Chapter 6: Effects, Indications, and Contraindications of Massage (Notes)
Learning Objectives
Explain the physiologic effects and benefits of massage.
Describe the effects of massage on the skin.
Describe the effects of massage on the muscular system.
Describe the effects of massage on the nervous system.
Describe the effects of massage on the circulatory system.
Explain the psychological effects and benefits of massage.
List 17 conditions most frequently relieved by regular massage treatment.
Differentiate among absolute, regional, and conditional contraindications.
List at least six common contraindications for massage.
Identify the major endangerment sites on the body.
Why Study Effects, Benefits, Indications, and Contraindications of Massage?
The effects and benefits of massage are the main reason to practice massage therapy.
Understanding effects, benefits, and indications helps practitioners recruit and educate clients and promote massage therapy to the public and healthcare industry.
It is crucial to know when massage is detrimental or contraindicated, or when it is indicated with special considerations.
This knowledge underpins the design of a safe protocol tailored to each client and therapy session.
Introduction
Historical evidence suggests massage was one of the earliest remedial practices for pain relief and restoration of healthy body functions.
Massage is natural and instinctive for soothing minor aches, reducing nervous tension, and alleviating fatigue.
Since the mid-1990s, research has supported many long-held beliefs about massage benefits and clarified or dispelled other claims.
Terminology and Contraindications
A contraindication is a medical reason not to massage; a contraindication can be absolute, regional, or conditional.
Massage techniques vary (traditional Western/Swedish, neuromuscular, myofascial, etc.). Techniques and their effects differ by client needs, goals, and therapeutic intent.
Massage is generally safe for all ages (infants to elderly) with exceptions due to contraindications.
If there is doubt about whether to massage a questionable condition, refer to the client’s primary health care provider for written recommendations.
Discuss the Effects and Benefits of Massage
Physiologic and Psychological Benefits
Massage has direct physiologic benefits: increases metabolism, hastens healing, relaxes and refreshes muscles, and improves lymphatic function.
It helps prevent and relieve muscle cramps and spasms and enhances local fluid movement, promoting oxygen and nutrient delivery to cells.
Blood carries nutrients to the skin; massage supports normal, healthy skin function.
Massage assists in pain management for conditions such as arthritis, neuritis, neuralgia, labor and delivery, whiplash, sciatica, headaches, muscle spasms, and more.
A massage can have a primary effect on a target area with secondary effects (e.g., relaxation); it can be structural (e.g., ROM) or systemic (e.g., relaxation, anxiety reduction); may be cumulative with multiple sessions.
Psychologically, massage relieves stress, reduces anxiety and depression, calms the nervous system, and promotes relaxation, mental clarity, and renewed energy.
Massage is beneficial regardless of illness or injury, but in some cases a physician’s recommendations are required.
Physiologic Effects of Massage (overview)
Effects vary by therapeutic intent and individual, and precise mechanisms are not fully understood.
Massage can influence musculoskeletal, nervous, glandular, and vascular systems through direct mechanical effects and reflex responses.
Two physical effects: mechanical (direct tissue effects) and reflex (indirect responses via nervous/energy systems).
Gentle skin stimulation (e.g., superficial stroking) can produce local or distant reflex effects.
Pressure on reflex points or trigger points can influence other body areas beyond the contact point.
Immediate skin effects include friction and stroking increasing skin blood flow, slight reddening, warming, and improved nutrition.
Effects on the Muscular System
Muscles are primary targets for Swedish, neuromuscular, and myofascial techniques.
Mechanical effects: enhance local fluid uptake in muscles, deform sensory/proprioceptive endings, stretch/compress muscle and connective tissues.
Reflex effects: relax or reset muscle tone, cause hyperemia, and warm tissues.
Benefits include relaxing tense muscles, releasing spasms, reducing trigger point activity, and preventing/relieving stiffness.
Massage can help muscles heal after injury with fewer connective tissue adhesions and scarring when applied appropriately and regularly.
2011 McMaster University study: acutely damaged muscle tissue benefits from massage by reducing inflammatory cytokines; massage may reduce pain and stimulate mitochondrial production and cellular repair; massaged muscles showed increased genetic factors related to mitochondrial growth and repair and a 30% reduction in inflammatory factors, reducing cellular stress.
Massage is contraindicated during the acute inflammatory stage after soft tissue injury; once swelling subsides, massage supports healing.
Massage can release fascial adhesions, reduce hyperplasia (excessive connective tissue thickening), and improve range of motion after tissue injury.
Proprioceptive mechanisms (muscle spindle cells and Golgi tendon organs) can be influenced by massage to release muscle tension and reset muscle tone.
Note: A value cited is a 2011 study indicating a 30% reduction in inflammatory factors and stimulation of mitochondrial growth in acutely damaged muscle. See Crane, 2012 for details; acute inflammation is a contraindication to massage.
Effects on the Nervous System
The nervous system consists of the CNS (brain and spinal cord) and the PNS (nerves connected to the body).
The PNS includes the autonomic nervous system (ANS), cranial and spinal nerves, with somatic (motor) and sensory fibers.
Autonomic nervous system: sympathetic (fight/flight) and parasympathetic (rest/repair).
Sensory input to the CNS is processed, and responses are mediated by neurotransmitters and autonomic pathways to maintain homeostasis.
Massage movements can stimulate or soothe the nervous system depending on technique.
Stimulation techniques (which can be either stimulating or sedative):
Friction (light rubbing, rolling, wringing) stimulates nerves.
Percussion (light tapping/slapping) increases nervous irritability; strong percussion briefly excites nerve centers, prolonged percussion can anesthetize local nerves.
Vibration (shaking) stimulates peripheral nerve centers connected to the nerve trunk.
Gentle gliding and light friction can produce calming/sedative effects.
Ischemic pressure on a trigger point can desensitize the point and help release the reflex cycle maintaining muscle hypertension.
Autonomic Nervous System Effects
Massage effects on the ANS are mostly reflexive.
Sympathetic nervous system (SNS): prepares body to expend energy; increases heart rate, redirects blood flow to muscles, inhibits digestion and elimination, increases epinephrine/norepinephrine, activates sweat glands, increases alertness.
Parasympathetic nervous system (PNS): counteracts SNS; promotes rest, digestion, elimination, and increased circulation to internal organs; promotes relaxation.
The SNS response is often prominent with short, invigorating massage (e.g., pre-event, 15-minute chair massage).
Longer, relaxing massage tends to sedate the SNS and stimulate the PNS, reducing epinephrine/norepinephrine, lowering heart rate and blood pressure, and enhancing relaxation.
The body’s homeostasis is maintained by the balance of SNS and PNS activity.
Neurotransmitters and Hormones
Massage influences several neurochemicals:
Epinephrine/adrenaline and norepinephrine: elevated with stress/fight-or-flight; massage can reduce these with longer, relaxing sessions.
Dopamine: mood, motivation, and reward; massage can elevate dopamine, contributing to positive mood and alertness.
Serotonin: mood regulation, appetite, sleep, memory; massage can increase serotonin, promoting calm and well-being and countering anxiety.
Endorphins and enkephalins: endogenous analgesics; massage increases their levels, contributing to pain relief and an elevated mood.
Field et al. (1996) and TRI (Touch Research Institute) studies show reduced cortisol (stress hormone) and improved cognitive performance (math tasks) after regular 15-minute massages.
EEG findings: 15-minute massages twice weekly reduced beta activity and increased delta activity, associated with relaxation and improved performance on cognitive tasks.
Gate Control Theory and Pain Modulation
Massage can alleviate pain via the gate control mechanism: stimulation of larger-diameter fibers (thermo/mechanoreceptors) can inhibit pain transmission from nociceptors traveling on smaller fibers, reducing pain perception at the spinal cord level.
This mechanism helps explain how massaging a painful area can reduce pain sensations in the CNS.
Central sensitization: a CNS phenomenon where chronic pain arises or persists even after tissue damage subsides; massage can be helpful when pain is centrally mediated by soothing techniques.
Massage can reduce referred myofascial pain and ischemia-related pain by improving circulation and reducing hypertonic muscle tissue.
Proprioception and Feedback Circuits
Techniques such as compression, positional release, stretching, and targeted pressure alter proprioceptive feedback from muscle spindle and Golgi tendon organs, enabling new, pain-free ranges of motion.
Effects on the Circulatory System
Clinical massage affects blood and lymphatic circulation; increased local blood flow improves cellular nutrition and waste removal; reduces strain on the heart by improving surface circulation.
Short-term effects include temporary reductions in blood pressure and heart rate, with increased systolic stroke volume and capillary dilation/permeability.
Massage can influence vessel walls directly or via reflex vasomotor nerve activity, modulating blood flow.
Specific circulatory effects include:
1) Light gliding causes immediate capillary dilation.
2) Light percussion causes transient vasoconstriction followed by relaxation.
3) Friction increases capillary bed permeability and interstitial fluid flow.
4) Light massage can enhance lymph flow.
5) Compression can cause hyperemia in muscle tissue.Immune function: Touch Research Institute studies (1996) suggested massage may increase activity of certain immune cells (e.g., T4 cells) in HIV-positive individuals, indicating potential immune support.
Blood composition: massage has been associated with increased red and white blood cell counts in some studies.
Psychological Effects of Massage
Massage can contribute to a sense of health, invigoration, and energy.
It can support recovery and self-image in addiction treatment, sexual abuse survivors, and others by improving self-worth and reducing aversion to touch.
Regular massage is associated with reduced anxiety and depression in various populations, including adolescents with abuse histories.
Many people seek massage for psychological as well as physical benefits; it promotes relaxation, awareness of body States, and motivation toward healthier lifestyles.
Conditions Generally Relieved by Regular Massage (LO 5 & LO 6)
1) Stress and tension relief, improving coping with daily situations.
2) Mental and physical fatigue relief, with renewed energy and mental clarity.
3) Pain in shoulders, neck, and back from muscle strain or irritated nerves.
4) Improved muscle/joint suppleness; reduced soreness and stiffness.
5) Prevention/reduction of muscle soreness from overexertion.
6) Improved digestion, assimilation, and elimination.
7) Facial massage improves skin tone, helps prevent blemishes, softens fine lines.
8) Relief from headaches and eyestrain.
9) Deep relaxation and often relief from insomnia.
10) Relief of muscular spasms.
11) Obesity and flabby muscles improved when combined with exercise and proper diet.
12) Pain in joints and sprains relieved.
13) Increased relaxation and stress relief aiding healing.
14) Reduced mental strain, improved productivity.
15) Mildly high blood pressure temporarily reduced.
16) Reduction or prevention of adhesions as traumatized tissue heals.
17) Increased range of motion (ROM).
Contraindications to Massage
Absolute, Regional (Partial), and Conditional Contraindications
Absolute contraindication: massage is absolutely not appropriate (e.g., severe, uncontrolled hypertension; high fever; shock; acute pneumonia; toxemia during pregnancy).
Regional/Partial contraindications: massage is contraindicated only in the affected region (e.g., local contagious conditions, open wounds, acute neuritis or arthritis); other areas may be massaged.
Conditional contraindications: require adaptive adjustments; certain techniques may cause discomfort or adverse effects, but other modalities may be beneficial.
The practitioner should know when massage is advised, but more crucial is knowing when to avoid or modify strokes.
Consultation and Medical Release
Obtain information during the first interview regarding health status and contraindications via intake forms.
If contraindications exist, the client is typically under a physician’s care; secure written recommendations (precautions and indications).
The practitioner may consult with the physician with client consent to coordinate care and referrals.
If new conditions arise during the session, refer to a physician.
When in doubt, err on the side of caution and obtain a physician’s release before continuing.
Common Contraindications (Major List)
Major contraindications include abnormal body temperature, acute infectious disease, high blood pressure, cancer, fatigue, intoxication, skin problems, pregnancy, scoliosis, and others (as referenced in the text).
Abnormal body temperature: normal range typically 98.6°F (37°C); ranges may vary; temperatures over 99.4°F (37.4°C) generally contraindicate massage; fever indicates infection.
Acute infectious diseases (e.g., pneumonia, severe colds, influenza) contraindicate massage to prevent spreading infection and systemic aggravation.
Inflammation (itis conditions): acute inflammation contraindicates direct treatment of the inflamed area; reflex or proximal area work may be beneficial to stimulate circulation.
Inflammation from tissue damage: acute trauma with hematoma is contraindicated; once acute swelling subsides, massage can aid healing.
Inflammation from bacterial infection with pus pockets contraindicates massage due to risk of spreading infection.
Other major contra-indications include fatigue, intoxication, pregnancy in certain contexts, and conditions requiring physician oversight.
Endangerment Sites
LO 10: Identify major endangerment sites on the body.
Rationale: certain areas contain delicate underlying structures (nerves, vessels, major organs) that are vulnerable to deep manipulation; when massaging these areas, lighter strokes and alternatives are used.
Table 6-2 lists endangerment sites with locations and structures of concern. Figures 6-6 to 6-9 illustrate these sites.
Endangerment Sites Overview (Categories and Structures of Concern)
Lateral view of the head and neck (Figure 6-6):
Inferior to the ear; anterior triangle; posterior triangle.
Structures: Facial nerve, external carotid artery, styloid process; Carotid artery, internal jugular vein, vagus nerve, and lymph nodes; Brachial plexus, subclavian artery, brachiocephalic vein, external jugular vein, and lymph nodes.
Axilla to medial arm to cubital area (Figure 6-7 to 6-8):
Axilla (armpit): Axillary, median, musculocutaneous, and ulnar nerves; axillary artery; axillary nerve and lymph nodes.
Medial brachium (upper inner arm): Nerves (ulnar, musculocutaneous, median); brachial artery; basilic vein; lymph nodes.
Cubital area (elbow front): Median nerve, radial and ulnar arteries, and median cubital vein.
Ulnar notch of elbow (ulnar nerve area near “funny bone”).
Posterior view of trunk and lower extremities (Figure 6-8):
Medial brachium; lumbar area; ulna notch; popliteal fossa; posterior knee region; tibial nerve, common peroneal nerve, popliteal artery, popliteal vein.
Kidneys (avoid heavy percussion in renal area).
Trunk and lower extremity anterior view (Figure 6-9):
Femoral triangle (bordered by sartorius, adductor longus, inguinal ligament): Structures include femoral nerve, artery, vein, great saphenous vein, and lymph nodes.
Abdomen: Upper area under the ribs; right side includes liver and gallbladder; left side includes spleen; deep center includes aorta.
Conditions, Medications, and Special Considerations
Medications and Massage (MASSAGE CORNER 6.1)
Medications may influence massage technique and safety; the therapist should know effects and side effects of common drugs.
Categories and cautions (examples):
Analgesics (narcotic): May blunt client feedback; risk of injuring tissue if force is excessive because client may not perceive movement accurately.
NSAIDs: Deep techniques may cause bruising; caution with deep gliding, kneading, friction, and ischemic compression.
Anticoagulants: Thinning of blood; deep techniques may cause bruising or excessive soreness; use gentle techniques or avoid deep manipulation.
Antidiabetic medications: May indicate poor circulation and slow healing; adjust pressure; monitor for signs of hyperglycemia.
Muscle relaxants: May dull feedback; over-stretching risk; use gentler techniques.
Steroids: Long-term use can weaken connective tissues; caution with deep friction, skin rolling, joint movements, and stretching.
Some medications require physician release before massage (e.g., narcotics, antipsychotics, cancer medications).
The therapist should track side effects like drowsiness, dizziness, low blood pressure, etc.
Resources for drug information: reputable drug references and websites.
Skin Contraindications (Table 6-1)
Contraindications related to the skin include: Acne, boils, impetigo, inflammation, broken vessels, lacerations, bruises, lumps, burns and blisters, rashes, carbuncles, hypersensitive skin, scaly spots, scratches, skin cancer, skin tags, sores, stings and bites, tumors, warts, wounds.
Most skin-related contraindications are local; contagious conditions contraindicate massage of any area.
Endangerment Sites (revisit)
See above; essential to adapt techniques in these areas to lighter strokes or avoid deep work to protect nerves, vessels, and organs.
Specific Conditions and Cautions
Osteoporosis: Fragile bones; massage must be tailored and physician-approved; avoid aggressive manipulation.
Varicose veins: Valves can be compromised; avoid deep massage proximal to varicosities; superficial techniques may be used with caution; avoid deep massage near affected veins to prevent emboli.
Phlebitis and thrombophlebitis (DVT risk): Avoid deep massage over inflamed veins; risk of embolus.
Hernia: Massage should not be performed directly over the herniated area; caution around the region.
Scoliosis: Massage should be physician-approved; exercise caution due to spinal curvature.
Frail older adults: Gentle massage can be beneficial; consider fragility and polypharmacy.
Pregnancy: Prenatal massage has benefits in normal pregnancies but requires physician clearance, especially in the first trimester (risk of miscarriage); first trimester massage is often postponed; positioning adjustments in later trimesters (side-lying or semi-reclining); avoid abdominal deep massage or prone positioning.
Cancer: Conditional contraindication; massage can be safe and beneficial with physician coordination and tailored approach; refer to Chapter 19 for cancer contexts.
Edema and lymphedema: Edema can be due to venous backpressure or systemic causes; pitting edema is a contraindication for local circulatory massage; lymphedema requires lymph drainage techniques (e.g., manual lymph drainage) with physician oversight.
Fatigue: In chronic fatigue, massage should begin very light and gradually build; aim to restore energy over time.
Intoxication and psychosis: Contraindications; refer to physician; medication considerations require physician release and monitoring.
Endangerment Sites – Practical Summary (Table 6-2)
Head and neck: Inferior to the ear; anterior triangle; posterior triangle; notable nerves and vessels include facial nerve, carotid arteries, jugular veins, vagus nerve, brachial plexus, and associated lymphatics.
Axilla to arm: Axilla contains major nerves and vessels (axillary nerve, brachial plexus branches); medial brachium contains nerves and vessels; cubital area involves the elbow and forearm nerves/arteries.
Elbow and forearm: Ulnar nerve proximity at medial elbow; potential for nerve compression if massaged improperly.
Trunk: Posterior and anterior trunk—risk around intercostal spaces, liver, gallbladder, spleen, aorta; abdominal region near the liver and spleen requires caution.
Lower extremities: Popliteal fossa, posterior knee, tibial and peroneal nerves; femoral triangle and inguinal region contain major vessels and nerves; kidney regions require cautious percussion.
These sites require lighter pressure and technique modification to avoid nerve injury, vascular compromise, or organ trauma.
Chapter 6: Practical Considerations and Applications
Always tailor massage to the individual client’s health status, medications, and contraindications.
Use a clinical reasoning process to plan a safe, competent massage experience (LOG ONTO bonus.milady.com/ for resources).
Emphasize a teamwork approach with physicians when applicable, especially for clients with chronic conditions, pregnancy, cancer, or recent surgeries.
Therapeutic touch should aim for a balance between safety and effectiveness; the goal is to maximize benefits while minimizing risks.
Quick Reference: Key Numerical and Factual Details
Normal body temperature: T_{normal} \approx 98.6^\circ\mathrm{F} \;(= 37^\circ\mathrm{C}) ; often cited range 96.4^\circ\mathrm{F} \le T \le 99.1^\circ\mathrm{F} \;(35.8^\circ\mathrm{C} \le T \le 37.3^\circ\mathrm{C})
Fever generally contraindicates massage; higher end of 99.4°F (37.4°C) often considered non-ideal for massage.
30% reduction in inflammatory factors observed in a McMaster University 2011 study on acutely damaged muscle tissue (organizing inflammation and repair processes).
A key study at the Touch Research Institute (Field et al., 1996) reported reductions in cortisol, improved EEG patterns (reduced beta, increased delta), and improved math performance after regular short massages.
15-minute massage sessions twice weekly produced measurable neurochemical and cognitive benefits in TRI studies.
Neurotransmitters/hormones of interest: epinephrine (adrenaline), norepinephrine, dopamine, serotonin; endorphins and enkephalins as natural analgesics.
Gate control theory (Melzack & Wall, 1996) explains pain modulation via large-fiber stimulation blocking nociceptive input at the spinal cord level.
Summary: Core Takeaways for Exam Preparation
Massage has multifaceted benefits: physiologic (circulation, metabolism, tissue healing), nervous system modulation (SNS/PNS balance, reflexes), endocrine/neurochemical changes (endorphins, serotonin, dopamine), and psychological improvements (stress reduction, mood).
Therapeutic massage requires careful consideration of contraindications: absolute (cannot massage), regional (local areas avoided), and conditional (techniques adjusted or avoided with certain conditions).
Endangerment sites require special technique adjustments to protect nerves, vessels, and organs; clinicians should be able to identify these sites and choose safer alternatives.
Medication interactions and patient health status must guide technique selection and intensity; physician releases and interdisciplinary communication are critical in complex cases (cancer, pregnancy, cardiovascular issues).
Regular massage can relieve a broad range of common issues, especially stress, fatigue, pain, and ROM limitations, highlighting its value as both a therapeutic and preventive modality.