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You should always Massage Distal to Proximal. Is this yet another Massage Myth?

Recently there has been significant discussion about the massage myths that are frequently perpetuated by therapists (and sometimes even taught in massage schools). For example, pregnancy massage being contraindicated during the first trimester and massage releasing toxins are myths that are in the process of being eliminated.

distal to proximal massage
Massage therapists are always taught that they must massage distal to proximal, from the extremities towards heart. The argument is that the bodywork can increase the back pressure in the veins and potentially damage the vein’s valves through undue pressure.

Although it may appear to be logical rationale, is there any evidence that massaging proximal to distal does cause damage?

If you can imagine a fluid filled balloon inside a second fluid balloon and apply a local pressure to the external balloon, then (without claiming to be a scientist), it is hard to imagine that there will be a significant increase in the local pressure of the internal balloon. Isn’t this the situation in say the hamstrings, the calves or the quads? Would applying a distal force in one of these muscle groups really cause an increase in pressure significant enough to cause damage to a valve in a vein, even if the therapist was performing a strong deep tissue massage?

Please note, I am not advocating that therapists throw out the mantra that you must always work towards the heart. It is always understandable that there should be caution with working distally with anyone who has varicose veins, risk factors for deep vein thrombosis, potentially weaker veins (ie the elderly), during pregnancy, etc. However, let’s say for reasonable fit and healthy clients, is it true that we can really damage their veins?

I’m struggling to find any evidence that it can and has happened.

There are those who argue that working in a distal direction can be effective in achieving your massage goals, particularly if you are performing structural bodywork or the like. If you are massaging with correct intentions and are in tune with the requirements of the client’s, then you should work in the directions that will get the best results for the client.

According to Art Riggs(1) there are significant advantages of working distally:

• Since most muscles attach proximally in order to exert force proximally, working distally lengthens short muscle fibers and fascia for lasting relief from contraction which limits joint function and causes discomfort.
• It frees and lengthens nerves that have shortened along with the muscles.
• It decompresses joints and releases tight ligaments for better osseous function.
• Possibly the most important benefit is that working distally helps train our clients to override protective holding and reprograms movement patterns as they release in the direction of lengthening and relaxation.

  
If you have never tried releasing soft tissues by working proximal to distal then maybe it’s time to consider introducing it to your range of massage strokes and techniques. Just be mindful of normal massage contraindications, what you are doing, why you are doing it and who you are doing it on.

(1) “Distal vs Proximal Work”. Art Riggs. http://www.abmp.com/textonlymags/article.php?article=91

By Richard Lane

Massage and Nausea

Unfortunately an occasional side effect of massage is that you can occasionally feel a little nauseous after the massage. Whilst you will hopefully feel relaxed, looser with less muscle and joint pain, it is possible that you may just feel a little off colour for a while.

For most people, this side effect of massage only last for a relatively short period. Some people will need to have a lie down and sleep. Others will drink plenty of water to feel as though they are giving their system a flush. Regardless, in the vast majority of cases, the nausea is only a transient hindrance.

Dizziness and nausea post massage
There is much discussion regarding the cause of the nausea and dizziness after a massage and it may well be the case that there are a number of different causes. One theory which is discounted by most therapists is that the nausea is caused by toxins that are release by the massage. For a discussion of this fallacy then please check out www.innerwestmassage.com.au/massage-toxins.php.
A recent hypothesis is that “Post Massage Soreness and Malaise” is the result of a mild case of Rhabdomyolysis which occurs when muscle cells are damaged and it interferes with the blood chemistry.

Personally whilst there may be some evidence to support this theory, if you follow this theory then you would agree that the deeper the massage, then the more likely you would be affected. Although this is a personal viewpoint, it doesn’t tally with my experiences.

For me nausea is more likely if I haven’t had a massage for a while and I have never noticed any correlation between the pressure/intensity of the massage and the degree of nausea experienced. I tend to subscribe to the theory of Dr Keith Eric Grant who considers that massage is about returning the body towards homeostasis and that the nausea may be the result of giving the lymphatic system a bit of a kick-along. Other therapists may argue differently to this but regardless this type of nausea post massage is very normal and not a cause for concern.

However, if you start vomiting and feel extremely dizzy post massage then that is a different kettle of fish. This happen whilst I was massaging someone a while ago and we had to stop the massage after about 20 minutes as the client was unable to continue. Although massage had only been carried out to the back, just the act of lying prone was too much for the client. Although she recovered and started to feel better once she rose from the table, this was not a normal state of affairs and seeing her doctor was the next step.

Although uncommon, one possible explanation for the extreme nausea in this case is atlantoaxial instability.

Atlantoaxial instability can be considered as a loose upper spine and is the loss of the integrity of the joint between the top two vertebrae, the atlas and the axis. For some people who may have had a neck injury or trauma, then when they move their head or neck then a bone projection (the “dens”) from the axis may effectively make contact with their brain stem. The result of this can range from mildly unpleasant through to downright dangerous.

  
Whilst massage is not necessarily precluded for people who suffer from atlantoaxial instability, extreme caution would be required. The neck can be considered vulnerable and only relatively gentle strokes should be attempted with the approval of a suitably trained diagnostic therapist. Most doctors would strongly recommend that there be no manipulation such as a chiropractic adjustment.

Although there may not have been a formal diagnosis of the condition then a massage therapist should be alert to the possibility. A client may be particularly tight high in the neck or be very guarded and protective of the way they hold their head. If any alarm bells are rung for the therapist then they back off with the intensity of their work and use the adage “too little is better than too much”.

By Richard Lane

Varicose Veins and Massage Contraindications

Virtually all massage therapists are taught that massaging varicose veins is contraindicated. The argument that is use is that increasing the back pressure in the veins either at the site of the varicose veins or distal to the varicose vein can increase vascular pressure, dislodge clots and the client runs the risk of a deep vein thrombosis. Massaging proximal to the site of the varicose vein is generally considered as being safe.

For most therapists this is probably reasonable advice although asking whether we can safely massage clients who have varicose veins is a fair question.

Varicose Veins and Massage Contraindications

Varicose veins are fairly prevalent amongst the general population although there are recognised risk factors such as gender (females are more susceptible to getting them), if you have been pregnant and if you need to stand a lot at work. Genetics can also play a significant role in whether or not you will develop varicose veins during your life. However, if you regularly exercise and have a high fibre diet then the risk of you getting varicose veins is reduced.

Within the veins of the body are valves which prevent blood flowing backwards through them. Whilst blood flow in the arteries is the result of the pressure exerted by the heart, the flow in the veins is more the result of a muscular pumping action. For example, in the legs which is where most varicose veins occur, the flow of blood against gravity is achieved by what is known as the calf pump mechanism. When the valves in the veins do not close properly as the veins become dilated then the blood can flow into superficial veins which cause them to dilate further. If there is continued constriction of blood flow in the veins to the heart (eg from constant standing) then the blood can pool in the legs and the veins can lose their elasticity. The result is the bulbous thick veins as shown in the above picture.

Blood clots are likely to develop, particularly in larger varicose veins and the risk of dislodging these clots are why therapists are taught never to massage varicose veins (directly or distal to the veins).

However, with suitable training and approval of client’s doctors, some therapists consider that massage can provide benefit for those who are affected by this condition. The massage strokes would tend to be short and of light pressure, more aimed at promoting local circulation and/or lymphatic drainage. Strokes such as petrissage, deep tissue frictions, stripping and cross-fibre are never recommended. Some therapists who have received training in massage veins would often consider having the leg elevated to promote venous return.

  
If you suffer from varicose veins yourself then there are a number of steps you can take yourself to reduce any pain associated with them. Firstly move and exercise as much as possible. As mentioned previously, movement assists the calf muscle pump mechanism and even moving your ankles backwards and forwards can provide some benefit (particularly if you are sedentary and have limited mobility). Secondly, if possible, stop standing for long periods of time. If you do have to stand then try to shift your weight from time to time. For some, compression clothing can help although probably a good idea to discuss this with your doctor to determine whether such garments will be appropriate for you.

By Richard Lane

Pregnancy Massage in the First Trimester

Massage for pregnancy

If you ring to book for a pregnancy massage and mention that you are in the first trimester then there are many therapists who will refuse to accept your booking. Day spas often will include on brochures and promotional materials that you should not come in for a massage if you are in the early stages of pregnancy.

So it appears as though the massage industry supports the view that massage during the first trimester is not safe.

However, for many women this is just not the case and there are no scientific reasons for healthy women not to get a massage during the first trimester. Indeed often women will receive bodywork without even knowing that they are pregnant.

The reasons for the varying positions on first trimester pregnancy massage stem from a misconception that massage can, in some cases, lead to miscarriage. This view is inaccurate and there is no causal link between massage and miscarriage. Whilst the prevalence of miscarriage is greatest in the few months of pregnancy, in general, the actions and the activities of the women will have no bearing on the likelihood of her suffering from an unfortunate miscarriage. Basically if it is going to happen then it will happen as the miscarrying embryo is typically chromosomally abnormal and not viable. Infections and diseases may be other causal factors. Exercising, stretching or having a massage, however, does not contribute any risk towards a miscarriage.

If a miscarriage does happen within a short period of having a massage, assuming that the massage therapist has not acted outside of their scope of training, then it is fair and reasonable to declare that having the massage was not the reason for the miscarriage. Whilst a woman may very well question what she did and didn’t do in the days before the miscarriage, in the long run hopefully she will be able to understand that what happened was going to happen regardless and she should not assign any blame to her (or others) actions.

Most massage therapists do understand this point, yet a significant proportion are still reluctant to perform a first trimester pregnancy massage. Their position is that they do not wish to be put into a position of the woman associating a miscarriage with any massage. This is very much a personal choice of an individual therapist and no therapist should ever be put into a position of providing massage services when they are not entirely comfortable to do so. Some clinics may make a similar decision on behalf of all therapists, more out of a misguided fear of litigation.

  
Whether a woman actually feels like having a massage during the first trimester though is a separate question. Nausea, morning sickness lethargy, breast tenderness, etc may act as negative influences and make her not want to get a massage anyway. However, this is a separate issue to whether she can get a massage or not.

Before booking in for a massage with a suitably trained therapist, we would also suggest that you discuss your intentions with your doctor just to ensure that there are no issues which may mean that pregnancy massage (at any stage of the pregnancy) is contraindicated.

By Richard Lane


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