Four Strategies for Deep Tissue Massage

Any soft tissue mobilization provided by hands is traditionally called massage therapy. Soft tissues are: skin, fascia, superficially and deeply located muscles, periosteum, etc. Massage therapy combines different disciplines such as medical stress management massage, pre and post event sports massage, orthopedic massage, specially designed massage protocols in cases of fibromyalgia, abdominal visceral massage and more.The goal of massage therapy is to cause multiple positive changes in the functions of organs and systems. Specifically, it is to release tension within the fascia and muscles, to increase blood supply to the tissue and to suppress the sympathetic reactions. In addition it is to stimulate the production of endorphins, to activate pain gate control in order to prevent pain impulse from reaching the brain, to manage scar tissue and more.

In my opinion, deep tissue massage therapy is not a separate modality but the integral part of any clinical work whether it is stress management, orthopedic, sports or any other kind of massage. In order to achieve the above-mentioned goals, deep tissue mobilization must be performed.

Physiological effect of massage on the human body

1. The local or mechanical factor is expressed by mechanical acceleration of venous blood drainage, some degree of lymph drainage acceleration, passive exercise for soft tissues, breaking down deposits of calcium in soft tissue and stimulation of its removal from the body.
2. The main power of massage therapy is in reflexive therapy. By mobilizing skin, connective and muscular tissue, we deform the mechano receptors, which in turn release action potentials/impulses. Through neurological pathways these electrical impulses stimulate motor and vasomotor centers. As a reflex, or involuntary reaction of organs and systems to original stimuli, the body responds by expressing positive changes such as: muscular relaxation, vasadilation, reduction of blood pressure, reduction of stress hormones production, etc.

To ensure that we achieve the most profound physiological effect on the body of the client, massage should be performed as deep as possible. The deeper we massage, the more we stimulate the nervous centers, and the faster and to a greater degree the reflexive therapeutic effects occur, the greater would be the production of endorphin  and the greater affect of all other positive factors  listed earlier. Note that deep tissue mobilization does not require excessive pressure. Pressure should be significant but shouldn't activate pain analyzing system, which could be recognized by two different factors:

1. Muscular protective spasm as a response to excessive pressure.
2. Client's reports "too much pressure" even in absence of the protective muscular spasm.

Note: In order to achieve successful results in any type of massage, 50 percent of the procedure time should be spent on kneaduing.

Four Strategies

1. To work in inhibitory regime

In order to reach safe, rapid and sustained results in managing neuromuscular disorders or in stress management, we must perform massage in inhibitory regime.

The term inhibitory relates to inhibition of sympathetic activity of the autonomic nervous system. An approximate balance of activities of sympathetic and parasympathetic branches of the autonomic nervous system corresponds to healthy state of the human being. Alternatively, imbalance of those activities causes different disorders. In the modern life more often such imbalance is caused sympathetic hyperactivity. For example, sympathetic reaction could produce anxiety including panic attack. Hence inhibitory regime is the regime specifying the pace and rhythm of massage movement that suppresses or inhibits the sympathetic activity of the central nervous system.

Every mechano receptor has its own level of adaptation, which means its capability to increase the level of electrical activities. The rhythm of massage strokes should be about 70-80 movements per minute and application of the technique on the massaged area should be prolonged, while gradually increasing pressure and minimizing disconnection. This produces a massive amount of nervous impulses that travel to and stimulate the corresponding nervous centers. With the prolonged application of the massage techniques, the nervous centers become inhibited by the massive, continuous flow of afferent electrical impulses from the massaged area.
Performing massage in inhibitory regime causes afferent impulses from massaged area to transmit to the upper motor centers in the cortex. As a result efferent impulses from upper motor centers are transmitted through the lateral corticospinal and rubrospinal tracts to the lower motor centers.

The dual stimulation of the lower motor centers by afferent impulses generated from peripheral receptors and efferent impulses from upper motor centers triggers efferent flow of impulses to the massaged area.

Continuing massage in inhibitory regime, leads receptors to reach their level of adaptation, which means that the production of action potentials is not increased proportionally to the amount of stimuli signals. Therefore depolarization in membranes of neurons within posterior horns of spinal cord doesn’t increase proportionally to the amount of input signals, but occurs at a constant rate and thus unable to produce sufficient amount of afferent impulses to transmit to lower and upper motor centers.

As a result muscular relaxation occurs, pain sensation decreases and more.

It’s important to remember that the level of adaptation also happens in the spinal neurons, which explains why impulses that are sent to muscles aren’t of sufficient magnitude, allowing muscles to sustain normal muscular resting tone.

Parallel with the process described above, reflexively, the body responds by vasodilation, reduction of blood pressure, reduction of stress hormones production, reduction in pain sensation and more. This approach aims at reducing the sympathetic tone and restoring balance in activities between the sympathetic and parasympathetic divisions of the autonomic nervous system.
The longer we continue to perform massage in inhibitory regime, the more superficial soft tissues relax, allowing us to work into deeper and deeper layers of soft tissue. The deeper we mobilize, the greater the amount of receptors we can stimulate. The more receptors we stimulate, the more we ensure that our performance may achieve the maximum therapeutic effects.

2. Shift superficial tissues to expose deeper layers

Sometimes, the only possibility to get to the deeper layers of muscles and other soft tissue, is by simply moving the superficial tissues out of the way. The superficial soft tissues in some areas must be shifted in order to reach the deeper layers.One example of this strategy is the medical massage treatment for piriformis muscle syndrome/sciatica. Piriformis muscle originates on the anterior portion of the sacrum and inserts into the greater trochanter.

In the treatment of this challenging disorder, we must get to this deeply located muscle as close as possible. In order to access this very deep structure, we must first relax gluteus maximus muscles, then shift them and hold them out of the way while we apply massage techniques to as close proximity of the piriformis muscle as possible.

3. Compression: shifting superficial tissues followed by transmission of pressure to the deeper layers

The additional strategy for deep tissue mobilization is to utilize techniques for compression of tissue. In this case, the transmission of pressure thru the superficial to the deeper layers of tissue will additionally significantly contribute to the release of tension in fascia and muscles as well as stimulate the production of endorphins.

There are many benefits to using deep compression techniques in massage therapy. Of the mechanical factors, compression techniques allow us to gradually tear down any pathological deposits, scar tissue, or in the case of chronic inflammation, adhesive scar tissue.
By performing massage therapy we generate two types of electrical impulses. One of them is action potential that travel thru peripheral neurological pathways, conducting their way to the central nervous system.

The other ones are piezoelectric charges that move in all directions, thru extracellular fluid and other molecular structures, creating streaming potentials that travel to the inner organs and there create massive additional afferent impulses.

These afferent impulses from the inner organs, in turn, further stimulate centers within the central nervous system and increase the power of reflexive therapy (positive changes in function of organs and system due to original stimulation by massage).

Piezoelectric charges / streaming potentials due to compressions of soft tissue, first were explained in the textbooks of Ross Turchaninov MD.PhD. To read more about his works, please

4. Stretch superficial muscle and perform massage on deep muscle underneath it

In some cases when we are trying to massage the deeper layers of soft tissue, it is helpful and sometime it’s even necessary to first stretch the superficial structures before applying massage techniques to the region. For example, when performing massage therapy in cases of TMJ disorders, we must massage all masticatory muscles as deeply as possible. During treatment, we hold the client’s jaw open to expose the belly of the masseter muscle and other chewing muscles.

Sometimes, clients can develop functional limitation in range of motion for different reasons. For example, after surgery or immobilization of a joint due to a fracture, or some chronic inflammatory condition, muscles can develop a state of contracture. Where contracture is a significant limitation in range of motion such as flexions and extensions.

Over time, continuation of this condition can lead to the muscles and tendons becoming functionally shorter. When we stretch out the structures and apply massage while the structure is under stretch, not only will it encourage the restoration of normal length and elasticity, but it also allows for much deeper mobilization.

How much pressure should be applied?

Some massage therapists equalize deep massage with putting greater pressure, which is not always the case. Surely when we perform deep tissue massage it feels stronger. The question is how much pressure should we apply?

In order to reach results, and to avoid injury from applying strong pressure, we must utilize the following rules.

1. Pressure has to be significant, gradually increasing to the maximum extent, but must avoid activating the pain analyzing system. Given that pain is a somewhat subjective sensation and cannot be measured like weight, or blood pressure, we have to design the pressure by consulting our client. The moment when the individual’s threshold of pain is determined, the therapist can properly increase pressure to the determined level.
2. Even if a client encourages you to continue to increase pressure while it causes protective muscular contraction reflex, you must reduce the pressure and restart the process of gradually increasing pressure to the maximum extent avoiding triggering muscular contraction reflex.

A very strong pressure could cause activation the pain analyzing system, including reflexive protective muscular contraction. If after activating the pain analyzing system we continue to perform massage vigorously, we could actually traumatize the muscles, causing their inflammation with the subsequent development of trigger points within the muscles and other difficult pathologies of muscular system. By gradually applying pressure we not only avoid injuring the client, but also relax the superficial layers of tissue allowing to mobilize the tissue to the deepest possible extent.

Whenever we perform massage for therapeutic purposes, it is imperative to mobilize tissues as deeply as possible. However, we must never force the way to go deep.
Remember the protocol for application of pressure; it must be significant, but shouldn’t activate the pain analyzing system. We can mobilize only as deep as the body will allow. You welcome to use my article as guidelines to create conditions for deep therapeutic massage.

If you would like to become better familiar with protocols, implementing four strategies for deep tissue massage please

REFERENCES

Goldberg, J ., Sullivan, S.J., Seabome, D.E. The Art of Stone Healing. Boca Raton, CRC, 2005.
Fleck D., Jochum L. The Effect of Two Intensities of Massage of H-Re?ex Amplitude. Phys. Ther., 1992, 72(6): 449-457
Bodhise PB, Dejoie M, Brandon Z, Simpkins S, Ballas SK. Non-pharmacologic management of sickle cell pain. Hematology, Jun;9(3):235-7, 2004
Dubrovsky V.I., Dubrovsky, N.M. Massage Manual. ‘Chuvashia’, Cheboksari, 1995
Fernandez-de-las-Penas C, Cleland JA, Cuadrado ML, Pareja JA. Predictor variables for identifying patients with chronic tension-type headache who are likely to achieve short-term success with muscle trigger point therapy. Cephalalgia, Mar;28(3):264-75, 2008
Garvey TA, Marks MR, Wiesel SW. A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine(Phila Pa 1976), Sep;14(9):962-4, 1989
Huldicka O., Broqwn M.D. Physical forces and angiogenesis. In: Mechanoreception by vascular walls. Edited by G.M. Rubani. ‘Futura Publishing Company, Inc.’ Mount Kisko, NY 1983
Krogh A. The Anatomy and Physiology of Capillaries. ‘Yale University Press’, New Haven, 1929
Kuprivan W. Physical Therapy for Sports. “W.B. Sandesr Co”, Philadelphia, 1995
Kurz W, Wittlinger G, Litmanovitch YI, Romanoff H, Pfeifer Y, Tal E, Sulman FG. Effect of manual lymph drainage massage on urinary excretion of neurohormones and minerals in chronic lymphedema. Angiology, Oct;29(10):764-72 1978
Lakin G.F. Biomatria. ‘Medicina’, Moscow, 1990
Lather I., Bevan J.A. Stretch-dependent myogenic tone in isolated blood vessel. In: Mechanoreception by vascular walls. Edited by G.M. Rubani. ‘Futura Publishing Company, Inc.’ Mount Kisko, NY 1983
Montanez-Aguilera FJ, Valtuena-Gimeno N, Pecos-Martin D, Arnau-Masanet R, Barrios-Pitarque C, Bosch-Morell F. Changes in a patient with neck pain after application of ischemic compression as a trigger point therapy. J Back Musculoskelet Rehabil., 23(2):101-4, 2010
Morhenn VB. Firm stroking of human skin leads to vasodilation possibly due to the release of substance P. J Dermatol Sci., Feb;22(2):138-44, 2000
Otsuki A, Fujita E, Ikegawa S, Kuno-Mizumura M. Muscle Oxygenation and Fascicle Length During Passive Muscle Stretching in Ballet-Trained Subjects. Int J Sports Med., 2011
Pick F. Verhandlungen des Kongress fuer Innere Medizine. XX, Weibaden, 1907
Smith JD, Davies N, Willis AI, Sumpio BE, Zilla P. Cyclic stretch induces the expression of vascular endothelial growth factor in vascular smooth muscle cells. Endothelium, 8(1):41-8, 2001
Von Mosiengeil Uber Massage, deren Technik Wirkung und Indikationen. Arch. F Klin, Chiurgie, 19:2-4, 1876
Wakim K.G. Martin G.M., Terrier J.C., Elkins E.C., Krusen F.N. The effect of Massage on the Circulation in Normal and Paralyzed Extremities. Arch Phys Med, Mar, 135-144, 1949
Yang W, Chen J, Zhou L. Effects of shear stress on intracellular calcium change and histamine release in rat basophilic leukemia (RBL-2H3) cells.Environ Pathol Toxicol Oncol, 28(3):223-30, 2009
Goldberg, J ., Seaborne, D.E., Sullivan S.J., Leduc, B.E. The Effect of Therapeutic Massage on H-Re?ex Amplitude in Persons with a Spinal Cord Injury. Phys. Ther., 1994, 74(8): 728-737
Morelli M, Chapman CE, Sullivan SJ. Do cutaneous receptors contribute to the changes in the amplitude of the H-reflex during massage?Electromyogr Clin Neurophysiol. 1999 Oct-Dec;39(7):441-7
Turchaninov, R. Therapeutic Massage. A Scientific Approach. 2000, Aesculapius Books, Phoenix