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Chapter: The Massage Connection ANATOMY AND PHYSIOLOGY : Integumentary System

Integumentary System and Bodyworkers

The importance of touch as an avenue for healing of the mind and body cannot be underestimated.

Integumentary System and Bodyworkers

The importance of touch as an avenue for healing of the mind and body cannot be underestimated. Studies of healthy, preterm infants have shown that massage facilitates growth and development.1 The internal state of mind directly affects the surface of the skin, evi-denced by blushing when embarrassed or turning pale when frightened. Often, diseases of the mind and body present as changes in color, tone, or even abnormal le-sions on the skin. Because the skin is the largest sensor that informs the mind about the external environment, it is conceivable for techniques used on the skin to af-fect the mind and internal organs in various ways.


It is well known that skin stimulation can trigger various reflexes. Some of the therapeutic effects of massage seem to arise from altered blood flow and pain suppression in deeper structures by such re-flexes. These reflexes, known as cutaneovisceral re- flexes, involve both the autonomic nerves and therich sensory plexuses in the skin. Some examples of cutaneovisceral reflexes are the abdominal reflex (contraction of the abdominal muscles on stroking the skin over the abdomen), the plantar reflex (con-traction of the muscles of the foot on stroking the sole of the foot), and the gag reflex (emptying of the stomach on tickling the back of the throat).

Massage has the ability to mechanically change the texture and consistency of skin. For example, theskin becomes softer and suppler when massaged. With recurrent and prolonged manipulation, the skin can become more resilient, flexible, and elastic. At the superficial level, massage helps to remove dry, scaly skin. At a deeper level, important effects of mas-sage include the ability to help realign collagen fibers in the dermis during and after the healing of deep skin wounds. Fibrous scar tissue can potentially trap nerves, blood vessels, and lymphatics. By realigning collagen fibers and facilitating the movement of skin over other superficial structures, massage can help prevent problems caused by this entrapment.

One of the physiologic effects of massage is the ca-pacity to increase local blood and lymph flow, im-proving the nutritive status, facilitating the removal of toxins released by injured tissue, and quickening healing. The increase in blood and lymph flow may be a result of direct mechanical displacement, as well as reflex nervous responses of blood and lymph chan-nels walls induced by application of pressure to cuta-neous areas. In addition, release of vasodilator sub-stances, such as histamine from mast cells, is linked to local increase in blood flow. It should be remem-bered that massage can quicken drug absorption in injection sites secondary to the increase in blood flow. Other physiologic effects include an increase in insensible perspiration and facilitation of sebaceous secretion.

Undoubtedly, massage can reduce the pain per-ceived by the brain, as explained by the gate-control mechanism. The therapeutic ef-fect may be a result of both a psychological and phys-iologic phenomenon. Even without scientific expla-nation, most persons automatically knead or touch or massage a painful area and find relief. Massage, in general, produces a sense of well-being and renewed vigor. Evidence also suggests that it reduces stress, anxiety, and pain perception and has a positive effect on immune function.3,4


The mechanical, reflex, physiologic, psychological, and psychoneuroimmunologic effects of massage are related to the technique used. Mechanical effects are those caused by physically moving the tissues (e.g., compression, stretch, etc.) Reflex effects are changes in function caused by the nervous system. Physio-logic effects involve changes in body processes caused by nerves, hormones, and chemicals. Psycho-logical effects are emotional or behavioral changes. Psychoneuroimmunologic effects are those that alter hormone levels and function through stimulation of the neurohormonal system.

The techniques used in the manipulation of skin and underlying tissue can be categorized as:

1.        superficial reflex techniques


2.        superficial fluid techniques


3.        neuromuscular techniques


4.        connective tissue techniques


5.        passive movement techniques.


Superficial Reflex Techniques

When superficial reflex techniques are used, the re-flexes produce changes . No mechanical effects are produced. Therefore, the direction of the stroke is unimportant. These techniques primarily affect the level of arousal, perception of pain, or autonomic bal-ance and have been shown to have positive effects on the physiologic and psychological development of premature infants.1 Examples of superficial reflex techniques include static contact, superficial stroking, and fine vibration.

Static contact is synonymous with a resting posi-tion, passive touch, superficial touch, light touch, maintained touch, or stationary hold. In this tech-nique, minimal force is used and the therapist’s hands are still. This technique produces sedative ef-fects and reduces anxiety. It is often used at the be-ginning and end of massage.

Superficial stroking is also known as light stroking, feather stroking, or nerve stroking. In this technique, the therapist’s hands glide over the skin with little pressure on the subcutaneous tissue. It is used to alter arousal levels and to reduce pain. Pain is reduced by stimulation of large diameter touch nerve fibers, which, in turn, reduce the transmission of pain im-pulses to the brain. Local reflexes triggered by the strokes reduce muscle spasm and tension.

Fine vibration, also known as vibration, cutaneous vibration, transcutaneous vibration, mechanical vi-bration, and vibratory stimulation, is a technique in which rapid, trembling movement with minimal pres-sure is produced by the therapist on the client’s skin. Studies of the effects of vibration using mechanical vi-bration have shown that the pain threshold increases, causing reduction in pain.5 Such an effect is produced even if the stimulation is given at different sites— proximal to, distal to, or on the site of pain or in the contralateral region. An increase in muscular tone may be seen below the site of stimulation.

Superficial Fluid Techniques

Superficial fluid techniques are those that effect structures in the dermis and subcutaneous tissue. Su-perficial effleurage and superficial lymph drainage techniques are in this category. In superficial ef-fleurage—also known as effleurage—gliding, stroking, or deep stroking, gliding movements are used. In addition to producing reflex effects similar to those of superficial stroking techniques, these move-ments affect lymphatic and venous return in skin and deeper structures by mechanical compression. They are, therefore, particularly effective in reducing edema. These techniques also have psychological and other physiologic effects, such as reduced anxiety, in-creased relaxation, reduced muscle excitability, and increased intestinal movement.

The superficial lymph drainage technique uses short, rhythmic, nongliding strokes in the direction of lymph flow. The strokes result in gentle stretching of the skin and superficial fascia, together with the stimulation of contraction of lymph vessels. If per-formed over a large surface area of the body, it effec-tively increases lymph return to the veins. In addi-tion, these techniques reduce anxiety and pain, produce sedation, and improve immune function.

Neuromuscular Techniques

Neuromuscular techniques include broad contact compression (compression, pressure, pressing), petris-sage (kneading), stripping (stripping massage, deep stroking massage), and specific compression (focal compression, ischemic compression, digital compres-sion, digital pressure, direct pressure, static friction, and deep touch). These techniques affect both superfi-cial and deeper tissues, such as muscle. Broad contact compression has been shown to increase blood and lymph flow.6It may increase or decrease muscle rest-ing tension and have a stimulating or sedative effect, depending on the rate and pressure of strokes. Hence, it is commonly used in sports massage.

In petrissage, the tissue is repetitively compressed, dragged, lifted, and released against underlying struc-tures. These strokes relieve anxiety, improve immune function, and positively alter allergic responses. In ad-dition, petrissage has been shown to increase mobility of connective tissue and extensibility of muscle, reduce muscle tension, enhance muscle performance, and in-crease joint motion.7These effects may be caused by cutaneovisceral reflexes and mechanical compression.

In stripping, slow, gliding strokes are applied from one attachment of muscle to the other. It may be used to reduce the activity of myofascial trigger points (points on the surface of the body that are sensitive to touch and cause pain that travels or spreads when palpated). In addition to affecting trigger points, stripping may have the same effects as petrissage. Strokes performed in the direction of the natural flow result in emptying of veins and lymphatics. For this effect to occur, the muscles must be totally relaxed and the effects of gravity must be employed (e.g., limb elevation, recumbent position). It is important for proximal muscles to be relaxed while working on distal areas. If the pressure exerted is excessive, the arterial blood flow that occurs in the opposite direc-tion of veins and lymphatics may be impeded. Heavy pressure may also result in a protective reflex con-traction of muscles.

In specific compression, pressure is applied to a specific muscle, tendon, or connective tissue in a direction perpendicular to the tissue in question. This technique is used extensively by bodyworkers, either alone or in combination with other tech-niques (e.g., shiatsu, acupressure, and reflexology). It may help soften adhesions and fibrosis. The fact that it is used to reduce pain and produce physio-logic effects in regions far from the site of appli-cation suggests that it works by triggering complex somatovisceral reflexes.8

Connective Tissue Technique

Connective tissue technique uses palpation to help re-model and lengthen connective tissue. Friction (circu- lar friction, transverse friction, deep friction, deep transverse friction, cross-fiber friction, and Cyriax friction), skin rolling (tissue rolling, rolling), myofas-cial release (myofascial stretching), and direct fascial techniques (connective tissue technique, bindegeweb-smassage, myofascial massage, deep tissue massage, deep stroking, strumming, ironing, myofascial ma-nipulation, and soft-tissue mobilization) are some of the methods used. This technique is accompanied by reactive hyperemia and local increase in temperature. Hyperemia may result from release of histamine from mast cells and autonomic reflexes. It is claimed9 that these effects may last for several hours following ma-nipulation. Connective tissue techniques may have a powerful analgesic action that may be explained by the gate-control theory and release of natural painkillers.

Friction massage frees adherent skin, loosens scars and adhesions of deeper tissues, and reduces local edema. Repetitive, nongliding techniques are used in friction massage to produce movement between the fibers of connective tissue. In skin rolling, the tissue superficial to the deep fascia (the connective tissue layer investing muscles) is grasped and, using gliding strokes, lifted and rolled over in a wavelike motion. This stroke results in mechanical stretch of the con-nective tissue, releasing adhesions that may restrict mobility. In myofascial stretching or release, nonglid-ing traction is applied to muscle and the associated fascia. This technique, similar to direct fascial tech-niques, also results in mechanical lengthening of the fascia and is widely used in musculoskeletal condi-tions to increase mobility.

Passive Movement Techniques

Passive movement techniques use passive motion to treat various conditions. They include shaking (mus-cle shaking, course vibration, rolling friction, and jostling), rhythmic mobilization, and rocking (pelvic rocking, rocking vibration). These techniques have greater effects on muscles and joints. They produce sedation (possibly by stimulating vestibular reflexes) and decrease anxiety and pain perception.

Percussive Techniques

Percussive techniques alternatively deform and re-lease tissue at varying rhythms and pressure. Clap-ping or cupping, tapping, hacking, pounding, and tapotement are some examples. These strokes result in initial skin blanching as a result of contraction of arterioles from mechanical stimulation. Blanching is followed by redness brought about by vasodilation from overstimulation. The effects of this technique on muscle tone and alertness vary with the rate, vigor, and duration of strokes.


Massage is often preceded by application of heat to the involved part. Local heat can be applied in the form of poultices, hot water packs, hot water bottles, electric pads, special electric lamps, chemical pads, paraffin baths, and diathermy. General heat may be used in the form of hot water baths, steam baths, va-por baths, dry thermal cabinets, and electric blankets.

When heat is applied for a short period, it causes peripheral vasodilatation, redness of skin, general and local muscular relaxation, increase in pulse rate and respiratory rate, shallow respiration, decrease in blood pressure, and diminished heat production. Heat opens up vascular channels and softens the tis-sues, permitting more effective application of mas-sage. It stimulates the circulation, speeds removal of inflammation waste products and, thereby, relieves pain, swelling, and spasm.


The rate of skin cooling is faster than the rate of re-warming, implying that a shorter period of cold appli-cation suffices to cool the skin. The depth of cold pen-etration depends on the duration and the area of application. Areas of the body containing more adi-pose tissue take a longer time to change temperature. If deeper structures are to be cooled, the duration of application is increased. When cold, in the form of wa-ter, is applied locally, it results in peripheral vasocon-striction and pallor. The vasoconstriction, in turn, re-sults in a decrease in skin temperature and reduction of edema, muscle spasm, and further hemorrhage.

Analgesic effects begin when skin temperature is lowered to approximately 13.6°C (56.5°F). Analgesia is produced by the reduction in nerve conduction ve-locity by cold. Systemic reactions, such as increase in heart rate, respiratory rate, blood pressure, and shiv- ering, may be produced. Soon after cold application has ended, peripheral vasodilatation may occur, with redness of skin, feeling of warmth, slowing of pulse and respiratory rates, and relaxation. This reaction may last for 20–30 minutes.

For therapeutic purposes, both types of reactions may be desirable and cold and hot applications may be alternated.


The special properties of water make it a good medium for heat and cold application. The applica-tion of water for therapeutic purposes is termed hy-drotherapy.

Water is referred to as a flexible therapeutic agent because of its unique chemical and physical properties. It can be used as a liquid, solid (ice), or gas (steam). Water transports heat by convection as it easily circu-lates. Because many calories (the unit of quantity of heat; also expressed in joules) are required to increase temperature by even one degree, cold water absorbs a lot of heat energy when it is warmed by surrounding objects. Conversely, a lot of heat is liberated when wa-ter is cooled. Also, a number of heat calories are re-quired for the conversion of water to steam. This prop-erty is advantageous as sweat evaporation from the surface of the skin cools the body effectively. Another therapeutic property of water is that of the Archimedes’ principle, which states that a body wholly or partly im-mersed in a fluid is buoyed up by a force equal to the weight of the fluid displaced. Patients with muscu-loskeletal problems are able to move with considerable ease under water. Water is frequently used as a medium for applying thermal stimuli. Table 2.1 gives an arbitrary classification of temperatures and adjec-tives used for describing temperature.

It should be noted that the results of hydrotherapy vary with age, weight, and general physical condition.

Therefore, care must be taken when treating young per-sons, elderly persons, those in a poor state of nutrition, and those suffering from chronic vascular diseases.


Some relaxing or therapeutic treatments use herbs, clay, mud, or paraffin. They may be used to treat mus-cle and joint disorders, as well as to beautify and smooth the skin. Sheets, towels, or cheesecloth bags containing herbs are placed in a steaming vat and, once impregnated with the herb, drained and used to wrap the body or body part. A warm blanket and a plastic sheet are used to retain heat. In a mud wrap, the body is coated with heated mineralized mud. Muscle relax-ation, increased circulation, and lymph drainage are some of the observed effects. Temporary weight loss may be observed as a result of increased loss of water by perspiration. Other beneficial wraps include a mix-ture of volcanic ash and paraffin and seaweed wraps.


All bodyworkers must be able to distinguish different lesions on the surface of the skin and to determine whether it is infectious. Many lesions may appear infectious but may not actually be infectious, such as some types of psoriasis, severe acne, or vitiligo. 

Touch therapy may be of great help to those clients who are often isolated from society because of their appear-ance. Areas of skin that ooze fluids or are visibly in-flammed, should be avoided at all times. Although the therapist is not expected to diagnose a condition, it is vital to have enough information about those skin dis-eases already diagnosed by a physician to work with clients with these disorders. Figure 2.11 indicates the appearance of common skin lesions or skin signs. It is important for all bodyworkers to avoid infected, acutely inflamed, or irritable skin lesions.

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