Modalities working with massage

Chapter 7 Modalities working with massage

CHAPTER CONTENTS

Connective tissue focus

Neuromuscular technique

Trigger point methods

Muscle energy technique

Positional release technique

Integrated neuromuscular inhibition (for trigger point deactivation)

Spray-and-stretch chilling methods

Integrating treatment strategies

In this chapter a number of modalities that integrate well with massage therapy will be discussed. To support proficiency, practical examples and skill enhancement exercises are included. The methods presented include:

• connective tissue focus

• neuromuscular technique

• trigger point methods

• muscle energy technique

• positional release technique

• integrated neuromuscular inhibition (for trigger point deactivation)

• spray-and-stretch chilling methods.

CONNECTIVE TISSUE FOCUS

The quality of the connective tissue can generally be assessed by the plasticity of the skin and subcutaneous layers. Thickened, adhered fascia is less mobile, and the skin will glide only a short distance before feeling tight (bind). With healthy tissue it is amazing how far it can comfortably be stretched in all directions. In the treatment of musculoskeletal problems, such as head and neck pain, the connective tissue of primary concern is the fascia that wraps the muscle fibers into bundles and compartments, and then wraps all these together to form the whole muscle. The outer layer of fascia makes up the muscle’s sheath, which maintains the overall shape and is smooth on the outside so the muscle can move freely and independently of other structures; it should have the same elasticity as the muscle. The structure of the head and neck is highly influenced by numerous connective tissue structures such as the dura and the ligamentor muci and connective tissue of the scalp.

The fascia is subject to trauma through overstretching or impact, and scar tissue and adhesions can form. The main problem, however, comes from chronic changes as a result of long-term stress. The fascia thickens and becomes more fibrous, which makes it less mobile and reduces its permeability. This affects the function of the underlying muscle and may restrict its free movement. In addition, if the interstitial fluid cannot pass freely through the fascia, the muscle may not get an adequate supply of oxygen and nutrients, and will be less able to eliminate metabolic waste material.

As well as releasing excessive tension or thickening in the fascia, connective tissue forces affect the autonomic nervous system through a neurofascial reflex. This stimulates local blood flow, and the skin appears red and is warm.

It is the adhesions and fibrous tissue created by scar tissue that cause the most dysfunction. In the early stages, scar tissue is quite sticky and can adhere fibers together. For a muscle to function, the fibers need to be able to glide smoothly alongside one another, but when stuck together they cannot do this and the affected area will not function optimally. Over time, a local area of muscle fibers can mat together into a fibrous mass.

The nonmuscular soft tissues can also be affected by fibrous adhesion, which will make them thick and less pliable. Adhesions can also form between differing structures, such as between ligaments and tendons, muscles and bone. This can lead to a significant restriction in movement and function.

Transverse strokes using shear and bend forces can break down the adhesions by literally tearing the adhesive bonds apart. Once the fibers are separated they are able to functionally slide again. Applied effectively, the massage methods should create a sensation of burning and localized pain, but must not cause any actual damage because the adhesions themselves contain no blood vessels. If done too heavily or on tissue that is in an early stage of repair, further damage can be caused.

When a large fibrous knot of compacted tissue has formed there may be little or no circulation running through it and therefore a natural healing process cannot take place. Massage increases tissue pliability and allows blood to flow more easily through it, stimulating healing.

Massage is able to stretch specific localized areas of tissue in a way that may not be possible with other approaches. Longitudinal (tension force) stroking and kneading (bend and torsion force) can stretch the tissues by drawing them apart and in all possible directions (Figure 7.1).

Figure 7.1 Application of connective tissue massage, modified from Bindegewebmassage. This system primarily introduced the mechanical forces of tension, bend, shear, and torsion.

In most instances, a lubricant is not used with connective tissue approaches because the drag quality on the tissue is necessary to produce results, and lubricant reduces drag.

Methods that primarily affect the ground substance require a quality of slow, sustained pressure and agitation. Most massage methods can soften the ground substance as long as the application is not abrupt. Tapotement and abrupt compression are less effective than slow gliding methods that have a drag quality. Kneading and skin rolling that incorporate a slow pulling action are effective as well. The appropriate application introduces one or a combination of the mechanical forces of tension, compression, bind, shear, and torsion to achieve results.

The fiber component is affected by stretching methods that elongate the fibers past the normal give of the fiber and enter the plastic range past the bind. This creates either a freeing and unraveling of fibers or a small therapeutic (beneficial and controlled) inflammatory response that signals for change in the fibers.

Tissue movement methods

The more subtle connective tissue approaches rely on the skilled development of following tissue movements. The process is as follows (Figure 7.2):

Figure 7.2 Tissue movement. A: Begin ease. B: End bind.

Twist-and-release kneading and compression applied in the direction of the restriction can also release these fascial barriers (Figure 7.3).

Figure 7.3 Tissue movement. A: Twist and release, neck. B: Twist and release, back.

The important consideration for all connective tissue massage methods is that the pressure vertically and horizontally actually moves the tissue to create tension, torsion, shear, or bend, which forces alteration of the ground substance long enough for energy to build up in it and soften it. The development of connective tissue patterns is highly individualized, and because of this, systems that follow a precise protocol and sequence are often less effective in dealing with these complex patterns.

A good grip with the skin is essential, so there must be no lotion or oil present. This grip can be with the hands or forearms. The technique is even sometimes performed with a towel to provide stronger contact with the skin.

Tissue can be moved toward ease (the way it wants to move) and is held for a few seconds to allow the tissue to soften. The client can add a neurologic component by contracting or relaxing the muscle as the massage therapist holds the tissue at ease. The entire procedure can be repeated while holding the tissue at bind (the way it does not want to move).

Some varieties of this process have been formalized into modality systems such as active release and deep tissue methods.

Active release

In active release, the massage therapist applies passive pressure, and the movement is provided by the client. Assessment identifies a local area of fibrotic tissue and/or adhered fibers. Compression is applied to hold the area in a static position; the tissues are then stretched away from that point. The points where the pressure is applied are often the same as those used for typical trigger points.

The basic method is to start with the muscle relaxed and held in a passive shortened position by moving the associated joint. Focused compression is applied directly into the adhered fibers to fix them in position. The muscle is then stretched by the massage therapist away from this fixed point by moving the joint. The pressure needs to be applied with sufficient force to prevent the target tissues from moving as the stretch takes place.

Active and resisted movements, instead of passive ones, can be used to stretch the muscle. In fact, this may be more effective since the neuromuscular function is involved as well as the focus on connective tissue. The client contracts the antagonist that reciprocally inhibits the muscle being treated and moves the area while the massage therapist maintains focused pressure. An easy way to do this is to have the client move the associated joint areas in a slow circle, or back and forth if the joint is a hinge joint. The tissues can also be stretched away from the pressure point using deep massage strokes made with the other hand or forearm. This is useful when it is not convenient to move the joint – for example, when treating the gluteal muscles while the client is in the prone position, where hip flexion to stretch the muscle would be impossible.

NEUROMUSCULAR TECHNIQUE

Neuromuscular technique (NMT) evolved in Europe in the 1930s as a blend of traditional Ayurvedic (Indian) massage techniques and soft tissue methods derived from other sources. Stanley Lief DC and his cousin Boris Chaitow ND DO developed the techniques now known as NMT into an excellent and economical diagnostic (and therapeutic) tool (Chaitow 2003a, Youngs 1962).

There is also an American version of NMT that emerged from the work of chiropractor Raymond Nimmo (Cohen & Gibbons 1998). NMT is an effective method to address trigger point activity.

Basics of NMT

A light lubricant is always used in NMT to avoid skin drag. The main contact is made with the tip of the thumb(s), more precisely the medial aspect of the tip. In some regions the tip of the index or middle finger is used instead as this allows easier insertion between the ribs for assessment (or treatment) of, for example, intercostal musculature.

Neuromuscular thumb technique

The therapist uses the medial tip (ideally) of the thumb to sequentially ‘meet and match’ tissue density/tension and to insinuate the digit through the tissues, seeking local dysfunction (Figure 7.4).

Figure 7.4 NMT thumb technique.

(Reproduced with permission from Chaitow & Fritz 2006.)

Neuromuscular finger technique

The therapist utilizes the index or middle finger, supported by a neighboring digit (or two), to palpate and assess the tissues between the ribs for local dysfunction. This contact is used instead of the thumb if it is unable to maintain the required pressure.

Posture and positioning

The therapist’s posture and positioning are particularly important when applying NMT, as the correct application of forces dramatically reduces the energy expended and the time taken to perform the assessment/treatment.

The examination table should be at a height which allows the therapist to stand erect, legs separated for ease of weight transference, with the assessing arm straight at the elbow. This allows the therapist’s bodyweight to be transferred down the extended arm through the thumb, imparting any degree of force required, from extremely light to quite substantial, simply by leaning on the arm.

The NMT thumb stroke

It is important that the fingers of the assessing/treating hand act as a fulcrum and that they lie at the front of the contact, allowing the stroke made by the thumb to run across the palm of the hand, towards the ring or small finger as the stroke progresses.

The finger/fulcrum remains stationary as the thumb draws intelligently towards it, across the palm. This is quite different from a usual massage stroke, in which the whole hand moves. Here the hand is stationary and only the thumb moves.

Each stroke, whether it be diagnostic or therapeutic, extends for approximately 4–5 cm before the thumb ceases its motion, at which time the fulcrum/fingers can be moved further ahead in the direction the thumb needs to travel. The thumb stroke then continues, feeling and searching through the tissues.

Another vital ingredient, indeed the very essence of the thumb contact, is its application of variable pressure (diagnostic pressure is in ounces or grams initially), which allows it to ‘insinuate’ and tease its way through whatever fibrous, indurated or contracted structures it meets.

A degree of vibrational contact, as well as the variable pressure, allows the stroke and the contact to have an ‘intelligent’ feel and seldom risks traumatizing or bruising tissues even when heavy pressure is used.

Application of NMT

Diagnostic assessment involves one superficial and one moderately deep contact only.

If treatment is decided on at that time then several more strokes, applied from varying angles, would be used to relax the structures, to stretch them, to inhibit contraction, or to deal with trigger points discovered during the examination phase.

When assessing (or treating) joint dysfunction, it is suggested that all the muscles associated with a joint receive NMT attention to proximal and distal attachments, and that the bellies of the muscles be searched for evidence of trigger points and other dysfunction (fibrosis, contractions, etc.).

A full spinal NMT assessment can be accomplished in approximately 15 minutes with ease, once the method is mastered. However, a diagnostic evaluation of a localized region – say covering the area of the neck and upper back, accompanied by other diagnostic and assessment modalities and methods – may be all that is necessary. With effective use of NMT, not only would localized, discrete ‘points’ be discovered, but also patterns of stress bands, altered soft tissue mechanics, contractions, and shortenings.

NMT exercise: finger and thumb strokes

Apply a light lubricant and position yourself and place your treating hand according to the illustration (see Figure 7.4), with your fingers acting as a fulcrum and the thumb (medial tip) feeling through the tissues, slowly and with variable pressure.

Practice this, in no particular sequence of strokes, until the mechanics of the body/arm/hand/thumb positions are comfortable and require no thought. Pay attention to varying the pressure, to meeting and matching tension in the tissues, and to using bodyweight, transferred through a straight arm, to increase pressure when needed.

Also practice the use of the finger stroke, especially on curved areas, by drawing the slightly hooked and supported (by one of its neighboring digits) finger toward yourself, in a slow, deliberate, searching manner. The objective is to obtain information, without causing excessive discomfort to the patient, and without stressing your palpating hands.

NMT in its treatment mode involves greater pressure in order to modify dysfunctional tissues, but in these sequences you can, if you wish, focus on ‘information gathering’ only, not treating. In time, with practice, treatment and assessment meld seamlessly together, with one feeding the other.

Chart any findings you make – tender areas, stress bands, contracted fibers, edematous areas, nodular structures, hypertonic regions, trigger points and so on. If trigger points are located, note their target area as well.

TRIGGER POINT METHODS

Theories of trigger point development are outlined in Box 7.1.

Box 7.1 Theories of trigger point development

There are three main theories (and a number of minor ones) that attempt to explain just what is happening that allows a trigger point to evolve.

1 ENERGY CRISIS THEORY

This is the earliest explanation of trigger point formation (Bengtsson et al 1986, Hong 1996, Simons et al 1999).

The theory suggests that increased demand on a muscle, possibly involving repetitive, very small-grade trauma (microtrauma) or actual injury (macrotrauma), causes calcium release from muscle cells, leading to shortening of the sarcomeres. This has the effect of obstructing normal circulation, so that tissues receive less oxygen. This causes the cells to be unable to produce enough energy (ATP) to allow the shortened sarcomeres to relax.

Waste products of metabolism accumulate (Simons et al 1999), and this causes some of the pain because of irritation and sensitization of sensory nerves (nociceptors).

This concept was partly supported by Bengtsson et al (1986).

2 THE MOTOR ENDPLATE THEORY

The motor nerve connects with a muscle cell at the motor endplate.

Research has shown that each trigger point contains very small areas (loci) that produce unusual electrical activity (Hubbard & Berkhoff 1993). These loci are usually found at the motor endplate zone (Simons 2001, Simons et al 2002).

The activity seen on EMG (electromyogram) is thought to be the result of an increased rate of release of acetylcholine (ACh) from the nerve cell. This may be enough to cause activation of a few contractile elements and be responsible for some degree of muscle shortening (Simons 1996).

By combining these two theories (energy crisis and motor endplate), a basic model exists that helps explain the origin of the trigger point.

There is a third theory.

3 RADICULOPATHIC MODEL

Some researchers have a different model altogether. They think that there is a neurologic cause, and that trigger points are a secondary phenomenon (Gunn 1997, Quintner & Cohen 1994).

Gunn (1997) suggests that myofascial pain often derives from intervertebral disk degeneration, which causes nerve root compression and paraspinal muscle spasm. This is described as a form of neuropathy (carpal tunnel syndrome is a neuropathy) that sensitizes and irritates structures in the distribution of the nerve root, and causes distal muscle spasm.

4 POLYMODAL THEORY (FIG. 7.5)

The polymodal receptor (PMR) hypothesis suggests that trigger points are nothing more than sensitized neural structures (pain receptors/nociceptors called polynodal receptors).

The PMR is a kind of nociceptor, and is responsive to mechanical acupuncture, and thermal and chemical stimuli. Its sensory terminals are free nerve endings and exist in various tissues of the entire body (Kawakita et al 2002).

Irrespective of which theory, or combination of theories, is actually proved to be correct, the fact remains that these noxious, painful troublemakers cause a great deal of pain and dysfunction.

Active and latent trigger points

The pain characteristics of an active myofascial trigger point (Figure 7.6) are as follows:

• When pressure is applied, active trigger points are painful and either refer (i.e., symptoms are felt at a distance from the point of pressure) or radiate (i.e., symptoms spread from the point of pressure).

• Symptoms that are referred or radiated include pain, tingling, numbness, burning, itching or other sensations and, most importantly, in an active trigger these symptoms are recognizable (familiar) to the person.

• Other signs of an active trigger point include the ‘jump sign’, palpable indications such as a taut band, fasciculation, etc.

Figure 7.5 Polymodal receptor hypothesis of acupuncture and moxibustion.

(Adapted from Kawakita et al 2002.)

Figure 7.6 Trigger points are areas of local facilitation that can be housed in any soft tissue structure, most usually muscle and/or fascia. Palpation from the skin or at depth may be required to localize them.

(From Chaitow 2003a.)

The pain characteristics of a latent myofascial trigger point are as follows:

• Commonly the individual is not aware of the existence of a latent point until it is pressed (i.e., unlike an active point, a latent one seldom produces spontaneous pain).

• When pressure is applied to a latent point it is usually painful, and it may refer (i.e., symptoms are felt at a distance from the point of pressure) or radiate (i.e., symptoms spread from the point of pressure).

• If the symptoms – whether pain, tingling, numbness, burning, itching or other sensations – are not familiar, or perhaps are sensations that the person used to have in the past but has not experienced recently, then this is a latent myofascial trigger point (Figure 7.7).

Figure 7.7 Altered physiology of tissues in region of myofascial trigger point.

Neck, head and face referral patterns and major trigger point locations are illustrated in Box 7.2; key and satellite trigger points are outlined in Box 7.3.

Only gold members can continue reading. Log In or Register to continue

Related

Stay updated, free articles. Join our Telegram channel

Tags: A Massage Therapists Guide to Treating Headaches and Neck Pain

Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access