Counseling Sheet

Agatha M. Thrash, M.D.
Preventive Medicine

‍DEFINITION

‍Massage is a healing art. It is designed to bring physical and mental health to those who are in need. Massage is simple. The student should not feel that there is some special technique or touch that some people innately have to make a good masseuse that is not possessed by all. Yet, each student should strive to perfect the techniques. This manual is designed to instruct the beginner in these techniques. The student should practice about half a dozen strokes at one sitting, being both the recipient and the therapist for each stroke.‍

EFFECTS OF MASSAGE

Tonic

An increase of the tone of skin, muscles, tendons, or blood vessels in a weak or chronically ill person.

Sedative and Stimulant

‍Sedation or stimulation from the therapist to the recipient, according to the nature of the application.‍

Vascular

‍Increase in lymphatic and venous circulation.‍

Skeletal

‍In muscle atrophy; prevention of excessive scar formation; relief of pain and swelling in sprains, fractures; stimulation of bone and tendon operations to muscle growth in fibrositis or myositis.‍

Visceral

‍Stimulation of the activity or tone of hollow muscular organs; increase of glandular secretions and kidney function; stimulation of oxidative and metabolic activities.

The effects of the massage are largely reflexive, rather than direct. Vasomotor nerves are stimulated by massage, and there is dilatation or constriction of distant blood vessels. Massage increases the number of blood cells, both red and white, in the peripheral bloodstream. Light stroking or friction causes a brief contraction of the capillaries, followed by dilatation of the same capillaries. Petrissage or percussion may cause a dilatation of the deeper blood vessels.

All massage procedures can be classified under three major headings: stroking, compression, and percussion.

Effleurage has a definite relaxing effect upon muscles, and should be used in muscle spasm, as in fractures or spastic conditions, pain, and myositis. Effleurage has also the effect of sedation.

Centripetal effleurage hastens the circulation; the lighter rotary spiral effleurage stimulates the smaller vessels, capillaries, and arterioles.

Superficial stroking, which is intended to secure reflex effect, must be performed slowly, gently, and rhythmically (10 to 12 strokes a minute).

Compression strokes are designed to improve circulation, hasten removal of waste products, or break up adhesions or fibrous nodules.

Petrissage improves the skin tone and should develop no friction, but should be a picking up and squeezing of the particular muscular and subcutaneous tissue to be massaged.

Friction may be superficial or deep. In deep friction, the palm is placed against the skin surface, and the skin is rotated without moving the hand over the surface of the skin, so that friction develops in the deeper tissues.

Avoid the use of a lubricant in both friction and petrissage, except to soften the hand of the masseuse or to oil scaly or dry skin.

There are times when pain must be induced to secure results, such as in breaking up adhesions and in the treatment of fibrositis in muscles of subcutaneous tissue.

Effleurage should follow all other strokes, even when it has been applied prior to the use of the more vigorous strokes.

Prolonged, heavy percussion may completely anesthetize a tissue through fatigue of the nerve endings.

Vibration by an electric motor strapped to the hand in an effleurage stroke is a good way of ending a massage treatment.‍

Contraindications

• Acute skin infections and ulceration
• Local acute inflammatory processes
• Acute lymphangitis
• Phlebitis and thrombosis
• Acute infectious fevers
• Acute osteomyelitis
• Acute, deep inflammatory conditions, such as appendicitis, cholecystitis, pleurisy
• Tuberculosis with fever
• Malignant tumor
• Hemorrhage
• Dermatitis
• Peptic ulcer

Lubrication or Friction

‍The massage may be done with a variety of lubricants, or with no lubricants. You must choose if you wish your hands to apply pressure and at the same time move smoothly over the surface of the skin, or if you wish to apply friction to the skin and little pressure to the underlying tissues. If you wish your hands to move smoothly, oil or powder may be used on the skin to achieve smooth movements.

Vegetable oil and mineral oil are equally satisfactory as massage oils. Mineral oil is cheaper. It is not absorbed by the skin, whereas vegetable oil is easily absorbed by the skin. Safflower oil, avocado oil, almond oil, or any other vegetable oil may be used. Mixtures are also quite good. Hand lotion and baby oils may be used if necessary. A few drops of musk, clove, cinnamon, lemon, or other oils may be added to scent the massage oil. Store your oils in plastic bottles that are not easily upset and have narrow openings, an eighth of an inch or smaller.

Powders do not cut down on the friction between the hand and the skin as effectively as oils. Some patients prefer powder to oil on their skin, and the wishes of the patient should be honored as far as possible. Talcum powders should be avoided, and starch powders chosen, because of the danger of aspirating the talcum and causing granulomata in the lungs.

A good body rub may be given with your hand dipped in water and used to friction the skin, or with a mitten or cloth wrapped around the hand to give friction to the skin, as in the cold mitten friction.

A dry rub may also be given effectively. This rub is usually short, and often follows a simple procedure, such as a foot bath.

A most satisfactory lubricant is mineral oil mixed with equal portions of alcohol. The bottle should be shaken before use and sprinkled through a cork sprinkler on the hands of the masseuse.‍

Working Surfaces

The easiest way to do a massage is on a massage table. The most difficult place to do a massage is on the patient's bed. The bed is not firm enough to provide support. If a table cannot be obtained, it is quite possible to give a good massage on the floor.

During a massage you should provide for your own comfort, making the massage no longer than you can carry out without getting tired. Bend your own back as little as possible while giving the massage so that you will not become excessively tired. A massage table eliminates bending and stooping, and gives easy access to the patient. 6' x 2' is a good size, well-braced. The height is from 29-31" including padding. Shaking and creaking of the table should be eliminated if possible. A 1" pad should cover the table. The simplest and cheapest way to build your own massage table is to make two small saw horses 28" high and 24" wide. A piece of ¾” plywood cut 2' x 6' with a foam pad to match completes the massage table.‍

Getting Things Ready

‍A few careful preparations will pay big dividends.

• Choose a place that is quiet and private. Noise and bustle are disconcerting, both to the patient and the therapist.
• Consider the warmth of the room. Nothing destroys an otherwise good massage more quickly than chill. The temperature in the room should be about 70° or slightly over for the comfort of the patient. There must be no drafts.
• Keep extra sheets on hand in case the patient should sweat and make the cover sheet damp.
• Get the oil in a convenient container, preferably warmed.
• Do not use bright lighting that will fall directly on the face of the patient. Facial tension and squinting can off-set much of the benefits of the massage.
• Do not have music in the massage room.
• Keep your fingernails short. Check for hangnails or rough spots on your skin. Make sure your hands are warm.
• Keep your hair arranged neatly, and out of the way.
• Your dress should be plain, neat, loose, and light, as you will be working in a warm room.
• Before beginning provide drinking water for both patient and therapist.
• Roll tissue is often handy to wipe spills or excess oil.
• Do not belittle yourself or your technique, nor be effusive in apologizing for circumstances, your lack of skill, or other things that may call for a reaction on the part of the patient. He should relax.

Preparation of the Patient

• Usually a massage follows another treatment, and the patient may be undressed already. If not, have the patient undress and cover with a clean sheet. An unfolded, full-length sheet for the patient's use should be given to him at the time he begins to remove his clothing. Have three small, linen towels available for covering the breasts, the genital area, and the eyes. To cover the eyes helps many patients to relax better, especially if there is much light in the room. While one part is being massaged, the remainder of the body should be fully draped. If a possibility of chilling occurs, add a light blanket to the draping. The towels for the breasts and genital area can be slipped under the main drape sheet without exposing the patient.
• Remove all rings, other jewelry, glasses, and contact lenses where practicable.
• Instruct the patient to lie on the massage table with the head even with the end of the table or padding, arms resting at sides.
• Instruct the patient to take several deep breaths and to completely relax, not trying to “help” with the massage in any way. When the patient is lying on his abdomen, you should instruct him to turn his own head from side to side as he feels comfortable, to prevent the neck from becoming stiff.
• Talk very little during the massage, but do not hesitate to ask the patient how he feels, or how he is reacting to the massage. Be careful not to hurt the patient with pressure.
• It is a good idea to instruct the patient to take a deep breath periodically during the massage. Have a plan for deep breathing after each major stroke is completed.
• If possible, allow the patient to lie still on the massage table for a few minutes immediately after the massage is over, and then transfer to a more comfortable bed for a few more minutes.

Applying Oil

• Never pour oil directly from the bottle to the patient's skin. Put the oil first on your own hands, and from there onto the patient.
• Hold your hand a little to the side of the patient so that if a few drops of oil should spill, they won't fall onto the patient.
• Pour approximately 3/4 teaspoon of oil into your palm at one time.
• Warm the oil in your hands, in an oven, or water bath before applying to the patient.
• Apply oil only to the part or parts of the body on which you are working, to prevent absorption of a part of the oil before you get to that part of the skin.
• Apply the oil with both palms, using a simple stroking movement which is gentle, definite, and steady.
• Cover the entire area you are about to massage, not missing any corners, and leaving no puddles of oil visible on the skin. About 2 teaspoons is enough for the average-size back. If you find you have applied too much oil, remove some of the excess with a tissue, or spread some to another part of the patient's body. A hairy chest, leg, or back requires extra oil.
• Place the oil bottle on an adjacent table rather than on the massage table. Two bottles of oil are good, one at the head and one near the end of the table to save extra steps and stretching to reach the bottle.
• Once making contact with the patient, try to minimize the number of times that you remove both hands from contact with the patient. In this way, the patient will have no uncertainty as to what you are doing or where you are, even with his eyes closed. If a lengthy break is necessary, speak to the patient before resuming so that he will not be startled as you resume the massage.

General Instructions

• At any time the patient seems nervous about being touched, instruct him to turn so that you can massage the back. Often, to do all of the back strokes will relieve the nervousness, and you may resume massaging the rest of the body. The act of obeying instructions reduces tension.
• The massage may begin with the back, the hands, the feet, the face, or the abdomen.
• During the massage, keep your eyes on the part you are working on, not on the patient's face. The patient's eyes may be covered with a light, dry towel, if he seems unable to relax and close his eyes.
• Never make the slightest apology to the patient for your lack of skill, but be ready with a light "excuse me" should you bump, scratch, or otherwise hurt the patient or make a loud noise as by dropping something.
• If the patient complains of physical discomfort, it must be alleviated promptly, or the massage will be less effective. Change the position of the patient, use bolsters to elevate the knees, a pillow under the top part of the chest as the patient lies on the abdomen to relieve some tension in a painful neck. A thick towel folded in a band about five inches wide and placed beneath the breasts can relieve pressure on the breasts when the patient is in the prone position.
• A tickling sensation or extreme sensitivity of the skin may be encountered along the ribs, on the soles of the feet, or over the abdomen. Heavy, firm pressure beginning some distance from the ticklish area will often quiet the tickling sensation.
• An occasional nervous patient may appreciate the presence of music in the massage room.
• A ten minute massage should include the back, the feet, the upper extremities, and possibly the abdomen. Spend the most time on the back if time is short.

How to Use Your Hands

Apply Pressure When You Do Massage

‍Once you have learned the strokes, the amount of pressure you will use will vary according to the particular stroke, the part of the body on which it is being used, the age and sensitivity of the patient. Some elderly or very thin individuals cannot tolerate much pressure. Some pressure is almost always necessary, however. Pressure usually feels good, as you will see when you yourself are being massaged. Experiment with different pressures on different body parts. Whenever you are afraid you may be pressing too hard, inquire of the patient and gently encourage frankness.‍

Mold Your Hand to Fit the Contour

Although certain techniques require that only a specific part of the hands be used, most massage strokes depend for their effectiveness upon your ability to keep your entire palm and fingers always in contact with the patient. Do not let either the heel of the hand or the ends of the fingers slip into the air as you move from one part of the body to another. When you glide your hand over the hip, shape it exactly to fit the hip. When you move it from the chest to the arm, curve it so that it molds evenly and smoothly around the shoulder as it passes.‍

Maintain an Evenness of Speed and Pressure

Try to eliminate trembling, jerking, and unnecessary stops and starts. Make any change of either speed or pressure a gradual one. Let the movement of your hand be as flowing and smooth as possible. Do not, however, be afraid to vary both speed and pressure. Rhythm is an essential part of massage. Certain strokes will not be effective at the same speed and pressure as other strokes. You can use different speeds and different pressures without sacrificing the steadiness of your movements.

Know Your Anatomy

By your knowledge of anatomy, define the underlying structures of the body of the person you are massaging. In this way you will increase the circulation to each tissue and achieve the desired effect of stimulating the removal of wastes and relaxation of tension.

Use Your Weight, Not Your Strength

‍Use your weight rather than your muscles to apply pressure. You do not need to be physically powerful to do massage. Whenever you want extra pressure, get it by leaning the weight of your upper body into your hands, rather than by straining with the muscles in your arms and wrists. Straining your muscles tends to give you stiff hands, a less flowing quality of movement, and a tired back. Allow your entire body to move with the stroke, not just your hand. This movement of the body need not be great, at times so slight that an observer would scarcely be aware of it.‍

Proper Stance

‍If you find that you experience fatigue or backache after giving a massage, give attention to how you are standing during the massage. A stance to try is as follows: Feet apart, knees bent and turned outward, and back straight. When you first try it, this stance may feel awkward. Having your feet apart, a couple of feet when necessary, permits you to easily swing your entire body without putting undue stress on large muscle groups of your back to support your weight. Instead, your weight shifts from one foot to another. Also, lowering yourself by bending at the knees rather than bending your back forward eliminates strain and fatigue in your lower back.‍

Names of Strokes

Effleurage

Light stroking, a stroking movement subdivided into superficial and deep.

Petrissage

Firm stroking, a compression movement consisting of kneading and frictions, both deep and superficial.

Percussion

Gentle beating with the flat side of the fist or edge of the open hand. Often designated as tapotement, including hacking, clapping, and beating.

Touch

The simple placing of the hand to mold over a part.

Vibration

Done with the hand or a mechanical device, with touch or effleurage.

Joint Movements

Passively taking a body part through its range of motion.

Nerve Compression

Locating a nerve by palpation, then exerting firm pressure.

Centripetal

A movement toward the center of the body.

Centrifugal

A movement away from the center of the body.‍

Strokes

Introduction

There are about eighty different massage strokes. Not all strokes need to be applied to each patient. In giving a massage, work progressively down the front of the body to the feet, and then up the other side of the body ending on the back. A complete massage takes about 45 minutes.

Make sure that you yourself do all the lifting or moving of the patient. Instruct him to relax as much as possible. Learn to make your transitions between strokes seem like part of the strokes themselves. Practice with a fellow student or a family member to test the effectiveness of each stroke. You should experience as well as perform each technique. Don't worry if a stroke at first seems clumsy or awkward to do. The patient is not likely to feel any clumsiness.

Head and Neck

• Begin with the head. If the patient has any nervousness about being touched, it will usually put him at ease to have the massage begin here. Stand at the head of the table. You may use a special lotion on the face such as Jergens to minimize getting the hair oily.
• Cover the forehead with the heels of your hands, letting the fingers extend down the temples. Pause for a few seconds. This is a touch stroke. After a few seconds, lift hands and begin with the second stroke.
• Using the balls of your thumbs, start at the center of the forehead, just below the hairline, stroking both thumbs at once in either direction outwards along the topmost strip. Press moderately, continuing to the temples and end with lighter pressure over the temples in a circle about 1/2 inch wide. Immediately pick up your thumbs, return to the center of the forehead, and work down the second strip, ending in a small circle on the temple.
• Massage the bony rims of the two eye sockets with your thumbs, while the fingers rest gently over the jaws. Use deep friction. It is good for the sinuses, and feels better than a rubbing movement on the skin. Massage both the upper and lower halves of the eye sockets.
• Lightly massage the eyes with your thumbs straight across the closed eyelids, using a minimum of pressure. Repeat three times, moving thumbs in the same direction.
• Starting just beside the nose, massage the fleshy parts of the cheeks, drawing the tips of the fingers in a path around the lower edges of the cheek bones toward the ears and back up to the temples for a circle. Work the muscles by making tiny circles with your finger tips with moderate pressure. This area is the index for tension in the face. Don't hurry. Stroke around the ears with the tips of your fingers several times, moving the ear gently and smoothly. End the massage of the ear by lightly pinching the outer edge of the ear between the thumb and the forefinger while gently rotating your thumb and forefinger.
• Place your left hand under the patient's head, and with your right hand squeeze the muscles in the back of the neck, gently rotating the hands as you squeeze. Change hands and use the same motion with the opposite hand. Be fairly gentle here, as many people have sore necks.
• Reposition yourself, this time at the side of the patient, and slip your fingertips into the hair, allowing the fingers to spread out so that they cover the entire scalp, if possible. With a gentle, rotary motion, massage the entire scalp for a few seconds.

Chest and Abdomen

• Spread oil on the chest and shoulders, abdomen, and sides of the trunk. Stand above the patient's head and place your hands with palms down in the middle of the chest, heels of your hands resting just below the collar bone. Glide both hands forward, pressing firmly on the chest, and more lightly on the abdomen. Keep hands together until you reach mid-abdomen, separating them at that point and moving downward on the sides. When fingertips touch the table, begin drawing the hands back toward you, along the sides of the trunk, returning to the starting point in a circle above the breasts, avoiding them. Repeat this major stroke six to eight times.
• “Pulling.” Standing at the side of the patient, reach directly across to the far side of the trunk, beginning where fingertips touch the table, pull each hand alternately straight up from the table. With each stroke, begin pulling with one hand just before the other is about to finish, so that there is no break between strokes. Start at the pelvis, just above the thigh, and work your way slowly up to the armpits and then back again. Each stroke should cover a little less than the width of one of your hands. Exchange sides and repeat.
• Stand at the right side. Support knees in the slightly bent position by bolsters to relax the abdominal muscles. Beginning in the right lower quadrant with your right hand, make gentle, full circles over the outline of the colon. Repeat about six times.
• Kneading the abdomen. Very gently, press the heel and fingers of one hand alternately downward into the abdomen, beginning at the center and working towards the side. As the side is approached, reach your other hand across the body and gently pick up the tissues at the back of the waist so that the tissues and organs are brought into closer contact with the kneading hand. At the end of each stroke, allow the hand underneath the waist to glide upward, following the waistline onto the front of the abdomen. Repeat two or three times on each side.

The Hand and Arm

• Grasp the hand so that your fingers are on the back of the hands, and press into the palm with your thumbs moving them in small circles. Work the entire palm, ending with fingers, doing each finger individually. End by milking the hand in a centripetal fashion two or three times, before the final part of grasping the fingers with the left hand, and stroking the hand toward the elbow.
• Beginning with the palms start a kneading and squeezing stroke in a hand-over-hand fashion, squeezing with one hand, relaxing while beginning squeezing and relaxing with the opposite hand in an alternate fashion and moving upward on the forearm and ending at the shoulder. In order to return to the hand, milk the arm downward, centripetally, until the hands again reach the palm. Repeat this stroke two or three times.
• Raise the forearm so that it is standing upright, elbow against the table. Ring the wrist with your thumb and fingers, and massage "toward the heart." Allow the fingers to glide between the muscle groups of the forearm as this stroke is repeated several times. As each stroke is accomplished, apply the major pressure as the stroke is moving toward the heart, and very gentle pressure as the hand is returned to the original position. Repeat the strokes for the arm.
• Range of motion. Gently work the joints of the upper extremity in their range of motion, beginning with the fingers, proceeding to the wrist, the elbow, and the shoulder. Repeat the entire procedure for the hand and arm on the opposite side.

Front of the Leg and Thigh

• Separate the feet several inches and apply oil to the entire front and sides of the leg and thigh. The strokes for the foot are much like those for the hand. First, do a centripetal milking of the foot, then a long, centrifugal stroking of the top of the foot and leg.
• Work the soles and the tops of the feet in a single stroke, the thumbs separating and massaging the muscles at the same time that the fingertips are separating and massaging the tissues on the opposite side of the foot. It is a good idea to work the sole of the foot first with the thumbs, fingers on the dorsal surface of the foot, and then change so that the thumbs work the dorsal surfaces and the fingertips the soles.
• To massage the heel, gently lift the foot from the table with the left hand, and work the heel by pressing the thumbs and fingertips into the tissues and firmly rotating, beginning at one portion of the heel and gradually working each part.
• Next, squeeze the foot just as you did the hand, hand-overhand motion, beginning with the base of the toes and squeezing the tissues alternately. This stroke begins at the base of the toes and ends at the knee.
• Long stroke. With the hands at the ankle, the left hand closer to the knee for the right leg massage, and the right hand at the ankle, allow the hands to cup across the top of the leg, fingers pointing in the opposite direction, in such a way that the fingers of the right hand point toward you, the fingers of the left away from you. Now glide both hands from the ankle steadily up the leg, using moderate pressure from your own shoulders, moving more lightly across the knee, and again firmly on the thigh, letting the hands separate slightly above mid-thigh, beginning a circle to return to the ankle, while the left hand makes a larger circle up over the hip and begins its return stroke down the side of the thigh. The massage toward the heart is much firmer than the return stroke toward the ankle. Repeat this long stroke five or six times.
• Petrissage. This stroke is done on the top of the thigh and is a combination of a slap, a pinch, and a knead. It is done by rapidly alternating the action of the two hands as follows: slap the cupped hand onto the thigh and grasp the tissue in the cupped hand, pinching it fairly firmly as it releases the tissue quickly. As the first hand is releasing the tissue, the opposite hand is beginning the slap and pinch. The stroke is done rapidly, moving from the knee to the pelvis and back again. Repeat for the opposite thigh.
• The kneecap. Gently cup the kneecap in your hand, rotating it to its full extension in all directions.

Back of the Leg

• Have patient turn into the prone position, head to one side, instructing him to turn the head to the other side if his neck feels tired. Spread oil over the right leg, buttock, and hip.
• The main stroke. This stroke is similar to the one for the front of the leg. Place the patient's feet a foot or so apart. Stand beside the right foot, placing the left hand across the back of the ankle with the fingertips pointing toward you, the right hand just above, with fingertips pointing toward the opposite side of the table. Pressing firmly, move both hands together up the leg; pressing more lightly over the back of the knee. Remember to transfer the weight from the left to the right foot as the stroke is performed. Separate hands at the top of the thigh, similarly as on the front of the leg, moving the right hand over the top of the hip, articulating the curve of the hip bone in a circle along the front of the hip, moving back down the side toward the foot. At the same time move the left hand down the inside of the thigh and back to the ankle. As the hands near the ankle, try to return them to the starting position of the stroke without a break in the flow of movement. Repeat this stroke three or more times.
• Wringing. Cup both hands and place them, fingertips pointing away from the therapist, side by side, along the base of the patient's calf. Have the underside of the fingers and as much of the palms as possible in contact with the leg. Move left hand away and down until the fingertips reach the table. At the same time, move right hand toward you and down, until the heel of the hand also reaches the table. This stroke resembles an "Indian burn." Reverse directions, working gradually up the length of the leg. The hand movement, though light in pressure, should be as fast and vigorous as possible without sacrificing definiteness. Keep the thumbs always brushing against each other.
• Milk the leg. Place palms against either side of the leg at the ankle, fingers pointing toward the table, or slanting at about 45 degrees. Across the calf, place both thumbs pointing in opposite directions and touching each other. Slowly glide both hands up the leg, squeezing gently with the palms and thumbs alike. End just as you reach the knee, returning at the same slow pace, but without pressure, to the ankle. The thumbs may remain touching each other throughout the movement, if the width of the leg is not too great. Repeat about three times, applying pressure each time during the upward movement only. Move to the thigh, starting just above the knee, and repeat the stroke.
• Raking. This is a good stroke anywhere, but especially on the thigh and back. Holding each hand with the fingers spread slightly apart and curved, stiffen the fingers so that the hand looks somewhat like a claw. Rake down the length of the thigh with short, alternating strokes, beginning at the top of the thigh or on the buttock, using only the fingertips for actual contact, work rapidly and with very firm pressure. Each stroke should be about 6 inches long, ending at the ankle.
• Finish the leg by lifting it onto the buttock, gently nudging it into extreme flexion, bouncing it several times in this position.

The Buttocks

• Kneading. Lift the flesh, squeeze, knead rhythmically, alternating hands. Cover one buttock thoroughly from waist to thigh, and then move to the other.
• With the fingertips of one hand, lightly probe the flesh about an inch to the side of the center of one buttock. Locate a slight hollow or indentation between two large muscles, the Gluteus medius and the Gluteus maximus. Press the heel of the hand straight into the hollow. Next vibrate the hand as fast as practicable for about ten seconds, then start moving the heel of the hand over the rest of the buttock in a circle, or in vertical lines.

The Back

• Generally the therapist should spend more time on the back than any other single part. Spread oil over the back, shoulder, and sides of the trunk.
• Main stroke. Stand at the end or side of the table. Place palms on either side of the topmost part of the back, with fingers pointing slightly toward the spine. The tips of the fingers should be on either side of the spinous processes. Glide hands down the entire length of the back, maintaining a firm pressure and leaning into the stroke with your own weight. Press extra hard with the fingertips into the depressions on either side of the spinous processes. Separate the hands at the lower end of the spine, moving over the sides of hips until the fingertips touch the table. Return to starting position by pulling both hands along the sides of the trunk, exerting moderate pressure. Repeat the stroke several times.
• Standing at the side of the table, place right hand on patient's lower back just to the right of the spine, fingertips of the right hand at the waistline pointing toward the head. Place your left palm down on top of the right hand. Make a circle with both hands around the hip bone to the table, circling toward the feet and returning to the starting position. Lean your weight into your hands. Repeat about four times.
• Place the right hand on the midline of the patient's spine, heel of your hand at the lower end of the spine, fingers pointing toward the head. Place your left hand across your right hand. Slowly glide the hands straight up the spine, pressure moderate and steady. At the top of the back, return the stroke at the same speed, but with the forefinger and middle finger pressing into the furrows that lie on either side of the spine, lifting the heel of the hand out of contact with the patient. Use as much pressure as possible. Repeat this stroke several times.
• Upper back. Knead the trapezius muscles by squeezing with the thumbs and fingers, gently covering the area from the base of the skull to the inferior margins of the scapulae.
• Shoulder blades. Place the patient's right hand, palm up, in the middle of his back. Lift his shoulder an inch or two from the table, and slide your right forearm in such a manner that, as you are standing at the head of the table, the patient's shoulder will rest in the crook of your right elbow, your right hand grasping the forearm immediately below his elbow. In this position the shoulder blade is raised, and the fingers of your left hand can run around the elevated scapula with firm pressure. Repeat several times. Next make tiny circles with your fingertips in the same areas, proceeding slowly in circles about 1/4 inch wide. Next, cupping the hand over the shoulder blade, fingers spread apart, move the skin over the shoulder blade in wide circles, several times to the right and then to the left. Repeat for the left side.
• Wringing. Pull your right hand toward yourself as you push your left hand away from yourself, beginning at the top and moving down the entire length of the spine and back again. Generate as much friction as possible, keeping the hands moving constantly and rapidly. Do not extend this stroke onto the sides, as it must be done rapidly.
• Place two of your fingers, or your thumbs, one on each side of the spine, beginning at the neck, and, proceeding the entire length of the spine, massage in about one inch circles between each spinous process, to massage the large nerve trunks as they come out from between the vertebrae.
• Hacking. Drum the outer edges of your hands very lightly and rapidly against the fleshy parts of the back, beginning at the shoulders and going up and down the spine once or twice.
• Feather stroke. Using both hands at once stroke straight down the back from neck to buttocks, using the fingertips only, as lightly as you can and continue to maintain contact with the skin.

Special Massages

Sprains

• Heat should precede the massage for sprains.
• Soothing effleurage to the sprained area, interrupted with petrissage to more distant part of the sprained limb.
• By the third or fourth day, the petrissage can be given nearer to the sprained area.
• On the sixth or seventh day the sprained limb is usually supported by strappings or bandages and permitted to be used, if it has been immobilized to this point.

Fractures

• Begin as early as gentle effleurage can be used without producing pain.
• Petrissage and passive and active joint movements are often not prescribed until there is some union of the bone.

Loosening Scar Tissue and Contractures

• Friction and petrissage are the strokes used.
• Pain must be produced, usually, to break up adhesions.
• The massage should be preceded by heat.
• Digital friction interrupted with effleurage.
• Digital kneading or friction repeated.
• Joint movements and tendon stretching.

Procedure for Constipation

• Deep breathing exercise: Take a full inspiration and hold for 20 counts, exhale fully and hold to the count of ten. Repeat 20-40 times. Do exercise 3 times daily when driving or working.
• The Mosher exercise: Lie on pad or floor on back. Three positions are assumed one after the other, continuing for 1-3 minutes. The positions are as follows: 1) Protrude the abdomen as high above plane as possible and hold for several seconds; 2) Relax abdominal muscles and assume “on plane” position; 3) Contract abdominal muscles to “hold in” abdomen for several seconds; 4) Relax and return to “on plane.”
• Reflex effleurage: Lie on back and gently massage colon. Begin with left hand over the cecum in the right lower abdominal quadrant. Follow the outline of the colon around the hepatic flexure. Change hands smoothly and continue around the splenic flexure, sigmoid and rectum. Repeat 8-10 times.
• Deep vibration to colon may be combined with reflex effleurage.
• Gentle percussion to colon, tapping, spatting, slapping.
• Digital kneading of colon, four times.
• Percussion to the lumbar spine.
• Exercises: winging and bridging: To do winging, lie face down on the floor, lift both the lower and the upper extremities, shoulders and head, off the floor behind your back, supporting the weight entirely with the abdomen. This exercise should be maintained for 3 seconds only on the first day. If no discomfort arises from having done the exercise, the second day may be advanced from one to three seconds. Continue advancing the number of seconds daily up to one minute. To do bridging, lie on your back on the floor, support the entire weight of the body on the heels and the shoulders by lifting the hips and thighs, head and arms, off the floor. This exercise should be maintained for 3 seconds only on the first day. If no discomfort arises from having done the exercise, the second day may be advanced from one to three seconds. Continue advancing the number of seconds daily up to one minute.
• Enema of cold water. Use a bulb syringe that will hold about 1/2 cup of water. Use cold water and only one bulb full. Use after each meal. Gradually the colon will be trained to empty itself after meals if the exercise is continued many weeks on a very regular schedule.

Directions for Brush Massage

• Use a stiff-bristle brush, but not so stiff that it will scratch the skin.
• Do the brush massage before the shower, while skin and brush are both dry.
• Begin brushing at the fingertips in long, slow strokes up to the shoulders. Cover all the skin on one hand and arm. Proceed to the other arm. Next, beginning at the toes, brush slowly all the skin up to the knees, then from the knees to the groin, from the low abdomen to the chest, from the shoulder to the waist. The strokes should be always moving from the most distant part toward the heart except the back which is brushed either from side to side, or in a sweeping arc. Reach every inch of skin possible, but go gently over tender areas or skin blemishes.
• Take a cool shower, ending in a cold water splash, for the finishing touch to the brush massage. It is necessary to use soap only on the hairy parts, hands, face, and feet. The use of much soap weakens the body's defenses against infection and dermatitis.