Muscular System and Massage
Most of the therapist’s work is likely to be related to the muscular system. There are too many muscle-re-lated problems, however, and they cannot all be discussed in this section.
Massage is beneficial in treating many muscu-loskeletal problems,2-6 such as tendinitis, sprain, tenosynovitis, and low back pain. It reduces swelling, increases blood flow, relieves pain and muscle spasm, and mobilizes fibrous tissue, and also improves mus-cle action and induces a state of general relaxation. Early institution of massage not only decreases pain but also accelerates the rate of functional recovery.
The gradual compression produced by strokes such as effleurage reduces muscle tone and induces a general state of relaxation that relieves muscle spasm.7The relaxation is produced by the localized stretch effect that lengthens sarcomeres in the imme-diate vicinity of the applied pressure. Strokes that in-volve application of firm pressure accelerate blood and lymph flow and improve tissue drainage. Knead-ing promotes the flow of tissue fluid and causes reflex vasodilation and marked hyperemia; this reduces swelling and helps resolve inflammation. Vigorous kneading decreases muscle spasm and can stretch tis-sues shortened by injury. Petrissage is particularly useful for stretching contracted or adherent fibrous tissue and will relieve muscle spasm. Acting deeper than kneading, petrissage also promotes the flow of body fluids and resolves long-standing swelling. Sub-stances released by ischemic tissue that sensitize pain receptors are also dispersed, relieving pain. Fric-tion massage2 breaks down scars and prevents scar tissue from matting muscle fibers together.
Postexercise effleurage reduces subsequent muscle soreness by rapidly reducing lactate concentration in the muscle cells. This has been shown to be a more effective treatment than either rest or a conventional active warm-down program.8-11 Massage can also be used to prevent denervated muscle from losing both bulk and contractile capability, assisting subsequent rehabilitation.12 Massage has been successfully used for prevention of delayed-onset muscle soreness13 and as an adjuvant therapy for conditions such as carpal tunnel syndrome,14 low back pain (not involv-ing nervous dysfunction),15-17 and joint sprains.18
Heat is often used during massage.19 Local heat can be applied by immersion in hot water, hot towels, paraffin wax baths, electrically heated pads, infrared lamps, or infrared lasers. The latter have the capacity to penetrate deep tissue. Heat causes local vasodila-tion, increased cell metabolism, pain relief, relax-ation of muscle spasm, increased range of motion, and decreased stiffness.19Some of the effects of heat on deeper structures is believed to be a result of reflex mechanisms. By stimulating other afferent fibers, heat reduces the number of impulses carried to the brain by pain fibers (gate-control theory).19,20 Muscle relaxation may be produced by a reduction of gamma motor neuron and alpha motor neuron activity.19 Heat also increases the extensibility of collagen. By increasing blood flow, it speeds the removal of pain-causing substances. Before the application of heat, therapists must ensure that the client has normal temperature and pain perception to determine a safe level of heat.
Therapists should also make sure that the local circulation is not impaired. Deep heat (e.g., infrared, ultrasound) should be avoided in areas that contain large amounts of fluid, such as the eye, joints, and acutely inflamed tissue because high thermal energy can build up. Deep heat should also be avoided over tissue containing metallic objects.
Cold may also be used therapeutically.21The term cold refers to removal of heat (i.e., one feels a sensation of cold if the temperature is lower than that of the body area to which it is applied). The temperature is described as tepid if it is 26.7–33.9°C (80–93°F); cool if it is 18.3–26.7°C (65–80°F); cold if it is 12.8–18.3°C (55–65°F), and very cold if it is below 12.8°C (55°F). Substances may be used in solid forms (ice, carbon dioxide, snow), liquid forms (water), or gaseous forms (ethyl chloride, alcohol, ether; they extract heat during evaporation) for eliciting cold sensations.
Although it sounds unappealing, application of cold (cryotherapy) is a more effective way of producing deep vasodilation than heat. Application of cold also has a pain-relieving effect and reduces muscle spasm.22 Cooling produces analgesia by reducing the rate of conduction through nerves. When the skin is cooled, it initially causes local vasoconstriction; how-ever, after 5 to 10 minutes, the blood flow through su-perficial and deep tissue increases and then oscillates. The increased blood flow raises the temperature and improves tissue nutrition. Ice applied for short peri-ods causes vasoconstriction and reduces bleeding. Prolonged application will cause vasodilation by tis-sue injury and increase tissue hemorrhage. Melting ice is the most effective way to chill the skin.
The therapist must remember that muscle is made up of different kinds of tissue. Although the bulk of the muscle is muscle tissue, the tension produced in the muscle is transmitted to the bone via connective tissue in the form of fascia, tendons, and aponeurosis. The pressure, stretching, friction, and movement exerted during a therapeutic session can make this connective tissue more pliable and have a beneficial effect.
All connective tissue exhibits thixotropy.23 This is the property by which connective tissue becomes more fluid and pliable when exposed to heat, friction, and/or movement and becomes more solid when ex-posed to cold and/or is unused. This inherent prop-erty is a result of the ground substance and collagen, elastic, and reticular fibers it is made of. The applica-tion of heat and cold in therapy capitalizes on this property of connective tissue.
As in any tissue, when injury occurs, it is followed by inflammation and healing. While healing, the con-nective tissue fibers/fascia of adjacent muscles may adhere (stick) to each other. These adhesions, other than restricting movement of muscle, may trap nerves and blood vessels supplying the muscle, pro-ducing further complications. Appropriate applica-tion of heat/cold and massage, passive, and active movements at the right time can prevent adhesion formation in tissue.
Another fact that should be remembered is that structures, such as tendons, fascia, aponeurosis and ligaments, that are made up of connective tissue with a high proportion of nonliving collagen fibers take a longer time to heal because of their structure as well as the reduced blood supply. Hence, treatment regi-mens that are too early, vigorous, or overenthusiastic should not be given when treating conditions related to these structures.
The tone of the muscle may vary from person to per-son. In some individuals who are paralyzed, the tone may be increased, and the muscle may be fixed in awk-ward positions that result from contractures. In other individuals, the limb may lie limp, with no tone at all. Both conditions are a result of dysfunction of the ner-vous system. It is important for the therapist to assess the client carefully and be fully equipped with all rele-vant information about the disorder. If in any doubt, it is better to get advice from a medical professional.
Some clients may be taking medications such as painkillers, anti-inflammatory drugs, or even muscle relaxants that depress pain sensations. It should be ensured that the client has not taken such medica-tions. If using these medications, therapy should only begin after the effects have worn off.
Trigger points are locations in tissue that are hy-persensitive and painful when compressed. Thera-peutic work on trigger points of various muscles24 seems to have a positive outcome, and it is worth-while to master the techniques needed to identify and treat these regions.
Many problems related to muscle may be a result of the occupation of the client or a result of bad pos-ture. An important element of therapy should be proper history taking and physical assessment. De-tails of occupation and work-related stresses and strains that may be the cause of the ailment should be obtained, and client education and strategies should be planned accordingly.
Lastly, but most importantly, the therapist should ensure that the techniques and posture used by them-selves during a massage are ergonomically healthy in order to prevent problems such as musculotendinous and nerve impingement injuries.