Originally published in Massage Bodywork magazine, August/September 2003.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.
The medical benefits of massage therapy in cases of
musculoskeletal abnormalities are gaining acceptance from health practitioners. However, another advance in cases of various inner organ disorders, as of yet, is not recognized. In an attempt to bridge the gap between the two developments, I, with the cooperation of Victor Gura, M.D. (an associate clinical professor at the UCLA School of Medicine), have conducted a pilot study using six subjects with diagnosed arterial hypertension. Ross Turchaninov, M.D. (medical massage practitioner) advised on the project's protocol.Chain Reaction
Medical massage therapy is a soft tissue mobilization method. Several factors explain its physiological effects. Medical massage creates a mechanical acceleration of venous blood flow and lymphatic drainage, mechanical breakdown of pathological accumulation (e.g., soft tissue calcifications), and passive exercise on soft tissues. By mobilizing the skin, connective tissue, muscle tissue and the periosteum, receptors located in these areas are stimulated, generating afferent electrical impulses. These impulses reach the central nervous system, stimulating the body to react via beneficial reflex mechanisms. The end results are vasodilation (resulting in decreased blood pressure and heart rate), increased arterial blood supply to tissues, muscular tension release and other healthful reactions.Explaining EH
The control of increased arterial blood pressure in those with hypertension is an important medical and social challenge. Hypertension is considered to be a major cause of heart attacks and strokes. An interesting fact, however, is that out of all hypertension cases, only 10 percent of patients have an established cause explaining their condition. For example, narrowing of the aorta, adrenal tumors or glomerulonephritis produces hypertension secondarily. In 90 percent of patients, the cause of hypertension is unknown. In such cases, the patient has "essential hypertension" or EH.
Modern conventional medicine recognizes an imbalance between the sympathetic and parasympathetic divisions of the autonomic nervous system as the initial trigger of EH. An increase in sympathetic tone produces arteriolar vasoconstriction with a subsequent increase in the peripheral vascular resistance. At the onset, these changes exhibit a transient character and the body uses self-regulatory mechanisms to restore the proper relationship between sympathetic and parasympathetic tones. This is why in earlier stages there are episodes of increased arterial blood pressure, without symptoms of hypertension. With time and repeated episodes of hypertension attacks, the body resets special receptors, called baroreceptors, in the arterial circulation to the new level, and the elevation of arterial blood pressure becomes sustained. As we have found, a correctly formulated protocol of medical massage therapy may play a critical role in controlling arterial blood pressure in some patients with EH.The Physiology
First, let's quickly review how medical massage therapy affects the arterial blood pressure in patients with EH. There are three major mechanisms which massage practitioners should use to help patients with hypertension: Balance the sympathetic and parasympathetic divisions of the autonomic nervous system, vasodilate the vertebral arteries and reduce peripheral vascular resistance. These three mechanisms are intimately correlated, hence the need to discuss them together as parts of the same process.
Vertebral arteries arise from the subclavian arteries. They ascend through the cervical vertebrae and enter the skull where they unite to form the basilar artery, supplying the posterior part of the brain. The vertebral arteries also give off two important arterial branches that supply the entire spinal cord: The anterior spinal artery and two posterior spinal arteries. The pathway of the vertebral arteries through the cervical vertebrae is quite complex. The transverse process of each cervical vertebra has a special opening called the transverse foramen through which the vertebral artery passes. Cervical vertebrae are positioned on top of one another such that these openings form a bony canal through which the vertebral arteries ascend.
The walls of vertebral arteries have their own sympathetic plexus innervation, regulating their constriction and dilation. It follows that any irritation to this plexus may result in their contraction. Even a minor facet joint subluxation, which may not even be visible by radiographic means, can produce an irritation slightly compressing the vertebral arteries. This constriction may lead to a reduced blood supply to the brain, which in turn will cause further vasoconstriction in an attempt to compensate for compromised circulation. The result is an inevitable increase in blood pressure or EH.
Other mechanisms that may cause a decrease in blood flow through the vertebral arteries are cervical spondylosis, emotional stress and physical overload of the neck and upper back muscles. As a result of these, a hypertonus develops in the cervical muscles. In order to maintain proper function, the brain's daily perfusion has to be approximately 2,000 quarts of arterial blood. This rate is regulated by special vascular receptors in the arterial structures of the brain. Even a minor reduction in the amount of blood circulation triggers compensatory reactions such as an increased heart rate, increased cardiac output and, most importantly, an increased peripheral vascular resistance.
Peripheral vascular resistance is a major opposing force to the heart's work. Every time the left ventricle ejects blood, the force of the cardiac contraction has to overcome the resistance of arterial vessels (especially on the level of middle-sized arteries in skeletal muscles). Thus, an increased sympathetic tone triggers arteriolar vasoconstriction, which increases peripheral vascular resistance, resulting in the heart having to work harder to pump blood.
The body has a protective mechanism designed to safeguard the blood supply to the brain. If circulation in the vertebral arteries decreases even slightly, peripheral vascular receptors report to the vasomotor center in the medulla oblongata and the heart rate increases. At the same time, motor (efferent) impulses are sent to the vascular structures in the skeletal muscles to constrict and decrease local arterial blood flow. This change allows for an extra amount of arterial blood to be available for the restoration of brain perfusion. The combination of an increased heart rate and an increased peripheral vascular resistance triggers hypertension. With a more persistent vasoconstriction of the vertebral arteries, the arterial hypertension becomes more enduring, resulting in higher systolic and diastolic blood pressure values. Treatment Method and Approach
The main objective of this pilot study was to determine whether or not the elimination of somatic abnormalities in the reflex zones would bring about an elimination of pain symptoms (neck, upper back and headaches), increased range of motion and hypertension reduction. This hypothesis was first proposed in 1973 by Professor Alexander Dembo of Leningrad. Unfortunately, his work was never fully embraced in the United States, hence my decision to replicate the pilot study in this country.
Six participants were involved: Two Caucasian females ages 34 and 54; three Caucasian males ages 42, 60 and 65; and a 32-year-old African American male.
All the research subjects were diagnosed with hypertension, combined with somatic abnormalities: Headaches, dizziness, pain and tension in the cervical and upper thoracic areas, referral of pain to the upper extremities, and range of motion restrictions in the cervical spine and shoulder joints. Diagnostic evaluation of somatic components revealed abundant abnormalities in the skin, connective tissue zones, skeletal muscles and the periosteum in the neck, anterior, lateral and posterior surfaces of the thoracic cage, as well as in the upper extremities. Each subject received a treatment every other day for a total of 15 treatments, followed by a two-week interim, and then an additional course of 15 treatments. Hemodynamic examinations -- cardio work, peripheral vascular resistance and blood pressure -- were conducted prior to the start of treatments and upon their conclusion.
The protocol for each session included three stages -- introduction, body of the work and conclusion. During the introduction stage of the session, treatment began by releasing tension in the cervical and upper shoulder muscles using medical massage techniques in the inhibitory regimen, a process of minimizing disconnection.
For example, every receptor has its own level of adaptation, which means its capability to produce electrical activities (also known as impulse or action potential). To work in the inhibitory regime means to minimize disconnection and to keep a rhythm of 70-80 movements per minute while gradually increasing pressure. Receptors will eventually not produce any more action potential, but the flow of afferent neural impulses from the contact area of our hands will continue. The motor and vasomotor centers include pain-analyzing systems, responding in vasodilation and dispolarization of the neuron, causing a reduction of pain sensation and muscular relaxation. This approach aimed at reducing the sympathetic tone and restoring balance between the sympathetic and parasympathetic divisions of the autonomic nervous system. During the main stage of the treatment, work proceeded toward cardiac reflex zones in the skin, connective tissue, skeletal muscles and periosteum according to the zone maps of physicians O. Glezer and V.A. Dalicho (see illustration at left and "The Development of Modern Medical Massage" on page 68). Direct massage influence was generated on the areas of the vertebral arteries. This bodywork included gentle pressure and circular motions on the localization of the insertion of the vertebral artery to the brain's circulatory system. Taking the distance from the mastoid process and C2 spinal process, the localization of this point will be one-third the distance from the mastoid process. By gently placing the finger there, the practitioner will be able to feel a pulse. Gentle, circular motion causes vasodilation of the vertebral artery, which originates from the sub-clavian artery. Now we have the capability to influence if we massage the area where the anterior scalene muscles insert into the first rib.
Peripheral vascular resistance (in the skeletal muscle groups of the upper and lower extremities) was reduced by using a combination of different kneading techniques especially designed for this purpose. In the final stage of the session, post-isometric muscular relaxation of the cervical musculature was applied. In cases of prolonged accumulation of pathological tonous in muscles, muscle fibers could be constricted creating an energetic imbalance inside the muscle. Any movement overloads the constricted part of the muscle, meaning that the more exercise is performed, the more pathology is accumulated. At the time of isometric tension (30 seconds), muscles will stretch instead of shorten, helping balance the tonous of muscles. After the 30 seconds, post-isometric stretching is performed, which additionally contributes to this balancing.Results and Discussion
It's important to remember that this pilot study was conducted to determine if more scientifically organized, double-blinded studies should be designed. Thus, results were not statistically examined due to the small group of subjects and are to be treated anecdotally. However, these results are important in that they open the door for discussion within the profession and give massage practitioners important information to discuss with other health practitioners.
At the end of the course of treatment, all subjects reported the disappearance of their somatic complaints. It was also evident, upon palpatory examination, that clinical symptoms were eliminated from reflex zones in the skin, fascia, skeletal muscles and periosteum. As originally expected, the elimination of somatic abnormalities was accompanied by normalization of blood pressure and restoration of proper hemodynamics in all participants. Potential Impact
The results of this pilot study provide the opportunity for the design of a larger double-blinded study that will be conducted under the supervision and participation of Gura. At this point, volunteer subjects are being sought to participate in this new study. Volunteers must have at least a six-month history of EH. The study will include those who are and are not already taking medications. Age and gender do not matter. Those enrolled will receive a complete physical examination, blood tests, hemodynamic reports and treatments at no cost. Researchers will also conduct diagnostic evaluations of somatic abnormalities in the reflex zone areas of the participants.
The potential impact of further studies is evident. More than 50 million Americans are suffering from EH, according to the U.S. Academy of Cardiology. Medications to control it have an array of side effects, including impotence in males. Add the enormous costs endured by individuals and insurance companies to treat it, and it's easy to see that massage, as performed in this pilot study, would be an inexpensive and welcome course of therapy. Since 1973, this massage method has been utilized in the former Soviet Union and proven to be very effective. If further studies in this country prove that massage therapy helps not only to reduce blood pressure but also to stabilize it, then the utilization of massage in treating people with high blood pressure will be recognized as a legitimate and effective alternative. Boris Prilutsky is director and senior instructor of the Institute of Professional Practical Therapy, School of Massage, Physical Therapy Aides and Chiropractic Assistants in Los Angeles, Calif. He has more than 30 years of clinical experience and 26 years in the area of massage therapy education. To reach him, write 1835 S. La Cienega Blvd., #260, Los Angeles, CA 90035 or e-mail firstname.lastname@example.org.