Outcome-based massage

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 headache and neck problems, outcome-based instructions to the massage therapist might include suggestions such as:

The instructions are unlikely to be: ‘Apply Swedish massage with reflexology and energy-based modalities.’

While the difference between massage modalities and massage based on outcome goals may seem simple, this is actually a major paradigm shift with which the massage community continues to grapple. Approaching therapeutic massage to address head and neck pain needs to be outcome based, since different massage modalities can be used alone or in combination, and with other methods to achieve a positive change for those experiencing headaches and neck problems.

To be proficient in outcome-based massage it is necessary to be skilled in evaluation and clinical reasoning in order to develop appropriate treatment plans. The information in previous chapters provides the foundation upon which the massage therapist can make appropriate treatment plan decisions in the context of treating head and neck problems.

It is possible to include much of the assessment process into a general full body massage session. This is especially true of all the palpation methods and neuromuscular technique (NMT) 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, and 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.

Because most people have preconceived ideas about what a massage should be (relaxing, passive, general) it becomes important to incorporate both assessment and treatment into the massage in such a way that the generalized full body experience of the massage is not compromised.

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 headache and neck pain symptoms even if nothing else is done (Yates 2004). It is prudent to preserve these qualities and benefits of massage when addressing specific conditions such as headache and neck dysfunction.

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 cervical 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 headache and neck pain are so common and massage has been shown to be beneficial (see Chapter 5), the massage therapist needs to be skilled in this area.

The headache and neck pain massage treatment suggestions in this text are most effective for muscle tension-type headaches and mechanical neck pain, although strategies for vascular-type headaches are offered.

Based on many years of professional experience, client populations that typically often seek massage experience headache and neck pain. Causal factors are typically a cumulative response to many different adaptive responses, such as postural distortion, a combination of short soft tissue and long weak muscles or lax ligaments, various types of joint dysfunction (especially instability), generalized stress and breathing dysfunction, repetitive strain, lack of movement – and the list goes on – as discussed in detail elsewhere in this book.

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. Headache and neck pain is a major treatment concern in health care in many populations, including children and adolescents, in 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 headache and neck pain and improvement in function require lifestyle changes on the part of the client/patient and compliance with various treatment protocols. Chapter 9 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, headache and neck pain 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. And 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. At the end of Chapter 6, massage treatment protocols are provided for various breathing dysfunctions, which can be a cause of head and neck pain.

Massage may actually be the treatment of choice for those people who will not be compliant with a multidisciplinary care plan for headache and neck dysfunction. Based on the assumption that they are not going to make behavioral changes, or do the necessary exercises, massage can replace – to some extent – the activities necessary to maintain pliability and flexibility in shortened soft tissue structures as well as reducing generalized stress. People can become discouraged, which increases the tendency to be noncompliant with self-treatment protocols. A massage twice a week can often manage the pain and dysfunction in these people by moving fluids, lengthening short structures, stimulating internal pain-modulating mechanisms, and by reducing generalized motor tone by decreasing sympathetic anatomic nervous system activity, as well as by providing pleasurable relaxation experiences.

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 head and neck 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 headaches and neck dysfunction. 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 2004). 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 head and neck pain.

Describing massage

There is an evolution taking place in massage. The shift from a modality focus (e.g., Swedish massage, reflexology, deep tissue massage, Amma, Lomi Lomi) to an outcome focus requires a change in terminology and how massage application is described. One definition of massage is that it represents the manual manipulation of the soft tissues. Soft tissue manipulations create various mechanical forces which cause shifts in the form and function of the body. The physiologic responses of the body to massage are not specific to the modality used but to what is described as qualities of touch.

Qualities of touch

Massage application involves touching the body to manipulate the soft tissue, influence body fluid movement, and stimulate neuroendocrine responses. How the physical contact is applied is considered the qualities of touch. Based on information from massage pioneer Gertrude Beard and current trends in therapeutic massage, the massage application can be described as follows (De Domenico 2007).

Depth of pressure (Figure 8.1)

Depth of pressure (compressive force) – which is extremely important – can be light, moderate, deep, or variable.

Figure 8.1 Massage applications systematically generate force through each tissue layer. This figure provides a graphic representation of force applied, which would begin with light superficial application, progressing with increased pressure to the deepest layer.

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. 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 thin, delicate 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 reach the location of the point as well as to 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 (Figure 8.2)

Drag describes the amount of pull (stretch) on the tissue (tensile force).

Figure 8.2 Gliding prone, proximal to distal, with drag.

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, whereas 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.

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 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.

Duration relates to how long compression is applied to soft tissue areas of dysfunction, or how long a stretch is held.

The following example describes how some of these qualities can be used to describe a massage modality. Myofascial/connective tissue methods may be indicated in the management and treatment of neck pain.

Massage used to influence superficial fascia can be explained as light pressure, with sustained drag, to create tension forces (Figure 8.3), stretching the tissues just past their end of range barriers (bind) in multiple directions, for a duration of 60 seconds and repeated three times.

Figure 8.3 (A) Light pressure with drag. (B) Stretch (drag).

Delivery of massage

Through these varied qualities of touch, delivery of massage methods can be adapted to achieve the outcomes best suited to meet the needs of the client.

The mode of application (e.g., gliding/effleurage, kneading/petrissage, compression) provides the most efficient way to apply the methods. Each method can be varied, depending on the desired outcome, by adjusting depth, drag, direction, speed, rhythm, frequency, and duration.

In perfecting massage application, the quality of touch is as important as the method. Quality of touch is altered when there is a contraindication or caution for massage. For example, when a person is fatigued, the duration of the application should be reduced; if a client has a fragile bone structure, the depth of pressure should be altered.

Components of massage methods

All massage methods introduce forces into the soft tissues. These forces stimulate various physiologic responses.

Some massage applications are more mechanical than others – connective tissue and fluid dynamics are most affected by mechanical force. Connective tissue is influenced by mechanical forces by changing its pliability, orientation, and length (Yahia et al 1993).

The movement of fluids in the body is a mechanical process (e.g., the mechanical pumping of the heart). Forces applied to the body mimic various pumping mechanisms of the heart, arteries, veins, lymphatics, muscles, respiratory system, and digestive tract (Lederman 1997).

Neuroendocrine stimulation occurs when forces are applied during massage that generate various shifts in physiology (NCCAM 2004):

Typically these two responses to massage (fluid dynamics and neuroendocrine) occur together, although the intent of the massage application can target one response more than the other.

Tension loading (Figure 8.4)

Tension forces (also called tensile force) occur when two ends of a structure are pulled apart from one another. Tension force is created by methods such as traction, longitudinal stretching, and stroking with tissue drag.

Figure 8.4 Tension loading.

Tissues elongate under tension loading, with the intent of lengthening shortened tissues. Tension loading is also effective in moving body fluids.

Tension force is used during massage with applications that drag, glide, lengthen, and stretch tissue to elongate connective tissues and lengthen short muscles. Gliding and stretching make the most use of tension loading.

The distinguishing characteristic of a gliding stroke is that it is applied horizontally in relation to the tissues, generating a tensile force.

When applying gliding strokes, light pressure remains on the skin. Moderate pressure extends through the subcutaneous layer of the skin to reach muscle tissue but not so deep as to compress the tissue against the underlying bony structure. Moderate to heavy pressure that puts sufficient drag on the tissue mechanically affects the connective tissue and the proprioceptors (spindle cells and Golgi tendon organs) found in the muscle. Heavy pressure produces a distinctive compressive force of the soft tissue against the underlying or adjacent bone.

Strokes that use moderate pressure from the fingers and toes toward the heart, following the muscle fiber direction, are excellent for mechanical and reflexive stimulation of blood flow, particularly venous return and lymphatics. Light to moderate pressure with short, repetitive gliding following the patterns for the lymph vessels is the basis for manual lymph drainage.

Note: The traditional term effleurage describes a gliding stroke.

Compression loading (Figure 8.5)

Compressive forces occur when two structures are pressed together. Compression moves down into the tissues, with varying depths of pressure adding bending and compressive forces. Compressive force is a component of massage application that is described as depth of pressure.

Figure 8.5 Compression loading.

The manipulations of compression usually penetrate the subcutaneous layer, whereas in the resting position they stay on the skin surface. Excess compressive force will rupture or tear muscle tissue, causing bruising and connective tissue damage. This is a concern when pressure is applied to deeper layers of tissue.

To avoid tissue damage, the massage therapist must distribute the compressive force of massage over a broad contact area on the body. Therefore, the more compressive the force being used to either assess or treat the tissue, the broader the base of contact with the tissue should be, to prevent injury.

Compressive force is used therapeutically to affect circulation, nerve stimulation, and connective tissue pliability. Compression is effective as a rhythmic, pump-like method to facilitate fluid dynamics. Tissue will shorten and widen, increasing the pressure within the tissue and affecting fluid flow.

Compression is an excellent method for enhancing circulation. The pressure against the capillary beds changes the pressure inside the vessels and encourages fluid exchange. Compression appropriately applied to arteries allows back pressure to build, and when the compression is released, it encourages increased arterial flow.

Much of the effect of compression results from pressing tissue against the underlying bone, causing it to spread. Sustained compression will result in more pliable connective tissue structures and is effective in reducing tissue density and binding.

Compression loading is a main method of trigger point treatment.

Bending loading (Figure 8.6)

Bending forces are a combination of compression and tension. One side of a structure is exposed to compressive forces while the other side is exposed to tensile forces.

Figure 8.6 Using bend forces to stretch trigger point area.

Bending occurs during many massage applications. Pressure is applied to the tissue, or force is applied across the fiber or across the direction of the muscles, tendons or ligaments, and fascial sheaths. Bending forces are excellent for direct stretching of tissue.

Bending force is very effective in increasing connective tissue pliability and affecting proprioceptors in the tendons and bellies of the muscles.

A variation of the application of bending force is skin rolling. Applying deep bending forces attempts to lift the muscular component away from the bone but skin rolling lifts only the skin from the underlying muscle layer. It has a warming and softening effect on the superficial fascia, causes reflexive stimulation of the spinal nerves, and is an excellent assessment method for trigger points.

Areas of ‘stuck’ skin often suggest underlying problems (see Chapter 6).

Shear loading (Figure 8.7)

Shear forces move tissue back and forth, creating a combined pattern of compression and elongation of tissue. Shearing is a sliding force.

Figure 8.7 Shear.

The massage method called friction uses shear force to generate physiologic change by increasing connective tissue pliability and to insure that tissue layers slide over one another instead of adhering to underlying layers, creating bind. Application of friction also provides pain reduction through the mechanisms of counterirritation and hyperstimulation analgesia (Yates 2004). Friction prevents and breaks up local adhesions in connective tissue, especially over tendons, ligaments, and scars (Gehlsen et al 1999).

All of these outcomes of applying shear force during massage can address various factors influencing headache and neck pain. For example, deep neck muscles can adhere to each other or develop local areas of fibrosis from microtrauma injury. The result is short, inflexible muscles, which can be a contributing factor in neck dysfunction. The fascia in the area can develop fibrotic changes that cause a decrease in pliability, and shortening of the structure can also contribute to neck pain. Trigger point referred pain patterns are aspects of pain symptoms, and the tissues surrounding trigger points that have been in place a long time may be fibrotic.

Friction is beneficial in these situations as properly applied shear force loading of the tissues can create a controlled inflammatory response that stimulates a change in tissue structure.

Friction consists of small, deep movements performed on a local area. The movement in friction is usually transverse to the fiber direction. It is generally performed for 30 seconds to 10 minutes.

The result of this type of friction is initiation of a small, controlled inflammatory response. The chemicals released during inflammation result in activation of tissue repair mechanisms together with reorganization of connective tissue. As the tissue responds to the friction, the therapist should gradually begin to stretch the area and increase the pressure and intensity of the method.

The feeling for the client may be intense and typically described as burning, and if it is painful enough to produce flinching and guarding by the client, the application should be modified to a tolerable level so that the client reports the sensation as a ‘good hurt’. The recommended way to work within the client’s comfort zone is to use pressure sufficient for the client to feel the specific area, but not to feel the need to complain of pain.

The area being frictioned may be tender to the touch for 48 hours after use of the technique. The sensation should be similar to a mild, after-exercise soreness.

Because the focus of friction is the controlled application of a small inflammatory response, heat and redness are caused by the release of histamine. Also, increased circulation results in a small amount of puffiness as more water binds with the connective tissue. The area should not bruise.

While using friction can be very beneficial, there are cautions to applying excessive shear forces to tissues:

• This method should not be used during an acute illness, or soon after an injury, or close to a fresh scar, and should only be used if adaptive capacity of the client can respond to superimposed tissue trauma.

• Excess friction (shearing force) may result in an inflammatory irritation that causes many soft tissue problems.

• Friction will increase blood flow to an area but also cause edema from the resulting inflammation and tissue damage from the frictioning procedure.

The method is best used in small, localized areas of connective tissue changes and to separate layers of tissue that might have become adhered. The most common areas where more surface tissue becomes stuck to underlying structures are: scars, pectoralis major muscle adhering to pectoralis minor, rectus femoris adhering to vastus intermedialis, gastrocnemius adhering to soleus, and hamstring muscles adhering to each other, overlapping areas of tendons and ligaments.

Rotation or torsion loading (Figure 8.8)

This force type is a combined application of compression and wringing, resulting in elongation of tissue along the axis of rotation. It is used where a combined effect to both fluid dynamics and connective tissue pliability is desired. Torsion forces are best thought of as twisting forces.

Figure 8.8 Torsion loading.

Massage methods that use kneading introduce torsion forces that lift, roll, and squeeze soft tissues. Kneading soft tissue assesses changes in tissue texture and can be an aspect of treatment, especially as an aspect of stretching tissue or encouraging circulation or fluid movement in soft tissue. Torsion force can be used therapeutically to affect connective tissue in the body.

Changes in depth of pressure and drag determine whether the kneading manipulation is perceived by the client as superficial or deep. By the nature of the manipulation, the pressure and pull peak when the tissue is lifted to its maximum, and decrease at the beginning and end of the manipulation.

Note: Petrissage is another term for kneading.

Combined loading (Figure 8.9)

Tension = areas stretched, bend = tissue lifted, torsion = tissue twisted.

Figure 8.9 Combined loading.

Combining two or more forces effectively loads tissue. The more forces applied to tissue the more intense the response. As tension and compression underlie all the different modes of loading, any form of manipulation is either tension or compression, or a combination.

Tension is important in conditions where tissue needs to be elongated and compression where fluid flow needs to be affected.

Joint movement methods

Joint movement is incorporated into massage for both assessment and treatment. Joint movement is used to position muscles in preparation for muscle energy methods and before stretching tissues.

Joint movement also encourages fluid movement in the lymphatic, arterial, and venous circulation systems. Much of the pumping action that moves these fluids in the vessels results from rhythmic compression during joint movement and muscle contraction.

The tendons, ligaments, and joint capsule are warmed from joint movement. This mechanical effect helps keep these tissues pliable.

Types of joint movement methods

Joint movement involves moving the jointed areas within the physiologic limits of range of motion of the client. The two basic types of joint movement used during massage are active and passive.

Active joint movement means that the client moves the joint by active contraction of muscle groups. The two variations of active joint movement are:

• active assisted movement, which occurs when both the client and the massage practitioner move the area

• active resistive movement, which occurs when the client actively moves the joint against a resistance provided by the massage practitioner.

Passive joint movement occurs when the client’s muscles stay relaxed and the massage practitioner moves the joint with no assistance from the client. Various forms of oscillation (rocking and shaking) involve passive joint movement.

Since muscle energy techniques are focused on specific muscles or muscle groups, it is important to be able to position muscles so that the muscle attachments are either close together or in a lengthening phase with the attachments separated. Joint movement is how this positioning is accomplished.

Joint movement is effective for positioning tissues to be stretched. The more surface muscles are relatively easy to position during the massage using joint movement. The method can also be used for the smaller, deeper joints of the spine and surrounding muscles but the positioning needs to be precise and focused.

Shortened tissue located in deep layers of muscle, or in a muscle that is difficult to lengthen by moving the body, can be addressed with local bending, shearing, and torsion in order to lengthen and stretch the local area, and this is easy to accomplish during the course of the massage (Box 8.1).

Box 8.1 Sequence of massage based on clinical reasoning to achieve specific outcomes

1. Massage application intent (outcome) determines mode of application and variation in quality of touch:

• Mode of application – influenced by type/mode of application (glide, knead, oscillation compression, percussion, movement, etc.).

• Quality of touch – location of application, depth of pressure (light to deep), tissue drag, rate (speed) of application, rhythm, direction, frequency (number of repetitions), and duration of application of the method.

2. Mode of application with variations in quality of touch generates mechanical forces.

3. Mechanical forces (tension, compression, bend, shear, torsion to effect tissue changes from physical loading) leading to influence on physiology.

4. Influence on physiology:

• Mechanical changes (tissue repair, connective tissue viscosity and pliability, fluid dynamic).

• Neurologic changes (stimulus response – motor system and neuromuscular, pain reflexes, mechanoreceptors).

• Psycho-physiologic changes (changes in mood, pain perception, sympathetic and parasympathetic balance).

• Interplay with unknown pathways and physiology (energetic, meridians, chakras, etc.).

5. These factors contribute to development of treatment approach.

6. Treatment resulting in desired outcome.

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