Therapeutic Massage

Massage therapy
The terms massage and massage therapy have been defined and differentiated at a 2010 best practice symposium for the profession involving thirty-two experts in the field of massage therapy. In general, massage is a patterned and purposeful soft tissue manipulation with or without emollients, liniments, thermal modalities or other external apparatus with aims of therapeutic change. Massage therapy includes the addition of non-hands-on components such as health promotion, and client education for self-care and maintenance. Massage therapy is another non-pharmacological approach that has been extensively researched, although has been burdened by poor methodological studies. A 2006 systematic review of twenty studies evaluated the clinical effectiveness of therapeutic massage for symptomatic relief of musculoskeletal pain. With positive results for massage compared to no treatment or sham treatment in many studies, the available evidence at the time was inconclusive due to small sample sizes, low methodological quality, and insufficient dosing. Due to the large number of systematic reviews published on massage therapy’s effect on non-specific low back pain, a systematic review of nine systematic reviews was completed in 2013. The methodological quality of the reviews varied from poor to excellent, but the primary research informing the individual reviews was generally weak quality. Overall, the 2013 systematic review found that a small body of evidence emerged to support the use of massage therapy for short-term treatment of non-specific low back pain, although authors cautioned the interpretation of this conclusion due to the methodological limitations of the primary research. Finally, a recent systematic review with meta-analysis was published in 2017, with fifteen studies exploring the efficacy of massage therapy for shoulder pain. The author of the review suggested that massage therapy is effective for improving shoulder pain in the short-term, although, further research using randomized controlled trials with large sample sizes is required in order to make conclusive evidence-based recommendations. Massage therapy is another unregulated profession in the UK, however, the Complementary & Natural Healthcare Council is a UK voluntary regulator for various health practitioners including massage therapists. Their registered practitioners comply with the council's standards of conduct, ethics and performance so service users can be confident the therapists are properly trained, qualified and insured.

Introduction
Massage is the place were physiotherapy started. There is also evidence of massage being used in many ancient cultures. Massage is an age old technique uses both stretching and pressure in a rhythmic fashion.

Preparation, Posture
Your ability to administer a good massage will depend largely on your own comfort, therefore maintaining a good posture is beneficial to both you and your client. The following are only basic guidelines and it may be that because of the environment you're in, adjustments may need to be made.

Work with your back as straight as possible. By flexing your hips and knees, you will be able to move more efficiently and with less stress on your back.

Foot position is also important and should be such that you can move in an antero-posterior direction without placing undue strain on your back.

Hand Position
The most useful areas of the hand to use are the ulnar border and base of the thumb.

Other important areas are the palm and the palmar surfaces of the fingers and thumbs. They provide sensory feedback, thus allowing you to adapt your massage with regard to timing and pressure according to the nature of the tissue. It is for this reason that the use of elbows and knuckles should be avoided.

Keep your arms and hands relaxed while massaging, with the hands conforming to the contours of the body.

Always pour the oil onto your own hands, never directly onto the client.

Try to warm the oil (and your hands) before applying to the naked skin. If this is not possible, at least warn the client of what is to come.

Physical Contact
Try to always maintain contact with your client. This allows them to relax, especially if they are lying face down. Removal of the hands may also be interpreted as an indication that the session is over and so cause unwanted movement.

If for some reason you must break contact, for example at a sports meeting where situations are not ideal, then make sure you cover the client and do not leave them exposed.

Massage Techniques
Massage techniques commonly employed include:

Effleurage (Stroking)
The hands are passed rhythmically and continuously over a client's skin, in one direction only, with the aim of increasing blood flow in that direction, stretching tissues, relaxing the client and aiding the dispersal of waste products. The word effleurage is derived from French, meaning "to skim". It involves stroking movements of the hands sliding over the skin and is always the first and last technique (as well as being used between other techniques) applied in a massage session. Effleurage may be used with varying tempo and pressure according to the stage of the condition and whatever the desired effect of the massage is.

Performing Effleurage
You should use a wide surface area of the palmar surfaces of the hands and fingers, either with both hands simultaneously or by alternating hands. Pressure is sustained throughout the stroke and is always toward the heart to encourage venous return. On the return stroke, the hands should maintain light contact and avoid the same path taken by the upward stroke. The position, speed and direction of the movements will vary depending on aim of technique and the part of the body being massaged. For example, long, stroking movements may be used on the legs and arms, while a more circular motion may be preferred for the back and neck.

Effleurage should be carried out in a smooth, rhythmical and relaxed manner, beginning with light touch at the start of the session. This should build up to deeper pressure with slower movements for increased circulation and stretching of the tissues at a later stage in the session. The hands should be relaxed and should follow the natural contours of the client's body. The technique should not be rushed, as you need time and quality of movement to determine any tissue abnormalities that require attention. Quick movements will not allow the client to relax and will certainly be more painful if any areas are tender.

When passing your hands over any bony prominences, pressure should be eased, both since there is no therapeutic value of massaging over bone, and to reduce discomfort felt by the client. To complete any massage, use effleurage to relax the client, especially if intense/painful techniques have been used during the session.

Aims of Effleurage

Not all of these aims may necessarily be accomplished in one session. Much depends on what the requirements of the client are. Lighter, brisk movements may be indicated is the client is about to participate in sport and needs to be stimulated and energized. The same techniques applies more slowly will be better employed after exercise to relax the client and aid in the removal of waste products.

It is very important to achieve your aims using effleurage before moving onto other techniques, such as petrissage. If the muscles have not relaxed sufficiently, deep tissue massage may be uncomfortable and painful. The more pliable the superficial tissue is after effleurage, the more beneficial the deeper massage will be.

Myofascial Release
Myofascial release is manual technique for stretching the fascia aiming to release fascia restrictions.. Fascia is located between the skin and the underlying structure of muscle and bone, and connects the muscles, organs, and skeletal structures in our body. Fascia can become restricted through injuries, stress, trauma, and poor posture.

Trigger Point Therapy
Trigger point therapy involves the applying of pressure to tender muscle tissue in order to relieve pain and dysfunction in other parts of the body. Trigger points are active centres of muscular hyperactivity, which often cross-over with acupuncture points. The video below shows how a client can do self trigger point massage using a small ball.

Compression Massage
Rhythmic compression into muscles used to create a deep hyperaemia and softening effect in the tissues. Often used for sports massage as a warm-up for deeper, more specific massage work.

Cross-Fibre Massage
Cross-fibre friction techniques applied in a general manner to create a stretching and broadening effect in large muscle groups; or on site-specific muscle and connective tissue, deep transverse friction applied to reduce adhesions and to help create strong, flexible repair during the healing process.

Swedish Massage
Swedish massage techniques includes long strokes, kneading, friction, tapping, percussion, vibration, effleurage, and shaking motions.

The sequence of used is generally

Contraindications
Include: Any type of skin infection; Open wounds; Circulatory problems such as thrombosis, bleeding disorders; Less than 48 hours after injury; during acute inflammation; Tumours if in the area being massaged.