In the January/February and March/April 2010 issues of JMS we started a discussion of what mechanisms scientifically sound therapeutic massage uses to support general health or enhance the healing processes in the body (see Diagram 1). In this and upcoming issue we will continue this conversation by focusing on what mechanisms are behind vasodilation triggered by massage therapy.
If one opens any massage textbook or professional article he or she will definitely find the mentioning of massage supporting peripheral vasodilation and enhancing blood flow. This is commonly accepted information, and practitioners learn this fact as soon as they start to study massage therapy and chance to observe it clinically in the form of local skin redness (or hyperemia) in the areas of prolonged skin stroking. However, there is much more in the simple fact that massage triggers local vasodilation and stimulates local blood flow. In this and upcoming issues of JMS we will review four major mechanisms which support peripheral and general vasodilation and enhance blood circulation: mechanical effect, effect of ischemic compression, activation of axon reflex and central reflex effect.
There is reasonable question which can be asked: What practical value has the discussion of vasodilation, blood flow and clinical application of massage therapy? It seems enough to simply remember this fact. However, this information has great clinical value, because if practitioner understands what mechanisms are responsible for enhancing vasodilation and blood flow he or she will be able to apply more efficient techniques. This why in this article we will separately emphasize the practical tips which will help the practitioners successfully implement theoretical information in the clinical setting.
In Diagram 1 we summarized the clinical effects of therapeutic massage. We based this table on publications, which scientifically examined therapeutic mechanisms of massage therapy. As mentioned above we have already discussed the impact of therapeutic massage on the cellular function and electrical environment (see January/February and March/April 2010 issues of JMS). To replay the diagram please click at the beginning of the sliding bar (blue line) located just below the diagram.
Diagram 1. Local healing mechanisms of massage therapy
In Part I and Part II of this article will concentrate on the upper right corner of the diagram which explains how therapeutic massage affects vasodilation and blood flow. In Part I of this article we will discuss the outcomes of the mechanical effect of massage strokes and the effect of ischemic compression.
MECHANICAL EFFECT OF THERAPEUTIC MASSAGE ON VASODILATION AND BLOOD FLOW
It is very easy to observe the mechanical effect of massage strokes. Just repetitively stroke the skin and observe its redness. As longer strokes are applied more redness develops and with excessive application the local vasodilation changes to local swelling. However, behind this seemingly simple and obvious fact there are a lot of factors involved.
First, there is a little bit of history. The impact of massage on the circulation was the first issue which was examined scientifically. In 1876 German physician Von Mosengeil injected India ink into the tissues of experimental animals and examined the ink distribution with and without application of massage strokes. His results were the first scientific proof of the physiological value of massage therapy. The work of Dr. Von Mosengeil (1876) greatly sped up the development of the medical massage concept in Europe, especially in Germany which became the most advanced country in studying and using various massage methods and techniques as an important medical remedies.
Another author and study which is worth mentioning is the work of another German physician, Dr. F. Pick (1907). In his experiments on anesthetized dogs Dr. Pick examined how various massage techniques affect the speed of venous blood flow. He found that effleurage increases blood flow in the massaged extremity only during its application. As soon as the operator stopped applying effleurage the blood flow returned to normal. On the contrary, kneading and percussion also increased blood flow, but their effect was registered up to two hours after the end of massage application. These results allowed Dr. Pick to conclude that effleurage techniques increase blood flow only by means of mechanical stimulation while kneading and percussion techniques additionally use vasomotor reflex pathways of the nervous system. That is what gives the effect of massage long life and your clients will greatly appreciate it.
Great contribution to the studying the of the massage’s impact on circulatory system was made by American scientist Dr. A. Krogh, MD from Yale University who in1929 examined the impact of massage strokes on the circulation in mammals. He found that after massage strokes the number of opened capillaries in 1mm2 of cross section of skeletal muscles increased to 1400 from 31 which was detected at rest and the coefficient of the capillary capacity increased from 0.02 to 2.80.
However, my favorite publication on this matter comes from Mayo Clinic in Minnesota (Wakim,et al., 1949). My colleagues from the Mayo Clinic were greatly surprised by the fact that this world – wide well known medical establishment ever studied massage therapy as medical modality.
One of the author of this study, a young physician was sent to Europe to study medical massage and after he came back the Mayo Clinic tested slow effleurage stroking and kneading in the relaxation mode (modification of Hoffa’s technique) versus vigorous, stimulating massage on the blood circulation in the upper and lower extremities.
Two groups were tested: healthy adults (48 subjects) and patients with flaccid palsy (7 subjects). For the healthy individuals in the group who received stimulating massage the average increase in blood circulation in the upper extremities was 57% and for the lower extremities 42% compared to 4% increase in blood circulation in the upper and lower extremities in the group which received slow stroking massage. In the group with flaccid palsy the results were even more striking: a 103% increase after the application of stimulating massage and a 22% increase after slow relaxation strokes on the same subjects.
Dubrovsky et al. (1995) detected increase of the blood circulation in the skeletal muscles from 4.2+ 0.01 ml/100/min to 63+0.01 ml/100/min after intense kneading. The authors registered vasodilatory effect even 3 hours after the end of the treatment.
Practical Tip 1
What are the practical outcomes of this information? I would like readers to do a very simple self-evaluation. How much time do you spend on effleurage techniques while working, let’s say, on the hamstring muscles and what speed of strokes are you using? If your routine consists mostly of the application of slow effleurage strokes you are not doing much for your client. The effect of your work will be temporary and short lived.
The sad part that heavy emphasize of value of effleuarge techniques is the most common error massage for which therapy schools and colleges should be blamed. As scientific data shows the effleuarge techniques are among the less valuable when it comes to the therapeutic outcomes of massage therapy.
Yes, for example kneading techniques are more physically demanding when compared to effleurage, but using them intensively really makes the difference for your clients and helps to build up successful practice. Another aspect of the application of kneading is correct body mechanics which make application even complicated massage technique effortless (see November/December 2009 issue ofJMS). Also, you can read more on this subject in our Video Library.
So, when should effleuarge be used? The practitioner must start and finish massage of each segment with a short application of effleuage strokes. Also he or she should use it as a transition tool between the application of more sophisticated massage techniques. If massage session consists mostly of effleuage techniques, it becomes a senseless rubbing of the body, because it produces short living outcomes and blocks the practitioner’s creativity. As a result, the practitioner trigger Phenomenon of Adaptation (see January/February 2009 issue of JMS) and it greatly affects his or her practice.
IMPACT OF MECHANICAL PRESSURE ON RELEASE OF VASOACTIVE SUBSTANCES AND VASODILATION
Another important outcome of mechanical effect of massage therapy is local and general vasodilation triggered by release of vasoactive substances from the massaged tissues: histamine, bradykinin and kalidin (Kutz et al., 1978; Kuprivan, 1995, Yang et al, 2009). These substances trigger local and general vasodilation if their concentration in the blood increases. As was detected in several studies the intense massage strokes (friction, percussion) release a greater amount of vasoactive substances and triggers local and general vasodilation.
Yang et al.(2009) in the experimental study examined mechanisms of vasodilatory effect of massage therapy. The mechanical impact of massage therapy on the soft tissue elicits direct pressure on all cells (e.g. fibroblasts, mast cells, etc.) as a result of their mechanical compression Indirect or secondary mechanical impact triggers the increase in interstitial pressure in the massaged tissues. In the last case the practitioner impacts cellular component in the deep layers of the soft tissue where direct mechanical compression is less prominent.
Authors of this study re-created direct pressure application on the mast cells isolated on the cell dish and examined their histamine release function. Mast cells are major histamine production factories. The study design (on the cell dish) allowed the authors to exclude any nervous system or hormonal and metabolic influences on the production and release of histamine.
Authors found that the immediate response of the mast cells to the application of simple mechanical pressure was an immediate increase in Ca +2 concentration which followed by release of the histamine. As it was concluded by the authors:
“Histamine is a well-known mediator of microvascular tissue dilation, and these results may have an important impact on understanding the mechanism involved in massage therapy.”
If stimulating massage strokes are used during full body massage the vasoactive substances are released into the general circulation, and in this case massage has a general vasodilatory effect on the entire body contributing to general vasodilation in inner organs as it has great impact on their functions, especially if they were initially compromised.
Kutz, et al (1978) detected a 129% increase in urine excretion of histamine after full body massage. Such dramatic increase in the urine excretion reflects great release of histamine into the blood circulation.
The mechanical pressure triggers vasodilation by another mechanism – release of Substance P from peripheral nerve endings. Massage strokes greatly stimulate peripheral nerve endings and as a result the Substance P is released. This neurotransmitter is found in CNS, intestine and peripheral nerve endings. As it was reported by (Morhenn, 2000) firm stroking of skin releases Substance P from peripheral nerve endings with following local vasodilation.
Practical Tip 2
If the practitioner wants to optimize the healing impact of the therapeutic massage session he or she should consider application of short burst of quick effleurage strokes while pressure is directed under a 45 degree angle (to increase the force of shear deformation of soft tissues) and increased usage of various friction techniques.
IMPACT OF PASSIVE STRETCHING ON BLOOD SUPPLY AND VASODILATION
Another aspect of the mechanical impact of the massage on the vasodilation is passive stretching. Stretching, as any other forms of mechanical pressure, stimulates the tonus of smooth muscles in the vascular walls. Initial reaction of the muscle tissue to the stretching is vasoconstriction with following vasodilation after the stretching stops (Laher and Bevan, 1983).
Interestingly enough regular daily stretching greatly reduces the initial vasoconstriction phase in the muscles which undergo passive stretch and greatly contributes to local vasodilation. This important data was obtained by Otsuki et al, (2011) who used near-infrared spectroscopy analyzed changes in muscle-blood volume and tissue oxygenation index during muscle stretching by professional ballet dancers who stretch daily and ordinary subjects.
According to Lakin (1990), who examined the effect of passive stretching on the peripheral circulation in the muscles, the stretch of the muscle on 5 millimeters triggers increase of the blood supply to 30%.
Besides the vasodilation and increase in the blood supply the passive stretching as a way to deliver mechanical stimulation has another important impact on the muscle tissue. According to several studies repetitive passive stretching delivers shear deformation to the capillary walls and stimulates proliferation of endothelial cells which helps to form new capillaries in the repetitively stretched muscles. This is why the passive stretching is such an important tool to help to recover the muscle tissue damaged as a result of trauma or chronic overload.
According to Smith et al. (2001) during the vascular wall stretching the smooth muscles release special enzyme called Vascular Endothelial Growth Factor and its presence activates the proliferation of endothelial cells and formation of new capillaries. This is a very unique and rarely mentioned clinical benefit of passive stretching. As it was concluded by Hudlicka and Brown (1983):
“Repeated stretch and relaxation could be important factor in addition to increase capillary wall tension and increased shear stress, in the remarkable degree of capillary proliferation in stimulated muscles”
Practical Tip 3
The practitioner must finish massage of every body segment (e.g. forearm or thigh) with 3-5 re-applications of passive stretching of each major muscle group located within the boundaries of massaged segment. It will greatly contribute to the long lasting effect of the massage session.
Practical Tip 4
Based on the research conducted by Otsuki et al. (2011) it is obligatory for the practitioner to inform, explain and, if needed, to teach the client to conduct daily passive stretching especially those muscle groups which usually carry more stress and tension. For example, daily stretching of cervical and upper shoulder muscles for those clients who work on the computer a lot. It will help client to avoid excessive tension build up while making future massage sessions more effective.
EFFECT OF ISCHEMIC COMPRESSION ON VASODILATION
The ischemic compression is a medical massage tool which is the main part of Trigger Point Therapy and it is rarely used during the stress reduction or therapeutic massage sessions. However, we will discuss it here because of its effect on the blood circulation in the area of hypertonus and trigger point(s).
We discussed the nature and mechanism of the formation of trigger points and hypertonuses in a four part article on this subject published in March/April,May/June, July/August and September/October 2009 issues of JMS. So here I will briefly summarize this information. For complete analysis and study of this topic it is best to use the links above to the Trigger Point Therapy article.
The correctly applied ischemic compression is a very powerful clinical tool which helps patients with wide range somatic abnormalities from lower back pain (Garvey et al. 1989) to headache (Fernandez-de-las-Penas et al., 2008) and sickle cell anemia pain (Bodhise et al, 2004).
The trigger point is within the area of muscle spasm where the rate of the arterial perfusion is significantly lower. The blood flow in the trigger point is still maintained to the degree needed for the minimal oxygenation of the muscle tissue, but its volume is not sufficient enough to allow the affected part of the muscle to effectively contract.
However, the blood flow around the area of the trigger point is not affected. During ischemic compression, the practitioner compresses the area of the trigger point and completely abolishes blood perfusion through the capillaries. As a result of this compression a condition of local hypoxia (i.e. lack of oxygen) is created.
While the practitioner compresses the tissue, the client’s heart continues to pump arterial blood and its pressure creates a so-called ‘blood depot’ around the practitioner’s finger. As soon as the practitioner releases the pressure, the body will take the extra measures to restore proper oxygenation of the compressed tissue and fresh arterial blood from the ‘blood depot’ is right there and available.
To let this extra amount of blood satisfy the tissues which are ‘hungry’ for oxygen and eliminate hypoxia, the nervous system produces reflex vasodilation of the previously constricted capillaries. What is more important, reserve capillaries which did not work initially become open as well to accommodate the oxygenated blood from the ‘blood-depot’. As a result, vasospasm is eliminated, and the blood perfusion is restored (Montanez-Aguilera, et al., 2010).
Practical Tip 5
The readers may see in video format step by step protocol of Trigger Point Therapy including scientifically based application of ischemic compression part in September/October 2009 issue of JMS.
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
Category: Stress Reduction Massage