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Chapter 9 / Massage Strokes andFlow 381
when applied perpendicular to the relaxed muscle fibers of a
passive contraction, is uniquely able to separate those fibers,
increase local circulation, and restore movement.
Application of Friction
More heat is created when there is more resistance between
your skin and the client’s skin, so if you are applying superficial friction to warm the tissues, less lubricant is better. The
rate of the strokes is moderately fast, somewhere around 1
to 3strokes per second, and the length of the stroke along
the skin, or excursion, is a few inches. You can use your
thumbs, finger pads, or palms to apply superficial friction
with just enough pressure to feel the surface resistance as
you briskly rub the client’s skin. When you vigorously rub
your palms together to warm them up, you are using superficial friction. To maintain proper body mechanics for superficial friction, keep your arms, wrists, and hands as relaxed as
possible and minimize the use of superficial friction because
it requires vigorous activity on your part.
Deep-fiber friction is applied without any slip on the
skin, so again, little or no lubricant is better. It can be
applied perpendicular to the length of the muscle fibers
with a strumming action, or it can be applied in a circular
motion over the muscle fibers. Typically, deep-fiber friction strokes take about 3 seconds to travel across 1 inch
of muscle tissue, without any slip on the skin. You can
use your thumbs, finger pads, the knuckle portion of a
fist, or your forearm, but it is wise to always remember
the body mechanics rules of keeping your joints stacked,
keeping your shoulders down, and maintaining a proper
lean. See Figure 9-13 for deep-fiber friction over the erector spinae muscles. Because deep-fiber friction can be
perceived as an invasive technique, you must prevent the
guarding response by warming up the tissue with other
techniques prior to applying it.
Contraindications for friction include open or contagious skin
conditions, bruised areas, moderate to severe varicose
veins, acute injuries, inflammation, and infection.
Vibration
Vibration is a stroke that involves high-frequency shaky
hand movements. Vibrations can travel through our bodies,
affecting everything from the surface of the skin to the deepest organs. A common misconception in massage is that deep
tissue work requires a lot of pressure or manipulation, but
vibration demonstrates just how incorrect that is. Consider
how the ground shakes when a large trailer truck rumbles
by or how you feel the booming bass of a nearby car stereo
sometimes more than you hear it. Vibration can be used to
stimulate the nerves, muscles, and organs; to increase circulation and temperature of local tissues; and as a form of
anesthesia. Some variations of vibration, including rocking
and jostling, are generally used for relaxation.
Effects of Vibration
Muscle contractions can be sustained when the muscle
receives 10 to 20 nerve impulses per second. Vibration can
stimulate muscle contractions when the frequency of the
vibratory movements matches or exceeds the frequency of
the nerve impulses for muscle contraction. Unfortunately,
our hands can move at a rate of about 10 to 12 movements
per second, which is not usually fast enough to stimulate
muscle contraction. Ifyou or your clients want the stimulating effects of vibration, you can consider using a machine
that is more effective at delivering the necessary high frequencies. Like the other initial reflexive effects of touch,
vibration initially stimulates the nervous system and organ
activity. The effect is very similar to being shaken awake or
shaken to pay attention. After several minutes of vibration,
the reflexive effects of relaxation begin: pain sensitivity is
decreased, circulation increases, the temperature of the tissues increases, and muscle tension decreases.
Figure 9-13. Deep-fiber friction.
Application of Vibration
Some people find it difficult to learn how to apply vibration
because you have to keep your shoulder, arm, wrist, and
hand very relaxed while moving them very fast. Without
loose joints and muscles, you will create excessive strain on
your muscles and you lose the effectiveness of the stroke.
Rest your relaxed fingertips or finger pads on the client’s skin
and start moving your wrist and hand with a gentle, nervous
trembling motion. Again, maintain proper body mechanics
382 INTRODUCTION TO MASSAGE THERAPY
by staying as relaxed as possible, from your shoulders through
your fingertips. Your fingers can remain stationary on the client’s skin or you can lightly slide your fingertips along the
surface of the client’s skin while applying vibration.
Do not apply vibration over open or contagious skin
conditions, bruises, varicose veins, acute injuries,
inflammation, or infection.
Variations of Vibration
Rocking is a technique in which you use smooth, rhythmic,
intermittent pushes to slowly rock a client’s limb or entire
body. Slow and gentle rocking movement is a well-known
way to soothe and relax babies and adults alike. Rocking
is accomplished by maintaining the back-and-forth rhythm
of the client’s body with well-timed series of pushes and
releases. You can put pressure on the client’s arm, leg, or
pelvis to create the rocking motion. You must tune into the
client’s natural rhythm when rocking to allow the body to
relax. Once you start rocking the client, make sure that you
push at exactly the same time the client’s body is starting to
roll away from you. If you push while the body is still rolling
toward you, there will be an irregularity and awkwardness
to the rocking that is more bothersome than relaxing. The
main purpose of rocking is to encourage relaxation.
Jostling moves the client’s limbs back and forth in a wavelike snaking motion. The purpose of jostling is to confuse the
nervous system and induce relaxation. It is applied by grasping
an arm or leg, providing a small amount of traction, and then
moving the extremity by wiggling it side to side (Fig. 9-14).
Figure 9-14. Jostling.
All of the movements of the synovial joints are listed in the
special muscle section at the end of Chapter 4, Kinesiology and
Body Mechanics. Movement of the synovial joints, whether
active or passive, encourages the production of synovial fluid,
which nourishes and protects the joint structures. Joint movement also encourages the circulation of lymph by activating
the skeletal muscle pump mechanism. Joint movements are
easily incorporated into a massage and are very beneficial for
the client. Passive movements require that you hold and move
your clients gently and securely. Figure 9-15 illustrates passive
lateral flexion of the neck. It takes more work on your part but
allows clients to relax while you evaluate the quality and quantity of the movement. Active movements allow you to save
your own energy because the client does the work while you
visually evaluate the quality and quantity of the movement.
Some clients do not like to participate during the massage session, but you can still incorporate active joint movements during the pretreatment and posttreatment assessments.
Chapter 9 / Massage Strokes andFlow 383
Figure 9-15. Passive lateral flexion of the neck. (A) Starting position. (B) Final position: at limit.
There are some areas of the body for which you may need
to adjust your speed and/or pressure in order to prevent
damage to your client’s body when applying massage techniques. Generally, deep, direct, and/or compressive pressure should be avoided in these vulnerable areas of the
body, such as where the nerves, blood vessels, bony structures, organs, and lymph nodes are more superficial or
unprotected:
• Nerves—Compressed nerves may result in sensations such as “pins and needles,” tingling, numbness,
or burning or shooting pain. If a client tells you that
he or she is experiencing any of the aforementioned
sensations, immediately adjust your pressure or
move to another area of the body. Check with your
client to see if the sensation has subsided to ensure
he or she is comfortable. Prolonged compression
may cause injury, bruising, or irritation to the nerves.
• Blood vessels—Compression on superficial arteries
and veins affects circulation. Prolonged compression to an artery will cut off the flow of oxygenated
blood to everything distal of the point of compression, potentially causing numbness, discomfort,
panic, or blackouts. Veins, which are weaker than
arteries, may be injured by excessive compression,
possibly resulting in varicose veins or blood clots.
Because arteries and veins are located very close
together, massage techniques will typically affect
both, so be cautious and avoid prolonged pressure to
superficial blood vessels.
• Bony structures—Compressive massage or sustained, direct pressure on or near small, fragile, or
prominent bony structures can cause pain, bruising
to the surrounding tissue, and in some cases, fracture of the bone.
• Organs—Some organs are located or anchored in a
way that makes them vulnerable to some types of
bodywork. Deep pressure, compressive techniques,
or tapotement on or around the kidneys, just below
ribs on posterior back, or to the abdominal area may
cause pain, nausea, bruising, or diminished function.
• Lymph nodes—The functions of the lymph nodes are
to produce lymphocytes and filter and clean lymph.
These oval, bean-shaped structures are located superficially in several areas of the body (see Fig. 3-65).
When lymph nodes are working overtime to filter
excess toxins or fight an infection, they are generally enlarged and inflamed. Avoid massaging lymph
nodes as their function could be impaired.
In the field of massage therapy, endangerment sites are
specific areas on the body where the nerves, blood vessels,
bony structures, organs, and lymph nodes are more superficial or unprotected that should be avoided (see Fig. 9-16):
• Eyes —Eyes are very sensitive structures, especially if
the client wears contact lenses. There are nerves in
this area that supply the face with feeling and motor
control. Exercise caution when applying massage
around the eyes.
• Temporomandibular joint (TMJ) —Located immediately anterior to the ear, the TMJ (jaw) is the only
bilateral joint of the body and is susceptible to alignment problems. Avoid deep pressure to the bony
projection itself as well as to the facial arteries and
nerves located just anterior to the ear and along
384 INTRODUCTION TO MASSAGE THERAPY
Eyes
Anterior triangle
of the neck
Axilla
Medial
humerus
Abdominal
Femoral
triangle
Medial lower
leg
Temporomandibular
joint
Xiphoid
process
Deep hip
lateral rotators
Lateral lower
leg
Posterior triangle
of the neck
Medial epicondyle/
cubital fossa
Kidneys
Popliteal fossa
Figure 9-16. Endangerment sites.
the edge of the jaw inferior to the TMJ. There are
specific techniques that may alleviate symptoms
associated with TMJ tension and/or pain, but they
require specialized knowledge and training so as not
to cause injury or make the client’s condition worse.
• Anterior triangle of the neck —Located just inferior
to the chin, the anterior triangle contains structures
that may be injured by invasive or deep pressure
techniques: carotid artery, jugular vein, vagus nerve,
hyoid bone, trachea, thyroid cartilage, and glands.
Applying massage in this area requires advanced
training and skill.
• Axilla— The soft area of the client’s armpit holds the
axillary and brachial arteries and multiple nerves:
axial, median, musculocutaneous, radial and ulnar
nerves, and the brachial plexus. If, when applying
massage to this area, the client feels tingling, “pins
and needles,” or burning, sharp, or shooting pain,
you are compressing the blood vessels and/or
nerves and should adjust your pressure or move to
a different area.
• Medial humerus —Located on the soft, medial
side of the upper arm, the brachial plexus and the
cephalic and basilic veins are located here and should
be avoided.
• Abdominal area —Many susceptible structures are
located in this area: abdominal aorta, inferior vena
cava, ovaries in a female client, liver, spleen, and
intestines. Light pressure applied in this area can
enhance blood flow and digestion, but too much
may diminish the function of these structures or
cause injury.
• Xiphoid process —This spear-like, bony projection is
the inferior portion of the sternum and should be
avoided.
• Femoral triangle —Bilaterally located toward the
medial side of the upper leg, just inferior to the
pelvis, this area contains the femoral artery and
vein, the femoral nerve, and the inguinal lymph
nodes.
• Medial lower leg —Located on the medial side of the
lower leg, this area contains the unprotected great
saphenous vein.
• Posterior triangle of the neck— Located at the posterior base of the neck, the spinous processes are sensitive areas.
• Medial epicondyle/cubital fossa —Located between
the olecranon process of the ulna and the medial
epicondyle of the humerus, this area contains the
Chapter 9 / Massage Strokes andFlow 385
radial nerve. Sustained compression may cause injury to the nerve. This endangerment site is especially
important for a massage therapist’s self-care regime.
Applying compression with your elbow can be an
effective technique, but you must use the area that is
distal to the olecranon process. If you use the pointy
part of the olecranon process, you will be putting
pressure on your cubital fossa and possibly endangering the radial nerve.
• Kidneys —Located posteriorly and superficially, just
deep to the inferior rib cage, the kidneys are unprotected and held in place by soft tissue. Avoid deep,
direct, or compressive pressure and heavy tapotement to this area.
• Deep lateral hip rotator muscles —The sciatic nerve
runs through these muscles, just deep to the gluteal
muscles. The thickest nerve in the body, the sciatic
nerve may be irritated by massage to these if it is
compressed in any way.
• Popliteal fossa —Located on the posterior of the
knee, this soft area contains the common peroneal
and tibial nerves as well as the popliteal artery and
vein and small saphenous vein.
• Lateral lower leg —The common peroneal nerve is
unprotected on the lateral side of the lower leg, just
inferior to the head of the fibula.
If your assessment of a client’s condition leads you to
believe that the client may benefit from work to these areas,
special training in some energy techniques that require little
or no pressure or off-the-body work will allow you to facilitate healing within the area.
Any time a client has reduced pain sensitivity, massage
therapists must be especially cautious about moving the client’s joints through their range of motion. There are different kinds of barriers that limit joint movement, and some of
them involve hypertonic muscle or restricted fascia. Pushing
the tissues past their barriers can injure anatomical structures. With experience, you can learn to feel the barriers to
avoid hurting clients; however, as a beginner, you may need
input from your clients. Generally, clients feel discomfort
when the limits of joint movement are being approached,
but with reduced pain sensitivity, they may not.
You are now faced with the challenge of putting all of your
academic knowledge and artistic skill into a massage. The
first time you stand beside a client who is lying on a massage table, waiting for a massage, you may wonder whether
it is possible to spend an hour massaging one body. Where
do you start? What strokes do you use? Should the client
start supine or prone? What position should the client be in?
You will find the answers to these questions by learning and
understanding massage flow, which is a routine-like sequence
of steps that leads the massage from one body part to the
next in a systematic, fluid pattern. Table 9-4 summarizes the
strokes, their purposes and effects, and contraindications.
Similar to a cooking recipe, a flow is a set of step-bystep directions for your massage. It usually specifies the client’s position on the table and tells you which body parts to
work on and in what order. A flow can also suggest massage
strokes to use on the different areas of the body. With practice, a flow becomes second nature and lets you evaluate
the tissues throughout the massage instead of focusing on
which body part to work on and what strokes to use. Good
cooking recipes present their directions in a logical order
that can be followed easily and efficiently. In the same way, a
good massage flow guides therapists through a fluid, logical
order from body part to body part without a lot of wasted
time or energy. For instance, a good flow might direct you
to massage the client’s right hand, work up the right arm to
the right shoulder, connect the right and left shoulder with
a resting stroke in which one hand is on each shoulder, and
with a nerve stroke, move down to the client’s left hand to
begin work there. A bad flow might instruct you to massage
the client’s right hand, then move to the left hand, then the
right shoulder, and then to the client’s left shoulder. As a recipe is written to help us prepare edible and presentable food
that people enjoy and does not make people sick, the massage flow is designed to accomplish the long-term treatment
goal without endangering the client’s health.
Flow Sequences for Different Client Positions
There are general flows for clients in the supine position,
prone position, laterally recumbent (side-lying) position, and
seated position. Each position limits your access to some
part of the client’s body, which is why most therapists prefer asking a client to assume two or three different body
positions during the massage. The flow sequences for these
different positions outlined below are very general directions that guide your movement around the client’s body to
386 INTRODUCTION TO MASSAGE THERAPY
Stroke Purposes and Effects Contraindications
Grounding Establishes boundary between therapist and client
Helps massage therapist conserve energy
Centering Helps massage therapist clear mind and focus
attention on client
Resting Establish contact with the client
Assess the client’s tissues
Connect areas of the client’s body throughout the
flow of the massage
Compression Enhances arterial circulation
Enhances lymph and venous blood flow
Warms tissues via increased arterial circulation
Decreases muscular hypertonicity (tension)
Softens fascia
Decreases pain
Effleurage Apply lubricant
Assess muscle and soft tissue
Light pressure has a reflexive effect on circulation
Deep pressure has a mechanical effect on
circulation
Enhances venous and lymph circulation
Enhances arterial circulation
Enhances cellular metabolism
Decreases muscular hypertonicity/tension
Decreases ischemia and pain
None
None
None
Application over open or contagious skin
conditions
Application over bruised areas
Application over moderate to severe
varicose veins
Application over areas of acute injury
Application over open or contagious skin
conditions
Application over bruised areas
Application over moderate to severe
varicose veins
Application over areas of acute or
subacute injury, inflammation, infection
Repetitive application for clients with
high blood pressure, cardiovascular
disease, varicose veins or edema
Petrissage Increases circulation of blood and lymph
Softens skin by stimulating sebaceous gland activity
Warms the soft tissues
Enhances pliability of muscles and fascia
Decreases muscular hypertonicity
Relieves pain
Encourages relaxation
Tapotement Brief applications are stimulating
Prolonged applications encourage relaxation
Prolonged applications have anesthetic effects on
hypersensitive nerve endings
Increased circulation of blood
Increases temperature of tissues
Stimulates muscle contractions
Breaks up lung congestion
Friction Increases temperature of tissues
Enhances flow of blood and lymph
Dissipates body heat from the skin
Breaks up fascial adhesions
Application over open or contagious skin
conditions
Application over bruised areas
Application over moderate to severe
varicose veins
Application over areas of acute injury,
inflammation, infection
Applications over the spine
Applications on client’s back over the
kidney area
Application over open or contagious skin
conditions
Application over bruised areas
Application over moderate to severe
varicose veins
Application over areas of acute injury,
inflammation, infection
Application over open or contagious skin
conditions
Application over bruised areas
Application over moderate to severe
varicose veins
Application over areas of acute injury,
inflammation, infection
continues on following page
Chapter 9 / Massage Strokes andFlow 387
Stroke Purposes and Effects Contraindications
Vibration Brief applications stimulate nervous system and
organ activity
Prolonged applications are relaxing
Decreases pain sensitivity
Increases circulation of blood
Increases temperature of tissues
Decreases muscle hypertonicity
access all the different body parts smoothly and efficiently.
Asyou gain experience, you will develop your own combination of strokes and techniques, but as a place to begin, the
following section includes suggestions for sample flows for
specific body parts.
Supine Position Flow
The supine position allows for direct access to the anterior
side of the body—the face, the chest, the abdomen, and the
anterior aspect of the legs. Persons with sinus congestion,
those who do not like confined spaces, and those who are
very talkative during a massage may prefer the supine position. Box 9-8 includes an illustrated series of steps for a general supine massage flow.
Prone Position Flow
Application over open or contagious skin
conditions
Application over bruised areas
Application over moderate to severe
varicose veins
Application over areas of acute injury,
inflammation, infection
is better served in the side-lying position. For example, it is
dangerous to keep a pregnant woman supine during her last
few months of pregnancy because the fetus can put excessive pressure on her descending aorta. Massage is very beneficial during pregnancy, though, and pregnant clients can
safely receive massage in the side-lying position as long as
there are no systemic contraindications. Prenatal or pregnancy massage is covered in more detail in Chapter 12,
Special Populations.
When a client has a lot of neck and shoulder restrictions, the side-lying position provides excellent access to the
entire region. It also gives you a unique ability to maneuver
the client’s neck and shoulders through all of the possible
joint movements, so if you find that many of your clients
are complaining of neck and shoulder problems, you should
incorporate the side-lying position. Box 9-10 includes an
example of a massage flow for a client who is lying on her
left side, properly positioned and bolstered.
Clients who are not very conversational or who are suffering back pain may prefer the prone, or face down, position.
Inthis position, you have particularly good access to a client’s back, gluteal muscles, and the posterior aspects of the
legs, but your access to the anterior aspect of the body is
limited. If a client uses the face cradle to maintain a neutral
neck position while lying in the prone position, the entire
neck and shoulder region is easily accessible to you. Box9-9
shows a sample flow for massaging clients in the prone
position.
Side-Lying (Laterally
Recumbent) Position Flow
The side-lying (laterally recumbent) position is not as popular as the others because it requires additional bolstering
and because the draping can be awkward and a bit challenging to learn. Many therapists do not incorporate this position into their massages, but there are times when a client
Seated Position Flow
You may need to give a complete relaxation massage to a
client who is seated. If someone is unable to climb onto
your table, is not comfortable lying down, or is bound to
a wheelchair, a seated massage may be the most appropriate position. This seated flow is designed for relaxation,
making it different from the stimulating focus of chair and
corporate massages with a short duration. Because clients
remain clothed for the massage, there are no draping considerations, but if they wear shorts and tank tops or short
sleeves, you have better access to their tissues and can apply
more strokes that offer clients more benefits. You can easily apply compression, tapotement, and vibration through
clothing, and possibly some petrissage or deep-fiber friction.
Effleurage, which is such a good stroke for assessing the condition of the client’s tissues, is not appropriate for clients
who are clothed. You can deliver a seated massage to a client
in a chair by following the steps in Box 9-11.
388
INTRODUCTION TO MASSAGE THERAPY
BOX 9-8
1. Stand or sit at the head of the massage table, facing the
client to massage the:
• Face
• Ears
• Scalp
• Neck
• Upper chest
• Shoulders
2. Walk to the client’s left side, undrape the left arm and
massage the client’s left hand, forearm, upper arm, and
shoulder, and redrape the arm.
3. Use connecting strokes to walk toward the client’s left foot.
4. Sit or stand at the client’s feet, undrape the left foot and
massage the:
• Sole
• Ball of the foot
• Toes
• Top of the metatarsals
• All around the ankle and heel
Chapter 9 / Massage Strokes andFlow 389
BOX 9-8
(continued)
5. Stand at the client’s left side, expose the left leg, and
massage the:
• Lower leg
• Upper leg
6. Redrape the left leg and move to the client’s feet.
7. Undrape the client’s right foot and massage the sole of
the foot, ball of the foot, toes, and all around the ankle
andheel.
8. Stand at the client’s right side. Expose the right leg and
massage the lower leg and upper leg.
390 INTRODUCTION TO MASSAGE THERAPY
BOX 9-8
(continued)
9. Redrape the right leg, undrape the right arm, and
massage the:
• Hand
• Forearm
• Upper arm
• Shoulder
10. Redrape the arm and apply head-to-toe nerve strokes to
reconnect the entire body.
Full-Body Massage Flows
The most common flow for a full-body massage utilizes
at least one position change during the massage. You can
combine the sample flows in any order to accomplish a
full-body or partial-body massage. Most massage therapists use the prone and supine positions, in either order,
but you should try several different combinations to get
comfortable with the change of positions and the draping
considerations:
• Clients start supine, then turn over, finishing in the
prone position
• Clients start prone, then turn over to finish in the
supine position
• Clients start prone, assume a side-lying position
on their right side, turn to lie on their left side,
then turn onto their back, finishing in the supine
position
• Clients start supine, lie on their left side, turn over to
their right side, then flip once more to finish in the
prone position
• Clients start in the side-lying position on one side,
then flip over to finish in the side-lying position on
the other side
It takes time for clients to change positions during a massage,
so you may want to minimize the position changes. Also, some
clients do not like to have to move during the massage and do not
appreciate having to flip over more than once during the massage.
On the other hand, therapeutic massage is intended to treat soft
tissue conditions that you discover before and during treatment,
and it may serve the client best to use more than two positions
during a massage. If you discover that the client will benefit from
multiple positions, educate him or her on your plan and why you
will be moving him or her around during the session. The sample
flows do not provide directions for a full-body massage because
we believe that an individualized massage is best.