Br J Sp Med 1994; 28(3)

Review

Massage - the scientific basis of an ancient art:part 1. The techniquesGeoffrey C. Goats PhD MCSPSchool of Occupational Therapy and Physiotherapy, University of East Anglia, Norwich, UK

Manual massage is a long established and effectivetherapy used for the relief of pain, swelling, muscle spasmand restricted movement. Latterly, various mechanicalmethods have appeared to complement the traditionalmanual techniques. Both manual and mechanical techni-ques are desscribed systematically, together with a reviewof indications for use in sports medicine.

Keywords: Massage, history, techniques, applications

The manipulative techniques traditionally classifiedas massage consist primarily of palpation, rubbingand kneading. These arose from the natural, intuitivedesire to rub a painful injury. Massage is widely usedin sports medicine and has much to offer the injuredathlete. The therapeutic effects are diverse andinclude control of swelling, increased blood flow, andrelief of pain and muscle spasm. Massage acceleratesinflammatory processes and mobilizes contractedfibrous tissue. Massage will also affect muscle toneand cause general relaxation.

HistoryThe first mention of massage appears in the NeiChing, the oldest existing medical work, writtenbefore the death of the Chinese Emperor Huang Ti in2598 BC1. Ancient Indian and Greek texts, includingthe work of Hippocrates, describe massage as aneffective therapy, especially for treating sports or warinjuries, and the practice spread widely within theRoman Empire. The social decadence of the lateRoman period tarnished the reputation of massagefor more than a thousand years and the merits of thismanual therapy remained hidden until the Renaiss-

2ance .The era of modem massage began in 1863 with the

publication of a treatise systematically classifyingeach technique according to the bodily systemaffected3. This stimulated scientific research and, asinstrumentation improved, modern massage techni-ques developed rapidly. These are described fullyelsewhere4-11. Some innovations were technological,such as pneumatic systems producing rhythmical

compression and the introduction in 1939 of ultra-sound therapy, now widely used in sports physio-therapy.

The techniques of massageTradition defines massage as 'hand motions practisedon the surface of the living body with a therapeuticgoal12. The resurgence of therapeutic massage beganin France and much of the nomenclature is in thatlanguage. The techniques, both manual and mecha-nical, are described below together with specificindications for their use. Contraindications to mas-sage are few, but include malignancy, infection ofbody fluid and unusually fragile skin.

Manual techniquesEffleurageThese slow rhythmic stroking hand movements,moulded to the shape of the skin, frequently beginand end a treatment session (Figure 1). The strokespass from distal to proximal and parallel to the longaxis of the tissue. Gradual compression reducesmuscle tone and induces a general state of relaxationthat relieves muscle spasm and prepares the patientfor more vigorous treatment. Firm pressure acceler-ates blood and lymph flow, improves tissue drainageand thus reduces recent swelling. Rapid strokes havethe opposite effect. These will increase muscle toneand may be useful during the final preparation forcompetition.

Address for correspondence: Dr G. C. Goats, School ofOccupational Therapy and Physiotherapy, University of EastAnglia, Norwich, NR4 7TJ, UK(© 1994 Butterworth-Heinemann Ltd0306-3674/94/030149-04 Figure 1. Effleurage

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KneadingKneading consists of slow circular compression ofsoft tissues against underlying bone. The greatestpressure is applied as the hands move proximally,although contact is continuous. Small areas areusually treated using the fingertips alone. Kneadingpromotes the flow of tissue fluid and causes reflexvasodilation and marked hyperaemia. This reducesswelling and helps resolve inflammation. Vigorouskneading decreases muscle spasm and can stretchtissues shortened by injury.

PetrissageSkin rolling is a forceful technique that can only beapplied to fleshy regions of the body. A fold of skin,subcutaneous tissue and muscle is squeezed, liftedand rolled against the underlying tissues in acontinuous circular motion. With each cycle, thehands progress on to adjacent tissue, taking care notto drag uncomfortably on the skin. Petrissage isparticularly useful for stretching contracted or adhe-rent fibrous tissue and will relieve muscle spasm.Acting more deeply than kneading, petrissage alsopromotes the flow of body fluids and can resolvelong-standing swelling.

'Wringing' evolved from the simple rolling petris-sage described above; superficial tissues are graspedin both hands and twisted in opposite directions.'Picking up' involves lifting and stretching softtissues away from underlying tissues. These variantsof the original technique represent a more localizedapplication and allow treatment of injuries in delicatesoft tissue lying over superficial bone, such as ananterior tibial muscle strain.

FrictionsFrictions are an accurately delivered penetratingpressure applied through the fingertips. The move-ment is mainly circular or transverse relative to thealignment of the underlying structures (Figure 2) withminimal lateral movement. Frictions are aimeddirectly at the site of damage. Tendons and ligamentsare treated under slight tension, while muscles arebest manipulated in a relaxed position, thus avoidingexcessive damage to the muscle cells.

:.. ...

i ;.

Figure 2. Frictions

The firm pressure needed for frictions is transmit-ted through the index finger reinforced by the middlefinger. Larger areas are treated using the index,middle and ring fingers of one hand supported bythose of the other. Friction massage begins withinitial gentle transverse movements that graduallybear more deeply into the tissue and continue for5-15min. Frictions do not attempt to soothe, butinstead cause mild tissue destruction, a marked localhyperaemia and an inflammatory reaction.

Frictions are very useful in sports therapy, esp-ecially for the treatment of adherent or contractedconnective tissue. Contracted tissue often signifi-cantly reduces athletic performance. The localizedstretching and degradation of collagen caused byfrictions can restore fibres to a more normalalignment during the remodelling phase of healing13.Function often improves greatly provided thathealing is accompanied by correct joint positioningand gentle exercise.

This massage technique will also temporarilyreduce pain by activating the 'pain gate' mechan-ism1' 1

TapotementTapotement is the name given to percussive massagetechniques. The purpose of these vigorous applica-tions, often misunderstood, is to vibrate tissues,trigger cutaneous reflexes and cause vasodilation.Thus muscle tone increases and retained interstitialfluid resulting from injury and inflammation isdispersed. Swelling reduces and healing is acceler-ated.

Several tapotement techniques exist, the simplestbeing 'clapping'. The therapist cups the hands andstrikes the patient's skin smartly with the concavepalmar surface. On impact the hollow space traps anair cushion next to the skin which reduces thestinging sensation and disperses the shock moreevenly through the tissues. Modifications of this basictechnique, which have the same therapeutic effects,include 'hacking' along the long axis of tissue usingthe ulnar border of the hand, 'beating' the skin withloosely flexed fingers and 'pounding' with tightlyclosed fists.

Vibrations and shakingThis type of massage produces yet coarser and moreenergetic vibration of tissue. 'Vibrations' are deli-vered by trembling both hands held firmly in contactwith the skin. Unlike effleurage, this methodcompresses swollen tissue and can reduce oedemawith less risk of infection spreading within naturalchannels in the body.

'Vibrations' are also used in chest physiotherapy todisperse mucus from the smaller elements of therespiratory tree and improve respiratory function.The performance of an athlete suffering the aftereffects of a mild chest infection might thus beimproved. The pleural membrane should damp suchvibration efficiently, but the demonstrable effective-ness of this technique indicates that the physicalprinciples involved require further research16.

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'Shaking' is a yet more vigorous treatment in whichmuscle of the chest wall is grasped and shakenforcefully. A physiological effect similar to that of'vibrations' is produced and the treatment canimprove thoracic mobility and assist ventilation.Secretions are expelled directly or ejected by trigger-ing a cough reflex.

Equipment techniquesDevices increasing pressureMassage using hand-held rollers was widespreadafter 1880 and is once again popular in fitness centres.There is scant evidence that the technique does morethan soothe, an effect likely to depend more upon themasseur than upon the equipment itself. Rollers arethe least sophisticated example of a family of devicesthat compress tissue.

Rhythmically alternating external pressure, appliedusing warm flowing water, is the basis for manytraditional hydrotherapy massage treatments nowrarely available within the UK National HealthService. These include 'undercurrent massage' with apowerful underwater jet applied to the skin, 'needleshowers' of fine but forceful jets of water directed onto a standing patient and, of course, the whirlpoolbath or jacuzzi17. Hydromassage is often available infitness clinics and plays an important role in sportsrehabilitation, particularly in Southern and EasternEurope. Hydromassage can cause deep relaxation,soften and debride scarred or hardened skin, andinduce generalized vasodilation that accelerates heal-ing of superficial tissues.Pneumatic external compression, applied using an

air-filled cuff or sleeve has a successful history fortreating swollen limbs. Modem systems such as'Flowtron' (Huntleigh Technology, Luton, UK) usean air compressor to inflate and deflate rhythmically aplastic sleeve wrapped around the limb (Figure 3).Pulsed pressure changes, within predeterminedlimits, alternately empty superficial veins and lymphchannels into the deep circulation, and then allowrefilling. Valves within the deep vessels ensure thisunilateral flow.Some devices encase the limb in a rigid chamber

that can be both evacuated as well as pressurized(e.g. Vasotrain; B.V. Enraf-Nonius Delft, Delft,

Fiur3Pnumtic|, copeso

Holland). Some pneumatic systems inflate anddeflate a series of cuffs sequentially. The resultingpressure wave can be directed in either direction andat any desired speed. Sequential compression re-duces claudication pain and improves skin conditionimpaired by vascular disease'8 19.These mechanical systems can speed up the early

stages of recovery from sports injury by reducingvenous congestion and improving blood supply. Thisquickens the inflammatory process and subsequenthealing. The taut sleeve triggers mechanoreceptors inthe skin and, by activating the pain gate mechanism,reduces pain and facilitates early mobilization andexercise.

Devices causing vibration

The first vibration therapy, advocated by severalfamous figures, consisted of a fast ride on horseback.Mechanical devices now offer a safer and morelocalized vibration treatment. The therapeutic prin-ciples involved are similar to those described fortapotement.The usefulness of coarse vibration devices, often

promoted by beauty salons as a way of removing fat,is highly questionable'7. Similarly, the various handheld devices sold to the public frequently produceminimal vibration yet often appear useful for treatingmusculoskeletal pain. A powerful placebo effectwould appear to be at work.

Therapeutic ultrasound operating at frequenciesbetween 1-3MHz is also a type of vibratory massage.The physiological and therapeutic effects mimic thoseof conventional massage techniques. This therapeuticmodality is used widely in sports medicine and theinterested reader is referred to specialized reviews for

20-22a more detailed discussion

SummaryMassage has for many years played an important rolein athletic rehabilitation and is enjoying a justifiedresurgence of interest. Sports therapy can now drawupon an extensive body of research documenting thediverse physiological and therapeutic effects ofmanual therapy. These will be explored fully in asubsequent article and will be instrumental inestablishing massage as a treatment of choice for awide range of sporting injuries.

References1 Huang Ti. The Yellow Emperor's Classic of Internal Medicine

(Translated by Veith I). Baltimore, USA: Williams andWilkins, 1949.

2 Celsus AC. De Medicina. Leiden, Netherlands, 1665.3 Estradere JDJ. Du Massage. Paris, France: Ecole De Medecine,

1863.4 Beard G, Wood EC. Massage: Principles and Technique.

Philadelphia, Pennsylvania, USA: Saunders, 1964.5 Bell AJ. Massage and the physiotherapist. Physiotherapy 1964;

50: 406-8.6 Francon F. Massage technique. In: Massage, Manipulation and

Traction. Licht 5, ed. Huntington, New York, USA: RE.Krieger, 1976: Chapter 3.

7 Hofer J. Total Massage. New York, USA: Grosset and Dunlop,1976.

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8 Hollis M. Massage For Therapists. Oxford, UK: BlackwellScientific Publications, 1987.

9 Mennell JB. Physical Treatment by Movement, Manipulation andMassage. 5th ed. London, UK: Churchill, 1945.

10 Reiter S, Garrett TR, Erickson DJ. Current trends in the use oftherapeutic massage. Phys Ther 1969; 49: 158-61.

11 Tidy NM. Massage and Remedial Exercises in Medical and SurgicalConditions. (Revised by Wale JO). 11th ed. Baltimore, USA:Williams and Wilkins, 1968.

12 Boigey MAJ. Manuel De Massage. Paris, France: Masson, 1950.13 Cyriax JH. Clinical applications of massage. In Massage,

Manipulation and Traction. (Licht S, ed.). Huntington, NewYork, USA: RE. Krieger, Chapter 8, 1976.

14 Melzack R, Wall PD. Pain mechanisms: a new theory. Science1965; 150: 971-9.

15 Watson J. Pain mechanisms: a review. 1. Characteristics of theperipheral receptors. Australian Journal of Physiotherapy 1981;27: 135-43.

16 Selsby DS. Chest physiotherapy. May be harmful in somepatients. BMJ 1989; 298: 541-2.

17 Licht S. Mechanical massage techniques. In: Massage,Manipulation and Traction. (Licht S. ed.) Huntington, NewYork, USA: RE. Krieger 1976: Chapter 5.

18 Collens W, Wilensky P. Intermittent venous occlusion in thetreatment of peripheral vascular disease. JAMA 1937; 109:2125.

19 Wakim KG, Martin GM, Krusen FH. Influence of centripetalrhythmic compression on localized edema of an extremity.Archives of Physical Medicine 1955; 36: 98-103.

20 Dyson M. Mechanisms involved in therapeutic ultrasound.Physiotherapy 73: 116-19.

21 Kitchen SS, Partridge CJ. A review of therapeutic ultrasound.Physiotherapy 1990; 76: 593-600.

22 Maxwell L. Therapeutic ultrasound: its effects on the cellularand molecular mechanisms of inflammation and repair.Physiotherapy 1992; 78: 421-6.

THE 13th CONGRESS OF SPORTS MEDICINE of the A.Z. SINT-JAN

International Congress Organized by:VZW BRUCOSPORT in cooperation with THE DUTCH SOCIETY of SPORTS MEDICINE

BRUGGE (Belgium), 14 & 15 October 1994

SESSIONSCardiology and Sports (DSSM) - G Schep, A Hoogeveen and J Hoogsteen (NL)Ethics and Sports (DSSM) - F Faro, R A A Bots and EM Vrijman (NL)Swimming Sports - H Toussaint, P Hollander (ML), W McMaster (US) and U Persyn (B)Arthrosis and Sports (DSSM) -M P Heijboer, H GW Vermeer, C N Van Dijk H Sala and S Lim (NL)The Hand and Sports - G Foucher (F), N Barton (UK), L De Smet (B) and R Leach (US)

KEYNOTE LECTURESH Mielants (B) Inflammatory locomotor symptoms in sportsmenJ Lonsdorfer (F) Unfitness after heart, lung or kidney transplantation and ways for exercise retrainingW Pffirringer (D) Change of sports traumatology in a changing world

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.-. -. L.:.:.::--.

Forfurther informtiont concerning te"Congres pleaseocnact:,.'Sekretariaat SPORTGENEESKUNDIGE DAGEN ..

Attn. CaneDe ..ycA.Z. Sint-Jan, Ruddershove 10,134000 BRUGGE (Belgium). - . . - ... . . . . ..~~~~~~~~~~~~~~~~~~~~~~~............... . ... .. . .- . - : ............................. F ......f32)(0S0)4S:22:8:::::-::-:..:-:-::.:::-7::::0::.: -t:::.-..::-.-..:.TeI(32) (05044*2230".-......-....- ~~~~~~~~~~~~~~~~~~~~~~. ... .. .. . .. ...- ....

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Fax:r(2) (0J50)M4512234 2%

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