Swedish Massage

1

The Most Essential Skill

Palpation is key

Practice constantly

2

Definition of Swedish massage

A form of soft, relaxing and de-stress massage

A system of therapeutic massage and exercise for the muscles and joints, developed in Sweden in the 19th century.

It involves the use of hands, forearms or elbows to manipulate the superficial layers of the muscles to improve mental and physical health. Active or passive movement of the joints may also be part of the massage.

3

Preparation for Treatment

Manual medicine tips Treatment room Pillowing and positioning Draping

4

Manual Medicine Tips

Infections & hygiene

In any clinical environment where patients are receiving treatments on a regular basis ---

A. wash your hands & clean your table between every patient visit; If you have a transmittable condition, such as a cold or flu, use a mask; if your condition is a concern do NOT offer treatment;

B. need to pay particular attention to the cleanliness & smoothness of our hands & finger nails;

C. before treatment: always wash hands, remove all jewellery & watch, ensure your equipment is clean;

D. after treatment: change the sheets and wash hands, first with warm or hot water, then finish with cool or cold, leave room neat & tidy.

5

Biomechanics

Pick the correct table height: with arms relaxed at sides, fingers or knuckles should brush table top when standing;

Adjust posture & biomechanics according to the technique being applied, & the body part being treated;

Keep shoulders relaxed;

Elbows are flexed & wrists are relaxed for all light & moderate techniques;

Stand with a feet shoulder width apart, place feet in the direction of movement; knees & hips should be slightly flexed, back is straight, shoulders relexed;

6

Patient movement tips

Physical contact creates non-verbal communication that can be sensed by the patient; if you are nervous or unconfident patients can sense it;

Clinicians must overcome the patient's tendency to muscle guard;

Firm & solid hand contacts;

Voice commands to the patient are helpful. "let me take the weight of your arm," "Take a nice deep breath," " Rest your tongue on the roof of your mouth,";

Smooth movements: jerky movement will stimulate joint proprioceptors which results in the muscles contracting around that joint to stabilize it;

7

The treatment room

should provide privacy for the client to get undressed;

should be warm, comfortable, clean and tidy;

is a quiet, relaxing environment;

should be an adequate supply of clean sheets, towels, face cradle covers, pillowcases and blankets;

8

9

10

11

12

13

14

Pillowing and positioning

1. Prone

Pillows are placed under the abdomen to reduce the lordotic curve; under the ankles to reduce plantarflexion

The face cradle height need to be adjusted for comfort.

2. Supine

Pillows are placed under the knees or head

15

16

Pillowing and positioning

3. Sidelying

One pillow is placed under the client’s head, supporting it in line with the rest of the spine; another pillow is placed between the knees; the third pillow may be used to support the chest and arm.

Multiple pillows can be used to elevate an edematous limb for grainage or to support an injured limb in a position that does not further stress injured tissue.

17

18

19

20

Draping

Draping the client, or covering the client with sheets or towels, is designed to make the client feel comfortable, secure and warm during the treatment.

21

22

23

24

25

26

27

The Principles of Massage

General- specific-general Superficial-deep-superficial Proximal-distal-proximal Peripheral-central-peripheral

28

General to specific to general

A rhythmical flow of massage is best achieved by working from a larger area of body into smaller area, & then gradually back to a larger area. To reduce guarding & minimize patient discomfort begin with general overall of larger areas before progressing to specific areas related to the clinical findings/chief complaint. reture to the larger structure, linking the specific to the whole before progressing to another area.

Part of therapist's hands: palmar, whole hand contect acclimatizes the patient to touch & allows them to relax. It also allows the therapist to palpate & recognize painful areas. With digits & thumbs, more specific work can be done to affect more specific structures. Return to general with full palmar contact, ensure sufficient venous & lymphatic return.

29

Superficial to deep to superficial

Begin movements with relatively superficial light pressure; progress to deeper and/or firmer pressure once the soft tissures have relaxed & circulation increase, then back to a superficial contact.

30

General to specific to generalsuperficial to deep to superficial

Refer to how a group of techniques is applied to an area of the body.

The first techniques are applied generally and superficially; these are followed by techniques that are more specific and deeper; then returns to more general and superficial techniques before moving to another area.

31

Effects

Accustom the client to the therapist’s touch;

Allow the therapist to palpate through layers of tissue in a systematic manner;

Increase local circulation;

Reduce sympathetic nervous system firing;

Prevent kick-back pain or post-treatment soreness;

32

For example:

An arm massage may begin with effleurage over the entire limb, then light petrissage, progressing to deep muscle stripping to specific hypertonic muscle, then finish with light petrissage, effleurage and stroking to the limb.

33

Proximal to distal to proximal

Refer to how techniques are applied to the limbs in order to increase the local circulation of blood and lymph;

Begin at the most proximal part of the limb, which is closer to the heart, progress distally, farther from the heart & then return proximally.

34

For example:

After the light effleurage to spread oil over the entire posterior leg, start to work proximally at the iliac crest and over the gluteals to the attachments at the greater trochanter. Next, techniques are used on the posterior thigh muscles, working proximally from the ischial tuberosity and greater trochanter through the muscle bellies to the knee. After that moves distally to the lower leg then foot. Finally, deeper effleurage is used from the distal foot to the proximal hip, encouraging local venous return.

35

Peripheral to central to peripheral

Is used specifically when treating acute and subacute local injuries and scar tissue, and when approaching areas of apprehension or pain.

36

Benefits:

By approaching healing tissue peripherally, can aid the removal of toxins and waste products; can break down the scar tissue.

By moving back to the periphery, can reduce the possibility of kick-back pain.

37

Goals of massage therapy

Help improve general health, promote stress reduction & relaxation;

Restore optimal function where possible; prevent further injury or dysfunction;

address compensatory changs due to injury or dysfunction, help prevent complications related to trauma, overuse or disease;

38

Above goals are accomplished through

Maintaining or increasing:a) circulation & tissue fluid exchange; b) respiratory function;c) Joint range of motion;d) Muscle tone & flexbility;e) Sedtive response/parasympathetic nervous system stimulation;

Preventing or decreasing: a) Adhesive tissue formationb) Edema(swelling)c) Paind) Muscle hypertonicity & muscle spasme) decrease sympathetic nervous system firing(promote relaxation)

39

Massage contraindications

general or systemetic contraindication --- exists when the situation or condition affects the whole body

Local contraindication --- is when the situation or condition affects a particular region or body part

Absolute contraindication -- pathological conditions or symptoms that cannot be treated under any circumstances. Absolute contraindications can be systemic or local.

Relative contraindication --- pathological cobditions or symptoms that are generally less acute or ina state of remission may be treated with caution and/or modification of technique(s).

40

Systemic(general) contraindications

Absolutea) Contagious infectionsb) Temperature of two or more degrees above normalc) Severe, active cardiovascular disease(arteriosclerosis, congestive

heart failure, high blood pressured) cancer( if metastatic)e) Acute rheumatoid arthritisf) Any condition that requres immediate first aid or medical attentiong) Hemophiliah) patient under the influence of alcohol or recreational drugs

41

Systemic(general) contraindications

Relative a) A mildly contagious infection

b) Temperature of less than two degrees above normal

c) History of cardiovascular disease or controlled by medication

d) Cancer if in remission or terminal

e) Rheumatoid arthritis if in remission or managed by medication

f) Neurologic conditions that alter a patient's perception of touch or pain

g) medication that alters pain perception or circulatory

42

Local contraindication

Absolute

a) Undiagnosed lump

b) Infectious & contagious disease of skin

c) Recent wound, burns &/or scars

d) Severe varicose veins

e) Thrombosis

f) Phlebitis( inflammation of a vein)

43

Local contraindication

Relative A. Benign tumor/cyst

B. Sprain/fracture - modify treatment

C. healing wounds, burns, scars

D. visible but not elevated or painful varicose veins

44

Swedish massage benifits

Improves the quality of sleep. Relieves stress, depression, irritation, and anxiety. Helps concentrate on daily activities and improves overall well-

being. Increases muscle strength, strengthens connective tissues, and

relieves cramps and muscles spasm. Sedates the nervous system and stimulates good blood

circulation. Firms up the muscles and skin tone, and speeds the healing

process after an injury or illness. Swedish massage aids in relieving symptoms like arthritis, carpal

tunnel syndrome, asthma, headache, TMJ(temporomandibular joint) dysfunction, and some athletic injuries

45

Principles

46

Technique components

StrokingEffleuragePetrissage

TapotementVibration Friction

47

1.Direction of movement

For relaxation or reduction of edema, the direction is centripetal (towards the heart) or in the direction of blood flow and parallel with the muscle fibre

For treatment of fibrotic areas, the techniques are applied in a cross-fibre direction

48

2. Pressure

For relaxation, the pressure applied is usually light to moderate Deeper pressure is used to reach deeper structures and for the

treatment of adhesion. With more pressure on the upward stroke of the limb and less

on the return stroke. Adjust the pressure according to the patient tolerance and the

stage of dysfunction or injury.

49

3. Rhythm

Should be even, smooth, flowing, fluid, consistent and continuous. Constant contact is important during the treatment. If the connection is broken, re-

establishing the contact must be gentle and careful. The different rhythms of the body would be the heart rate and also the breathing rate. So

working with deep tissue along with the clients’ breath rate is a really great way to help the client to relax and allow you to get deeper into the massage. So an example of that would be watching the inhalation and exhalation of your client and as they exhale applying the pressure at that point.

50

4. Rate

Dependent on the desired effect.

Generally, for relaxation, the rate is slower and can be matched to the rate of respiration; for a stimulating effect, techniques are applied more quickly.

51

5. Duration

Local treatment last 20 – 30 minutes.

Full body last 45 – 90 minutes. More than 90 minutes can be debilitating.

Infants, children should be shorter.

Excessive treatment may increase pain.

52

Stroking

Stroking is among the lightest techniques used for massage

Uses: the palmer surface of the hand or the fingers is used

Pressure is applied superficially

Often used as an introductory or closing techniques

53

Effleurage

To warm up the muscles before the deep tissue massage, the therapist applies gentle gliding strokes with the palms, thumbs, and fingertips. With long, circular, and sweeping strokes, the massage concentrates more than one part of the body.

The direction of effleurage is centripetal or towards the heart All Swedish massages start and end with the effleurage strokes which targets to promote

healthy functions of the veins.

54

55

56

Effects of effleurage

Relax

Increase local venous and lymphatic return

Decrease edema

Increase local circulation

57

58

Petrissage

Meaning to knead

Palm, fingertip, thumb, forearm or knuckle, one or both hands may be used

Is used after the tissue is warmed up

There are six types of petrissage

59

1. muscle squeezing

The muscle is compressed between the palm and fingers or between both palms

60

2. Muscle Stripping

Applied with thumb, elbow, ulnar border of the hand or fingertips

Pressure: moderate to deep

Direction: from the distal to proximal along the fibredirection

61

62

3. Wringing

Both hands are used

The tension is created as each hand moves in an opposite direction and then to the initial position

63

4. Picking up

The fingers and thenar eminence or the palms of the hands squeeze the muscle, lifting it up from the underlying tissue using a vertical pressure

64

5. Skin rolling

The skin is lifted between the thumb and fingers and gently rolled over the area being treated

65

6. Kneading

Using the thumb, fingertips, palmar surface or ulnar border of the hand or forearm to perform short, rhythmical unidirectional or circular movements

66

67

Effects of petrissage

Increase local circulation

Loose adhesion

Decrease muscle hypertonicity

68

Contraindications of petrissage

Acute condition

Severely atrophied or atonic muscles

Severe varicosities

69

Tapotement

Tapotement is meaning to rap, drum or pat

Can be used at any time during the treatment

Is applied in a sequence from light to heavier, then back to light

Can be performed using fingertips, the ulnar borders of hands, the full palmar surfaces of the hands or the fists

70

1. Pincement

The tissue is gently plucked between the thumb and fingertips

71

2.Tapping

The tissue is tapped with the fingertips

72

3. Hacking

This is performed with the ulnar border of the hand.

For less force the hand is relaxed.

For greater force the hand is stiff.

73

4. Clapping or Cupping

The hand is held in a cupped position, with the fingers and thumb together; with the wrist pronated, the tissue is struck with alternating hands.

74

5. Beating The hand is held in a loose fist

and can be performed using the extensor surface of the phalanges of the digits or the ulnar surface of the fist.

75

Effects of Tapotement

Increase local circulation

Loosen mucus with respiratory conditions

Increase or stimulate sympathetic nervous system firing

Stimulate hypotrophied muscles

76

Myofascial Trigger Points

Definition Types of trigger points Palpation of trigger pointsContraindications Techniques

77

Definition

A trigger point (TrP) is a hyperirritable spot, usually within a taut band of skeletal muscle or its fascia. It is point tender on site, often exhibits a predictable pain referral pattern and causes a shortening of the affected muscle.

78

79

80

Results Of the 255 trigger points, 92% had anatomically corresponding acupuncture points. Of these acupuncture points, 79.5% had regional pain indications similar to their corresponding trigger points. Complete or near-complete agreement in the distributions of the myofascial referred-pain patterns and acupuncture meridians were found for 76% of corresponding points; at least some agreement was found for another 14%.

81

The Causes of MTPs

The exact physiological mechanism is not fully understood.

Travell believed a taut band may be a contracture of muscle fibres that were damaged in the trauma that initiated the trigger point.

！A healthy muscle does not contain trigger points; taut bands of muscle fibres and tenderness are not present; referral pain cannot be elicited; the local twitch response is absent. ！

82

83

84

85

86

87

88

Types of trigger points – I

Active trigger point --- is painful at rest and with movement of the muscle containing it.

The trigger point in the taut band prevents the muscle from fully lengthening and reduce its strength.

Tissue local to the trigger point exhibits ischemia.

The trigger point is tender.

When it is compressed, it refers pain in a pattern. The pain may be referred locally or distant to the affected muscle.

89

Active trigger point cont’d

Palpation produces a local twitch response and possible referred autonomic phenomena.

--- This response occurs when the taut band is palpated transversely, like strumming over a guitar string.

90

Types of trigger point cont’d

Autonomic phenomena include vasomoter change, increased sudomotor activity (sweating), pilomotor response (gooseflesh), lacrimation (tearing) and nasal irritation and discharge.

91

92

93

Types of trigger point cont’d - II

Latent trigger point ---produce pain only when palpated. All the other characteristics of an active trigger point may occur with a latent trigger point.

Latent trigger points are more common than active ones and may persist for years after the initial injury.

94

Types of trigger point cont’d - III

Primary trigger point --- is directly activated by acute or chronic mechanical strain or overload of the affected muscle.

IV. Secondary trigger point ---is activated in the overworked synergist or antagonist muscle.

95

Palpation of trigger point

The trigger point is located in a palpation taut band of fibres in the affected muscle; the texture of this taut band is distinctly ropy; the tone of the muscle is increased.

To clearly palpate a taut band and its trigger point, the muscle must be relaxed.

There are flat palpation and pincer grasp palpation. The most tender spot is the trigger point.

Jump sign: the pain maybe intense enough to cause the client to wince, jump or cry out.

96

97

Palpation of trigger point cont’d

When a trigger point is accurate located and compressed, it will refer pain or autonomic phenomena in its referral zone. Referred pain may develop immediately or after about 10 seconds of palpating compression

There is no inflammation or edema present with a trigger point.

A cluster of trigger points can seem to be a centimetre in size like a tiny “nodule”.

98

Contraindications

Avoid vigorous techniques or deep pressure, since “kick-back” pain may result.

In the case of acute or early subacute over stretch injuries, such as strains or sprains, treatment of trigger points local to the injury is CI.

Percussion and stretch are CI on anterior or posterior leg compartments.

Avoid prolonged chilling of a muscle containing a trigger point, as this may activate it.

Avoid combining prolonged ischemic compressions and frictions to the same muscle at the same appointment, since this can overtreat the tissue.

99

Common techniques for TrP treatment

I. Slow repetitive muscle stripping The pressure is initially light and is gradually increased with successive stroke.

The ulnar border, fingers or reinforced thumbs are used.

Muscle stripping causes a temporary local ischemia, followed by a reactive hyperemia as pressure is released, flushing metabolites out of the tissue.

In one study, 10 separate treatments of repetitive muscle stripping were effective in eradicating trigger points.

100

Common techniques for TrP treatment

II. Alternating ischemic compressions Using reinforced fingers or thumbs, pressure within the client’s pain tolerance is applied for

seven to ten seconds at a time and then released, creating ischemia and then hyperemia, and then repeat it.

--- Pain from the trigger point should diminish with each application, eventually disappearing as the trigger point is reduced.

--- Full eradication of the active trigger point may take place over several appointments.

101

Common techniques for TrP treatment

III. Prolonged ischemic compression is the most specific massage technique; reinforced finger, thumb or elbow pressure is

slowly applied to the trigger point, maintaining pressure at the client’s pain tolerance level, until the trigger point reduces as though it is softening or melting. The client fells pain diminish. Ideally, this takes between 20 seconds and one minute.

--- If the trigger point is not eradicated after a minute of ischemic compression, the therapist should apply repetitive petrissage, use stretch and heat, and leave the trigger point until a subsequent appointment.

102

Spine and Thorax

Bones Muscles Trigger points

103

104

105

Bones of the Spine and Thorax

106

107

Palpation of the low Back

108

Muscles of the Spine and Thorax

109

Suboccipitals

110

Suboccipitals

111

Splenius capitis & cervicis

112

113

Splenius

114

Erector Spinae group

115

116

117

118

119

Erector Spinae group

120

Quadratus Lumborum

121

122

123

124

Head, Neck & Face

Bones Muscles Trigger points

125

Bones of Head Neck & Face

126

127

Muscles of the Head Neck & Face

128

Temporalis

129

Masseter

130

Sternocleidomastoid (SCM)

131

132

Scalines

133

Scalene Palpation

134

Scalines

135

Shoulder and Arm

Bones and Bony Landmarks Muscles of Shoulder and Arm Triggerpoints

136

137

138

Bones of the shoulder and arm

139

Muscles of the shoulder and arm

140

141

142

143

144

145

146

147

148

149

150

151

152

153

Trapezius

154

155

Trapezius

156

Levator scapular

157

Levator Scapulae

158

159

160

Deltoid

161

162

163

Rotator Curf muscle

164

165

166

167

168

169

Pectoralis Major

170

Pectoralis Minor

171

Biceps brachii

172

Triceps Brachii

Extensor of wrist

173

174

Flexor of wrist and hand

175

176

7. Pelvis & Thigh

Bones and bony landmarks Muscles of the Pelvis and thigh Trigger points

177

Bones and bony landmarks

178

179

180

Muscles of Pelvis and Thigh

181

182

Quadriceps Femoris group

183

184

Rectus femoris

185

Vastus lateralis

186

Vastus intermedius

187

Vastus medialis

188

Hamstrings

189

190

Semitendinosus

191

Semimembranosus

192

Biceps femoris

193

Gluteals

194

195

Gluteus maximus

196

Gluteus medius

197

Gluteus minimus

198

Adductor group

199

Adductor longus & brevis

200

Gracilis

201

Adductor magnus

202

Tensor Fasiac Latae and Iliotibial Tract

203

Tensor Fasciac Latae

204

Piriforms

205

Piriformis

206

Gastrocnemius and Soleus

207

Gastrocnemius and Soleus

208

Gastrocnemius

209

Soleus

210

9. 211Manual Lymphatic Drainage (MLD)

Definition Technique Effects CI

211

Understanding the lymphatic system

212

Relationship of lymphatic vessels to the cardiovascular system

213

214

• Thymus - T-cells mature• Lymph nodes – filtration of

lymph to identify and fight infection. Contain a large number of lymphocytes like B-cells and T-cells

• Spleen – produce immature immune cells, and synthesizes antibodies,

• Bone marrow – Production of T-cells and B-cells

Terms

Lymph is the name for tissue fluid that enters lymph capillaries.

Lymph vessels begins as dead-end lymph capillaries found in most tissue spaces.

Lymph capillaries are very permeable and collect tissue fluid and protein.

lacteals are specialized lymph capillaries in the villi of the small intestine; they

absorb the fat-soluble and products of digestion, such as fatty acids and vitamins A,D,E, and K.

Lymphangion Lymph valve segments, The lymphangions pulsate with an average

frequency of 10 per minute. By means of systoles, these ”lymph hearts” drive the lymph as a pump does 215

216

Anatomy

lymph capillaries unite to form larger lymph vessels, whose structure is very much like that of vein. There is no pump for lymph, but the lymph is kept moving within lymph vessels by the same mechanisms that promote venous return.

Skeletal muscle pump: lymph vesseles in the extremities, especially the legs, are compressed by the skeletal muscles that surround them.

Respiratory pump: alternately expands and compresses the lymph vessels in the chest cavity and keeps the lymph moving.

217

218

Lymphatic tissue

Consists mainly of lymphocytes which are produced from stem cells in the red bone marrow, then migrate to the lymph nodes and nodules, to the spleen, and to the thymus.

The thymus has stem cells that produce a significant portion of the T lymphocytes.

219

Lymph nodes and nodules

Are masses of lymphatic tissue.

Are found in groups along the pathways of lymph vessels, and lymph flows through these nodes on its way to the subclavian veins.

220

Nodes of the Neck

221

1. Submental

2. Submandibular

3. Supraclavicular

4. Retropharyngeal

5. Buccal

6. Superficial cervical

7. Jugular

8. Parotid

9. Retroauricular & occipital

Lymph Nodes Anatomy

Are bean-shaped and range in size from a few millimeters to about 1-2 cm in their normal state

Small all over the body

Function:

Filter lymph

Produce lymphocytes

Produce plasma cells

222

Spleen

The largest mass of the lymphatic tissue in the body. Size: 5”X3”X2” ---heart or fist

Function:

Filter blood

Destroy the old RBC

Produce lymphocytes

223

Main functions of the lymphatic system

to collect and return interstitial fluid, including plasma protein to the blood,and thus help maintain fluid balance,

to defend the body against disease by producing lymphocytes

to absorb lipids from the intestine and transport them to the blood."

224

Definition of MLD

MLD encourage lymph flow and reduces certain types of edema, decreases pain perception and the effects of the sympathetic nervous system.

225

226

The Techniques of MLD

Light, repetitive techniques are used to pump the lymphatic fluid through the superficial lymphatic capillaries

Each manipulation must be repeated minimum of five times in order to pump the lymphatic fluid through the tissue

The strokes are unidirectional and overlapping

The pressure is applied centripetally, or towards the heart, in a rhythmic manner, starting at the proximal lymph nodes and working distally towards the edematous site

227

Types of Strokes

2 main schools of thought: Ratray

Push the fluid

Vodder Expand the vessels

228

How Much Pressure?

The strokes must be done in a way that achieves the effect without inflicting damage. The hand does not merely slide over the skin. Strokes should be firm enough to stimulate relaxation, but strokes that are too firm must absolutely be avoided.

Too much pressure can damage the thin anchor filaments In the area where the collectors are actively pumping, strokes that are too firm might lead to cramps of the lymph vessel wall musculature.

On the other hand, work that is too light will not have the desired effect.

There is no generally valid benchmark value for the intensity used in manual lymph drainage. The stroke must be calibrated to each region of the body.

For example, the gluteal region is treated more firmly than the neck. Thus it is not possible to prescribe an optimal treatment pressure.

229

Effects of MLD

Lymphatic drainage encourags lymph flow and reduces pain, edema, excess fibrin and metabolic products in the inflammatory process.

230

Effects of MLD

The authors of a 2015 systematic review concluded that lymphatic massage might be more effective than connective tissue massage in relieving symptoms of stiffness and depression in people living with fibromyalgia.

231

What is MLD used for

lymphedema fibromyalgia swelling or edema skin disorders fatigue insomnia stress digestive problems arthritis migraine episodes

232

233

234

235

236

237

238