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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5521_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Preface
- •How to Use This Book
- •Reviewers
- •Acknowledgments
- •Brief Contents
- •Contents
- •Pathology in Brief
- •The Middle Ages (400–1400)
- •The Renaissance (1450–1600)
- •The 18th Century
- •The 19th Century
- •The 20th Century
- •Contemporary Massage Therapy
- •Swedish Modalities
- •Deep Tissue Modalities
- •Neuromuscular Modalities
- •Circulatory Enhancement Modalities
- •Energy Modalities
- •Oriental/Eastern Modalities
- •Structural and Postural Integration Modalities
- •Movement Modalities
- •Special Populations
- •Touch Physiology
- •Massage Research
- •Interpretation of Touch
- •Integrative Medicine Centers
- •Oncology Massage
- •History of the Spa Industry
- •Medical Spas
- •Spa Massage Education
- •Education
- •Body of Knowledge
- •Scope of Practice
- •Code of Ethics
- •Standards of Practice
- •Legal Regulations
- •Education
- •Competency
- •Limits of Practice
- •Accountability
- •Ethics for the Profession
- •Conduct
- •Business Practices
- •Legal Requirements and Ethical Responsibilities
- •Professional Associations
- •Physical Boundaries
- •Conceptual Boundaries
- •Client Relationships
- •Professional Relationships
- •Anatomy
- •Physiology
- •Cellular Functions
- •Components of the Cell
- •Tissues
- •Tissue Membranes
- •Integumentary System
- •Skeletal System
- •Muscular System
- •Nervous System
- •Cardiovascular System
- •Lymphatic System
- •Respiratory System
- •Digestive System
- •Urinary System
- •Endocrine System
- •Special Senses
- •Anatomical Terminology
- •Arthrology
- •Range of Motion
- •Myology: The Study of Muscles
- •Body Movements
- •Components of Good Body Mechanics
- •Body Awareness
- •Improper Body Mechanics
- •Pathology
- •Pharmacology
- •Abnormal Conditions of Cells and Tissues
- •Integumentary (Skin) Conditions
- •Skeletal System Conditions
- •Muscular System Conditions
- •Nervous System Conditions
- •Cardiovascular System Conditions
- •Lymphatic and Immune System Conditions
- •Respiratory System Conditions
- •Digestive System Conditions
- •Endocrine System Conditions
- •Reproductive System Conditions
- •Conditions of the Special Senses
- •Word Elements
- •Translating Terms
- •Spelling and Pronunciation
- •Effective Communication and Interviewing Skills
- •Documentation
- •Subjective Information
- •Objective Information
- •Activity and Analysis Information
- •Plan Information
- •Putting the SOAP Together
- •Case Studies
- •Wellness versus Therapeutic Massage Assessments
- •Fascia
- •Compensation Patterns
- •Assessment Documentation
- •Ideal Posture
- •Anterior Postural Assessment
- •Posterior Postural Assessment
- •Lateral Postural Assessment
- •Postural Deviations
- •Feet
- •Active Range of Motion
- •Passive Range of Motion
- •Assessment of Skin Temperature
- •Textures and Movement of Soft Tissues
- •Rhythms
- •Case Studies
- •Progressive Case Study 3: Kirsten Van Marter
- •Initial Session
- •Subsequent Sessions
- •Healing Time
- •Duration of Future Sessions
- •Frequency of Future Sessions
- •Length of Treatment
- •Techniques and Areas to Include or Avoid
- •Reevaluation
- •Considerations for Self-Care
- •Hydrotherapy
- •Stretches
- •Rest
- •Nutrition
- •Body Awareness
- •Ergonomics
- •Treatment Recommendations
- •Case Studies
- •Supine Position
- •Prone Position
- •Side-Lying (Laterally Recumbent) Position
- •Determining Client Positioning and Bolstering
- •Sheet Draping
- •Towel Draping
- •Communication for Client Positioning and Draping
- •Grounding
- •Centering
- •Resting Stroke
- •Compression
- •Effleurage
- •Petrissage
- •Tapotement
- •Friction
- •Vibration
- •Flow Sequences for Different Client Positions
- •Supine: Chest, Neck, and Head
- •Supine: Arm
- •Supine: Abdomen
- •Supine: Leg and Foot
- •Prone: Back
- •Prone: Leg and Foot
- •Closing Sequence
- •Chair Massage
- •Corporate Chair Accounts
- •Indications and Contraindications for Chair Massage
- •Healing: Phase I
- •Healing: Phase II
- •Healing: Phase III
- •Pain–Spasm Cycle
- •Fascia
- •Direction of Ease
- •Lengthening and Stretching
- •Arterial Enhancement
- •Venous Enhancement
- •Lymph Drainage
- •Proprioceptive Neuromuscular Facilitation Techniques
- •Myofascial Techniques
- •Trigger Point Techniques
- •Hydrotherapy
- •Effects of Hydrotherapy

Chapter 3 / Body Systems
101
myofilaments remain the same length, but that the overall
length of the sarcomere shortens because the myofilaments slide together. Calcium molecules first uncover sites
on the actin where the myosin can attach. Once those sites
are exposed, the myosin’s cross bridges latch onto the actin
filaments like Velcro. Temporarily connected, the actin filaments are pulled closer together, overlapping the myosin
filaments. Figure 3-38 illustrates the sliding filament mechanism. The overlapped filaments create a shorter sarcomere,
resulting in a shorter fibril. When many fibrils shorten, the
whole muscle cell shortens. Clearly, calcium is necessary for
muscle contraction, which is one of the reasons calcium
should be included in a balanced diet.
Muscular Control Mechanism
The sliding together of the myofilaments begins with a
nerve impulse from the CNS via a somatic motor neuron.
One somatic motor neuron can stimulate hundreds of
Tendon
Bone
Muscle
Single myofibril
H zone
I band I band
Sarcomere unit
M line
H zone
H zone
A bandA band
A band
A band
Z lineZ line
I band
I bandI band
Myofibrils
Myosin (thick filament)
Actin (thin filament)
Troponin complex
Bundle of
muscle fibers (facide)
Single
muscle fiber
Mitochondrion
Myosin tail
Tropomyosin
Nucleus
Sarcoplasmic
reticulum
Sarcolemma
(plasma
membrane)
Myosin head
Myosin
binding site
Cross section of filaments
Figure 3-38. Sliding filament mechanism. (Reprinted with permission from McArdle WD, Katch FI, Katch VL. Exercise Physiology:
Energy, Nutrition, and Human Performance. 5th ed. Baltimore: Lippincott Williams & Wilkins, 2001.)

102 INTRODUCTION TO MASSAGE THERAPY
Posterior
Ventral
root
Mixed
spinal
nerve
Motor
neuron
Figure 3-39. Motor unit. (Reprinted with permission from Bear
MF, Connors BW, Paradiso MA. Neuroscience: Exploring the
Brain. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 2001.)
Lower
motor
neurons
Muscle
cells
Anterior
Axonal terminals at
neuromuscular junction
Ventral
horn
muscle cells, but each muscle cell is controlled by only one
somatic motor neuron. The more muscle fibers one nerve
must supply, the less precise the movements. One motor
neuron and all of the muscle cells it stimulates is called a
motor unit (Fig. 3-39). The extension of this neuron that
communicates to the fibril is called an axon (AK-sahn) and
branches out with axonal terminals, like tree branches, as
it nears the muscle cells. Each axonal terminal meets the
motor end plate, the place on the muscle cell membrane
that receives the nerve impulse, at a synaptic cleft, which is
the space between the axon and muscle cell. This collection
of structures, including the axonal terminal, the synaptic
cleft, and the motor end plate, is called the neuromuscular
junction. Figure 3-40 illustrates the neuromuscular junction.
The axonal terminal releases a chemical neurotransmitter called acetylcholine (ah-SEE-tuhl-KOH-leen) that is
received by the motor end plate and triggers muscle contraction. (The series of events that occurs at the neuromuscular
junction is described in detail below in the nervous system
section.) As soon as the acetylcholine causes the muscle
fiber to contract, it is broken down by a chemical in the synaptic cleft to prevent an unwanted sustained contraction. If
more nerve impulses are conducted to the same muscle cell,
it can sustain a prolonged contraction.
A minimal amount of current, called the threshold
stimulus, is necessary to stimulate the contraction of a
muscle cell. When the threshold is reached, the muscle cell
reacts with complete contraction. All the muscle cells in a
motor unit respond as one when stimulated. This response
is commonly called the “all-or-none” principle, meaning the
muscle cells contract completely or not at all. The all-ornone principle may seem counterintuitive, since we know
muscle contractions can be precise or forceful. Remember,
there are thousands of muscle cells in a whole muscle. The
strength of the whole muscle contraction is determined by
the number of muscle cells that have been stimulated to
contract. In other words, a whole muscle contraction does
not require every muscle cell to contract. The precision of
a movement is determined by the number of muscle cells
that are controlled by a single nerve cell. A motor unit that
Figure 3-40. Neuromuscular
junction.
Axon terminal
Muscle cell
nucleus
Axon to
motor neuron
Motor end
plate
Muscle cell
Mitochondrion
Synaptic
vesicle
Sarcolemma
Synaptic cleft
Neurotransmitter
(acetylcholine)

Chapter 3 / Body Systems
has a few muscle cells will be able to control the contraction more precisely than a motor unit that has hundreds of
muscle cells.
103
Bone
Structures of a Whole Skeletal Muscle
A skeletal muscle is made up of bundles of muscle cells held
together with connective tissue. This fibrous connective tissue, called fascia, carries blood vessels and nerves into the
muscle and mechanically transmits the force of the contraction from one end of the muscle to the other. The basic
component of the muscle tissue bundle is the muscle cell,
or muscle fiber. The cells are very fragile, but each one is
wrapped in a connective tissue covering called endomysium
(EN-doh-MAHY-see-um). Several cells and the nerve cells
that supply them are bundled together to create a fascicle
(FAS-sih-kul), which is wrapped with connective tissue called
the perimysium. The fascicles, along with blood vessels,
nerves, and muscle spindles (special sensory receptors of
muscles that are discussed below in the nervous system section), are then bundled together by the epimysium, which
is the connective tissue covering of the whole muscle. The
epimysium blends into the tendons or aponeuroses, which
attach the muscles to bones, cartilage, or other connective
tissue coverings. The thickest part of a muscle that is primarily made of muscle cells and has a pinkish appearance
is sometimes called the belly of the muscle. Tendons are
very strong and thin and can easily anchor at transverse
bony projections and joints to provide durability and save
space. Once the small, delicate cells are wrapped in connective tissue and bundled together, a very strong and resilient
structure is created. Figure 3-41 illustrates the structures that
form a skeletal muscle.
Functions of the Muscles
The primary function of the muscular system is to create
movement, but muscles also produce heat, support the skeleton, maintain posture, and provide some protection from
external forces.
Movement
All muscle cells have the ability to contract, bringing the
ends of the cell closer together. On a cellular scale, this
movement is amplified by the many bundles of muscle cells
to create movement of entire muscles. Cardiac and smooth
muscles in the walls of organs squeeze contents out or push
contents through organs or, in the case of blood vessels,
change the diameter of the tube.
The main function of skeletal muscles is to move bones
and sometimes to move connective tissue structures such
as the lips. Most muscles attach indirectly to bone, meaning that their connective tissue covering continues past the
muscle and blends into a tendon or aponeurosis, which then
Tendon
Muscle
belly
Epimysium
(deep fascia)
Perimysium
Endomysium
(between fibers)
Capillary
Single
muscle cell
(muscle fiber)
Figure 3-41. Structures of a skeletal muscle. (Reprinted with
permission from McArdle WD, Katch FI, Katch VL. Exercise
Physiology: Energy, Nutrition, and Human Performance. 5th ed.
Baltimore: Lippincott Williams & Wilkins, 2001.)
Muscle
fascicle
Endomysium
Sarcoplasm
Nuclei
Sarcolemma
attaches to the bone. If muscles attach directly to a bone,
their connective tissue covering fuses with the connective
tissue that covers the bone.
Each skeletal muscle has two kinds of attachments:
origin and insertion. The origin of a muscle is the attachment
on the bone or connective tissue structure that is more stationary during muscle contraction. The insertion of a muscle is the
point of attachment that moves most during contraction, often at
the distal end.
All muscles have at least one of each of these
two attachments. If muscle inserts into a bone, the bone will
be pulled toward the origin of the contracting muscle. If a
muscle inserts into a connective tissue structure, such as the
lips, the lips will be pulled toward the origin of the contracting muscle (Fig. 3-42).
In addition to moving the skeleton and connective tissue structures, muscles also help move blood and lymph.
Muscles become shorter and wider when they contract,
which you see in a bodybuilder who strikes a pose. As the
muscles contract, they constrict the blood and lymph vessels, squeezing the fluids out.
Heat Production
The core temperature of the body is maintained in a safe
range of 96.8° to 98.6°F. Skeletal muscles release heat in the

104 INTRODUCTION TO MASSAGE THERAPY
Tendons
Biceps brachii
Insertion
Radius
Ulna
Figure 3-42. Muscle attachments: origin and insertion.
process of contraction, and the heat generated helps maintain the body’s core temperature. Shivering, for example,
involves the body making small, involuntary muscle contractions to release chemical energy or heat.
Humerus
Tendon
Origins
Scapula
Skeletal Support
Skeletal muscles support and maintain posture by holding
the body upright against gravity and by stabilizing joints.
The skeleton is only a collection of bones, joints, cartilage,
and ligaments. Even standing still, our muscles work continuously to hold the skeleton up in a balanced, stable position.
Protection
Physical exertion is often followed by muscular fatigue,
and massage is one of the most practical, beneficial treatments for muscular fatigue. By increasing nutrient delivery
and waste removal from the muscles, massage minimizes the
accumulation of chemicals that cause symptoms of muscular
fatigue, such as lactic acid. Massage also maximizes healing.
Alert
Massage techniques that are too aggressive may
create fatigue-like symptoms or initiate a protective
reflex contraction in the muscles.
Manipulation of the muscles also produces heat, partly as a result of the increased circulation, partly because
of increased chemical activity in muscle cells, and partly
because of the heat generated when fascia is subjected to
pressure. Muscle contractions produce heat as a byproduct
of chemical reactions, and manipulation of the muscles
increases these chemical reactions. Recall the thixotropic property of deep fascia, discussed earlier in the chapter. Without movement, fascia can thicken, contract, and
become less pliable, restricting muscle movement and circulation within the muscles. Manipulation of the muscles
deforms the fascia, which creates heat, similar to how
bending a paperclip back and forth heats up the area being
deformed. Because fascia and muscles are so intertwined,
softened fascia can also restore muscular movement.
The muscles protect the structures underneath them. Our
organs and bones would be much more vulnerable to trauma without the muscles surrounding them.
Effects of Massage on the
Muscular System
Massage increases the nourishment and development of
smooth, cardiac, and skeletal muscles by enhancing the
delivery of oxygenated blood and removal of cellular waste.
The skeletal muscles and the surrounding soft tissue,
which make up about half of our body weight, are the primary focus of massage therapy. In fact, sometimes massage
is the best treatment for muscles, tendons, and fascia. It has
been proven that massage can reduce tension by lengthening
shortened muscles. It is highly effective at breaking the pain
cycle by relieving muscular tension and increasing circulation. Inactive and paralyzed skeletal muscles benefit greatly
from massage because it delivers oxygen and nutrients to
muscle cells to keep them healthy.
Massage increases the excitability of muscles, making them more sensitive to nerve impulses. Faster reaction
times, more effective movements, and better coordination
can all result from massage.
Nervous System
The nervous system serves as the body’s communication
and control center. The nervous system regulates bodily pro-
cesses to maintain homeostasis, keeping everything in the
body in balance.
cesses the information, and directs the body to respond to
it. A stimulus is an irritant or something that can cause a
response, and it can come from the inside of our bodies
as well as the external environment. The nervous system
is constantly monitoring these stimuli, integrating the
input, and controlling the body to respond appropriately. When the nervous system is not functioning properly,
the communication can break down or become inhibited,
and the body’s ability to carry out its normal functions
is diminished. Simply, the body then cannot maintain
homeostasis.
The nervous system is integral to muscle and soft tissue function, which is why massage therapists should
understand its structures and functions. The tissues of the
nervous system are organized into two separate divisions,
called the central nervous system (CNS) and the peripheral
nervous system (PNS). The CNS consists of the brain and
The nervous system receives stimuli, pro-

Chapter 3 / Body Systems
105
spinal cord. The PNS is made up of all the nerve tissue outside the brain and spinal cord, including the cranial and spinal nerves.
Nervous System Tissue
The tissues of the nervous system include neurons, or nerve
cells, and supportive cells called neuroglia. Individual neurons are organized in bundles with protective connective
tissue wrappings. These bundles are called tracts, nerves,
ganglia, and plexuses. Nerve tissue can be classified functionally by the direction of the nerve impulse, either toward
or away from the CNS.
Neuron
The neuron, or nerve cell, is the basic unit of the nervous
system (Fig. 3-43). The neuron has three main parts: the
body, dendrites, and an axon. The body is the main portion
of the neuron and contains the nucleus and other organelles
Figure 3-43. Structure of a neuron
(nerve cell).
that drive its functions. Dendrites are highly branched, treelike fibers that start the communication path by receiving
impulses from the external and internal environments and
conducting that information toward the cell body along
their plasma membranes. The axon is a long single fiber
with branched ends that conducts impulses away from the
cell body and takes the information to another structure,
such as a muscle. Nerve cells are sometimes called nerve
fibers because of their long axons and dendrites.
Some neurons have specialized Schwann cells strung
along their axons and dendrites. These cells form a multilayered membrane of insulative tissue for the nerve cell called
the myelin (MAHY-uh-lin) sheath. It protects and insulates
nerves and allows nerve impulses to be transmitted very efficiently. The nuclei and cytoplasm of the Schwann cells are
located on the outer surface of the myelin sheath, the neurilemma (NOO-rih-LEH-muh). Between the Schwann cells,
along the neuron, are gaps called nodes of Ranvier (rahnvee-AY), which are the active areas during nerve impulse
transmission.
Dendrites
Nucleus
Nucleolus
Cell body
(soma)
Schwann cell
nucleus
Axon
terminal
Axon
Neurilemma
Axon
Unmyelinated
region
Myelinated
region
Myelin
sheath
Neurilemma
Node of
Ranvier
Schwann cell
Schwann
cell nucleus
Axon
Muscle fiber
Neuromuscular
junction
Unmyelinated fiber Myelinated fiber

106 INTRODUCTION TO MASSAGE THERAPY
The neurilemma produces a chemical growth factor
involved in a cellular repair mechanism for nervous tissues.
Nerve cells are not regenerated on a regular basis, nor are
Nerve cell
they replaced upon damage. However, the axons and dendrites of injured nerve cells can regenerate from within the
layers of neurilemma. This is a very slow process, and the
tissue is not always functional once regenerated, but it gives
Astrocyte
hope to those with nerve injuries. The brain and spinal cord
contain no Schwann cells, and repair of the brain or spinal
cord is nearly impossible.
Blood
capillary
Neuroglia
The nerves are supported and connected with accessory
cells called neuroglia. They come in five different forms
(Fig.3-44):
• Astrocytes—support and anchor nerve cells to blood
capillaries
• Ependymal cells—line the cavities of the brain and
spinal cord to help circulate the fluid that bathes and
cushions the organs in those cavities
• Microglia—phagocytes that consume cellular debris
• Oligodendrocytes—fatty cells that wrap around
nerves in the CNS to create the myelin sheath for
insulation
• Schwann cells—form the myelin along a nerve cell
in the PNS
Nerve Tissue Organization
In the CNS, neurons are collected together into bundles
called nerve tracts. In the PNS, neuronal cell bodies are
grouped together to form ganglia, and axons are grouped
together to form a nerve.
The nerve has a structure similar to that of a muscle,
with bundles of axons wrapped in connective tissue that are
then bundled together with blood vessels in more connective tissue. Each neuron is wrapped with a connective tissue covering called an endoneurium (EN-doh-nur-ee-um).
The neurons are grouped together in fascicles and wrapped
in a perineurium (PAIR-ih-nur-ee-um). Several fascicles are
grouped together, along with blood vessels, to form a nerve.
The entire nerve is wrapped with a fibrous connective tissue
covering called the epineurium (Fig. 3-45).
Nerve plexuses are large networks of intertwined
nerves. The four main plexuses are the cervical, brachial,
lumbar, and sacral, each serving a different region of the
body (Fig. 3-46). These plexuses are important in massage
therapy because they must be dealt with carefully to avoid
damaging the nerve structures.
There are collections of individual nerve cell bodies in
the PNS called ganglia (GAYNG-lee-uh). Even though they
are part of the PNS, ganglia are located very close to the
spinal cord, within the vertebral canal.
Nerve cell
Microglia
Cerebrospinal fluid
Ependymal cells
Brain or spinal
cord tissue
Nerve fiber
Oligodendrocyte
Myelin
Body of nerve cell
Satellite cells
Schwann cells
(form myelin sheath)
Dendrites of the
nerve cell
Figure 3-44. Forms of neuroglia.

Chapter 3 / Body Systems
107
Epineurium
Perineurium
Endoneurium
Peripheral
nerve
Blood vessels
Fascicle
Neurilemma
Axon of a
nerve cell
Figure 3-45. Structures of a nerve. (Reprinted with permission
from Stedman’s Medical Dictionary, 27th ed. Baltimore: Lippincott
Williams & Wilkins, 2000.)
Classification by Function
There are many types of nerves that monitor, integrate, and
respond to external and internal stimuli and changes occurring within the body. Functional classification of nerve cells
separates them into two separate groups. Sensory (afferent)
neurons receive sensory input and transmit that information
to the CNS. Motor (efferent) neurons carry messages from
the CNS to the muscle or organs that must react. Groups of
sensory neurons form sensory nerves, and groups of motor
neurons are called motor nerves. Most nerves, however, are
mixed nerves, which have both sensory and motor neurons
that carry information to and from the CNS.
Sensory Neurons
Sensory neurons are classified by their location, sensitivity,
or structure. They send signals to the CNS in response to
external or internal stimuli. Proprioceptors (PROH-pree-
oh-SEP-torz) are sensory nerve cells sensitive to body position, muscle tone, and equilibrium. They are located in
the muscles, tendons, joints, and inner ear. Exteroceptors
respond to stimuli from the external environment, such
as touch, pressure, temperature, smell, sight, and hearing.
These are mostly found in the skin and near the surface of
the body. Interoceptors, also called visceroceptors, detect
stimuli such as pressure within the organs and blood vessels.
For a massage therapist, the proprioceptors and exteroceptors are the most important of all the sensory receptors.
In the muscle, the muscle spindles are complex proprioceptors that are sensitive to the length of the muscle fibers and
respond to changes in that length. Between the collagen
fibers in tendons are Golgi (GOHL-jee) tendon organs that
respond to tension within the tendon that results from muscle contraction (Fig. 3-47). Both muscle spindles and Golgi
tendon organs provide information to the CNS regarding the length and tension of a muscle and its tendon(s).
1st cervical nerve
1st cervical vertebra (C1)
Cervical plexus
7th cervical vertebra (C7)
8th cervical nerve
1st thoracic vertebra (T1)
1st thoracic nerve
Brachial plexus
Dura mater
Cervical
enlargement
Conus
medullaris
12th thoracic
vertebra (T12)
12th thoracic
nerve
1st lumbar
vertebra (L1)
1st lumbar nerve
Cauda equina
Lumbar plexus
5th lumbar
vertebra (L5)
5th lumbar nerve
1st sacral vertebra
(S1)
1st sacral nerve
Sacral plexus
Figure 3-46. Nerve plexuses. (Reprinted with permission from
Bear MF, Connors BW, Paradiso MA. Neuroscience: Exploring the
Brain. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 2001.)

108 INTRODUCTION TO MASSAGE THERAPY
Spinal cord
Sensory nerve
Motor nerve
Figure 3-47. Muscle spindles and Golgi tendon organs.
Within a joint capsule are Ruffini end organs and Pacinian
corpuscles. Both respond to pressure within a joint, essentially sensing the position of the joint by sensing different
amounts of pressure at different places.
The muscle spindles and Golgi tendon organs respond
as muscles move a joint through its range of motion, but
joint proprioceptors are active when a joint is at the ends of
its range. All of the proprioceptors act as a group to provide
a sense of joint position, body position, effort, heaviness,
and timing of movement. Input from the proprioceptors,
along with input from other sensory organs such as the eyes
and equilibrium sensors, is sometimes called a kinesthetic
sense. Manipulating the muscle spindles and Golgi tendon
Sensory nerve
Muscle
spindle
Golgi tendon organ
Tendon organ capsule
(connective tissue)
organs with advanced massage techniques can encourage
muscles to shorten or lengthen. One of these techniques,
appropriately called proprioceptive neuromuscular facilita-
tion, is discussed in the Therapeutic Applications chapter.
The integument contains several different exteroceptors
that constantly monitor our surroundings (Fig. 3-48). The
closer these exteroceptors are to the surface of our skin, the
more sensitive they are:
• Free nerve endings, also called nociceptors, located
in the lower layer of the epidermis, detect pain and
temperature.
Figure 3-48. Sensory receptors of the
integument. (Reprinted with permission
from Bear MF, Connors BW, Paradiso
MA. Neuroscience: Exploring the Brain.
2nd ed. Baltimore: Lippincott Williams &
Wilkins,2001.)
Merkel’s
disc
Epidermaldermal border
Free nerve
ending
Meissner’s
corpuscle
Hair follicle
receptor
Pacinian
corpuscle
Ruffini’s
ending
Hairy skin
Glabrous
(hairless) skin
Epidermis
Dermis

Chapter 3 / Body Systems
109
• Merkel cells, found in the lower layer of the epidermis, detect very light touch.
• Meissner’s corpuscles, found in the upper part of the
dermis in the lips, hands, feet, and genital organs,
detect very light touch.
• Ruffini end organs, located in the dermis, detect heat
and strong or continuous pressure.
• Pacinian corpuscles, found in the deep dermis, sense
vibrations and deep pressure.
Motor Neurons
Motor neurons carry signals from the CNS to the muscles,
creating a response that involves muscle contraction. The
skeletal muscles can be effectors, or endpoints, for nervous
signals, under voluntary control. The motor neurons can
also control involuntary activity of the organs, glands, and
smooth and cardiac muscle.
Mixed Nerves
Most of the nerves of the body are mixed nerves that contain both sensory and motor nerve cells. They can monitor
for input, integrate the information received, and stimulate
the body to respond to the input. The sciatic (sahy-AT-ik)
nerve in the leg is an example of a mixed nerve that can
receive and send information via individual neurons that run
alongside each other.
Nerve Impulses
rushing from the high sodium concentration outside
the cell to the lower sodium concentration inside. With
the extra supply of sodium ions inside, the membrane
becomes depolarized; that is, the negative and positive
charges on either side of the membrane are balanced.
4. Repolarization—Almost as soon as the sodium has
rushed in, the permeability of the membrane reverts,
preventing any more sodium from entering. The cell
membrane becomes more permeable to potassium,
which quickly rushes out of the cell, restoring the
positive charge outside the cell and the negative charge
inside. The sodium–potassium pump uses ATP to move
sodium ions out and potassium ions in to maintain sodium–potassium gradients necessary for the resting state.
This process is called the action potential, also known
as the nerve impulse (Fig. 3-49). There is a threshold stimulus that acts as a switch for the impulse. If a stimulus is not
strong enough and does not reach the threshold stimulus,
the nerve impulse will not occur at all. Stimuli above the
threshold stimulus will trigger the nerve impulse over the
entire nerve cell. The permeability of the entire membrane
spreads down the neuron, carrying the signal. This all-ornone response of whether there is an action potential or
not means that either the whole nerve cell responds to the
stimulus or it does not.
The PNS is equipped with Schwann cells that are strung
like beads along the nerve cell. The Schwann cells insulate
Nerve cells have two primary functions: irritability and conductivity. A neuron’s irritability allows it to respond to a
stimulus and translate that perception into a nerve impulse.
Its conductivity allows the neuron to communicate that
nerve impulse to another neuron, a muscle, or a gland.
Irritability
The neuron’s irritability is the result of a chemical process
of depolarization. There are several steps to creating a nerve
impulse from a stimulus. Following is the series of events
that takes place in response to a stimulus, such as a sharp
thorn poking your finger:
1. Resting state—A nerve membrane at rest is in a polarized state, meaning that the positive and negative
charges on either side of the membrane are not balanced. There are more sodium ions outside the neuron
than there are potassium ions inside, creating an overall
negative charge inside the membrane.
2. Excitation—When the thorn is perceived by a pain
receptor, a neurotransmitter chemical is usually
released to alter the permeability of the membrane.
3. Depolarization—The membrane becomes more permeable to sodium ions, and they diffuse into the cell,
Stimulus
++
++ + + + + + + + +
Depolarization
+++++
+++++ ++++
Repolarization
+
+
+
+++
+
Figure 3-49. Action potential (nerve impulse).
+++++++
++++
+
+
+
+
+
+
+
+
+
++
++

110 INTRODUCTION TO MASSAGE THERAPY
the nerve membrane and in between the Schwann cells are
gaps called nodes of Ranvier. The myelin provides insulation
to the axon, like the plastic coating around electrical wires,
preventing the nerve impulse from spreading out and shortcircuiting. The nerve impulse is forced to jump from node
to node instead of traveling along the entire surface of the
membrane. By jumping over the Schwann cells, the impulse
can travel much faster and transmission speed increases. The
CNS does not have any Schwann cells, but it is equipped
with oligodendrocytes that form the myelin sheath on some
of the neurons that need insulation. The myelin insulation is
especially helpful when there are hundreds of neurons transmitting hundreds of nerve impulses through one nerve.
Once the impulse reaches the end of the axon, it will send
a signal to the next cell. There, the action potential may continue along the next cell or stimulate activity of a gland or organ.
Alcohol, cold temperature, continuous pressure, and
anesthetics are some factors that can reduce the speed of
the action potential. These factors either reduce the membrane’s permeability to sodium or prevent oxygen and other
nutrients from reaching the nerve. Without oxygen, cells
suffer and eventually die.
Synaptic Transmission (Conductivity)
If the electrical impulse at the end of the axon is strong
enough, the impulse will be conducted from one neuron to
another neuron or an effector (muscle, organ, or gland). The
impulses are conducted in a tiny but active gap called the
synapse (SIHN-aps). The nerve cell that needs to transmit
the impulse is called the presynaptic cell, and the cell that
will receive the impulse is called the postsynaptic cell.
The electrical nerve impulse on the presynaptic cell
triggers the axonal terminal to release a neurotransmitter
chemical into the synapse. Approximately 30 different neurotransmitters are made in the brain and stored in vesicles
at the axonal terminals all over the body. Some of the neurotransmitters are epinephrine (adrenaline), norepinephrine
(noradrenaline), dopamine, serotonin, and acetylcholine.
Acetylcholine, discussed in the muscular system section, is
the neurotransmitter released at the neuromuscular junction. Once the vesicles release the neurotransmitter into
the synapse, special receptor sites on the postsynaptic cell
receive the neurotransmitters. The receptor site is activated
and starts the action potential along the postsynaptic cell.
The synapse is designed such that the axon produces
the neurotransmitters and the dendrites have specific receptor sites. In other words, a specific neurotransmitter must be
received by the dendrite to complete the conduction. This
design ensures a specific, one-way communication along the
path (Fig. 3-50). Although most synapses are chemical (neurotransmitters and receptors), electrical synapses occur in
cardiac or smooth muscle tissue where rhythmic, sequential
muscle contractions are required.
Figure 3-50. Synapse. (Reprinted
with permission from Bear MF,
Connors BW, Paradiso MA.
Neuroscience: Exploring the Brain.
2nd ed. Baltimore: Lippincott
Williams & Wilkins, 2001.)
Synaptic
cleft
Secretory
granules
Axon terminal
(presynaptic
element)
Synaptic
vesicles
Receptors
Mitochondria
P
o
s
t
s
y
n
c
a
i
t
p
e
t
i
r
d
n
e
d
Fusion and exocytosis
(Neurotransmitter released)
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