GENERAL CHARACTERISTICS
Percussion is the most stimulating of the massage techniques. The physiological effect of percussion is a result of a combination of vibration and rhythmic compression. Its therapeutic impact mostly depends upon the speed of the strokes.
During percussion, the practitioner rapidly strikes the massaged area using different contact areas of the hand. To successfully perform percussion, the operator must immediately withdraw the hand after it makes contact with the body. This is called elastic percussion. In such a case, the hand bounces back like a rubber ball from a wall.
The amplitude of the stroke and the force of the percussion are other important elements. Percussion delivers shock waves through the massaged area as well as throughout the entire body. This impact elicits different physiological responses from the tissue and body systems. The stimulating effects of percussion are especially noticeable if this technique is applied to motor points or on tendons.
PERCUSSION OVER MOTOR POINTS
A motor point is the area where the motor nerve that provides the innervation of a particular skeletal muscle enters that muscle. The motor point cannot be found by palpation or by any other type of examination.
Electromyographically, the motor point is the area where an externally applied electrical current with lowest magnitude is able to produce a muscular contraction. Percussion strokes over the area of the motor point have the greatest stimulating effect on the muscle.
The area of the motor point is easy to detect because it is to be found in the middle of the muscle belly. However, this simple recommendation has one important element which is frequently missed. The middle of the muscle belly, however, does not always correspond with the middle of the muscle itself.
This video shows the application of percussion in the area of the motor point of the biceps brachii muscle. As you can see, percussion is applied in the middle of the arm on its anterior surface.
Anatomical landmarks in the video: the two upper solid lines indicate the tendon of the long head of the biceps brachii muscle; the two lower solid line indicate the tendon of the biceps brachii muscle above the elbow joint; the black dot indicates the motor point in the muscle belly and at the same time the middle point of the arm.
Thus, the middle of the belly of the biceps brachii muscle and middle point of the arm coincide with each other. In a case such as this, the application of percussion on the motor point is an easy task.
The video also shows the application of electric vibration in the area of the motor point. This treatment decreases the tone of the targeted skeletal muscle.
Let’s look at another example. This video shows the application of percussion on the motor point in the extensor digitorum muscle.
Anatomical landmarks in the video: the small circle indicates the lateral epicondyle of the humerus, being the origin of the extensor digitorum muscle; the two solid lines indicate the tendinous part of the extensor digitorum muscle; the black dot indicates the motor point in the middle of the muscle belly; the cross sign indicates the middle point of the forearm.
In the video, percussion is applied to the motor point of the extensor digitorum muscle, which in this case is located superiorly to the middle point of the forearm on the dorsal surface. Therefore, the motor point of the extensor digitorum and middle point of the forearm do not coincide with each other, because the muscle has long tendons which start in the middle of the forearm.
Thus, to perform percussion over the motor points correctly, the practitioner has to keep in mind the muscular anatomy in the massaged area.
PERCUSSION ON THE TENDON
Percussion on the tendon is another excellent way to stimulate the skeletal muscles. It activates the muscle spindle receptors, which increase the muscle tone, and prepares the muscle for optimal performance. The most widely known, and a classic, example of percussion on a tendon is the doctor’s striking of the patient’s patellar tendon (just below the kneecap) with a tendon hammer, thereby eliciting the quick knee-jerk reflex.
The video shows two examples of percussion applied to tendons: on the tendon of the quadriceps femoris muscle and on the tendon of the triceps brachii muscle.
PHYSIOLOGICAL ROLE OF PERCUSSION
Rhythmic percussion causes a reflex contraction of the skeletal muscles, consequently their stimulation as well as an increase in muscle tone. These effects of percussion are helpful in cases of muscular weakness caused by neurological disorders or by long immobilization in fixing casts. It is also very useful to apply these strokes part of sports massage directly before a competition.
Despite the initial stimulating effect of percussion, the light prolonged application of this technique on normal muscles produces their relaxation. This paradoxical phenomenon never occurs with muscles that have any type of hypertonic pathology: hypertonus, trigger point or myogelosis. This is why any percussion technique in these areas is always contraindicated.
Thus, percussion is applicable across the board in therapeutic massage, sports massage and medical massage, except — because of the stimulating effect of the technique — in specifically stress reduction massage, or in cases of tension or spasm in the skeletal muscles.
Percussion greatly impacts the peripheral circulation of the area treated. During percussion, the practitioner compresses, with each strike, the walls of the arterial and venous vessels. As a result of these quick compressions, the vessels respond with reflex vasodilation, and local circulation increases. The stimulation of local blood circulation is achieved more quickly after percussion than after any other massage technique; however, its effect is not as long-lasting as compared with kneading, for example.
Percussion has profound effects on the patient’s body because of its shock-delivering impact. As a result of percussion, the sympathetic part of the autonomic nervous system is stimulated. In this way, percussion affects, via reflex pathways, even the functions of the internal organs.
Like vibration, percussion waves spread throughout the whole body. However, the physical impact of percussion is much stronger than that of vibration, as percussion waves spread over a greater distance. Thus, percussion is the only manual massage technique which delivers a great amount of mechanical oscillations to a internal organ from a distance.
There exists a significant number of scientific articles which have reported that percussion enhances breathing, increases blood oxygenation, and reduces tension in the respiratory muscles. Patients with chronic respiratory abnormalities greatly benefit from percussion because it stimulates sputum drainage and clearing of the bronchial tree.
TECHNICAL DISTINCTIONS OF PERCUSSION AS COMPARED WITH OTHER MASSAGE TECHNIQUES
During percussion, the actual contact between the practitioner’s hand(s) and the massaged area is brief. Owing to this, the strokes can be directed either along venous and lymph circulation or against it. However, the direction of the final series of percussion strokes should follow the direction of drainage.
The best way to perform percussion is to apply strokes along the segment, constantly changing the direction of their pathway (in any number of axes).
There is another important point relating to the application of percussion in cases of medical massage. Light percussion plays an important role in the treatment of neuralgia (i.e., inflammation) of the peripheral nerves. In such cases, percussion should be applied along the pathway of the affected nerve.
As mentioned previously, the therapeutic effect of percussion depends upon the speed of the strokes. The speed of the strokes has to be significant but the pressure (of the impact of each strike) must not be strong. The amount of pressure depends upon the energy and angle of the impact. The more vertical the strokes (the strikes), the greater the compression of the soft tissue.
Speed (energy) and pressure here have a strong inverse correlation: a higher speed of strokes demands lower pressure, and vice versa.
The rhythm of the strokes is another important aspect of the percussion technique that should be discussed separately. With steady rhythm, prolonged percussion has a less stimulating impact, compared with the same strokes delivered with a constantly changing rhythm. Thus, the operator can use a change of the rhythm as an additional therapeutic tool.
TYPES OF PERCUSSION
SIMPLE PERCUSSION
TAPPING (TP)
Simple percussion using the fingertips is called tapping (TP). The bi-manual application is used mostly on the face (see the video). It is most effective to use both hands. Slightly bend the phalanges, spread the fingers, and gently hit the massaged area using the fingertips. The fingers should alternate with each other when they hit the massaged area, as, for example, during typing.
The one-handed variant of TP is used in the areas of the motor trigger point or tendon. It offers great advantage compared with other percussion techniques because the practitioner may use the fingertip(s) of one (usually the third) or two (the second and third, or third and fourth) fingers. In such a case, the percussion targets only the area of the motor point without affecting the surrounding muscle tissue.
The more vertical the position of the finger(s), the harder the impact is. Notice that TP is accomplished by the flexion-extention at the metacarpo-phalangeal joints with wrist joints tightened.
SLAPPING (SL)
Simple percussion using the palms is called slapping (SL). It can be a one-handed or two-handed technique. SL can be applied with or without tightening the joints of the hand.
To perform the first type of SL, tighten the wrist, metacarpo-phalangeal and interphalangeal joints, and rhythmically hit the massaged area with one or both hands. The practitioner may use both hands together (the first part of the video) or may alternate hands (the second part of the video).
Also, SL can be conducted in either a fixed or mobile mode. This variant of SL with tightened hand joints has a more stimulating impact on the tissue.
In another variant, SL can be conducted with relaxed hand joints. In such a case, SL strokes come from the relaxed flexion-extension at the wrist joint(s). This type of SL can be also done using one or two hands, and in the mobile or fixed mode. This variant of SL with relaxed hand joints has a less stimulating impact on the tissue.
HACKING (HC)
HC is percussion delivered by the ulnar edge of one or, more frequently, both hands. The practitioner has to place the hands on their ulnar edge at a distance of about one inch apart from each other, and strike the massaged area by alternating the hands. The hands are always placed perpendicularly to the direction of the muscle fibers in massaged area.
There are two variants of HC: with relaxed, or with tightened, hand joints. If HC is performed with relaxed hands (the first part of the video), the strokes are gentler. If, however, the practitioner brings the fingers together and tightens the wrist joints, the force of the strokes increases dramatically (the second part of the video). In this case, the practitioner has to be very careful not to damage the soft tissue in the massaged area as a result of the tissue’s excessive compression against underlying bone structures.
HC can be performed in the fixed or mobile mode. The video shows the application of HC in the fixed mode in the area of the right sacroiliac joint.
This video shows the application of HC with tightened, and then with relaxed, hands in the mobile mode along the paravertebral muscles.
HC also stimulates the functions of the internal organs. In the abdominal area, this technique must be performed lightly and only with relaxed hands and fingers. At the beginning of the video, HC along the descending colon is shown.
It is very helpful to use one-handed HC along the intercostal spaces on patients with chronic pulmonary disorders. In such a case, HC should be done with a tightened hand and the fingers pressed together so as to increase the therapeutic impact.
The second part of the video shows the application of HC with tightened hand along an intercostal space on the patient lying on her side. During application of HC, try to fit the ulnar edge of your hand or 5th finger exactly between the two neighboring ribs.
BEATING (BT)
BT is a type of simple percussion in which the practitioner uses the fists. The practitioner may use one of two possible contact areas for the execution of BT: the ulnar edge of the fists or the palmar surface of the fists (the knuckles of the distal interphalangeal joints).
BT using the ulnar edge of the fists is usually more vigorous than BT using the palmar surface of the fists. Both types of BT can be applied in the fixed or mobile mode; using one hand or both hands; and in the synchronized (both hands striking at the same moment) or the alternating regime.
CUPPING PERCUSSION (CP)
CP is a unique technique because it combines several factors to produce a therapeutic effect. Besides rhythmic compression and vibration, CP employs the impact of compressed air. This technique can be performed with one or two hands.
The main contact areas are (simultaneously) the thenar plus hypothenar eminences, the side of the thumb, the 5th finger, and the fingertips of the 2nd-to-4th fingers brought together. Thus, the hand has a cup-like shape, shown at the beginning of the video from two views. All fingers have to be tightly compressed against each other.
The goal of this hand position is to deliver the maximum therapeutic impact from the air compression during the stroke. With correct execution of CP, air exits from between the hand and the massaged surface, but not from between the fingers themselves.
Lift the hand(s) and hit the massaged area using flexion-extension at the wrist joint while keeping the fingers and hand in the very tight, cup-like shape. With proper execution, a loud sound is produced by the air blowing out between the skin and the combined contact areas of the cupped hand. The video shows the quicker and slower CP in the fixed mode, as well as CP in the mobile mode.
The more flatly the hand is positioned (i.e., the less of a cup-like shape the hand has), the less loud the noise produced — which indicates the less air compression involved in the treatment.
Slow, gentle CP with only 1 or 2 strikes on the same area produces local vasoconstriction, as well as temporary bradycardia (i.e., decreased heart rate). Fast, energetic strokes over the same area produce local vasodilation and have a strong analgesic effect.
Energetic CP on the larger joints is a very helpful technique to apply on patients with osteoarthritis, especially of the knee joint(s). CP reduces pain and, more importantly, the regular application of this technique slows the progression of degenerative changes in the affected joint.
WHIPPING PERCUSSION (CP)
During WP, the operator strikes the massaged area with one or two hands, hitting the body surface at a sharp (i.e., a small) angle. The contact areas are the palmar surface of the 2nd-to-5th fingers only, or the whole palm. It works best to use both hands, but one hand can be used as well. The hands can come from the same direction or from opposite directions, in both cases alternating with each other.
During WP, the practitioner uses the entire upper extremity and hands (or hand) in whip-like strokes. The actual area of therapeutic impact is restricted to the size of thepractitioner’s hand(s) because there is no mobile mode for the application of this technique. If the practitioner wants to apply WP to a neighboring area, he or she must relocate the hand(s) to the new site of contact with the body surface.
The beginning of the video shows the application of the one-hand application of WP in a slow manner, for demonstration purposes. Tighten all hand joints, compress the fingers together and slightly abduct the thumb. The stroke starts up in the air and the hand “flies” downward as a plane landing, until it hits the body surface. After a split-second contact with the body, the hand flies up slightly in the same direction, then is made to assume the starting position again. The second part of the video shows the actual speed of the clinical application of one-handed WP.
The next part of the video shows two-handed WP conducted in a slow manner, for demonstration purposes, and then at the actual speed of clinical application. During this variant, both hands strike the same area, flying in from opposite directions.
The higher the practitioner’s hand is positioned at the beginning of the stroke, the less frequently the operator makes contact with the massaged area, and the lower the intensity of impact created. A lower height allows the operator to significantly increase the speed of WP, and, consequently, its stimulating impact.
WP is a powerful method of stimulating the nervous system and skeletal muscles and producing local hyperemia. In a medical setting, WP also has applicability in cases of scarring, connective tissue zones, peripheral neuralgia, and obesity.