REVIEW

Connective tissue massage:

a bridge between complementary
and orthodox approaches
. . . . . . . . . .

E. A. Holey

Abstract Connective Tissue Massage (CTM) is a bodywork technique which lies at

the boundary between alternative and orthodox approaches. A manual therapy
technique, it utilizes connective tissue re¯ex zones which are then manipulated by a
gentle shear force with the aim of reducing pain, restoring balance in the autonomic
nervous system and inducing segmental and suprasegmental re¯ex e€ects on the
visceral and hormonal systems. CTM requires a holistic approach in its assessment in
order that the degree of autonomic imbalance is established and that subsequent
clinical decision making is guided by the zonal positions. The technique, itself,
however, is ®rmly rooted within orthodox scienti®c concepts and the zones can be
seen, palpated and anatomically explained. The approach to treatment, the scienti®c
rationale and research ®ndings are discussed to justify the claims made for this
powerful technique.

Introduction De¢nition and development

Elizabeth A. Holey, MA MCSP DipTP SRP
Senior Lecturer, University College of Ripon and
York St John, Lord Mayor's Walk, York YO31
7EB, UK
Correspondence to: Elizabeth A. Holey
Tel.: 09104 716907; Fax: 01904 716907;
E-mail: ehly@globalnet.co.uk
Received: February 1999
Revised: March 1999
Accepted: March 1999
...........................................
Journal of Bodywork and Movement Therapies (2000)
4(1), 72^80
# 2000 Harcourt Publishers Ltd
Connective Tissue Massage (CTM)
or Manipulation is a bodywork
technique which lies at the interface
between alternative and orthodox
treatment approaches. It is intended
by this paper to discuss how CTM is
a re¯ex therapy technique, but one
in which the re¯ex zones are
anatomically and physiologically
de®ned. The author will also explore
how the localized application of this
particular manual therapy is
informed by a holistic assessment
which guides decision making
concerning treatment progression.
CTM is a re¯ex therapy which
utilizes a shear force at connective
tissue interfaces in the skin to
stimulate autonomic nerve endings
and to restore balance between the
sympathetic and parasympathetic
components of the autonomic
nervous system (ANS). The strokes
are applied to re¯ex zones known as
`Heads's zones' which can be seen
and palpated and which will be
discussed later in this paper. The
history of CTM's development
serves to illustrate its e€ectiveness.
Whereas manual therapy techniques

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 Connective tissue massage

usually evolve, CTM was discovered by Dr Head (Head 1889). The zones within a spinal segment facilitates
by Elisabeth Dicke, a German are present between the dermis and the synapses within it, thus altering
Krankengymnast who had become hypodermis in acute states and the level of activity in other
bedridden whilst awaiting between the dermis and fascia in structures which share the same
amputation of her leg for severe chronic states (Haase 1968). The segmental innervation (Fig. 2).
arterial insuciency. To relieve her changes may include trophic The point of stimuli convergence
back pain, she massaged the painful changes, swellings, thickenings, is thought to be the Wide Dynamic
area and realized she had thickened, indurations and hyperalgesia. They Range (WDR) neuron, originally
indurated tissue around her low occur in the dermatomes which isolated by Pomerantz et al. (1968)
back and buttocks. By pulling at the share the same segmental and found in lamina V of the
a€ected tissues, she restored their distribution as the sympathetic spinal cord. These neurons
mobility and her back pain resolved. supply of the associated organ respond to in¯uences from viscera,
Surprisingly, the circulation in her (Holey 1995). muscle and skin and hyperactivity
leg increased and a digestive The zones re¯ect `facilitated in any of these structures would
problem also improved. The segment' activity as described by lower the synaptic threshold
amputation no longer necessary, Korr (1979) and Upledger (1989) in of the WDR, `facilitating' the
Dicke spent the rest of her career which irritation in any structure whole segment and the resultant
exploring the technique which she
named bindegewebsmassage and
which was further developed and
researched by Teirich-Leube and
Kohlrausch (Schuh 1992).
The powerful clinical e€ects of
CTM ensured that it gained a well
established place within European
physiotherapy. It was introduced to
the British National Health service
by Maria Ebner, a physiotherapist,
in the 1950s. Today, the technique is
showing renewed interest amongst
those manual therapists who are
open to `alternative' and
complementary concepts but enjoy
placing them within an anatomical
and physiological context. As a
re¯ex therapy technique, CTM
requires the therapist to begin
treatment in areas well away from
the symptomology and to assess the
needs of the patient in a holistic way,
in order that the full extent of the
zonal involvement may be
recognized and treated. The re¯ex
zones which CTM utilizes are the
only ones which can be seen,
palpated and which have a clear
anatomical relationship to the
dysfunctional structure.

The re£ex zones

The tissue changes recognized by Fig. 1 Examples of Head's Zones, changes in surface contour re¯ecting autonomic re¯ex activity.
Dicke were found to correspond to In acute states, zonal areas contain soft, super®cial swelling, In chronic states, the swelling moves
the skin zones previously identi®ed to the edges and the tissues become drawn in or puckered and adherent.

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 Holey

observable and palpable connective

tissue changes would denote
acute or chronic segmental
disturbance.
The zones provide useful
information in patient assessment
and selection, for example, zonal
presence is indicative of autonomic
disturbance and suggests that the
patient may respond favourably to
CTM. The more numerous the
zones, the more widespread is the
Fig. 2 The Facilitated Segment.
autonomic disturbance. They also
help with the clinical decision
making process, with regard to
progression of treatment (see
below). There is some evidence for
inter-rater reliability of zone
recognition (Holey & Watson 1995).

The technique
CTM uses a specialised stroke in
which a gentle shear force is applied
to the connective tissue interfaces in
the skin. The strokes are very
speci®cally applied to bony
attachments of fascia, or where
fascia is super®cial. A characteristic
`cutting' sensation is produced
which is indicative of the fascial
layer being stimulated. The stroke
must be modi®ed to ensure that
discomfort is not produced, i.e. it
should not be painful. To prepare
the tissues for the fascial stroke, the
skin technique, the subcutaneous
technique or the ¯at technique can
be used (Schuh 1992, Holey & Cook
1997) (Fig. 3).
There is a dearth of clinical CTM
research but its uses are known from
clinical experience which has found
it to successfully treat:

. Circulatory problems
. Visceral dysfunctions
Fig. 3 The Strokes of Connective Tissue Massage. (a) Fascial technique: the pad of the middle . Pain, particularly sympathetic
®nger targets the facial layer and exerts a shear force at the connective tissue interface. Flexion at pain
the same distal interphalangeal joint ensures the slack in the super®cial layers is taken up. (b) Skin . Nerve root pain
(haut) technique: ®ngertips are brushed lightly along the skin. (c) Shallow (¯at) technique: the
skin is pulled towards the therapist by the ®ngers and thumb tips are then placed under the fold,
. Gynaecological and hormonal
on the fascial layer, to allow a shear force to occur. (d) Subcutaneous (unterhaut) technique: the disorders
subcutaneous layer is pushed very gently and repetitively to desensitize tender tissues. . Anxiety.

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These clinical problems fall into
one of three categories: segmental
(visceral conditions and
sympathetically-maintained pain);
suprasegmental (hormonal and
anxiety disorders) and mechanical
(local pain) which assists us in
attempting to establish how CTM
works.
The initial patient assessment
requires a holistic subjective
interview to determine
symptomology and how the patient
feels, behaves, sleeps and functions
viscerally. This helps to establish the
level of autonomic imbalance and
sympathetic or parasympathetic
dominance. The ®ndings of the
objective assessment indicate
segmental and suprasegmental
involvement, chronicity and
causative factors through zone
recognition, with broader objective
testing establishing markers for
improvement and outcome
measures. The position of zones
guide the therapist through a course
of treatment, for example, the
strokes may be applied
dermatomally for nerve root pain,
locally for mechanical pain,
segmentally for visceral problems or
suprasegmentally for anxiety,
hormonal disorders or a high level
of sympathetic irritability.
Clinical e¡ects
The full potency of CTM can be
experienced if the technique is
applied incorrectly and the basic
principles not followed. This
produces adverse reactions which
may include palpitations, dizziness,
and fainting although these are
avoidable. If used correctly, the
technique leads to the following
therapeutic e€ects. The initial
changes are noted by the therapist,
within the patient's tissues a triple
response is produced in the skin and
a ¯uid redistribution follows. The
tissues feel less swollen with more
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mobility and reduced tension.
Indurations `smooth out' and the
patient describes feeling `looser'.
Patients with degenerative joint
disease su€ering from sti€ness on
waking describe a noticable loss of
sti€ness and resultant increase in
functional mobility. Later in the
course of treatment (usually after
the third treatment) the pain reduces
and peripheral circulation is
increased. Painful states can
sometimes disappear suddenly
(often after three treatments); the
author has observed this event in
patients su€ering from re¯ex
sympathetic dystrophy, nerve root
pain and degenerative joint disease.
It was traditionally thought that
the triple response was produced via
mechanical trauma to the mast cells
with subsequent release of heparin
and histamine (Ebner 1978).
However, the vasodilation could
also be caused by stimulation of the
circulatory plexi which lie
horizontally at the interfaces within
the skin.
Stimulation of autonomic endings
may reduce sympathetic
vasoconstrictor tone resulting in
vasodilation. Noradrenaline may be
released which also reduces tone in
the muscle of vessel walls. It has also
been found that shear forces applied
to endothelial cells cause release of
Nitric Oxide, a powerful vasodilator
(Noris et al. 1995).
It is known that segmental re¯exes
are in¯uenced by skin stimulation
(Sato et al. 1997). Shortly following
a session of CTM treatment,
patients often experience a bowel
movement (indeed CTM can be used
to treat constipation; Holey &
Lawler 1995), increased bladder
output and increased menstrual
¯ow, and the latter can be dramatic
if a woman is treated during her
menstrual period, which is therefore
unwize. These e€ects appear to be
the stimulation of segmental re¯exes
which can be used to treat organ
dysfunction.
75
Sato and Schmidt (1971)
demonstrated the presence of supra-
segmental re¯exes which can be
stimulated by ®bre types II and III
and delta types in the skin and,
therefore, will respond to shear
forces (via Merkel's endings) and the
cutting sensation produced by the
fascial stroke. These re¯exes are
mediated by the medulla and the
cerebral cortex (Koizumi & Brooks
1972). This probably explains
Arkarcali and Sener's ®ndings
(1994) in their study in which a
course of CTM in 19 women
resulted in signi®cant improvement
in the Blatt Mensopausal Index.
Patients often present with
sympathetic dominance which
makes them `speedy' hyperactive
and/or anxious. Conversely, they
may be parasympathetically
dominant by which they present as
being sluggish or listless. A side-
e€ect of CTM is that autonomic
balance is restored, sometimes after
a transient swing in the opposite
direction presumably by the same
mechanism.
Perhaps the most exciting and
applicable results to bodyworkers
are the powerful e€ects of CTM on
pain. Conditions which often
respond poorly to other modalities
can respond positively to CTM. This
is a claim made about many
techniques but the author's clinical
experience (both personal and
observed) has shown for example,
that unresponsive, intractable
radicular pain may be centralized,
i.e. moved from the periphery
towards the spine (McKenzie 1990)
and reduces or resolves. Reese
(1998) describes a situation in which
myotomal power and dermatomal
sensation were restored to a leg
following a course of CTM to a
patient awaiting surgical
intervention. The mechanism by
which this works is not clear but
may have two components. It is
known from the increased menstrual
¯ow which can occur, that CTM
 Holey

Fig. 4 Layers of the skin and circulatory plexi. Reproduced, with permission, from Physiotherapy 81 (12): 1995. Originally published by Schuh
(1994), Fischer-Verlag, Stuttgart.

increases deep circulation. This
probably occurs via segmental
autonomic re¯exes. Jayson (1992)
has found on cadaveric studies that
degenerative disc disease results in
venous obstruction and dilation in
veins supplying nerve roots,
resulting in nerve root atrophy and
pain. It may be possible that CTM
restores blood ¯ow to the area of the
nerve root via segmental re¯exes,
when applied dermatomally. Some
of this pain may also be
sympathetically-maintained as
described by Roberts (1986). He
describes a theoretical model in
which continuous stimulation of C
nociceptors can sensitize WDR
neurons. These respond readily to
mechanoreceptor stimulation, which
in turn ®re in response to
sympathetic stimulation. Thus, a
constant increase in sympathetic
stimulation maintains the pain cycle.
Reducing sympathetic activity by
CTM may break the cycle (see
Holey 1995 for a broader
discussion).
Stimulation of the
mechanoreceptors by CTM may
also close the `pain gate' via pre- and
post-synaptic inhibition. CTM has
been found to induce release of

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Box 1 Connective T|ssue Zone Palpation

When palpating CT zones, the therapist should look for asymmetry in feel or behavior between the tissues on both sides of the
body or di€erent zonal areas.
Steps to follow
. Place your ®ngertips on the edges of the zone and very gently and super®cally press the epidermis and dermis of the skin. If it
allows indentation with a soft feel, this indicates swelling. A slight ripple e€ect can sometimes be seen around the therapists'
®ngertips.
. Using your ®ngerpads, allow them to sink into the dermal layer, to target the connective tissue underneath. Push the skin
cephalad without sliding on top of the skin. The skin should create small folds above your ®ngertips before you feel the
underlying resistance. In areas of considerable CT tension, little movement can occur and the skin tends not to fold. (Diagram
A)

. Gently grasp the skin between ®nger and thumb tips and roll the skin on its connective tissue. In areas of underlying tension, it
will not roll or pinch. (Diagram B)

. Grasp the skin between the length of your ®nger and thumb and try and lift it away from its supporting tissue. Tenderness or
inability to lift indicates zonal change. (Diagram C)

. Look for open pores, colour change, mottling, hair loss, tenderness.
Changes to note through a course of treatment:
The tissues will feel looser and will stretch further before discomfort is provoked. They become less sensitive to handling. The
skin moves more easily on its connective tissue layer and the end-feel of the movement becomes springy. Swelling reduces and
tight bands disappear. These changes correspond to subjective improvement as reported by the patient.

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Box 2 Case study

Mrs A
57-year-old clerk
Married to 2nd husband (retired). Shortly to retire herself.
History of Present Complaint: 2 years previously had fractured 1 neck of humerus followed by re¯ex sympathetic dystrophy.
Complaining of 1 thumb pain. 1 hand dominant.
Complaining of: Pain down extensor aspect of thumb, constant for 2 years but worse on movement, especially ¯exion. Aching and
burning in nature. Diculties with activities requiring ®ne hand coordination.
Other factors: Constipated, overweight, sleep pattern unproblematic but slightly variable, coccyx pain on prolonged sitting severe
enough to ensure that cinema and theatre trips were impossible. Swims weekly and enjoys in frequent walking trips. Post-
menopausal. No drugs.
Social history: Recently re-married to a retired man. Concerned that her impending retirement might strain this new relationship;
therefore keen to be ®t enough to pursue hobbies, etc.
On examination: Hand movements ± all functional but all end of range ®nger, thumb and wrist movements lost with inelastic end-
feel. Shoulder: 1208 ¯exion, 1308 abduction, medial rotation ± hand to iliac crest, lateral rotation ± hand to top of head. Scapular
®xation and control poor.

CT Zones present: bladder ‡‡‡

bowel ‡‡ L4R
R arm ‡‡‡
stomach ‡
all central zones apparent.

Treatment 1: `basic section' (sacral and gluteal area) treated ± fascial strokes Reported on next visit: bowel habits more regular

Treatment 2: `basic section' repeated

Reported on next visit: `bowels feel marvellous'
sleep improved
hand moving more `easily'
coccyx much more comfortable
when asked about the thumb pain `oh, I've not felt it for 3 days'
Treatment 3: `basic section', lat. dorsi, scapular and shoulder strokes added (see diagram) MET to shoulder, stretches to hand,
shoulder and hand excercise programme, self-massage to hand taught
Reported on on next visit: able to sit for longer periods without coccyx pain, no return of thumb pain, hand and shoulder
movement improving
Treatment 4: As treatment 3
On next visit: No thumb or coccyx pain, hand almost normal, shoulder movement ± ¯exion and abduction reduced by 208,
rotations, almost full
Treatment 5: as above. Own exercise programme progressed. Discharged.

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endogenous opiates (Kaada &
Torsteinbo 1989), indicating that
post-synaptic inhibition occurs.
Other research ¢ndings
It has already been stated that CTM
has been shown to reduce
menopausal symptoms (Arkarcali &
Sena 1994) and increase plasma
endorphin levels (Kaada &
Torsteinbo 1989). Other studies,
however, show scant evidence for
the impressive clinical results
reported by CTM users. Whilst
detailed critical review of research is
beyond the scope of this paper, it
will be referred to and reasons for
the inconclusive results discussed.
Circulatory e¡ects
Horstkotte et al. (1967) found that,
following a course of CTM, 18 male
patients demonstrated an increase in
peripheral blood ¯ow which
exceeded that of the control group
who received the conventional drug
therapy of the time. An earlier
experiment reported by Ebner
(1980) showed ®ngertip temperature
rising after CTM and peaking 30
minutes after end of the
intervention, although further
details are unrecorded. Kaada and
Torsteinbo (1987) measured
vasointestinal polypeptide levels
after CTM to determine whether
this powerful vasodilator is
responsible for the increased blood
¯ow. However, levels were not
found to be signi®cantly raised
during CTM.
Autonomic e¡ects
A rise in sympathetic activity during
CTM was shown in the study
undertaken by Kisner and Taslitz
(1986). They studied the e€ect of
one treatment on nine healthy
volunteers. The e€ects of CTM on
normal subjects are often weak, as
could be expected and clinical
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Connective tissue massage
experience shows that CTM is
followed by increased
parasympathetic activity which is
utilized therapeutically. Delayed
responses were not measured in this
small sample. Reed and Held (1988)
studied sequential CTM in an older
sample of, again, healthy subjects.
No signi®cant changes in heart rate,
skin temperature, galvanic skin
response or mean arterial blood
pressure were recorded. The
measures were taken during
treatment and the subjects were
asymptomatic. Future research
should measure the e€ects of
sequential treatment and delayed
responses in symptomatic
individuals and current
technological methods of autonomic
measures should be used.
E¡ects on anxiety
The autonomic balancing responses
to CTM can be useful in the
treatment of anxiety. McKechnie et
al. (1983) found that anxious
patients responded favourably to
CTM. Autonomic function was
found to move towards a
parasympathetic direction across
individual measures but no
signi®cant results were shown across
the whole group (n=5).
E¡ects on pain
Kaada and Torsteinbo's work of
1989 on plasma endorphin levels
discussed previously, was a sound,
scienti®c study. Less rigorous, but
interesting, was the report of Frazer
(1978) who reported ®nding CTM to
be more e€ective than epidural
analgesia in a single subject.
E¡ects on subacute asthma
One single CTM treatment over the
respiratory zones showed no change
in FEV1 (Forced Expiratory
Volume in 1 second) at 15 and 30
seconds post-treatment in a patient
79
with subacute asthma (Robertson et
al. 1984).
Comment
Unfortunately in today's, health
care culture, there is a danger that
treatments without a strong
scienti®c evidential base may lose
favour amongst health-care
purchasers despite their obvious
clinical bene®ts. Workers outside
state or insurance funded health care
will then have the responsibility of
keeping useful techniques within the
repertoire of manual therapy.
Techniques such as CTM should be
used widely, in order that it will
continue to evolve and more creative
uses will be developed (Holey &
Schuh 1995).
Conclusion
CTM is an interesting modality both
to use and to study. It has been used
in orthodox health care for a
number of decades and within that
setting has pioneered a holistic
approach. It currently attracts a
wider interest as it stands at the
boundary between complementary
and orthodox health-care provision.
Its powerful clinical e€ects are
undermined by a weak research
base; however, empirical
observation shows that it warrants
a wide application for the bene®t of
patients.
ACKNOWLEDGEMENT
The author wishes to thank Eileen Cook
BSc (Hons) MCSP for her helpful
comments on the text.
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