). According to classical
concept about 20 per cent of the lactate produced during exercise is reoxidised into
pyruvate and then disseminated to CO2 and H2O. The remaining 80 per cent lactate
is taken up by liver and turned into glucose, via 'Cori Cycle', which then can be
reconverted into glycogen or delivered to blood. The muscles can then use this
glucose in glycogenesis to restore their glycogen depot (Krebs, 1964). In the light of
this theory, it was reasonable to assume that increasing the blood flow during
recovery by massage or other means would enhance lactate availability to liver
and its removal.
However advances in the last two decades have challenged this theory. The
isotope (13C) tracer studies conducted by Brooks et al. (1984), Brooks and Gaesser
(1980), Donovan and Brooks (1983) on rats, by Depocas et al. (1969), Issekutz (1984)
on dogs, by Pagliassotti and Donovan (1990) on rabbit as well as the human studies
of Hubbard (1973), Brooks and Gaesser (1980), Gaesser and Brooks (1980), etc.
consistently indicated that combustion of lactate in the aerobic pathway is the main
route of the lactate removal during exercise and recovery.
Lactate is now not considered as dead-end metabolite but as a substrate, which
can be used to generate ATP (Brooks, 2000). Most of the lactate produced during
exercise is removed by direct oxidation (55-70%), whereas the balance amount is
converted to glycogen (<20%) protein constituents (<10%) and other compounds
(<10%) (Gaesser and Brook, 1984). Further it is established that reduced splanchnic
blood flow and incompatible hormonal milieu which persist for some time after
strenuous exercise, grossly reduces the capacity of liver to utilise the lactate available
in systemic circulation. The circulating lactate mostly perfuse the heart and active
muscle bed, which can use lactate as substrate (Brooks, 1986; Stanley, 1991). In this
situation, theoretically, accelerated reduction of blood lactate would not be obtained
if the muscle bed remains inactive as happens in case of massage. On the other
hand, increased requirement of ATP during muscle activity would call for more
substrate, which can be provided by the circulating lactate. Active recovery helps
to maintain an elevated metabolic rate which serves to promote lactate clearance
via an accelerated rate of lactate oxidation. Active recovery also promotes lactate
clearance via an increased use of lactate as a fuel by the heart and contracting skeletal
muscle. Lactate, which is produced in Type lIb fibres, is transported into Type I or
Ila fibres, where it is oxidised. Therefore, glycolytic fibres within an exercising
muscle bed can shuttle oxidisable substrate (in the form of lactate) to neighbouring
cells with higher respiratory rates. From the above discussion it becomes clear that
muscle activity might be the most essential component of accelerated lactate removal
150 Principles and Practice of Therapeutic Massage
strategies. The very nature of lactate metabolism may not allow any recovery
intervention that excludes the component of muscle activity, to succeed in achieving
the accelerated lactate removal.

Role of Massage in Psychological Recovery

Massage is an important aid in combating some of the psychological problems of
the athlete. It helps in promoting the psychological recovery after an intense physical
exertion.
Most of the studies on the effect of massage on recovery accede that as far as
subjective parameters are concerned massage does exert positive effect on the
recovery process. Robertson et al. (2004) observed a significant (p<.05) lower fatigue
index in the massage trial. Tanaka et al. (2002) reported significant difference in
fatigue VAS change between massage and rest conditions. Hemmings et al., (2004)
observed that massage intervention significantly increased the perception of
recovery. Similar observation on the subjective parameters were also made by Farr
et al. (2002).
Autonomic nervous system more specifically its sympathetic component
increases its activity during exercises to cope with the increased demand. After
cessation of the activity this effect should be reversed to ensure better replenishment
of energy stores. However, many a times, the stress of losing or winning the game
and associated emotions does not allow the sympathetic arousal to subside down.
This manifests as an increase in heart rate, poor appetite, muscle tiredness and
inability to sleep. If this condition is prolonged, the individual can become exhausted
leading to diminished work capacity and psychological burn out.
Massage is one of the most important techniques, which is employed to achieve
lower arousal level along with several other techniques such as spa, warm bath,
showers, floatation tanks, etc. The positive effect of massage on the reduction of
anxiety and the improvement of mood is well-established and it is utilised in sports
setup not only after exercises but also before and during competitions.
Anxiety and muscular tension are interdependent phenomenon. Conversely,
adequate muscular tension is a prerequisite for optimum performance. Experiments
have demonstrated the relation of muscle tension and muscle response to anxiety.
It is found that highly anxious subjects not only perform with an excess of muscular
tension compared to less anxious subject, but their coordination is also affected.
Weinburg and Genuchi (1980) pointed out that anxiety has a disruptive effect as
the precise neuromuscular patterning involved in precision sports.
Excess level of anxiety tends to restrict the attentional field and the athlete may
begin to attend to a limited number of cues. However all anxieties are not disruptive.
An optimal level is necessary to perform well.
Massage can effectively modulate the level of anxiety associated with sports
competition if utilised in a proper manner. Psychophysiological parameters
 Definition and ClassificationSports Massage 151
of Massage 151
associated with the symptoms of tension and anxiety have been shown to decrease
significantly with massage (Makeehnic et al., 1983). It not only reduces muscle
tension and facilitates deep relaxation, but also provides a feedback to athlete about
the muscle tension. This helps athlete learn to monitor the muscle tone.
Regarding promotion of psychological recovery of the athletes Bruncker and
Khan (1993) have opined that it is always better to complement progressive
relaxation technique with deep therapeutic massage, as these two techniques highly
reinforce each other.
Massage can be a useful remedy in following sports related psychological
symptoms:
• Inconsistency in performance
• Poor performance while travelling
• Diminishing performance on a session as the tournament progress
• Persistent tiredness
• Recurrent illness or injury.

Role of Massage in the Prevention of Injuries

Heavy training predisposes to the development of tight bands within entire muscle
or group muscles due to prolonged contraction of the active muscle. It occurs during
the period of adaptation to increased volume and intensity of training. It places an
excessive force either at the muscle insertion or at the musculotendinous junction.
If this tightness is asymmetric, it contributes to the development of biomechanical
abnormalities apart from compromising the ability of muscles to elongate and to
absorb the shock. This predisposes the tissue to strain especially when any
movement attempts to stretch the tight tissues and reduces the range of motion
and excursion of muscle. Many of these abnormalities detected during massage
session can be corrected by massage techniques or alternately the athlete can be
referred to other members of sports medicine team as appropriate.
Massage can reduce the excessive postexercise muscle tone, as well as increase
the muscle range of motion and thereby help reduce the tight band and its associated
problems. Dubrovsky (1982) found that massage decreased the resting as well as
contractile muscle tone.
Heavy training also predisposes to the development of trigger points, which
not only impairs the training and competition performance but can also progress
to frank injury if athlete continues to work, ignoring their presence. The role of
massage in deactivating the trigger points is well-known.
Regular massage also provides an opportunity to identify any soft tissue
abnormality that if left untreated may progress to injury. This is more important
for those anxious athletes who tend to hide their injuries in an attempt to prevent
the appearance of cowardliness and subsequent social insecurity that withdrawal
from contest might entail. In these persons massage plays an extremely important
role of finding and alleviating problem area before it becomes serious.
152 Principles and Practice of Therapeutic Massage
Crossman et al (1985) found that general massage significantly increased the
range of motion of hamstring in normal female subjects. They further suggested
that athlete may also benefit from massage treatment for prevention of injuries
associated with hamstring limitations.
Nordschow and Bierman (1962) found that generalised massage in which no
special attention was given to specific tension area, 4 out of 5 subjects were constantly
found to relax muscle and increase their flexibility.
Previously unresolved soft tissue may be irritated further by intense physical
training. Repeated microtrauma of these lesions may lead to laying down of
excessive connective tissue which tends to adhere and reduce flexibility. Regular
massage not only mobilises the tissue and prevents them to become adherent but it
also breaks down the established adhesion and restores the flexibility of soft tissue.

CATEGORIES OF SPORTS MASSAGE

Athletes have different physical and psychological requirements during various
phases of sports sessions. The massage techniques should be tailored to meet these
requirements. Depending upon the needs and the physical status of the athletes,
the practice of sports massage can be classified under the following categories:
• Preevent massage
• Preparatory massage
• Intermediate massage
• Postevent massage
• Training massage/regular fine tuning
• Medical massage/massage for injury rehabilitation.
Table 10.2: Categories of sports massage

Category Used during Duration

Preevent massage 8 hours before competition 20-30 min
Preparatory massage 30 minutes before competition 5-10 min
Intermediate massage During interval and half times 2-3 min
Postevent massage 1-3 hours after competition 30-60 min
Training massage During conditioning period 60-90 min
Medical massage As and when required

Preevent Massage
This kind of massage is given before 8-12 hours of competition. The goals are to
ensure optimal arousal, to dispel excessive precompetitive anxiety and to keep the
muscles, to be used for competition, prepared for executing the physical task. After
massage, the athlete should remain loose, but not overtly relaxed, with an alert
mind. Techniques used in this kind of session should be light, relaxing and warming.
The session must remain pleasant, pain-free and simulating to the psyche of the
athlete.
 Definition and ClassificationSports Massage 153
of Massage 153
The massage should be given to only those parts of the body which are going to
withstand greatest stress during the event. It is important to identify the anatomical
areas, which will be maximally stressed in the event. The stress imposed on different
body segment is very much dependent upon the nature of sports. Therefore, the
body part approached during prevent massage may not be the same for athletes of
two different sports.
For example, weightlifting stresses the spine and arms to the maximum whereas
for throwers the maximally stressed areas are shoulder girdle and arm muscles.
Runner and jumper should be massaged from foot to thigh whereas in throwers
(Discus, Javelin, Shotput) the muscles of hand, arm and shoulder girdle should be
prime site of intervention. The muscles of arms and shoulder should be treated
symmetrically for rowers and gymnast, whereas in tennis, badminton, fencer and
bowler, the unilateral dominant upper extremity would be the area of emphasis.

Procedure
Aims
1. To decrease the pre-competition anxiety by inducing generalised relaxation
2. To increase the circulation and warm up the prime muscles
3. To identify and correct the area of excessive tension.
Techniques Used
• Superficial stroking, effleurage, kneading, picking up, skin rolling, hacking,
pounding
• Limited use of friction and deep kneading.
Time and Duration
8-12 hours before competition. Preferably before active warm up and stretching
exercises.
Duration 20-30 minutes
Sequence
The preevent massage should be administered in two phases.
• Massage for relaxation
• Massage to specific muscle group.
Massage for relaxation First massage is given to invoke its sedative effects in order
to calm down the athlete having preactivity excitement. Back massage is preferred
in this phase. Following is the outline of the protocol to be followed in this phase.
• Client should lie prone in comfortable position
• Superficial stroking consists of long strokes used several times until change in
the tone of muscle occurs.
• Then effleurage is done starting with light strokes, gradually progressing to
deeper strokes.
154 Principles and Practice of Therapeutic Massage
• Kneading for errector spinae, latissimus dorsi, levator scapulae and
rhomboideus followed by picking up for upper fibres of trapezius.
• Ironing and skin rolling.
• The area of tension and pain should be identified during the effleurage and
friction and kneading can be applied to those areas.
• To end with, deep effleurage is practiced once again.
Massage to specific muscle group After the sedative back massage, the muscle groups,
which are to be used in the events should be treated in the following order.
• Deep effleurage followed by kneading, picking up and muscle shaking over
the muscle belly.
• The speed and rhythm of massage should be increased gradually and each
manoeuvre should be repeated several times.
• Friction to musculotendinous junctions and ligaments, and finger kneading to
the insertion of muscle can also be used.
• This phase should end with the application of percussion techniques in the
form of hacking, beating and pounding along with very brisk superficial stroking
over the whole length of muscle.
Caution The friction and deep kneading should be used with caution. These
manoeuvres should not produce pain. The area of chronic injuries should be left
untouched during preevent massage, otherwise the painful procedure over these
lesions will adversely affect the psychology of the athlete. These areas can be treated
after the event.
At the end of preactivity massage, athlete should feel warm and comfortable.
He should rest for sometime before participating in active warm up and stretching
exercise programme.

Preparatory Massage
This is used 30-45 minutes before competition prior to warm up and stretching
exercises. The purpose is to achieve the optimal arousal level of player. It must not
be painful and should be used only for those muscles, which are going to be used
maximally during the event. It should be short, light and loosening.
Aim To modulate the arousal level, i.e. to stimulate the relax athlete and to relax
the excited athletes.
Techniques used Superficial stroking, both hands palmar kneading, muscle shaking,
hacking and beating or pounding.
Time and duration 30 minutes prior to competition, for 5-10 minutes.
Sequence The superficial stroking, double hand palmar kneading, and hacking
should be practiced over the muscles; the rhythm of technique should be brisk and
depth should be light.
 Definition and ClassificationSports Massage 155
of Massage 155
Intermediate Massage
It is employed during half time or between individual games of long series, as in
boxing during the short interval period between the round. It should be short, light
and loosening. The techniques procedure, and aim are similar to preparatory
massage. For better effects, ice cold towels can be used prior to massage over the
muscle that are either in use or going to be used.

Postevent Massage
This kind of massage is used after hard training or tough competition as an aid for
a speedy recovery of the athlete. The intent of this massage is restorative. It facilitates
the athlete’s recovery by decreasing fatigue, soreness, spasm and by speeding the
removal of metabolic waste. It may significantly reduce the intensity of DOMS by
increasing the blood and lymph flow and relaxing the muscle.
For massage to be effective, the time period after exercise at which massage is
administered is critical. Soviet sports therapists have suggested that to enhance the
athletic performance, restorative massage should be administered between one to
three hours after termination of strenuous exercise (Smith et al., 1994). The hypothesis
is that the residue of metabolic waste is not get fixed in the tissue immediately after
the physical exertion and thus can be excreted out easily. However, it can be given
even up to eight hours after the events when light techniques are used and one to
two days later for deeper techniques (Liston, 1995).

Aims
1. To facilitate drainage of metabolic waste product by increasing the circulation
2. To enhance the feeling of well-being
3. To promote deep muscle relaxation.

Techniques used
• Effleurage, kneading, picking up, wringing and muscle shaking.
Time and duration One to three hours after the competition for 30-60 minutes.
Deep penetrating techniques that encourage venous and lymphatic drainage
are recommended. Hard painful massage techniques are contraindicated
considering the relative postexercise anoxia in the muscle tissues.

Procedure
— The athlete should take warm shower prior to massage.
— Before massage, the player has to be examined thoroughly in order to detect
any injury that might have occurred during events. If any contraindication such
as haematoma, tendon tear, muscle rupture, blows, kicks, etc. is found massage
should not be administered. Rather prime attention should be given to the
treatment of that injury.
156 Principles and Practice of Therapeutic Massage
— Athlete should be placed in a position of comfort. Then the muscle groups
primarily used in the event should be approached in the following order.
• To start with slow and firm effleurage is given to the part. Depth of it should
be increased gradually keeping the speed and rhythm constant throughout.
• Slow kneading, picking up and muscle shacking should be practiced then.
As the muscles relax, the depth of manipulation should be increased. This
helps to squeeze out the accumulated waste product from the muscles.
• To the end, deep and slow effleurage should be practiced once again.
• All these techniques should be repeated several times.

Caution
• The use of percussion technique and deep friction should be avoided over the
painful area.
• In general fatigue and exhaustion, it is especially effective to massage the body
segment having greater receptive field such as spine, thigh, etc.
• When there is strong fatigue, the emphasis should be given to lessen the activity
of excitatory process which were increased under the influence of physical and
psychological load (Paikov, 1986). For this purpose, superficial stroking with
slow rhythm and finger kneading to temporal region of face may be interspersed
between the other techniques.

Training Massage
It is otherwise also called regular fine tuning massage. Administered during the
regular training session as a part of total conditioning programme of the athlete,
these massage sessions are designed to search out the area of biomechanical stress
and to relieve them before they become problematic. When an activity is commenced
after a period of relative inactivity or when the training level is increased, a lot of
soft tissue changes take place in the body. Many of these changes like formation of
tight bands, activation of silent trigger point, stressing of the previous chronic
injuries, etc. can seriously affect the training schedule and many a time may compel
the athlete to abandon the conditioning sessions. The aim of this massage is to
support and prepare the body for the considerable conditioning, which one must
undergo to reach the top form.
Ideally these massage session should be incorporated on a weekly or fortnightly
basis in the overall training schedule. This session can help an athlete to maintain a
balance between optimal training and over training.
Procedure In addition to all elements of postevent massage, deep kneading,
friction and trigger point work, are the techniques of emphasis. However, the
techniques should be selected as per the individual’s requirement and physical
status.
• As a rule, session should begin with light techniques and gradually depth should
be increased.
 Definition and ClassificationSports Massage 157
of Massage 157
• Deactivation of trigger point and mobilisation of adherent structure are best
done in this phase.
• Unlike all other categories where the emphasis is on the area to be used, here
the massage should be administered to the whole body.
• Athlete may receive a treatment cramp during friction and trigger point work.
He may also become very relaxed. Therefore after these sessions, he should not
immediately undergo for vigorous physical activity. Rather his training intensity
should be increased gradually.

Medical Massage/or Massage for the Rehabilitation of Injuries

Unlike the previous categories, the client here is an injured athlete. Therefore,
massage technique should be used only as an adjunct to the total therapy plan.
The sessions are designed to speed up the healing process, prevent compensatory
problems, maintain as well as increase the range of muscle excursion and to create
a scar which is stronger yet does not inhibit normal broadening out of the muscle
upon contraction.

Acute Injuries and Massage

Minor sprains and strains (grade I and II), tenosynovitis, tendinitis, painful scar,
tenovaginitis and endurated subcutaneous tissue, etc. are the common acute sports
injuries where massage have a role. The massage treatment’s aims and protocol for
these conditions are described in detail elsewhere in this book. However, it is
essential to point out that all acute injuries are associated with acute inflammation
where massage is an absolute contraindication. Therefore in dealing with an acutely
injured athlete, one should refrain from administering massage to the painful area
till the real cause behind the pain is determined.
Many coaches, players and dance gurus in India have extreme faith in the healing
capability of massage and frequently they undertake massage treatment, either by
themselves or by quacks, in the conditions where massage is actually
contraindicated. This does not alleviate the symptoms, but rather complicates the
case. Therefore, application of massage in acute injuries should not be encouraged
and if at all required, it should be administered by qualified and experienced
physiotherapists.

Chronic Injury and Massage

Delayed onset muscle soreness causing generalised pain, 48 hours after
unaccustomed work, trigger points, chronic scar adhesions, fibrositis and various
myofacial pain are the conditions where deep massage techniques are extremely
useful. In chronic ligamentous sprain, muscle strain, tenoperiosteal injuries, etc.
where there occurs adhesion formation, the deep transverse friction is the treatment
of choice.
Medical massage sessions are painful especially when the aim is to break the
adhesion, and athlete should refrain from heavy training during this period.
158 Principles and Practice of Therapeutic Massage

11
Outlines of the
Lymphatic System

In order to practice massage in a scientific manner, it is necessary to know the

arrangement of lymphatic vessels and nodes in the body. The salient features of
this arrangement is presented in this chapter. The text mainly deals with the course
of lymphatic vessels. The location of lymphatic nodes and their respective area of
drainage are presented schematically in the charts. The readers are advised to refer
textbooks of Anatomy for further reading.

General Considerations
Lymphatic system is an accessory route by which the larger molecules like protein,
debris and other matters from tissue space return back to the circulation. Ten per
cent of the fluid filtering from the arterial capillaries enters the lymphatic system.
Lymphatics have valves at the very tip of the terminal lymphatic capillary and also
along their larger vessels, upto the point where they empty into venous circulation.
Lymphatic capillaries form plexuses in the tissue space, which have much wider
mesh than those of adjacent blood capillaries. They are generally permeable to
colloidal material and larger particles such as the cell debris and the microorganism.
Lymphatic capillaries join to form wider lymphatic vessels, which pass to the
local lymph node. The lymph nodes are arranged in the form of regional groups
and each group has its specific region of drainage. Nodes within a group are often
interconnected to each other.
A normal young adult has some 400-450 lymph nodes. The arm and the
superficial thoracoabdominal wall contains about 30 nodes. The leg, superficial
buttock, infraumbilical abdominal wall and perineum contain about 20 nodes. Head
and neck carry some 60-70 nodes. Rest is divided between the thorax, abdomen
and pelvis.
All lymphatic vessels are divided into superficial and the deep vessels according
to their location in respect to the deep fascia. These vessels terminate ultimately
into either the left thoracic duct or the right lymphatic duct which in turn open into
left and right bronchocephalic veins respectively. Therefore, the lymphatics from
all parts of the body empties into the venous system.
 Definition Outlines of the Lymphatic
and Classification System 159
of Massage 159
The thoracic duct receives lymphatics from the lower limbs, abdomen and left
side of head, part of chest and the left upper limbs. The right lymphatic duct receives
the lymphatics from the right side of the head and the right side of the chest.
The lymphatic capillaries are not present in the avascular structures such as
epidermis, hair, nails, cornea, articular cartilage, central nervous system and bone
marrow.

Lymphatic Drainage of the Upper Limb

Most superficial and deep lymphatic vessels of the upper limb drain into lateral
axillary lymph node. Therefore, each stroke of effleurage in the upper limb should
be directed towards the axilla (Flow chart 11.1).

Superficial Drainage
Superficial lymph vessels of the upper limb drain the skin and subcutaneous tissues
and end mostly at the lateral axillary node. They begin in the cutaneous plexus.
Fingers are drained by the digital plexus along the medial and lateral borders of
the fingers upto their web space. In the web space the digital plexus join the palmar
vessels which pass back to the dorsum of hand and join the dorsal vessels of the
forearm. The lymphatic of the proximal palm drains towards the wrist medially
along its ulnar border. Laterally, they join the vessels of the thumb.
The dorsal vessels after running proximally in parallel through the forearm
curve successively around the borders of the limb to join the ventral vessels. Anterior
carpal vessels run in the forearm parallel with the median vein of the forearm upto
the level of elbow region, then they follow the medial border of the biceps upto the
anterior axillary fold. They then pierce the deep fascia at the anterior axillary fold
and end into the lateral axillary lymph node. Vessels which are lateral in the forearm,
follow the cephalic vein upto the level of the tendon of the deltoid. Thereafter most
vessels incline medially to reach the lateral axillary nodes, whereas some vessels
continue with the vein to the infraclavicular nodes. Vessels, which are medial in
the forearm, follow the course of the basilic vein. They are joined by the vessels
curving round the medial border of the limb. Some of these vessels end in the
supratrochlear node, proximal to the elbow. The lymphatic vessels from the deltoid
region (outer and upper arm) pass around the anterior and posterior axillary fold
to end in the anterior and posterior axillary node respectively. Overall lymphatic
vessels from the forearm emerge on the medial side of the upper arm to reach the
lateral axillary lymph nodes. The scapular skin drain, either to the subscapular
axillary lymph node or to the inferior deep cervical node (supraclavicular node).

Deep Drainage
The structures situated beneath the deep fascia, mainly muscles, are drained by the
deep lymphatic vessels. Deep lymphatic vessels accompany the main neurovascular
bundle of the upper limb (radial, ulnar, interosseous and brachial) and drain into
the lateral axillary lymph node.
160 Principles and Practice of Therapeutic Massage
Flow chart 11.1: Lymph nodes of the upper limb
 Definition Outlines of the Lymphatic
and Classification System 161
of Massage 161
The lymphatics of the scapular muscles empty themselves mainly into the
subscapular axillary node whereas those of the pectoral muscles drain to the pectoral,
central and apical groups of axillary nodes.

Lymphatic Drainage of the Lower Limb

The lower limb has a superficial and a deep set of lymphatic vessels. Unlike upper
limb, they drain into two different sets of lymph nodes and there exists no
communication between the superficial and deep lymphatic channel. However,
this arrangement does not affect the direction of effleurage in the lower limb, because
both the superficial and the deep inguinal nodes are situated at the groin (femoral
triangle) (Flow chart 11.2).

Superficial Drainage
Like upper limb, the superficial lymph vessels of the lower limb drain the skin and
subcutaneous tissue. They are much more numerous than the deep vessels and
take a direct course to the superficial inguinal lymph node.
The superficial lymph vessels begin in the subcutaneous plexus.
Superficial lymphatics from the medial side of foot and leg ascend with the
long saphenous vein to the superficial inguinal node. Those from the lateral side of
foot and leg ascend and cross in the region of knee to join the medial group of
vessels.
The medial vessels begin on the tibial side of the dorsum of foot. Around medial
malleolus they branch off. Some vessels pass anteriorly whereas the other pass
posteriorly around the medial malleolus. They again join each other near the great
saphenous vein and follow its course up to the distal superficial inguinal nodes,
which are situated at the groin.
The lateral vessels begin on the fibular side. Some cross the leg anteriorly to
join the medial vessels, whereas the others accompany the small saphenous vein
and end into the popliteal lymph node situated at the back of knee.
There is a lymph shed, along the back of the lower limb. The vessels from the
medial half of the limb, pass around the medial surface of the limb. The vessels
from the lateral half pass round the lateral surface of the limb to converge on the
inguinal lymph nodes.
The superficial lymph vessels of the gluteal region drain anteriorly to the lateral
superficial inguinal lymph node.

Deep Drainage
The deep lymph vessels of the lower limb accompany the main blood vessels
(Anterior and posterior tibial, peroneal, popliteal and femoral) of the lower limb
and terminate at the deep inguinal node situated at the groin.
162 Principles and Practice of Therapeutic Massage
Flow chart 11.2: Lymph nodes of lower limb
 Definition Outlines of the Lymphatic
and Classification System 163
of Massage 163
The deep vessels from the foot and the leg enter into the popliteal node at the
back of knee. This node is connected to the deep inguinal lymph node through the
lymphatic vessels, which follow the course of the femoral vessels in the thigh.
The deep vessels from the gluteal and the ischial region drain along with the
corresponding blood vessels (gluteal and internal pudendal) through the greater
sciatic foramen into the internal iliac node situated in the pelvis.

Lymphatic Drainage of Trunk (Flow chart 11.3)

Neck
The vessels draining the superficial cervical tissue pass along the margin of sterno-
cleidomastoid muscle and drain into the superior deep cervical node.
The vessels from the superior region of the anterior triangle of the neck drain to
the submandibular and the submental nodes.
The deep tissues of the head and the neck drain to the deep cervical nodes
either directly or through the distant groups.

Thoracic Wall
The superficial lymphatic vessels of the thoracic wall branch off subcutaneously
and converge on the axillary nodes.
The vessels superficial to the trapezius and the latissimus dorsi, unite to form
10 to 12 trunks which end in the subscapular posterior axillary nodes.
The vessels in the pectoral region including those from the skin covering the
periphery of mammary gland and its subareolar plexus drain into the pectoral
(anterior) axillary node.
The vessels near the lateral sternal margin pass between the costal cartilage to
the parasternal nodes.
A few vessels from the upper pectoral region ascend over the clavicle and drain
into the inferior deep cervical nodes, which are arranged in a vertical chain.
The lymphatic vessels from the deeper tissues of the thoracic wall drain mainly
to the parasternal, intercostal and the diaphragmatic lymph node.
The parasternal nodes are situated at the anterior end of the intercostal space.
They drain mammary glands, deeper structures of the supraumbilical anterior
abdominal wall and the deeper parts of the anterior thoracic wall. The vessels
emerging from these nodes form the bronchomediastinal trunk.
The intercostal nodes are situated posteriorly in the intercostal space near the
head and neck of the ribs. They drain the posterolateral aspect of the chest and the
mammary gland. The lymphatics of the posterior muscles attached to the ribs, end
mostly in the axillary node. Some lymphatic vessels from the pectoralis major end
in the parasternal nodes. The intercostal muscles of the anterior thoracic wall are
164 Principles and Practice of Therapeutic Massage
Flow chart 11.3: Lymphatic trunks
 Definition Outlines of the Lymphatic
and Classification System 165
of Massage 165
Flow chart 11.4: Lymph nodes of the head and neck
166 Principles and Practice of Therapeutic Massage
drained by the intercostal lymphatic vessel to the parasternal node. The intercostal
muscles of the posterior thoracic wall drained to the intercostal nodes.

Abdominal Wall
The umbilicus forms the “watershed” for the anterior abdominal wall as far as the
lymphatic drainage is concerned.
Superficial lymphatics of the region above the umbilicus run obliquely upward
to the pectoral and the subscapular axillary nodes. Whereas those from the region
below the umbilicus drain downward to the superficial inguinal nodes.
The deep lymphatic vessels follow the course of the deep arteries. The posterior
vessels run along with the lumbar arteries to the lateral aortic and the retroaortic
node. The vessels from the upper anterior abdominal wall run along with the
superior epigastric vessels to the parasternal node. The vessels from the lower part
of abdominal wall end in the circumflexiliac, inferior epigastric and the external
iliac nodes. The vessels of the pelvic wall follow the course of the internal iliac
artery and terminate in the iliac or the lateral aortic nodes.

Lymphatic Drainage of the Head

The overall lymphatic drainage of the head can be divided into 4 territories namely
upper, middle, lower and the lateral (Flow chart 11.4).
The upper territory, which includes the greater part of the forehead, the lateral
halves of eyelid, the conjunctiva, the lateral part of the cheek and the parotid area,
drains into the preauricular (parotid) node, which is situated just anterior to the
tragus.
The middle territory, which includes a strip over the medial part of forehead,
the external nose, the upper lip, the medial part of the lower lip, the medial halves
of the eyelid, the medial part of the cheek and the greater part of the lower jaw,
drains into the submandibular node. The lower territory which includes, the central
part of the lower lip and the chin, drains into the submental nodes situated below
the chin. A strip of scalp above the auricle and the upper half of the auricle’s cranial
aspect and margin constitute the lateral strip, which drains into the upper deep
cervical and the retroauricular nodes. The occipital scalp is drained partly to the
occipital nodes, which are commonly superficial to the upper attachment of the
trapezius.
 Glossary

Abduction : A movement that takes a body part away from the

midline of the body.
Adduction : A movement that brings a body part towards the
midline of the body.
Adhesion : The result when two structures become attached,
united or struck together.
Adipose tissue : Tissue largely composed of fat cells.
Anterior : Front portion of the body.
Arousal : A psychological state of preparedness, willingness to
execute a task.
Cardiac arrhythmia : Any variation in either the force or rate of heart beat
from the normal.
Centrifugal : Away from the centre of circulation, i.e. heart.
Centripetal : Towards the centre of circulation, i.e. heart.
Cocontraction : Simultaneous contraction of two opposing groups of
muscles around a joint/joints so that tension develops
in the part but no movement results.
Connective tissue : Supporting or framework tissue of body formed by
collagenous and elastic fibres, basic cell type is
fibroblast, derived from mesoderm.
Contractile unit : The structures having inherent property of contraction
functionally related to muscles.
Contralateral : Opposite side.
Distal : Part farthest from a reference point, for example, in
reference to shoulder elbow is distal.
Dorsiflexion : Act of moving the foot up towards the leg.
168 Principles and Practice of Therapeutic Massage
Embolism : Sudden blocking of a blood vessel by a blood clot or
other foreign materials introduced into the circulation.
Erythema : Redness of skin due to increased blood flow.
Extension : A movement that brings two parts of a joint towards a
straight line or movement that returns a segment from
flexed position to neutral position.
Facilitation : The promotion of performance of function, the
reinforcement of a reflex and neural activity.
Fascia : A sheet of fibrous tissue that envelops the body beneath
the skin and also encloses the muscle or group of
muscles and separates their several layers.
Flexion : A movement that brings the two parts of a joint into a
bend position.
Hemoptysis : The spitting of bright red blood from lungs.
Homeostasis : A state of equilibrium between the opposing forces in
the body with respect to various functions and to the
chemical compositions of fluid and tissue.
Hypothenar eminence : Slightly elevated area of the palm near medial border
of hand.
Inflammation : A reaction of living tissue to injury characterised by
increased flow of blood and exudation of fluid from
blood vessels with consequent redness, pain, heat and
swelling.
Inhibition : Putting restraint on an activity or function so that a
stimulus evokes no response.
Ipsilateral : Same side.
Ischaemia : Insufficient blood supply to a part of body relative to
local need.
Lateral : Outer side of a segment, the side away from the midline
of body.
Lesion : The site of injury, pathological condition or
dysfunction.
Lordosis : Hollow of spine in neck and lower back, spinal
curvature with convexity in the forward direction.
Medial : Inner side of a segment, the side closer to the midline
of body.
Muscle tone : A state of slight tension, usually present in muscles
even at rest, a state of preparedness of a muscle to resist
the stretch, controlled by nervous system. In injuries
 Glossary 169
Definition and Classification of Massage 169
involving brain and spinal cord the tone of muscle
increase (hypertonicity) whereas injuries to peripheral
nerves or anterior horn cells or spinal nerve roots result
in decrease of tone (hypotonicity).
Non contractile unit : Structures having no inherent property to contract or
relax, includes joint capsules, ligaments, bursa, fascia,
etc.
Periosteum : The thick fibrous membrane covering the entire outer
surface of bone except at the articular ends. It consists
of an inner layer which forms new bone tissue and an
outer layer containing blood vessels and nerves
supplying the bones.
Placebo : A treatment which is known to have no physiological
curative effects when given to a patient brings about
favourable results mostly due to psychological factors.
Plantar flexion : Act of moving the foot downwards away from the leg.
Posterior : Back portion of the body, dorsal.
Pronation : Act of turning the palm downwards, performed by the
medial rotation of forearm.
Prone : Lying on the tummy.
Proximal : Part closer to a reference point, for example, in
reference to elbow shoulder is proximal.
Scar : A mark remaining after healing of the wound which
consists of the fibrous tissue replacing the normal tissue
destroyed by injury or by disease.
Sedation : The act of soothing or allying irritability, relief of pain
or production of calmness.
Stretch reflex : Involuntary contraction of muscle when it is suddenly
stretched, due to stimulation of proprioceptors
controlled by central nervous system.
Supination : Act of turning the palm upwards, performed by lateral
rotation of forearm.
Supine : Lying flat on the back.
Tender : Abnormal painful sensitivity to touch and pressure.
Thenar eminence : Small elevated area of the palm at the base of thumb.
Trigger point : A hyperirritable site on the external surface of body
which is painful on pressure and gives rise to
characteristic referred pain and autonomic responses
to a distant area which is located away from the site of
stimulation.
 References 171
Definition and Classification of Massage 171

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 Index
A severe spasticity 36 Fingertip kneading 55
Abdominal wall 166 very hairy skin 37 Flatulence 113
Accessories 93 local contraindications 37 Foot 98
Acupressure massage 129 acute inflammation 37 Forearm mid pronated 96
Acute inflammation 37 arteriosclerosis 39 Forearm pronated 95
Acute injuries 157 malignancy 39 Forearm supinated 96
Adherent skin 111 myositis ossificans 39 Friction 65
Adipose tissue 21 open wound 39
other conditions 40 G
AIDS 29
poisonous foci 39 General and local relaxation 28
Arterial flow 10
recent fracture 38 General massage 7
Arteriosclerosis 39
skin diseases 38 Gluteal region 99
Athletic world 137
Autonomic nervous system 18 stroking group of
H
Axon reflex 10 manipulation 41
thrombosis 39 Hacking 71
B varicose vein 38 Half lying 83
Couch 93 Head 166
Back 98
Cream 93 High fever 34
Beating 72
History of massage 115
Bedsheet 94 D connective tissue massage 120
Bell’s palsy 105
Deep drainage 159, 161 Hoffa massage 123
Blood 13
Deep massage techniques 7 Hypertension 32
Burns 111
Deep X-ray therapy 35
I
C Digital ischaemic pressure 127
Digital kneading 54 Immunological effects 22
Calf muscles 97
DOMS management 137 Intermediate massage 155
Cancer 30
Character of technique 3 Drapping 86
K
Chronic injury and massage 157
E Kneading 52, 64
Circular friction 66
Effleurage (by Hoffa) 124 Knee 97
Circulatory effects 11
Clapping 69 Effleurage or deep stroking 45
L
Commonest error 132 Engorged breast 112
Enhancement of circulation 27 Lactate removal 146
Compression devices 126
Exchange of metabolites 13 Light massage techniques 7
Connective tissue massage 120
External cardiac massage 132 Local contraindications 37
Contact and continuity 90
External cardiac massage 130 Local massage 7
Contact heel percussion 74
Low stool 93
Contraindications 33
general contraindications 34
F Lower limb 96,161
Lower motor neuron lesion 104
deep X-ray therapy 35 Face 99
Lubricant 91
high fever 34 Fall-out standing 89
Lungs 27
osteoporosis 36 Fatigue 141
Lymphatic drainage 159,161,
patient preference 37 Fibrositis 110
163,166
severe renal and cardiac Finger kneading 54 Lymphatic flow 9
diseases 35 Finger pad kneading 55 Lymphatic system 158
186 Principles and Practice of Therapeutic Massage
lymphatic drainage of head 166 Muscle function 142 Percussion 69,74,75
lymphatic drainage of lower limb Muscle injury/strain 108 Percussion/tapotement
161 Muscle spasm and pain 25 manipulations 6
deep drainage 161 Muscle strength 20 Periosteal massage 123
superficial drainage 161 Myositis ossificans 39 Petrissage 59,64,124
lymphatic drainage of upper tappan 124
limb 159 N
Physiological effects 8
deep drainage 159 Neck 99,163 effects 9
superficial drainage 159 Nervous system 15 adipose tissue 21
lymphatic drainage of trunk 163 New systems of massage 120 blood 13
abdominal wall 166 acupressure massage 129 circulatory system 9
neck 163 digital ischaemic pressure 127 exchange of metabolites 13
thoracic wall 163 effleurage (by Hoffa) 124 massage 9
external cardiac massage 130 metabolism 14
M Hoffa massage 123 nervous system 15
Manual massage 7 mechanical devices of massage respiratory system 20
Massage 1 125 skin 21
basis of classification 3 compression devices 126 soft tissue 19
classification of techniques 3 vibration devices 125 immunological effects 22
classification of massage 3 periosteal massage 123 mobility of soft tissue 24
features of massage technique 2 petrissage (by tappan) 124 motor system 16
on the basis of character of procedure 130 facilitatory effects 16
technique 3 commonest error 132 inhibitory effects 17
percussion/tapotement complication of external muscle strength 20
manipulations 6 cardiac massage 132 on autonomic nervous system
pressure manipulations 4 mouth-to-mouth breathing 18
stroking manipulations 4 131 on the arterial flow 10
vibratory manipulations 5 patient position 130 activation of axon reflex 10
on the basis of depth of tissue technique 131 decrease of venous congestion
approached 6 rolfing 124 11
deep massage techniques 7 stripping massage 123 release of vasodilators 10
light massage techniques 7 stylus massage 128 research on the circulatory
on the basis of means of tread massage 123 effects of massage 11
administration of underwater massage 132 on the venous and the lymphatic
technique 7 technique 133 flow 9
manual massage 7 psychological effects 22
vacuum cupping 128
sensory system 15
mechanical massage 7
O Picking up 60
on the basis of region massaged
Pillows 94
7 Obesity 29
Poisonous foci 39
general massage 7 Oedema 26,101
Positioning 80
local massage 7 Oils 93 Postevent massage 155
Massage on the circulatory system Open wound 39 Pounding 72
9 Osteoporosis 36 Powder 93
Massage technique 2 Practical aspects of massage 80
Mechanical devices of massage 125
P
accessories 93
Mechanical massage 7 Painful neuroma 111 bed sheet 94
Medical massage 157 Palmar and digital kneading 59 couch 93
Metabolism 14 Palmar kneading 53 low stool or without arm
Motor system 16 Patient position 130 support chair 93
Mouth-to-mouth breathing 131 Patient preference 37 pillows 94
 Index 187
Definition and Classification of Massage 187
small kidney tray or bowl 95 Psychological effects 22 caution 156
soap 95 Psychological recovery 150 procedure 155
towel 94 techniques used 155
water tap 95 R
preevent massage 152
appearance 89 Radical mastectomy 102 aims 153
therapist 89 Recent fracture 38 duration 153
attitude 89 Recovery following intense
therapist 89 procedure 153
exercises 141 sequence 153
back 98 Rehabilitation of injuries 157
contact and continuity 90 techniques used 153
Reinforced kneading 58 time and duration 153
drapping 86 Relaxation 113
face 99 preparatory massage 154
Renal and cardiac diseases 35 recovery of muscle function 142
gluteal region 99
Respiratory percussion technique role of massage 137,150,151
half lying 83
75 athletic world 137
lower limb 96
over calf muscles 97 Respiratory system 20 prevention of injuries 151
over foot 98 S psychological recovery 150
over knee 97 training massage 156
over leg 97 Secretion 114
Sports massage 152
over thigh 96 Sensory system 15
Sprain 106
over tibial and peroneal Shaking 78
Stance 87
muscles 97 Side lying 84
therapist 87
lubricant 91 Sitting 84
Stimulating percussion technique
cream 93 Skin diseases 38
75
oils 93 Skin graft 111
Stride standing 87
powder 93 Skin rolling 62
Stripping massage 123
neck 99 Small kidney tray or bowl 95
Stroking group of manipulation 41
oedema 101 Soap 95
Stroking manipulations 4
prone lying 81 Soft tissue 19,24
Stylus massage 128
precautions 82 Spasticity 36
Superficial drainage 159,161
selection 91 Sports massage 135
Superficial stroking 42
technique 91 categories 152
Supine lying 82
sequence 95 DOMS management 137
side lying 84 efficacy 137 T
sitting 84 massage 137 Tapotement 69
stance of the therapist 87 efficacy 141 Tapping 72
fall-out standing 89 exercises 141 Techniques 41
stride standing 87 fatigue 141 beating and pounding 72
walk standing 88 massage 141 beating 72
supine lying 82 recovery 141 pounding 72
precautions 83 general considerations 158 caution 76
thoracolumbar region 98 historical perspective 136 circular friction 66
upper limb 95 intermediate massage 155 clapping 69
forearm mid pronated 96 massage and lactate removal 146 caution 71
forearm pronated 95 medical massage 157 technique 70
forearm supinated 96 acute injuries and massage variation 71
Preevent massage 152 157 contact heel percussion 74
Preparatory massage 154 chronic injury and massage percussion techniques 74
Pressure manipulations 4,51 157 physiological effects 74
Prevention of injuries 151 postevent massage 155 effleurage or deep stroking 45
Prone lying 81 aims 155 physiological effects 49
188 Principles and Practice of Therapeutic Massage
specific contraindications 51 thumb pad kneading 57 techniques 113
technique 45 thumb tip kneading 58 lower motor neuron lesion 104
therapeutic use 51 transverse friction 66 caution 105
variation 47 caution 69 procedure 105
finger kneading 54 physiological effects 68 sequence 105
finger pad kneading 55 specific contraindication 68
techniques used 105
fingertip kneading 55 technique 68
muscle injury/strain 108
whole finger kneading 55 use 68
friction 65 vibration 76 aims of treatment 109
hacking 71 caution 77 caution 109
kneading 52 physiological effects 77 position 109
palmar and digital kneading 59 technique 76 procedure 109
palmar kneading 53 therapeutic uses 77 techniques used 109
technique 53 vibratory manipulations 76 painful neuroma 111
digital kneading 54 wringing 63 procedure 114
percussion or tapotement 69 caution 65 radical mastectomy 102
petrissage 59 kneading 64 aims of treatment 102
picking up 60 petrissage 64
position 102
technique 60 physiological effects 64
sequence 103
variation 61 technique 64
positioning of patient 80 therapeutic use 65 techniques used 103
pressure manipulations 51 Tendonitis 108 relaxation 113
reinforced kneading 58 Tenosynovitis 107 removal of secretion 114
technique 58 Tenting 73 sprain 106
variation 59 Therapeutic applications of aims of treatment 106
respiratory percussion massage 101 caution 107
technique 75 adherent skin 111 position 106
shaking 78 burns 111 procedure 107
contraindication 79 skin graft 111 techniques used 106
physiological effects 79 techniques 111
tendonitis 108
technique 78 Bell’s palsy 105
aims of treatment 108
therapeutic use 79 aims of treatment 105
skin rolling 62 caution 106 caution 108
technique 62 position 105 procedure 108
variation 63 sequence 106 techniques used 108
specific contraindication 75 techniques used 106 tenosynovitis 107
stimulating percussion technique engorged breast 112 aims of treatment 107
75 aims of the treatment 112 caution 108
superficial stroking 42 position 112 position 107
cautions 45 sequence 112 procedure 107
physiological effects 44 techniques used 112 techniques used 107
technique 42 fibrositis 110
traumatic periositis 109
techniques of thousand hands aims of treatment 110
aims of treatment 109
44 position 110
therapeutic uses 45 sequence 110 caution 110
variation 44 techniques used 110 sequence 110
tapping 72 flatulence 113 techniques 109
tenting 73 aims of treatment 113 venous ulcer 103
thumb kneading 57 position 113 aims of treatment 103
 Index 189
Definition and Classification of Massage 189
caution 104 Thoracolumbar region 98 V
procedure 103 Thousand hands 44 Vacuum cupping 128
sequence 104 Thrombosis 39
Varicose vein 38
techniques used 104 Thumb kneading 57
Vasodilators 10
Thumb pad kneading 57
Therapeutic uses 24 Venous flow 9
Thumb tip kneading 58
enhancement of circulation 27 Venous congestion 11
Tibial and peroneal muscles 97
general and local relaxation 28 Venous ulcer 103
Time and duration 153
massage 29,30,32 Tissue 6 Very hairy skin 37
AIDS 29 Towel 94 Vibration 76
cancer 30 Training massage 156 Vibration devices 125
hypertension 32 Transverse friction 66 Vibratory manipulations 5
obesity 29 Traumatic periositis 109 Vibratory manipulations 76
mobilise secretions in the lungs Tread massage 123 W
27 Trunk 163
muscle spasm and pain 25 Walk standing 88
reduction of oedema 26 U Water tap 95
Therapist 89 Underwater massage 132 Whole finger kneading 55
Thigh 96 Upper limb 159 Without arm support chair 93
Thoracic wall 163 Upper limb 95 Wringing 63