YMCA Level 3 Diploma in Performance Massage

Diploma in Performance Massage Manual

Diploma in Performance Massage

Manual

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YMCA Diploma in Performance Massage

In this manual you will learn:

• Further anatomy and physiology for performance massage

• Massage professional practice

• Understand the principles of soft tissue dysfunction

• Assessing clients and treatment planning

• Application of performance massage

• Providing post-treatment care advice.

Section 1: Further anatomy and physiology for performance massage

This section will cover the additional anatomy and physiology knowledge required by fitness professionals if they are to provide safe, predictable, and effective massage

Structural organisation of the human body

The body has six levels of structural organisation (in size order smallest first)

Chemical

The body is made up of chemicals, e.g., oxygen, carbon dioxide, hydrogen. Different chemicals combine to form the various molecules of the human body, e.g., water, carbohydrates, protein, DNA.

Cellular

The most basic structural and functional unit of life. Cells are the building blocks of the human body and capable of performing functions essential to life, e.g., muscle cell, nerve cell, blood cells

Tissue

A collection of two or more cells of similar function or origin which are grouped together to form a specific function, e.g., nervous, muscular, epithelial, and connective tissue.

Organ

Two or more major tissue types which perform a specific role or function for the body, e.g., heart, lungs, liver. kidneys, skin

System

Two or more organs, each with its own specific function, working together to achieve a common purpose (e.g., cardiovascular, digestive, skeletal, muscular, circulatory, respiratory, nervous, endocrine, urinary, reproductive.

Organism

All the organ systems function together create an individual form of life, such as a plant, animal, bacterium, protist, or fungus

Structure of a human cell

Structure

Nucleus

Cell membrane

Nucleolus

Ribosomes

Vacuoles

Centrosome

Golgi apparatus

• Control centre of the cell.

Function

• Contains most of the cell's genetic material

• Separates the interior of all cells from the outside environment.

• To make ribosomes

• Combine amino acids to build proteins.

• Ribosome is a tiny structure which processes genetic instruction (from nucleus) to create proteins. It is the protein factory of the cell combining amino acids to build proteins.

• Regulates the cell cycle (division).

• Modifies, sorts and packages proteins for secretion.

Mitochondria

• Energy conversion/production of ATP

Lysosomes Digestion

Vesicles

Cytoplasm

Endoplasmic reticulum

Material taken up from outside the cell. Obsolete components of the cell itself

• Transportation of material into, out of or within the cell

• Fluid that fills a cell

• Provides a surface area for chemical reactions

• Permits transport of cellular materials.

Types of human tissue

Tissue type Structure

Epithelial tissue

• Closely packed cells arranged in 1 or more layers

• Covers the body surface.

• Provides a lining for most cavities and hollow organs

• Composed of epithelial cells.

Function

• Major tissue that form glands

• Functions include protection, secretion, absorption, excretion, filtration, diffusion, sensory reception.

Glandular tissue

• Lines the interior of various bodily structures

• Secretes bodily products such as sebum and hormones such as insulin.

• Mucous membrane lines the interior walls of tubes that open to the outside of the body.

• Serous membranes cover organs and line body cavities.

Membranes

• Synovial membranes line freely moveable joint cavities

• Meninges cover the brain and spinal cord.

Lymphoid tissue

• bone marrow

• thymus

• white blood cells

• spleen

• lymphocytes

• lymph nodes

• Functions as part of the immune system to help protect body from infection and foreign bodies.

• bone

• cartilage

• blood

• contains protein fibres such as elastin, collagen, reticular

Connective tissue

• nerves

• brain

• spinal cord

• Bind structures together, provides support and protection, fills spaces and stores fat.

• Gives structure to tissues and organs.

• Provides a medium for nutrients and oxygen to diffuse between tissues and organs.

• Helps repair damaged tissue.

• Forms a communication network by conducting electrical signals across tissues

• Initiates and /or conducts nerve impulses

Nervous tissue

Muscle tissue

• cardiac

• smooth

• skeletal

• Respond to stimuli

• Regulates and controls bodily functions and activity

• Role in emotions, memory & reasoning

• Ability to shorten and contract to produce movement of body parts

Structure and functions of the skin

The skin is the largest organ of the body forming a versatile, waterproof covering that serves as the first line of defence against injury or invasion by hostile organisms and infectious bacteria. It is referred to as the integumentary system.

Structure of the skin

The skin can be divided into two main parts:

• Epidermis

The epidermis consists of five layers/divisions (horny, clear, granular, prickle cell, basal) making up the outer layer of the skin that protects the dermis below. It contains no blood or lymphatic vessels but is pierced by hairs, the follicles of which allow the secretion of sebum onto the skin and sweat ducts. Production of skin cells begins in the deepest layers pushing the cells above them up towards the surface. As the cells move away from the base layers they die, fill with the protein keratin which hardens as the cells reach the surface.

• Dermis

The three divisions of the dermis are much thicker than the epidermis and are mainly formed by connective tissue (elastin and collagen fibres). This very tough tissue contains various structures such as hair follicles, sweat and sebaceous glands, fat cells, nerves, blood, and lymphatic vessels.

Functions of the skin

• Protection from infection due to the presence of keratin and protection from injury via reflex responses to stimuli.

• Regulation of temperature as sweat gland activity and vasodilation of superficial vessels is stimulated to allow heat loss through convection, conduction and radiation. The need for heat conservation will result in vasoconstriction of superficial vessels. Hair attempts to trap a layer of air next to the skin to slow down convection and involuntary contraction of muscles produces heat

• Excretion of sweat which is 99% water and 1% salts

• Sensation as the outermost organ detects the stimuli of temperature, pressure, touch, and pain

• Secretion of sebum to lubricate and protect the skin by making it acidic

• Formation of chemicals including Vitamin D (for calcium utilisation) and melanin (to protect underlying structures from UV radiation, i.e., suntan)

Structure and functions of the lymphatic system

The lymphatic system is part of the vascular system and is often referred to as the secondary circulatory system.

Definitions

• Lymph

Interstitial fluid derived from the blood now travelling within the lymphatic system where it is filtered and returned to the bloodstream.

• Lymphatic system

A network of vessels transporting lymph from the tissues to the bloodstream.

• Lymph node

Small round structures located along the vessels through which lymph flows.

• Lymph nodule

Small deposits of lymphatic tissue producing lymphocytes.

• Lymphocyte

A type of white blood cell involved in immunity and the production of antibodies.

Structure of the lymphatic system

The lymphatic system is a system which transports lymph. It begins from the tissues with blind-ended capillaries and ends at the left and right subclavian veins. The lymphatic system has two main layers of circulation; the superficial circulation which is located just below the skin and the superficial fascia (60% - 70%) and the deep muscular and visceral circulation

• Lymphatic capillaries

These begin in the tissues forming a dense network of large, single cell thick capillaries. The overlapping cells create one-way valves and tissue fluid can easily diffuse into these low-pressure, blind-ended tubes. Once tissue fluid is inside the lymphatic capillaries, it is known as lymph. Lymph is transported from the capillaries which join up to form vessels.

• Lymphatic vessels

As with the circulatory system, back flow of lymph needs to be prevented and so the vessels have nonreturn valves. The vessels continue to merge forming larger trunks and into two main ducts These two ducts are called the right lymphatic duct and the thoracic duct, where lymph will be returned to the blood.

• Lymphatic nodes

These are small oval shaped structures of specialised lymphatic tissue surrounded by a capsule The nodes are located along the network of lymphatic vessels through which the lymph will flow. Lymph nodes filter lymph and produce and store lymphocytes. Lymph nodes have more vessels entering (afferent) than leaving (efferent) in order to slow lymph flow. This aids lymphocytes in removing pathogens (fighting infection).

• Lymphocytes:

These are white blood cells involved in immunity and the production of antibodies. The lymphocyte’s main function is to prevent harmful pathogens (bacteria and viruses) from gaining access to the bloodstream. They also begin detoxifying waste products before they re-enter the blood.

Lymphocyte production is stimulated by:

1. the presence of harmful pathogens

2. an increased flow of lymph through the nodes.

In the event of infection the nodes can increase in size because larger numbers of lymphocytes are produced. This can cause the nodes to become tender.

• Lymph nodes:

These appear in major clusters. Lymph node clusters can be found around joints. As the joint moves it aids in assisting the pumping of lymph through the system.

Occipital

Back of the neck

Axillary In and around the armpit

Cubital Crook of the elbow

Inguinal

Anterior aspect of the groin area

Popliteal Posterior aspect of the knee

Spleen (Lymphatic organ)

Functions of the lymphatic system

There are three functions of the lymphatic system:

Left side of the abdomen inferior to rib cage

• Remove excess fluid from the tissues (oedema) and return it to the bloodstream. The lymphatic system plays an important role in reducing oedema (excess tissue fluid), maintaining blood viscosity and vascular homeostasis.

If the excess tissue fluid wasn’t removed and returned to the blood:

• The blood would become gradually more viscous (thick and sticky).

• The tissues would become more swollen.

• Filter fluid to prevent infection of the blood and tissues.

• Aid digestion via the absorption of lipids from the small intestine.

Capillary – tissue exchange:

Blood circulates through the vascular system. Blood travels in various sized vessels to supply all the tissues of the body with nutrients and oxygen and to remove waste products. Capillary beds in the tissues slow the flow of blood to achieve optimal contact time with the fluid that fills the interstitial tissue space

Plasma from the capillaries moves into the tissues. This fluid is referred to as interstitial or tissue fluid and it bathes all the cells of the tissues.

It is via the tissue fluid that nutrients and waste products pass between the blood and the cells. The differing concentrations in the two areas allow exchange to take place (diffusion). The blood is rich in nutrients and oxygen so these diffuse into the tissue fluid where concentrations are very low but where levels of carbon dioxide and metabolites will be high. Consequently, carbon dioxide and metabolites will be pulled back into the capillaries where concentrations of waste products are low.

Most, but not all, of the tissue fluid passes back into the circulatory system. However, some molecules will be too large to re-enter the blood capillaries, or the concentration gradient may not be suitable to allow this to happen. Any remaining fluid will drain into lymphatic capillaries.

Structure and functions of the urinary system

The urinary system (also known as the renal system) produces, stores and eliminates the fluid waste excreted by the kidneys (urine).

The kidneys

• Structure

These are two bean-shaped organs which are approximately 10cm long, 5cm wide and 2.5cm thick. They are positioned against the posterior abdominal wall at the normal waistline, with the right kidney slightly lower than the left.

The kidneys consist of three principal parts

o the cortex or outer layer

o the medulla or middle portion

o the pelvis, which is the hollow, inner portion from which the ureters open.

• Function

o Filter waste products from the blood

o Produce urine.

As blood circulates in the kidneys, a large quantity of water, salts, urea and glucose filters through them. All the glucose, most of the water and salts and some of the urea are returned to the blood vessels - the remainder passes into the kidney pelvis as urine. The kidneys process approximately 150 - 180 litres of fluid each day but only about 1.5 litres of this leaves the body as urine through the ureter.

The ureters

• Structure

These are two slender muscular tubes 26 - 30cm long

• Function

The ureters carry urine from the kidneys to the bladder.

The bladder

• Structure

The bladder is a very elastic muscular sac lying immediately behind the symphysis pubis. It has a capacity of approximately 600ml, although the desire to urinate is experienced when it contains 150ml.

• Function

The bladder stores urine until excreted through the urethra.

The urethra

• Structure

This is a narrow muscular tube passing from the bladder to the exterior of the body. The female urethra is 4cm long and the male urethra is 20cm long.

• Function

The urethra carries urine from the bladder out of the body.

Section 2: Massage professional practice

This section will cover the professional and legal responsibilities when applying massage.

Legislation in massage Data Protection Act 2018 (DPA 2018)

The Data Protection Act 2018 is the UK's implementation of the General Data Protection Regulation (GDPR).

Everyone responsible for using personal data has to follow strict rules called 'data protection principles'. They must make sure the information is: used fairly, lawfully and transparently.

It covers all the guiding principles to be observed during personal data processing: lawfulness; fairness and transparency; purpose limitation; data minimisation; accuracy; storage limitation; integrity and confidentiality; and accountability.

You should follow correct data handling procedures when storing your clients’ personal information. Information should be stored in a locked filing cabinet as hard copies or password protected if stored on a computer. If you stop using your computer to hold client information, then this information must be professionally wiped. Hard copies must be destroyed in line with GDPR requirements by using a registered shredding company.

You should also take steps to maintain client confidentiality. You should protect your clients’ anonymity by not sharing any of their information with third parties.

Your clients have the right under law to access their own therapeutic records so you should take care to keep them accurate and up to date. Records may also be needed for reference in legal proceedings.

The Health and Safety at Work Act (1974)

The Health and Safety at Work Act is concerned with the safe working practices for all staff whether employed or self-employed. The act applies to anyone who enters the premises. A safe working environment includes equipment, systems of training and work and personal protection. You should make sure that you are following health and safety executive (HSE) guidelines These guidelines should be displayed in your place of work.

Workplace Health, Safety and Welfare Regulations (1992)

The workplace regulation is concerned with the health and safety of the actual workplace, e.g. toilets, hand washing facilities, supply of drinking water, general cleanliness, working temperature, ventilation and resting facilities. It’s vital to maintain a high standard of hygiene and cleanliness in your working environment as well as your own personal hygiene.

Management of Health and Safety at Work Regulations (1999)

The Management of Health and Safety at Work Regulations is concerned with ensuring risks and hazards are minimised though risk assessments and provision, e.g. procedures for emergency situations. This includes ensuring there are competent and trained staff to undertake risk assessments. All risk assessments should be completed and up to date.

First Aid at Work: Health and Safety (First-Aid) Regulations (1981)

The first aid regulations apply to all workplaces regardless of the number of employees. It also applies to the self-employed. The regulation is concerned with providing adequate and appropriate equipment, facilities, and personnel to ensure individuals receive immediate attention if they are injured or taken ill at work

Duty of care

By law, a ‘duty of care’ must be shown to all clients A duty of care can be described as follows:

‘‘…a person act toward others and the public with watchfulness, attention, caution, and prudence that a reasonable person in the circumstances would. If a person's actions do not meet this standard of care, then the acts are considered negligent, and any damages resulting may be claimed in a lawsuit for negligence.’’ Collins Dictionary of Law (2006)

Working with children and vulnerable adults

If you are working with children (under 18) and vulnerable adults, you MUST have a chaperone present. A chaperone acts as a safeguard for both you and the other party and is a witness to the conduct and the continuing consent of the procedure. They also provide protection to healthcare professionals against unfounded allegations of improper behaviour.

The presence of a chaperone helps make sure that the child or vulnerable adult fully understands and consents to examination and treatment and in some cases may act as a signatory for informed consent, e.g. if the client is underage or a vulnerable adult. You may not treat anyone under the age of 18 without written consent from a parent or guardian.

Informed consent

Informed consent is a legal requirement, and it is essential that you work within the boundaries of informed consent. No matter your intention, to examine and/or treat someone without their express permission may be considered assault or an invasion of privacy.

For informed consent to be valid then consent should be given:

• Voluntarily, i.e. the decision should be freely given by someone without the influence or pressure from any person.

• With capacity, i.e. the person must be able to understand the information presented and can use it to make an informed decision

• Informed, i.e. the person must be given all the information about what the treatment involves. This includes benefits, risks and treatment options. For example:

o The proposed treatment and purpose related to subjective and objective assessment

o Benefits and any risks of the proposed treatment and how the treatment may feel

o The results that may be expected.

o Frequency and duration of treatments

o Alternative treatment options

Informed consent is required to be obtained before and after subjective and objective assessment and before commencing treatment. Treatment may be stopped at any time by the client It is good practice to record the reason why treatment stops.

Consent should be given in writing by obtaining a signature of the client assessment record. It will also be given verbally throughout the treatment process.

Process of informed consent

Explain the reasons for informed consent

Inform the client of treatment aims and objectives, benefits and risks of treatment.

Provide the opportunity for the client to ask questions and respond to questions

Record and sign all information

Store written informed consent securely and confidentially.

Legal consequences

The consequences of noncompliance with legislation and professional standards can be serious. They may include:

• Legal proceedings against you and prosecution or liability claims

• Invalid insurance

• Loss of professional membership

• Loss of right to practice

• Personal injury to clients

• Breach of professional codes of conduct

Scope of practice within massage

Cautions and contraindications to massage

Cautions and contraindications are conditions to be taken into consideration when carrying out a massage treatment.

A caution is a situation in which a massage practitioner may proceed with the treatment but will need to modify techniques with due regard to the client’s condition or needs.

A contraindication is where the risks outweigh the benefits for treatment. There are two types of contraindications:

• Local – when certain areas of the body should be avoided.

• Systemic – when treatment on the client should not be carried out.

The table below shows conditions that your clients may have, what you should do and possible consequences to any treatment.

Diabetes

Systemic Refer to GP

Massage may be possible but medical advice should be sought before treatment

Severe pain

Local/systemic

Refer to appropriate service GP, 111, Minor injuries, A & E

Inappropriate treatment, deterioration of condition

Impetigo

Any condition of which the therapist is unaware of how massage will affect it

Local/systemic Refer to GP Spread infection as contagious

Local/systemic Refer to GP

The massage therapist has a duty of care to the client- so if in doubt, they should refer.

Referral procedures when working with other professionals

You have a professional responsibility to constantly review, amend or cease the treatment process and understand when you need to refer another professional.

Referral may be required, if for example:

• contraindications are identified

• treatment is not working

• client needs are outside limits of professional knowledge or responsibility

• client needs are outside scope of practice.

Procedure for referral

Gain informed consent from the client (review the information in the client record form and liaise with the referring healthcare professional).

Exchange the client record form with the referring healthcare professional

Review the assessment and treatment information with the client.

Update the assessment information and produce a treatment plan

Establish a method for updating the referring healthcare professional of any progress.

Communication

‘‘…ineffective communication is the most frequently cited category of root causes of sentinel events. Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety.’’

The Joint Commission (2007) National Patient Safety Goals.

With your client

When working with clients, you should:

• Demonstrate that you value equality and diversity, including respect for:

o gender

o ethnicity

o religion

o physical and mental ability

o sexual orientation and status.

• Always maintain a professional appearance and manner

• Ensure client confidentiality. This includes protecting client anonymity and making sure client data is protected and not passed on or intercepted by third parties. It is unprofessional, unethical and a breach of client confidentiality to discuss any aspect of your clients care without permission.

With a healthcare professional

When dealing with other healthcare professionals it’s important to:

• Act in a professional manner including language used in letters and attitudes to other types of professionals.

• Communicate in a professional manner (verbal and non-verbal body language).

• Respectful of individual responsibilities.

• Open to the opinions of others.

• Receptive to suggestions, comments and constructive criticism.

• Respond in a timely manner.

You should keep records which are:

• accurate

• detailed

• unambiguous

• consistent with expected best practice

Standards relevant to the massage profession

Professional standards: key principles

The key principles of professional standards as set out by massage membership organisations include:

• Complementary and Natural Healthcare Council (CNHC) www.cnhc.org.uk/

• General Council For Massage Therapists (GCMT) www.gcmt.org.uk/council-members.html

• Institute of sport and remedial massage (ISRM) www.theisrm.com/about_us.php

• Sports massage association (SMA) www.thesma.org/

The role of professional organisations

Professional organisations establish and maintain the ethical, professional and educational standards for massage. They help give confidence to the general and sporting public, the medical profession and government agencies that massage therapists are suitably trained to provide a quality service.

They also support and promote members and their profession. Their main functions include:

• Holding national registers for massage therapists

• Supporting and promoting members and their profession

• Establishing and maintaining ethical, professional, and educational standards

• Making sure the best possible massage care is available to sports and non-sports people

• Promoting and developing programmes of continuing professional development (CPD)

• Keeping members informed of the legislative developments in complementary medicine, education and training.

• Promoting and developing work opportunities with other sport and medical bodies.

• Negotiating professional indemnity insurance (rates and cover) for members.

• Obtaining membership discounts for other products and services.

The purpose of regulation

Regulation is key to protecting the public, establishing minimum requirements and setting standards. Regulation ensures that the following principles are applied:

• Proportionality - the profession is governed by fairness and justice.

• Accountability - therapists are held to a standard by clients, peers, and the profession.

• Consistency - therapists offer a similar and high level of practice and approach.

• Transparency - the methods used are clear and open to regulation and critique.

Continuing professional development (CPD)

Continuing professional development is key to personal development and maintaining your skills and experience in your professional life.

You can do this through further training and education. It may also be a professional requirement depending on your role. CPD allows you to keep up to date with developments, follow the latest research and gain awareness of different or divergent views.

Emergency situations

Depending on where you are working, you will have certain responsibilities and a protocol to be followed in the event of an emergency.

• Home/clinic – Whether you are working in either your own clinic or your client’s home, you will need to have a policy or manual for emergency situations, e.g. medical, fire, electrical etc. You should have had therapist first aid training, child and vulnerable adult training (if appropriate). You should also have a lone worker policy and appropriate insurance. You must provide access to a first aid box and a telephone You must also make sure the home is compliant with health and safety regulations.

• Organisation – When working in an organisation you must make sure your clients understand organisational policies and procedures and health and safety. You will also need to make sure you have details of both their and your own insurance coverage. You will also need to make sure you and your clients know where the telephone and the first aid kit can be found.

• Event – If you are working at an event then you need to make sure you understand the event organisers’ policies and procedures and follow their health and safety regulations. You should also agree protocols with the organisers before the event and make sure you have appropriate insurance coverage.

• Outdoors – When working outdoors, you should have protocols in place before the treatment. You need to be compliant with health and safety regulations, make sure you have the correct insurance and provide your clients with access to first aid.

Principles of professional practice in massage

The importance of valuing equality and diversity in professional practice

The importance of valuing equality and diversity when working with clients includes:

• The removal of barriers and fair access to treatment

• Establishing rapport, trust and confidence.

• Adopting a nonjudgmental approach which maintains respect and dignity.

• Respecting the views and beliefs of clients (gender, ethnicity, culture, sexuality, age, lifestyle, social status) and compliant with equality and diversity legislation

• Ensuring fair treatment through equal opportunities.

• Meeting individual needs and requirements

• Providing a safe, supportive, and welcoming environment

The importance of insurance Insurance requirements

To practice massage, you should have professional liability and professional indemnity insurance.

In the event of a client suing for compensation because of a treatment, this will help pay for:

• Your legal defence.

• Any damages awarded.

• CPD may also be a requirement of insurance coverage.

You should have public liability and professional indemnity insurance. This ensures that if somebody make a claim against you in the event of an accident in your treatment environment (or have a reason to claim against you) you will have the appropriate insurance cover to address the claim.

Public liability Insurance provides protection from claims made by individuals (members of the public or clients) who sustain an injury, e.g. someone may slip on ice on your premises or trip over. This type of insurance does not provide cover for a claim against treatment or advice given.

Professional indemnity insurance provides protection from a claim due to negligence, breach of duty of care, omission or loss of documents/data or unintentional breach of confidentiality. This includes cover when treating a client or providing advice.

Employers’ liability insurance is a legal requirement if you have employees. It protects the employer from injuries sustained by any employees on the premises.

Product liability insurance protects against any claim (injury or damage) as a result of any defect in goods sold, supplied or demonstrated to the client by the therapist.

Risk, equipment and product protection protects your business equipment and products against loss or damage.

Income protection (permanent health) insurance is a short-term insurance product, which can provide a regular income in the event you are unable to work due to sickness or injury.

The importance of professionalism

It’s important that, as a massage therapist, you provide a high standard of treatment. This optimises the benefits of the therapy and helps prevent cross infection. It also promotes trust and confidence in your skills as a therapist. This can aid client retention and satisfaction.

Additionally, showing that you respect and care about your clients helps to maintain your reputation and uphold the credibility of the profession.

Professional conduct

Professional conduct refers to behaviour and standards and involves responsibilities that relate not only to treatments but also to other personnel such as the general public, colleagues, umpires, referees, spectators etc. They are a minimum set of standards referred to as a ‘code of conduct’ and frequently linked to membership of your professional body. Conduct usually relates to:

• Acting in the best interest of your client

• Obtaining informed consent

• Keeping accurate and detailed record cards

• Confidentiality of clients’ personal information and treatment

• Act with honesty and integrity

• Declaring any conflicts of interest

• Working within scope of practice

• Referring to other professionals when needed.

• Keeping up to date with professional development.

The importance of appearance and standards

Ensuring a professional service to clients is imperative and so you must ensure that high personal and clinical standards are upheld at all times. It can take as little as 5-10 seconds for a person to form a first impression to evaluate you. Opinions are formed principally on your appearance, body language, demeanour and dress. This sets the standard for future relationships, and it is difficult to reverse if the wrong impression is given.

When you are treating clients, you should always follow high personal and clinical standards. These include:

• Dress & appearance: Dress appropriately in a professional uniform, remove jewellery and ensure hair is tidy (long hair tied back). Ensure nails are short in length, footwear is appropriate.

• Personal hygiene: Your clothing should be clean and appropriate, and you should follow high standards of personal hygiene. You should also make sure your equipment and environment meet appropriate hygiene standards.

• Infection control: You should ensure the highest infection control procedures to reduce and prevent the transmission of infection. Coughs, viral infections such as colds (including coronaviruses), verrucas or fungal infections (athlete’s foot) can be highly transmissible from person to person. Cross infection can be higher in sporting environments involving communal areas and sharing of clothing and equipment. Washing hands thoroughly before and after every treatment, use of alcohol hand sanitiser, clean laundry per client, correct disposal of waste, cleaning equipment and high contact points such as door handles between clients can all contribute to a reduction in transmission.

• Body language: Your body language should be positive, open and welcoming whilst remaining respectful and professional.

• Behaviour: It’s important to treat your clients with respect. Your attitude and conduct should always be professional and appropriate You should give your clients your full attention during treatment sessions. Prepare yourself mentally - be calm and relaxed.

• Good practice: You should keep up to date with the latest knowledge and skills in your area through CPD. However, you also need to have awareness of the limitations of your own knowledge and skills and refer clients when necessary or appropriate.

• Reliability: You should make sure you are on time for treatment sessions and not keep clients waiting.

• Personal professional conduct: You should ensure you build a rapport with your clients based on mutual respect, valuing the individual and diversity, ensuring confidence, trust & integrity. Be polite and sensitive and address your client appropriately.

• Attitude: Positive attitude should be conveyed at all times. You should give your client full attention during the treatment.

• Limitations: Be mindful of limitations in knowledge and skills Act with integrity and honesty and refer to other professionals when needed.

Personal vs. clinical standards

Personal standards

Dress and appearance

Personal hygiene

Behaviour

Reliability

Personal professional conduct

Positive communication - verbal and non-

verbal

Work within scope of practice

Continuous professional development (CPD)

Clinical standards

Professional competence

Hygiene & Infection control

Client referral

Insurance

Health and safety

Client referral

Informed consent

Record keeping & data protection

The importance of good communication skills

Good communication skills with your clients, colleagues and employer are essential as a therapist in order to:

• Develop a successful positive relationship.

• Develop and establish rapport and trust.

• Gain client confidence and respect

• Establish subjective information and identify contraindications/actions

• Gain informed consent

• Establish client feedback throughout the process

• Client referral

• Develop a professional network

It is important to be able to communicate information clearly and concisely. There are two main types of communication. These are verbal and non-verbal.

Direct communication

Direct communication can take a variety of methods when using words to convey a message, each have their own advantages and disadvantages. When speaking, speak clearly, concisely and at an appropriate speed. Choose your words appropriately, deliver information logically and in a succinct manner. It’s important to avoid any language which may be taken as judgmental, blaming or critical. Avoid complex terminology and negative connotations

Advantages and disadvantages of different means of communication are shown in the below table.

Means of communication

Face to Face (in person)

Advantages

• Establishes trust and enables a rapport to build

• Messages are communicated immediately.

• You can exercise your personal influence with the use of body language

• You can judge the reaction of the other person.

• Any doubts or misunderstandings can be identified and resolved immediately.

• Boost active participation in conversation

• Enhances conflict resolution

Disadvantages

• Lack of evidence unless recorded.

• Requires direct contact

• Time consuming

• Although reasonable for the client, third parties may have time constraints.

• Logistical considerations

• Be mindful of non-verbal cues

• Poor articulation.

Face to face (remote)

• Establishes trust and enables a rapport to build.

• Messages are communicated immediately.

• You can also exercise your personal influence with the use of body language.

• You can judge the reaction of the other person

• Any doubts or misunderstandings can be identified and resolved immediately.

• Boost active participation in conversation.

• Enhances conflict resolution.

• Can be time efficient.

• No logistical considerations.

• Requires direct contact

• Lack of evidence unless recorded.

• Has limitations in the of body language

• May not be as effective as face to face in building a rapport.

• Technological and equipment considerations

• Be mindful of non-verbal cues

• Poor articulation.

Telephone

• No logistical considerations.

• Messages communicated immediately.

• Doubts or misunderstandings can be identified and resolved immediately.

• Very time efficient.

• No logistical considerations.

• Doesn’t require face to face contact

• No consideration required for body language.

• Limitations in trust and rapport building due to lack of body language

• Can’t use body language as an influencing factor.

• Difficult to judge a person’s reaction

• Lack of evidence unless recorded.

• Poor articulation

Text/WhatsApp /messaging service

• Very time efficient.

• Useful for reminders or delivery of concise information

• Can be automated

• Confirmation of delivery

• Message communicated immediately & direct.

• No logistical considerations.

• Doesn’t require any conversation or face to face contact

• No consideration for body language.

• Good articulation & can prepare delivery.

• Recorded evidence

• No need for personal contact

• Consent required.

• Can’t use body language to deliver message

• Not for lengthy communication

• Can’t judge a person’s reaction.

• Limitations in trust and rapport building

Written - letters/emails

• Time efficient

• Confirmation of delivery

• Message communicated clearly and concisely.

• No logistical considerations.

• Doesn’t require any conversation or face to face contact

• Don't need to consider body language.

• Good articulation & can prepare delivery.

• Can develop trust and rapport building.

• Consent required

• Can’t use body language to deliver message.

• Can’t judge a person’s reaction

• Delay in information being received.

• Delays in response to information delivered.

• Confidentiality concerns as can be read by anyone

• No need for personal contact.

• Provide evidence for future use

• Clear and self-explanatory.

Non direct communication (body language)

A high proportion of our communication is indirect. This is more commonly known as body language. It’s a powerful tool to build a rapport, develop client base and address a variety of situations. The table below shows the main types of body language and their benefit.

Body language

Eye contact

Posture

Facial expression

Gestures

Touch

Space

Benefit

• Frequent eye contact can ensure confidence.

• Make gentle eye contact on first meeting and develop the gaze.

• Intense eye can be too demanding and detrimental.

• Adopt a confident posture and move confidently. ‘Head up, shoulders back’ open through the chest will enable you to feel more confident and in turn the person will have more confidence in you.

• The face is very expressive and can be a strong communication tool particularly with emotion, e.g. happiness, sadness, anger, fear, disgust, disapproval, disappointment etc

• Beware of your emotional state and ensure that you project positivity Be pleasing and confident in appearance.

• Be aware of hand gestures and ensure they cannot be misinterpreted and are not overly expressive or intrusive.

• Clearly distinguish between personal and professional. A hug is personal and not appropriate for the workplace. A handshake on greeting would be more appropriate and a reassuring gesture. Firmness projects confidence

• Be aware of personal space - some people prefer this more than others. Invading personal space can appear dominant and aggressive whereas too much space can appear allusive and distant.

Effective communication

Effective communication will depend on your ability to be emotionally aware, read situations, respond appropriately and on your ability to self-reflect. Be attentive to your client and actively listen.

How to produce, maintain and store client records

It’s important to keep accurate and confidential records to protect both yourself and your clients. It’s also a legal requirement and you must comply with data protection regulation and respect confidentiality. You should provide evidence of:

• Duty of care: How you have demonstrated duty of care and the judgement you have used to support your professional actions.

• Scope of practice: How you have kept to scope of practice in the treatment and advice given to your clients.

• Informed consent: You must keep a record of the informed consent of your clients.

• Progress: You need to keep a record of your client’s progress during their treatment and if the desired results are being achieved.

• Professional competence: You should bear in mind that you may be required to transfer your records to a third party, e.g. if you refer a client or in the event of an insurance claim. Accurate and well-presented client records will provide evidence that you are competent to perform your role.

Information which should be recorded and principles to apply when recording treatments

You should follow certain principles when recording the treatments you have carried out. These can include:

Accurate record of the:

• Subjective assessment:

Verbal and written information relating to the client and their condition before treatment, including:

o the client’s personal/lifestyle details

o any contraindications

o relevant medical history questions

o the reason for the client’s visit

o appropriate questions regarding the possible causes for the client’s current status

o the client’s signature (to confirm informed consent).

• Objective assessment:

Measurable examination methods used to assess the client before any treatment and their results, such as:

o Observations

o Range of motion tests.

o Palpation.

o Treatment process: The proposed treatment plan, including techniques and reasoning, any adaptations and alterations made. Aftercare advice should also be documented. The plan should be:

unambiguous completed in an indelible format any alterations initialled completed within 24 hours kept confidential stored for eight years before disposal.

Keeping your records: legal requirements

All client data must be stored in accordance with the data protection act. Hard copy data must be stored in a safe place and in a lockable cabinet. Electronic data needs to be password protected with regular back-ups made and firewall protected. Hard copy and electronic data should not be accessible by third parties. Written permission must be given to gain access to client records. Clients have the right to access their own records.

Records should be kept for up to eight years but not longer than necessary. Client records must be destroyed as legally required which may include the use of a professional data shredding agency or professionally wiping the drive when disposing of a computer.

Section 2: Points to discuss

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You understand…

The legislation you must follow as a massage therapist

The legal consequences if you don’t

Your scope of practice including when and how to refer clients to other professionals.

How to communicate with clients and other professionals in an appropriate way.

The professional standards you must follow

How to keep and store your records.

TEST YOURSELF

Describe how you should store and maintain your client records according to law.

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Revision notes on Section 2:

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Section 3: The principles of soft tissue dysfunction Introduction

This section will cover the knowledge and understanding required to differentiate between soft tissue injuries and soft tissue dysfunction

Common causes of injury & dysfunction

Injuries and soft tissue can be caused by a variety of factors. The cause is classified and is either intrinsic or extrinsic. Here are some examples:

Intrinsic factors

• Anatomical factors such as leg length differences, body misalignments, joint abnormalities, posture deviations

• Individual factors are factors which are specific to the individual and their medical history such as previous injuries, conditions, levels of activity, stress levels, lifestyle and body composition.

• Physiological factors are factors which relate to how the body functions and facilitates movement such as early onset of fatigue, reduced flexibility, muscle weakness or imbalance and hyper flexibility

• Age factors are factors which are related to the ageing process of the body such as loss of collagen/elasticity, slower recovery, decreased force production. The younger body is at risk of injury due to different rates of development and inability to withstand forces.

Extrinsic factors

• Training related factors, relate to training program design such as recovery, frequency, intensity, duration, training methods and performance technique

• Equipment factors relates to equipment selection and suitability such as footwear, personal protective equipment, size, weight, fitting, and impact from equipment.

• Environmental factors, relates to environmental temperatures such as heat, cold, extreme temperatures and playing surfaces such as the impact (hard or soft), if surfaces are level. Environmental factors which may cause trips or falls

• Psychological factors relate to mental demands of sport such as aggression, assertiveness, mental stress.

• Nutritional factors relate to the adequate intake of hydration, glucose, and protein.

Differentiating between soft tissue injury and soft tissue dysfunction

Onset Soft tissue injury

Soft tissue dysfunction

When? Onset of symptoms readily established. Exact onset of symptoms often vague and not readily established.

How? Mechanism of injury (MOA) normally identified as one or more of the following types of extrinsic trauma:

Cause can be hard to determine. Normally established as being due to intrinsic factors such as:

Typical presentation

Dysfunctional soft tissue

• training related

• equipment

• psychological

• vehicle

• environmental.

Often an acute pain (which commenced immediately after MOA)

Exact site easily identified (client points to area)

• muscle imbalance(s)

• muscle weakness(s)

• muscle tightness(s)

• muscle(s)

overuse/underuse

• compensatory movement patterns

General aching/stiffness

Source tends to be more generalised and harder to identify (client rubs area).

Non-pathological, free from disease, non-injured and free from inflammation.

Types of soft tissue dysfunction

General aching/stiffness and or impaired sporting performance resulting from:

• tight/weak muscle(s)

• muscular imbalance(s)

• compensatory movement

• restricted flexibility

Injured soft tissue

Soft tissue which has been damaged, needing management throughout its stages of repair.

Types of soft tissue injuries

Common overuse type injuries include:

• shin splints

• stress fracture

• compartment syndrome

• tenoperiostitis

• golfer’s elbow (medial epicondylitis)

• tennis elbow (lateral epicondylitis)

• rotator cuff impingement

• plantar fasciitis

• carpal tunnel syndrome.

•

Common acute injuries include:

• skin:

o graze / abrasion.

o cut / laceration

• muscle tissue:

o strains (damage to muscle fibres)

o DOMS (damage to myofibrils).

• connective tissue:

o strain (damage to tendon)

o tendinopathy.

o tendinitis (inflammation of tendon overuse/friction)

o tendinosis (degeneration of the tendon’s collagen in response to chronic overuse)

o ligament sprain (damage to ligament)

o joint capsule sprain (damage to joint capsule)

o hyaline cartilage damage

o meniscal tear

• bursae.

o bursitis (inflammation of a bursa overuse/friction)

o haemabursa (damage to a bursa impact trauma)

• nervous tissue:

o neuropraxia − bruising to a nerve, for example, hitting your ‘funny bone’

o pressing/trapping a nerve (impingement) for example, sciatica

o neurotmesis (severance of a nerve).

Severity of soft tissue injury

Strains (damage to a muscle or tendon) can be graded 1, 2 or 3:

• Grade 1 is the least severe and is a minor partial tear. There may be evidence of:

o mild to moderate pain on contraction or stretch

o mild degree of swelling and discolouration

o minor functional impairments may be noticed during more intense exercise

o muscle may appear weaker than normal

o possible minor muscle spasm (tightening)

o usually tenderness on palpation.

• Grade 2 is a more severe partial tear.

There will be greater evidence of the signs and symptoms including:

o moderate to strong pain on contraction, stretch and on palpation

o swelling can be moderate to severe

o a greater degree of functional impairment and muscle weakness

o muscle spasm localised and in the surrounding tissue

o maybe obvious palpable indent in the muscle tissue.

• Grade 3 is a total rupture where there is complete or near complete lack of continuity within the affected fibres.

Signs and symptoms will be increased including:

o severe pain as the injury occurs and diminishes soon afterwards, severe swelling and discolouration

o significant weakness, loss of function

o muscle spasm localised and in surrounding tissue

o loss of strength when muscle strength testing

o on palpation, a hollow and bump deformity, local and diffuse pain

Sprains (damage to ligaments/fibrous capsule). They can be graded 1, 2 or 3:

• Grade 1 is the least severe and is a minor partial tear. There may be evidence of:

o local pain and tenderness

o minimal swelling

o minimal loss of function

o no obvious deformity or instability

o possible associated minor muscle spasm

o if palpable possible local tenderness.

• Grade 2 is a more severe partial tear.

There will be greater evidence of signs and symptoms including:

o pain at rest and upon weight bearing

o considerable swelling

o considerable loss of function

o evidence of instability

o If palpable, tenderness

o associated muscle spasm.

• Grade 3 is a total rupture where there is complete or near complete lack of continuity within the affected fibres.

Signs and symptoms will be increased including:

o severe pain as the injury occurs and diminishes soon afterwards to less than a grade 2

o severe and rapid swelling around the joint

o severe loss of joint function

o severe joint instability

o associated muscle spasm.

Note: associated pain levels are not a reliable indicator of severity

Soft tissue repair

Stages of soft tissue repair

The process of soft tissue repair includes three key stages (or phases):

• Acute (inflammatory) stage:

The acute stage is the initial reaction to injury and typically lasts for three to five days post injury. The signs and symptoms of inflammation (heat, redness, swelling, pain and tenderness) accompanied with possible impaired function will be present.

o Redness and heat are due to increased circulation which occurs a few minutes after injury.

o Swelling occurs due to the damaged capillaries, vasodilation of blood vessels, increased vessel permeability and increase of fluid into interstitial spaces.

o Pain is due to the increase in pressure at the injured site and damage to nociceptors (local nerve fibres) from the swelling

o Loss of function occurs due to the pain and swelling.

o Immediately after the injury there is a degree of cell death (necrosis).

o An acute vascular response follows, initially with vasoconstriction due to the instant release of hormones as a protective mechanism. This lasts only for a few minutes

o The next response lasts for around an hour, Histamine and other chemicals are released causing vasodilation and increased permeability of the vessel walls

o Following, is localised oedema, due to leakage of plasma from post capillary venules and leakage of lymph from damaged lymph vessels. The enzyme Thrombin facilitates platelets gathering forming clots therefore bleeding begins to reduce and white blood cells ( neutrophils, macrophages, lymphocytes) gather, there primary role is phagocytosis.

o Phagocytosis is the ingesting and disposing of tissue debris, clearing the area of damage and any possible infection. This ensures the area is ready for the repair phase

• Sub-acute (repair or cellular proliferation phase):

This follows the acute stage and typically lasts a further two to five weeks. This phase of healing is where new tissue is laid down at the injury site. Since inflammation has now ceased the redness and heat caused will have diminished. However, swelling and pain may still be present.

o The first structural repair works begins with a network of new capillaries and lymphatics, therefore improving circulation (oxygen and nutrient delivery) and drainage

o Next follows granulation of tissue formation and a rapid increase in fibroblasts at the site of injury. fibroblasts develop, initially a weak mesh of connective tissue by producing ground substances (such as collagen) needed for repair. The tissue is fragile, vascular, and vulnerable to reinjury.

o The proceeding three to four weeks will see a reduction in the capillary network. The mesh of connective tissue strengthens as crosslinks form between the collagen fibres and scar tissue begins to form.

• Chronic (remodelling) stage:

This is the last stage of healing and dependent upon severity it can last up to one to two years post injury. There is continued reduction in swelling and pain. There is also an increase in structured organisation of tissue. There is a gradual return to full function.

o The collagen tissue mesh (granulation tissue) develops from a fragile network (matrix) of unorganised fibres into mature scar tissue which is avascular with poor elasticity.

o Lymphocytes continue to work to reduce the size of oedema

o Rehabilitation is vital during this stage of healing to align the collagen mesh along the lines of external stress bringing order to the matrix

Factors which influence soft tissue repair

Various factors will influence the speed and effectiveness of any soft tissue repair process. These include:

• Size: the larger the injury then the higher the likelihood that it will take longer to heal.

• Types of tissue: Avascular tissues such as ligaments and tendons will take longer to repair than those with greater blood supply, e.g. muscles.

• Severity of injury: Grade 3 injuries take longer to repair than grades 2 and 1.

• Age: The repair process for older clients will generally take longer to complete than for younger clients.

• Medication: Although anti-inflammatories may help relieve the symptoms of inflammation, inflammation is vital for the repair of soft tissue. This means that taking drugs such as nonsteroidal anti-inflammatories (NSAIDs) may slow the repair process.

• Health conditions: Medical conditions can affect the individual’s capacity to heal, e.g. diabetes, autoimmune diseases such as lupus, rheumatoid arthritis, immunocompromised. Other conditions such as obesity, alcoholism and smoking can also affect the capacity to heal.

• Nutrition: Those with a good balanced diet with adequate nutritional intake will heal better than nutrient depleted individuals. An adequate supply of nutritionally rich food containing protein is vital for the repair of soft tissue.

Inflammation

Inflammation is a protective tissue response to injury or destruction of tissues, which serves to destroy, dilute or wall off both the injurious agent and the injured tissues. Disposal of dead or dying tissue and promotion of the repair and renew of normal tissue.

Section 3: Points to discuss

Test your learning by filling in the boxes below.

Check your understanding!

You understand…

Typical presentations of soft tissue injuries and soft tissue dysfunction

Types of soft tissue injury and common causes

Signs and symptoms

TEST YOURSELF

Please tick:

Why is inflammation important for the repair of soft tissue?

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Revision notes on section 3:

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Section 4: Performance massage treatments

Introduction

This section will cover the knowledge, understanding and skills required when planning, providing and evaluating pre-event, post-event, inter-event and maintenance massage using a range of basic massage techniques. It does not include working on recent acute injuries or pre-existing conditions which is beyond the scope of practice of this qualification

Massage

Massage is based upon a universal intuitive instinct to rub areas that hurt. The word ‘massage’ comes from the Arabic root word ‘massa’ which means to touch, knead or squeeze

History

The earliest written records of massage therapy were discovered in Egypt and China (approx. 3000 BC). Chinese massage techniques originated from the theory that diseases and illnesses happen because of a deficiency or imbalance in the energy in specific pathways (known as ‘meridians’) which correspond to physiological systems.

Hippocrates is quoted as stating that physicians should be experienced in rubbing: ‘for things that have the same name have not always the same effect. For rubbing can bind a joint that is loose and loosen a joint that is too rigid’ and ‘rubbing can make flesh, and cause parts to waste.’

In the 16th century, Ambroise Paré, a French doctor to four different French kings, adopted a more anatomical and physiological approach and used a great deal of massage in his practice. Swedish physician Per Henrik Ling is considered to be the father of physical therapy. Per Henrik Ling developed the Swedish gymnastics movement system and the Swedish massage

Development of massage for performance

Records show that the ancient Greeks used massage on athletes before and after sport. It was thought to help prepare the muscles before activity and remove extra fluid and metabolites after sport.

Galen of Rome (129-c.199 AD) wrote 16 books on friction massage and gymnastics (remedial exercise), describing the pressure direction and frequency of treatment.

Performance massage has evolved to combine and adapt a variety of techniques from a diversity of bodywork disciplines to help deal with the effects of intense physical exertion on the body.

The primary purposes of performance massage include:

• Easing stiffness and pain in both muscles and joints.

• Increasing flexibility in soft tissue structures such as muscles.

• Improving mobility of joints.

• Physiologically preparing muscles before exercise.

• Helping the client in their recovery from physical exertion.

Massage as a compliment to other therapies

Massage can also be used to support and complement other therapies and treatments in the following ways:

• Reducing physical, physiological, and psychological tension before manipulative therapies such as:

o chiropractic

o osteotherapy

o physiotherapy.

• Aiding:

o cognitive therapies by promoting a feeling of wellbeing and reduced mental stress

o palliative care by relaxing the whole body, promoting restful sleep and reducing mental stress

o restful sleep

The fundamentals of performance massage treatments

The application of performance massage may cause physiological, neurological, psychological and physical (mechanical) effects.

Physical (mechanical) effects of performance massage

Changes which occur regardless of the client’s nervous system response or mental reaction.

Physical effects include:

• the mechanical pumping and squeezing action of the strokes which assists the flow of fluids, e.g. blood and lymph

• increases tissue flexibility

• loosens adhesions

• relieves muscle tension

• reduces oedema

• stretches soft tissue

• reduces stress on joints

• mobilization of muscle fibres

• improved kinaesthetic awareness

• reduce muscle spasms.

Physiological and neurological effects of performance massage

These effects are a result of a sympathetic or parasympathetic response.

These include:

• increase in lymph flow

• improvement in local blood flow

• removal of waste products

• promotion of healing

• pain reduction

• varying the method of application

When nerves and sensory receptors are stimulated, messages are sent to the brain and there is a parasympathetic response which aids:

• vasodilation to both blood and lymphatic vessels

• reduction in neural stimulation (contraction) of muscles

• reduction in the production of sympathetic (stress) hormones

However, varying the method of application can cause a sympathetic response. A sympathetic response would cause the opposite to occur and result in chemical changes such as an increase of adrenaline and endorphins in the body This alters the client’s psychological state

Psychological effects of performance massage

Psychological effects are a result of an effect on mental state

Effects include

• reduction in anxiety

• reduced tension

• relaxation

• stimulation

• pain reduction

• elevation in mood

• improved attentional focus

• improved sleep

• improved confidence

Varying the method of application

A more vigorous massage will have a sympathetic response aiding:

• increased mental alertness

• stimulate the client to help prepare them for activity

• increase adrenaline and endorphin levels in the body

A more relaxing massage will elicit a parasympathetic response. As the body perceives a reduction in physical tension the mind follows, eliciting:

• reduction in physical tension

• feeling of wellbeing and relaxation

• lowering of anxiety

Placebo effects

The placebo effect, i.e. the client’s preconceptions about what the treatment will do, can have a significant impact on performance or treatment outcome. To maximize the effectiveness of any treatment and avoid any undesired effects, the therapist should be aware that the mind and the body are reflections of each other.

Alteration/stimulation of either the sympathetic or parasympathetic response (through treatment or communication) will influence all corresponding reactions

The benefits of performance massage include

• Increase the supply of nutrients to vascular tissue which enhances and assists healing and repair

• Aid in the removal of metabolic waste products from tissue which assists in recovering from activity.

• Help to reduce pain by lessening tension in muscles, reducing pressure build-up due to congestion and removal of metabolic irritants

• Increase in range of movement, thereby reducing risk of injury by aiding in efficiency of movement.

• Promotes confidence by enabling the client to relax and have a sense of wellbeing.

• Pain reduction through the release of endorphins.

Contexts in which performance massage can be used

Pre-event

Performance massage can be used to prepare athletes for high-intensity activity. A short, invigorating massage normally proves extremely effective in ‘psyching’ up the athlete, mentally preparing them for their sports performance.

The benefits of pre competition massage include:

• To boost circulation rapidly and increase blood flow

• To warm the area

• To relax muscles and decrease tension

• To reduce anxiety

• To stimulate circulation and increase the supply of nutrients and oxygen to the muscles to stimulate the athlete mentally.

If the client shows excess nervousness or excitability, a more relaxing ‘de-stressing’ massage treatment may be useful. A sympathetic nerve response will help kick-start the metabolic functions of the body This will increase oxygen uptake at the cellular level and help delay the onset of lactic acid accumulation.

Although not a replacement for a conventional warm up the massage is an extremely efficient method to prepare muscles for stretching.

Inter or intra-event

Performance massage can be used to minimise the likelihood of muscles tightening up during the short rest periods between multiple competitions/events held on the same day. This kind of inter or intraevent massage would follow a similar format to that of pre-event massage and should focus on the main muscles stressed together with any input from the athlete.

Post-event

Performance massage can help recovery from intense activity. A relaxing massage will help the athlete ‘unwind’ from the mental demands of intense training and competition. The benefits of a post event massage includes:

• removal of waste products from muscles

• prevent muscle soreness

• normalise the muscle tissue

• support metabolic recovery and lymph flow

• restore flexibility and joint mobility.

Techniques are performed much slower than pre-event to help restore a resting state. The stretching of tissue is needed to restore and improve flexibility and mobility.

Maintenance

The primary focus of using performance massage for maintenance is to correct any soft tissue dysfunction caused by high intensity training (e.g. tight muscles)

It requires a detailed examination before treatment to establish both the athlete’s symptoms and the massage therapist’s clinical findings.

A proposed massage strategy is then discussed and agreed. Treatment is then carried out using massage methods appropriate to the presentation and needs of the client. After treatment, effectiveness is evaluated against the original treatment aims

Treatment planning

Subjective and objective assessment is conducted prior to treatment to assess the client’s suitability for treatment and to establish and agree aims of treatment, i.e. an action plan

Accurate client assessment will establish a baseline against which to measure the progress of the client and efficacy of treatment during reassessment.

Client assessment includes:

• subjective assessment

• objective assessment

Subjective assessment

Subjective assessment involves eliciting verbal and written information relating to the client and their condition prior to treatment.

Consultation will consist of:

• Face to face discussion

• Completion of a client record card including personal details, medical background, medication, activity history, lifestyle history and information related to the problem, e.g. when, cause, symptoms, pain etc.

• Referral to written information supplied by/with client

• Answer to client questions fully and clearly and explain the objective assessment procedure

• Obtain clients signature to confirm informed consent prior to examination. When obtaining informed consent ensure you give a full explanation of the purpose/requirement of physical assessment, the procedure and the reason for possible removal of some clothing during assessment. Remember if a client is under 18 or can’t give consent then a chaperone will be needed.

Accurately record all findings.

Remember first impressions count and it is important to demonstrate effective communication skills, including for example:

• professional attitude and appearance

• positive body language

• rapport and understanding

• clear explanations avoid jargon

Objective assessment

Objective assessment involves examination methods used to determine the client’s condition prior to any treatment and to record results.

You should ensure client privacy using towels where appropriate

• Observations –observing the area to be treated including signs of swelling of inflammation, scars, skin condition, atrophy, hypertonic tissue. Observation of the client’s posture and gait noting any muscle imbalance/atrophy and/or compensatory movement patterns

• Range of movement –safely and effectively instructing the client to perform comfortable movement patterns of all joints relevant to treatment Signs of muscle weakness and compensatory weakness should be noted.

• Palpation –of the site being examined and noting skin feel, pain or tenderness, adhesions, tone and/or spasm

• Range of movement –safely and effectively instructing the client to perform comfortable movement patterns of all joints relevant to treatment. Signs of muscle weakness and compensatory weakness should be noted.

Accurately record all findings.

Conducting client assessment

Ensure presence of appropriate chaperone if necessary

Forming a treatment plan

Conduct subjective assessment

Establish informed consent.

Conduct objective assessment

A treatment plan is constructed with information obtained during subjective and objective assessment.

Establish treatment aims

These may include:

• preparation for sports activity

• assist in injury prevention

• facilitate post exercise recovery

• enhance feeling of wellbeing.

Discuss (and record) proposed actions

Upon completion of the subjective and objective assessment, the information obtained will be summarised and appropriate actions against each symptom/finding recorded.

Details should include:

• area’s to be treated including techniques to be used (purpose, effect and possible side effects).

• proposed massage medium.

Agree treatment plan

Informed consent MUST be obtained prior to objective assessment and before any treatment is carried out. Remember it is a legal obligation. No consent means no assessment or treatment is allowed. The client should be fully informed about the treatment they will receive as well as the limitations and benefits of treatment

Forming a treatment plan

Summarise subjective & objective information

Present proposed treatment plan to client

Agree treatment goals

Obtain informed consent

Application of performance massage

Environment

• In a clinic:

o The room should be warm, quiet, private and well ventilated.

o The area must be kept clean and tidy with hand washing facilities available and a supply of clean towels, linen and paper couch roll.

o A bin for disposal of waste should also be available.

• Outside:

o The ground should be level and stable and there should be no obvious hazards such as doorways, stairs or lots of people walking by. You should seek shelter from the elements and consider the use of a canopy but avoid working underneath trees.

o Although a bare couch is easier to keep clean, the sun may make it very hot if it is left exposed for long periods.

o Towels should be used prudently by encouraging clients only to remove minimal clothing to maintain warmth and privacy. The massage should be done through clothing whenever possible.

o Keep hands clean by using alcohol wipes.

o If massaging in a confined area, take regular breaks.

Types of equipment & props

• Couch

You should avoid choosing a couch based on price alone It should be robust, secure and stable and the height should be adjustable and sturdy enough to accommodate the varying weights and sizes of your clients.

You may also wish to consider the advantages and disadvantages of an inclined back and/or a face hole and the advantages and limitations of different materials (wood, aluminum, carbon fibre, etc.).

The number of legs on the couch can make a difference too; more legs will make the couch harder to level and adjust but as a consequence may be more stable.

• Ground/floor

A performance massage on the ground/floor is really only suitable for legs and mats should be used.

• Chair/bench

Your chair should be robust, secure, and stable It should be a suitable width and shape and provide adequate support. The lighter the chair then the easier it is to transport and move but heavy chairs may provide a greater level of stability and comfort. A bench is more suited for legs (front and back), whilst a chair lends to front of legs, back of the lower leg, neck, and shoulders.

• Massage chair

Massage chairs are really only suitable for the back, neck or shoulders. If using a massage chair, you should make sure it is robust, secure and stable. It should also be fully adjustable and able to support clients of varying weights.

• Couch roll

A couch roll will protect towels and clothing from contamination.

• Towels

Towels provide warmth and ensure modesty and privacy.

• Props

Props are used to help support joints and aid client comfort. Used effectively they also help relax muscles and increase the effectiveness of the treatment. They can be either in the form of bolsters made specifically for this purpose or fashioned from rolled up towels covered with couch roll. This prevents hyper extension of joints, assist relaxation of muscles and provide support.

Effects and benefits of commonly used mediums in performance massage

• Oils

Oils provide a smooth, friction free medium that allows large areas to be massaged easily. They can be natural, vegetable and plant-based oils, nut or seed oils. If qualified, you can also use essential oils. Natural oils can also nourish the skin. You should make sure your client does not have any related allergies before using oils.

• Creams and lotions

Creams and lotions can be thicker than oil, with less gliding ability. They are generally easier to use than oils when manipulating tissues since they allow effective ‘purchase’ whilst minimising the risk of pinching. Can be more hypoallergenic and help to prevent folliculitis. They are also less greasy than many oils which reduces the likelihood of stains to clothing and towels.

• Powder

It is useful when the client does not want any oil or cream on their body or if they have excessive body hair. It is good for use in pre-event massage as a dry medium It can provide greater friction than oil or cream but has less ability to glide.

• Massage waxes

A combination of bee's wax blended with oils (such as sweet almond or grapeseed) which helps provide a firmer grip when required.

• Massage gels

Provide an oil-like glide without the greasiness often associated with oils. They are also more readily absorbed than other massage mediums.

Client positioning

The client should be positioned for:

• comfort

• ease of access to treatment sites

• non-invasive of contact of tissues

Positions can include:

• prone

• supine

• side lying

Therapist positioning

• Stance (lunge):

o wide base of support

o weight on back foot/staying behind the stroke

o spine aligned with back leg

o enables effective use of weight transfer, i.e. therapist ‘leans’ on client

• Stance (squat)

o maintain neutral spine

o unsuitable for effective application of pressure.

Contra-actions

Signs and symptoms Response

• Redness/itching, indicative of an allergic reaction to chosen medium.

• Heightened emotional state, exaggerated parasympathetic responses

• Remove medium using cologne or similar alcohol-based cleanser

• Cease treatment/use alternative medium (according to client’s choice)

• Maintain a professional approach and assure client that reactions are not unusual (and are ‘involuntary’)

When considering which massage techniques are most likely to meet the goals of the proposed treatment (treatment planning), the sports massage therapist should consider not only their type but their intended purpose, method(s) of application available and expected effects upon the client physically, physiologically and psychologically.

Weight on rear leg enables effective use of pressure.

Massage techniques

Name Purpose Methods Effects

Effleurage

• Introduce the performance massage therapists’ touch to the client

• Relax the client

• Apply the massage medium, e.g. oil.

• Encourage blood and lymphatic circulation

• Warm up the soft tissues.

• Monitor the tissues as part of palpation

• Link other performance massage techniques.

• Provide a rest between specific, deep-tissue techniques.

• Conclude the treatment.

• Longitudinal/ transverse

• Superficial/deep.

• Increase circulation at the level of application.

• Improve skin condition

• Increase relaxation of soft tissues

• General relaxation of soft tissues.

Transverse effleurage, fingers follow direction of stroke across the muscle fibres (upper trapezius).

Name Purpose Methods Effects

Petrissage

• Mobilise muscles or groups of muscles.

• Reduce intramuscular congestion

• Reduce tension in muscle fascia.

• Assist in free movement of muscles or muscle groups.

• Wringing

• Rolling.

• Kneading.

• ‘Picking up’

• Increase muscle and fascial mobility

• Increase circulation.

• Reduce fibrous adhesions in muscle fibres and fascia.

• Improve skin condition, especially elasticity.

Petrissage (squat stance), showing effective contact of tissues whilst minimising use of individual fingers.

Name Purpose Methods Effects

Compressions

• Often used as a warm up for deeper, more specific massage work.

• Rhythmic pressure applied to muscles

• Deep hyperaemia (increased blood flow) resulting in a “softening” effect of tissues.

Vibrations /shaking

• To stimulate client

• Relax muscles.

• Increase circulation

• Decrease muscular tension.

• Physical/mental ‘preparation’ for activity (pre-event).

Tapotement

• To stimulate the client (sympathetic response).

• To help tone muscles that have atrophied due to disuse/poor neural recruitment.

• Hacking.

• Cupping

• Beating.

• Pounding.

• Mental stimulation.

• Increased muscle tone.

Passive stretching

Therapist taking affected joint through an extended range of motion. However, before undertaking any passive stretching the therapist must ensure that:

• On presentation, the client has no pain or inflammation

• The area to be stretched has been warmed.

• There are indications for undertaking passive stretching.

• The client:

Application variables

Application variable

Speed

○ Undertakes active stretching prior to passive stretching.

○ Has a pain free movement pattern

○ Has no radicular or radiating pain or paraesthesia.

○ Has no coexisting pathology

○ Has no contraindications.

Pressure

Impact on treatment

• Faster application elicits sympathetic responses

• Slower application elicits parasympathetic responses

• Superficial pressure has little physical/physiological response and may irritate client.

• Firmer pressure will produce greater physical/physiological responses and help reassure and relax client

• Excessive pressure may cause client to tense up

Depth Determines which soft tissue structure may be accessed:

• shallow: skin, blood/lymph capillaries

• moderate: fascia, blood/lymph vessels, ligaments

• deep: muscles.

Application considerations (including safety)

Method of application Considerations

Hand positions

• Reinforced digits

• Fingers aligned to direction of force

• Avoid excessive use of fingers

Effective contact

• Maintain contact throughout treatment

• Begin superficial progress to as deep as required

• Rhythmical application of techniques

• Use pressure that is sufficient to reach target structures while ensuring minimal client discomfort.

• Effleurage: pressure applied in direction of venous return reduced on return strokes

Appropriate direction

• Longitudinal effleurage strokes applied towards the major lymph nodes/direction of venous return

• Shorter strokes applied in whichever direction is considered to have the greatest effect.

• Work away from bony structure to avoid pinching/discomfort.

Regions treated

• Work on proximal areas before distal

• Avoid working directly on bony structures or endangerment sites (Areas of the body that contain superficial, delicate structures that are relatively unprotected and therefore prone to injury)

Meeting the needs of the client during the treatment process

When carrying out a massage treatment, your client should be comfortable and suitably positioned throughout. The application and duration of massage techniques should be appropriate to the client, their condition and the aims of the treatment. Any contra-actions should be acted on accordingly.

You will need to adapt your own posture and position throughout the application to make sure the application is safe and effective.

You will need to communicate with your clients throughout the treatment, monitor visual and oral feedback and adapt the treatment strategy accordingly. You should also remove the massage medium when necessary.

Make sure you apply and maintain professional standards throughout your treatments and restore the working environment to a safe and hygienic condition after treatment.

Performing performance massage treatments

Prepare treatment area, equipment & self

Prepare & position client for massage treatment

Perform massage techniques effectively Adapt treatment, posture & position as required

Maintain interaction & communication throughout treatment

Remove massage medium

Restore working environment to safe & hygienic conditions

Post treatment-care advice

Lifestyle factors are the modifiable habits and ways of life that can greatly influence overall health and wellbeing. Factors can be classified as positive or negative

Positive lifestyle factors

Factors which will have a positive impact on the client’s recovery include the following:

• access to additional resources, e.g. gym member

• high level of commitment, e.g. their own reasons for rapid recovery

• access to coaching/expert advice

• flexible working hours or being able to balance work

• eating a balanced diet

• getting sufficient sleep

• being able to make time for relaxation

• avoiding smoking

• limiting alcohol.

Negative lifestyle factors

Factors which will have a negative influence on the client’s recovery include:

• unable to rest the injured area due to work

• childcare demands

• high volume of seated activity, e g desk worker

• necessity of climbing stairs

• too much physical activity

• not getting enough sleep

• smoking

• having an unhealthy diet or deficit calorie intake

• high alcohol intake

Activities of daily living (ADL)

ADL can account for stress and demands placed upon a client’s body. These are basic tasks that must be accomplished every day for an individual to thrive. These include:

• maintaining a safe environment

• communication

• breathing

• eating and drinking

• elimination

• washing and dressing

• controlling temperature

• mobilization

• working and playing

• expressing sexuality

• sleeping

They should therefore be taken into consideration during assessment.

Aftercare

After the treatment it’s important to present aftercare advice to clients and provide opportunities for questions. You should also be prepared to give further information, advice and inform clients how they can play a more active role in optimising their health. This should be communicated clearly and accurately in a manner appropriate to the client and your own scope of practice. Advice and information can be about:

• rest

• hydration

• stretching.

• Referral to another professional

• develop unexpected symptoms

• treatment is not working

• outside the limit or professional knowledge and scope

• adverse reaction awareness

• nutrition

Advice can also be on the effects of massage and the appropriate times to repeat its application, including:

• erythema

• dehydration

• tiredness

• bruising.

Remember to record your massage sessions as legally required. It’s also important to record information & advice and the methods used for monitoring progress.

Evaluation of treatment

If you are to provide a high standard of treatment and make potential improvements, it’s important that you evaluate your treatments and obtain feedback. Self-reflection is also important:

• To evaluate your own strengths and areas for improvement.

• To improve professional practice.

• To inform professional development and training.

• For health and safety.

When self-reflecting it‘s important to reflect on a variety of aspects of your professional performance These could include:

• Massage performance including posture, use of body weight, application of techniques, client positioning

• Communication skills during the assessment process, throughout treatment. Consider both verbal and non-verbal communication used.

• Assessment skills including client handling.

• Record keeping.

• Treatment planning.

• Techniques and adaptations.

• Aftercare advice.

The methods used to evaluate the effectiveness of treatments include both subjective and objective feedback.

Subjective and objective feedback

• Subjective feedback

This can be highly influenced by a person’s feelings and therefore be biased. It can include:

o seeking client’s opinion/satisfaction level

o degree of muscle soreness

o degree of muscle stiffness

o feeling of wellbeing/preparation for activity.

• Objective findings

Generally measured or comparable outcomes and includes:

o reassessment of examination findings

o palpation of treated tissues

o observation of area

o re-evaluation of comfortable movement patterns.

Since subjective feedback is based entirely upon the client’s own judgement it can be misleading.

Therefore, objective feedback will generally give the most reliable conclusions as it is a measured method.

The best ways to get feedback from your clients include:

• Recording the client’s reaction to the treatment.

• Reflecting on the feedback received and self-analysis of treatment.

• Interpreting feedback from the client and your own findings and measuring these against the aims of the treatment

• Evaluating the treatment and identifying areas and opportunities for improvement.

It’s essential to provide opportunities for further feedback:

• To keep the client informed.

• To ensure full understanding.

• To promote a client’s empowerment.

• To establish immediate feelings and impressions.

• To evaluate client satisfaction.

Post massage treatment evaluation

Carry out post massage assessment of client Obtain feedback from client Evaluate treatment

Identify areas and opportunities for improvement

Present aftercare advice to clients, providing opportunities for questions

Report progress (if necessary) to healthcare professional

Ensure all records are detailed, up to date and accurate

Section 4: Points to discuss

Test your learning by filling in the boxes below.

Check your understanding! Please tick:

You understand…

How massage came to be developed and its complementary uses

The fundamentals of performance massage – the equipment and environment

How to evaluate your massage treatments and meet the ongoing needs of your clients.

TEST YOURSELF

Describe the main massage techniques used in performance massage

Write your answer here:

TEST YOURSELF

Hitting the spot

Your client has been training hard for a marathon and they’ve asked you for a leg massage.

Create a basic massage sequence which you feel will meet the needs of your client.

Write your answer here:

TEST YOURSELF

The bare necessities

You’ve been asked to provide performance massage for a mountain bike team. The course is around 400 metres from the car park, across a muddy field.

As you will need to carry everything yourself, make a list of all the essentials you think you will need.

Write your answer here:

Revision notes on Section 4:

Write up any notes about the chapter you want to make here:

Create your own glossary

Throughout this manual you will come across words and terms that you may have never heard before. As you read the manual, pick the key terms that you want to remember and record them here with their definition.

Peter Brukner, Karim Khan - Clinical Sports Medicine, McGraw Hill

Sandy Fritz - Mosby's Fundamentals of Therapeutic Massage, Mosby Lifeline

Gerard J-Grabowski, Sandra Reynolds Tortora - Principles of Anatomy and Physiology, Harper Collins

Memmler Cohen, Wood- Structure & Function of the Human Body, LIppincott

Steve Bedford - Sports Performance Massage, Taylor & Francis Ltd

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