Therapeutic massage

CHAPTER- 9
THERAPEUTIC
MASSAGE

CHAPTER: 9 THERAPEUTIC MASSAGE
© T h e r a p e u t i c E x e r c i s e H a n d B o o k Page 1
INTRODUCTION
Massage is the practice of soft tissue manipulation with physical, functional, and in some
cases psychological purposes and goals. The word comes from the French massage "friction
of kneading” or from Arabic ‘massa’ meaning "to touch, feel or handle" or from Latin massa
meaning "mass, dough".
Massage involves acting on and manipulating the body with pressure – structured,
unstructured, stationary, or moving – tension, motion, or vibration, done manually or with
mechanical aids. Target tissues may include muscles, tendons, ligaments, skin, joints, or
other connective tissue, as well as lymphatic vessels, or organs of the gastrointestinal
system. Massage can be applied with the hands, fingers, elbows, forearm, and feet.
In professional settings massage involves the client being treated while lying on a massage
table, sitting in a massage chair, or lying on a mat on the floor. The massage subject may be
fully or partly unclothed. Parts of the body may be covered with towels or sheets.
HISTORY
Professional therapeutic massage is an age-old healing art, which can alleviate physical,
mental and emotional ailments. The practice dates to the Chinese in 3000 BC. Other
references in the bible refer to anointing the body with oil. In 460 BC, Hypocrites prescribed
it as a beneficial treatment for his patients.
In one form or another, it developed in all the nations of the old World. Hippocrates, who is
considered a father of medicine, said that all physicians should have experience of the
techniques of rubbing, it is recognized that rubbing can bind a joint that is too loose and
loosen a joint that is too rigid. Furthermore, rubbing can make the flesh and cause parts to
waste, it is these latter beliefs that are so important for those concerned with figure
improvement. In 1813, the Royal Central Institute was established in Stockholm, Sweden,
and here the known massage movements were studied scientifically and systematized. This
was the most important single development in the field in modern times and it is because of
this that remedial massage is often called "Swedish".

Ancient and medieval times:
Writings on massage have been found in many ancient civilizations including Rome, Greece,
India, Japan, China, Egypt and Mesopotamia. A biblical reference from 493 BC documents
daily massage with olive oil and myrrh as a part of the beauty regimen of the wives of
Xerxes. Hippocrates wrote in 460 BC that "The physician must be experienced in many
things, but assuredly in rubbing".
The ancient Chinese book called Huangdi Neijing by the Yellow Emperor recommended
"massage of skin and flesh". The technique of massage abortion, involving the application of
pressure to the pregnant abdomen, has been practiced in Southeast Asia for centuries. In
Romania some illnesses were treated by a massage in which the client was trodden on by a
tame bear.
Modern times:
 Marathon runners receiving massages at the 2004 ING Taipei International Marathon
 China: In modern times, massage in China has developed by absorbing western ideas
into the traditional framework. It is widely practiced and taught in hospital and medical
schools and is an essential part of primary healthcare.
 United States: Massage started to become popular in the United States in the middle
part of the 1800s, and was introduced by two New York physicians based on Per Henrik
Ling's techniques developed in Sweden.
During the 1930s and 1940s massage's influence decreased as a result of medical
advancements of the time, while in the 1970s massage's influence grew once again with
a notable rise among athletes. Massage was used up until the 1960s and 1970s by
nurses to help ease patients’ pain and help them sleep.
Because it is illegal to advertise or offer sexual services in much of the United States,
such services are sometimes advertised as "massage," hence the rise of the term
"massage therapy" in an attempt to provide a distinction between sexual and non-
sexual services.
 United Kingdom: Massage is popular in the United Kingdom today and gaining in
popularity. There are many private practitioners working from their own premises as
well as those who operate from commercial venues.
 Massage in sports, business and organizations: The 1996 Summer Olympics in
Atlanta was the first time that massage was offered as a core medical service. Massage
has been employed by businesses and organizations such as the U.S. Department of
Justice, Boeing and Reebok.

DEFINITION OF MASSAGE
Definition: Therapeutic massage involves the manipulation of the soft tissue structures of
the body to prevent and alleviate pain, discomfort, muscle spasm, and stress; and, to
promote health and wellness.
Or
AMTA (American massage therapy association) defines Massage as, "a manual soft tissue
manipulation that includes holding, causing movement, and/or applying pressure to the
body."
MASSAGE THERAPY:
Massage therapy is “a profession in which the practitioner applies manual techniques, and
may apply adjunctive therapies, with the intention of positively affecting the health and
well-being of the client." (AMTA)
MASSAGE EQUIPMENT
There are some equipments are needed for massage therapy. These equipments are given
below:
 Massage table
 Massage chair
 Massage mat
 Body support
 Draping materials
 Lubricants
 Additional equipment(Music)
PREPARATION FOR MASSAGE
Uncomfortable massage is usually born of failure of coordinated performance by the
therapist. Minor adjustment of foot position & trunk position will change the relationship of
the therapist to the support & the subject; & the totality of hand contact & the angle of
contact will be altered by the posture of the trunk & arms. So the therapist must make
certain preparation before beginning massage.

SELF/THERAPIST’S PREPARATION:
 General Preparation:
 Attention to personal appearance & hygiene
 Wear protective clothing which allows freedom of movement
 Keep short hair
 Remove wristwatch & ring
 Keep short clean nail
 Wash hand before & after treatment
 Fill ROM of all forearm & Hands joints
 Hand exercise:
 Touch the finger tips of one hand with the finger tips of the other and press so that
your thumbs and little fingers are separated widely
 Push the fist of one hand between two adjacent fingers of the other hand so that
they are separated into wider abduction. Keep your fingers in the same plane.
Repeat for each space (Figure-1)
 Place your hands together as in prayer and with your thumbs resting on your chest
push your wrists downwards to extend them without separating the heels of your
hands
 Reverse your hands, placing the backs together and push your elbows downwards
thus flexing your wrists
 Place your hands in the prayer position and, keeping them together, turn them
down and up. Try to touch your abdomen and chest alternately at each rotation
(Figure- 2)
[Figure- 1] [Figure-2]

 Relaxation:
Relaxation of therapist’s hands is very important so that therapist always use his/her
hands in full contact with the model/patient. Relaxed hand contact is one in which the
hand conforms to the contour of the part. The natural rest position of the human hand is
with the fingers and thumb a little apart and very slightly flexed at each joint and it can
easily be adjusted to allow contact with any size of body part
ENVIRONMENTAL PREPARATION:
 Treatment room is well heated
 Well ventilation system
 Maintain privacy in the room
 Appropriate lighting of the room
 Adjustable treatment couch
 Treatment couch is covered by large & small washable blankets & sheets
 Standard size of pillows & pillows covers
 Keep different kinds of lubricant equipments
PREPARATION OF PATIENT:
 Patient should be suitably undressed
 In supine lying need one or two head pillows & a pillow under the knees
 In prone lying need two head pillows crossing one another so that the nose rest
below the crossing, a pillow under the abdomen & a pillow under the ankle joints
for semi flexion of both knee
 Use sheet to cover body to keep body warm
TYPES OF MASSAGE/MANIPULATION
There are different types of massage. The types are used in Physiotherapy profession is
given below:
1. Effleurage
2. Stroking
3. Petrissage
 Kneading
 Picking up
 Wringing
 Rolling
 Shaking
4. Friction
 Circular friction
 Transverse friction
5. Tapotement or percussive
 Clapping
 Hacking
 Vibration
 Beating
 Pounding
 Taping

EFFLEURAGE
Definition:
Effleurage means in which the intention is primarily to assist venous & lymphatic drainage
& in which the direction of the work is from distal to proximal.
Principles:
1. It is unidirectional
2. It starts from distally & ends at proximal area, (e.g.: Finger tip to Axilla; Toes to
Groin; Buttock to Axilla.)
3. Pressure of technique should be such as to push fluid onwards in the superficial
vessels.
Procedure:
1. At first therapist stand in the walk standing position (Figure-3).
2. Next therapist fit the part (which will treat), making 'C' curve the whole hand by
one or two hands
3. In case of using both hands may fit as together on opposite aspects of a part or may
follow one another. (Figure-4& 5)
4. For single hand, one hand is for manipulation & other is for supporting the part.
(Figure-6)
5. At the end of the every line of effleurage there should be a small increase in depth &
a slight pause.
6. Next therapist lifted off his hand & return to the distal part & start the next line of
work
[Figure-3] [Figure-4]

[Figure- 5] [Figure-6]
Indication:
1. To relieve congestion
2. To reduce Edema
3. Traumatic periostitis
4. Peripheral congestion of the breast
STROKING
Definition:
Stroking means in which the intention is primarily to obtain a sensory reaction either
sedative or stimulative & in which direction is not important but is often from proximal to
distal.
Principles:
1. It is unidirectional
2. Start from proximal & end at distal area
3. Pressure & speed depends on effects
4. Slow stroke for 'Sedative' effects
5. Faster stroke for 'Stimulating' effects

Procedure:
1. At first therapist stand in 'Walk standing' position
2. Hand position is obliquely
3. Next start with firm contact & finish with a smooth lift off of therapist hands
4. Starts in slow motion & then go faster
5. At the beginning time 5 seconds for one stroke, (slow stroke)
6. Then try faster & every 5 seconds done 4 stroke
7. Pressure can be achieved at the slower rate
8. The whole area under treatment should be covered by a sequence of stroke
9. Stroke may be performed using:
a) One hand: For narrow area.
b) Two hands simultaneously: For broad area
10. A technique called 'thousand hands': In which one hand performs a short stroke,
the second hand does the same overlapping the first, & the hand pass over one
another to gain contact as the manipulation process down the length of the part
under treatment.
Indication:
1. Evacuation of pus & granular sequestration
2. Sedative effects
3. Sensory stimulation
PETRISSAGE MANIPULATION
Definition:
Petrissage manipulations are those in which the soft tissues [mainly muscles) are
compressed either against underlying bone or against themselves
They are divided into:
1. Kneading manipulation: When the tissues are compressed against the underlying
structures
2. Picking up manipulation: When the tissues are compressed then lifted and
squeezed
3. Wringing manipulation: The tissues are lifted and squeezed by alternating hand
pressure
4. Rolling manipulation: When the tissues are lifted and rolled between the fingers
and thumbs as in skin rolling or muscle rolling
5. Shaking manipulation: When the tissues are lifted and shaken from side to side

KNEADING
Definition:
Kneading is a circular manipulation performed so that the skin & subcutaneous tissues are
moved in a circular manner on the underlying structures. It is a part of 'Petrissage'
manipulation, when the tissues are compressed against the underlying structures.
Principles:
1. Circular manipulation
2. Performed with
 The palmar aspect of the whole hand
 With the palm only
 With all the fingers
 With the pads
 Tips of the thumb
 With the fingers
Procedure:
1. In performing all kneading manipulations use walk standing so that the body
weight can move easily from one foot to the other
2. On flat areas, (e.g. the back) the pressure with the right hand is from 8 o'clock to 11
o'clock with that hand circling clockwise. The left hand circles counter clockwise
and exerts pressure from 4 o'clock to 1 o'clock (Figure- 7)
3. On the limbs, the pressure is exerted from 6 o'clock to 9 o'clock with the right hand
and from 6 o'clock to 3 o'clock with the left hand (Figure- 8)
4. On the non-pressure phase of the circle the hand maintains contact but glides on to
the next area of skin a small enough distance to allow the next circle to cover at
least half the previous area.
5. The right hand moving clockwise will slide downwards from 4 o'clock, while the left
hand will glide downwards from 8 o'clock

[Figure- 7, for flat area] [Figure- 8, for round area]
Kneading may be performed with:
 The whole hand - whole hand kneading (Fig- 9)
 The palm only - palmar kneading (Fig- 10)
 The fingers only:
 flat finger kneading (Fig- 11)
 finger pad kneading (Fig- 12)
 finger tip kneading (Fig- 13)
 The thumb:
 thumb pad kneading (Fig. 14)
 thumb tip kneading (Fig. 15 )
 Both hands when one is superimposed on the other superimposed (rein forced)
kneading (Fig- 16)
 Elbow kneading (Fig. 17)
 Heel of hand kneading. (Fig-18)
Indication:
1. Assist the maintenance of power & range in muscles near the site of injury or
during immobilization.
2. It is a good preventive of the painful muscular cramps suffered by some athletes.
3. Effective for diminishing the sensitivity of painful amputation stumps.

[Figure- 9, Whole hand kneading] [Figure- 10, Palmar kneading]
[Figure- 11] [Figure-12] [Figure-13]
[Fig- 14, thumb pad kneading] [Fig-15, finger tip kneading]

[Fig-16] [Fig-17] [Fig-18]
SHAKING
All long muscle bellies may be shaken and the manipulation may be performed on the larger
muscles such as biceps, triceps, and the quadriceps and also on the small muscles of the
thenar and hypothenar eminences.
 For longer muscles the length of your thumb should be placed on one side of the
muscle belly and all your fingers placed on the other side of the muscle belly. Your palm
should be off-contact (Fig.). Your hand is then rapidly shaken from side to side as you
traverse the length of the muscle belly avoiding contact with the underlying bone. Stand
in walk standing so that your weight is transferred as you work from proximal to distal
on the muscle belly. The muscle will be 'thrown' rapidly from side to side and feels very
invigorated.
 For very small muscles, the tip of your thumb should be placed on one side, and an
appropriate number of finger tips placed on the other side of the muscle belly, and the
shaking movement described above is performed.
VIBRATIONS
Definition: Vibrations are often wrongly called shakings. The difference is that a vibration
involves a movement in which the tissues are pressed and released using an up and down
motion. In shaking, the movement on the model is sideways and involves rapid radial and
ulnar deviation of your wrists.
Vibrations may be fine or very coarse and demonstrate best on a partly filled rubber hot
water bottle or on the abdomen though the more common use is on the chest. Vibration may
be performed with the whole hand, or the finger tips. Practice with your hand stationary or
side it backwards & forwards on the area. They are best practiced by placing the whole hand
on a partly filled hot water bottle with the arm outstretched, and oscillating the whole hand
into rapid and minute wrist flexion and extension. The movement is sustained from the
shoulder and can be observed to occur spontaneously in some people if the arms are
outstretched.

THE DEEP FRICTION MASSAGE/MANIPULATION (DFM)
Definition:
Frictions are small range, deep manipulations performed on specific anatomical structures
with the tips of the fingers or thumbs. No other part of the practitioner's hand must rest on
the part. There are two types of frictions:
 Circular
 Transverse
Circular frictions
1. Circular frictions are performed with the finger tips.
2. The structure to be treated should be identified by careful palpation and the finger
tip placed so that they cover the area. The rest of the hand is kept off-contact.
3. Pressure is applied and a small, stationary manipulation is performed, in a circular
manner and at gradually increasing depth for three or four circles.
4. The pressure is released and the manipulation 15 repeated. One hand may
reinforce the other on deeper structures.
5. The manipulation can be used over ligaments and myofascial junctions Fig. 2.27).
Transverse frictions (DTFM)
Transverse frictions were advocated by Dr J. Cvriax in 1941 for treatment of tendon,
ligament, myofascial junctions and muscles. The manipulation is a unidirectional movement
performed with:
 Either the thumb tip or the finger tip of the index finger sometimes reinforced by
placing the tip of the middle finger on top of the index finger nail
 Or by the middle finger reinforced by placing the index finger on top of the middle
finger nail (more useful when the hand is curved round a limb]
 Or by two finger tips when a long structure is affected (such as a tendon)
 Or by the opposed fingers and thumb on structures which can be grasped e.g.
tendocalcaneous
Phases:
There are two phases of transverse friction massage. They are:
1. Active phase
2. Relaxed phase (Passive)

Procedure:
1. Identify the structure to be treated and place your fingers across the longitudinal
axis of the structure, i.e. across the length of the collagen fibres .
2. Now perform the friction by moving your digit and the model's skin as one, keeping
your digit, hand and forearm in a line parallel to the movement to be performed.
3. Do not flex and extend only your digit or wrist.
4. Try to use a movement from your upper arm, trunk or feet so that you achieve
greater power with less fatigue.
5. Start to move your fingers forwards and backwards across the structure under
treatment with sufficient sweep.
6. The movement must not take place between your fingers and the model's skin, but
between the affected structure and the overlying tissues.
7. The model's skin must be dry to ensure your ringers do not slip.
8. Maintain the friction for five to ten minutes but the area should be examined at
intervals to check that bruising is not occurring or the skin blistering.
9. Keep tendons taut by putting them on the stretch, but keep muscles relaxed by
positioning the model so that the part and the attachments of the muscle are
approximated during treatment.
Indication:
1. For ligament lesion
2. Tendon lesion
3. Muscular lesion
4. Capsular contracture
5. Subdeltoid bursitis
[DTFM in EPL] [DTFM in ankle] [DTFM in elbow]
DTFM in knee

EFFECTS OF THERAPEUTIC MASSAGE/MANIPULATION
On circulatory system:
The following are some of the beneficial results that can receive from massage
treatments:
 The squeezing, compressive & pushing elements of massage carried out with
centripetal pressure are widely considered to bring out drainage of venous blood &
lymph
 Red blood cells increase, as well as the amount of hemoglobin in the bloodstream.
Blood circulation is increased by the dilation of capillaries. Lymph flow is increased.
Lymph, which is a key player in the body's immune system, is the bodily fluid that
transports white blood cells.
 Bring peripheral blood to the heart
 Massage produce the blood flow thus accelerate healing
 It removes chemical substance which produce pain & thus reduce pain
 Improve lymphatic drainage
 Assist in removal of deposits of tissue
On the Nervous system (NS):
 Massage inhibit 'Hoffman reflex' (H-reflex)  Reduce spinal motor neuron
excitability of SCI patient Produce a viable option to other accepted treatment
technique.
 Stroking produce stimulation on pain afferent fiber activate pain gate thus reducing
pain.
 Massage also produce sedative effects on the CNS.
 Improve muscle tone Induce muscle tone
 Soothe and relax nerves
 Relieve Stress
 Release emotional tension
 Relieve pain in certain conditions
On Musculoskeletal system:
 After friction massage  break down of scar tissue fiber arrange in direction of
stress  thus improve muscle or soft tissue strength.
 In case of DOAMS massage improve blood flow  Remove lactic acid  decrease
fatigueness.
 Muscles gain elasticity and lose tenseness.

On respiratory system:
 Vibration, Shaking with the use of Gravity remove the distal sputum to the trachea
& thus clear secration.
 Massages accelerate ventilation & perfusion & thus proper oxygenation of blood.
 Help breathing Stimulate breathing Assist the flow of nutrients & oxygen to tissues
On intigumentary system:
 Massage constant passage of hand over the skin  remove dead surface cells 
sweat gland, hair follicles & sebaceous gland function better.
 Friction massage on scar tissue  convert one type of collage fiber into another
type of collage fiber  arrange the fiber in line of stress  recover scar tissue.
 Nourish the skin (with the right oils) Promote nourishment, repair and renewal of
body cells
BENEFITS OF MASSAGE
1. Pain relief: Relief from pain due to musculoskeletal injuries and other causes is cited as
a major benefit of massage. Pressure point massage may be more beneficial massage in
relieving back pain.
2. State anxiety: Massage has been shown to reduce state anxiety, a transient measure of
anxiety in a given situation.
3. Blood pressure and heart rate: Massage has been shown to reduce blood pressure
and heart rate as temporary effects.
4. Attention: After massage, EEG patterns indicate enhanced performance and alertness
on mathematical computations, with the effects perhaps being mediated by decreased
stress hormones.
5. Diseases: Massage, involving stretching, has been shown to help with spastic Cerebral
palsy Massage has been used in an effort to improve symptoms, disease progression,
and quality of life in HIV patients, however, this treatment is not scientifically
supported.
6. Other: Massage also stimulates the immune system by increasing peripheral blood
lymphocytes (PBLs). However, this immune system effect is only observed in
aromatherapy massage, which includes sweet almond oil, lavender oil, cypress oil, and
sweet marjoram oil. It is unclear whether this effect persists over the long term.

Overall Indication of massage:
1. For relaxation
2. For muscular lesions
3. Lesion of tendons, with & without a sheath
4. Ligamentous lesions
5. Capsular contractre
6. Subdeltoid bursitis
7. For sensory stimulation
8. For facial palsy patient
9. Massage for scar, burn & plastic surgery
10. Treatment for hematoma
11. Massage for oedema
12. For chest thrapy
Contraindication of massage:
1. Skin disease (acute infection)
2. In the presence of malignant tumours
3. Early bruising
4. Open wound
5. Tuberculosis (TB)
6. Inflammation due to bacterial action
7. Traumatic arthritis
8. Ossification of soft structures
9. Infective arthritis
10. Perineuritis

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