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How can I tone weak muscles during a massage session?

 

Erik Dalton Responds
erik dalton

 

That’s a good question, and one quite fitting for all bodywork modalities. Traditionally, massage therapy has focused on restoring length (extensibility) to tight myofascial tissues, while the job of strengthening has been assigned to personal trainers and other manual therapy groups. The structural integrative therapist is keenly aware of restoring proper balance between tonic/phasic and global/core muscles to assure positive posture and pain-management outcomes.

Yet, some bodyworkers may lack the appropriate skills for strengthening weak muscles. And depending on one’s certification, scope of practice can be an important issue. Many state regulation boards restrict the massage therapist from offering home retraining exercises or allowing referrals to personal trainers. Despite all these apparent complexities, I’ll try to provide a time-sensitive and practical answer.

Before discussing muscle weakness, let’s briefly address tone. The term muscle tone has always sparked controversy in biomedical and manual therapy circles due to conflicting definitions among various leading authors. In anatomy and physiology, muscle tone, known as residual muscle tension or tonus, refers to the continuous and passive partial contraction of muscles. While residual tonus helps maintain posture, it is not to be confused with the concept of toning in physical exercise.

The word tone simply describes the state of our muscles. When at rest, muscles must maintain a constant state of partial contraction to ready us for action.This reflex helps guard against danger while also assisting in balance control. Muscle tone is involuntary, so you can’t change it by lifting weights or doing Pilates. Having said that, I’m intentionally guilty of misusing the term when describing hands-on, muscle-spindle tonifying techniques discussed later in the article.

Tightness-weakness syndrome

According to the legendary rehabilitation researcher Vladimir Janda, M.D., muscle imbalance implies an altered relationship between muscles prone to tightness, or shortness, and those prone to weakness, or inhibition (e.g. tight pecs=weak rhomboids, tight psoas=weak G-max). Predictable aberrant postural patterns like these are commonly seen in our flexion addicted society and are thought to develop from abnormal afferent information due to a number of factors, including faulty posture, joint blockage, excessive physical demands, painful or noxious stimuli, gravitational exposure, habitual movement patterns and psychological stressors.

Any change within the sensorimotor system due to pain, pathology or adaptive changes will be reflected by compensations or adaptations throughout the system. This leads to systemic and predictable patterns of muscle imbalance. Oddly, the chain of events leading to muscular weakness often takes a strange path.

Clinical experience demonstrates that moderately tight muscles tend to be stronger than normal. Often, however, we encounter a decrease of strength (i.e., the hand-grip test) in clients experiencing prolonged tightness in muscles, such as the forearm flexors. This type of muscle inhibition is called tightness-weakness1 and expresses the close association between neurological weakness and altered viscoelasticity of the muscle and its enveloping fascia.

Caution must be taken when evaluating for muscle weakness. Correcting tightness-weakness syndromes doesn’t rely on strengthening, which would further tighten the tissue, resulting in increased weakness; rather, the correction is made by creating elasticity through deep-tissue massage, myofascial release and assisted stretching routines. This protocol places emphasis on the viscoelastic components of the noncontractile connective tissues.

Stretch-weakness syndrome

Weakness must also be viewed from a neurological perspective. The act of releasing tight agonist muscles also results in improved strength in their inhibited antagonist, likely mediated via Sherrington’s Law of Reciprocal Innervation. Massage therapists unknowingly correct aberrant postural patterns and relieve pain every day by applying Sherrington’s principles. For example, techniques that open up the chest wall reciprocally strengthen the lower shoulder stabilizers.

Likewise, lengthening the lats and subscap reciprocally strengthens the posterior rotator cuff. Too often, therapists defy this basic neurological concept by “fasciamashing” stretch-weakened rhomboids and lower traps. The end result is increased pectoral tightness and greater postural deformity as gravity pulls the shoulders and head further forward. Situations like this demand the stretch weakened rhomboids be strengthened, not lengthened.

“Years of experimenting and refining fast-paced,spindle-stimulating maneuvers has proven to me that muscles can be strengthened manually.”

Spindle stimulation

I’ve always been fascinated with muscle spindle neurology as it relates to the myosynaptic (stretch) reflex. Recall that the muscle spindle is the third most complex sensory organ (behind eyes and ears). We’ve all seen how muscles fight back by tightening and shortening when the restrictive barrier is violated as therapists work too quickly/deeply or overstretch musculotendinous tissue. But we want to find out if we can use a modified version of this process to tone weak muscles in a clinical setting.

Muscle spindles are very sensitive to changes in length and increase their rate of firing when the muscle is lengthened by a very small amount. The interesting thing is this detection mechanism is adjustable. When relaxed, the muscle spindles are relatively insensitive to stretch. However, when the gamma motor neurons are active, or put on the stretch, muscle spindles become shorter and hence, much more sensitive to changes in muscle length. If the muscle spindle contracts faster than does the muscle as a whole, there will be a considerable amount of afferent activity, because the sensory ending within the spindle will be mechanically stretched. Thus, a sudden lengthening of the muscle causes the muscle to contract. This property of adjustable sensitivity is the key to turning on weak muscles using fast-paced, spindle-stimulation maneuvers.

By placing the rhomboids and lower traps on the stretch (client prone, grasping the opposite wrist behind the back), the therapist can stimulate a contraction by working the stretch-weakened tissue in all directions using fists, fingers and forearms. This not only activates the dynamic gamma motoneuron (DGM) system of the spindles causing the muscle under stretch to shorten, but it also promotes greater inhibition (relaxation) of the antagonist pectorals via Sherrington’s Law.

Years of experimenting and refining fast-paced, spindle-stimulating maneuvers has proven to me that muscles can be strengthened manually. Try this simple experiment: Ask your prone client to raise the leg closest to you as high as possible, and make note of the degree of hip extension. Then, place the leg in a figure-four position (hip and knee flexed, so the foot rests against the opposite knee). With force coming from the ground, begin two minutes of fast-paced gluteal stimulation, with soft fists in all directions. (Note: Make sure to apply enough pressure to kick in a mild stretch reflex). Then, place the leg back in the neutral position and recheck for improved hip extension.

Add these techniques to your postural balancing sessions, beginning with spindle-stimulation maneuvers to weak shoulder stabilizers and gluteals, and watch your client’s posture improve. If your state massage laws allow, reinforce these techniques by teaching your client home-retraining exercises using Thera-Band resistant bands and loops.

Contraindications

Before concluding, I want to offer a word of caution. These, as well as other methods aimed at strengthening, must not be performed in the presence of joint dysfunction caused by capsular tightness or loss of joint play. Any alteration in joint function caused by soft-tissue capsular restriction affects the muscles that cross the dysfunctional joint, resulting in inhibition or facilitation.

In the presence of joint blockage caused by capsular tightness, normal articular reflexes may be interfered with, so when the tightened area of the capsule is placed under stretch, it will cause reflex inhibition of the muscles that would stretch that part of the capsule further.2 Corrections should first be aimed at mobilizing the joint capsule, followed by spindle-stimulation techniques to turn on the weakened tissues.

References

  1. Janda, V. “Muscle strength in relation to muscle length, pain and muscle imbalance.” Harms-Rindahl, K, ed. Muscle Strength. New York: Churchill Livingstone, 1993.
  2. Warmerdam, A. Manual Therapy, Pine Publications, 1999.