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Massage provides an additional assist to the veins and lymphatic vessels, aiding in their mechanical emptying and facilitating forward movement of blood and lymph. The effect is similar to a combination of suction and a force pump. Careful observation, of the superficial veins, will show the veins collapse and refill as they are manipulated by the hands of the therapist. This aids the circulation in the deep veins as well as that in the arterioles and capillaries of the region. Gentle centripetal stroking massage is a mild stimulant to the vasomotor nerves supplying the blood vessels of the skin. Prolongation of the massage brings about hyperemia of the region. Massage usually arouses dormant capillaries and increases the speed and extent of the circulation in that region.

Studies researching the effects of massage on circulation conclude that deep stroking and kneading massage produces moderate, consistent and definite increase in the blood flow to the extremities of patients who have flaccid paralysis, just as it does in normal extremities.

A demonstrated increase in the diameter and permeability (the condition of the capillary wall that enables substances in the blood to diffuse into tissue spaces or into cells, or vice versa) of capillaries after mechanical stimulation has been recorded. Also massage provokes the release of histamine (stimulates gastric secretions, flushing of skin, dilatation of capillaries, lowers blood pressure and reduces headaches) and acetylcholine (an ester of chorine occurring in various organs and tissues of the body. It is thought to play an important role in the transmission of nerve impulses at synapse and myoneural junctions), accompanied by vasodilatation, while increasing blood flow and discharge of erythrocytes (a mature red blood cell) from the spleen. As already noted, the mechanical effect of massage increases the movement of blood, making the exchange of nutrients and waste more efficient and improving the tropic (concerned with nourishment) state of the skin and underlying structures.

Massage gives a brief increase in arterial blood pressure, but after the massage, the net outcome is a decrease. The reason for this outcome is the venous pressure is increased. So the effect of massage is the arterial circulation is hastened by the quicker outflow from the veins and the diminishing pressure within them. After the massage, there is active hyperemia in the skin and the muscles and the number of erythrocytes in the superficial vessels are increased by 40 to 50 per cent. Reports have definitely observed peripheral vasodilatation together with an increase in the rate of peripheral blood flow following massage. The release of acetylcholine and the production of histamine and histamine-like substance in the tissues play an important role in vasodilatation induced by massage.

Light pressure results in an instant temporary capillary dilation, whereas heavier pressure results in a more enduring dilation, with connective tissues playing an important role in the vasodilatation induced by massage. Deep stimulating massage acts as a nerve transmission and is used selectively in order to stimulate the sensitive endings of the nerves and to produce vasodilatation by means of axon reflexes and release of histamine. Massage produces a definite increase in the circulation and increased exchange of substances between the bloodstream and the tissue cells, along with improved metabolism.

The Vascular System:

Reference: Pathology for Massage Therapist 2nd Edition by Don Newton, MA, DC pages #33-#52. Massage therapy has a powerful effect on the blood and lymph systems. Knowledge of the common vascular diseases is therefore of great significance to the massage therapist and may be lifesaving to the client.

Client/Patient under Physician's care: (Including blood thinner medication pre and post operative.) Ethics plays a major role in this situation. One of the basic principles for ethical behavior is RESPECT. That includes esteem and regard for clients, other professionals and oneself. The client's attending physician should be contacted out of respect in order to treat their patient with Massage Therapy. (The doctor's patient becomes our client.) A simple prescription, which at first can be a verbal release by phone, is all that is necessary. Therapy should not be given until the client's doctor has been consulted.

Treatment Protocol:

The following protocols are designed to establish a way for the student to become familiar and comfortable with the hands-on application of medical massage techniques. They are intended for use on complaint-related conditions and syndromes. Medical history, palpatory and assessment skills, and ongoing client/therapist communication are all important to the successful treatment of soft tissue pathology.

These routines are a model for the student to base their work and to feel comfortable in addressing these client situations. Keep in mind, there are numerous ways to accomplish the same thing and get similar results. Different strokes and different approaches may well be effective. These protocols offer a basis for which you can establish your own individualized work as a Massage Therapist.

Heart Conditions:

The client should always have their upper and lower extremities supported. It's vital to remember never stress the heart. Use gravity to assist the massage treatment. No stripping of the muscles; always use mild and gentle, yet firm, evenly distributed pressure through the hand while contouring to the musculature of the body. Applications of ice or heat must be moderate as well. Ice would shock the body causing stress on the heart, as well as to its systems, while too much heat would injure the capillaries when vasodilatation occurs. Focus of the massage should be to the lower extremities to increase the venous circulation while decreasing the pressure on the arterial walls. No direct pressures should be applied to the chest or deep pressures on the posterior aspect of the heart while massaging the back.

Characteristics:

Weakness in the heart

Compromised cellar structure (e.g.: capillaries)

Edema in the extremities

Emotional component (e.g.: depression)

Tends to feel cold (poor circulation)

Assessment: Visual

Broken capillaries

Edema (extremities - ankles)

Lack of muscle tone (tonicity)

Body posture or attitude (anxious or irritated - depression

Palpation

Coldness to the touch (extremities)

Treatment Plan:

Place the head and legs in an inclined position with bolsters and pillows to encourage venous blood flow.

All effleurage strokes are to be mild to moderate, NO deep stripping of the muscles.

Employ all forms of petrissage to increase the blood and lymphatic circulation.

Use mild joint movement and static friction where applicable.

Use longitudinal friction when necessary to warm and lengthen muscle tissue and finish the area with a moderate passive effleurage stroke to stretch muscles, keeping in mind the goals of your treatment.

High Blood Pressure:

The abdominal area is a contraindication for massage application because of the extra pressure, which stresses the inferior vena cava and may endanger the client's health.

Note - Be aware of the clients who are on mind altering drugs or alcohol. These clients are not to be treated. Hemorrhage in the tissue may occur due to the extreme vasodilatation occurring in the capillaries.

Diabetes Mellitus:

Reference: pages 82-84 Pathology A to Z by K. Premkumar
Up to 10% of the U. S. population has diabetes mellitus (hyperglycemia). Family history as well as a viral infection of the pancreas may play a role in its etiology. Other risk factors include obesity, stress, pregnancy and some medications.

There are two types. Type I (insulin-dependent; juvenile onset) diabetes usually occurs before age 30 and may be present at birth. It involves defective pancreatic insulin production and is usually treated with regular insulin injections.

The more common Type II (non-insulin dependent; adult onset) diabetes usually occurs in obese adults after the age of 40 and is treated by diet, exercise and drug therapy. (At all times, consult with the patient's physician and explain your proposed treatment, and what you expect to do.) Normal glucose level in blood in between 80-120 mg/100 ml, whereas in a patient suffering with diabetes mellitus, the fasting glucose will be 200-300 mb/100 ml. It is most common in people who are overweight and in the older age group. The cause of diabetes, here, has been attributed to decreased number of defective receptors for insulin in fat cells. There is an association between incidence of diabetes and family history.

Focus and Intent of treatment:

Emotional and physical stress must be addressed. Relax the nervous system. Long rhythmical continuous effleurage (30% of treatment) gentle medium/slow continuous strokes are used to relax the body while encouraging circulation of blood.

If the patient has an inactive lifestyle but needs to increase his or her amount of exercise, your massage can act as a passive exercise for this patient. Petrissage should be utilized for at least 50% of the treatment time to help tonify muscles.

Peripheral nerve damage - add some gentle friction to the lower extremities after a sufficient amount of effleurage has been completed to aid the body in absorption of fluids. This will give a more adequate flow of blood to the extremities. (Remember friction can not be done on areas that are swollen, as direct pressure down - characteristic of friction - will further close the dysfunctional vessels. If done improperly, friction will cause more vascular damage and bruising. Your massage should create no pain. Lighten the pressure to defer to pain.

Stimulation through vibration (20%) improves visceral reflexes - including the function of the adrenal glands, which play an important role in the body's autoimmune function. Apply vibration over the adrenals. Vibration has been proven to improve some visceral reflexes, including the function of the adrenal glands. Adrenal glands play an important role in the body's autoimmune function, so by stimulating the suprarenal glands, you will aid the body's own restoration process.

Massage therapy assists with the complications that occur from diabetes. The high glucose levels have detrimental effects on almost all systems. Eyesight is affected due to bleeding in the retina. There is loss of sensation in the periphery especially the hands and feet. (The massage therapist should observe the patient's feet carefully while treating.) The effect on the autonomic nervous system results in parenthesis (low back pain supine/prone) diarrhea, and impotence. The high levels of cholesterol in the blood speed up the formation of arteriosclerosis with its associated complication of thrombosis and emboli. The patient is generally dehydrated, weak and fatigued. A diabetic is prone to infection and takes longer to heal. Massage therapy increases circulation, decreases and addresses swelling especially in the lower extremities, stimulates periphery nerve impulses in hands and feet, affects the autonomic nervous system.

Diabetes

Characteristics:

Edema in extremities

Compromised cellular structure (e.g.: capillaries)

Emotional stress

Back pain (from adrenals)

May have inactive life style

Injection site (insulin dependent)

Neuropathy (lack of feeling in feet)

Assessment:

Visual

Foot irritation (cuts, infection)

Edema (extremities - ankles)

Discoloration (capillaries)

Injection site discoloration

Monitor aspects of depression

Palpation

Coldness to the touch (extremities)

Poor muscle tone

Contracted muscles of the back

Focus of Treatment: Attention should be given to the adrenal glands, latissimus dorsi and teres major muscles as well as the lower extremities especially the feet.

Treatment Plan for Diabetics:

Do a general full body massage with special attention to the legs and feet. Execute with long effleurage strokes mild/moderate pressure, no stripping of the muscles.

Additional focused area in the prone position to be added to the back massage.

To palpate adrenals, place hand (ulnar) crosswise at level of 12 rib, kidney is under hand adrenal at thumb above kidney.

These techniques provide improved nutrition to kidney and adrenals.

Compression/twist to latissimus dorsi - fingertips together, in a rotary motion. Emphasis is on fingertips creating a rotary force as one unit on the flat muscle structure.

Latissimus dorsi stretch - from the same side of the table, hand-over-hand, inferior to superior, following lats up into the axillary area as joint movement simultaneously occurs to fully elongate the muscle.

Vibration - hand-over-hand, placed longitudinally, starting with the heel of the hands at the crest of the ileum moving superiorly in 1/2-inch increments to the inferior angle of scapula. This action can be executed inferior to superior as well.

Rhythmic shaking (vibration) of the adrenals - same side of table, moving the hands in a wave-like motion, two hands on one side of the lats, shuffle back & forth, while entrapping the organs. This vibration can be done for 30 seconds up to three minutes, with some rest in between, and should be done at the end of the back massage.

Client Position: Supine

Bolster in the supine V position (wedge under back/neck and legs/feet)

Keep client warm (extra blanket - warm room) because of poor circulation

General massage consisting of

30% effleurage

50% petrissage

20% vibration

Focus on extremities

For edema - work proximal /distal/proximal

Do not massage near injection site for insulin dependent clients

Client position - Prone

General massage as above (bolster under feet)

Adrenal twist - stand at side of table and place both hands flat on the ribs. Your little finger (of the lower hand) in on the 12th rib. With slight compression, twist your hands to the left and then to the right - repeat 3X

Latissimus Dorsi stretch - hold your client's arm overhead (with your upper hand) and use your lower hand to glide from the lower spine to the axillary/deltoid region.

Vibration - hand over hand from the PSIS (iliac crest) to the inferior angle of the scapula. The direction you use dose not really matter. You can start at the scapula or at the crest.

Adrenal shake - rhythmic shaking of the adrenals glands. Stand at the side of the client facing their head. Place your upper hand on the posterior ribs and your lower hand on the side ribs. The motion is lateral rocking. The top hand goes down and out - the side hand goes in and up. Create a rhythm with the movement.

I hope these guidelines will help you become a better Massage Therapist.