Connective Tissue Massage

Types of tissues in the body

1- Epithelial
2- Connective
3- Muscular
4- Nervous
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Epithelial tissue

• covers the body surface and forms the lining for most internal cavities. The
major function of epithelial tissue includes protection, secretion, absorption,
and filtration. The skin is an organ made up of epithelial tissue which
protects the body from dirt, dust, bacteria and other microbes that may be
harmful.
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Connective tissue

• is the most abundant and the most widely distributed of the tissues.
Connective tissues perform a variety of functions including support and
protection. The following tissues are found in the human body, ordinary loose
connective tissue, fat tissue, dense fibrous tissue, cartilage, bone, blood, and
lymph, which are all considered connective tissue.
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There are three types of muscle tissue

• skeletal, smooth, and cardiac. Skeletal muscle is a voluntary type of muscle

tissue that is used in the contraction of skeletal parts. Smooth muscle is
found in the walls of internal organs and blood vessels. It is an involuntary
type. The cardiac muscle is found only in the walls of the heart and is
involuntary in nature.
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Nerve tissue

• is composed of specialized cells which not only receive stimuli but also
conduct impulses to and from all parts of the body. Nerve cells or neurons are
long and string-like.
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Fascia

• is a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches, stabilizes,
encloses, and separates muscles and other internal organs.[1] Fascia is classified by layer, as superficial
fascia, deep fascia, and visceral or parietal fascia, or by its function and anatomical location.

• Like ligaments, aponeuroses, and tendons, fascia is made up of fibrous connective tissue containing
closely packed bundles of collagen fibers oriented in a wavy pattern parallel to the direction of pull.
Fascia is consequently flexible and able to resist great unidirectional tension forces until the wavy
pattern of fibers has been straightened out by the pulling force. These collagen fibers are produced by
fibroblasts located within the fascia.
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Definition

• CTM is a reflex therapy which utilizes a shear force at connective

tissue interfaces in the skin to stimulate autonomic nerve endings and to restore
balance between the sympathetic and parasympathetic components of the
autonomic nervous system (ANS). The strokes are applied to reflex zones
known as ‘Heads’s zones’ which can be seen and palpated.
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• The principles of CTM are based on the notion that "dysfunction of an internal
organ" can be diagnosed by "the increased tone of superficial muscles,
especially of the back", and "a changed character of interstitial fluid in the
subsutaneous tissues" along with "hypensensitivity to touch".
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History

• CTM was discovered by Elisabeth Dicke, a German Krankengymnast who had

become bedridden whilst awaiting amputation of her leg for severe arterial
insufficiency. To relieve her back pain, she massaged the painful area and realized
she had thickened, indurated tissue around her low back and buttocks. By pulling
at the affected tissues, she restored their mobility and her back pain resolved.
Surprisingly, the circulation in her leg increased and a digestive problem also
improved. The amputation no longer necessary.
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The reflex zones

The tissue changes recognized by Dicke were found to correspond to

the skin zones previously identified by Dr Head (Head 1889). The zones are present between
the dermis and hypodermis in acute states and between the dermis and fascia in chronic
states (Haase 1968). The changes may include trophic changes, swellings, thickenings,
indurations and hyperalgesia. They occur in the dermatomes which share the same segmental
distribution as the sympathetic supply of the associated organ (Holey 1995).
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• The zones reflect ‘facilitated segment’ activity as described by Korr (1979) and
Upledger (1989) in which irritation in any structure within a spinal segment facilitates
the synapses within it, thus altering the level of activity in other structures which share
the same segmental innervation (Fig. 2). The point of stimuli convergence is thought
to be the Wide Dynamic Range (WDR) neuron, originally isolated by Pomerantz et al.
(1968) and found in lamina V of the
spinal cord. These neurons respond to influences from viscera, muscle and skin and
hyperactivity in any of these structures would lower the synaptic threshold of the
WDR.
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Summary of CT zones
• CTM may be applied to three sections of the back: base, thoracic and cervical,
depending on the dysfunction to be treated (Figure 1a). For dysfunctions
involving pelvic organs, CTM is applied to the basic section. The basic section
CTM consists of the manipulation of the following regions: sacral, lumbar, last
thoracic vertebrae and subcostal region. Six different sets of strokes were used.
The strokes were short (approximately three cms) and long (approximately 10
cms). Each set of strokes was repeated three times, first on the right and then
on the left lumbosacral and dorsal regions.
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Connective Tissue Zone Palpation
Steps to follow
1- Place your fingertips on the edges of the zone and very gently and superficially
press the epidermis and dermis of the skin. If it allows indentation with a soft feel,
this indicates swelling. A slight ripple effect can sometimes be seen around the
therapists’ fingertips.
2- Using your finger pads, allow them to sink into the dermal layer, to target the
connective tissue underneath. Push the skin cephalad without sliding on top of the
skin. The skin should create small folds above your fingertips before you feel the
underlying resistance. In areas of considerable CT tension, little movement can
occur, and the skin tends not to fold. (Diagram A)
3- Gently grasp the skin between finger and thumb tips and roll the skin on
its connective tissue. In areas of underlying tension, it will not roll or pinch.
(Diagram B
• 4- Grasp the skin between the length of your finger and thumb and try and
lift it away from its supporting tissue. Tenderness or inability to lift indicates
zonal change. (Diagram C)
 Physiological effects
1- Local effects
• a) Release of histamine from mast cells which leads to a triple response, local
swelling and arteriolar dilatation mediated by local axon reflexes.
• b) The increased blood flow to the region assists the resolution of subacute or
chronic inflammation and reduces pain by removing nocigenic chemicals from
the tissues.
• c) The mechanical distortions produced by CTM strokes help to mobilize
connective tissue and improve function in much the same way as traditional
massage.
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2- General effects
• a) CTM appears to affect the parasympathetic and sympathetic systems
• b) CTM applied to the sacral region increased blood flow to the foot.
• c) This type of manipulation also appears to exert a powerful analgesic action.
Vigorous stimulation of cutaneous mechanoreceptors by CTM probably
activates the 'pain-gating' mechanism: i.e. it reduces discomfort by blocking
the transmission of information along small diameter peripheral sensory fibers
that carry pain to the ascending pathways in the spinal cord.
 Indications
1- CTM can benefit patients suffering from:
• a) Cardiac and respiratory diseases
• b) Peripheral circulatory deficits
• c) Neurological pathologies
• d) Gynaecological and obstetric problems
• e) Disorders of the digestive and urinary tracts.
2- CTM used primarily to relieve the symptoms of spinal and peripheral joint
dysfunction, osteoarthritis and rheumatoid disease, nerve root pain, sciatica and
neuralgia.
 Contraindications
• The contraindications to CTM are few. The most important include restrictions on
the treatment of patients with malignancy, acute inflammation or closed
abscesses, and those who are in the third trimester of pregnancy. Patients with a
history of hypotension or who are menstruating should be treated with
considerable caution.
 Skin response to CTM
• a) The expected skin response, described by Lewis in 1927 as the ‘triple response,
includes, sequentially, the appearance of a red line, then a red flush in the tissue if the
stroke is repeated in the same area, then a slight swelling of the tissue (wheal).
• b) The first reaction always occurs if there is tension in the tissue and the technique is
performed correctly, and the last two occur depending on the strength of the stimulus and
the number of stroke repetitions.
• c) The skin response decrease as tension in the tissue decreases.

• d) Bruising is a common reaction following the first two to four treatments and is not a
contraindication to treatment.
• e) Typically, the tissue remains sensitive for 2–3 days following treatment. After a series
of treatments, post-treatment reactions diminish
 Connective tissue techniques

• CTM uses a specialized stroke in which a gentle shear force is applied

to the connective tissue interfaces in the skin. A characteristic ‘cutting’
sensation is produced which is indicative of the fascial layer being stimulated.
The stroke must be modified to ensure that discomfort is not produced, i.e. it
should not be painful. To prepare the tissues for the fascial stroke, the skin
technique, the subcutaneous technique or the flat technique can be used.
 Connective Tissue Massage Strokes for each zone.

• (a) Fascial technique: the pad of the middle finger targets the facial layer
and exerts a shear force at the connective tissue interface. Flexion at
the same distal interphalangeal joint ensures the slack in the superficial
layers is taken up.
• (b) Skin (haut) technique: fingertips are brushed lightly along the skin.
• (c) Shallow (flat) technique: the skin is pulled towards the therapist by the
fingers and thumb tips are then placed under the fold, on the fascial layer, to
allow a shear force to occur.
• (d) Subcutaneous (unterhaut) technique: the subcutaneous layer is pushed
very gently and repetitively to desensitize tender tissues.
 Connective Tissue Massage Strokes for each section (basic-thoracic-cervical).

a) Short (approximately three cms)

• 1- Achieve adequate adherence of the pads of 3rd & 4th fingers to the skin, with the wrist leading
the mov, a slack is taken up in the superficial skin tissue and tension then applied to the deeper
CT.
• 2- This should be done without a sliding movement between skin & finger pads.
• 3- Sensation experienced by the patient may be cutting or scratching, but not be unduly
uncomfortable.
• 4- Short strokes are usually applied in a sequence (repeated consequentlly).
• 5- Number of repetitions depends on:
• 1. The effect achieved 2. Patient reaction
b) Long (approximately 10 cms)
• 1- Long strokes differ from short strokes in that: Movement is allowed between
finger pads & skin.
• 2- Again appropriate slack of sup. tissue taken up.
• 3- Fingers are drawn along surface with constant pressure and speed in a direction
→ apply appropriate tension to CT.
• 4- A mobile fold of tissue should precede the stroking fingers.
• 5- The effect of both short & long strokes will be:
- Physical as the CT is stretched.
- Reflex by the effect on the NS.
Strokes for basic section
• The therapist initiated CTM, using the index and middle finger of one hand,
alternating with the middle and ring fingers. The fingers were placed on the
skin at an approximately 45-degree angle and moved to cause traction, but
never forced through the tissue, controlling them with the shoulders and
upper hand.
• 1- The first set consisted of short strokes ending at the edge of the sacroiliac
joint and of the iliac crest (Figure 1b).
• the second group consisted of long strokes descending along the
border of the sacroiliac joint, towards the gluteal cleft (Figure 1c).
• the third group short strokes perpendicular to the spine and ending at the joint of
L5 with the S1 vertebrae (Figure 1d).
• the fourth three long strokes starting from the external border of the sacrum
and moving outwards. The first stroke passes close to the iliac crest, starting
at the transverse process of L5 and moving towards the anterior superior iliac
spine, where it comes to an end. The second starts at the widest part of the
sacrum, passes laterally and forward, and finishes in the same manner as the
first stroke. The third stroke starts at the gluteal cleft and passes forward
above the great trochanter and ends in same way as the first and second
strokes (Figure 1e).
• The fifth group consists of five short strokes, approximately, which move from
lateral to medial over the erector spinae area, following the space between the
transverse processes of the lumbar vertebrae (Figure 2a).
• - The sixth group is one long stroke, moving from medial to lateral following the
lower edge of the last rib (Figure 2b).