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Editor's note: Part I of this article appeared in the October 2001 issue of Massage Today, available on line at www.massagetoday.com/archives/2001/10/05.html.

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Why do stimuli from the stomach that are delivered to the central nervous system (CNS) radiate to somatic structures, and why in turn are the stimuli from reflex zones activated by the flow of motor impulses to the stomach? The phenomenon of convergence is responsible for this effect. The number of afferent sensory neurons delivering information from peripheral receptors to the spinal cord is greater than the amount of spinal neurons in the posterior horns of the spinal cord. The posterior horns accept and primarily process this information (see figure 2).

In other words, there is more than one sensory neuron in contact with each spinal neuron in the posterior horns of the spinal cord. In this instance, the information brought to CNS by sensory neurons from the stomach excites the entire neural plate of the spinal neuron. The sensory information delivered by sensory neurons from the peripheral receptors in the skin or skeletal muscles also excites the entire neural plate of the same spinal neuron. This stimulation by sensory stimuli from the stomach or reflex zones activates the lower motor cells in the anterior horns of the spinal cord. They generate motor input not only to the location of the original abnormality (the stomach, in our example), but also to the somatic structures innervated by the same segment of the spinal cord.

Simpler mechanisms of reflex zone formation are applied in cases of somatic abnormalities. This mechanism is responsible for the reflex zones' formation along the pathway of irritated or compressed peripheral nerves. For example, the chronic irritation of the sciatic nerve by overtensed piriformis muscle will produce pathological symptoms through the entire lower limbs. In this manner, irritation of peripheral nerves in the upper part of the body will cause the formation of reflex zones in the lower extremities, supported by the affected peripheral nerve.

Finally, reflex zone formation can be caused by direct compression of the spinal nerve by a herniated disc. As a result of irritation or compression of the spinal nerve, various areas of pathological excitement develop in the spinal cord, especially in the lower motor centers in the anterior horns. Abnormal impulses flow from the spinal cord to the inner organs, and to other parts of the body that are innervated by the affected spinal nerve. Further development follows the same pattern of relation between reflex zones and inner organs or parts of the body as mentioned previously.

Let's now look at another important issue, and ask another important question: "What local events lead to the formation of reflex zones?" First, let's briefly review the physiology of excitation and the conduction of nerve impulses. A nerve impulse or "action potential" is a propagated electrical disturbance originating in the peripheral receptors or in the upper nervous centers; it is conducted through afferent, ascending sensory or efferent, descending motor neurons. Both ascending information to the central nervous system about any kind of peripheral receptors activation, and descending motor commands from the central nervous system, are delivered as a series of action potentials. Any single action potential is the result of changes in the conductance of sodium and potassium through the membrane of the nervous cells. Every action potential has a threshold. A threshold is the firing level of the action potential. This means that if applied stimuli are weak, they are unable to evoke an action potential. In this case, full action potential is replaced by a local response.

A local response is a weak electric excitement that stays within the stimulated receptor, rather than propagating along the neuron. As soon as the stimuli are strong enough, the action potential is generated and conducted through the neuron. This mechanism protects the nervous system from overflow with useless information. Normally, the threshold activation of peripheral receptors has stable electrical magnitude. The continuous radiation of motor impulses to the reflex zones in skin, connective tissue, muscles, or periosteum evokes unusual phenomena in these tissues. The magnitude of the threshold is reduced in all receptors located in these areas. As a result, receptors start to generate action potentials as a response to even the weakest stimulus, even those that normally had subthreshold levels and have never produced action potentials. (Korr, 1947). This phenomenon is called hyperirritability. The affected soft tissues respond by building up tension, especially in contractile elements. Vasoconstriction and local edema are formed, further diminishing blood circulation and decreasing tissue metabolism.

The decrease of the threshold of peripheral receptors, i.e. the condition of hyperirritability, is the starting point of reflex zone formation (Korr, 1947; Glezer, Dalicho, 1955; Kunichev, 1985; Shterngertz, Belaya, 1994; Loginova, 2000). Figure 3 shows how the action potentials are generated, both in the receptors of the normal parts of the body and in the areas of reflex zones.

In 1947, in a series of brilliant clinical experiments, Prof. I. Korr showed that hyperirritability is a key to understanding reflex zone formation. In his experiments, Korr inserted microelectrodes in muscles with clinical symptoms of hypertonic abnormalities, then exposed his subjects to different types of stimulation: physical activity, decreased and increased temperature, loud sounds, bright light, etc. When subjects were exposed to each of these stimuli (even visual and auditory) the skeletal muscles in the area of reflex zones reacted with increased tension, which was detected by electromyography. This caused the additional decrease of peripheral circulation in already-affected areas. Thus, as Prof. I. Korr showed, any type of sensory stimulation of the CNS causes the further development of reflex zones in the tissue which are no longer protected from theactivation of peripheral receptors by subthreshold stimuli.

A number of clinical abnormalities can be found found in the areas of reflex zones in the skin, connective tissue, skeletal muscles and periosteum. During diagnostic examination, the practitioner should detect all abnormalities and record them on prepared diagrams of the body. At the end of the diagnostic examination, the practitioner will have a complete picture of somatic abnormalities for the patient. Such an approach to diagnostic examination allows the practitioner to formulate the optimal treatment protocol.

I. Cutaneous Reflex Zones

A. Visual examination of the skin. Have bright light in the room for visual inspection of the cutaneous reflex zones. Look for areas revealing the following symptoms:

1. Local hyperemia, paleness or pigmentation. Hyperemia is sign of overactivity of the sympathetic of the part of the autonomic nervous system, insufficient venous drainage, or chronic inflammation. Paleness is sign of overactivity of the parasympathetic nervous system or insufficient arterial supply. Pigmentation usually accompanies skin aging. However, in some cases the excessive local pigmentation is a pathological symptom. The best example is pigmentation on the lower 1/3 of the leg in the patients with varicose veins.
2. Areas of hairless skin. In the areas of reflex zones, the practitioner can detect regions with lesser amounts of hair on the skin surface. The classical example of this symptom is areas of hairless skin on the legs of patients who suffer from thromboangiitis obliterans (i.e., Buerger disease).
3. Stretch marks. Long-lasting somatic abnormalities in the areas of cutaneous reflex zones can cause stretch marks. This symptom has limited clinical value when estimated alone. In the majority of cases, stretch marks do not have any direct connection with cutaneous reflex zones; rather, they are a result of accelerated growth during puberty, cellulite or pregnancy. However, stretch marks may play role in the diagnostic procedure when they are examined along with other local abnormalities in the areas of cutaneous reflex zones. They have more clinical value when detected in unusual locations or when the patient is male.
4. Glossy skin. Glossy skin is a symptom of peripheral edema.

B. Palpatory examination of the skin. Palpatory examination of skin is always conducted after visual examination. Conduct the palpatory examination after placing the patient in comfortable position. Let the patient relax for two-to-three minutes. The palpatory examination of the cutaneous reflex zones must be conducted in comparison to the opposite side of the body, if the process is unilateral, and in comparison with neighboring parts of the body if the process is bilateral. All palpatory examination of the skin must be done with light touch or pressure, because the practitioner examines the most superficial layer of soft tissues.

1. Coarse superficial epithelium. This is very valuable symptom. The sensation of skin roughness often accompanies the cutaneous reflex zones. In some cases, this roughness matches exactly the borders of cutaneous reflex zones. Patients, especially female patients, even complain about this symptom during consultation, noting that topical lotions did not bring any improvement.
2. Edema. Insufficient venous blood and lymph drainage will cause an accumulation of fluid in the subcutaneous tissue and skin.
3. Hyperthermia or hypothermia. See above, in the section on visual inspection.
4. Sudomotor reactions. Sudomotor reactions are increased or decreased sweat production in the areas of cutaneous reflex zones. A decrease in sweat production can be also detected in the areas of coarse superficial epithelium.
5. Hyperaestesia. Hyperaestesia is a condition in which a quick but light stroke over the skin surface is felt as a sharp pain. This is a clinical sign of neurological abnormalities in the skin.
6. Hyperalgesia. Hyperalgesia is a condition in which light pressure causes severe pain. This is also a clinical sign of neurological abnormalities in the skin.
7. Cutaneous trigger points. Cutaneous trigger points are one of clinical examples of hyperalgesia.
8. Paraesthesia. Paraestesia or a tingling sensation is a classical sign of neurological abnormalities in the skin.
9. Numbness. Numbness is also clinical sign of neurological abnormalities in the skin.

II. Connective Tissue Zones (CTZ)

Connective tissue zones are also examined by palpation. Several diagnostic techniques target the CTZ in the each level. In general, the practitoner is looking for following abnormalities in the areas of CTZ:

A. Connective tissue zones in the dermis of skin (1st level of CTZ)

1. Increased tension
2. Local swelling
3. Depressions in the subcutaneous tissues

B. Connective tissue zones in the fascia and aponeurosis, which cover superficial muscular groups, e.g., fascia between skin and superficial muscular group (2nd level of CTZ)

1. Decreased elasticity and mobility of skin folds.

C. Connective tissue zones in the deep fascias, located between superficial and deep muscular groups (3rd level of CTZ)

1. Decreased mobility of superficial muscular group compared to deep ones.

III. Reflex Zones in Skeletal Muscles

Reflex zones in the skeletal muscles are examined by palpation and direct compression. The moderate compression of muscular tissue elicits sharp pain in the area of hypertonic muscular abnormalities. Patients show the so-called "jump symptom." Sharp pain elicited during moderate compression is another example of hyperalgesia.

A. Hypertonus: Areas of increased tension in the skeletal muscle. In large muscles, the hypertonus usually involves several muscular bundles, but small muscles can be affected entirely.

B. Trigger Point: The area of hypertonus with the most intensive pain sensation felt by the patient.

C. Myogelosis: The scientific term for "nut-like" structures in the skeletal muscles. Myogelosises are formed mostly in the muscles which perform substantial isometric work. One of the most common examples of this hypertonic muscular abnormality is myogelosis in the horizontal portion of the upper part of trapezius muscle.

IV. Periostal Reflex Zones

The periosteum is the thin connective tissue membrane covering all bones. It supports bone metabolism and remodeling. The periostal reflex zones are available for diagnostic examination only in the areas at which bone structures are covered by skin only. Examination of periostal reflex zones is conducted by palpation and direct compression.

A. Structural abnormalities in the periosteum: roughness, depressions. The structural abnormalities are the first sign of periostal reflex zones, before even the periostal trigger points are formed and the patient feels any pain.

B. Periostal trigger points: The areas at which the degenerative process in the periosteum has reached maximum and pain receptors are activated.

Following diagnostic examination, the practitioner will able to formulate the proper protocol of medical massage therapy. The formulation of a correct protocol is of course key to successful treatment. As mentioned, this protocol is a combination of different methods and techniques. For example, connective tissue massage is the best way to work on the connective tissue zones, but it is useless in the areas of periostal reflex zones, where periostal massage is the most effective therapy. The practitioner must utilize the particular methods and techniques created for the treatment of particular type of reflex zones. For example, if the patient does not have abnormalities in the periosteum, periostal massage techniques must be excluded from the protocol. However, if one measures the clinical validity of different methods of medical massage, I believe that segment-reflex massage is as appropriate as all known methods of Western medical massage therapy. The major advantage of segment-reflex massage is its integrative approach to treatment.The modern protocol of segment-reflex massage includes therapeutic massage, connective tissue massage and periostal massage, as well as its own therapeutic techniques and approaches. This unique combination allows the practitioner to target the reflex zones precisely and deliver an effective therapeutic impact to the affected areas of the body. In any case, the protocol of medical massage therapy must be individually adjusted to each new patient, because there are no two identical cases.

In conclusion, I want to emphasize that reflex mechanisms of massage therapy allow the massage practitioner reach a completely new level of professional expertise. At first, the clinical application of reflex mechanisms of massage therapy is a challenge. However, the professional benefits are far more rewarding than the time spent by the practitioner to achieve this level of expertise.

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