The previous five posts in this series have aimed to give a very brief introduction to the variety of massage techniques available. Some you may have been familiar with by name without really knowing what they could do for you or if you needed them. I hope the posts have proved helpful but would be very happy to answer any individual questions that have arisen from the posts.

Of course like anything it is important to know how to do something but when to do it (and when not to) and why to do it is quite different. This ability comes from experience, constant study and review and always being attentive to client feedback. The therapist must listen to the client and fix upon the best treatment plan for each individual not practice the ‘latest thing’ or your own speciality. This is where clinical reasoning is essential, to be able to listen to the client and assess what may help and what may not is a skill the therapist needs to become accomplished in. It is not sufficient to be proficient in a variety of techniques or be a specialist in one but have a tool kit of things to draw on. It is also an advantage to have a network of similarly working professionals who you can refer to. It may be that on some occasions the best treatment plan for the client does not involve massage and it is very important to know when this is and get them referred to the right person as soon as possible.

Evidence based research is difficult in the complementary field for many reasons not least of which is funding and availability but this is no reason to abandon it or ignore the small perhaps less conclusive studies we have. Although so much needs to be done a quick internet search can show that massage can be worth considering in many situations. The key is to go to a therapist who knows what type of massage and when to apply and just as importantly when not to.

This is a very specialised and specific form of massage designed to assist in the flow of lymph around the Lymphatic vessels. The lymphatic system works with the blood system and aims to speed the removal of inflammatory and waste products. It is often used for Lymhphoedema and available in many Cancer care facilities for over congestion in the system.

It does, however, have benefits to the sports person or indeed anyone with soft tissue injury that is accompanied by swelling. It is also helpful post cosmetic surgery to reduce inflammation. The massage is very light, gentle and rhythmic aiming to very gently stimulate lymphatic flow. If pressure is too strong the muscular and neurological systems will engage and these can produce chemicals that may aggravate or add to the swelling.

In a massage clinic the technique is generally used to reduce swelling perhaps in the post operative phase or from a sprained ankle for example. It can also be of benefit to joints swollen with osteo or rheumatoid arthritis. As a treatment it is very soporific.

Schillinger et al carried out a trial in 2006 where MLD was given after an endurance run on a treadmill. Those who received the massage showed lower levels is blood lactate from fatigue in the muscle than the control group. They held that:

* “The observed decrease in serum levels of specific skeletal muscle enzymes following an MLDT intervention demonstrates the potential for expedited regenerative and repair mechanisms to skeletal muscle cell integrity following structural damage as the result of taxing loads associated with physical activity”

An earlier study in by Härén et al in 2000 using MLD following a radial fracture found;

** “that the MLDT group displayed statistically significantly decreased measures of hand volume suggesting less edema present in the injured extremity. This preliminary evidence supports efficacy of MLDTs in sports medicine and rehabilitation specific to managing wrist bone fractures”.

As with most research into complementary therapies there is so much more scope for evidence but both these studies show that MLD may in some cases be an effective option for treatment.

References

* Schillinger A, Koening D, Haefele C, et al. Effect of manual lymph drainage on the course of serum levels of muscle enzymes after treadmill exercise. Am J Phys Med Rehabil. 2006;85:516–520. [PubMed]

**12. Härén K, Backman C, Wiberg M. Effect of manual lymph drainage as described by Vodder on œdema of the hand after fracture of the distal radius: A prospective clinical study. Scand J Plast Reconstr Surg Hand Surg. 2000;34:367–372. [PubMed]

These two techniques work hand in hand to alleviate tension spots and pain with the aim of restoring movement. As with previous techniques discussed a lot of the effectiveness is due to the competency of the therapist to assess the tissues and select the correct technique for the current situation.

This is one of the things I love most about massage in that it is constantly changing and therefore challenging. Even though I may have seen a client regularly over a long period of time I constantly allow my hands to feel the muscle tissue as things can and do change. It would be wrong to consistently offer the exact same treatment every time without assessing first.

Neuromuscular work is done on tight, knotted muscle where the pressure to these areas brings about a physiological change in the restricted tissue. It is commonly used on muscles that have been subjected to continuous tension such as the neck and shoulder muscles of those sat at desks for years. Some of these points will be the Myofascial Trigger Points (MTP’s) discussed earlier but others will simply be tension ‘knots’ with no referral pattern. The muscles come to recognise the extra tension as ‘normal’ because the muscle spindles adjust over time until a very tight muscle becomes recognised as ‘normal’. This is usually the point at which the area begins to show signs of inflammation and cause pain. Neuromuscular pressure can help release the tension and relieve the pain. It is believed this comes about due to ischemic changes in the tissues being compressed (*Hou et al, 2002).

Soft Tissue Release works to release tension in soft tissues – not surprisingly. By applying pressure to tension areas and then moving or stretching the tight muscle relaxation can result. It is a technique that can in certain circumstances be demonstrated by a therapist for a client to use at home. A study by **Hanten et al in 2000 found this type of home treatment with a therapist monitoring to be effective for the treatment of MTP’s.

“Ischemic compression therapy provides alternative treatments using either low pressure (pain threshold) and a long duration (90s) or high pressure (the average of pain threshold and pain tolerance) and short duration (30s) for immediate pain relief and MTrP sensitivity suppression”.
(**Hanten et al, 2002)

References
*Hou, C. R. Tsai, L. C. Cheng, K. F. Chung, K. C. Hong, C. Z. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity.Archives Physical Medicine and Rehabilitation 2002 Oct:83(10): 1406-14

**Hanten, W. P. Olson S. L. Butts N. L. Nowicki A.L. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Physical Therapies 2000 Oct;80(10):997.1003

Trigger Points, also known as Myofascial Trigger Points (MTP’s), are areas of extreme tension in soft tissue. They are often referred to as ‘knots’ but this isn’t quite correct as although both form in soft tissue and can have the same cause MTP’s cause referred pain whereas knots do not necessarily. Trigger Points have been well mapped within muscular tissue due primarily to the work of Dr. Janet Travell, White House Physician to President John F. Kennedy.
Trigger Points can be very painful and will undoubtedly restrict and confine range of movement. To give you an example of how Trigger Points manifest; tension in the muscles of the neck from working at a computer can lead to tension headaches. This is due to the continual contraction of the muscles during the working day causing them to remain in a contracted state bringing the positive activity of Trigger Points referring pain into the head.

What causes the build up of Trigger Points?
• Overload
• Overuse
• Constant activity
• Long term inactivity
• Arthritis
• Fibromyalgia
*This list provides only a few examples but is not exhaustive.

Symptoms of active Trigger Points
• Pain
• Reduced range of movement
• Hypertonic muscle tissue
• Resistance to more usual methods such as heat, stretching
• Increased muscle tone in surrounding area
• Reduced blood and lymph flow
• Presence of inflammatory markers

Once the therapist has established the presence of MTP’s and used Myofascial Release to stretch out restricted fascia they will begin to work on relieving the hypertonic points in the tissues. These points are known to be hyper-irritable and can cause pain when compressed. The therapist needs to work with the client to ensure treatment is as comfortable as possible whilst still being effective to release the tension.

There is little scientific research to back up claims about Trigger Points but whatever name we give to them and call our therapeutic interventions, massage therapy helps to relieve tight muscle tissue and restore normal function.
Trigger Points are common amongst those who have sedentary jobs as the postural muscles are constantly contracted throughout the working day. They are also common in athletes due to the repetitive nature of training.
“If athletes knew about the effects of myofascial trigger points and took the time to do the appropriate self-treatment, there would be many fewer sports injuries”.
Clair Davies (1)

References
(1) Davies, C. And Davies, A. 2013. The Trigger Point Therapy Workbook. Third edition. Oakland CA: New Harbinger Publications Inc.

The muscles in the human body are wrapped up rather like a parcel and each layer of wrapping paper is known as fascia. It provides a connective tissue throughout the body in a web-like formation without interruption or breaks. If this fascia becomes tight as wrapping can it puts pressure on the muscle and surrounding connective structures binding the tissue together thus causing pain and limited movement. An experienced soft tissue therapist will be able to feel the tension in the tissues and define whether the fascia is restricting movement or something other. By using techniques to release the fascia the therapist can then work through the wrapping to get to the taut muscle tissue.
Fascia has the ability to resist strong force causing amazing tensile strength allowing movement of the internal structures of the body. However, this means it does not respond to strong use of force from the massage therapist and needs to be coaxed into relaxation. John F. Barnes, PT a world renowned authority on Myofascial Release gives its aim as allowing the tissue to ‘glide’ and therefore ease pain and restore flexibility (a).

Myofascial Release is perfect to relieve tension from overuse of specific areas; for example the shoulder area of a tennis player. It is also valuable for the treatment of osteoarthritis, Rheumatoid Arthritis and fibromyalgia among other more systemic conditions. A study in 2011 found the following:

“After a 20-week weekly programme of myofascial therapy, fibromyalgia patients showed a significant reduction in pain” calculated using the McGill Pain Questionnaire (b).
The study also reported the techniques did not help improve “postural stability” but this proves an earlier point I made that you need to find a therapist with a ‘tool kit’ of techniques rather than one who specialises in just one.
Once fascia has been released and has the ability to ‘glide’ we can look deeper into the causes of dysfunction and that brings us to Myofascial Trigger Points or MTP’s which I will describe next time.

(a) Therapeutic Insight: The John F. Barnes’ Myofascial Release Perspective—Enhance Your Effectiveness, June 5, 2014
(b) “Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial”.  Adelaida Marı´a Castro-Sa´nchez1, Guillermo A Matara´n-Pen˜ arrocha2, Manuel Arroyo-Morales3, Manuel Saavedra-Herna´ndez1, Cayetano Ferna´ndez-Sola1 and Carmen Moreno-Lorenzo.

A good question and one I get asked often as it is not always easy to know the difference when it is not your field of work. The simple answer is if you have soft tissue pain or limited movement you need a soft tissue therapist qualified in one or other or preferably both. The techniques used are the same but their application and the client recovery will follow different patterns.

I always allow the client to explain what it is that has brought them to my clinic and assure them we will discuss what I can do to help. Then each client gets an individual treatment plan which is reviewed at each session. As a client it is for you to present your symptoms and it is the therapist’s job to recommend a course of treatment based on knowledge and experience creating a bespoke service.

Your chosen soft tissue therapist should have a ‘kit bag’ of techniques and advice that they use appropriately. A good therapist will ask for and welcome feedback during or after a treatment and as a client you should always feel you could say if you find the treatment painful or uncomfortable. Pressure should then be adjusted accordingly.

Over the next few posts I will explain the various techniques we can use whether as sports massage to help the athlete or deep tissue massage to help the office worker.