Introduction

Massage therapy is the manipulation of the skin, muscle, or superficial soft tissues either manually or with an instrument or mechanical device for therapeutic purposes. It has been developed over thousands of years and across the world as a method to promote and restore health. There are over 80 different forms of massage, ranging from soft and pleasurable to deep and uncomfortable. This discussion will be limited to some of the most commonly used forms of therapeutic massage. With the more recent boom of research on myofascia and its relationship to whole body function, the importance of many forms of massage as myofascial therapeutic treatments is recognized.

Development of Massage Therapy

Defined by Hippocrates as “the art of rubbing,” massage has an extensive history. References of massage date back to 2500 BC, making it one of the first treatment modalities ever documented. Although first described in China, ancient Greeks and Indians also implemented massage, but it was the Roman empire that notably embraced massage therapy for sport and war injuries [1, 2].

Like other forms of manual therapy, massage therapy was originally applied to humans and subsequently to domesticated animals. Early animal massage therapists were initially trained as human massage therapists that adapted their training to animals. Numerous animal massage schools and certification programs arose in the 1980s–1990s, but there is still no universally accepted standard of education or certification for animal massage therapists as there is for human massage therapists. In the United States, the legal requirements for animal massage therapy are determined by each state’s veterinary board. It was shown that the training and experience of the therapist is an important factor in the effectiveness of massage [3].

Massage is generally considered safe and has a low risk of adverse effects. Contraindications to massage are not absolute rules based on empirical data, but rather guidelines grounded on common sense. Potential contraindications include acute inflammation, skin infection, nonconsolidated fracture, burns, active cancer tumor, deep vein thrombosis, and rhabdomyolysis [4–6].

Massage as Therapy for Musculoskeletal Pain and Dysfunction in Humans

The force, speed, depth, and pressure used in different forms of massage therapy to mobilize the tissues is highly varied, a factor that makes comparing research on massage therapy difficult. A 2014 review of massage therapy research indicates that moderate pressure massage is more effective than light pressure massage for improving chronic pain conditions; where moderate pressure massage involves moving the skin and light pressure massage involves lightly stroking but not moving the skin [7]. It is theorized that the need for moderate pressure versus light pressure massage indicates involvement in stimulation of pressure receptors which in turn can activate the vagus nerve. The stimulation of the vagus nerve is theorized as the mechanism for massage therapy’s effects on gastric function, heart rate, blood pressure, and cortisol levels [7]. A massage research review of years 2013–2016 covered approximately 20 randomized controlled trials conducted on pain syndromes. Results suggest massage is effective in reducing pain, increasing range of motion and/or improving function in several types of musculoskeletal pain/dysfunction categories, including back and neck pain, knee and upper limb arthritis, and muscle pain [8].

Despite research that claims widespread benefits of massage for pain, there are recent reviews that question the validity of such claims. Recent reviews found no studies of moderate to high strength to support claims of pain relief [9, 10]. This finding is consistent with an earlier review of sports massage that concluded there were only equivocal results on blood flow, blood lactate removal, and delayed onset of muscle soreness, with blood lactate removal following exercise more efficiently removed through active recovery strategies rather than through massage [11]. It is noted that applying scientific principles to the study of massage and other forms of manual therapy presents methodological challenges for researchers

In addition to other design challenges, the skill and experience of the therapist is a variable which is not easily reproduced across studies.

Research in Animals

In 2002 the Jack Meagher Institute published a small but pivotal equine study showing the positive effects of increased range of motion demonstrated as increased stride length on horses massaged for 20 minutes using direct pressure, cross-fiber friction, and compression. In this small, controlled study, horses underwent treadmill locomotion evaluation to record stride lengths before and after massage. The specific muscles targeted with massage therapy were major muscles involved in the planned work: the supraspinatus, triceps brachii, biceps femoris, and superficial gluteal muscles. After massage, the stride length at the walk increased by 3.6% (4.8 inches) and the stride length at the trot increased by 1.2% (1.7 inches). Due to increased range of motion, a decreased stride frequency was documented [12]. Although these findings imply a positive effect of sports massage on athletic performance in the horse, the findings are not considered clinically significant due to the small sample size. These findings were consistent with larger studies involving human athletes which demonstrated that therapeutic massage induced improvements in flexibility and range of motion [13, 14]. Similarly, a subsequent comparative crossover design study demonstrated that massage to the caudal muscles of the equine hind limb, that is the superficial gluteal, semitendinosus, biceps femoris, and semimembranosus muscles, significantly increased both passive and active hind limb protraction. This study measured active hind limb protraction as increased stride length, a result supportive of the previous Jack Meagher study [15]. Other studies showed massage therapy in horses resulted in lowered mechanical nociceptive thresholds within the thoracolumbar region as measured by pressure algometry [16] and a reduction in stress-related behavior [17].

Despite these few promising equine studies, there is still not ample controlled research to support longstanding claims that massage can increase blood flow, promote relaxation, reduce muscle hypertonicity, increase tissue extensibility, reduce pain, and promote return to normal function [11, 12, 18]. Despite of a lack of clear evidence of massage therapy benefits in horses, its use and acceptance by animal owners and veterinarians has grown. A recent international survey of veterinary groups on rehabilitation modalities used in horse treatments revealed that massage was used by 69% of the respondents [19].

Research and literature covering the use of massage in small animals is minimal. Techniques originally described for humans are being used on small animals and the indications and purported benefits extrapolated from human and equine research [2]. Massage use in dogs and cats includes indications outside the common musculoskeletal/athletic massage therapy in horses and also includes: control of postoperative swelling and edema, support to intensive care patients, osteoarthritis and orthopedic rehabilitation, chronic pain and palliative care of geriatric and cancer patients [2].

Massage Techniques

Depending on the patient, diagnosis, and desired outcome, different techniques are employed by therapists. While there are some preferred techniques for specific issues, the final choice is usually based on practitioner’s experience and opinion of the superiority of certain techniques for desired outcomes. Independent of the techniques chosen, the therapist should evaluate the tissue and take note of the tissue’s tone, temperature, moisture content (hydration), pliability, elasticity, and contour [20]. Massage may be performed using the fingers, palms, knuckles, elbows and even shoulders. Mechanical devices are becoming more common and mostly provide vibration or percussion to the tissues. Mechanical devices do not provide the evaluation of tissues and the feedback changes in tissue that is only possible through the therapist’s hands, so it is not advised to rely solely on mechanical devises for treatments.

Massage may be divided broadly as medical or therapeutic massage in which there is a specific injury or physiological goal being addressed or sports massage in which improved athletic outcomes/injury prevention is the goal. Common Therapeutic massage techniques performed in equine and small animal rehabilitation include effleurage, petrissage, tapotage, friction, and skin rolling [2, 6, 20]. To treat equine back pain, massage sessions of 20 to 30 minutes are recommended with the addition of passive mobilization likely improving results [6, 20].

Sports massage is performed either before or after competition. The rationale behind pre-exercise or pre-competition massage is that it prepares muscles for the upcoming activity. Post exercise or post competition massage is chosen based on the claim of enhanced removal of metabolic waste. Neither claim is fully supported by research. Sport massage techniques are numerous and most often focuses on various “point therapies” such as stress point therapy and trigger point therapy, and use techniques such as compression, direct pressure, friction, effleurage, and myofascial release [6].

Description of Techniques

Effleurage or stroking: This technique is commonly used at the beginning and at the end of massage sessions and as a transition between other techniques. It is a technique that prepares the patient and the superficial tissues for deeper work and is used to promote venous and lymphatic fluid return. Effleurage uses long and slow rhythmic strokes with pressure being applied as the therapist’s hands are moving away from their own body and preferably in the direction of venous return of the patient [20].

Petrissage or kneading: This is a technique that is firmer and deeper than effleurage and involves a large portion of muscle while using the hands in a down, around, and up motion in an attempt to recreate the compression and relaxation cycle of a working muscle. On the large muscles of horses, the therapist would use a loosely clenched fist with alternating hands in which one hand is pushing down while the other is coming up. The benefits of kneading are enhanced circulatory and lymph flow, decreased muscle tension, and mobilization of scar tissue including adhesions following a hematoma [6, 20].

Skin rolling: The skin is picked up between the fingers and thumb rolled over the underlying tissues in a continuous manner. Skin rolling, although seemingly superficial, is mobilizing the subcutaneous fascia which is contiguous with the fascia throughout the whole body and thus may have much further reaching physiological effects. It is also used to improve circulatory flow through the dermis [6, 20].

Friction:

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