The Art of Massage
J. H. Kellogg, M.D.
The principal movements included under this head
are: Flexion, extension, abduction, adduction, pronation supination,
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
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
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
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.