According to the basic principles of medical massage, pathological changes in the soft tissues can develop at different levels: the skin, superficial fascia, superficial skeletal muscles, deep fascia, deep skeletal muscles and, finally, the periosteum. Soft tissues can be affected individually at each level or in any combination. In this article, we concentrate on the superficial fascia and skin.
Although diagnostic tools and treatment techniques to restore connective tissue function are a cornerstone of somatic rehabilitation, these modalities had received limited exposure among somatic practitioners until recently. Thanks to Fascia Congresses, the role of connective tissue structures in somatic rehabilitation has regained professional interest, and several significant scientific discoveries have been reported, for example, the role myofibroblasts play in combination with other factors in the formation of tension in the fascia.
Although Fascia Congresses played an important role in casting the spotlight on tension in connective tissue, the methods of its treatment have not changed. First, we would like to emphasize that only three methods offer sufficient clinical potential for quick and effective relief of tension in the connective tissue structures: Connective Tissue Massage (CTM) or Bindegewebsmassage, Myofascial Release (MR) and Cupping Massage (CM). These techniques may be used in combination, such as MR combined with CTM. In such a case, the more general impact of MR on fascia is combined with the intimate physiological action of CTM. In another scenario, CM can be conducted along the strokes of CTM.
There are other methods and techniques which are able to target the fascia, such as Rolfing. We emphasized the value of CTM, MR and CM because they target the connective tissue structures specifically. We would like to make our readers aware that many other methods and techniques to address connective tissue currently promoted in continuing-education classes are a repackaging of the same ideas, often in far less clinically effective forms. In this article, we discuss the application of CM and its combination with CTM.
First, a short historical review: Initially, the importance of tension build-up in the connective tissue and its impact on chronic somatic and visceral abnormalities was made known to the medical community through the work of German physical therapist Elisabeth Dicke in 1929. As with many important discoveries, Dicke’s discovery was an accidental find. For several years, she suffered a failure of arterial circulation in her lower extremities as a result of Thromboangiitis Obliterans. The disease had progressed to the stage where amputation was a real possibility. Dicke also experienced chronic lower-back pain caused by her limping. While rubbing her lower back to relieve tension, she noticed sensations of warmth and weak pulsations in her feet. Intrigued by her finding, she started using various techniques on her lower back. She noticed that the most intense warm sensations in her feet were triggered when she pulled the skin on her lower back. After several months of self-therapy, she was able to restore circulation through her lower extremities.
E. Dicke shared her findings with Prof. W. Kohlrausch. Their combined efforts, as well as the later works of Prof. N. Veil and Dr. Leube in Austrian and German clinics, shaped a major method of somatic rehabilitation they called Bindegewebsmassage or CTM, as it is known in the rest of the world.
The basic theoretical concept of CTM is Connective Tissue Zones (CTZ), which form in connective tissue concentrated at three levels: the dermis of the skin, the superficial fascia and the deep fascia. The CTZs are formed in the soft tissue as a response to acute injury, chronic inflammation (e.g., Rheumatoid Arthritis), chronic overload or low-grade irritation of the peripheral nerves, which are responsible for the innervation of the affected area. The last cause is quite common yet is frequently misunderstood and missed by therapists or physicians. As a result of these factors, the collagen fibers, which are the main component of connective tissue, lose elasticity and flexibility. This hardens and shortens the entire fascia, which, in turn, decreases the mobility of the skeletal muscles it covers. Such restrictions contribute to the later formation of hypertonic muscular abnormalities in the form of hypertonus, trigger points and later myogelosis. Tension in the CTZs contributes to another clinical phenomenon: the restriction of mobility between the different layers of soft tissue. Fig. 1 illustrates the soft tissue arrangement in the posterior shoulder.
Please pay attention to the third and fifth layers in the picture: the superficial and deep fascia. The superficial fascia separates the skin and subcutaneous tissues from the superficially located skeletal muscles, and the deep fascia separates the superficial and deep skeletal muscles. You may notice the short fibers that cross each other. These fibers are called fibrotic bridges, and they hold soft tissue together to prevent excessive side displacement of the superficially located tissue relative to the deep tissue. The simplest way to see fibrotic bridges is to examine an area of cellulite, which is often a concern for many women. Each tiny dimple, visible on the skin when squeezed, is the place where an individual fibrotic bridge originating from the superficial fascia inserts into the collagen fibers of the dermis. The excessive accumulation of subcutaneous fat puts pressure on the fibrotic bridges, shortening them and giving the skin its bumpy appearance.
From the medical massage point of view, fibrotic bridges have an even more profound meaning. When tension builds up in the fascia where each fibrotic bridge originates, it shortens the bridges and “glues” the skin to the superficial fascia or the superficial skeletal muscles to the deep skeletal muscles, and greatly limits the ability of soft tissues to slide against each other during normal ROM. Such restrictions cause profound changes in the function of skeletal muscles and, finally, the periosteum. Fig. 2 illustrates the fibrotic bridges between the skin and subcutaneous tissues and the superficial fascia on the posterior shoulder.
1 – superficial fascia
2 – posterior portion of the deltoid muscle
3 – fibrotic bridges between the superficial fascia and subcutaneous tissues
4 – deep fascia
5 – infraspinatus muscle
One of the goals of CTM, as well as MR and CM, is to restore the elasticity of the fibrotic bridges. Furthermore, the therapy will secondarily decrease the tension built up in the superficial fascia with a subsequent decrease in muscle tension. Besides restoring somatic function and eliminating active CTZs, CTM, MR and CM can also help patients with chronic visceral disorders. As shown in many clinical studies, chronic visceral abnormalities trigger the formation of CTZs as a reflex reaction of the body to the long-lasting pathology of the inner organs. CTZs will form in the parts of the fascia that share the same innervation with the affected inner organ. Fig. 3 illustrates the location of CTZs for the major visceral systems of the human body.
As we discussed above, there are three major clinical tools to affect CTZs: CTM, MR and CM. Here we will discuss Cupping Massage (CM). CM is an ancient Chinese medical practice. Since 1950, it has been adopted as an accepted modality for use in all hospitals in China and many other countries (Cao et al., 2012). There are several variations of cupping: retained cupping, flash cupping, moving cupping, wet cupping, medicinal cupping, and needling cupping.
Different types of cupping, alone or in combination with other modalities, have been shown to help patients with pneumonia and chronic bronchitis (Wang, 2010), facial paralysis (Qiu et al., 2003), herpes zoster (Ci, 2010), chronic cervical pain (Lauche et al., 2012), chronic lower-back pain (Farhadi et al., 2009), etc. Thus, cupping offers additional health benefits to patients beyond restoring the function of the fascia. Here we will discuss moving cupping, or CM, as part of the medical massage session. For successful somatic rehabilitation, CM alone is not sufficient and should be used only as a tool in combination with other techniques and modalities.
Originally, for moving cupping, as well as other types of cupping, fire was used to create the necessary vacuum in the cup before placing it on the body. The practitioner lit a cotton ball on a metal stick, quickly placed it inside the glass cup and, within seconds, the fire had consumed all the oxygen inside the cup. When the cup was immediately placed on the body, it sucked the skin and subcutaneous tissue into the cup. Later, cups with a valve on top and a pumping device to pump the air out were developed, enabling practitioners to have more control over the intensity of the pressure during CM. However, this method requires extra time to remove oxygen from the cup, and if the vacuum is lost, the entire procedure must be repeated. Additionally, the rims of cups made from glass or hard plastic are inflexible, which unnecessarily traumatizes the soft tissue in the areas where cupping is applied.
Newer plastic materials have resulted in better products, including those made for cupping. These new materials allow for flexible and softer cups without compromising the efficacy of CM. Boris Prilutsky, one of the authors of this article, developed the CM protocol using flexible silicone jars.
The video below shows a cupping set made from transparent silicone. The rim of each jar is much softer than the rims of glass or hard plastic cups, but does not alter the basic procedure of the CM application.
First, the practitioner chooses a jar that matches the massaged area (see video below). The practitioner spreads lubricant over the skin where CM will be used. The amount of lubricant should be significant to allow the jar to slide freely over the skin. The therapist presses in the middle of the jar to push the air out, tightly places the jar on the skin and releases the pressure. This procedure creates a vacuum inside the jar. The amount of pressure applied to the top of the jar will determine the intensity of the vacuum and how much soft tissue will be sucked inside the jar. Since the jars discussed in this article are transparent, it is easy to observe how much soft tissue is sucked in, and to decide whether to increase or decrease the degree of vacuum.
The next step in the application of CM entails sliding the jar over the massaged area. To enhance the application, the practitioner may carefully lift the jar while sliding it along the skin to additionally stretch the fibrotic bridges. Be sure not to detach the jar from the skin surface and lose the vacuum.
There are two methods to apply CM. In the first, the practitioner slides the jar back and forth over the area where he or she detected tension in the superficial fascia (see video below). A larger jar can be used to cover a larger area and save time.
In the second scenario, the practitioner combines CM with CTM. In such a case, CM is applied along the strokes recommended by CTM. Fig. 4 shows the sequence of CTM strokes on the lower and middle back.
In cases of CTM, smaller jars should be used, since they are more stable and can easily move along the contours of the body. The video below demonstrates the advantages of using a smaller jar when CM is applied along the strokes of CTM in the lower back. When applying CM along the CTM strokes, the strokes should be slow; the practitioner should slightly lift the jar while pushing it forward, and the returning strokes should be flat. The video illustrates this recommendation with a lower-back treatment on the right side, using strokes #13 and #15 from Fig. 4 as an example.
Since the CTM protocol is the result of decades of scientific research by Austrian and German scientists, it is the best and most efficient method to reduce tension in the fascia and restore its normal function.
CM has another clinical benefit, since it can be used for the treatment of reflex zones formed in the skin itself, i.e., cutaneous reflex zones. In any area of the body where the patient feels tingling, numbness, burning pain, etc., the practitioner may use CM. In such cases, it is not necessary to lift the jar. Instead, increase the speed of the back-and-forth application to trigger local hyperemia (see video below).
We highly recommend CM as an alternative to CTM or in combination with it. However, we would like to emphasize that CM should be used only as an additional therapy tool to address, first of all, tension in the superficial fascia and, secondly, the reflex zones in the skin, i.e., the cutaneous reflex zones.
Personal message from Mr. B. Prilutsky
I feel privileged to have developed the silicone-jar massage methodology as a part of MEDICAL MASSAGE PROTOCOLS to help practitioners with their clinical work. For the last two-and-a-half years, I have used silicone jars on a daily basis on my patients, and I feel very comfortable suggesting their application to our colleagues. It is an excellent supportive technique and significantly accelerates the healing process. I highly suggest that readers consider this treatment option.
You can find silicone jars on the Internet, or you can visit the website Medical Massage Education, where sets of jars and an educational DVD are available.
REFERENCES
- Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PLoS One. 2012;7(2):e31793. doi:10.1371/journal.pone.0031793
- Ci HF. Clinical observation of therapeutic effect of combination of acupuncture and cupping therapy on 104 cases with acute herpes zoster. Modern Medicine & Health. 2010;26:1550-1551.
- Dicke E, Schliack H, Wolff A. Bindegewebsmassage. Hippokrates-Verlag; 1979.
- Ebner M. Connective Tissue Manipulations: Theory and Therapeutic Application. 3rd ed. Krieger Publishing Company; 1985.
- Farhadi K, Schwebel DC, Saeb M, et al. The effectiveness of wet-cupping for nonspecific low back pain in Iran: a randomized controlled trial. Complement Ther Med. 2009;17(1):9-15. doi:10.1016/j.ctim.2008.05.003
- Lauche R, Cramer H, Hohmann C, et al. The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomized controlled pilot study. Evid Based Complement Alternat Med. 2012;2012:429718. doi:10.1155/2012/429718
- Qiu JZ, Fan CM, Wei FY, Gao CL. Clinical observation of therapeutic effect of medicinal cupping on acute facial neuritis. China J Mod Med. 2003;13(21):146.
- Wang L. Clinical observation of flash cupping for treating chronic obstructive pulmonary disease in remission. China J Mod Med. 2010;8:2574-2575.
Category: Medical Massage
Tags: JMS 2014 Issue #1
