clinical skills: massage
Three-count stroking of the trapezius/ three-stroke trapezius Big tree/Bilateral tree stroking
Examples of Effleurage
Vibration pg. 282
Fine vibration needs to be done for 5 to 15-30 min for analgesic
precautions
MS: decreased sensation-not accurate feedback osteoporosis: different degrees -fragile bones
venous system valves
towards heart, don't push on valves in opposite directions -matters most for limb -not as superficial vessels on back must know status of circulatory system first -assist with normal flow
Percussion/Tapotement
-do not do after trigger point (don't stimulate stretch reflex)
before you start
-don't hyper-extend thumb
precautions 2
-head injury: may not be able to give accurate feedback -MI/stroke: body needs to be stabilized. clear with physician. -hypotension: might pass out -chronic kidney disease: what stage -meds: blood thinners, narcotics, BP meds
more contraindications
-itis (inflammation of vessel) -depending on type of cancer
lymphatic system
-large PRO fit thru lymphatic system if not returned thru venous -can increase capacity up to 50% when needed (usually returns 10% fluid -transport: hormes, nutrients, waste -massage: push waste up to axillary and waste down to inguinal -one way valve -depend on muscles, g, ROM, massage
Deep transverse friction for scars-
-skin roll to find tightest area of scar -S curve: 1 finger above and below -along scar to move in -2 fingers on scar rub up and down
Understanding the Lymphatic System
40% at dermis: so those lymphatic system worked on in massage -can work lightly to maximize capillaries not crush them large PRO attach and can help remove larger waste products defends against infection and disease
Effleurage
Can do effleurage 2 minutes or longer. Repeat the stroke 5-10 times 40 -gliding over the skin -warm up loatin light, increase P
Petrissage/Effleurage technique pg.273 Horizontal Stroking on the back
Deeper stroke, AKA Kneading Research indicates that this technique reduces anxiety, and may be useful in alleviating behavioral symptoms of depression, improved immune function and improved allergic responses. Also, a reported decrease in perception on pain during labor, after surgery, with cancer, and with other chronic orthopedic conditions Petrissage - Petrissage involves compression of underlying skin and muscle between the fingers and thumb of 1 hand or between the 2 hands. - Tissue is squeezed gently as the hands move in a circular motion perpendicular to the direction of compression. - The main mechanical effects are compression and subsequent release of soft tissues, reactive blood flow, and neuroreflexive response to flow.
Direct Pressure/Specific Compression/Ischemic compression (Trigger Point Pressure Release)
Difference between deep friction vs trigger point massage: trigger point applies pressure over an area of tissue where the pt has symptoms Adhesions - use deep massage to break up Muscle spasms - need to base the massage of what the tissue does Scar tissue - same as adhesions Edema - mostly superficial, su use superficial stroke (edema can decrease ROM, so keep this in mind when reading pt hx & case studies)
Vibration - Manual or mechanical for pain relief
Fine vibration =/= course vibration of shaking, compression r percussion Frequently involves small portable vibrators, usually @ 100Hz Used to achieve pain relief for acute or chronic pain, including dental pain, phantom limb pain, myofascial pain, neuropathic pain Contact: palmar surface or fingertips Pressure: minimal Tissues engaged: skin Direction: NA Duration: 5-40 min for analgesia Rate: 4-10Hz manual, 100Hz machine-produced Combines with stroking or compression
potential effects of massage
Following strenuous physical activity, metabolic waste products can be hastened back into venous return by massage. Stiffness & soreness following strenuous activity can be lessened or prevented by massage immediately following the activity. This is a primary consideration in post event & recovery sports massage, as well as for patients performing strengthening exercises during rehabilitation.
Trigger Point Pressure Release 2
Repeat 3 and 4 no more than 3-4 times
Percussion AKA Tapotement pg. 280
Repeated rhythmical light striking Contact with fingers, fingertips, ulnar border of hands, heels of hands Pressure: light to heavy Engages: superficial subcutaneous tissues to deeper muscle & contained viscera (such as the lungs) Direction of movement: perpendicular to the surface of the client's body 2-10per second, duration 30 seconds to 10-20 minutes Used: briefly at end of regional or full body treatment for stimulation effect. alternating with vibration, rib springing, rhythmic mobilization of the rib cage with client in postural drainage positions Avoid bony prominences Encourage coughing and forced expiration Tapotement - This percussion-oriented massage involves striking soft tissue with repetitive blows by using both hands in a rhythmic, gentle, and rapid fashion. - Numerous variations can be defined by the part of the hands making an impact with the body. - The therapeutic effect of tapotement may result from compression of trapped air that occurs on impact. - The overall effect of tapotement may be stimulatory; therefore, healthy persons with increased tolerance for this approach are more likely to find this type of massage useful. More in cardio....
Example of Effleurage--
Superficial technique, using Gentle strokes, Provides an introduction to your hands Enables you to palpate as you go Massage for edema In an extremity, you must "Uncork the bottle" so start at least 2 joints above the swelling Contact: whole relaxed palmer surface of hand Pressure: light Engages: skin, superficial fascia, fat Direction: On limbs: centripedal (alternating both sides of limb, towards trunk) On torso: towards axillary or inguinal lymph nodes Rate: 5-50 cm/sec Duration 2 mi or more. Longer if it is all that the patient can tolerate or if done for edema (according to where in subacute stage) Use with: petrissage & superficial stroking USED for: alone, as a prelude and postlude to other massage techniques With extremities - work on smaller strokes and gradually increase Effleurage - In this approach, the practitioner's hands glide across the skin overlying the skeletal muscle being treated. - Oil or powder is incorporated to reduce friction; hand-to-skin contact is maintained throughout the massage strokes. - Effleurage can be superficial or deep. - Light strokes energize cutaneous receptors and act by neuroreflexive or vascular reflexive mechanisms, whereas deep-stroke techniques mechanically mobilize fluids in the deeper soft tissue structures. - Deep stroking massage is performed in the direction of venous or lymphatic flow, whereas light stroking can be in any direction desired. - Effleurage may be used to gain initial relaxation and patient confidence, occasionally to diagnose muscle spasm and tightness, and to provide contact of the practitioner's hands from 1 area of the body to another. - The main mechanical effect of effleurage is to apply sequential pressure over contiguous soft tissues so that fluid is displaced ahead of the hands as tissue compression is accomplished.
Trigger Point Definitions Ch. 22
Trigger points of referred pain: may elicit pain on being pressed or may radiate pain without pressure referred pain is described as "dull and aching, often deep, with intensity varying from low grade discomfort to severe and incapacitating torture. Pressing an active trigger point usually intensifies pain in the reference zone of the trigger point. Active trigger points are tender, prevent full lengthening, weaken the muscle and refer pain on direct compression Precise trigger point locations are discovered by palpation.
Example of Petrissage cont. - Picking Up or "C-Kneading"
Use more on extremities - One handed technique for smaller body parts Centripedal direction Uses power stroke to lift, re-open to a C-shape while gliding back Massage for edema In an extremity, you must "Uncork the bottle" so start at least 2 joints above the swelling Contact - Palmar surface, especially webspace between thumb & index finger Pressure: Light to medium Engages: Muscle & associated fascia Direction: parallel o long axis of body segment Length: 5-20cm or more Rate: 1-3 sec per cycle Duration: 20-60 seconds or more Preceded by general petrissage, followed by more-specific forms of petrissage
Examples of Petrissage/effleurage - Horizontal Stroking aka Wringing
Use this on many muscles Squeezing muscle & skin Hard to do with flat muscles (back ms) Preceded by effluerage, followed by more specific petrissage, or by itself for a region in a short time. Contact with entire palmar surface, thumb Light to heavy pressure Engages muscle and associated fascia Direction of motion is ACROSS long axis of the body segment 10-20 sec duration Applied around the partial circumference of the muscle belly or limbs Skin rolling 1-4 cm/sec, 30 sec or more
general contraindications
What used to be known as Reiter syndrome is now referred to as reactive arthritis (ReA). This change has occurred in part because of Hans Reiter's affiliation and activities with the Nazis during WWII. Reactive arthritis refers to acute nonpurulent arthritis complicating an infection elsewhere in the body. Reactive arthritis falls under the rheumatic disease category of seronegative spondyloarthropathies, which includes ankylosing spondylitis, psoriatic arthritis, the arthropathy of associated inflammatory bowel disease, juvenile-onset ankylosing spondylitis, and juvenile chronic arthritis. inflammation: redness, heat, swelling, pain
Examples of Petrissage cont. Specific kneading
Working on a trigger point .5 to 2 seconds per cycle Up to 20 seconds at a time In extremities - use smaller strokes and friction massage (which is uncomforrtable) deep cross-friction massage over tendon (scar) to loosen a tendon or tissues that are sticking After FRICTION - ICE !!!!!!!
Trigger Point Pressure Release 1
area: -tighten -thumb in slight F -press down to pt tolerance 4/10 pain level (if already have this pain then assess if you should do it) -increase P slowly -feel release, then increase P a little more -might do effleurage/petrossage first how it works:-sustained shortening of sarcomere -dysfx A-M link not letting go -creating hypoxia to break that link -release metabolic waste -follow with effleurage/petrossage to get rid of wastes *-stretch the muscle afterwards 30s and then do AROM to maintain newly acquired range*
Deep transverse friction pg. 279
cause microtrauma to disorganized crosslinks of collagen-hyperemia -trigger fibroblast formation -lay down collagen in correct organized formation Patella tendon, Plantar fascia, lateral epicondyle (tennis elbow), suprasinatus origin Repetitive specific non-gliding technique that produces movement between fibers of dense connective tissue, increasing tissue extensibility & promoting ordered alignment of collagen w/in the tissues. Used to treat any condition in which mobility may be compromised by irregular tissue remodeling that occurred during tissue healing. Indicated in almost all chronic-stage orthopedic injuries including: sprains, strains, fractures, Is a manual intervention for repetitive strain injuries (tendinitis,tenosynovitis, bursitis, palntar fasciitis Place the part in a position between neutral and full stretch so that you don't slide and that it can still be accessed. Does NOT require oils for massage SHORT FINGERNAILS SHORT strokes Contact: reinforced fingers, thumb, knuckle, olecranon Pressure: light to heavy Tissues engaged: dense CT (ligament, tendon, fascia, scar tissue, connective tissues) Direction: transverse, circular or parallel Slow speed: 1-3 cycles per second, Duration: 30 sec to 15 min Perform the friction, slow, to the area until softening of the tissue or 2 minutes, whichever comes first. Take breaks of several seconds to change contact surfaces. Max of 6 min the first time and increase by 2-3 minutes every session to a max of about 15 min If overtreated: follow with coldpack Deep friction - Pressure is applied with the ball of the practitioner's thumb or fingers to the patient's skin and muscle. - The main effect of deep friction massage is to apply shear forces to underlying tissues, particularly at the interface between 2 tissue types (e.g., dermis-fascia, fascia-muscle, muscle-bone interfaces). - Deep pressure keeps superficial tissues from shearing so that shear and force are directed at the deeper tissue surface interface. - Deep friction massage frequently is used to prevent or slow adhesions of scar tissue.
Palpation of Soft Tissue Layers
edema acculumating in superficial fascia
effleurage effects
engage to superficial fascia: superficial circulation of venous return/lymphatics -venous return to heart -lymphatics: lymph nodes dense fascia: pliability of CT: regulate tone -info to sc to bring back response
Effects and benefits of massage
facilitating return of cardiovascular and lymphatic system circulation clearance of met waste/biproducts delivering of O2 and nutrients to cells
potential effects of massage 2
help with repair of tissue assist with edema: fluid back to general circulation healthy scar formation release adhesions CT health-pliable stimulate sensory receptors: assist in reducing pain -body awareness: proprioceptors muscular system: -milk the muscle: help remove debris and bring in nutrients -info to sc to normalize tone of muscle PS: release endorphins and decreases amount of cortisol -increase body awareness circulation: general/local -enhance venous return -decrease BP/HR lymphatic: lymph to nodes-kills bacteria/viruses pain: sensory receptors stimulate at skin-highly myelinated and travel fast to sc at same level where pain levels arise at-block pain signal at layer (Gate theory)
endangerment sites
kidney: T12-L3 belly button: defending aorta
remember
know why behind lymphatic system/cardiovascular system intertwined together absorb from interstitial fluid circulatory system returns 90% of fluid, lymphatic system 10% (increases up to 50% if edema for short period of time) lymphatic system: drains into axilla, inguinal area-jugular veins-circulatory system
Mechanisms to explain effects of massage 1-2
mechanical: hands reflex: mediated by NS -calm or make more alert
Petrissage
milk the muscle (get rid of metabolites) -regulate NMJ: tone of muscle
Lymphatic System
non-contractile if immobilized then depend on external forces: gravity -place in 30-45 degrees -massage 1 way valve
Mennell's Superficial Stroking p. 273
opp direction towards head in irregular pattern: arousal Duration: 10 seconds to 10 minutes, depending on therapist's intention
Mechanisms to explain effects of massage 3-4
physiological: -mediate proprioceptive system -assist scar to heal, producing endorphins psychological -endorphins -connection to pt
Mennell's Superficial Stroking - effleurage
slowly: calm pt down -only engaging the skin opp direction towards head in irregular pattern: arousal
Purpose/effect: -static contact/passive touch
static contact/passive touch: -put hand on patient PS NS contact: calming down move smoothly from one thing to the next
Swelling of the wrist? swelling at the knee ? Edema on the whole arm.... Lumbar spasm... Upper back trigger points.... Lateral epicondylitis..... Scar adhesions.... Ankle sprain...... techniques
swelling of wrist: effleurage, can do petrossage above swelling of knee: same^ edema whole arm: effleurage only lumbar spasm: muscle layer upper back trigger point: trigger point release lateral epicondylitis: cross friction massage scar adhesion: cross friction massage ankle sprain: cross friction massage
Deep transverse friction for scars
warm up with effleurage/petrossage *1 minute* cause algesia -if feel better not worse do 1 more minute -total 2 minutes -effleurage/petrossage -2 more minutes -3 cycles total -6 minutes increase 2-3 every session -maximum 15-20 minutes tops -in 3 sessions will know if it is working for this pt or not can continue for 8-12 sessions
effleurage--When used FOR localized swelling:
whole arm/leg: send out to someone in lymphatics for massage swelling: create a reservoir -position 30-45 degrees -start close to lymph nodes -next stroke a little bit farther down injury in softball: -if inflammation do not touch swelling at elbow: -start at periphery reservoir=uncork the bottle