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Chapter 10 / Therapeutic Applications 451
Skin Rolling
1. Establish the contact point and check the tissue for
the direction of restriction while maintaining contact.
a. Push the tissue away from you.
b. Pull the tissue toward you.
2. Grasp the tissue in a roll, pulling it slightly in the direction
of ease, away from the client’s spine.
3. Gently change direction, pulling the rolled tissue into the
direction of restriction.
4. Slowly transport the rolled tissue in the direction of
restriction by gathering the tissue with your fingers and
feeding it into your thumbs, keeping the roll of tissue
elevated. Continue the skin roll for several inches, or until
the restriction diminishes.
c. Push the tissue to your left.
d. Push the tissue to your right. Tissues do not move easily
in this direction, making this the direction of restriction.
5. Release the roll of tissue carefully. Apply a resting stroke to
allow tissues to reorganize. Return to the original contact
area and reevaluate the tissue for restriction.
452 INTRODUCTION TO MASSAGE THERAPY
Figure 10-4. Variations of skin rolling: C-stroke and S-stroke. (A) Lift tissue into a roll. (B) Then deform it into a C-stroke or (C) an
S-stroke .
direction of restriction. The scar, held in a passive stretch,
may start to deform as the tissues are loosened and collagen rearranged.
Maintain your contact point and avoid slipping on the
client’s skin while you apply sustained 45° pressure. You may
Scar Release
1. Palpate the scar to determine the direction of restriction.
Anchor one end of the scar with a finger or thumb.
feel your finger start to move as the underlying tissues soften
and spread out. Massage can help create more functional and
mobile scar tissue, but the number of treatments depends on
how severe the scarring is and how long the client has had
the scar. Box 10-11 illustrates the steps of scar release.
3. Continue to follow the tissue as the fascial adhesions
release.
2. Using your other hand, apply 45° pressure with a finger
or thumb in the direction of restriction while maintaining
the pressure and your contact point. Follow the tissue as it
softens and deforms.
4. Slowly relieve your pressure when you feel the resistance
fade away.
Chapter 10 / Therapeutic Applications 453
Craniosacral Therapy
Craniosacral therapy (sometimes called cranial sacral therapy and abbreviated CST) is a gentle technique that uses
about 5 g of pressure, the weight of a nickel, to evaluate
and enhance the craniosacral (KRAY-nee-oh-SAY-kruhl) system in which cerebrospinal fluid (CSF) bathes the brain and
spinal cord. By improving the flow of CSF throughout the
craniosacral system, overall health can be improved.
In the 1940s, William G. Sutherland, DO, developed a
technique he called cranial osteopathy. It is based on his observations of cranial bones moving very slightly in a unique
rhythm, distinct from the pulse or breathing pattern. He suggested that restrictions of the cranial movement can negatively
affect a person’s health. Cranial osteopathy treats an imbalance
or interrupted rhythm by manipulating the cranial bones.
John E. Upledger, DO, OMM, born in 1932, further
advanced the practice and developed his own form of CST.
Using the same basic theory and principles as cranial osteopathy, CST works more with the fascial component of the
dura mater and dural tube that encase the brain and spinal
cord. From 1975 to 1983, Dr. Upledger performed research
at Michigan State University that confirmed the rhythmic
movement of the cranial bones and clarified the craniosacral
mechanism as the cause for the CSF pulse. His theory suggests that restrictions in the flow of the CSF can cause dysfunctions of the central nervous system, such as sensory and
motor dysfunctions and neurological disabilities.
The rhythmic flow of CSF is conducted throughout the
body via the three-dimensional fascia, making it possible to
feel the movement almost anywhere on the body. Like the
cardiac pulse, it is very subtle and difficult or nearly impossible to feel when you apply too much pressure. Although
some persons learn to see this slow and very slight movement, most persons can learn to feel it using a very light
touch, with no more force than the pressure applied by a
nickel resting on your skin. The rate is much slower than the
breathing rate, as it generally takes about 10 seconds to complete a cycle. It can be felt as a 4-second outward expansion
of the body, followed by a 2-second pause, and then about a
4-second inward contraction or shrinking of the body.
CST practitioners first evaluate the craniosacral rhythm
at different key points on the body for smoothness, amplitude, and bilateral evenness. Restricted movement can indicate an obstruction of the CSF flow. By applying very small
amounts of pressure to the cranial bones or other areas on
the body, you can manipulate the movement, which helps
the body restore and regulate the flow of CSF. Theoretically,
improving the flow of CSF can relieve a number of associated health conditions such as headaches, autism, tinnitus,
poor eye–hand coordination, and vertigo.
The techniques are taught at clinics and workshops
worldwide. The Upledger Institute, located in Florida, is one
of the foremost authorities on CST and offers courses and
certification programs for massage therapists, osteopaths,
chiropractors, physical therapists, and other healthcare professionals. See the Upledger Institute web site (www.upledger
.com) for more information.
Myofascial Friction Techniques
The fascial layer surrounding the muscles can become sticky
or adhesive for several reasons, primarily insufficient hydration, poor nutrition, and inadequate activity. When an adhesion or scar tissue forms, collagen fibers are deposited in a
random pattern with the fibers going in multiple directions.
Friction is the main form of myofascial work specifically
intended to disrupt and break down adhesions and scar tissue in soft tissue structures with linear fiber alignment such
as muscles, tendons, and ligaments. The three basic types of
friction are cross-fiber friction (XFF), circular friction (CF),
and longitudinal friction (LF). The mechanism of friction
actually reinjures the affected tissue to initiate phases II and III
of the healing mechanism, which involve the production and
proper alignment of collagen fibers. Understanding the process of collagen fiber alignment in phase III, you can help the
original injury heal with a more mobile and functional scar.
The recovery period following a friction treatment is as
important as the treatment itself. Make sure that the client
uses the frictioned muscle regularly and without resistance
or weight. The activity should be slow and careful, and it
should move through the full range of motion to create a
functional scar. Without this gentle activity, a CT adhesion
is likely to return.
James H. Cyriax, MD, MRCP, was an orthopedic doctor
whose approach to musculoskeletal disorders included three
principles:
1. Every pain has a source.
2. Treatment must reach the source.
3. Treatment must benefit the source to relieve the pain.
Starting at the location of a person’s pain, he followed the
myofascial lines of tension back to the site of the initial adhesion
and was able to treat the pain by applying XFF to the adhesion.
His work was so successful that Dr. Cyriax is credited with reintroducing manual therapy to the medical community. Because
XFF can be very intense and uncomfortable, take great care to
stay within the client’s tolerance. Figure 10-5 illustrates XFF.
CF is applied in small, circular motions to the affected
tissue. It can be a very useful technique for addressing deep
adhesions and scars (Fig. 10-6).
LF can help separate the randomly arranged fibers,
freeing them up to allow more muscle movement. It differs
from the other friction techniques because it is applied in
the direction of the muscle fibers with a quicker and more
superficial stroke. Figure 10-7 shows the application of LF.
Several principles guide the use of any type of friction
(Box 10-12).
454 INTRODUCTION TO MASSAGE THERAPY
ABC
Figure 10-5. Cross-fiber friction. (A–C) The stroke runs perpendicular to the muscle fibers.
Figure 10-6. Circular friction.
ABC
Figure 10-7. Longitudinal friction. (A–C) The stroke runs parallel to the muscle fibers.
Principles for Applying Friction
• Educate the client about the technique. The therapist should
explain that friction is a deep treatment designed to provide
a controlled reinjury of the tissue and may induce pain. The
therapist can explain that reinjury will allow the body to heal
the tissue in a more functional manner.
• Obtain the client’s consent to receive friction treatment.
• Fingernails must be short to apply this technique.
• The tissue must be warm prior to application.
• No lubricant is used, to allow the therapist to maintain the
contact point.
• The client must be in a comfortable position that gives the
therapist access to the affected tissues.
• Pressure is applied in one or more directions based on the
objective of the treatment.
• The pressure should be deep enough to penetrate the tissue
and be annoying to the client yet remain within the client’s
pain tolerance.
• The therapist must tell the client that ice is recommended
following treatment to reduce inflammation.
Chapter 10 / Therapeutic Applications
455
Trigger Point Techniques
Usually activated by acute or repetitive overuse, a trigger
point (TrP) is a localized area of hypertonicity. TrPs occur
at the motor end unit, which is the neuromuscular junction, or meeting point between a nerve cell and the muscle
cell it controls. TrP techniques are sometimes considered a
subcategory of myofascial release and sometimes a form
of neuromuscular (NOO-roh-MUSS-kyoo-lahr) therapy.
In addition to treating fascial restrictions, TrP techniques
address hypertonic areas of muscle tissue. Janet Travell,
MD (1901–1997) developed TrP therapy, and her research
continues to be the most widely referenced in this type
of treatment. Putting pressure directly on top of a TrP
is usually painful for the client, and because of the nerve
involvement, it refers vague, aching discomfort or an itchy
sensation to the surrounding areas, in a specific pattern. It
is usually painful for the client to actively move a muscle
with a TrP, and the pain tends to limit the range of motion
before reaching the end feel.
The difference between a tender point and a TrP is
the involvement of a motor end unit. Tender points are
areas of hypertonicity that do not refer pain. TrPs are so
named because the malfunctioning neuromuscular junction triggers pain in specific patterns elsewhere on the
body. Maps and charts of specific TrPs and their referred
pain patterns are available for many muscles and can be
very helpful. Figure 10-8 is a TrP map for the latissimus
dorsi muscle.
A TrP is not a pathologic disease, but it does result from
a hypertonic muscle. The decreased circulation in a hypertonic area reduces nutritional exchange to the area, causing
it to be hypersensitive and hyperirritable. This is another
example of the pain cycle in action. Several factors can create or perpetuate TrPs:
• Mechanical stresses, including skeletal misalignment
• Poor posture
• Long-term muscle constriction, such as compression
by a purse or backpack
• Nutritional inadequacies
• Insufficient hydration
• Psychological factors, such as stress or the sympathetic nervous system response
• Inadequate sleep
TrPs that have existed longer than 3 weeks are considered chronic, and they can cause numbness and tingling
along their specific referral patterns. They can also cause satellite TrPs in the synergistic muscles, created as a result of
the original muscle being shortened and pulling the synergists into shortened positions.
The general benefits of wellness massage offer relief
to clients suffering from TrPs, but specific TrP techniques can provide relief to the localized and referred
pain, tingling, numbness, sensation of heat or cold, and
itching. A TrP can feel like a nodule or localized area of
hypertonicity amid a taut band of tissue running parallel to the muscle fibers. According to Dr. Travell, several
methods can be used to release the hypertonicity at these
troublesome neuromuscular junctions: PNF and friction techniques (discussed above), TrP pressure release,
and strumming. A combination of techniques can also
release a TrP.
Figure 10-8. Trigger point map for the latissimus dorsi. (MediClip
image copyright © 2003 Lippincott Williams & Wilkins. All rights
reserved.)
Trigger Point Pressure Release
In the trigger point pressure release (also the direct pressure release) technique, you first extend the target muscle
to its comfort barrier and palpate the TrP. Figure 10-9 illustrates the techniques for palpating TrPs. Increase your finger pressure on the TrP until you feel tissue resistance and
maintain that pressure until the tissues release. This may
take between 30 and 45 seconds. The release will feel like
the nodule is melting as it lets go. Keep your contact finger
on the original contact point on the client’s skin and follow
the release. The tissues may soften to allow your finger to
sink deeper or the tissues may move in an irregular path at
an irregular speed with fascial unwinding. There is a delicate balance between applying enough pressure to release
the TrP and applying so much pressure that it worsens. The
completion of the release is similar to the feeling you get at
the bottom of a slide; initially, there is a force that pulls you,
and then the pull slowly fades away.
456 INTRODUCTION TO MASSAGE THERAPY
until you come in contact with the TrP. Maintain light pressure on the TrP until it releases and melts under your finger.
Following the release, continue the strum across the rest of
the muscle’s fibers. Finally, the tissues need to be elongated
and stretched.
Trigger Point Release Using
Combined Techniques
Sometimes a TrP is particularly persistent, and you will have
to try several different approaches to facilitate its release.
Using a combination of techniques in a single application
can sometimes be the gentlest, quickest, most effective
choice:
• TrP pressure and PR
• TrP pressure and RI
• TrP pressure and PIR
• TrP pressure and CT strokes
• CT strokes and CST
Figure 10-9. Techniques for palpating trigger points. (Reprinted
with permission from Bucci C. Condition-Specific Massage
Therapy. Baltimore: Lippincott Williams & Wilkins, 2012.)
The release is effectively a neurological lengthening of
the muscle fibers. To maintain the new length, the muscle
and fascia must then be stretched for 5 to 10 seconds while
you wait for a tendon reflex to relax the muscle further.
Lengthening without stretching may cause the muscle to
revert to its shortened position. Think of the longer loaf of
bread in the shorter bag.
The more severe the TrP, the more it refers pain, so
apply only minimal pressure to release the TrP. When
spasm and muscle guarding are accompanied by satellite
TrPs, release the satellite TrPs first. Your initial pressure
on the TrP may be uncomfortable for the client but should
not register as pain. As you continue to hold the point, the
discomfort will diminish as the TrP releases. After circulation and nutrition are restored to the area, you may feel
the area heat up. This TrP technique requires very little
physical work and is a good approach to use when PNF is
unsuccessful.
Strumming
If PNF and the pressure release technique do not release
TrPs, you may need to try a more aggressive approach. Dr.
Travell’s strumming technique is very much like XFF. It is
most effective when the TrP is located near the center of
the muscle belly. When you find a TrP, strum your finger
perpendicular to the muscle fibers, at the level of the TrP
To combine TrP pressure with a PNF technique, apply
pressure to the TrP with a monitoring finger (or knuckle or
thumb) and use the pressure release technique while concurrently using the PNF technique. The combinations that
use PNF along with the pressure release are very effective
and typically last longer.
Combining TrP pressure release and CT strokes often
comes naturally. The primary difference between the
45°stroke and TrP pressure release is simply the monitoring finger. In both techniques, you apply pressure and wait
for the client’s tissues to deform, become more liquid, and
release. The combination of these techniques requires maintaining contact with the TrP with a monitoring finger while
the CT is being rearranged.
The combination of CT strokes and CST is not used as
much as the other combinations, because there is no monitoring finger on the TrP. Either technique can release a TrP
using slow, steady pressure to facilitate a myofascial change.
Basically, CT strokes, craniosacral techniques, and TrP pressure release are variations of each other, the difference being
the monitoring finger.
As with all PNF techniques and TrP release techniques, the target muscle and its CTs should be elongated
and stretched following treatment. TrP release is a versatile
addition to your toolbox of techniques. It is important to
remember from the pain section in this chapter that light
pressure is also effective for “closing the gate” of impulses to
the brain. Incorporate this concept by finishing your work
with a resting stroke, thus reducing the perception of pain.
Additionally, following the law of facilitation, consistent
massage with either light or therapeutic pressure will help
clients reduce their chronic pain patterns.
Chapter 10 / Therapeutic Applications 457
Trigger Point Techniques for
Specific Conditions
While no single technique is a cure-all, TrP therapy can
often do a lot to alleviate pain and tension in a particular
area or with a particular condition. What follows are common areas or conditions that clients complain of when they
seek massage therapy for treatment.
Chronic Neck Pain
There are many causes of neck pain: trauma, injury, or postural distortions such as the forward head posture so often
seen in clients who sit at a computer for work. It is important to know which muscles may be involved in the neck
pain, so the first step is to identify them using assessment
skills. Some of the muscles involved in the neck pain may
include:
• Levator scapula
• Trapezius
• Rhomboids
• Subclavius
• Pectoralis major
• Sternocleidomastoid
• Scalenes
• Masseter
• Temporalis
• Medial and lateral pterygoid
• Splenius capitus and splenius cervicis
• Semispinalis
• Suboccipitals
Once the muscles are identified, TrP maps may help you
locate a starting point when looking for TrPs. Figure 10-10
shows TrP maps for the muscles that may be involved in
neck pain.
When treating chronic neck pain, first prepare the tissue with general effleurage to increase the circulation to the
area. If you choose the direct pressure release technique,
locate the TrPs in the target muscles and follow the steps
below:
• Palpate the TrP and gently increase your finger pressure until you feel resistance.
• Hold for approximately 30 to 45 seconds until you
feel a melting of the tissue.
• Stretch the affected area.
• Perform a resting stroke.
• Reassess the client.
Chronic Low Back Pain
As in neck pain, the causes of chronic low back pain are
trauma, injury, overuse or repetitive stress, or postural distortions. Compensation patterns may be part of the postural
distortions, possibly resulting from ongoing postural strain
such as daily heavy lifting or tight hamstrings. Perform
an adequate assessment to determine which muscles are
involved in your client’s low back pain. The following muscles may be involved:
• Quadratus lumborum
• Iliacus
• Psoas major, psoas minor
• Rectus femoris
• Tensor fascia latae
• Gluteus maximus, gluteus medius, gluteus minimus
• Deep hip rotators (piriformis, gemellus superior,
gemellus inferior, obturator internus, obturator
externus, quadratus femoris)
• Hamstrings
Figure 10-11 illustrates the TrPs and referral patterns
for some of the muscles involved in chronic low back
pain.
When treating chronic low back pain, start by warming
the area with effleurage. If you choose the direct pressure
release technique, locate the TrPs in the target muscles and
follow the steps below:
• Palpate the TrP and gently increase your finger pressure until you feel resistance.
• Hold for approximately 30 to 45 seconds until you
feel a melting of the tissue.
• Stretch the affected area.
• Perform a resting stroke.
• Reassess the client.
The responses to therapeutic massage vary widely, but
these more advanced techniques give you the opportunity to treat specific soft tissue conditions efficiently and
effectively. Massage students and massage therapists who
understand the mechanisms of injury and tissue repair and
the pain cycle can use one or a combination of these techniques when a client is looking for more than a wellness
massage. The therapeutic applications in this chapter can
easily be added to a wellness massage session. Techniques
based on the concepts of lengthening muscles, stretching
CT, and going in the direction of ease will minimize the
458 INTRODUCTION TO MASSAGE THERAPY
Trigger point
Referral pattern
Levator scapulae
Pectoralis major
Rhomboids
Scalenes
Subclavius
Trapezius
Trigger point
Referral pattern
Semispinalis
capitis and
cervicis
Splenius capitis
and cervicis
Sternocleidomastoid
Suboccipitals
Trigger point
Referral pattern
Lateral pterygoid
Masseter
Medial pterygoid
Temporalis
Trigger point
Referral pattern
Semispinalis
capitis and cervicis
Splenius capitis
and cervicis
Trapezius
Trapezius
Figure 10-10. Trigger point maps showing trigger points and referral patterns for muscles involved in neck pain. (Reprinted with
permission from Bucci C. Condition-Specific Massage Therapy. Baltimore: Lippincott Williams & Wilkins, 2012.)
Chapter 10 / Therapeutic Applications
Trigger point
Referral pattern
Iliopsoas
Quadratus lumborum
Rectus femoris
Tensor fasciae latae
459
Trigger point
Referral pattern
Gluteus medius
Gluteus minimus
Piriformis
Figure 10-11. Trigger points and referral patterns for some of the muscles involved in chronic low back pain. (Reprinted with permission
from Bucci C. Condition-Specific Massage Therapy. Baltimore: Lippincott Williams & Wilkins, 2012.)
460 INTRODUCTION TO MASSAGE THERAPY
amount of effort needed to change the musculature while
increasing the effectiveness and permanence of changes.
Clearly, it is important to address fascia when treating the
muscles.
Your knowledge of medical terminology, anatomy,
physiology, ethics, professionalism, documentation, and
business practices as provided throughout this text are
especially important for practicing therapeutic massage,
because you are more likely to be communicating with persons in the medical, legal, and insurance fields. Also, the
use of professional documentation, assessment, and treatment plans elevate a simple massage to a legitimate form
of healthcare.
Documentation keeps all the details straight, so stay
on top of your SOAP notes. Remember to include selfcare recommendations that are relevant to the client’s
goals, simple, specific, and easy to follow. Clients who
want to restore function and return to a healthier condition will be more likely to participate in their own healthcare and will appreciate your pre- and posttreatment
assessment and self-care recommendations. On the other
hand, some clients will seemingly resist improvement.
You cannot force a client to accomplish a goal. In reality, you are not directly making the changes to a client’s
tissues—you are helping the client’s own body make the
changes. Keep in mind that you are only a facilitator, and
try to not get frustrated with clients who do not work
toward their treatment goals.
Most clients respond well to these therapeutic techniques, and some will be interested in knowing how the
techniques work. Any time clients are interested in your
work, you have the opportunity to educate them about massage. The more people know about the benefits of massage,
the better.
1. Describe the events that occur in each of the three
phases of healing.
4. Define the following:
a. Muscle guarding
b. Target muscle
c. Stretching
d. Direction of restriction
e. Tender point
f. Unwinding
g. Trigger point
h. Lengthening
5. Practice the PNF procedures on a partner. First
assess the joint range of motion moved by your
target muscle, then perform each of the following techniques, and finish with a posttreatment
assessment to determine whether any changes in
muscle length occurred:
a. Direct manipulation
b. Positional release
c. Post-isometric relaxation
d. Reciprocal inhibition
6. Describe the difference between the stretch reflex
and the tendon reflex.
7. Practice each of the following connective tissue
techniques on a partner, and ask your partner
for feedback regarding discomfort, sensations,
and responses:
a. 45° stroke
b. Skin rolling
c. C-stroke
d. S-stroke
8. Practice your palpation skills by trying to feel the
craniosacral rhythm on several different people.
With your “client” in a supine position, use a very
light touch (the weight of a nickel) on the cranium,
anterior superior iliac spines, the knees, and the toes.
2. Provide a real-life example of the pain cycle, includ-
ing specific muscles or injuries for each stage of
the cycle.
3. List at least five of the principles of therapeutic
massage.
9. List at least five of the principles for applying friction.
10. Practice the two different TrP release techniques
(direct pressure and strumming) on a partner. If
your partner does not have a TrP, pretend that you
found one and proceed with the techniques.