Chapter Six Outcome based massage
Chapter contents
Introduction
When massage is used to address a specific problem or set of symptoms it is considered outcome based massage. Outcome based massage targets results instead of methods and modalities. Various methods can be combined to achieve outcomes. For example, if a massage therapist is working with a multidisciplinary health care team to treat pain, outcome based instructions to the massage therapist might include suggestions such as:
It is possible to include much of the assessment process in a general full body massage session. This is especially true of all the palpation based assessment. In fact it is desirable to consider the first few massage sessions as assessment. Then based on assessment information gathered during massage sessions, coupled with other information from a comprehensive history, tests performed outside the context of massage, together with information from other professionals involved with the patient, a specific treatment plan can be developed to achieve the outcome goals.
People enjoy massage because it feels good, and is a nurturing integrated experience. This major strength of massage needs to be preserved, not replaced. General nonspecific full body massage, based on the outcomes of decreased sympathetic arousal and maladaptive stress response, tactile pleasure sensation, and nurturing is effective in the treatment of pain symptoms even if nothing else is done (Yates 2004). It is prudent to preserve these qualities and benefits of massage when addressing specific pain conditions.
The massage therapist can increase the effectiveness of massage treatment by becoming more skilled in how to target a specific outcome, such as reducing pain and stiffness in the lumbar area. This is accomplished by incorporating assessment skills and targeted treatment methods based on that assessment information into the full body massage session. Targeted treatment such as for deactivation of trigger points can feel intense and/or uncomfortable. These methods are often better accepted and integrated by the patient when ‘wrapped’ in the pleasure and nurturing experience of a general massage session. Since chronic pain is so common and massage has been shown to be beneficial (see Chapter 2), the massage therapist needs to be skilled in this area.
Desired outcome
It is logical that individuals undergoing medical procedures such as surgery may develop pain secondary to the positioning required to perform the procedure, extended bed rest, reduced physical activity, anxiety, and other predisposing factors. Pain is a major treatment concern in health care in many populations including in children and adolescents, postural distortion during pregnancy, postural strain from obesity, and muscle pain as part of osteoporosis and other conditions related to aging (Yates 2004).
Management of pain and improvement in function requires lifestyle changes on the part of the client/patient and compliance with various treatment protocols. Chapter 8 also discusses lifestyle choices which could possibly be creating the symptom and be the cause of the dysfunction. Unfortunately, many people are not diligent when it comes to implementing these changes. For these individuals, pain, especially the types related to soft tissue dysfunction, can frequently be symptomatically managed with massage. This means that the massage outcome goal is pain management more so than targeting a change in the factors causing the condition. Just as pain medication will wear off, so will the effects of massage, so it may need to be more frequent in order to maintain symptom management.
The goal is not to ‘fix’ the pain but to both mask it and superimpose short term beneficial changes in the tissue. If these patients are treated with medication they would take muscle relaxants, some sort of analgesic and anti-inflammatory, and possibly mood modulating drugs. All of these medications have potentially serious side effects with long-term use, making them undesirable in management of chronic pain. Massage may accomplish similar results to that achieved by medication, if applied frequently and consistently – and without the side effect problem. Massage can replace or help reduce the dose of various medications, and it can be used indefinitely to treat the symptoms of chronic pain.
Massage has few if any side effects, is cost effective, produces at least short-term benefits and since people typically enjoy massage they tend to be compliant about attending sessions (Fritz 2008a,b). This situation is not ideal but it is not the worst-case situation either, and it is possible that eventually the patient/client will reach a point in their life when they are able and willing to be more responsible for the lifestyle and attitude changes necessary to manage pain syndromes.
Describing massage
Depth of pressure
• Depth of pressure (compressive force), which is extremely important, can be light, moderate, deep, or variable.
• Most soft tissue areas of the body consist of three to five layers of tissue, including the skin; the superficial fascia; the superficial, middle, and deep layers of muscle; and the various fascial sheaths and connective tissue structures.
• Pressure should be delivered through each successive layer to reach the deeper layers without damage and discomfort to the more superficial tissues (see Fig. 6.1).
• The deeper the pressure, the broader the base of contact required on the surface of the body.
• It takes more pressure to address thick, dense tissue than delicate, thin tissue.
• Depth of pressure is important for both assessment and treatment of soft tissue dysfunctions. Soft tissue dysfunction can form in all layers of tissue.
• In order to treat various changes in soft tissue (such as a trigger point) it is necessary to be able to apply the correct level of pressure to both reach the location of the point, as well as compress the tissue to alter flow of circulation. Soft tissue dysfunctions located in surface tissue require less depth of pressure than those located in deeper muscle layers.
Drag
• Drag describes the amount of pull (stretch) on the tissue (tensile force).
• Drag is applicable for various types of palpation assessment for soft tissue dysfunctions, including skin drag assessment and functional technique used to identify areas of ease and bind.
• Ease is identified when tissue moves freely and easily while bind is where tissue palpates as stuck, leathery, or thick.
• Drag is also a component of connective tissue methods used to treat soft tissue dysfunctions and lymphatic drainage methods.
Direction
• Direction can move from the center of the body out (centrifugal) or in from the extremities toward the center of the body (centripetal).
• Direction can proceed from proximal to distal (or vice versa) of the muscle, following the muscle fibers, transverse to the tissue fibers, or in circular motions.
• Direction is a factor in stretching tissues containing soft tissue dysfunctions or in the methods that influence blood and lymphatic fluid movement.
Speed
• Speed is the rate that massage methods are applied.
• The speed can be fast, slow, or variable depending on the demands of the tissues being addressed and of the state of the client/patient. Faster and more energizing in situations where stimulation is called for, slower and more rhythmic where calming influences are needed.
Rhythm
• Rhythm refers to the regularity of application of the technique.
• If the method is applied at regular intervals, it is considered even, or rhythmic.
• If the method is disjointed or irregular, it is considered uneven, or arrhythmic.
• The on/off aspect of compression applied to a trigger point to encourage circulation to the area should be rhythmic, as should lymphatic drainage application.
Frequency
• Frequency is the rate at which the method is repeated in a given time frame.
• This aspect of massage relates to how often the treatment, such as ischemic compression or gliding, is performed.
• In general, the massage practitioner repeats each method about three times before moving or switching to a different approach.
• The first application can be considered assessment, second treatment, and third post assessment.
• If the post assessment indicates remaining dysfunction, then the frequency is increased to repeat the treatment/post assessment application.
Duration
• Duration is the length of time that the method lasts, or that the manipulation stays focused on the same location.
• Typically, duration of a specific method is approximately 60 seconds although functional methods that position the tissue or joint in the ease (the way it wants to move) or bind (the way it does not want to move) can be an exception and may need to be applied for longer periods.
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