Focused Massage Application Outline Indirect and Direct Functional Techniques Fluid Dynamics Inflammation and Fluid Dynamics The Lymphatic System Lymphatic Drain Massage Contraindications and Cautions Indications Principles Treatment The Circulatory System Massage Methods Treatment Step-by-Step Protocol for Full-Body Lymphatic Drain Phase 1—Preparing the Torso Phase 2—Decongesting and Draining the Torso Phase 3—Limbs Integrated Fluid Movement Step-by-Step Protocol for Lymphatic Drain Massage for Swelling of an Individual Joint Area or Contusion Procedure Connective Tissue Focus Tissue Movement Methods Active Release Trigger Points Perpetuating Factors Assessment Methods of Treatment Joint Play Protocol for Mobilization With Movement Specific Releases Scalenes Occipital Base Sternocleidomastoid Rectus Abdominis Hamstrings Multifidi, Rotatores, Intertransversarii, and Interspinalis Subscapularis and Latissimus Dorsi Rhomboid, Pectoralis Major and Minor, Anterior Serratus Diaphragm Psoas Quadratus Lumborum Deep Lateral Hip Rotators Groin Area Muscles Sacroiliac Joint and Pelvis Alignment Pelvis Rotation (Indirect Functional Technique) Summary Objectives After completing this chapter, the student will be able to perform the following: 1 Perform indirect functional techniques. 2 Perform direct functional techniques. 3 Perform circulation support and lymphatic drain massage. 4 Perform connective tissue application. 5 Perform trigger point therapy. 6 Perform joint play. 7 Perform specific releases. Key Terms Active Release Anterior Rotation Anterior Serratus Bind Connective Tissue Methods Deep Lateral Hip Rotators Diaphragm Edema Fluid Dynamics Groin Area Muscles Hamstrings Indirect Functional Techniques Inflare Interspinalis Intertransversarii Joint Play Lymph Nodes Lymphangions Lymphatic Drain Massage Mobilization With Movement Multifidi Outflare Pectoralis Minor Pelvis Alignment Posterior Rotation Psoas Quadratus Lumborum Rectus Abdominis Rhomboid Rotatores Sacroiliac Joint Scalenes Sternocleidomastoid Subscapularis Trigger Points This chapter discusses various massage methods that target specific tissues or body functions. Subjects discussed include indirect functional techniques, fluid dynamics, connective tissue, trigger points, joint play, and specific releases.
Indirect and Direct Functional Techniques Objectives
1. Perform indirect functional techniques. 2. Perform direct functional techniques. Indirect functional techniques are usually referred to as indirect techniques or indirect methods of treatment. These methods are very gentle and safe. Rather than being treated as a specific modality, functional indirect methods need to be incorporated into the massage application, regardless of whether the focus is soft tissue or joint movement. These methods, rather than engaging and attempting (by whatever means) to overcome resistance (bind), do the exact opposite. The soft tissue or joint is taken in all directions to the point of maximum ease. The massage practitioner simply maintains the joint or tissue in this ease position. No further treatment is provided at this point, and after a couple of minutes, the position is gently released. Direct functional techniques are the opposite of indirect methods. These methods begin at the restriction barrier (bind) and move into resistance. Direct methods are more invasive than indirect methods. Because these methods produce changes by increasing the intensity of the mechanical force application to move tissue beyond the point of bind, the potential for adverse effects is increased. Regardless of how methods are done, the underlying principles are assessment of ease and bind and the natural tendency of the body to seek homeostasis. Soft tissue or joint mobility is assessed for motion restriction by palpation and/or joint movement, and restricted motion is treated by taking the dysfunctional tissue or joint in the direction of easier movement, which would be away from the restriction or bind, and toward the way the tissue or joint wants to go in all planes of movement (sagittal, frontal, transverse). The soft tissue ease position is maintained until a sense of softening is perceived. If the massage practitioner cannot easily palpate or identify this sensation, the position should be held in this area 30 to 60 seconds. Breathing can enhance the ease position and is assessed by having the client inhale and exhale, typically holding the breath for a few seconds in the direction that further contributes to the ease of tissue tension. Because indirect functional techniques are noninvasive methods, they should be the first approach attempted to normalize tissue and joint movement. On the other hand, stretching is considered a direct technique because it engages the bind and moves through it. Stretching is more invasive than indirect methods, increasing the potential for adverse reactions. A modification that incorporates the indirect method and more aggressive direct stretching involves moving back and forth between the ease position and the bind position. This can be described as indirect/direct. First, the ease position is identified and held, as previously described. Then the restrictive barrier of a joint or tissue is engaged in each plane of motion and is held taut at the barrier until softening occurs. The corrective activating force moves slightly through the restrictive barrier and again sustains the area in this position for 30 to 60 seconds, until the tissue softens. Various forms of oscillation can be added. It is effective to alternate 2 or 3 times between direct and indirect application. Ease/indirect and bind/direct methods can be combined with muscle energy methods. As discussed, during muscle energy application, muscles (contractions) are actively used to support the response. Muscles are placed in a specific direction, which can be ease or bind; the client then pushes slowly in a controlled manner against a counterforce usually supplied by the massage therapist. A variation is to introduce a mild degree of overpressure at the point of maximum ease, which actually results in taking the soft tissue just into a bit of bind. The result is release of previously restricted tissues. It is essential that all movements are directed and controlled by the practitioner. A refinement of this application involves adding gentle focused oscillation while the tissue or the joint is in the ease position. Vibration, tiny shaking movements, and small focused rocking all are effective. In another variation, the client produces the oscillation with tiny pulsed movements against resistance provided by the massage practitioner (pulsed muscle energy). Indirect and direct functional methods serve as the basis for connective tissue methods, described in greater depth later in the chapter. Connective tissue methods can be indirect (i.e., a restricted area is placed into a position of little resistance until subsequent relaxation occurs) or direct (i.e., the affected area is placed against a restrictive barrier with constant force [stretched] until fascial release occurs). A sequence of indirect and direct functional techniques is shown in Figure 13-1.
FIGURE 13-1 Examples of direct and indirect application. A, Moving tissues into ease takes less effort. B, Moving tissues into bind requires more effort. C, The indirect ease position places target tissues on slack. D, Moving tissue with direct methods to and through bind makes tissues taut. E, Local tissues can be addressed by moving them into ease and holding. F, Direct/bind local tissue stretching is effective. G, Very specific points can be addressed first by moving the area into ease. H, Then, after holding a specific target area in ease, move the area into bind, possibly just into the bind. Log on to your Evolve website to view additional examples of direct and indirect application.
Fluid Dynamics Objective
3. Perform circulation support and lymphatic drain massage. The body is an interconnected network of fluid compartments that contain blood, interstitial fluid, lymph, synovial fluid, and cerebrospinal fluid. Normal flow within the tissue and exchange of fluid between compartments are essential for homeostasis. Any impediment to normal flow leads to fluid stagnation, resulting in impaired tissue nutrition and repair. Stagnant tissue fluid becomes toxic, which, as the protein content increases, can lead to fibrotic tissue changes. Fluid tension in the body is called hydrostatic pressure. Body fluid is classified as extracellular (outside the cell) and intercellular (within the cell). About onethird of body fluid is extracellular and is located in two compartments: 1. The blood circulatory system, including arteries and veins 2. The interstitial or anatomic space around cells and lymphatic vessels Fluids also move across compartments by diffusion from areas of high salt concentration to areas of lower salt concentration. The rate and volume of fluid movement are determined by pumping mechanisms such as the heart, muscle contraction and relaxation, rhythmic compression of fascial structures during movement, and respiration. Other factors influencing fluid movement include the viscosity of the fluid, the permeability of the membranes, and the size of the various vessels through which fluid travels. Vasodilators and constrictors of the circulatory system therefore influence the movement of body fluid. Massage that addresses the extracellular fluid can mechanically support the movement of fluid within these compartments by stimulating hydrokinetics (transport of fluid) along pressure gradients from high pressure to lower pressure. The mechanical pumping and oscillation applications of massage and the reflexive release of vasodilators (primarily histamine) produced during massage, coupled with the vasodilatation or constriction response of hydrotherapy, interplay in various ways to influence the outcome of the application.
Inflammation and Fluid Dynamics Inflammation results in increased interstitial fluid, which then raises hydrostatic pressure in the area. Tissue swelling produces pain caused by pressure on pain receptors. This increase in tissue pressure can serve a protective function by mechanically limiting movement and producing pain. This is important during the first few days after an acute injury, but the process then needs to begin to reverse itself for normal healing to take place. The inflammatory process heightens the influence of chemical vasodilators affecting the venules and capillaries. Greater permeability of blood vessels is noted locally, with reduced flow velocity. This leads to the formation of local edema and stasis, with reduced exchange of nutrient and waste products. Pressure on vessels, or reduction of tissue space by changes in muscle tone, fascial pliability and length, and bony impingement, can also impede fluid exchange in the tissue. Carpal tunnel syndrome is an example in which the median nerve is impinged by fascial shortening and edema. Restoration of fascial pliability and reduction of edema support normal function. Massage treatment uses tensile forces to elongate shortened connective tissue, compressive forces to support the pumping action, encouraging the movement of tissue fluid, and neuromuscular applications to reduce and normalize muscle tone.
Edema Edema, which is the presence of abnormally large amounts of interstitial fluid, can be caused by a variety of factors, some of which are discussed here. • Lack of exercise. Exercise in which muscles alternately contract and relax stimulates lymph circulation and cleans muscle tissue. If muscles stay contracted or flaccid, lymph circulation decreases drastically inside muscles, and edema can result. • Overexercise. During exercise, both blood pressure and capillary permeability increase, allowing more fluid to seep into interstitial spaces. If movement of fluid exceeds the ability of the lymphatic capillaries to drain the areas, fluid accumulates. This seems to be a contributing factor to delayed-onset muscle soreness. • Salt. The body maintains a specific ratio of salt to fluids. The more salt a person consumes, the more water is retained to balance it, which can result in edema. • Heart and kidney disease. These diseases affect blood and lymph circulation. Lymph massage stimulates the circulation of lymph. Caution is indicated because the increase in fluid volume could possibly overload an already weakened heart and kidneys. • Menstrual cycle. Water retention and a swollen abdomen are common before or during the menstrual cycle. • Lymphedema. Lymphedema is a condition of stasis of lymph secondary to obstruction of lymph vessels or disorders of the lymph nodes. Limbs affected by this condition become very swollen and painful, resulting in difficulty moving the affected limb and disfigurement. Lymphedema can be life-threatening. Interstitial fluid is contaminated, and even small wounds can become infected. • Inflammation. Increased blood flow to an injured area and release of vasodilators, which are part of the inflammatory response, can cause edema in localized areas. This is a common response to injury and surgery. • Other causes. Medications, including steroids, hormones, and chemotherapy for cancer, may cause edema as a side effect. Scar tissue and muscle tension can cause obstructive edema by restricting lymph vessels.
The Lymphatic System Massage generally stimulates the circulation and lymph movement. The lymphatic system transports fluid from around the cells through a system of filters. Interstitial fluid becomes lymph fluid once it enters the lymphatic capillaries. The lymphatic system permeates the entire tissue structure of the body in a one-way drainage network of vessels, ducts, nodes, lacteals, and lymphoid organs. Segments of lymph capillaries are divided by one-way valves and a spiral set of smooth muscles called lymphangions. This system moves fluid against gravity in a peristalsis-type undulation. The lymphatic tubes merge into one another until major channels and vessels are formed. These vessels run from the distal parts of the body toward the neck, usually alongside veins and arteries. Valves in the vessels prevent backflow of lymph. Lymph nodes are enlarged portions of the lymph vessels that generally cluster at the joints. This arrangement assists movement of lymph through the nodes by means of the pumping action from joint movement. All of the body’s lymph vessels converge into two main channels: the thoracic duct and the right lymphatic duct. Vessels from the entire left side of the body and from the right side of the body below the chest converge in the thoracic duct, which in turn empties into the left subclavian vein, situated beneath the left clavicle. The right lymphatic duct collects lymph from the vessels on the right side of the head, neck, upper chest, and right arm. It empties into the right subclavian vein beneath the right clavicle. Movement of lymph occurs along a pressure gradient from high-pressure to low-pressure areas. Fluid moves from the interstitial space into the lymph capillaries through a pressure mechanism exerted by respiration, peristalsis of the large intestine, compression of muscles, and pull of the skin and fascia during movement. This action is especially prominent at the soles of the feet and the palms of the hands, where major lymph plexuses exist. It is likely that the rhythmic pumping of walking and grasping facilitates lymphatic flow. Lymph circulation involves two steps: 1. Interstitial fluid flows into the lymphatic capillaries. Plasma is forced out of blood capillaries into spaces around the cell walls. As fluid pressure between cells increases, cells move apart, pulling on the microfilaments that connect the endothelial cells of the lymph capillaries to tissue cells. This pull on the microfilaments causes the lymph capillaries to open like flaps, allowing tissue fluid to enter the lymph capillaries. 2. Lymph moves through a network of contractile lymphatic vessels. The lymphatic system does not have a central pump, as the heart does. Various factors assist in the transport of lymph through the lymph vessels. The “lymphatic pump” of the body is the spontaneous contraction of lymphatic vessels that results from increased pressure from lymphatic fluid. These contractions usually start in the lymphangions adjacent to the terminal end of the lymph capillaries and spread progressively from one lymphangion to the next, toward the thoracic duct or the right lymphatic duct. The contractions are similar to abdominal peristalsis and are stimulated by increases in pressure inside lymphatic vessels. Contractions of the lymphatic vessels are not coordinated with the heart or breath rate. If pressure inside the lymphatic vessels exceeds or falls below certain levels, lymphatic contractions cease. During breath inhalation, the thoracic duct is squeezed, pushing fluid forward and creating a vacuum in the duct. During exhalation, fluid is pulled from the lymphatics into the thoracic duct to fill the partial vacuum.
Lymphatic Drain Massage Objective
3. Perform circulation support and lymphatic drain massage.
Contraindications and Cautions Edematous tissues have poor oxygenation and reduced function, and they heal slowly after injury. Chronic edema results in chronic inflammation and fibrosis, making the edematous tissue coarse, thicker, and less flexible. Lymphatic drain massage may lower blood pressure. If the client has low blood pressure, the danger is that it may fall further, and the client may be dizzy when standing up. When a person is ill with a viral or bacterial infection and fever, circulation of lymph through the nodes slows, giving the lymphocytes more time to destroy the bacteria or virus. Because massage moves fluid through the lymphatic system more quickly, it can interfere with the body’s efforts to defeat attacking cells and can prolong the illness. During fever, white blood cells multiply rapidly, but bacteria and viruses multiply more slowly; fever therefore is part of the body’s healing process. Because lymphatic drain massage lowers body temperature, do not give such a massage to a client with a fever. Lymphatic drain massage affects the circulation of fluid in the body and can overwhelm an already weak heart or kidneys. Do not perform lymphatic drain massage on anyone with congestive heart failure or kidney failure, or undergoing kidney dialysis, unless the massage is specifically ordered by the client’s physician.
Indications Simple edema, screened for contraindications, responds well to massage focused on the lymphatic system. This approach is helpful for soft tissue injury, which includes surgery (with supervision), because it speeds healing and reduces swelling. Traveler’s edema is the result of enforced inactivity, such as sitting in an airplane or a car for several hours. It can affect anyone who sits for extended periods. Interstitial fluid (tissue fluid) responds to gravity, causing swelling in the feet, hands, and buttocks of a person who has to sit without moving very much for a few hours. Lymph drainage massage can remove the edema and reduce the pain and stiffness caused by the edema. Caution is indicated for the formation of blood clots with prolonged inactivity. Because many professional athletes often travel, this is a concern for massage. Exercise-induced, delayed-onset muscle soreness is partly the result of increased fluid pressure in the soft tissues. Lymphatic drain massage is effective in reducing pain and stiffness associated with this condition. Lymphatic drain massage softens scar tissue and stimulates improved circulation.
Principles Pressure provided by massage mimics the drag and compressive forces of movement and respiration and can move the skin to open the lymph capillaries. The pressure gradient from high pressure to low pressure is supported by creating low-pressure areas in the vessels proximal to the area to be drained. Depth of pressure, speed and frequency, direction, rhythm, duration, and drag are adjusted to support the lymphatic system. Pressure should be just sufficient to move the skin. Disagreement exists about the intensity of pressure used. Some schools of thought recommend very light pressure. Others use deeper pressure and hold that the stronger the compression used, the larger will be the increase in the flow rate of lymph. This text combines the two approaches. Lymphatics are located mostly in superficial tissues, in the outer 0.3 mm of the skin; surface edema occurs in these superficial tissues, not in deep tissue. Moving the skin moves the lymphatics. Stretching the lymphatics longitudinally, horizontally, and diagonally stimulates them to contract. Simple muscle tension puts pressure on the lymph vessels and may block them, interfering with efficient drainage. Massage can normalize this muscle tension. As muscles relax, lymph vessels open, and drainage is more efficient.
Treatment In general, massage first drains the surface area using lighter pressure; then areas of muscle tension are worked on using appropriate massage methods and pressure. Finally, work is finished in the area with another surface lymph drain. The greater the amount of fluid in the tissue, the slower the massage movements. Massage strokes are repeated slowly, at a rate of approximately 10 per minute; this is approximately the rate at which the peripheral lymphatics contract. Move lymph fluid toward the closest cluster of lymph nodes, which for the most part are located in the neck, axilla, and groin. Massage near the nodes first, then move fluid toward them, working proximally from the swollen area toward the nodes. Massage the unaffected side first, then the obstructed side. For instance, if the right arm is swollen because of scar tissue from a muscle tear, massage the left arm first. The approach is a rhythmic, slow repetition of massage movements. Full-body lymph drain massage lasts about 45 minutes. Focus on local areas for about 5 to 15 minutes. The methods of lymphatic drain massage are fairly simple, but this is a very powerful technique that elicits body-wide responses. Although disagreement about the method has been expressed, all approaches have some validity. Therefore, the technique described in this text combines the various methods used to support lymphatic movement in the body. The massage session begins with a pumping action on the thorax. Place both hands on the anterior surface of the thoracic cage. While the client exhales completely, passively follow the movements of the thorax with your hands. When the client starts inspiration, resist the movement of the thorax for 5 to 7 seconds. Repeat this procedure 4 or 5 times. Pumping action on the thorax increases lymph drainage through the lymphatic ducts by additionally lowering intrapleural pressure and exaggerating the action of inhalation and exhalation of breath. The massage application consists of a combination of short, light, pumping, gliding strokes beginning close to the torso at the node cluster and those directed toward the torso; the strokes methodically move distally. The phase of applying pressure and drag must be longer than the phase of release. The releasing phase cannot be too short because the lymph needs to drain from the distal segment. Therefore, the optimal duration of the pressure and drag phase is 6 to 7 seconds; for the release phase, it is about 5 seconds. This pattern is followed by long, surface gliding strokes with a bit more pressure to influence deeper lymph vessels. The direction is toward the drainage points (following the arrows on the diagram in Figure 13-2).
FIGURE 13-2 Direction of strokes for facilitating lymphatic flow. (From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St Louis, 2013, Mosby.) The focus of initial pressure and finishing strokes is on the dermis, just below the surface layer of skin, and on the layer of tissue just beneath the skin and above the muscles. This is the superficial fascial layer, which contains 60% to 70% of the lymphatic circulation in the extremities. It does not take much pressure to contact the area. If too much pressure is applied, the capillaries are pressed closed, which nullifies any effect on the more superficial vessels. Generally, light pressure is indicated initially, and this increases to a moderate level (including kneading and compression, as well as gliding) during repeated application to the area to reach the deep lymphatic vessels; it then returns to lighter pressure over the area. Drag is necessary to affect the microfilaments and to open the flaps at the ends of the capillary vessels. A pumping, rhythmic compression on the soles of the feet and the palms of the hands supports lymph movement. Rhythmic, gentle passive and active joint movement reproduces the body’s normal means of pumping lymph. The client helps the process through deep, slow breathing, which stimulates lymph flow in the deeper vessels. When possible, position the area being massaged above the heart, so that gravity can assist lymph flow. (See specific protocol, beginning on page 219.)
The Circulatory System Objective
3. Perform circulation support and lymphatic drain massage. The circulatory system is a closed system composed of a series of connected tubes and a pump. The heart pump provides pressure for the blood to move through the body via the arteries and eventually into the small capillaries, where actual blood gas and nutrient exchange occurs. Blood returns to the heart by way of the veins. Venous blood flow is not under pressure from the heart. Rather, it relies on muscle compression against the veins to change interior venous pressure. As in the lymphatic system, backflow of blood is prevented by a valve system.
Massage Methods The purpose of circulatory massage is to stimulate efficient flow of blood through the body. Current research seems to indicate that this effect is not as pronounced as was once believed (see Chapter 3). However, because the research findings are somewhat mixed, it is prudent to consider a form of massage application that logically would support this body function by mimicking normal function. Massage to encourage blood flow to the tissues (arterial circulation) is different from massage performed to encourage blood flow from the tissues back to the heart (venous circulation). Because of the valve system of the veins and lymph vessels, deep, narrow-based stroking over these vessels from proximal to distal (from the heart out) is contraindicated. A small chance exists of breaking down the valves if this is done. However, compression, which does not slide, as does gliding or stripping, is appropriate for stimulating arterial circulation.
Treatment Compression is applied over the main arteries, beginning close to the heart (proximal), and systematically moves distally to the tips of the fingers or toes. Manipulations are applied over the arteries, with a pumping action at a rhythm of approximately 60 beats per minute, or whatever the client’s resting heart rate is. Compressive force changes internal pressure in the arteries, stimulates intrinsic contraction of arteries, and encourages movement of blood out to the distal areas of the body. Compression also begins to empty venous vessels and forms an arterial-venous pressure gradient, encouraging arterial blood flow (Figure 13-3).
FIGURE 13-3 Direction of compression over arteries to increase arterial flow. (From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St Louis, 2013, Mosby.) Rhythmic, gentle contraction and relaxation of the muscles powerfully encourage arterial blood flow. Both active and passive joint movements support the transport of arterial blood. The next step is to assist venous return flow. This process is similar to lymphatic massage in that a combination of short and long gliding strokes is used in conjunction with movement. The difference is that lymphatic massage is done over the entire body, and movements are usually passive. With venous return flow, gliding strokes move distal to proximal (from fingers and toes to the heart) over the major veins. The gliding stroke is short—about 3 inches. This enables the blood to move from valve to valve. Long gliding strokes carry blood through the entire vein. Both passive and active joint movements encourage venous circulation. Placing the limb or other area above the heart brings gravity into assistance (Figure 13-4).
FIGURE 13-4 Direction of gliding strokes to facilitate venous flow. (From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St Louis, 2013, Mosby.) Athletes experience fluid dynamics issues in various ways. Hydration is especially important and is discussed in Unit One. In terms of methodical application, the massage outcome can target each main fluid area: arterial, venous, and lymphatic functions. All of these areas are strained during exercise. Cardiovascular fitness is a major focus of many exercise programs and of sport conditioning and training. Application of massage support to influence fluid dynamics is dependent on whether massage is applied as part of the “warm-up–cool-down–recovery,” or as part of the rehabilitation process. In general, massage application targeted to increase arterial flow is part of the warm-up process. Venous congestion can occur post exercise, as does an increase in interstitial fluid. Methods to address venous return can decrease interstitial fluid by moving it into the lymphatic system. Recovery involves normalizing all fluid movement. Injury rehabilitation involves managing swelling and encouraging effective circulation to the injured area to support healing. Specific situations involving focused massage applications include injury swelling; sprains, strains, or other contusions; surgery swelling; delayed-onset muscle soreness; and chronic swelling (joint). Strains, sprains, contusions, and surgery require specific treatment. These local injuries of the first and second degree (mild and moderate) benefit from both local and systemic lymphatic drain massage. It is important to decongest the entire drainage area affecting the injured area, for example, a sprained ankle requires drainage of the entire leg into the trunk. PRICE (protection, rest, ice, compression, elevation) treatment should be used for the first 24 hours. Movement of fluid from superficial tissues can begin after the acute stage begins to diminish—as always, proper medical care needs to be provided and medical team orders followed. Treatment of delayed-onset muscle soreness can begin as a preventive measure immediately after activity begins. Part of the process of delayed-onset muscle soreness involves inflammation with increased capillary permeability. Increased influence of the sympathetic autonomic nervous system on blood pressure leads to increased fluid movement from capillary beds into tissues. This increases interstitial fluid and hydrostatic pressure within the tissues. Lymph capillaries are unable to effectively drain the area, and congestion increases, which puts pressure on the pain-sensitive receptors. Chronic swelling usually occurs around joints, tendons, and bursae. Edema acts as a protective mechanism in attempting to reduce the problem that is causing the inflammation. A portion of the treatment for this condition involves addressing fluid issues of both blood and lymph. When massage is used, the goal is to reduce the fluid enough to increase function—not to interfere with the protective process and increased stability provided by hydrostatic pressure (Figure 13-5).
FIGURE 13-5 Effects of hydrostatic pressure. The entire area around the contusion needs to be drained, but caution is necessary because the capillaries have been damaged, and the massage must not interfere with the healing process. However, blood in the interstitial fluid increases the protein content of the fluid, which increases the potential for formation of fibrotic tissue. This is why it is essential that the lymphatic system remove interstitial fluid containing blood. Appropriate massage application can enhance this process. Use of massage to increase arterial and venous circulation and lymphatic movement will be recommended throughout the text to serve the athlete and others who are involved in fitness and rehabilitation programs. The following section provides a precise description of the massage application that affects first arterial flow, and then venous return; both approaches involve addressing capillary beds. Next, lymphatic drain massage for interstitial (extracapsular) tissue fluid and intracapsular fluid (inside the joint capsule) is described. These three approaches are easily and effectively combined. Methods of mechanical and reflexive fluid movement are primarily focused on mechanical force. To understand them, it is necessary to understand both the structure and the function of vascular and lymphatic systems. It is also necessary to appreciate the properties of a fluid, including properties of water, colloids, and viscosity. Fluids naturally move from high pressure to low pressure with gravity. The more viscous (thick) the fluid, the slower it moves. Fluid moves against gravity only with a pump. The faster and stronger the pump, the more fluid is moved. Permeability is the rate at which a fluid (water) moves across a membrane. Fluid moves by osmosis and diffusion. The application of effective massage is dependent on all of these factors (Figure 13-6).
Increasing Arterial Circulation Various mechanisms can influence arterial circulation. The massage application needs to address all these areas. However, effects of pressure in the vessels and of stimulation of vasodilatation are especially important. These effects include the following: • Increased sympathetic arousal, which increases both stroke volume and heart rate • Increased buildup of pressure within the vessels • Vasodilatation of the capillaries The general massage should be brisk, lasting 15 to 30 minutes. Active participation of the client in various forms of range of motion and muscle energy methods is effective in increasing both sympathetic arousal and demand for blood as a result of muscle activity. Deliberate temporary pressure against the arteries results in a buildup of fluid pressure between the heart and the temporary blockage caused by the therapist’s pressure. This leads to an increased flow rate of the blood when the pressure block is released. Compression of the arteries in a rhythmic fashion moves arterial blood faster toward the capillaries to supply the nutritional and oxygen requirements of tissues. Usually, the target areas are limbs, hands, and feet. To create temporary pressure, do the following: 1. Position the area where increased arterial circulation is desired, below the heart if possible: Seated, standing, and semireclined positions are most desirable. 2. A broad-based compression force is used against the tissue over the arteries. Begin close to the torso. If the arms are the target, begin where the arms join the torso (same for the legs). 3. Compression must be deep enough to close off the arteries so that pressure builds. The rate of on/off compression of the arteries is timed to the client’s heart rate, which is determined by the closest pulse rate in the area. For example, if the pulse rate is 60 beats per minute, the compression rate would be approximately 1 second on/1 second off—it is helpful to count, such as “1—(compress) and (release); 2—(compress) and (release).” 4. Pressure systematically moves distal toward fingers and toes. 5. The athlete can make a fist and can release or curl the toes and release at the same rhythm. Perform three or four repetitions in the area until the distal area is increased in temperature. Next, rhythmically knead and compress the target area to create hyperemia (histamine response and vasodilatation). Squeeze out the capillary beds to allow movement of blood into the venous system, creating space for the arterial blood. This will facilitate exchange of nutrients and gases, as well as plasma movement into interstitial spaces. Pressure and squeezing techniques have a pumping effect on circulation. Pressure forces blood out of the vessels in one direction only (toward the heart) because of the unidirectional valves. When pressure is released, the vessels are refilled from the arterial supply.
Microcirculation The walls of the blood vessels need to be soft and pliable so that they can assist the pumping action and allow filtration and absorption through them. Because a massage stroke forces blood through the capillaries and arterioles, it has a stretching effect on the vessel walls, and thus can help increase their size, capacity, and function.
Venous Return As with all methods, this massage application supports the anatomy and physiology of normal function. To support normal venous circulation, the venous pump is mimicked. A combination of short and long gliding stokes is used over the veins. Depth of pressure is a bit greater than that used with lymphatic drain massage because the intent is to actually pump blood through a tube. Position the area, usually a limb, somewhat above the heart to allow gravity to assist fluid movement: 1. As with lymphatic drain, begin close to the torso and glide no more than 3 to 5 inches with the direction toward the heart to take advantage of the valve system in the veins. Systematically move toward the distal end of the limb. 2. Use kneading to move blood within capillary beds, dispersing it through soft tissue. 3. Have client actively contract and relax muscles and move joints in the area. Think of this action as similar to that of a pump. Passive joint movement can be used if necessary. It is effective to move the joint through its entire range of motion. 4. Repeat the entire sequence, then shift location a bit to address a different vein. 5. Calf muscles act as a secondary heart pump, especially influencing venous returning blood flow. The client can move the ankle in slow circles to activate this pumping action. This can also be taught as a self-help method. It is especially effective if the client lies on a slant board with the head slightly lower than the heart. This method is helpful even if the target area is not placed above the heart. 6. The respiratory pump supports venous return by channeling thoracic pressure during breathing. This is primarily caused by diaphragm action. Therefore it is important for the breathing mechanism to be normal.
Lymphatic Drain Massage The following protocol is meticulous and detailed. It covers all current applications for lymphatic drainage that are based on physiologic mechanisms. It is presented in the ideal order of application to target lymphatic fluid flow. (Author’s note: I personally seldom perform the procedures as written here. Instead, I pick, choose, and modify. However, for learning purposes, I strongly suggest that you practice the protocols for both full-body application and local application until you are comfortable with the procedures, concepts, and outcomes.) This protocol addresses increased movement of interstitial fluid into the lymphatic capillaries without fibrosis. Management of fibrotic tissue is discussed on page 227. Contraindications for lymphatic drain massage include the following: • Compromised urinary or cardiovascular function, especially congestive heart or kidney failure • Systemic illness with symptoms such as fever, diarrhea, vomiting, and unexplained edema • Edema present in the acute phase of an injury (first 24 hours) • Edema that is contributing to joint stability Because surgery, abrasions, and puncture wounds break the protective skin barrier, sanitation around the area of the wound is critical. Lymphatic drain massage around surgical areas and injury can be used safely, but not within the first 24 to 48 hours. Extreme care must be taken not to disturb the tissue healing process. Direct work over an area of surgery needs to be delayed until incision sites are healed (5 to 7 days, maybe longer). Lymphatic drain massage targeted to a specific joint is most effective in the context of a general full-body massage application.
Assessment for Increased Interstitial Fluid Volume Common history components: • Increased physical activity such as a competition or a game followed by a 24- to 48-hour period of relative inactivity • Increased physical activity as above, but with insufficient recovery time (common in training camp schedules) • Increased salt intake • Increased water intake without appropriate electrolyte balance • Decreased fluid intake • Water weight gain of 3 to 5 pounds Common complaints: • Delayed-onset muscle soreness; sore all over, best described as achy • Stiffness that will not stretch out and is not clearly confined to a particular area • Sensation of the skin and muscles being “fat or taut” Visual assessment: • Loss of muscle and joint definition • Appearance of being swollen • Client appears sluggish. Physical assessment: • Skin and superficial fascia palpated as taut from increased hydrostatic pressure • Skin and superficial fascia palpated as boggy, spongy, soggy (increased fluid but not enough to push against skin, as previously described) • Difficulty palpating muscle fiber structure due to fluid accumulation overlay • Decreased definition of joints • Reduced range of motion of joints as a result of edema • Difficulty in lifting the skin and fascia from the surface layer of muscles • Deep, broad-based and narrow, superficially based types of compression; both are painful • Pitting edema and prolonged blanching of skin after compression • Drag on the skin and superficial fascia can create pockets of fluid that feel like small water balloons. Other observations: • Reflexive methods are ineffective in resolving complaints. • Connective tissue applications may make symptoms worse, at least temporarily. Supportive measures: 1. Increase fluid intake with proper electrolyte balance (50% water-diluted sport drink or pediatric fluid replacement drink such as Pedialyte). 2. Eat diuretic-type foods such as pineapple, papaya, berries, cucumbers, radishes, and celery. Full-body lymphatic drain massage takes 45 to 90 minutes depending on the size of the client. Begin working on least affected areas, then progress to the target area.
Step-by-Step Protocol for Full-Body Lymphatic Drain Massage Objective
3. Perform circulation support and lymphatic drain massage.
Log on to your Evolve website to watch Video 13-1: Lymphatic Drain.
Phase 1—Preparing the Torso 1. Position the client on the back (supine) with arms and legs bolstered above the heart but with no areas of joints in a closed packed position (typically ends of range of motion). 2. Begin on upper thorax and use glide, knead, and compression to prepare the tissue. Goals are to increase skin pliability and connective tissue ground substance pliability, and to reduce any areas of muscle tension so that lymph capillaries and vessels are unobstructed. Continue into the abdomen, paying particular attention to abdominal and diaphragm muscles. 3. Mobilize the ribs by applying gentle but firm, broad-based compression beginning at the sternoclavicular joint, and work down toward the lower ribs. Make two or three passes, working from the sternum out toward the lateral edge. If an area of restriction is found, various methods can be used to increase mobility in the area. Compressing the restricted area while the client coughs is usually effective. Massage the intercostals. 4. Place client in side-lying position, and use glide, knead, and compression to continue to increase tissue pliability and rib mobility. Work from the iliac crests upward toward the axilla. Pay particular attention to the anterior serratus. Repeat on the other side. 5. Place client in the prone position (face down). Use glide, knead, and compression to increase tissue pliability and rib mobility. Begin at the iliac crest and systematically work toward the shoulder and neck. Do both left and right sides.
Outcome Torso soft tissue pliability and rib mobility allow effective deep breathing and movement of lymph into the torso.
Phase 2—Decongesting and Draining the Torso (Figure 13-7)
FIGURE 13-7 Principal lymph vessels and nodes. (From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St Louis, 2013, Mosby.) 1. Reposition client in the supine position with arms and legs bolstered above the heart. 2. Place hand (a flat or loose fist) just below either clavicle, and compress and release. Repeat 3 or 4 times. Repeat method over sternum. Repeat method over the abdomen. Compress with exhale, release with inhale. Note: Repeat this procedure approximately every 15 minutes during the session (Figure 13-8).
FIGURE 13-8 Examples of decongesting the torso. A, Rhythmic compression just under the clavicle. B, Rhythmic compression over the sternum. C, Rhythmic compression over the abdomen. 3. Begin surface draining procedure. This process consists of dragging and sliding the skin to the tissue bind in various directions to pull on the microfilaments, while opening the ends of the lymph capillaries so that interstitial fluid can move from around cells into lower-pressure areas of lymph vessels. This needs to be done in a repetitive, rhythmic, slow manner, as with a pump. Drag skin to bind and let it return, drag skin again, etc. Each skin movement has a slightly different direction vertically, horizontally, diagonally, and circularly. The skin movement phase is a little longer than the release phase. Remember, the massage application is structured to mimic the pull of skin and fascia that would normally affect microfilaments attached to the lymphatic capillaries. Begin skin drag at the closest lymph node area, and work distal. This decongests and lowers pressure, allowing fluid to move from high pressure to low pressure. 4. Begin skin movement at the thorax midline above the diaphragm, and work toward the area under the clavicles. (Do both sides.) When this area is thoroughly addressed, repeat chest compression. 5. Continue with skin movement below the diaphragm, and change direction to drain toward the groin. 6. Have client do deep breathing while you gently but firmly knead the abdomen; then repeat chest compression. Compress on exhale, release on inhale. 7. Position client on side and repeat skin drag method, starting near the axilla, and drain from the waist up toward the axilla; below the waist, drain toward the groin, starting proximal to the region where drainage occurs. Do both sides. 8. While client is in the side-lying position, rhythmically compress the ribs (compress on exhale, release on inhale). 9. Place client in the prone position and drain again: Above the waist toward the axilla, and below the waist toward the groin. Compress the ribs in rhythm with the breathing.
Outcome Torso is decongested and is able to receive fluid from limbs.
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