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Chapter 4 / Kinesiology and Biomechanics 221
Platysma
Zygomaticus major
Zygomaticus minor
Orbicularis oculi
Frontalis (left half)
Galea aponeurotica (left side)
Mylohyoid
Digastric
anterior belly
posterior belly
Frontalis (left half)
Orbicularis oculi
Thyrohyoid
Hyoid bone
Sternocleidomastoid
Thyroid cartilage
Zygomaticus minor
Zygomaticus major
Orbicularis oris
sternal head
clavicular head
Plate 4-31
Orbicularis oris
222 INTRODUCTION TO MASSAGE THERAPY
Transverse
process (C-4)
Articular
Cervical multifidi
process (C-5)
Obliquus capitis
superior
Longissimus capitis
Semispinalis cervicis
Middle scalene
Posterior scalene
Rectus capitis posterior minor
Rectus capitis posterior major
Obliquus capitis inferior
Rotatores (cervical)
Multifidi (representative portion)
Rotatores (thoracic)
Cervical
rotatores
C-7
Plate 4-32
Chapter 4 / Kinesiology and Biomechanics 223
Middle
Posterior
Scalenes:
Semispinalis capitis
Ligamentum nuchae
Occipitalis
Galea aponeurotica
Splenius capitis
Ligamentum nuchae
Semispinalis capitis
Middle
Splenius capitis
Posterior
Scalenes:
Splenius cervicis
Plate 4-33
Splenius cervicis
Trapezius (left side)
224 INTRODUCTION TO MASSAGE THERAPY
Cervical multifidi
Transverse
process (C-4)
Articular
process (C-5)
Cervical
rotatores
Transverse process, C-1
Rectus capitis:
posterior minor
posterior major
Multifidi
Obliquus
capitis
superior
Obliquus
capitis
inferior
Rotatores (cervical)
Multifidi (representative portion)
C-7
Mylohyoid
Digastric
anterior belly
posterior belly
Hyoid bone
Thyrohyoid
Thyroid cartilage
Sternocleidomastoid
sternal head
clavicular head
Rotatores (thoracic)
Plate 4-34
Horn of hyoid bone
Attachment of
stylohyoid m. to
styloid process
of skull
Sternohyoid
Omohyoid
Levator scapulae
Superior angle
of scapula
Styloid
process
Digastric
posterior belly
anterior belly
Plate 4-35
Hyoid bone
Chapter 4 / Kinesiology and Biomechanics 225
then shift in the opposite direction, away from the
tabletop. Notice your wrist angle, axillary angle, and
1. Define the following terms:
• Anatomical position
• Axillary angle
• Biomechanics
• Body mechanics
• Concentric muscle contraction
• Eccentric muscle contraction
• Kinesiology
• Prime mover
• Synergist
• Antagonist
• Fixator
2. Demonstrate the following body movements:
the stress on your shoulder joint as your body moves
too close and too far away from your contact hand.
9. Practice efficient alignment with a partner. Lean
on a variety of objects of different heights, and try
to maintain the head-to-heel line using the asymmetric stance. You can try leaning on the seat of
a chair, the top of a massage table, a doorknob, a
windowsill, or a bookshelf.
10. Practice using relaxed wrists and hands. Ask a part-
ner to rest his or her arm on the desktop, tabletop,
or massage table. First, clench your hand into a tight
fist and use your tightened forearm to lean on your
partner’s arm for a few seconds. Then, relax your
arm, wrist, and hand and lean on your partner’s arm
a second time. Ask your partner for feedback regarding how the two pressures differ, which one was
• Flexion of the elbow
more comfortable, and whether or not one hurt.
• Extension of the knee
• Lateral flexion of the spine
• Medial rotation of the humerus
• Abduction of the femur
• Circumduction of the hip
• Dorsiflexion of the ankle
• Supination of the hand
• Lateral deviation of the mandible
• Elevation of the scapula
3. List at least five components of a synovial joint.
4. Describe static and dynamic muscle contractions.
5. Identify and describe the three methods of gener-
ating energy in muscles.
6. Name the three components of good body
mechanics.
7. Practice walking with your stroke. Ask a partner to
lie prone on the massage table, and put your relaxed
hand on his or her lumbar region. Move the stroke
toward the partner’s head without changing your
axillary angle by walking with the stroke.
8. Familiarize yourself with the proper wrist position.
Perform active wrist extension, and notice the limit of
the ROM. Rest your hand on a desktop, tabletop, or
massage table, and lean on that hand. Without moving your feet or your hand, slowly shift your weight
so your shoulders move closer to the tabletop and
are eventually positioned directly over your hand, and
SUGGESTED READINGS
Aslani M. Massage for Beginners . New York: Carroll & Brown, 1997.
Bruder L. Navigating the pathway to phenomenal touch: 10 steps to trans-
form your massage. Massage Magazine 2002; (96): 74–82.
Cael C. Functional Anatomy, Musculoskeletal Anatomy, Kinesiology, and Palpa-
tion for Manual Therapists . Baltimore: Lippincott, Williams & Wilkins,
2010.
Frye B. Body Mechanics for Manual Therapists: A Functional Approach to Self-
Care . Baltimore: Lippincott, Williams and Wilkins, 2010.
Greene L, Goggins RW. Save Your Hands: The Complete Guide to Injury Preven-
tion and Ergonomics for Manual Therapists . Coconut Creek, FL: Body of
Works Books, 2008.
Latchaw M, Egstrom G. Human Movement with Concepts Applied to Children’s
Movement Activities . Englewood Cli s, NJ: Prentice-Hall, 1969.
Lidell L, Thomas S, Cooke CB, et al. The Book of Massage . New York: Simon
& Schuster, 1984.
Lindsey R, Jones BJ, Whitley A. Body Mechanics, Posture, Figure and Fitness . 4th
ed. Dubuque, IA: Wm. C. Brown, 1979.
Maxwell-Hudson C. Complete Massage . New York: Dorling Kindersley, 2001.
Moorcroft C. Myology and Kinesiology for Massage Therapists . Baltimore: Lip-
pincott, Williams & Wilkins, 2012.
Muscolino J. Kinesiology: The Skeletal System and Muscle Function . 2nd ed. St.
Louis: Mosby, 2011.
Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System . 3rd
ed. Baltimore: Lippincott, Williams & Wilkins, 2001.
Premkumar K. Anatomy & Physiology: The Massage Connection . 3rd ed.
Baltimore: Lippincott Williams & Wilkins, 2012.
Rattray F, Ludwig L. Clinical Massage Therapy: Understanding, Assessing and
Treating over 70 Conditions . Toronto: Talus Incor porated, 2000.
Seedor MM. Body Mechanics and Patient Positioning . New York: Teachers
College Press, 1977.
Souriau P. The Aesthetics of Movement . Souriau M, trans-ed. Amherst, MA:
The University of Massachusetts Press, 1983.
Trager M, Hamond C. Movement as a Way to Agelessness: A Guide to Trager
Mentastics . Barrytown, NY: Station Hill Press, 1995. http://www.exrx
.net/Lists/Articulations.html, accessed 12.6.11. The 12 Body Systems
5
Objectives
Upon completion of this chapter, the student will be
able to:
■
Define pathology and describe how it relates to
massage therapy
■
Define pharmacology and describe how it
pertains to massage therapy
Key Terms
Acute : Refers to a condition that has developed very
quickly and severely, or has a short duration.
Chronic : Refers to a condition that has persisted for a
long time, develops slowly, or recurs.
Contraindication : A situation or condition in which
massage could worsen the condition.
Etiology : The study of the source or cause of disease.
Indication : A condition for which massage could be
beneficial and is recommended.
Local contraindication : A situation in which mas-
sage would be considered therapeutic except in a
■
List at least three classes of pharmaceuticals
■
Describe the difference between an indication
and a contraindication
■
Describe the difference between a local and a
systemic contraindication
localized area, whereby using massage could cause
further harm.
Pathology: The study of disease processes or of any
deviation from a normal, healthy condition.
Pharmacology: The study of the preparation,
mechanisms, applications, and effects of
medications.
Subacute : The period from about 3 days to 3 weeks
after a condition started.
Systemic contraindication : A condition or situation in
which massage should be avoided altogether.
226
Chapter 5 / Pathology and Pharmacology 227
athology is the study of disease processes or any
deviation from a normal, healthy condition. For mas-
P
sage therapy in particular, pathology is the study of
disease or dysfunction to determine whether or not massage
is contraindicated.
Pathological conditions are often treated with medi-
cations to alleviate their symptoms or treat their cause.
Pharmacology (fahr-muh-KAH-loh-jee) is the science of the
preparation, mechanisms, application, and effects of these
medications.
Massage can affect pathological conditions as well as
the effects of medications. This chapter guides you through
the process of assessing the appropriateness of massage; you
may need to consult more expanded resources on pathology
and medications. See Suggested Readings and web sites at
the end of this chapter for more information.
Pathology
This chapter covers some common pathological conditions
and body conditions massage therapists encounter in their
practice. Some conditions that upset the body’s homeostasis are considered precursors to, or symptoms of, a disease
process. For example, increased muscle tension in and of itself is not necessarily pathological, but it is sometimes a precursor to, or symptom of, fibromyalgia, a chronic muscular
pain condition.
Diseases have different causes, signs, and symptoms.
Etiology is the study of the source or cause of disease,
which may point to heredity, infection, autoimmunity,
trauma, or aging. Signs and symptoms of a disease are the
subjective and objective indicators that lead to a diagnosis of
a pathological condition or disease.
Pathological conditions can be characterized by the
length of time they have persisted or how suddenly they
presented. The stages of healing may vary depending on the
severity and depth of the injury or condition and the individual’s capacity for healing:
be avoided. There are also systemic contraindications ,
which are health conditions in which massage should be
avoided altogether because massage could aggravate the
condition or spread the disease. Any time fever is present,
as in the acute stages of a cold, massage is systemically
contraindicated.
Conversely, an indication is a condition for which
massage would be beneficial or recommended. If you
question whether massage should or should not be applied, withhold massage treatment until the appropriate healthcare professional can examine and diagnose the
condition. Remember the rule: when in doubt, refer out. It
is not within your scope of practice as a massage therapist
to diagnose or prescribe, so suggesting a client see another
healthcare professional must be done sensitively and carefully. Use a gentle approach when bringing awareness to
a possible symptom or condition and explain that a more
thorough examination is prudent. If the client asks you
about a condition that you think may require a diagnosis,
you can simply say, “I cannot diagnose any medical conditions, but massage may not be helpful. I recommend that
you see your healthcare professional for further evaluation
before we continue treatment.” However, if you happen
to notice a condition or a set of symptoms that may require a diagnosis, you can carefully encourage the client
to recognize and discuss the symptoms. Once the client is
aware of the symptoms or condition, you could suggest
that a professional diagnosis may put his or her mind at
rest. Referring clients out for conditions reinforces a clientcentered philosophy.
Each condition presented in this chapter includes a
brief description, some symptoms that can help identify it,
and an explanation of whether massage is commonly indicated (recommended) or contraindicated (inappropriate).
Additionally, there are “In Brief ” boxes offering snapshots of
conditions so you can quickly see the risks and benefits of
massage therapy.
• Acute —refers to a condition that developed quickly
and severely, or has a short duration
• Subacute —the period from about 3 days to 3 weeks
after a condition started
• Chronic —refers to a condition that develops slowly,
recurs, or persists for a long time
A contraindication for massage is a situation or
condition for which massage should be avoided because
it could worsen the condition. Some conditions are considered local contraindications , meaning that massage
should be avoided only in the affected area. For example,
massage is appropriate for someone who has a bruise,
but the bruise itself is a local contraindication and should
Pharmacology
Pharmacology is the study of the preparation, mechanisms, applications and effects of medications. Common
medications and treatments for symptoms or conditions
identified in this chapter are mentioned because a client
may be using them when they come for massage treatment. They are mentioned as information only. These
treatments and medications are prescribed by other
healthcare professionals, not massage therapists. In this
text, a healthcare professional is a practitioner who can
diagnose and prescribe, such as a medical doctor (MD),
osteopathic doctor (DO), nurse practitioner (NP), or
chiropractor (DC).
a
A
228 INTRODUCTION TO MASSAGE THERAPY
that require that the client monitor pain levels, such as po-
Alert
Diagnosing and prescribing are not in the massage
Di
therapist’s scope of practice.
sitional release, because the medication sometimes reduces
the client’s perception of pain and pressure.
Alert
Generally, if a medication is taken internally and is delivered
through the bloodstream, massage techniques such as effleurage and pétrissage, which increase blood flow, may increase
the effect of the medication in the body. It is always good to
know about the client’s health and treatment regimens that
may be affected by massage.
Thousands of medications are prescribed for various
symptoms and pathological conditions. Many of them
can be categorized into major groupings or classifications
of medications by their purpose and the mechanism that
makes them work. Because medications are so common,
you should be aware of basic drug classifications and how
such drugs may interact with massage. Intentionally or
not, massage can amplify or reduce the effect of a medication, and it can relieve side effects of some medications.
The Physicians’ Desk Reference (PDR) is a yearly publication
that compiles the drug manufacturers and drug products
as well as indications and contraindications for their use. A
PDR is a good reference to have so you can look up specific drug names and identify possible contraindications for
massage. Additionally, there are excellent resources specific
to massage: Pharmacology for Massage Therapy and Massage
Therapy and Medications (see Suggested Readings). If you
do not have a reference book or are not sure whether massage is contraindicated when a client is taking a particular
medication, you should consult with the client’s healthcare
professional.
Following are some common drug classifications,
their indications, how the medications work, implications
for massage, and their common names.
note that these change as new drugs are introduced and old
ones are removed from the market—this requires you to research the most recent and accurate information regarding
medications.
It is important to
Anti-inflammatory Drugs/
Analgesics
Inflammation is the body’s response to different kinds of
irritants, including bacteria, exposure to extreme temperatures, chemicals, hormonal changes, autoimmune activity,
or a physical injury. Generally characterized by heat, redness, swelling, itching, and pain, inflammation may be reduced with various anti-inflammatory medications. When
clients are taking an anti-inflammatory and/or analgesic
medication, you want to be careful with massage techniques
be avoided.
Common classifications and names are:
Muscle Relaxants
Muscle relaxants reduce the chemical activity responsible for
communication between the nervous system and the muscular system. As a result, the muscles receive fewer signals
to contract. They are prescribed to reduce muscular tension
and acute muscular spasm resulting from injury or anxiety.
While taking muscle relaxants, clients may feel weak and
tired, often with reduced sensitivity to pain. Massage techniques that require clients to monitor pain levels, such as positional release, direct pressure, or friction, should be used
with caution or avoided altogether depending on how the
client is feeling after sustaining an injury.
Any massage techniques that create therapeutic
inflammation, such as deep transverse friction, should
• Salicylates—relieve pain, reduce fever, reduce swelling and joint stiffness (aspirin, buffered aspirin,
Anacin, Bayer, Bufferin)
• Acetaminophen—relieve pain, reduce fever (Tylenol,
Panadol, Tempra)
• Non-steroidal anti-inflammatory drugs—relieve
inflammation, joint stiffness, swelling, and some
can reduce fever (ibuprofen: Advil, Motrin, Nuprin;
Relafen; Aleve; Lodine)
• Corticosteroids—steroidal anti-inflammatories that
reduce redness, swelling, itching (cortisone, hydrocortisone, methylprednisolone, prednisone, Aristocort,
Cortastat, Liquid Pred, Solu-Medrol, Sterapred)
• Narcotic—relieve pain and some suppress cough
(codeine, hydrocodone, morphine, oxycodone,
Demerol, Darvon, OxyContin)
• Combination medications—relieve pain and some
reduce swelling or fever (Excedrin Extra-Strength
combines acetaminophen, salicylates, and caffeine;
Darvocet, Lortab, and Percocet combine narcotics
with acetaminophen)
Common classifications and names are:
• Centrally acting skeletal muscle relaxants—Flexeril,
Skelaxin, Valium, Soma
• Peripherally acting skeletal muscle relaxants—Dantrium
Chapter 5 / Pathology and Pharmacology 229
Anti-anxiety Medications
Anti-anxiety medications are prescribed to manage or alter
the sympathetic nervous system response. Suppression of
the central nervous system (CNS) may result in side effects
such as dizziness, poor coordination, forgetfulness, confusion, and depression. With the client’s diminished ability to
monitor changes that occur during massage, it is important
to make adjustments accordingly. Additionally, the client’s
ability to move after a massage may be hindered and dizziness is likely, so encourage your client to use caution when
sitting up and getting off the massage table.
Common classifications and names are:
• Barbiturates—amobarbital (Amytal), phenobarbital
(Luminal)
• Benzodiazepines—alprazolam (Xanax), diazepam
(Valium), lorazepam (Ativan), triazolam (Halcion)
• Buspirone—buspirone hydrochloride (BuSpar)
Antidepressants
Many kinds of antidepressants are prescribed to minimize
or eliminate depression, and sometimes to relieve pain or to
help people stop smoking. Usually, antidepressants change
the chemistry of the nervous system by increasing the production of certain chemicals or blocking specific chemical
pathways. These medications sometimes cause constipation,
a side effect that can be relieved with massage. Since massage increases the levels of some of the critical brain chemicals involved in depression, be aware that the client may
have an abnormal reaction to the medication, and use massage in cooperation with the prescribing healthcare professional. Common classifications and names are:
• Tricyclics—nortriptyline (Alti-Nortriptyline), amitriptyline (Elavil), imipramine (Apo-Imipramine)
• Monoamine oxidase inhibitors—isocarboxazid
(Marplan), phenelzine (Nardil), tranylcypromine
(Parnate)
• Selective serotonin reuptake inhibitors (SSRIs)—
fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro), citalopram
(Celexa)
• Other antidepressants—nefazodone (Serzone),
bupropion (Wellbutrin), venlafaxine (Effexor)
Cardiovascular Disease
Management
Drugs used to manage cardiovascular disease affect the
body via the dilation of blood vessels or by diminishing the
sympathetic nervous system response. When a client is taking one of these medications, the massage may cause the client to feel more fatigued, sluggish, and/or dizzy afterward.
Make clients aware that this may occur and caution them to
sit up and get off the table slowly once the massage session
is over. Most common classifications and names are:
• Antilipemics (for high cholesterol)—cholesterol
synthesis inhibitors (Lipitor, Zocor, Mevacor,
Pravachol), fibric acid derivatives (Tricor, Lopid),
bile-sequestering drugs (Colestid, Prevalite)
• Antianginal drugs (for angina)—beta-adrenergic
antianginals (beta blockers: Inderal, Toprol XL,
Betaloc, Lopressor, Tenormin, Corgard), calcium channel blockers (Norvasc, Cardene, Calan,
Procardia, Cardizem), nitrates (Nitrodisc, Nitrostat,
Cedocard, Monoket)
• Antihypertensive drugs (for hypertension)—sympatholytic drugs (Cardura, Tenex, Dopamet,
Hytrin), vasodilating drugs (Hyperstat, Nu-Hydral,
Nitropress), angiotensin-converting enzyme inhibitors (Accupril, Monopril, Vasotec, Lotensin)
• Diuretics (for hypertension and water retention)—
thiazide and thiazide-like diuretics (Lozol, Lozide,
Naturetin, Renese), loop diuretics (Lasix, Bumex),
potassium-sparing diuretics (Spiractin, Inspra)
Anti-infectives
Antimicrobial drugs are used to treat infections by disrupting chemical processes within the offending microorganisms. Anti-infectives sometimes have gastrointestinal side effects, and massage may be able to reduce those symptoms.
While the client’s body is fighting infection, with or without
the aid of antibiotics, the immune system is compromised.
During that time, it is important to avoid overstressing the
body. Keeping the client’s best interest in mind, use gentler
massage techniques to minimize the mechanical and reflexive effects of massage. Most common classifications and
names are:
• Antibacterial drugs (fight bacterial infections)—penicillins (Augmentin, Wymox, Cloxapen, Ticillin),
cephalosporins (Keflex, Declor, Cefzil, Vantin,
Rocephin), tetracyclines (Declomycin, Monodox,
Vibramycin), macrolides (erythromycin: Erythrocin,
Diomycin), vancomycin (Vancocin), aminoglycosides (streptomycin, tobramycin), fluoroquinolones (Cipro, Levaquin, Maxaquin), sulfonamides
(Bactrim, Sulfatrim), nitrofurantoin (Furadantin,
Macrobid)
• Antiviral drugs (fight viral infections)—antiherpesvirus drugs (Zovirax, Famvir, Valtrex), influenza drugs
230 INTRODUCTION TO MASSAGE THERAPY
(oseltamivir: Tamiflu; zanamivir: Relenza; rimantadine: Flumadine)
• Antimycotic drugs (fight fungal infections)—amphotericin B (Amphotec, Fungizone), fluconazole
(Diflucan), ketoconazole (Nizoral)
Antihistamines
Chemicals called histamines are released when the body goes
through an allergic response. Histamines cause capillaries to
leak extra fluids, resulting in swelling and itching. In some
cases, they can even cause contractions of involuntary muscles such as the bronchi, restricting or preventing the essential process of breathing. Antihistamines block the effects of
histamines (the prefix, anti-, means against), decrease blood
vessel dilation and permeability, decrease nerve sensitivity in
the skin, and reduce the itching and swelling associated with
allergies. Common side effects of antihistamines are drowsiness, anxiety, dizziness, and lethargy as well as distorted or
masked reactions to the massage. You must be aware of
these effects and educate your clients so your clients know
what to expect. Common classifications and names are:
• Ethanolamines—clemastine fumarate (Tavist,
Dayhist), dimenhydrinate (Dramamine), diphenhydramine hydrochloride (Benadryl, Hydramine)
• Alkylamines—brompheniramine maleate (Dimetapp),
chlorpheniramine maleate (Chlor-Trimeton)
• Piperidines—cetirizine (Zyrtec), desloratadine
(Clarinex), fexofenadine hydrochloride (Allegra,
Allegra-D), loratadine (Alavert, Claritin)
Most medications are taken orally, but some are applied
topically or are injected. Be careful to avoid areas that are
being treated with topical medications or the area immediately surrounding the injection site. Not only are those areas
possibly undergoing some sort of infection/healing process
that presents a local contraindication, massage can interfere
with the absorption or you can accidentally transfer some of
the medication onto your own body.
Any area that has received topical applications or injec-
tions of medication should be avoided for up to
24hours afterward, depending on the drug and the
condition being treated.
Anticoagulant Therapy
Clients who are taking anticoagulants such as warfarin
(Coumadin) or anisindione (Miradon) currently have or are
at risk for blood clots.
Any anticoagulant (“anti-clotting agent” or “blood thinner”)
presents a systemic contraindication for massage
that requires the prescribing healthcare professional’s clearance before proceeding with massage.
The parasympathetic nervous system response to massage may be enhanced by medications. Be aware that clients
taking medication may feel especially weak or tired following a massage. Be available to help clients sit up and get off
the table if they need assistance, and make sure that they are
alert and awake enough to get home safely.
The following section identifies each body system, lists some
pathologies (abnormal conditions) associated with that system, notes some of the related pharmacological treatments,
and discusses if or when massage is indicated.
Abnormal Conditions of Cells and Tissues
There are some abnormal conditions of cells and tissues of
the body that you may see in your massage practice.
Cancer
Although cancer occurs in different body systems, all over
the body, it starts at the cellular level when normal body cells
undergo a mutation (genetic change) and start replicating at
abnormally high rates. A mass of these cells is called a tumor.
A solid tumor occurring in the cells is a carcinoma, whereas
one that occurs in muscular or connective tissue is a sarcoma.
Cancer in the blood and lymph does not typically result in a
solid tumor and is referred to as hematologic cancer or more
specifically, leukemia, myeloma, and lymphoma. If the mutated cells travel to another place in the body, they can encourage the growth of a tumor where they settle.
Massage is locally contraindicated at the site of the tumor
or tumors.
The American Cancer Society’s web site (www.cancer
.org) lists some known carcinogens, including:
• Alcoholic beverages
• Arsenic
• Asbestos