The Art of Massage
J. H. Kellogg, M.D.
    The principal movements included under this head are: Flexion, extension, abduction, adduction, pronation supination, circumduction, stretching.
    Certain principles which apply to all the different forms of joint movements must first be considered before describing particularly the individual movements. The most important of these are the following:

    1. Joint movements may be either passive or resistive. In passive movements there is simple motion of the joint, effected wholly by the manipulator, and without any effort on the part of the patient. In passive movements, the effect is chiefly confined to the joint, involving its articular surfaces, the ligamentous bands by which the joint is supported, and the blood and lymph vessels connected with it. In resistive movements, not only the joint but the muscles acted upon, are involved, since both the patient and the masseur take part in the movement, the patient resisting the movements which the masseur endeavors to execute, or vice versa.

    2. The extent of the movement in passive motion of the joint should be sufficient to produce a distinct feeling of resistance, the degree of which will indicate the extent to which the liga mentous structures of the joint are acted upon.

    3. The degree of resistance employed in resistive movements should always be carefully regulated to the condition of the patient's tissues. Too great resistance is likely to leave the muscles sore, requiring several days' rest from treatment, and perhaps discouraging the patient. Slight soreness, however, may be expected at the beginning of treatment. This is due simply to the congestion of the muscle resulting from the afflux of blood, and will be followed by improved nutrition which will terminate in an increase of strength.

    4. In resistive movements, resistance on the part of the masseur should carefully follow the movements of the patient in flexion and extension. The ability to do this well can only be acquired by careful practice.

    5. In case of great feebleness of the muscles, the movements must sometimes be assistive rather than resistive, until the patient acquires ability to lift the limb, which may sometimes be found lacking at the beginning of treatment, or until the connection between the will and the muscles, which has been at first interrupted, shall be restored. Sometimes the patient fails to contract a muscle through lack of confidence. Assistive movements made in such a manner as to give the patient the impression that the movement is effected through his own volition, will overcome this obstacle with surprising readiness.
    Every experienced gymnast is acquainted with the fact that when a muscle is once contracted to the extent of its capacity, much greater force is required to overcome the contraction than the same muscle would have been capable of exerting in contracting against resistance. This fact may be utilized in the treatment of patients whose muscles are extremely feeble, the resistance being made by causing the patient to first flex the limb or extend it, as the case may be, and endeavor to hold it in position while the manipulator applies force to change its position.

    6. In resistive movements either the patient or the masseur may initiate the movement. Usually the patient initiates the movement, and the operator, the instant the movement starts, begins to offer resistance, first very slight, but gradually increasing to the limit of the patient's strength, then diminishing, so as to allow the completion of the movement on the part of the patient ; that is, the complete extension or flexion, abduction. or adduction, supination or pronation, of the limb, as the case may be. If the muscle is very feeble, the patient should completely extend, flex, abduct, adduct, supinate, or pronate the limb, before the resistance is begun, the masseur then making the attempt to execute the opposite movement, while the patient endeavors to retain the limb in the position in which it has been placed.

    7. Patients often need to be taught how to execute a movement, especially those whose muscles have been long at rest. Sometimes the patient fails to move a limb as requested, because he contracts both the extensors and the flexors equally at the same time, producing a: trembling oscillation between flexion and extension instead of a definite movement. This obstacle must be met by careful training, in which assistive movements may be at first required.

    8. When it is desired to limit the motion to a single joint, the portion of the limb on the proximal side of the joint_that is, the side next the body should be steadied so as to prevent motion of the next joint above, while the distal part of the limb is grasped and made to execute the .movements required.

    9. As a general rule in resistive movements, the fingers pull to resist flexion while the heel of the hand pushes to resist extension. The same principle applies to abduction, adduction, and other movements.

    Physiological Effects. - The venous and lymph channels, especially the latter, are larger in the vicinity of the joints than in other parts of the limbs, a fact which is doubtless attributable to the great amount of absorption required to keep the articulating surfaces in perfect working order. This fact attaches very great importance to manipulations involving the joint or its immediate vicinity. On account of it, joint movements and manipulation of the joints are capable of producing very powerful derivative effects upon neighboring and more distal parts. Through the direct influence of movements and massage upon a joint, its nutrition may be modified to a very marked degree, as the result of the hyperaemia induced and the increased circulation of fluids in the blood and lymph channels. The influence of movements upon a joint is well illustrated in the large finger joints of artisans, especially those who use the hands in heavy lifting.

    Therapeutic Applications. - Joint movements are of special value in the various forms of chronic joint disease in which movement is lessened, as in the stiffening which arises from rheumatism, rheumatic gout, chronic synovitis, and the treatment of fractures and sprains by complete immobilization. Joint movements, cautiously employed, may also be of use in the derivative treatment of an acute inflammatory process in a neighboring and more distal joint. It should be remarked that great care is necessary in treatment by the application of joint movements in neuroses of the joint, such as are frequently left after attacks of inflammation arising from injury or otherwise. Even the gentlest manipulations are sometimes very badly borne in these cases. Often derivative friction practiced upon the joint above and the neighboring soft tissues will alone be tolerated by these cases until after a very considerable degree of improvement in the nutrition of the parts and a lessening of the patient's general nervous irritability have been secured. It is sometimes necessary to postpone joint movements several weeks, and perhaps for two or three months. It is hence highly important that cases of this sort should be recognized at the outset, as otherwise the patient is likely to be made worse and, becoming discouraged by the treatment, give it up. Hydrotherapy and electricity are almost indispensable in the early stages of the treatment in these cases.

Flexion, Extension, Abduction, Adduction, Supination, Pronation, and Circumduction. - Practically the same principles govern the application of these several different movements.
    The chief points to be considered. in addition to those already presented. relate to the special mode of executing the different motions for different parts, which may be briefly described as follows:

    Flexion and Extension of the Wrist (Fig. 64). - With the forearm halfway between supination and pronation, take the patient's hand as in shaking hands, right to right or left to left. The other hand should seize the forearm just above the wrist. In this position, passive movements of both flexion and extension may be executed. The same position is also used for resistive flexion.

    For resistive extension, the patientís forearm should be pronated and the hand of the patient grasped by the masseur with his opposite hand; that is, left to right and right to left. The other hand should steady the arn, by grasping it just above the wrist (Fig. 65).

    Pronation and Supination of the Hand. - For passive pronation and resistive supination (Fig. 66), the masseur grasps the wrist of the patient with his opposite hand (right to left or left to right), in such a manner that the back of the wrist and the lower ends of the bones of the forearm fall into the hollow of his hand, the thick portion of the thumb resting just behind the lower end of the radius so as to control it. The other hand is placed beneath the elbow to support the patient's arm, care being taken not to hold the bones of the forearm so tightly as to prevent their free movement.

    For passive supination and resistive pronation of the hand (Fig. 67), the masseur grasps the patient's right hand with his own right, supporting the arm with his left. With the patient's arm in pronation, the hand of the masseur should grasp the forearm in such a way that the palm of his hand will rest upon the front of the wrist, the fleshy portion of the thumb falling upon the front side of the lower end of the radius.

    Flexion and Extension of the Forearm (Fig. 68). - The masseur grasps the wrist of the patient with his corresponding hand, and with his other hand seizes the arm just above the elbow and steadies it.

    The same grasp serves for either passive or resistive flexion or extension, and may be employed for passive pronation and supination, abduction and adduction, and rotation of the humerus. All of these movements, with the exception of resistive flexion and extension, may be accomplished in making the wrist describe a circle.

    Circumduction of the Arm. - The masseur stands behind the patient, fixes the shoulder with his opposite hand, and with the other seizes the arm just below the elbow, and causes the lower end of the humerus to describe as great a circle as possible without too great resistance. The peculiar formation of the shoulder joint gives the greatest resistance at the upper part of the circle.

    This same grasp is a suitable one for resisting the action of the muscles which pull the arm forward and those which draw it backward.

    Circumduction. may also be performed by standing in front of the patient aind seizing the wrist with the corresponding hand and the elbow with the other hand (the patient sitting).

    Backward movements of the arm may be resisted by taking the hand of the patient with the corresponding hand, and with the other hand grasping the arm above and behind the elbow.

    The deltoid may be resisted by placing one hand upon the shoulder and the other upon the outside of the arm near the elbow. It is most convenient for the masseur to stand behind the patient.

    Movements of the Ankle (Fig. 69). - The masseur should sit facing the patient, who sits with leg extended. Seize the foot with the corresponding hand at the junction of the toes with the body of the foot, the thumb falling upon the sole of the foot; with the other hand. grasp the leg above the ankle. This grasp is convenient for passive and active flexion, and extension and also circumduction The pressure should be applied against the distal ends of the metacarpal bones, rather than upon the toes.

Movements of the Knee Joint (Fig. 70). - These movements are usually combined with movements of the hip joint, as follows:
    The heel of the patient is grasped by the corresponding hand of the masseur, while the other grasps the calf of the leg. In passive movements the limb, is simply pushed up, and allowed to return to extension by its own weight.

    For passive circumduction, the assisting hand is placed upon the top of the knee instead of the calf, the knee being made to describe as large a circle as possible with moderate resistance.

    In resistive flexion and extension of the leg, the leg and foot are grasped as in movements of the ankle. Considerable force must be used by the masseur in resisting extension, which may be done either when resting upon the knee placed upon the edge of the couch, throwing the body forward, or by standing with the back to the patient and clasping the hands across the sole of the foot beneath the instep.

    Abduction and Adduction qf the Thighs (Fig. 71). - The patient lies with the knees half flexed by drawing up the heels. Abduction is resisted by placing the hands against the outer side of the knees; adduction, by placing them against the inner surface.

    Resistive Flexion of the Thigh. - The patient draws up the leg while the masseur makes resistance by placing the hand upon the anterior surface of the thigh, near the knee.

    Joint Stretching. - This is a powerful means of stimulating the nutrition of a joint. Enlargement of the joint has long been noticed to be a consequence of " cracking" the fingers. Joint stretching is much practiced by the Turks in connection with the shampooing of the Turkish batb. Stretching may be applied as follows :

    The Arm and Shoulder Joints. - The patient lying upon the back, the head and shoulders slightly elevated and the arms extended upward, the masseur stands behind and seizes the hands of the patient in such a manner that the palmar surfaces of the hands are in contact, the thumb of the masseur passing between the thumb and the first finger of the patient, while his fingers pass around the fleshy portion of the thumb and the back of the hand of the patient. The grasp might be described by saying that the patient and masseur each grasps the otber's thumbs with the corresponding hand. A series of vigorous elastic pulls are made, avoiding sudden twitches. The application of the force applied should be gradual, the withdrawal sudden.
    This movement not only acts upon the joints of the shoulders and arms by stretching them, but may be a powerful means of expanding the chest by making the patient inspire while the masseur stands in a chair behind him and resists the downward pull of his arms. As before stated, the pull should not be continuous, but should be intermittent, each strain lasting three to five seconds, the patient being allowed to take a breath during each interval.

    The arm and shoulder joints may also be stretched as follows: The patient lying with the arm extended at the side, the masseur, facing the same side, grasps the patient's hand with his opposite hand, placing the other hand against the chest close to the axilla, and pulls with force graduated to the strength of the patient.

    Stretching of the joints of the legs may be applied by seizing the foot and pulling in the line of the body. The toe joints are stretched by pulling each toe separately.

    The Finger Joints. - Flexion, extension, and stretching movements should be applied to the finger joints especially in the treatment of cases in which these joints are stiffened by disease or by improperly treated fractures of the wrist or forearm, and in writer's cramp.