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Massage Skill

There is a long history to massage from the earliest accounts of medical care. The
purpose of massage is to produce therapeutic effects on the tissues of the nervous,
muscular, and respiratory systems of the body and on the local and general circulation
of the blood and lymph. The definitions of massage are many but all of them describe
the use of the hands as a means to bring about responses in the soft tissues. In the
healing arts the responses are therapeutic ones.

Indications and Contra-indications

The major indication for massage is post-acute soft tissue trauma, particularly sprains
and strains. Massage should not be conducted in areas of acute injuries with on-going
hemorrhaging, infections, thromboses, and neural damage.

Massage Movements

Stroking and Effleurage: this involves a centripetal

movement using broad flat surfaces of the hands or
arms. Stroking may follow body contours or follow the
direction of muscle fibers. Firmer strokes take place
by using the same pressure but modifying the hand to
the edge, tips of fingers, the ball of the thumb, and the
knuckles. Deep stroking should follow the course of
veins and lymph vessels to assist in forcing fluids in
these vessels back towards the heart. Slow strokes
promote relaxation whereas faster strokes encourage
blood flow and stimulate the tissues. Ideally one hand
should be in contact with the skin at all times. Stroking
with the hands going in the same direction at the same
times is one option. Another is alternating with one
hand just before the other hand leaves the skin. Light
effleurage is usually done at the beginning and end of
a massage session.
Tapotement: this involves gentle tapping or pounding of the
skin. Use of the ulnar side of the wrist, or cupped hands, or
relaxed hands with the fingers pressed together. The
attempt is to slap the skin.

Vibration: this involves rapid shaking of the tissues or a slower and rhythmic pattern of

Petrissage: this is firm grasping of the tissues between the

thumb and fingers in a rolling and pushing manner that
proceeds in a centripetal direction. This process stretches
and separates muscle fiber, fascia, and scar tissue.

Kneading: this is a lifting and compression that is vertical to the tissues. Some have
referred to this as a petrissage movement, so the process is the same.

Friction: this is light to hard pressure slowly progressing to

deep tissues using linear strokes or circles in a direction that
slips over the skin on light pressure and using the entire palm
of the hand. The deeper strokes are made by a forceful
friction between the fingertips and the underlying tissue
usually in a cross-fiber direction. The goal of this massage
stroke is to mobilize muscle and separate adhesions in
muscle, tendon, or scar tissue that restrict movement and
cause pain. This stroke is not necessarily pleasing and may
be painful. Often this type of stroking is followed by a
stretching routine.

Components of Massage

Direction: the direction of most massage may be centripetal (the direction of venous
blood flow) even though the succession of the movements is in the opposite direction
Pressure: the amount of pressure is solely dependent on the relaxation of muscle. Even
light pressure could influence every structure throughout the part if muscle relaxation
has occurred. Deep pressures may be applied without any sense of being forceful. Firm
pressure may be used but avoid pain.

Rate and Rhythm: the movements must be slow, gentle, and rhythmical with no
hesitancy or irregularity about it. The time between the end of the stroke and the
beginning of the next stroke should be identical to the time of the stroke during the
movement. Breathing rates offer a slow and rhythmic rate.

Media: Dry massage is very common, but use of talcum powder, or an oily medium are

Position of the Patient: the position should be on a table for most body parts so that
the limb and body are supported in a comfortable position. The operator should be able
to work in a comfortable position. Gravity is often used to assist the process.

Duration: the range of massage duration is quite long 5-75 minutes. Massage for
edema reduction is often given for 5-10 minutes. Friction massage is given for about 5

Frequency: this is quite varied but 1-3 times daily is recommended.

Physiologic Effects

Although it is difficult to separate physiological from psychological effects of massage, it

may not be necessary if mental confidence in the process is achieved. The following are

Changes in blood flow: deep, friction, or vigorous massage can produce an increase in
blood flow, histamine release, and increased temperature. It does not appear to affect
an increase in cardiac output, blood pressure, or lactic acid concentration.

Neuromuscular changes: petrissage has been shown to decrease neuromuscular

excitability but only during the massage. Massage routines that consist of deep
effleurage, circular friction, and transverse friction have been shown to increase
flexibility. There appears to be no effect to assist fatigue reduction or muscle recovery
with massage.

Reduction of edema: properly done, massage can increase venous and lymphatic flow
that assists in the removal of edema. This type of massage forces the fluid within the
vessels to move toward the heart. The strategy with edema removal is to mobilize
proximal areas of edema before attempting to move more distal areas.

Pain control: mechanical pain is interrupted through reducing muscle spasm and
reducing edema. Chemical pain is reduced by increasing blood flow and encouraging
the removal of cellular wastes. Simple touching can reduce pain by activating sensory


Both your hands and the patient’s skin should be clean. Your hands should be warm
and your nails trimmed. Remove rungs, watches and wrist jewelry. Use less lubricant
with petrissage and even less with fractioning.

General Application

Before beginning, position the patient comfortably with the part to be massaged
properly exposed. If edema reduction is the goal, elevate the part to enhance drainage.
Explain what you are going to do and for the patient to inform you if painful. For
effleurage and petrissage the direction of stroking is toward the heart and the hands
should not lose contact with the skin. The rhythm of the stroke should be slow to
promote relaxation. Maintain a comfortable position during the treatment and use
proper body mechanics. When using friction massage you should warn the patient that
the treatment will be uncomfortable but it will not last. Use the thumb or finger pads in
a cross pattern. Firm, consistent pressure and rhythm are used. Often a cross-friction
pattern is used perpendicular to the tissues fiber arrangement.