In the January/February and March/April 2010 issues of JMS, we began a discussion of the mechanisms that scientifically sound therapeutic massage uses to support general health or enhance the body’s healing processes (see Diagram 1). In this and the upcoming issue, we will continue this conversation by focusing on the mechanisms behind vasodilation triggered by massage therapy.
If one opens any massage textbook or professional article, he or she will definitely find the mention of massage supporting peripheral vasodilation and enhancing blood flow. This is commonly accepted information, and practitioners learn it as soon as they start studying massage therapy and have the chance to observe it clinically as local skin redness (or hyperemia) in 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 that support peripheral and general vasodilation and enhance blood circulation: mechanical effect, ischemic compression effect, axon reflex activation, 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 a practitioner understands what mechanisms are responsible for enhancing vasodilation and blood flow, he or she will be able to apply more efficient techniques. This is why, in this article, we will separately emphasize practical tips to help practitioners successfully apply theoretical knowledge in the clinical setting.
In Diagram 1 we summarized the clinical effects of therapeutic massage. We based this table on publications that scientifically examined the therapeutic mechanisms of massage therapy. As mentioned above, we have already discussed the impact of therapeutic massage on cellular function and the electrical environment (see the 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
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 mechanical massage strokes and 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 many factors at play.
First, a bit of history. The impact of massage on circulation was the first issue examined scientifically. In 1876, German physician Von Mosengeil injected India ink into the tissues of experimental animals and examined the distribution of the ink with and without the 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 accelerated the development of the medical massage concept in Europe, especially in Russia and Germany, which became the most advanced countries in the study and use of various massage methods and techniques as an important medical remedy.
Another author and study worth mentioning is the work of 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 strokes, the blood flow returned to the baseline. On the contrary, kneading and percussion also increased blood flow, but their effects were observed up to 2 hours after the end of massage application. These results allowed Dr. Pick to conclude that effleurage techniques increase blood flow solely through mechanical stimulation, whereas kneading and percussion techniques also engage vasomotor reflex pathways of the nervous system. That is what gives the effect of massage a long life, and your clients will greatly appreciate it.
A great contribution to the study of the impact of massage on the circulatory system was made by American scientist Dr. A. Krogh, MD, from Yale University, who in 1929 examined the effects of massage strokes on circulation in mammals. He found that after massage strokes, the number of opened capillaries in 1 mm² 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 at Mayo Clinic were greatly surprised to learn that this worldwide, well-known medical establishment had ever studied massage therapy as a medical modality.
One of the authors 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 in the lower extremities, 42%, compared to a 4% increase in blood circulation in the upper and lower extremities in the group that received slow effleurage stroking massage. In the group with flaccid palsy, the results were even more striking: a 103% increase after stimulating massage and a 22% increase after slow relaxation strokes in the same subjects.
Dubrovsky et al. (1995) detected an increase in 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 a 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 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 is that the heavy emphasis on the value of effleurage techniques is the most common error message for which therapy schools and colleges should be blamed. As scientific data shows, the effleurage techniques are among the least valuable when it comes to the therapeutic outcomes of massage therapy in regard to vasodilation.
On the contrary, kneading techniques (14 types developed by the Western School of MT) are more physically demanding than effleurage, but using them intensively really makes the difference for your clients and helps build a successful practice. Another aspect of kneading is proper body mechanics, which makes even complex massage techniques effortless (see the November/December 2009 issue of JMS). Also, you can read more on this subject in our Video Library.
So, when should effleurage be used? It is the main tool for soft-tissue drainage, helping move interstitial fluid into the lymphatic system and lymph through it. Also, the practitioner must begin and end each massage segment with a brief effleurage. Also, he or she should use it as a transition tool between the application of more sophisticated massage techniques. If a massage session consists mostly of effleurage techniques, it becomes a senseless rubbing of the body, producing short-term outcomes and blocking the practitioner’s ability to maintain or restore local circulation. creativity. As a result, the practitioner triggers the Adaptation Phenomenon (see the January/February 2009 issue of JMS), which greatly affects his or her practice.
IMPACT OF MECHANICAL PRESSURE ON RELEASE OF VASOACTIVE SUBSTANCES AND VASODILATION
Another important outcome of the mechanical effect of massage therapy is local and general vasodilation triggered by the 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 observed in several studies, intense massage strokes (friction, percussion) release greater amounts of vasoactive substances and trigger local and general vasodilation.
Yang et al. (2009) conducted an experimental study examining the mechanisms underlying the vasodilatory effect of massage therapy. The mechanical impact of massage therapy on soft tissue exerts direct pressure on cells (e.g., fibroblasts, mast cells, etc.) through mechanical compression. Indirect or secondary mechanical impact triggers the increase in interstitial pressure in the massaged tissues. In the last case, the practitioner impacts the cellular component in the deep layers of the soft tissue where direct mechanical compression is less prominent.
Authors of this study recreated direct pressure application on mast cells isolated in a cell dish and examined their histamine release function. Mast cells are major producers of histamine. The study design (on the cell dish) allowed the authors to exclude nervous system, hormonal, and metabolic influences on histamine production and release. The authors found that mast cells responded to simple mechanical pressure with an immediate increase in Ca2+ concentration, followed by histamine release. 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 a 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 a great impact on their functions, especially if they were initially compromised.
Kutz et al. (1978) reported a 129% increase in urine histamine excretion after full-body massage. Such a dramatic increase in the urine excretion reflects a great release of histamine into the blood circulation.
Mechanical pressure triggers vasodilation via another mechanism: the release of Substance P from peripheral nerve endings (a.k.a. pain receptors). Massage strokes greatly stimulate peripheral nerve endings and as a result the Substance P is released. This neurotransmitter is found in the CNS, the intestine, and the peripheral nerve endings. As reported by Morhenn (2000), firm stroking of the skin releases Substance P from peripheral nerve endings, leading to local vasodilation.
Practical Tip 2
If the practitioner wants to optimize the healing impact of the therapeutic massage session, short bursts of quick effleurage strokes with pressure directed at a 45-degree angle (to increase the force of shear deformation of soft tissues) should be used. Also, increase the use of various friction techniques (15 types developed by the Western School of MT).
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 form of mechanical pressure, stimulates the tonus of smooth muscles in the vascular walls. The initial reaction of the muscle tissue to the stretching is vasoconstriction, followed by vasodilation after the stretching stops (Laher and Bevan, 1983).
Interestingly, regular daily stretching greatly reduces the initial vasoconstriction phase during passive muscle stretch and contributes to longer, more sustained local vasodilation. This important data was obtained by Otsuki et al. (2011), who used near-infrared spectroscopy to analyze changes in muscle-blood volume and the tissue oxygenation index during muscle stretching in professional ballet dancers who stretch daily and in ordinary subjects.
According to Lakin (1990), who examined the effect of passive stretching on the peripheral circulation in muscles, a 5-millimeter stretch of the muscle triggers a 30% increase in blood supply.
Besides vasodilation and increased blood supply, passive stretching, as a means of mechanical stimulation, has another important impact on muscle tissue. According to several studies, repetitive passive stretching induces shear deformation of capillary walls and stimulates endothelial cell proliferation, thereby promoting the formation of new capillaries in muscles undergoing repetitive stretching. This is why passive stretching is such an important tool for recovering muscle tissue damaged by trauma or chronic overload.
According to Smith et al. (2001), during vascular wall stretching, smooth muscles release a specific enzyme called Vascular Endothelial Growth Factor, which activates endothelial cell proliferation and the 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 the massage of each body segment (e.g., forearm or thigh) with 3-5 re-applications of passive stretching for each major muscle group within the boundaries of the massaged segment. Each passive stretching must be done during the client’s prolonged exhalation. It will greatly contribute to the long-lasting vasodilatory and new capillary formation effects 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 the client avoid excessive tension buildup and make future massage sessions more effective.
EFFECT OF ISCHEMIC COMPRESSION ON VASODILATION
Ischemic compression is a medical massage tool that is a main part of Trigger Point Therapy, and it is rarely used during 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. Use these publications for a complete analysis and study of this topic.
The correctly applied ischemic compression is a very powerful clinical tool that helps patients with a wide range of somatic abnormalities, from lower back pain (Garvey et al., 1989) to headache (Fernandez-de-las-Penas et al., 2008) and sickle cell anemia pain (Bodhisattra et al, 2004).
The trigger point is within the area of muscle spasm, where arterial perfusion is significantly reduced. The blood flow to the trigger point is still maintained to the degree needed for minimal oxygenation of the muscle tissue, but its volume is insufficient to allow the affected part of the muscle to contract and relax effectively.
However, blood flow in the area around the trigger point is not affected. During ischemic compression, the practitioner compresses the trigger point, completely abolishing 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 takes extra measures to restore proper oxygenation of the compressed tissue, and fresh arterial blood from the ‘blood depot’ is immediately available.
To let this excess blood supply tissues that are ‘hungry’ for oxygen and eliminate hypoxia, the nervous system triggers reflex vasodilation of previously constricted capillaries. What is more important, reserve capillaries that did not work initially also open 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
Readers can see, in video format, the step-by-step protocol for Trigger Point Therapy, including the scientifically based application of ischemic compression, in the September/October 2009 issue of JMS.
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Category: Stress Reduction Massage