Art of Massage

Massage therapy can be a valuable modality for musculoskeletal and neurological conditions.

By Michael Sheynin, PT

Ask athletes if they'd like a massage while nursing an injury, and you'll be hard pressed to find any who would decline.

But physical therapists, constrained by shrinking reimbursements and less treatment time, are offering massage less and less. As a result, massage therapy is becoming a lost art, reserved solely for spas and relaxation. Still, massage can be a valuable modality in achieving outcomes for patients with musculoskeletal and neurological conditions.

While stretching and specific strengthening are invaluable in treating common injuries, massage helps prepare soft tissues for stretching and alleviates muscle spasms, trigger points and pain, thus creating an ideal environment for further treatment. Massage also can help prevent injuries by warming up muscles before the activity, stimulating circulation and relieving nervous tension.

Most athletes can benefit from massage. It's effective, for example, for treating overuse injuries, such as tennis elbow (lateral epicondylitis) and shin splints (anterior compartment syndrome); and acute muscle strains, such as groin or hamstring pulls, and lower back strain.

In addition, some athletic activities precipitate chronic strain patterns from overuse and over-development of some muscle groups. For example, runners almost invariably have tight hamstrings and calf muscles. Tennis players usually have tight pectoral muscles on the dominant side, which may lead to muscle imbalance between the pectorals and rotator cuff muscles, impingement problems and rotator cuff tears.

Depending on the condition and the desired goal, you can use various massage techniques to help treat these problems. To choose techniques, therapists should first identify the specific goals of the athlete. For example, if the athlete uses massage pre-event to stimulate blood flow, calm nervous tension and prepare for optimal performance, then we would use more shallow techniques with lighter strokes. However, when rehabbing an acute injury, we would want to use deep strokes to access deeper muscle tissues and tendons.

To understand what approach to use, however, we must first familiarize ourselves with several common massage techniques:

Effleurage, an introductory technique involving light strokes, is used to apply oil or a cream, sooth and warm the muscles in a relatively large area and to make initial contact with the patient.

Petrissage is a deeper technique involving grabbing, kneading strokes. Therapists can use this technique after effleurage to "milk" the muscles of waste products that collect from trauma or abnormal inactivity.

Friction is used to work deep into the muscles or around bony prominences. It often involves short deep strokes using firm contact with underlying tissues. To get this effect, the therapist uses his thumb, knuckles or the heel of the hand. Friction breaks down adhesions and scar tissue and also increases blood flow to tendon attachments.

Friction massage can be divided into three categories. Broad cross-fiber friction stretches the muscles and separates muscle fibers. Local cross-fiber friction, such as transverse friction massage used around the lateral epicondyle, increases blood flow, breaks down adhesions and smoothes scar tissue. Transverse friction massage is the most commonly used massage technique to treat various tendon inflammations, such as tennis elbow or patellar tendon pain. Circular friction addresses trigger points and spasmed, painful muscles.

Ischemic compression works on trigger points, which are areas that refer pain to other areas when stimulated. Trigger points can be active or inactive. Active trigger points produce and refer pain during normal activities, whereas inactive trigger points produce pain only when pressure is applied to them.

Most experts believe eschemic compression deprives trigger points of oxygen, rendering them inactive and breaking the cycle of pain-spasm-pain. Usually, the pressure is applied for eight to 12 seconds. If the patient reports a lessening of local and referred pain, the therapist can repeat treatment. However, if pain doesn't subside, the pressure is probably too strong and the therapist needs to adjust.

Compression with active stretch (or "pin-and-stretch") technique involves applying and holding pressure on a muscle belly while the patient actively stretches the muscle. Sometimes therapists use gentle gliding in the opposite direction of the stretch, instead of holding. This technique works well in breaking down adhesions, separating muscle fibers and increasing muscle length and normal movement patterns.

I use this technique frequently on the hamstrings. During this procedure, the patient lies on his back with his hip and knee flexed to 90 degrees. The therapist applies constant pressure on the patient's hamstring with a forearm or an elbow and then asks the person to extend the knee. The patient holds the stretch for several seconds and then repeats eight to 10 times.

I've used these massage techniques in many athletes with muscle-tendon injuries. One patient, an 18-year-old high-school pitcher with right shoulder strain, benefited from therapy and massage in unison. James complained of pain in the right anterior shoulder chest area, especially when releasing the ball. X-rays showed normal subacromial joint space and no evidence of a spur.

During initial evaluation, James exhibited pain to palpation in the right scapular-thoracic area with spasms and trigger point activity .in the rhomboids, levator scapulae and infraspinatus. His right anterior shoulder area was sore to palpation as well, with the most painful spot over the bicipital groove. James' right pectoral muscles were extremely tight and painful to palpation.

He had moderate forward head posture and rounded shoulders, with the right humeral head fixated in the anterior translation position. Range of motion of the right shoulder was normal except for internal rotation, which was tested functionally. James was only able to reach behind his back to the level of L4 vertebra. Strength of the right shoulder was 5/5 except for shoulder scaption with thumbs up (which was 4/5) and thumbs down (which was also 4/5). He tested negatively for rotator cuff tear and impingement.

We diagnosed James with infraspinatus strain and bicipital tendinitis. Treatment goals focused on decreasing pain and spasm with soft tissue mobilization. We also wanted to increase ROM and strength and stabilize the right shoulder with stretching, rotator cuff strengthening and scapular strengthening, and stabilization.

Because James was very tense initially, we used effleurage over the upper back and neck area, followed by a deeper petrissage and broad cross friction to further warm the muscles. Finally, we used circular friction and ischemic compression on the trigger points in the right rhomboids, levator scapulae and infraspinatus muscles.

The most active and stubborn trigger point was in the infraspinatus. But after the first session, pain in the right anterior shoulder subsided by 50 percent.

During subsequent sessions, we used pulsed ultrasound over the infraspinatus trigger point before massage, and ice massage at the end of the sessions. We addressed the tightness of the right pectoral muscles by stretching and using gentle hold-and-stretch techniques. During the hold-and-stretch technique, James performed horizontal abduction of the shoulder in various degrees of elevation while I gently glided the palm of the hand over his pectoral muscle from the humerus to the sternum.

We followed massage with joint mobilization to increase posterior translation of the humeral head and, once pain subsided by 80 to 90 percent, with rotator cuff and scapular strengthening and stabilization. James rehabilitated fully and was discharged from PT after 14 visits.

In another case, Lisa, a 39-year-old amateur marathon runner, came in with the diagnosis of right hamstring strain and lateral knee pain. She, like James, benefited from massage. On exam, Lisa exhibited moderate to severe tightness of bilateral hamstrings, pain on palpation in the right lateral hamstring, iliotibial band (ITB), gluteus medius and tensor fascia latae (TFL). We diagnosed her with hamstring strain and ITB syndrome.

The massage techniques included effleurage to relax Lisa and prepare the muscles for deep tissue work. We also used petrissage to "milk" the muscles and get rid of waste products, which further warmed up the hamstrings and ITB. Lisa's TFL was tight, so we used cross fiber friction. In addition, deep longitudinal stroking over the hamstrings and ITB lengthened the muscle fibers to prepare Lisa for stretching.

We told Lisa to take a break from running and also advised her to see a podiatrist for a pair of orthoses. The massage helped us warm the area to implement hamstring and ITB stretching with a quad strengthening program that balanced out the hamstring and quadriceps muscles.

Sometimes therapists stay away from massage, arguing patients might like it so much that they won't to do anything else thus sabotaging rehabilitation. This argument seems shortsighted. I want my patients to like treatment because it ensures they will refer my services to others and that they'll tell their physician they were happy with therapy. It's my job to make sure patients understand the importance of continuous stretching and strengthening exercises. Massage is a passive treatment; by no means should it be the only treatment, but it should definitely be used.

In a time when reimbursement is ever-decreasing, physical therapists must position themselves as the primary givers of rehabilitative services. Yes, massage requires one-on-one attention, so you can't treat several patients at the same time. But using massage along with other treatment techniques ensures swifter results—an outcome that you, your patient and even your payer will welcome with open arms.

Targeted Touch

Physical therapists at the Medical College of Georgia (MCG) in Augusta aren't content to simply know that a massage feels great. They want to know why.

Dr. Mary Ellen Franklin and Donavon Reimche, faculty members in the department of physical therapy, have conducted studies pinpointing the health benefits of massage.

Dr. Franklin targets her research based on the hunch that the body responds systemically after a massage. For instance, one study measured levels of the stress hormone cortisol in urine after people received a massage. She found that cortisol levels tended to be altered after a massage, with the degree of variation correlating to the intensity of the muscle stimulation.

These observations prompted Dr. Franklin to study additional hormone levels after a massage. For instance, she suspects that the muscle-loosening process may trigger endorphin release, which enhances a sense of well-being.

A study supervised by Reimche showed that a hamstring massage increased knee range of motion for a week. And the technique could be used on people who have restrictions in motion due to tight muscles, he says.

On the other hand, massage isn't appropriate for everyone. Massage can shunt fluids centrally and stress the heart, says Dr. Franklin, so people with pre-existing medical conditions should consult a physician before getting a massage.

She also recommends that people with health problems get a massage from someone with extensive training in patient care.

At MCG, massage is part of the PT curriculum. Students learn different strokes and techniques to target specific body areas, illnesses and injuries. They also learn the physiological basis behind massage. For instance, nerves can cause muscles to tighten, says Reimche. Or connective tissue may adapt to a contracted position and not allow full range of motion.

Once therapists address the problem during massage, they teach patients adaptations in posture and movement. "Our goal is to get people to the point where they can function independently," Reimche says. "If you don't change the habits and positions that caused the problem, we're right back to where we started."

Many of those habits and positions, he says, occur from sedentary lifestyles and excessive hours behind a desk. Clinicians recommend regular exercise and frequent breaks from desk-bound tasks. A few stretches and a brief walk every half-hour can make a big difference, Reimche noted.

The consensus is clear, he says. Regular movement offers great benefits to most people, and targeted touch is a powerful tool to energize muscles.

—Compiled by ADVANCE staff