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Neuromuscular therapy enhances the function of joints, muscles, and the general arthrokinematics of the body. NMT can improve healing by facilitating the return of appropriate core (lumbo-pelvic-hip) muscle function throughout the entire kinetic chain. A special focus is given to the treatment of trigger points, local ischemia, neural interferences, postural and biomechanical dysfunctions, nutritional factors and emotional wellbeing.

Neuromuscular therapy consists of alternating levels of concentrated pressure on the areas of muscle spasm. The massage therapy pressure is usually applied with the fingers, knuckles, or elbow. Once applied to a muscle spasm, the pressure should not vary for ten to thirty seconds.

Muscles that are in spasm will be painful to the touch. The pain is caused by ischemic muscle tissue. Ischemia means the muscle is lacking proper blood flow, usually due to the muscle spasm. This in turn creates the following undesirable process:

• Because the muscle is not receiving enough blood, the muscle is also not receiving enough oxygen
• The lack of oxygen causes the muscle to produce lactic acid

• The lactic acid makes the muscle feel sore following physical activity.

After the muscle is relaxed through massage therapy, the lactic acid will be released from the muscle, and the muscle should start receiving enough blood and oxygen.

Neuromuscular therapy will feel painful at first, but the pressure of the massage should alleviate the muscle spasm. At this point, it is extremely important to communicate with the massage therapist regarding the pressure - whether the pressure is too much, too little, getting better, getting worse. The therapist should listen and respond accordingly. The massage therapy pressure should never be overly painful. In fact, most people describe the pressure as “good pain”.

Following a neuromuscular therapy massage, any soreness that presents itself should fade after twenty-four to thirty-six hours. The muscles that were tight should remain noticeably more relaxed for four to fourteen days, depending on stress, activity level, and severity of back pain prior to beginning massage therapy.

The following factors can all help to maintain and enhance trigger point activity:

1. Nutritional deficiency, especially vitamin C, B-complex and iron
2. Hormonal imbalances (low thyroid, menopausal or premenstrual situations, for example)
3. Infections (bacteria, viruses or yeast)
4. Allergies (wheat and dairy in particular)
5. Low oxygenation of tissues (aggravated by tension, stress, inactivity, poor respiration).

The following information is taken from a Medial Guide to Complementary & Alternative Medicine "Complementary and Alternative Medicine in Rehabilitation" by Eric Leskowitz, Chapter 3 - Massage Therapy by Douglas Alexander.

A therapy combining swedish, deep tissue, trigger point release, and myofascial release of soft-tissue. NMT balances the central nervous system (brain, spinal cord and nerves) with the musculoskeletal and myofascial systems to help alleviate pain and dysfunction throughout the body.

NMT techniques focus on deeply penetrating muscle tissues (to the client's tolerance) allowing the therapist to "iron out" damaged fibers and release bound up "trigger points" that are initiating referred pain in the body. NMT emphasizes regaining proper circulation to areas which have become contracted, cold, and starved of oxygen.

Massage therapy uses touch to help people relax and normalize their physiology.  However, massage affects the body and mind in many ways beyond relaxing stubborn, stuck muscles.  This chapter explores how massage therapy works so that you, as a rehabilitation clinician, can decide whether it might be helpful for a particular client.

THE CORE RESPONSES TO MASSAGE THERAPY

Massage therapy is a health profession created around and within a natural impulse to touch for comfort and caring.  Although massage therapy interventions can be very technical, they build on the basic psychological and physiological response to caring touch.

Primates can often be seen in the act of social grooming. They take turns stroking and attending to each other’s fur.  The context of this touching speaks without words, “I know you and care about you.” This comforting social context is at least as important as the pragmatic concerns of bug and dirt removal.  Similarly, the context of massage therapy is as important as the mobilization of a particular joint or nerve, a heroic stretching campaign, or a gently ruthless search for trigger points (TrPs).

The massage experience is unique.  During the treatment-whether it lasts 15 minutes or 1 hour and 30 minutes-the massage therapist covers and uncovers, picks up and sets down, pushes, pulls, and kneads the client’s flesh.  Words are seldom spoken as the massage therapist responds to nonverbal cues of held and released breath, muscle guarding, and letting go.  Most of us have not had this much physical attention since we were infants. This nurturing experience is at the core of any massage therapy intervention and is extremely valuable at any stage in the lifespan.

Tiffany Field pioneered studies of simple soothing massage routines for premature babies, who tend to be denied regular handling.  The babies massaged in intensive care neonatal units demonstrated increased weight gains and alertness and accelerated discharge time from the ward.  These studies have been duplicated in a number of centers with similar results.

Field has gone on to study the basic physiological responses to simple, soothing massage for people with a wide variety of health problems, such as those living with HIV, Parkinson’s disease, chronic fatigue syndrome, depression, diabetes, or bulimia.  An exhaustive set of research abstracts is available at the website for the Touch Research Institute.

In almost all situations the basic physiological response to a soothing massage is decreased stress hormone levels, elevated immune response, better sleep patterns, better self-image, and less body pain.  For people living with HIV and other immunosuppressive diseases, the psychoneuroimmunological effects of massage therapy can only be helpful.  In addition, some diseases/conditions have attendant social isolation, which Massage Therapy can often help alleviate.

The simplest guideline would be to consider massage therapy for anyone who has been or is under stress or who has impaired immune function, sleep disturbance, poor body image, or body pain.  To get a better understanding of how people may benefit from massage therapy, let’s examine further how it works.

MASSAGE THERAPY AS MANIPULATION OF CONSCIOUSNESS

The seemingly simple shift of consciousness from goal-directed thoughts and feelings to an inner-directed reflective state is fundamental to the massage experience.  It is a behavioral skill or quality that many people have forgotten.  Many of us live our lives like Indianapolis 500 race car drivers, without thorough between-race maintenance.  After the 500 mile race, the car is totally disassembled and rebuilt with new parts before it is ready to race again.  During the metaphorical race we all pause for an occasional pit stop, but most us never do this fundamental between-race maintenance.  We mistake a pit stop for thorough maintenance.  It is amazing that our bodies hold up as well as they do.

The metaphor for the race car driver can easily be extended.  Most of us have forgotten how to shift gears in our consciousness to a state of deep rest and relaxation.  In a state of rest and relaxation, muscles naturally relax, and the body heals itself.

The behavioral pattern of not giving the body time to rest and psychological/cognitive inability to slow consciousness to a rest and recovery state creates a vulnerability to sickness and/or injury.  Most of the clients I have seen that fail to recover from light impact, seemingly innocuous car accidents have this vulnerability.  They may be able to knock sense out of a complex spreadsheet but not have a clue how to stop and relax long enough to allow a simple and minor muscle injury to heal.

Several years ago I arrived at the home of a feisty older woman to perform a massage therapy house call.  She had been a nurse in the Second World War and was now housebound as a result of severe degenerative changes in her body.  When I arrived I was shocked to find two police cars with their lights flashing.  As I approached the house I was met by policeman who let me in.

I was worried for my client, but I should have known better.  She was in the process of telling off two towering policemen, “You have enough information for now, she must rest.”  I soon found out that the person who “must rest” was a young woman whom my client had placed in her own bed.  The young woman had had a minor car accident just outside the house.  My client had ascertained that the woman was safe, but shaken up, so she had put her to bed.  She then had put on soothing music and made some herbal tea before calling the police.

As a result of my client’s intervention, the young woman was relaxed and calm.  Her physiology was normalized and primed for healing.  One wonders how well people would recover from accident/injury if only they would fully relax directly afterward.

Massage therapy allows people to relearn this fundamental shift to rest and recovery that many of us have forgotten.  People often suffer from a nonspecific, functional complaint for which a physician has been unable to identify pathology.  Although massage treatment is very general, usually consisting of a full body relaxation massage, the client gradually makes gains in measurable functional outcomes such as improved sleep, better concentration, and increased ability to function at work.  When this happens, the client is usually accessing deeper, reflective states of consciousness during the massage treatments, as well as bringing some of the qualities of these states into his or her life.

It is generally accepted that “massage is relaxing,” but how are these changes maintained after someone gets off the massage table and reenters the maelstrom of his or her life? Relaxation is not a skill to be practiced only on massage tables, or in meditative postures.  Relocation is a state of calmness and equipoise that one brings to the cry of children or the work required to meet a deadline.

SOMATOSENSORY NOISE-OR LISTENING TO THE SYMPHONY

The key to understanding the carryover effects of massage is to appreciate the considerable muscle tension that most people carry around from day to day.  For example, a first-time massage client may arrive with considerable tension in the upper trapezius muscles and compression of the cervical spine.  The tension in the client’s trapezius escalates toward the end of the day, causing a temporal headache through TrP referral.  The compression of the neck through muscle tension and poor posture irritates facet joints in the client’s cervical spine.

The client senses tension in his or her body but lacks a clear awareness of just where the tension is and what the effects are of the body use choices he or she makes.  The client may hold the telephone with the shoulder instead of using the hand, for example.  This just adds to the tension.

During the client’s first massage he or she becomes acutely aware of how sore his or her neck is in terms of the precise location and quality of soreness.  Think of when you heard a symphony for the first time.  It probably seemed like a richly textured sea of sound.  It took a few listening experiences to begin to pick out various instruments and to appreciate how they play together to weave beautiful and stirring harmonies.

When people receive their first massage, they are often surprised to find that their flesh resembles a discordant symphony.  As one client once remarked, “I’ve got sore spots in places I didn’t even know I had places!”  The more massage the client participates in, the more the client senses a rich variety of feelings in his or her flesh.  For example, it is common to feel areas that are dense and tense in close proximity to areas that are stretched and tired of feeling, as well as other areas that may feel raw and bruised.

The client often comes to an awareness of his or her flesh as a rich, three-dimensional tapestry.  The Massage Therapist is not a bulldozer that plows through all this variegated tissue but a caring, sensitive biofeedback device that allows the client to become aware of the exact state of his or her myofascial tissue.

The physical state of the muscle-muscle tone or tonus-is a product of physical factors such as elasticity, viscosity, and plasticity, as well as the idling contraction of motor units within the muscle.  This sense of their being two components-physical and neuromuscular-that contribute to the texture of a muscle is one of the central keys to effective massage therapy.  We will address physical factors later in this chapter.  For the moment, let’s focus on neuromuscular tension.

NEUROMUSCULAR TENSION

Muscles are designed to contract and shorten, as well as to lengthen in controlled ways.  They do this through the contraction of sub volumes of muscle called motor units.  In an ideal erect posture the sustained, weak contraction in muscles such as those in the neck is achieved through the rotating contraction of a number of motor units.  After one motor unit within the neck muscles contracts, it relaxes and another motor unit contracts.  This rotation, or sharing, of the work allows the muscle to be working and takes care of all its nutritional and other needs.  A muscle that is contracting strongly will have more motor units activated, with shorter rest periods before any one motor unit is called on to work again.

A muscle that is tense will have many motor units contracting at once and/or fail to rotate motor unit activation.  It is probable that a tense muscle is prone to ischemia, resulting in a buildup of metabolic waste products, as well as simple physical wear and tear.

The relative activity of working motor units in a muscle is sensed by the massage therapist as a “rubbery” quality in the muscle.  As a muscle relaxes, the rubbery spot or region is felt to melt or deflate.  This is one of the key events in a massage treatment that is specifically addressing neuromuscular tonus.  If the spot has been a source of myofascial pain, then the pain will be felt to melt or dissolve to the same extent that the knot melts or dissolves.

This melting or dissolving of tension is accompanied by a lovely feeling within the client of letting go or release.  It may vary from a subtle, barely noticeable feeling to a significant change of consciousness that reflects a fundamental shift in the client’s thoughts and feelings.  When a massage therapist feels the melting or release of a rubbery spot that the client has identified as painful and the client reports no change in sensation consequent to the tissue softening, then the therapist knows that there are more than neuromuscular pain factors at play.  If this pain point was a key feature of the client’s initial presentation, then referral to another healthcare professional probably needs to be considered at this point.

The resting tonus, or idle, of a muscle is set in a largely unconscious way.  The massage process allows the client to sense tonus directly.  Simply by attending to the sensations in his or her flesh, the client often finds the “tonus control switches,” and resetting of the tonus of the muscles automatically follows.  This is one of the profound pleasures of Massage Therapy; simplly by attending to our flesh, our flesh normalizes.

We often carry so much tension around with us that we don’t know when we are adding more.  If we are lucky, at one point in our lives we had a healthy body.  For a variety of reasons, tension can build up over the years.  Muscle tension in the body can be compared with water filling a bathtub.  If the bathtub is empty, then we are quite aware of adding a thimbleful of water to it.  However, once the bathtub is half full, it is not obvious when a thimbleful of water has been added.  In other words, if tension keeps getting added to the system, additional quanta (or units) of tension may be invisible.

The Weber-Fechner principle describes this phenomenon.  It states that the smallest perceptible change in a sensory stimulus is a fraction of the stimulus that is already there.  This means that if you are carrying a paperback novel and someone adds another one on top of it, you will feel a change in the perceived weight you are carrying.  However if you are carrying a refrigerator and someone places a paperback on top of it, you won’t notice any difference in weight.

Similarly, when our muscles are relaxed with a normal resting tonus, we feel the effects of our body use decisions.  For example, we will notice the tension in our neck or shoulder within seconds of holding the telephone with our shoulder.  However, if our muscles are rocklike with tension already, we won’t notice the increase in tension from holding the telephone with our shoulder.  When the muscles finally complain loudly though activation of one or several myofascial TrPs, the ache seems to have “come out of nowhere!”

Massage therapy works to systematically release each person’s characteristic pattern of tension. When the somatosensory noise-the backdrop level of sensory input-from tense, muscles, active and latent TrPs, joint compression, etc., drops to a certain level, the client often becomes aware of creating tension through certain habitual actions.  It is at this point that the client can become more self-correcting.  As a client once said, “No one ever has to tell my dog that he is tense.  He knows it and changes position or stretches right away.  Before massage I lacked this skill.  However, after receiving massage therapy I have developed the same awareness that my dog has naturally!”

The ability of the client to develop somatic awareness is part of the foundation of successful massage therapy.  It is important for the massage therapist to help the client find effective postures in which to stretch tight muscles and to teach the client how to strengthen weak and inhibited muscles, as well as improve posture.

A recent study by Preyde demonstrated that massage therapy can help a significant number of people with sub acute low back pain.  As a population, 60% of subjects had experienced low back pain before the current episode.  The average duration of the current episode was greater than 3 months.  Preyde had four pools of approximately 25 subjects.  The comprehensive massage therapy group received Massage Therapy coupled with exercises tailored to each client.  The soft tissue manipulation group received Massage Therapy manipulations alone, with no exercise prescription.  A third group received only exercise prescription, and a fourth group received a placebo of sham laser.  Each subject received six treatments/interventions over the course of roughly a month.  Outcome measures consisted of the Roland Disability Questionnaire, the McGill Pain Questionnaire, the State Anxiety Index, and the Modified Schober test (lumbar range of motion).

The comprehensive Massage Therapy group had improved function, less intense pain, and a decrease in the quality of the pain relative to the other three groups.  Both the comprehensive Massage Therapy group and the soft tissue manipulation group had a significant change in function.  However, 1 month after the interventions were finished, 63% of the comprehensive Massage Therapy group reported no pain, compared with 27% of the soft tissue manipulation group, 14% of the exercise group, and 0% of the sham laser group.

Preyde’s is a landmark study because it studies Massage Therapy as it is practiced: treatments and exercise/postural advice tailored to the client with a treatment frequency of roughly one to two treatments per week.  Massage Therapy without the inclusion of exercise prescription was only half as effective as comprehensive massage therapy in terms of pain reduction.  In the profession, such a form of therapy (without exercise/postural advice) is considered incomplete.  A Massage Therapist reading this study feels that the blending of the effects of the massage and the somatic awareness of the client work together with targeted exercises and postural advice to make for a potent intervention.

One of the specific ways massage therapy can help people beyond psychoneuroimmunological change and reduction of somatosensory noise is through the resolution of myofascial trigger points.

Myofascial trigger points are hyperirritable spots within taut bands of skeletal muscle that refer pain, and sometimes autonomic phenomena, in predictable patterns.  Travell and Simons are responsible for bringing the phenomena of trigger points into broad awareness.  Numerous authors and clinicians have furthered the process through treatments, seminars, and publications.

Simons has devoted the majority of his professional life to exploration of myofascial trigger points.  He has recently published a picture of TrPs based on clinical evidence and electromyographic and microscopic study.  The palpably dense and sensitive “knot” within a taut band of muscle is now thought to be a cluster of electrically active loci in the motor endplate zone of the muscle.

Myofascial TrPs are caused by acute or chronic overload, direct trauma, and chilling.  Chilling in this case is not the act of relaxing, but exposure to a cold draft! Finding the exact location of a TrP that is causing myofascial pain often involves a bit of detective work.  This is because the hallmark of TrPs is their tendency to refer pain (Usually distally) to their actual physical location.  Working backward from published TrP referral maps and the client’s history, the massage therapist carefully explores for palpably taut bands of muscle.  When taut bands are found, the therapist further explores for hyperirritable loci, which may be causing all or part of the client’s pain experience.

It is important to have the hands-on skills to identify TrPs in a client’s muscles and to release them with an appropriate strategy.  It is just as important to understand the context that created a trigger point and is maintaining it.  TrPs may be caused by different stressors and may interact with other clinical problems.

The following case studies show two very common low back pain scenarios.

 A CASE STUDY

Low back pain from TrPs and facet joint dysfunction

The client’s erector spinae and multifidi muscles in his low back are tight with several trigger points from an old ice hockey injury.  These trigger points are often quiescent (latent) but also are often reactivated by the heavy lifting he performs at work.  The client’s somatic experience is a chronic feeling of shortness and dull ache in the low back as he fatigues over a long day of work.  This is punctuated by stronger ache and more fatigue in the region when the trigger points are activated by lifting.  Once or twice a year he gets a facet joint jamming because of the chronic approximation of the facet joints in the region of the tight multifidi muscles.  At this time he also has a precise, sharp pain in the region of the facet joint, which takes a few days to a week or 2 to abate. 

Care for this client will involve normalizing the inflammation, pain, and particular restriction associated with the facet join jamming, followed by progressive stretching of the thoracolumbar fascia and normalization of the trigger points in his erector spinae and multifidi muscles.  This can be done through precise compression and stripping manipulations.  He will find that drawing his knees up to his chest while lying on his back is relieving and therapeutic.

 A CASE STUDY 

Low back pain from Muscle Imbalance, Fatigue and Disk Compression

A client with chronic low back pain has excessively tight abdominal and hamstring muscles.  His erector spinae muscles are overstretched from an unbalanced stretching program.  He has a feeling of chronic fatigue and weakness in his low back because his erector spinae and multifidi muscles work overtime when he is lifting and bending.

When the massage therapist touches this clients low back muscles on the massage table, they feel tight and achy to the client.  There may actually be some trigger points in the erector spinae and multifidi, but the muscles are mostly in pain from post-exercise soreness from being overloaded.  The client will get some relief out of stretching his low back, but it will not feel like his back is getting all the help it needs.  This is because he needs to strengthen his low back and change the pattern of how his muscles are recruited during daily activities.  He must bend so that his buttock muscles help the erector spinae and multifidi muscles with the lifting.  The only way he will be able to do this is if he and the Massage therapist can get adequate length out of his hamstrings.

If the client does not stop this chronic pattern of loading the lumbar spine in a flexed position, then over the years his lumbar disks will deteriorate and he will get a new pain from the disks being strained.  This will feel like a central or nearly central pain in his spine.  If this is not recognized and measures taken, then it will probably gradually or even quickly, progress to sciatica.  This process has been graphically illustrated by McKenzie. 

When sciatic pain expresses itself, the client will find that flexion of the low back is not helpful, or actually makes things worse.  Extension, or backward bending, will often be more helpful. 

Treatment of TrPs is usually stock-in-trade for massage therapists.  However, it is important for clients, and some Massage Therapists, to realize that not all sore spots in people are TrPs.  It is common to find areas that are overstretched, strained, twisted, weak, congested, and/or adhered.  These areas need to be treated appropriately and self-care steps taken to normalize function.

TRIGGER POINTS vs.TENDER POINTS

Myofascial TrPs should not be mistaken for the tender points of fibromyalgia.  The tender points of fibromyalgia are hypersensitive spots within or above skeletal muscle or over bone that usually do not meet the criterion of occurring within a taut band of muscle.  They also don’t refer pain in characteristic patterns and are usually only locally sore.  For the Massage Therapist the muscle usually feels “empty” of TrPs and even tension and is often weak feeling and hypertonic.  Gerwin differentiates between TrPs and tender points through these and other criteria.

The tender points of fibromyalgia are best thought of as signs of a centrally mediated hypersensitivity rather than local tissue abnormalities.  The Massage Therapist is most helpful with these clients through the systemic physiological normalizing effects of Massage Therapy, as opposed to “squishing the fibromyalgia out of the person.”  If the massage intervention helps to normalize and deepen sleep patterns, then it might be very helpful for the client with fibromyalgia.  That being said, it is true that fibromyalgia clients can also have true fibromyalgia clients can also have true TrPs, which will then need to be carefully and thoroughly treated as well.

AN EXERCISE IN RELEASING NEUROMUSCULAR HYPERTONICITY

The following exercise illustrates how common neuromuscular hyper tonus is in the body, as well as how quickly it can change when precisely targeted.

Allow your head to fall toward your chest just to the point at which you feel tension building up at the base of your skull where the skull joins the neck.  Holding your head in this position, look up into your eyebrows and take a deep breath in.  Hold your breath for a comfortably long period while you study the sensation of tension at the base of the skull.  Then exhale, allowing your eyes to relax and unfocus.

Notice how your head spontaneously drops further toward your chest.  Allow it to continue to fall until tension again prevents it from falling further.  Again look up into your eyebrows and take a deep breath in.  Again feel the tension at the base of the skull and how it dissipates as you release the breath and relax your eyes.  Repeat a third time.

This is a simple exercise that can show the effects of breath inhibition and static muscle contraction.  It can also show the difference between neuromuscular tonus dysfunction and physical change in the muscle.  If there is still tension at the base of the skull after this exercise, the region is likely going to have a more fibrous texture than the previously rubber quality.

CONNECTIVE TISSUE RESTRICTION-OR GULLIVER IN THE LAND OF THE LILLIPUTIANS

TrPs and other neuromuscular restrictions, in which the nervous system has set the tonus of the muscle too high, feel rubbery and have a certain spring-like feeling.  However, it is also common for the Massage Therapists to find dense, fibrous, and inelastic areas as well.  This fibrous feeling often coincides with a neuromuscular tension feeling in the same tissue.  When this occurs, it is important to reset the tonus or resolve the TrP before addressing the fibrous tissue.  If the fibrous tissue is still a problem, it requires a different approach.

To resolve fibrous proliferation or adhesion, it is important to understand how it came to be present in the tissue.  It is usually present after an injury that caused post inflammatory adhesions, and/or through immobilization or altered use of the tissue.  When a muscle, tendon, ligament, joint capsule, or fascial sheet is immobilized, placed in shortened positions, or simply not used through a normal full range of motion, the normal maintenance/repair processes of connective tissue still carries on.  This means that collagen fibers continue to be fabricated and laid down, but their fiber direction and adherence to each other and other tissues is not dictated by the normal therapeutic motion.  As a result, collage cross-links are formed that prevent the tissue from moving normally when motion is called for.  It is not a matter of simply relaxing this tissue because it is physically stuck together, knitted in nonfunctional ways that prevent the tissue from lengthening properly.

This shortening phenomenon occurs within the planes of connective tissue unsheathing muscles, as well as within the muscles themselves.  While any one restrictive fiber is threadlike, the overall effect of these fibrous elements acting three dimensionally is considerable.  This is often analogues to Gulliver’s experience in the land of the Lilliputians.  A single thread could not have held Gulliver down.  However, the gestalt of several hundred or several thousand threads which a person engages all at once, proves impossible to break.  Similarly, if one holds one’s arm to the chest in a sling after injury, the joint capsule of the shoulder shortens, as do all the adjacent muscles and the connective tissue sheets overlying them.

It might take a force of 20 pounds operating through each square inch of this tissue to achieve length.  This is easily achieved through the application of precise force in the context of a massage.  The therapist leans (carefully!) into the client’s pectoral fascia and slowly strips through the tight tissue with a gently ruthless thumb or two.  If the client tries to do this by self-stretching, he or she might need to stretch and area of 10-15 square inches at once.  As a result, the necessary force to achieve length in the connective tissue overlying the pectoral muscles would be in the realm of 200 to 300 points.  Attempting to put such force through one’s shoulder would cause injury to weaker links in the kinetic chain.

This is a little-appreciated dynamic in many rehabilitation cases.  As a result of pain avoidance and disuse, clients often have several shortened areas (or global tightness-think of scleroderma) that restrict certain movements and/or breathing.  To try to free themselves is to strain against an invisible straitjacket or several layers of plastic wrap.  This is fatiguing and depressing, to be held down by the very tissue that one uses to move.  In addition to the challenge of engaging these physical restrictions, one also struggles with the deconditioning which naturally occurs with lack of normal motion and exercise. 

The Massage Therapist works as a soft tissue homogenizer, picking up thick, fibroses bands of tissue and kneading, torquing, and stretching them.  Educated hands naturally gravitate toward tight tissue, and while they will give normal tissue a caress, they tend to not challenge it.  Tissue that is overstretched and incompetent feeling is often coalesced and repacked by the interventions which sometimes return normal length and properties to overstretched and torn ligaments. 

Weintraub has formalized four palpatory states that are common to injured fibrous tissue in tendon and ligament injury.  He states that he often finds fibers that feel lax, torn, adhered, or misaligned and that chronic injuries usually have at least two of these factors at play.  This is a very helpful typology that can guide therapists toward stretching, condensing, ungluing, and realigning manipulations rather than just going on “hunt-and-squish” or stretch journeys.

THE NERVOUS SYSTEM AND DOUBLE CRUSH PHENOMENA

For a long time Massage Therapists have been treating myofascial tissue and the nervous system indirectly though creating therapeutic sensations.  It is just beginning to be appreciated that the nervous system is an organ that is amendable to hands-on treatment as well.  CranioSacral Therapy and nerve mobilization are two common and contrasting approaches to the nervous system. 

However, Butler’s work on Nerve Mobilization is also very important to Massage Therapists.  

Much of a person’s pain experience may be coming from the sheaths of the spinal cord and the peripheral nerves, as well as the neural tissue itself.  The myofascial system is in a particularly effective position to adversely affect the nervous system and its sheaths.  Tight muscles and/or connective tissue can compress nerve sheaths, causing a type of pain that feels almost myofascial (i.e. aching, pulling, and tight feelings).  If the compression is sufficient then the nerve itself and its conduction properties can be affected, causing altered sensation resulting in burning, tingling, numbness, and hyperalgesia or hypoalgesia.

The way in which the nervous system is affected by the myofascial system is seldom clear because it is often the combination of several sub clinical compromises that give rise to sheath irritation and/or conduction change.  The double crush phenomenon was first identified by Upton and McComas.  Briefly stated, a client with a nerve compromise is more vulnerable to another nerve compromise more proximally or distally along the same nerve. 

From a Massage Therapy perspective, multiple sub clinical impairments of the nervous system can give rise to neural symptomatology.  This goes against the grain of conventional wisdom, which looks for a “single” source for much pain and dysfunction in the body is hyper tonicity and lack of elasticity in the myofascial system that is creating multiple sub clinical compromises of the nervous system.

The Massage Therapist’s approach to the treatment of carpal tunnel syndrome is a good example of treating multiple sub clinical impairments.  Treatment usually starts with a relaxing massage to the neck and shoulders, which decreases somatosensory noise and teaches the client how to attend to muscle tension in the body and how to find the metaphorical “control knobs” to turn down alpha motor neuron firing.  The therapist examines for muscle tension in a global sense, as well as for a specific pattern of tension that will tend to compromise the median nerve.  This would include tension in the scalene muscles through which the nerve roots of the brachial plexus pass, under the clavicle and pectoralis minor, in the forearm where the median nerve passes under the pronator teres muscle and flexor digitorum superficialis and the flexor retinaculum at the wrist.  By normalizing the tension and length of muscles and connective tissue at neural interface points, the health of the median nerve is optimized.  Consequently, it is common for signs of neural dysfunction to be gradually alleviated over the course of a treatment series.

In an ideal situation the client gradually learns how to stretch the muscles of the neck, shoulders, forearms, and hands.  The client also learns how to breathe using the abdominal muscles because the scalenes are often hypertonic and short due to constant recruitment during breathing.  This tense pattern of breathing needs to be gradually dismantled and the client needs to begin to breathe predominantly with the diaphragm.

Once again it is clear how the generalized, holistic approach of Massage therapy often has serendipitous outcomes. 

For clients suffering from frank neurological disease/trauma, Massage therapy is not curative but often is helpful.  For many of these clients, touch has been withdrawn as a result of people’s reaction to their condition and/or attendant isolation and loneliness.  Massage Therapy can be a nurturing link to the world of human touch and can facilitate touch in the person’s relationships. 

In terms of technical benefits, massage has not been shown to be a consistent therapy for alleviation of spasticity, but it does help clients to relax and maintain range of motion.  Stroke clients suffering from unilateral neglect may benefit from having stimulation and awareness drawn toward the neglected side of their body.  It is common in Massage therapy education to talk about massage interventions that are designed to maintain the nutritional status of denervated tissue, but I don’t know of any literature that supports this contention.  Clients with neurological problems often have functional body parts that are working overtime.  Massage Therapy can help overworked body parts adapt to the necessary challenges, usually through stretching, release of TrPs and help in adjusting to increased workloads.

In all clients with neurological dysfunction, Massage Therapy helps with relaxation and adaptation of functional parts that may be working overtime and it helps people remain connected to the mainstream of life.

BODY IMAGE, SELF-CONNECTEDNESS AND SELF-CARE

One of the most common subjective outcomes during a massage is a feeling of “returning home” to the flesh.  Stressful thoughts and ideas are gradually set aside, and a comforting and grounded sense of awareness of the body often occurs.  Massage Therapists encourage clients to cease talking and to pay attention to their breath and somatic awareness during the treatment.

The acceptance and nurturing of the client’s body by the Massage Therapist can be a powerful factor in healing and prevention of disease.  People who have undergone disfiguring surgeries (or any surgery) often cut off their awareness from the part of their body that was treated.  Similarly, people who have been traumatized physically, sexually, and/or emotionally often dissociate from the traumatized body part (or the entire body).  This can have far reaching repercussions on their quality of life, relationships, and self care. 

It is common for touch of a traumatized region to activate memories of the traumatic experience.  Many people do not perform breast self examinations or basic dental hygiene or have Pap smears performed as a result of posttraumatic reactions.

While Massage Therapy is not psychotherapy, it is vital that the Massage therapist be aware that possible post trauma situations may be encountered during Massage Therapy care.  Well-trained, well-intentional therapists employ the psychological equivalent of universal precautions for infectious disease when interacting with clients.  The massage interaction itself must be boundary conscious at all times.  The therapist must seek informed consent for treatment from the client, which can be withdrawn or modified whenever the client wishes.  Although the massage therapist is not performing psychotherapy, he or she must be trained in some type of emotional first aid to know how to deal with touch-triggered emotional responses.  Haldane is a good reference in this regard.

 A case study

Psychological impact of Cancer Surgery

I once massaged a woman who had a skin cancer lesion removed from her left arm several months prior.  She was cleared by her physician and surgeon for Massage Therapy care.  Her entire left shoulder and neck were much more dense and inelastic than the right, although she was strongly right dominant.  As I approached the arm, the texture of her skin and muscle tissue became increasingly dense and inelastic. 

I asked her for permission to touch her arm where the cancer lesion has been removed.  She acquiesced somewhat nervously, not for any medical reason but from a sense of anxiety about my touching her arm.  As I got closer to the spot, she reported that area felt “dead”, or at least “numb.”  I asked her if I could help her “bring it back to life” and she agreed to let me give it a try.  I gently held her arm and slowly kneaded the triceps region where the lesion had been removed.  Very slowly it began to soften and differentiate into a palpably distinguishable muscle mass with softer and more pliant fibers.  As this happened, she silently wept.  She reported that she felt that we were massaging “life” back into a part of her body that she had vacated.  After the treatment she told me what a relief it was to connect to her arm again and how she had wept with sadness at her sense of loss, as well as released fear over how part of her body could attack itself.  She felt that she had returned to “herself.”

This type of change has often happened in my office with clients who have had various surgical interventions such as mastectomies and lumpectomies, as well as physical and emotional traumas.

Return to a normal somatic awareness is a commonly discussed outcome amongst Massage Therapists and is increasingly being paid attention in the scientific literature.  Bredin showed how Massage helped women cope with body image challenges after mastectomy.  Hart, Field, and Hernandez-Reif report that anorexic patients body dissatisfaction was improved after a trial of Massage Therapy, and Hernandez-Reif, Field, and Theakston reported how multiple sclerosis patients have improved body image after a massage therapy treatment series.

This “soft outcome” of Massage Therapy interventions is perhaps one of the most important effects of Massage Therapy.  Massage Therapy accepts the client and the client’s body, nurturing the person and modeling what is sometimes a new relationship of trust, warmth, and affection between the client and his or her body.

Feeling at home and trusting of their body is often quite a struggle for people with chronic recurrent diseases such as multiple sclerosis and lupus, as well as those with functional disorders such as irritable bowel syndrome.  Massage Therapy helps these people deal with the stress of the uncertainty of their situation, and it often helps them to feel more connected to their body and state of health, which often seem unpredictable and precarious.

SUMMARY

Massage Therapy is both a simple and a complex intervention.  Built around the natural impulse to touch a person to provide comfort and to bond, it has powerful effects simply on the basis of providing caring, respectful, and boundary-conscious touch.  It has the systemic effects of immune system enhancement and physiological normalization, and it lessens excessive muscle tonus in the body.  By reducing the somatosensory noise of muscle tension and compression in the body, as well as quieting the chattering of the mind, massage therapy often makes it possible for people to notice the effects of their body use choices and to make changes that are not of a recipe nature but that arise spontaneously from an accurate awareness of how their body feels.

Precise clinical effects are achieved through the normalization of tension in specific problematic muscles and resolution of myofascial TrPs. Shortened connective tissue is lengthened, and often numerous sub clinical nervous system compromises are alleviated.

There are numerous other affects that Massage therapy may have on, for example, swelling, constipation, and concentration that space precludes us from exploring in this chapter.The interested reader is referred to the texts of Clifford and Andrade and Rattray and Ludwig.  Perhaps the most important effects are those of body acceptance and feeling at home in the flesh.