Menstruation occurs when production of the ovarian hormones, especially progesterone, is reduced. This hormonal adaptation results from failure of the ovum to become fertilized.
Menstruation itself is quite often preceded by premenstrual tension (PMT); this condition is in fact a syndrome and is therefore a combination of symptoms, ranging from water retention to back-ache and depression. Water retention is perhaps the most common symptom, and ensues from the cyclic increase in the steroid hormones. PMT can also be caused by endocrine changes such as progesterone deficiency, oestrogen/progesterone imbalance and raised aldosterone levels.
Pelvic congestion is a major feature of PMT and can refer pain to the back, over the sacrum, to the lower abdomen and down the thighs.
Fluid retention is another common characteristic;
this can lead to hypersensitivity and nerve pain in some regions, and even to headaches.
Alongside these changes are those which affect the fascia. In stable conditions, fascia is a flexible tissue that can expand with the increased fluid build-up. When it is subjected to mechanical stresses such as postural patterns and imbal-ances, the fibroblast cells within the fascia are activated and this leads to certain adaptations.
Collagen fibres are laid down, causing the fibres to thicken and adhere to each other, and as the fascia becomes harder and unyielding it is unable to accommodate fluctuations of fluid in the inter-stitial spaces. The consequence of such a restric-tion is that any build-up of fluid creates additional pressure on the nerve endings, which exacerbates the pain. Malfunction of the fascia can also give rise to trigger points, which are sometimes observed in the cervical muscles.
Trigger points can bring on or exacerbate headaches during the premenstrual period.
Massage application
● The relaxing effect of massage is very signifi-cant, as it helps to lessen the intensity of ten-sion, irritability, depression and crying spells (Field, 2002). However, in some cases of PMT the abdominal area, or indeed the whole body, may feel too tense and tender for the physical contact of massage. In this situation massage to the feet, hands and the head may be tolerated and suitable as a starting point. With the effect of relaxation and the reduced pain sensitivity other movements can then be applied, pro-vided the massage is always comfortable to the subject. Light effleurage techniques are mostly used, to soothe the pain, but movements such as kneading to some areas like the calf can also be used.
● Postural patterns and imbalances can compli-cate and increase the symptoms of PMT.
Massage is used to address tightness and dys-function in muscles and, in so doing, reduces mechanical stresses, spasms and fatigue.
Passive movements to the joints can be carried out.
● Massage techniques for venous return and lymph drainage are carried out in between menses just prior to menstruation. The goal of the massage in this case is to remove conges-tion and to enhance the eliminaconges-tion of toxins
and excess fluid. The breast tissue is also sus-ceptible to fluid retention and can, if appropri-ate, be treated with lymph massage movements.
● The application of massage techniques to deal with trigger points can be too painful during periods of fluid retention. Once the oedema is reduced, however, the area is treated with on-and-off pressure and passive stretching.
Pregnancy
The general effects of massage in pregnancy Massage therapy can be of great benefit in preg-nancy as it helps to relieve some of the discom-forts associated with postural changes and additional weight. It also helps to maintain a good overall function of the body and provides relaxation and emotional support. The applica-tions of massage during the second and third trimesters as well as postnatally are discussed further on in this chapter while some of the gen-eral benefits are given in this section.
Relaxation
● Anxiety is not usually an antenatal feature but should there be any apprehension associated with the pregnancy or any mood swings, mas-sage is an excellent way of providing relax-ation and support. If there happens to be stress that is related to psychosocial factors, massage can likewise be of benefit.
● Relaxation techniques can be applied through-out pregnancy and it is worth bearing in mind that the calming effect of massage can also be seen as extending to the baby in utero.
● Through its effect on the parasympathetic nervous system (Tovar and Cassmere, 1989) massage can stimulate the production of the body’s natural endorphins; it can therefore be of great value in reducing pain (Jacobs, 1960).
● The sedating effect of massage helps with rest and relaxation and in turn lowers the levels of catecholamines. These compounds can inter-fere with oxytocin and other hormones during labour and they can also affect the baby in utero if they pass through the placenta.
Musculoskeletal
Hormonal changes, increase in body weight and postural adaptations are amongst the contribut-ing factors to the back pain often endured durcontribut-ing pregnancy (Cailliet, 1995; French’s Differential Diagnosis, 1985). Massage can play a significant role, particularly during the later months of pregnancy, in alleviating pain in the lumbar area.
In some cases, sciatica, which is often connected with tightness of the lumbar muscles and/or of the piriformis muscle, can likewise be eased with massage.
While not pertaining to the posture directly, carpal tunnel syndrome of one or both wrists does occur sometimes during pregnancy and may give rise to considerable discomfort.
Increased fluid retention may be a contributory factor to the symptoms, and massage for venous return and lymph drainage on the upper limbs is therefore of benefit.
Circulation
During pregnancy the body increases its produc-tion of progesterone which may in turn cause hypotonicity in the peripheral blood vessels and consequently lead to a sluggish circulation, oedema and varicose veins. The circulation can be impaired further by the pressure of the uterine weight on the pelvic vessels. With a slow venous return in the iliac, femoral and saphenous veins the body’s susceptibility to blood clot formation is raised. Blood clot formation increases four to five times during pregnancy while fibrinolytic activity (clot-dissolving) activity decreases dra-matically to avoid haemorrhaging during child-birth. Massage movements, effleurage in particular (Dubrovsky, 1982), can be preventative in this respect as it helps to provide the ‘back pressure’ that is necessary to maintain the blood flow in the pelvic and peripheral vessels.
Effleurage and lymph massage movements to the lower limbs assist the venous flow and reduce the build-up of fluid. Decreasing the con-gestion lessens the possibility of varicose veins, albeit that the massage is omitted if these have already developed.
Conversely, the pregnant woman may suffer from high blood pressure during the gestation period and, in such a situation, relaxation move-ments can be applied to help lower the readings.
An enhanced systemic circulation means there is also a good blood supply to the placenta and subsequently a good distribution of nutrients reaching this organ.
Improving the blood flow can help raise the number of red blood cells in the circulation. One possible pathway is the freeing up of any cells caught up in congested areas. An increase in the number of circulating red blood cells has the effect of preventing anaemia, or lowering its severity. In addition, more oxygen-carrying haemoglobin is released into the tissues systemi-cally, and this helps combat fatigue.
Organ function
Another benefit of massage is the improved func-tion of organs. An enhanced liver funcfunc-tion, for instance, leads to the elimination of toxins (through the expelled bile) and subsequently to an elevation of the energy levels. Unless there is eclampsia (see Contraindications) the normal levels of toxins released by the liver are not likely to cause systemic toxaemia and therefore mas-sage is safe.
Reduced peristaltic activity and constipation are often present during pregnancy. As pressure on the abdomen is best avoided, the massage treatment for improving peristalsis is applied by means of the stroking movements on ‘reflex areas’ to the digestive system; these include the thighs, the buttocks and the feet (reflex zones).
Connective tissue
To maintain tissue pliability and prevent the like-lihood of stretch marks, extremely light massage strokes can be applied on the abdomen, using only the flat palm of the hand and with an appro-priate body cream or oil.
The perineum too can be massaged during pregnancy to maintain the flexibility and elastic-ity in the tissues, thereby lessening the need for an episiotomy during childbirth. As it is not
ethical for the massage therapist to carry this out, instructions can be given to the pregnant woman or her partner. A study to evaluate the effective-ness of perineal massage during pregnancy for the prevention of perineal trauma at birth was carried out at the Department of Family Medicine, Laval University, Quebec City, Canada. It was found that perineal massage is an effective approach to increase the chance of delivery with an intact perineum for women with a first vaginal delivery but not for women with a previous vaginal birth (Labrecque et al., 1999). No differences were observed between the groups in the frequency of sutured vulvar and vaginal tears, women’s sense of control, and sat-isfaction with the delivery experience. A similar study, which looked at the effects of antenatal perineal massage on subsequent perineal out-comes at delivery, was carried out at the Department of Obstetrics and Gynaecology, Watford General Hospital, Hertfordshire, UK.
The research concluded that antenatal perineal massage appears to have some benefit in reduc-ing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above (Shipman et al., 1997).
Contraindications
While massage is beneficial and effective throughout pregnancy it can easily become con-traindicated if certain disorders or complications arise, e.g. symphysis pubis dysfunction where massage is specifically ruled out in the pelvic area. Other possible contraindications listed here are meant to be pointers for the massage ther-apist and are not hard and fast rules. If the suit-ability of the massage is a borderline decision, then advice or authorization should always be sought.
● It is an essential precaution that massage is car-ried out without causing pain to the expectant woman. Adrenal stress hormones, released as a response to pain, have the effect of elevating blood pressure, respiration rate and heart rate;
the immune function is also lowered and blood
flow to the uterus is impaired (Gorsuch and Key, 1974). It is easy to imagine how the same negative effects of the stress hormones can also diffuse into the fetal circulation through the placenta.
● As indicated earlier, massage on the pregnant abdomen is avoided other than very superfi-cially for the purpose of applying creams or lotions. Abdominal massage is totally con-traindicated if the linea alba is strained (diasta-sis recti) because of the increased pressure on the interior abdominal wall by the pregnant uterus.
● Compression is also avoided in the inguinal region as it can generate pressure on the iliac and femoral veins.
● Systemic massage is also contraindicated if complications arise during the pregnancy, par-ticularly when there is a risk of increased intrauterine pressure. A case in point is an abnormality of the placenta (detachment or dysfunction) or irregularities in the uterus or cervix.
● Equally significant are disorders that can influ-ence the blood supply to the fetus, such as high blood pressure and multiple fetuses.
● Pain in the abdomen that is not related to the later stage of pregnancy, and therefore to cramps or contractions, may have some under-lying aetiology that requires investigation.
Massage is therefore contraindicated until a diagnosis is carried out.
● Other precautions relate to persistent diar-rhoea and gestational diabetes.
● Itching without the presence of a skin rash may be indicative of obstetric cholestasis and is a further contraindication to massage. Obstetric cholestasis is a liver disease which manifests in pregnancy and which completely resolves within a week or two of delivery. It tends to start around the 28th week and is likely to be caused by the high levels of oestrogen hor-mones causing a reduction in the flow of bile.
An excessive amount of bile acids accumulate in the liver and leak into the blood, causing itching of the skin and in some cases jaundice.
A deficiency of vitamin K may also be present as a result. The itching of obstetric cholestasis
is often in the palms of the hands, the soles of the feet, and can spread to the limbs and trunk.
It is different, however, to the normal itching of pregnancy which can occur around the breasts and abdomen. Massage in the region of the liver is not only difficult but is also not advised during pregnancy; it can cause discomfort and the increased circulation may even exacerbate the symptoms.
● Eclampsia is another contraindication to mas-sage. This condition refers to severe toxaemia of pregnancy accompanied by high blood pres-sure, albuminuria (serum proteins, especially albumin, in voided urine, which are indicative of kidney impairment), oliguria (diminished amount of urine formation), tonic and clonic convulsions, and coma. A very gentle and short massage for relaxation may be possible with the aim of reducing the high blood pressure.
This is best carried out to the upper back and shoulders, for example, and with the patient in a sitting position. Oedema does present in the lower limbs, but this is more likely to be a result of kidney and liver failure than lymphatic blockage. In any event, owing to the serious-ness of the condition it is best to avoid any drainage massage movements on the legs.
● During the middle and later months of preg-nancy, massage with the subject lying supine is best avoided as the weight of the fetus presses on the major blood vessels such as the inferior vena cava (supine hypotensive syndrome). If the supine position is the only feasible option then cushions and bolsters may be used to prop up the subject in a semi-sitting posture.
This reduces some of the pressure on the abdominal vessels and allows for massage to certain regions such as the lower limbs.
● Massage in the prone position should be avoided after the twelfth week of gestation or much earlier in the case of multiple fetuses.
Even with the use of special cushions or equip-ment, the prone position may increase the intrauterine pressure and will inevitably inten-sify the tension on the over-strained uterine and lumbar ligaments.
● Because of the laxity in the ligaments more or less systemically, extreme caution is required if
passive movements to joints are carried out.
Traction techniques, especially to the lower limbs, are contraindicated.
● Persistent or severe backache may need refer-ral to a ‘manipulation therapist’ such as an osteopath, physiotherapist or chiropractor.
● In some cases, pain is felt in the lower abdomen, the pubic area, the groin or radiating down the inner thighs. This type of pain is usu-ally made worse by walking or climbing stairs and is likely to be that of diastasis symphysis pubis (DSP) or symphysis pubis dysfunction (SPD). DSP and SPD are two conditions of pregnancy which certainly require the atten-tion of a doctor or manipulative therapist.
Fortunately these conditions only affect a small proportion of women.
DSP means an abnormally wide gap between the two pubic bones at the symphysis pubis joint, situated at the front of the pelvis. It can only be diagnosed conclusively by investigation such as X-ray, ultrasound or MRI scan. In the non-pregnant woman the normal size of the gap is 4–5 mm. Under the influence of the pregnancy hormones the pubic ligaments slacken and this gap increases by at least 2–3 mm during preg-nancy. Therefore, it is considered that a total width of up to 9 mm between the two bones is normal for a pregnant woman. Following deliv-ery, this natural extra gapping decreases within days, although the supporting ligaments will take 3–5 months to return to their normal state, making the symphysis pubis a strong joint again.
An abnormal gap is considered to be 1 cm or more, sometimes with the two bones being slightly out of alignment, and remains evident after the time that the joint should have regained the normal non-pregnant width.
SPD refers to a dysfunction of the symphysis pubis joint. The symphysis pubis, along with the sacroiliac joints at the back of the pelvis, plays an important part in holding the pelvis absolutely stable during movements involving the legs and pelvis. Laxity of the pelvic ligaments may cause instability in the sacroiliac and symphysis pubis joints, and may give rise to the symptoms of groin and pubic pain. Although less serious than
the DSP condition, symphysis pubis dysfunction necessitates appropriate attention.
The first trimester
In early pregnancy, usually the first 3 months (first trimester), many hormonal and physiologi-cal changes are taking place in the body.
Massage is unlikely to harm the fetus or dis-turb the natural processes. However, being such a delicate and important time for the expectant mother and bearing in mind that miscarriage (spontaneous abortion) is most common during the first trimester, it is advisable that any possible complications are avoided. Low back pain or pelvic pain may be one of the symptoms of spon-taneous abortion and must not be mistaken for simple muscular ache. Consequently, lumbar massage for back pain is contraindicated. It is postulated by some authors that massage on the sacrum can lead to contractions of the uterus and to spontaneous abortion, and this is therefore specifically contraindicated. Support for this hypothesis is not readily available but this cau-tionary note to the massage is worth bearing in mind. Musculoskeletal pain in the lumbar area that abates with a change of posture or lying position may indicate that the pain is not referred from a contracting uterus. However, a cautious approach is necessary in all cases of back pain during this stage even if other possible causes such as soft tissue strains, spinal dysfunctions or urinary tract infections are ruled out. Massage on the abdominal area is certainly not recom-mended during this phase. Care may also be needed while there is still morning sickness or vomiting. Relaxing massage movements are oth-erwise of benefit.
Second and third trimesters
Changes to the posture and structure occur mostly during the second and third trimesters of pregnancy. Studies have shown that 48–56% of all pregnant women experience backache during
Changes to the posture and structure occur mostly during the second and third trimesters of pregnancy. Studies have shown that 48–56% of all pregnant women experience backache during