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Chapter 9 / Massage Strokes andFlow 411
BOX 9-19
(continued)
b. Starting at the shoulders and brushing down, toward
the sacrum
11. Stretch the client’s pectoral muscles:
a. Ask client to sit up and take a deep breath.
412 INTRODUCTION TO MASSAGE THERAPY
BOX 9-19
(continued)
b. Ask client to place both hands behind the head and
inhale slowly.
c. Ask client to exhale slowly as you slowly pull the
elbows back, toward you, to the end feel.
d. Repeat two to three times.
12. Apply a resting stroke to the client’s shoulders.
Courtesy of Kathy Latimer, RRT, NCTMB.
m
Chapter 9 / Massage Strokes andFlow 413
Corporations and business organizations generally schedule your visits on a weekly or monthly basis
with a contractual agreement, and they typically pay
you directly, rather than requiring their employees to
pay you individually. Make sure that you and the business both understand each other’s expectations and
accommodations:
• Your time commitment
• Specific location and space you will use
• Length of each appointment
A
• Appointment scheduling responsibility
• Payment arrangements
• Fee schedule
• Who is responsible for payment
• When payments must be made
• Sound system, or music
• Your parking arrangements
• Missed appointments
• Your tardiness or inability to meet the schedule
B
Figure 9-19. Face cradle coverings. (A) Paper towel. (B) Bouffant cap.
Alert
Some people are allergic to latex, so be sure to have
So
gloves that are made from a nonlatex material.
Corporate Chair Accounts
Acquiring an account to provide corporate chair massage may be as simple as contacting local companies,
educating them on the benefits of massage, and setting
up an initial session for their employees. Corporations
can justify the financial cost of massage therapy in the
workplace with increased productivity and the ability to
attract and retain high-quality employees, and improve
employees’ health and thereby minimize health insurance
premiums. Many hospitals, doctors’ offices, pain clinics,
regional conference gatherings, and schools provide chair
massage.
If you and the organization establish and clarify these
responsibilities at the beginning, you can avoid potential
complications and misunderstandings in the future.
Indications and Contraindications for Chair Massage
The indications and contraindications for massage are generally the same as those for chair massage, but there are
pain patterns in the lumbar, thoracic, shoulder, and cervical (neck) regions for which chair massage is indicated
(Box9-20).
A routine massage that strictly follows a given flow applies
the same number of strokes in the same order and treats the
body parts in the same order for every client. Although a routine is easier in that you do not need to think about what to
incorporate into the session, a routine also seriously limits
your capability to provide a client-centered massage. Going
back to the recipe analogy, people commonly substitute
ingredients or alter the directions of a recipe with excellent
results. Consider a good cook who can make delicious food
without a recipe, using everyday cooking tools and whatever
ingredients are in the house. Those creations allow the cook
414 INTRODUCTION TO MASSAGE THERAPY
is provided in Table 9-5 to help you evaluate the individual
needs of your client and to decide what course of treatment
Indications and
Contraindications for
ChairMassage
Indications
• Cervical
• Muscle pain and tension
• Decreased ranges of neck motion
• Tension headaches
• Shoulder
• Decreased ranges of shoulder motion
• Subacute shoulder strain
• Subacute or chronic shoulder pain and muscle
tension
• Carpal tunnel syndrome
• Thoracic area
• Pain between scapulae
• Decreased range of motion of scapula
• Lumbar area
• Subacute low back strain
• Decreased flexibility
• Subacute or chronic low back pain and muscle
tension
Contraindications
• Systemic
• Acute stage of contagious disease
• Fever
• Local
• Acute inflammation
• Swollen lymph glands
• Acute injuries (24 to 72 hours after injury)
• Recent surgery (24 to 72 hours after surgery)
• Open wounds, blisters, burns, and abrasions
• Bruises/contusions
• Skin infections
• Rash
would be most appropriate for him or her. (Please note that
this model is also incorporated into chapter exercises in
Chapters 10 and 11, and will help you apply critical thinking
skills to realistic client scenarios.)
Throughout the flow of the massage session, you
should “listen” and respond to the client’s tissues, traveling
only as fast as the tissues allow. In general, the more tense
the muscle, the more slowly you should move. If you move
too quickly or with too much pressure, the client might hold
his or her breath, the client’s body might resist the work, or
the client’s body might tense up and effectively push you
out. When there are any indications that the body is tensing
up, you need to adjust your stroke, the pace, or the intention
of the massage. You must remain psychologically flexible
about the flow instead of approaching your massage with a
determined and uncompromising attitude.
By combining techniques and strokes and applying
them to different body parts in different orders, you can
create thousands of different flows. As a result, therapists
often develop their own unique general flow for a massage
session. The key to a good massage lies in blending rhythm
and pressure with continuity and focused contact. Once
you have learned the basic massage strokes and are comfortable applying them, your flow will become natural and
effortless.
There will be situations when you are practicing massage that will require you to make modifications to your
treatment. Whether a client is coming in for his or her first
or fifteenth massage, you must assess your client before
every session to know whether there are any health conditions that are local or systemic contraindications. If a client
has a systemic contraindication, such as a fever or viral infection, you should reschedule the appointment. You may have
to modify the direction or rate of movement, excursion,
rhythm, or pressure in response to the current condition of
the client’s tissues and pain tolerance.
Client comfort and relaxation as well as the long-term
success of your practice depend on your use of client posi-
to add special ingredients or combine the ingredients in interesting ways to make the dish more successful than a standard
recipe. In the same manner, you can make adjustments to
a massage flow by tailoring the session to each client with
different strokes or techniques. Your artistic combination of
strokes and techniques, the speed at which you apply them,
and the length of time you keep the client in any one position creates a unique massage every time. Flow can be varied
to accommodate your equipment, the client’s body position,
or the condition of the client’s soft tissues. For example, a client who complains of excessive shoulder pain may want you
to spend extra time working on the shoulder area with therapeutic techniques. Follow a flow loosely to allow the massage to fit the needs of the client. A critical thinking model
tioning, draping, and body mechanics. Once you are adept
at simple draping, you can explore adaptations and supplemental draping options with extra blankets, towels, or an
additional sheet. It can be an awkward process at first, but
with practice, you will develop your own draping techniques. The outcome will be good if the client’s comfort
level remains your primary intention.
Massage has many physiological benefits, but you
must assess your clients before and during treatment to
make sure there are no contraindications. You can educate clients about their conditions and how massage might
benefit them. Massage that lasts for 10 minutes or longer
can improve circulation of blood and lymph, increase the
warmth of the tissues, decrease pain, induce the relaxation
Chapter 9 / Massage Strokes andFlow
415
Review client
information
Condition What current soft tissue or pathological conditions is the client
experiencing?
• What are the functional limitations associated with this
condition?
• Is massage indicated or contraindicated for this condition?
If contraindicated, refer client to appropriate healthcare
professional. (See pathology quick reference in Appendix for
specific conditions.)
• Has the client undergone any other treatment for this condition?
If so, what have the results been?
• How long has this condition been present and how long does it
typically last?
Interview Pain Using open-ended questions and reflective listening, what
are the past or present conditions that might be causing
pain or compensation patterns (pay attention to nonverbal
communication)?
• Qualify the pain as sharp, dull, or radiating (radiating pain may
indicate nerve involvement and possible referral to another
healthcare professional, whereas sharp pain may indicate a
recent injury).
• Quantify the pain on a scale of 1–10.
• Does the pain increase or decrease during the day?
• What tends to aggravate or reduce the pain?
Sleep If sleep seems to be affected by the condition, compare the
client’s past sleep patterns with the present:
• Bedtime and amount of time it takes to fall asleep
• Number of consecutive hours of sleep
• Number of times client awakens during the night
• Pain/discomfort level upon waking
• Anything the client thinks might be affecting sleep
Hydration How much water does the client tend to drink during the day?
Physical activity What are the client’s physical activity habits?
Assessment Determine which
muscles are involved
Determine which areas
to treat
(Insufficient water levels can result in thickened fascia, increasing
friction between tissues and increasing pain.)
• Duration/frequency of physical activity/exercise
• Does the client tend to warm up and/or stretch prior to or after
exercise? (This is an opportunity to educate clients.)
• Does the client tend to increase water consumption following
exercise?
What movements are involved, causing pain or are restricted?
• Consulting the special muscle section in Chapter 4, what
muscles are involved in the movement(s)?
• Consulting Table 10-1, what are the antagonists to the involved
muscles?
• Consulting Box 7-2, identify any compensation patterns.
Given the muscles involved and compensation patterns revealed,
choose only two or three areas to address (to minimize the body’s
recovery after treatment).
• Avoid treating areas that elicit pain upon passive contraction
(outside the scope of practice).
continues on following page
416 INTRODUCTION TO MASSAGE THERAPY
Massage continued
Goals Based on the client’s input, the physician diagnosis and treatment,
and massage therapy assessment, what are some appropriate
short-term and long-term goals?
Design the
massage
Determine techniques to
use during the massage
Treatment adaptation Are there any adaptations that should be made to a standard
Consider the history, interview, and assessment to decide which
techniques to use:
• If the client’s goal is general relaxation, and massage is not
contraindicated, use one or a combination of the basic massage
strokes.
• Clients who rub or knead their shoulder when describing
shoulder pain might respond well to effleurage and petrissage on
the shoulder.
• A client with chest congestion might benefit from tapotement on
the upper back area.
• Friction can be beneficial for scar tissue and fascial adhesions.
• People involved in sports tend to respond well to proprioceptive
neuromuscular facilitation techniques.
• Long-term conditions and compensation patterns may have
fascial restrictions that can benefit from myofascial work.
• A hypertonic area that refers pain and may have been activated
by overuse may respond well to trigger point work.
massage flow?
• Are there any conditions that require positioning or bolstering
considerations (pain, sinus congestion, low back pain)?
• Are there any local contraindications that you must avoid during
the massage?
• Are there any sensitivities or allergies to consider?
• Does the client have any special needs such as assistance on or
off the table (visual impairment, physical impairment)?
response, decrease muscular tension, and normalize the
activity of the nervous system.
Practice massage strokes and flows and get constructive
feedback as you learn. Receive massage from others; it helps
you understand how much one person’s touch differs from
another’s. By experiencing different therapists’ flows, you
will also understand how a flow can influence the response
to the massage. The basic techniques are much more effective when applied appropriately. With a lot of experience,
the distinct differences between the individual strokes
become less defined. For instance, you could be applying an
effleurage stroke when you come across a fascial restriction,
and instantly turn the effleurage stroke into a compression
stroke. The compression may lead you into an application of
vibration or any one of the therapeutic techniques. As you
get more comfortable with applying the different strokes
and knowing when to use them, they will run together and
your massage will become more fluid and efficient.
1. Describe the following terms:
a. Laterally recumbent
b. Prone
c. Supine
2. Practice client positioning with a fully clothed part-
ner on the massage table in the prone, supine, and
side-lying positions, with and without a face cradle,
and with and without the following bolsters:
a. Neck (prone, supine, and side-lying)
b. Chest (prone)
c. Pelvis (prone)
d. Ankles (prone)
Chapter 9 / Massage Strokes andFlow 417
e. Knees (supine)
f. Top leg (side-lying)
g. Along the length of the back (side-lying)
3. Practice draping with a partner on the massage
table (the partner should be undressed and underneath the drape) to expose different areas of the
body:
a. Prone position—back, leg, foot, arm
b. Supine position—arm, upper chest, abdomen,
leg, foot
c. Side-lying position—back, top arm, top leg,
bottom leg
4. Practice helping undressed clients on and off the
massage table, maintaining modesty by keeping
them covered with the drape.
5. There are circumstances for which certain client
positions are recommended. Identify at least two
reasons to put a client in each of the three positions: prone, supine, and side-lying.
6. Name the two primary reasons for draping clients
during a massage.
7. Explain the importance of grounding and center-
ing before a massage session.
8. Lead a partner through diaphragmatic breathing
by describing the process of taking a deep breath
using the diaphragm.
9. Explain the purpose of using a resting stroke.
10. List and describe the six basic massage strokes.
11. Practice each of the six strokes on a partner. Ask
your partner to watch your shoulder, elbow, wrist,
and hand as well as your head-to-heel line while
you apply the strokes. Ask your partner to let you
know if any part of your arm looks tight and tense
or if you have abandoned the head-to-heel line.
12. Describe the difference between superficial and
deep effleurage.
13. Describe at least one effect of each basic massage
stroke:
a. Compression
b. Effleurage
c. Petrissage
d. Tapotement
e. Friction
f. Vibration
14. Describe the benefits of using joint movement
during a massage session.
15. Write a flow for a relaxation massage, including
step-by-step instructions for client positioning,
bolstering, draping and redraping of specific areas
of the body, and specific strokes and techniques.
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Objectives
10
Upon completion of this chapter, the student will be
able to:
■
Describe what happens in each of the three
phases of healing
■
Explain the three stages of the pain cycle
■
Identify the four signs of inflammation
■
Explain the difference between lengthening and
stretching
■
Name the three types of circulatory
enhancement massage
Key Terms
Direct manipulation (DM) : A proprioceptive neuro-
muscular facilitation (PNF) technique in which you
use the muscle spindles and Golgi tendon organs to
relax a hypertonic muscle.
Direction of restriction : The direction in which tissues
resist movement the most.
Hypertonic (HAHY-per-TAHN-ik): Excessively tense
ortight.
Lengthening : The neurological process that lengthens
myofibrils and results in a longer muscle.
Lymph : The fluid that started out as blood plasma, leaked
out through the capillaries to become interstitial fluid,
and is picked up by the very delicate ends of the lymphatic vessels from tissues all over the body.
Muscle energy techniques (METs): Bodywork appli-
cations that use the nervous system to change a
■
Describe at least three ways to enhance the flow
of lymph
■
Name and locate the major lymphatic ducts on
an illustration of the skeleton
■
Correctly perform at least three proprioceptive
neuromuscular facilitation techniques on a partner
■
Correctly perform at least one connective tissue
technique
■
Correctly perform at least one trigger point
release technique
muscle’s resting length, also called proprioceptive
neuromuscular facilitation.
Muscle guarding : Hypertonic muscles stabilizing or
splinting an injured area.
Positional release (PR) : A PNF technique that relieves
hypertonicity by holding the body in a painless
position and waiting for the nervous system to
trigger relaxation, also called strain/counterstrain.
Post-isometric relaxation (PIR) : A PNF technique that
uses active contraction and relaxation of the target
muscle to lengthen the muscle.
Proprioceptive neuromuscular facilitation (PROH-pree-
oh-SEP-tive NOO-roh-MUSS-kyoo-lar fah-SIHL-ihTAY-shun) (PNF) : Bodywork applications that use the
nervous system to change a muscle’s resting length,
also called muscle energy techniques.
419
420 INTRODUCTION TO MASSAGE THERAPY
Reciprocal inhibition (RI) : A PNF technique in which
the client contracts a target muscle’s antagonists to
reflexively relax the target muscle.
Resting length : The length to which a relaxed, inactive
muscle can be safely extended.
Right lymphatic duct : A major drain that collects
all of the lymph from the upper right quadrant of
the body, including everything on the right side
of thebody above the diaphragm, and empties it
intothe right subclavian vein.
Strain/counterstrain (SCS) : A PNF technique that
relieves hypertonicity by holding the body in a painless position and waiting for the nervous system to
trigger relaxation, also called positional release.
Stretching : An elastic deformation of the fascia that
extends its length.
his chapter focuses on therapeutic and rehabilitative massage applications. In addition to providing the
T
general benefits of the basic massage strokes such as
relaxation, pain relief, enhanced circulation, and decreased
muscular tension, therapeutic applications treat soft tissue
conditions more efficiently. Clients often complain of tightness in a particular muscle, a “knot” or localized area of
tight muscle tissue, pain or discomfort in a specific muscle,
restricted movement, and specific soft tissue injuries. By
understanding the body’s tissue repair mechanism, you will
know how to prevent further injury to the area and you will
appreciate how massage promotes the healing process.
There are principles for applying therapeutic techniques
that can maximize the efficiency of your work. It makes
sense to want to work with the body rather than against it,
but sometimes that means you accentuate the client’s problem before you resolve it. Second, you must incorporate both
lengthening and stretching of soft tissues into therapeutic
massage because without both, the results of the massage
could be short lived. If your treatment does not improve their
condition, clients can lose interest or question your skills.
Four main categories of therapeutic applications are
introduced in this chapter: circulatory enhancement, neuromuscular techniques, myofascial techniques, and trigger
point (TrP) techniques. Circulatory enhancement is a way of
using massage techniques to mechanically manipulate the
Target muscle : The muscle being treated in a
therapeutic technique.
Tender point : A small, painful area of hypertonicity,
also called a tender spot.
Thoracic duct : A major drain that collects the lymph
from everywhere in the body, except the right side
of the head and thorax, and empties it into the left
subclavian vein.
Trigger point (TrP) : A localized area of hypertonicity
atthe motor end unit, or neuromuscular
junction,that refers symptoms to other areas
ofthe body.
Unwinding (myofascial unwinding) : The process in
which soft tissues move in different directions,
circles, or wavy lines as the collagen fibers change
shape and the fascia softens.
flow of blood and lymph. Neuromuscular techniques utilize
the nervous system to create reflexive changes in the length
of muscles. Myofascial techniques concentrate on manipulating the fascia in and around the muscles, mechanically
changing the shape or structure of the muscles and other
soft tissues. TrPs, localized areas of hypertonicity that occur
at the neuromuscular junction, can be treated with both
mechanical and reflexive techniques.
Another difference between wellness massage and therapeutic massage is the depth of the treatment plan. Sometimes
therapeutic massage is referred to as treatment-oriented massage. For professional consistency, include a treatment plan
for all of your clients, but when clients are looking for specific results for a particular condition, incorporate more details
in your plan for future treatment. Specify the duration and
frequency of future sessions, suggested techniques, client
likes and dislikes, self-help suggestions, and, when appropriate, professional healthcare referrals. With all of the specific information in a therapeutic treatment plan, a standard
SOAP note or other medical charting method is more appropriate than a shortened health form or history form.
Therapeutic techniques are nothing more than the
basic massage strokes. Compression, effleurage, petrissage,
tapotement, friction, joint movements, palpation skills, and
the principles of proper body mechanics are your foundations for therapeutic applications.
When tissues are injured, the body automatically repairs
the damage with regeneration, the process of replacing
destroyed cells, and with fibrosis, the production of fibrous
connective tissue (CT). Bones, epidermis, and mucous
membranes can successfully regenerate and be repaired
with CT. Muscle cells and nerve cells, however, cannot be
replaced. Injured muscle tissues and nervous tissues can
only be repaired with CT. The extent to which any given