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Chapter 9 / Massage Strokes andFlow 361
BOX 9-4
Prone Position on the Table
1. Offer the sheet, folded in half, to your client, and
demonstrate how you want him to wrap up in the sheet
with the fold under his armpits and the free edges
opening to the front. Leave the room and let the client
undress and wrap himself in the sheet.
2. Offer the client your hand for support and stabilization
while he uses a step stool to get on the table in a prone
position.
3. With the client prone and wrapped in the sheet, you
pull the sheet out from under him.
362 INTRODUCTION TO MASSAGE THERAPY
BOX 9-4
Prone Position on the Table (continued)
4. Unfold the sheets.
BOX 9-5
1. Tuck the top edge of the sheet tightly under the
client’s armpits, and push the bottom corners of
the sheet under the client’s bent knees.
2. Ask your client to grab the bottom corners, lift
the hips, and pull the sheet up to the waist.
Chapter 9 / Massage Strokes andFlow 363
BOX 9-5
Table(continued)
3. Take the corners of the sheet from your client
and firmly tie them in front of the client’s waist.
4. Lift the client’s shoulder closest to you and tuck
the sheet under it, pushing it toward the far
shoulder.
5. Walk to the other side of the table and gently lift
upon the client’s closest shoulder, ask your client
to roll onto the side, and firmly tie the corners
behind the client’s back.
364 INTRODUCTION TO MASSAGE THERAPY
BOX 9-5
Table(continued)
6. Walk to the other side of the table to face the client
and
a. slide one arm under the client’s neck and your
hand on the back.
b. slide the other arm under the client’s knees.
7. Lower your hips and pivot the client into a sitting
position.
8. Offer your hand for support and stabilization asthe
client puts on socks and then steps off the table.
Chapter 9 / Massage Strokes andFlow 365
Without question, massage affects the physiology of the
human body. You may recall Dr. John Kellogg’s determination
of the mechanical, reflexive, and metabolic effects of massage (see Chapter 1). Mechanically, massage directly changes
the shape or condition of the skin, fascia, muscle, and connective tissues via pressure and manipulation and enhances
their movement and pliability. Reflexively, the application of
massage strokes stimulates the nervous system to change the
shape or condition of the tissues in the areas that were directly addressed as well as in other areas of the body. In other
words, a massage stroke on someone’s foot can neurologically encourage the hip flexor muscles to flex and pull the foot
away from the touch. Metabolic effects are a combination
of mechanical and reflexive responses that create a change
that affects the whole body. For example, sustained touch on
someone’s arm can warm the area that is being contacted and
can also lower the person’s heart rate and blood pressure by
stimulating a parasympathetic nervous system response. The
metabolic effects of massage are primarily due to the responses of the circulatory and nervous systems, which transport
blood, lymph, nutrients, hormones, neurological signals, and
neurochemicals to and from all parts of thebody.
The effects of massage on the different organ systems
are incorporated into the text of Chapter 3 and outlined
below in Table 3-6. In addition to the effects on specific organ
systems, massage also plays a part in thermoregulation. Even
when muscles are “at rest,” some of the muscle cells in a
muscle are contracting to maintain muscle tone. The primary mechanism for producing body heat is muscle contraction. Heat is similarly produced when muscles are kneaded,
but the increased temperature of the muscles does not raise
the body temperature significantly. Brisk, superficial massage on the skin, sometimes called superficial friction, creates
vasodilation in the blood vessels of the skin. As a result, body
heat is dissipated and the core temperature can drop.
Alert
It is possible to create fatigue-like symptoms with
It
massage techniques that are too aggressive.
Although the benefits of massage vary greatly
depending on health, lifestyle, stress levels, pathological conditions, or injuries, it can safely be said that
massage is beneficial to most people and can have an
enormous impact on the body’s ability to restore and
maintain homeostasis. It is important to remember that
you, the massage therapist, function only as a facilitator
of this rebalancing. You are not personally making the
changes; you are helping the client’s body cause these
changes tooccur. Following are some general benefits of
massage:
• Reduces pain (see Box 9-6)
• Reduces edema
• Relieves hypertonic muscles
• Encourages a balance between sympathetic and
parasympathetic nervous system activity
• Reduces adhesions in the connective tissue and fascia
within and surrounding the muscles
• Restores movement and circulation to soft tissues
• Reduces stress and stress hormones (see Box 9-7)
Massage is generally beneficial for most people.
Conditions and situations in which massage is recommended or that are positively affected by massage are
called indications for massage (see Table 9-2). Even
though massage carries a low risk for injury, a poorly
trained therapist can certainly damage tissues and elicit
pain. There are some instances where massage should
not be applied and some conditions for which you should
obtain clearance from a healthcare professional before
proceeding with massage. The most important thing to
remember when you are unsure whether to apply massage
is “WHEN IN DOUBT, DON’T.”
Use the pathology appendix
of this text or a thorough massage pathology book if you
have any question about whether to proceed with massage. See Table 9-3 for a brief list of contraindications for
massage.
366 INTRODUCTION TO MASSAGE THERAPY
Integumentary system • Mechanically warms the skin with friction
• Increases circulation of blood and lymph within the skin
• Stimulates sebaceous gland secretions, which make skin more supple and pliable
• Stimulates sweat production, which cools the body upon evaporation of sweat
• Breaks down fascial adhesions in the subcutaneous layer (superficial fascia) to
restore circulation and movement to skin
Skeletal system • Joint movement stimulates synovial fluid production, which cushions and lubricates
synovial joints
• Increases the health of skeleton by enhancing circulation of blood and lymph to and
from the bones
Muscular system • Increases nutrition and development of muscles by enhancing circulation of blood
and lymph to and from the muscles
• Increases the excitability of muscles, making them more sensitive to nerve impulses
• Discourages the formation of lactic acid in muscles following physical exertion
• Accelerates recovery of fatigued muscles by reducing the lactic acid buildup
• Increases heat in and around muscles to loosen fascia and restore movement and
circulation to the muscles
• Decreases hypertonicity in muscles and tendons
Nervous system • Increases production of dopamine, a pain-relieving chemical involved in voluntary
movement and clear thinking
• Increases production of endorphins, strong pain-relieving chemicals
• Increases production of enkephalins, strong pain relievers involved in sensory
integration
• Increases secretion of oxytocin, a chemical that increases the pain threshold,
stimulates smooth muscle contractions, decreases sympathetic nervous system
activity, and has sedative effects
• Increases production of serotonin, which generally diminishes pain and appetite,
regulates moods and sleep patterns, and stimulates smooth muscle contractions
• Decreases production of cortisol, a natural anti-inflammatory produced in response to
stress that can accelerate tissue breakdown and prevent tissue repair
• Decreases substance P, a neurotransmitter that triggers the pain response
Circulatory system • Increases circulation of blood and lymph in and around the area being addressed
• Reduces the symptoms of ischemia by increasing circulation to capillaries with poor
blood flow
• Increases permeability of capillary walls, enhancing delivery of oxygen and nutrients
• Sustained percussion can cause vasodilation deep within the area being addressed to
increase blood flow
• Increases circulation of lymph to help the body fight germs
• Increases circulation of lymph, which increases removal of metabolic waste
• Reduces edema
Respiratory system • Encourages slow, deep contractions of the diaphragm, which helps remove carbon
dioxide waste via the lungs
• Percussive techniques can relieve chest congestion by loosening mucus within lungs
Digestive system • Enhances the digestive process reflexively by stimulating the parasympathetic
nervous response
• Mechanically pushes indigestible waste through the intestines
continues on following page
Chapter 9 / Massage Strokes andFlow 367
Urinary system • Increases cellular and chemical waste excreted via urine
• Encourages constriction of the smooth muscle of the urinary bladder to eliminate
more urine as a reflexive response of the parasympathetic nervous system
Endocrine system • Increases delivery of hormones and other chemicals as a result of increased
circulation of blood
• Reduces levels of cortisol and norepinephrine (noradrenaline), stress-related
hormones
RESEARCH BOX 9-6
Massage and Pain: The Gate
Control Theory of Pain
In 1965, researchers Ronald Melzack and Patrick Wall
published the now-famous Gate Control Theory that
explained the pain mechanism. Afferent (sensory) nerve
fibers transmit sensory nerve impulses from all over
the body, through the spinal cord, and up to the brain.
According to the theory, once the nerve impulses arrive
at the spinal cord, they must pass through a “gate” in
order to reach the brain and be recognized. Essentially,
if the gate is open, impulses will travel to the brain. But
if the gate is closed, no sensory input is transmitted to
the brain and no sensation is perceived. The gate opens
in response to impulses along the pain-sensitive nerve
fibers, and it closes in response to impulses along the
larger fibers that detect light touch, temperature, and
pressure. Theoretically, light touch or pressure interferes
with pain by closing the gate so the pain impulses cannot
pass through to the brain, thus reducing the pain and the
perception of it. In other words, massage can reduce the
sensation of pain. This theory is supported by the natural
tendency for people to rub a bumped shin or hold their
hand over a sore area.
Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965; 150:971.
Dickenson AH. Gate control theory of pain stands the test of time. Br J Anaesth
2002;88:755–757.
Davis P. Pain: opening up the gate control theory. Nurs Stand 1993;7:25–27.
The gate control theory of pain. Br Med J 1978; 2:586–587.
American Journal of Pain Management: www.ajpmonline.com.
Journal of Pain and Symptom Management: www.elsevier.com/locate
/jpainsymman
International Journal of Acute Pain Management: www.elsevier.com/wps
/product/cws_home/622996
RESEARCH BOX 9-7
Massage and Stress
Cortisol decreases and serotonin and dopamine
increase following massage therapy. In this article, the
positive effects of massage therapy on biochemistry
are reviewed including decreased levels of cortisol
and increased levels of serotonin and dopamine. The
research reviewed includes studies on depression
(including sex abuse and eating disorder studies), pain
syndrome studies, research on autoimmune conditions
(including asthma and chronic fatigue), immune
studies (including human immunodeficiency virus
[HIV] and breast cancer), and studies on the reduction
of stress on the job, the stress of aging, and pregnancy
stress. In studies in which cortisol was assayed
either in saliva or in urine, significant decreases were
noted in cortisol levels (averaging decreases 31%).
In studies in which the activating neurotransmitters
(serotonin and dopamine) were assayed in urine, an
average increase of 28% was noted for serotonin and
an average increase of 31% was noted for dopamine.
These studies combined suggest the stress-alleviating
effects (decreased cortisol) and the activating effects
(increased serotonin and dopamine) of massage
therapy on a variety of medical conditions and stressful
experiences.
Field T, Hernandez-Reif M, Diego M, et al. Cortisol decreases and serotonin
and dopamine increase following massage therapy. Int J Neurosci 2005;
115:1397–1413.
368 INTRODUCTION TO MASSAGE THERAPY
Research has shown that massage is beneficial for the following conditions:
Anxiety Immune function
Cancer symptoms Migraine headaches
Carpal tunnel syndrome Pain
Chronic fatigue Posttraumatic stress disorder
Depression Premenstrual syndrome
Diabetes in children Preterm (premature) infants
Fibromyalgia Sleep
Hypertension (high blood pressure) Stress
Local Contraindications Systemic Contraindications Clearance from a Healthcare Professional
Acute sprains/strains Acute or contagious viral or
bacterial infections
Blisters Acute systemic inflammatory
processes
Bone fractures Acute burns Cancer
Bruises Acute gout Burns
Bunions Aneurysm Impaired cardiovascular system
Contagious skin conditions Fever Traumatic brain injury
Cuts and open wounds Fungal infections that cover
large areas of the body
Cysts Intoxicated clients
Fungal infections Recent surgery
Gouty joints
Local inflammation
Moderate to severe varicose veins
Pitting edema
Aneurysm
Atherosclerosis
Recent major surgery
Subacute and postacute burns
Chapter 9 / Massage Strokes andFlow 369
As previously stated, the application of massage is as much
of an art as it is a science. The evolution of massage into
an art occurs gradually, starting when you first learn how to
apply the basic massage strokes. Each particular stroke has
the following components:
• Direction of movement—the direction the stroke
moves in relation to the client’s body (toward or
away from the heart, across the muscles fibers)
• Excursion—the length of the stroke along the client’s skin (a sweeping stroke may travel along 10 to
15 inches)
• Rate of movement—the speed at which a stroke
moves along the client’s skin (sweeping strokes often
travel about 1 to 2 inches per second)
(percussive strokes have a fast, even rhythm of
approximately 10 to 20 strokes per second, whereas
sweeping strokes are applied at a slower rhythm of 1
stroke every 5 to 10 seconds)
• Pressure—the amount of force applied directly into
the client’s tissues
The directions of movement and excursion affect the
outcome of a stroke. Long, sweeping strokes directed toward
the heart tend to decrease edema and encourage relaxation:
they mechanically increase movement of lymph and venous
blood, and they move generally parallel to the muscle fibers
and crowd fibers toward the origins of the muscles, which
influences the proprioceptors in the joints and muscles to
relax the muscles. In contrast, short, sweeping strokes directed away from the heart tend to have energizing effects. They
mechanically increase the flow of arterial blood and they
create tension at the origins of muscles, which influences
the proprioceptors to tone the muscles. Strokes directed perpendicular to the muscle fibers (cross fiber) or in a circular
direction across the fibers reduce soft tissue adhesions and
increase mobility of those tissues.
The rate and rhythm of movement also affect the outcome. To achieve relaxation, apply strokes with a slow, even
rhythm to promote a parasympathetic nervous response. For
a stimulating effect, apply the strokes quickly, at a rate faster
than the client’s rate of respiration, or with an uneven rhythm.
Diffuse pressure, applied lightly with the whole hand or
with a broad surface such as the forearm, is often considered most relaxing. Concentrated pressure applied with supported fingers, thumbs, or the distal end of the elbow may
initially have a stimulating effect, but prolonged applications
of pressure will have a relaxing effect on the client.
Over time, as you practice and develop comfort with
the components of the different strokes, you will focus less
on the application of each stroke and more on the integration and combination of strokes to individualize the benefits
and outcomes for a particular client. Practice, along with a
client-centered focus, will help develop the palpation skills
and intuition you need to provide an appropriate and beneficial massage. (Chapter 7 leads you through the assessment
process for determining appropriate massage treatment.)
There are several techniques and strokes that you may
incorporate into a basic massage. Some do not require any
pressure or manipulation of soft tissues, and others do.
Grounding, centering, and resting strokes require no lubricant because there is no slip , which is the sliding movement
of your skin across the surface of the client’s skin.
Grounding
Grounding is a process that is typically used before the
massage to create a kind of boundary between yourself and your clients. Massage therapists who regularly
give several massages a day sometimes feel drained or
exhausted after a particular client, suggesting that some
people “take” more of our core energy than others.
Instead of thinking that you are “giving” clients your
energy, slightly change your frame of mind and think of
yourself as a conduit for energy, a mechanism that redirects and refocuses the client’s energy. Think of yourself
more as a conductor of energy than as a source of energy.
changing the perception of your work, you may not feel
the exhaustion that results from conceptually giving away
your own energy. Grounding is an intangible screen of
protection that helps you keep your energy separate from
your client’s energy.
Spending time with people who are laughing and happy
can raise our spirits, just as people who are sad and depressed
By
370 INTRODUCTION TO MASSAGE THERAPY
CD
Figure 9-6. Resting strokes. (A) Shoulders of supine client. (B) Forehead and heart. (C) Connecting back to gluteals. (D) Connecting
gluteals to leg.
can make us feel gloomy. Basically, we are susceptible to
other people’s emotions. A similar phenomenon sometimes
occurs with a client’s symptoms. There are occasions when,
following a massage, your client’s original complaints seemingly manifest themselves in your own body. Although it
may sound incredible, it does happen, and the experience can
be unsettling and unpleasant. Grounding techniques used
before and during a massage can prevent such situations.
Generally, you ground yourself as you establish initial
contact with a client at the beginning of the massage. The
following visualization technique is an easy way to ground
yourself while establishing contact with a fully draped client
on the massage table:
1. Stand next to the massage table and direct your thoughts
to your feet and their contact with the floor.
2. Imagine your feet as the roots of a tree, giving you
stability and acting as a sort of drain for any unwanted
tensions or stressful energy.
3. Establish contact by gently resting your hands on top of
the sheets, on your client:
a. If the client is supine, rest your hands on the shoul-
ders or feet.
b. If the client is prone, rest your hands on the back,
shoulders, or feet. (See Fig. 9-6 for different hand
positions for resting strokes.)
4. Close your eyes and take a few deep breaths as you clear
your mind and focus on your client.
Grounding techniques can be used before the massage,
either outside or inside the treatment room, and they can
be used during a massage if you feel distracted or if you are
running out of energy. You can ground yourself anytime,
any day, in your personal life as well as your professional life.
Centering
Centering is the process of focusing your attention on the
massage session and being present in the moment. It should
be done before every massage session and can be combined
with your grounding technique. You may find it challenging to clear your mind. Instead of paying attention to the
distractive thoughts you want to forget, such as schedules,
grocery lists, errands, finances, or social commitments, you
can start centering yourself by focusing on your breath.