Manual and Medical Massage Therapy: A review of scientific literature relative to technique Wednesday, July 02, 2003 - Prepared by the AMMA Staff

This article outlines and lists the techniques of manual and medical massage therapy in relationship to contemporary studies regarding the physiological effects of this therapy. It is by understanding the measured effects of our therapy that we are able to refine our technique and to determine the exact type of treatment that would best benefit a specific patient. Manual and medical massage therapy has several therapeutic roles including: To support the natural healing process of the body following injury or trauma. The repair processes of connective tissue regeneration and remodeling are dependent upon mechanical stimulation. To correct aberrations that develop in the connective tissue following injury or trauma. Connective tissues thicken and shorten after injry and the mechanical stimulation of manual and medical massage therapy can elongate shortened tissues. To effect and mitigate the effects of the inflammatory process in connective tissue, especially edema and fluid dynamics in tissue. To stimulate mechanoreceptors and facilitate inhibition of nociceptors thereby reducing pain. The manual and medical massage therapist treats and effects all of the body’s soft tissue structures including the following: Collagen and elastin fibers Stimulation of fibroblsts and chondrocytes Muscles Tendons Fascia Ligaments Peri and intro articular tissues Soft tissue aberrations such as adhesions, contraction, contractures, cross links, and scar tissue The joint complex unit Muscle tendon unit mechanoreceptive reflexes Skin mechanoreceptors Deep tissue mechanoreceptors Superficial and deep tissue fluid dynamics Lymphatic fluid dynamics Sympathetic nervous stimulation Motor neuron innervation Manual and Medical Massage therapies employ certain physical forces or simple mechanical physics. These physical forces can be broken down into two forms of force, although the means by which these two physical forces are delivered take on the form of many different techniques. These two physical forces include (1) connective tissue elongation and (2) connective compression. Virtually all manual and medical massage therapy techniques fall into one of both of these two categories. The different techniques can be further organized into the following categories based on physical load to the tissue fibers: Traction Compression Torque Bending Shearing Jamming Shaking Combined technique Current research into connective tissue pathology and healing has indicated that manual and medical massage therapy technique based on the above listed physical forces can promote healing in injured and damaged tissues. For example: Physical movement supports collagen repair and realignment along parallel lines of stress, Hunt T K, Van Winkle W 1979 Normal repair. In: Hunt T K Dunphy J E Fundamentals of wound management. Appleton-Century-Crofts, NY, ch.1, p 2-67. Intra articular adhesions in joints were found to be reduced by free movement, Evans E. B, Eggers G W N, Butler J K, Blumel J 1960 Experimental immobilization and remobilization of rat knee joints. Journal of Bone and Joint Surgery 42(A) 5: 737-758. Passive motion has been shown to stimulate repair mechanisms in ligaments, Fronek J, Frank C, Amiel D, Woo S I-Y, Coutts R D, Akeson W H 1983 The effect of intermittent passive motion (IMP) in the healing of medial collateral ligament. Proceedings of the Orthopaedic Research Society 8:31 (abstract). Passive stretching of muscle tissue has shown o accelerate muscle tissue growth, Leivseth G, Torstensson J, Reikeras O 1989 The effect of passive muscle stretching is osteoarthritis of the hip. Clinical Science 76: 113-117. Mobilization of tendons has been demonstrated to stimulate tissue reorientation and revascularization at the site of injury, Gelberman R H, Amiel D, Gonsalves M, Woo S, Akerson W H 1981 The importance of controlled passive mobilization on flexor tendon healing. Acta Orthopaedica Scandivavica 52: 615-622 Cyclical stretching of ligaments and the muscle tendon unit will "precondition" the tissue to a greater state of elongation, Taylor D C, Dalton J D Seaber A V, Garrett W E 1990 Viscoelastic properties of mescle-tendon unitys: the biomechanical effects of stretching. American Journal of Sports Medicine 13(3): 300-309. Muscle contraction has strong positive effects on blood flow and fluid dynamics in the tissue, Kirkebo A, Wisnes A 1982 Regional tissue fluid pressure in rat calf muscle during sustained contraction or stretch. Acta Phsiologica Scandinavica 114:551-556. Gillham L 1994 Lymphoedema and physiotherapists: control not cure, Physiotherapy 80(12): 835-843 Passive muscle pump techniques positively effect fluid dynamics in connective tissue, Laughlin M H 1987 Skeletal muscle blood flow capacity: role of muscle pump in exercise hyperemia. American Journal of Physiology 253(22): 993-1004. Fluid dynamics into and out of the joint and synovial fluid movement, the transsynovial pump is dependent upon acrive and passive joint motion, Levick J R 1987 Synovial fluid and transsynovial flow in stationary and moving normal joints. In:Helminen H J, Kivaranki I, Tammi M (eds) Joint Loading: biology and health of articular structures. John Wriht Bristol, p 149-186 Muscles spindles have been found to be 100 times more sensitive to low amplitude stretches than high amplitude stretches. Matthews P B C 1981 Muscle spindles: their messages and their fusimotor supply. In: Brooke Hart J M, Mount Castle V B, Broods V B, Geiger S T (eds) Handbook of Physiological Society, Besthesda, MD, ch 6. Mechanoreceptors can be stimulated by applying direct pressure to the joint capsule or ligaments. Schaible H-G, Grubb B D 1993 Afferents and spinal mechanisms of joint pain. Pain 55:5-54. Skin mechanoreceptors have been shown to be stimulated by light pressure to the skin or stretching of the skin. Gandevia S C McCloskey DI, Burke D 1992 Kinaesthetic signals and muscles contraction. Trends in Neuro Science 15(2):64-65 Massage to the muscle belly has been shown to reduce motorneuron excitability. Sullivan S J, Williams L R T, Seaborn D E, Morelli M 1991 Effects of massage on alpha neuron excitability. Physcial Therapy 71(8):555-560. Joint mobilization that involves pain triggers muscle contraction in joint muscles. Carpenter R S H 1990 Neurophysiology, Edward Arnold, London. Oscillatory stretching stimulated mechanoreceptors and connective elongation and relaxation, whereas high force stretches produce the opposite effect. Lederman E 1997 Harmonic technique. Churchill Livingstone, Edinburgh. Nociceptors do not adapt to, or fatigue after, noxius mechanical stimuli. Meyer R A, Campbell J A, Raja S 1994 Peripheral neural mechanisms of nociception. In: Wall P D, Melzack R (eds) Textbook of pain, 3rd edn. Churchill Livingstone, London, p 13-42. Listed above are just a few of the studies that support the techniques and treatment approach of manual and medical massage therapy. The following material outlines the clinical coordination and application of technique to patient conditions: Muscle strain and inflammation Objective: 1. Acute Support repair process and improve fluid dynamics. 2. Chronic Improve tissue elongation Techniques: 1. Acute Compression and gentle repetitive ROM 2. Chronic Strength training and cyclical stretching technique Soft tissue contraction, contracture, adhesions, and scar Objective: 1. Chronic Soft tissue stretching and elongation Techniques: Joint physics applied to joint complex Passive oscillatory and cyclical stretching and active stretching Deep tissue to joint capsule massage and mobilization Joint inflammation, edema, post fracture, adhesive capsulitis Objective: 1. Acute Soft tissue repair and normalize the fluid dynamics of the joint complex. 2. Chronic Increase joint complex range of motion through oscillatory and cyclical stretching Techniques: 1. Acute Repetitive motion technique and ROM 2. Chronic Stretching, ROM, Repetitive motion, deep tissue massage to the joint complex. Abnormal motor tone due to neurological injury such as stroke Objective: 1. Acute If inflammation or ischemia is present and contributing to pain, use technique to stimulate fluid dynamics in the tissues. 2.Chronic Deep muscle belly massage and joint complex treatment. Techniques: Direct muscle belly compression Soft tissue oscillatory and cyclical stretching techniques. Repetitive motion of the joint complex. Connective tissue manual elongation techniques Stimulation of skin mechanoreceptors via friction technique. The current scientific literature and research studies supports the following findings regarding neuro motor control of connective tissues: Skin mechanoreceptors have been found to respond with more neuronal signaling when light vigorous contact is applied intermittently. They respond stronger to continuous movement and stretching than they do to static manual techniques. The joint complex mechanoreceptors will respond equally to both active and passive stimulation. Generalized techniques that involve non painful range of motion will recruit a larger number or receptors. In joints where the tendon enters the joint, muscle contraction will increase tension within the joint and further recruitment of the mechanoreceptors. Intermittent compression of the muscle tendon unit has been shown to decrease motor tone or motor neuron excitability. This means that intermittent compression of the muscle tendon unit inhibits muscle tendon contraction and promotes muscle tendon relaxation. This technique worked in both normal an abnormal neurological conditions such as post stroke patients and spasticity. Many so called PNF techniques claim to reduce "muscle tone" and readjust the sensory map. These techniques most likely stimulate increased motor neuron activity and it is unlikely that they have any effect on the "awareness" of the central nervous system. High force, high velocity manipulative techniques and high amplitude active stretching technique, especially with added agonist or antagonist contractions most likely increases motor neuron excitability. If a muscle is neurologically over stimulated by increased motor neuron activity will suddenly increase range of motion or forceful stretching increase or decrease that muscles neuro excitation? Research finds that these techniques do increase motor neuron activity and associated motor tone in the muscle. It is highly unlikely that the GTO’s perform the role that has been commonly assigned to them, they do not reflexively stimulate muscle contraction to retard movement. The entire theory of reflex inhibition in the muscle tendon unit and at the joint complex has been called into question by recent research. Any reflexive control by GTO’s or receptors would be very minor at best and would be easily over ridden by conscious volition towards a movement and by higher brain centers. The GTO is simply another mechanoreceptor with weak inhibiting ability on muscle stretching and contractive stimulation. The following statements reflect current scientific thought based on cnotemporary research: The tendon reflex is probably not seen in real life. The tendon reflex is a physiological "myth" and an artifact of poor research procedures and observations. The tendon reflex is too weak to increase the force of contraction of a muscle. Stimulating weak reflexes on the periphery of the neurological system can not over ride upper lever motor and sensory brain functions. Three techniques have been shown to reduce motor neuron activity affecting motor tone in specific muscle groups; (1) tapping, (2) scratching, and (3) stretching. All of these techniques primarily affected receptors in the skin. Massage technique applied to the muscle belly has also been shown to reduce motor tone. Passive, active, and active/contraction (agonist) stretches have been shown to reduce motor tone. The greatest result was measured when active/contraction technique using the antagonist muscle technique was performed. Studies involving the effect of manual and massage therapy techniques on motor tone have indicated the effects are of short duration, usually limited to the time period that the technique is being applied. No studies have been performed that measure the effects of combined treatment protocol involving medical massage, manual therapy, therapeutic exercise and modalities. All of the following individual techniques have been observed to inhibit motor neuron excitability for short periods of time usually limited to the duration of the application of technique: Continuous and intermittent pressure on the tendon. Manual tapping of the muscle belly. Kneading massage or medium tissue technique. Friction. Light skin stretching Passive and active muscle stretching First and second layer massage. Joint capsule stretching and motion. Clinical conclusions based on the scientific literature: Mechanoreceptor or afferents work in combination. No single group of receptors can be exclusively stimulated by manual and medical massage therapy. The supposed reflex contribution of GTO’s or so called "proprioceptors" is very mild in comparison with that of descending motor innervation. This weak reflex effect can be easily negated by higher level brain processes. Mechanoreceptors inhibit nociceptors, but do not control the output of motor neurons. The so called "reflex response" or neuro reorganization claimed in PNF and therapeutic massage is only transitory at best and if it occurs it only lasts during the manipulation and does not have long term effects. Isolated episodes of manipulation and does not have long term effects. The more the reflex system is stimulated the more it adapts and fails to respond to the stimulation. All reflex responses are controlled by over riding descending influences from higher brain centers. The tendon reflex does not occur in normal motor activity. Previous studies involved contrived physiological artifacts and did not observe or measure actual physiology activity. In some cases, especially with brain injury due to stroke or other conditions, the stimulation of abnormal reflexes may lead to counterproductive adaptation in these reflexes. Most reflex promoting treatment is performed passively. Any sensory feedback will be ignored as "noise" in the body and not responded to. General joint and connective tissue activity of the entire body will over ride the activity of a single muscle, tendon or joint. Reflex inducing techniques can be used in cases of brain injury and central damage to over ride abnormal muscle activity so that movement that is useful or functional (not normal) can be rehabilitated.