Why use Hot Stones in Massage?

Why should you include Stones in your Massage Treatments?

Hot Stone Therapy

Hot Stones can be used as a tool for relaxation and deep tissue massage. The main use of Stones is for the purpose of releasing tension in muscles and/ or relaxing the mind, body and soul.

It is believed that hot stones first started around 5000 years ago in different areas of the world. The main reasons for using hot stones was pain relief. In India, Mayan Civilization, Ancient Greece and Rome, China, Hawaii, and Native American all started by simply placing warm rocks on different areas of the body and found that heat helped sooth sore muscles and created a better quality of life.  In 1993 Mrs. Mary Nelson was a key influencer to bring hot stones back to mainstream therapies. During 2000’s heat has been gaining more traction and continues to be commonly studied in the health science field. There have been more positive findings of the possibilities of heat on chronic and acute injuries. Some of the benefits that have been clinically proven are,

·       Decrease Parasympathetic response

·       Increase blood circulation (which increases but not limited to, proteins, oxygen, nutrients to the localized area)

·       Improves range of motion (by increasing elasticity of muscles)

·       Decrease pain during the massage

·       Heat can decrease DOMS (delayed onset muscles soreness)

·       The metabolic rate and the tissue extensibility will increase

·       Enhancing quality of sleep short term

*The therapist will also have some of these benefits when using the stones by holding them with their hands. The therapist’s hands will feel warmed up, with less pain and potentially a faster healing time.

Explanation of above benefits

1. Parasympathetic response decreases due to heat. In a study of 139 people, when heat and massage was applied for 40min 5 days a week for 2 weeks. After 2 weeks of heat and massage application there was significant decrease in serum cortisol level and there was a significant decrease in serum norepinephrine level after for 4 weeks. Indicating an overall down regulation of sympathetic activity (YH, L., Park, (B., & Kim, S. (2012).)

2.     Increase in blood circulation by stimulating vasodilation in vessels, which promote healing by increasing nutrients and oxygen to injured site. This also increases local tissue metabolism (which is thought to promote tissue healing).

3.     As muscles tightening and create a thick Type 3 collagen tissue (scar tissue) it will limit how well blood can circulate through those areas; therefore, using “Heat-induced changes in the viscoelastic properties of collagenous tissues may underlie the demonstrated efficacy of heat therapy for improving range of movement.” This will increase the elasticity of connective tissues.

4.     With heat there was an increased pain relief when using heat for a longer duration as opposed to cold. As well as decreasing in pain intensity, in terms of pain examination, was higher in thermotherapy group compared to cryotherapy in the second visit. (Dehghan, M., & Farahbod, F. 2014)

5.     Heat was shown to be “138% greater with the heat wrap versus the cold pack at hour 24 post exercise,” for DOMs (Delayed onset of Muscle Soreness) when applied for a longer duration of time. Heat therapy in the form of deep moist heat or a heating pad is a mild analgesic that has a number of effects on the human body including increase in local blood flow, mitochondrial biogenesis, improved range of motion and pain relief (Bleakley & Costello, 2013; Hyldahl & Peake, 2020; McGorm et al. 2018). Several clinical practice guidelines recommend the use of heat to manage acute and chronic low back pain (Bleakley & Costello, 2013; Chou et al., 2018; Qaseem et al., 2017) (Lebert, R. (n.d.)

6.     The metabolic rate and the tissue extensibility will also increase. Heat increases oxygen uptake and accelerates tissue healing, it also increases the activity of destructive enzymes, such as collagenase, and increases the catabolic rate. (Thermotherapy. (n.d.)

Taking these benefits and adding it to the massage therapy field using hot stones will aid to increase patients results. There are two main types of stones that are non-porous and retain heat, these two are the Jade Stone and Basalt Stone. The stones provide an excellent modality to add to the therapist’s tool kit. Not only do hot stones have an added benefit to massage, I believe that hot stones can add an element of safety.

Every massage starts with warming up the muscles for similar reasons as to why you would want to warm up at the beginning of exercise. Warming up the muscles before getting deeper into the layers is crucial because if they are not warmed up properly you are at risk of tearing the healthy tissue. This happens because the muscle is cold and not pliable therefore adding stress to the muscle can create bigger tears in the muscle fibers that take longer to heal and potential injury. Using Hot Stones for the purpose of putting more heat into the muscles will aid in helping prevent further injury and promoting healing in the tissue. It will ensure that the tissue is warmed up enough to massage, therefore adding an element of safety. A major benefit with using external heat is to create blood flow a little faster and push the heat deeper into the tissues, as opposed to only the superficial layers. Massage with the hands will take a while to be able to achieve, similar results. You will be able to achieve more with greater elasticity and blood flow in the tissues.

I would like to highlight the parasympathetic system because this system is supposed to help your muscles let go and relax. Down regulating this system is very important during massage because if the sympathetic system is heightened the muscles may be subconsciously protecting an old injury therefore not relaxed and creating a fight or flight response. Massage is most effective if the muscles are relaxed, if the muscles are tense the therapist cannot adequately break up the thick type three collagen fibers (the knots), if the therapist forces the pressure, the muscle is at risk of creating bigger tears/ bruising and increasing the chance of injury. Since heat has shown to decrease the parasympathetic system forcing the muscles into subconscious relaxation, the therapist can now be more effective at releasing tension in muscles. While decreasing this system the patient also will feel less pain, patient comfort is always a priority. With heat the patients perceived pain does not go over a 5-6 (on a scale of 10 being the most pain) making the massage with hot stones more comfortable and just as if not more effective. We can enhance massage with heat because the heat down regulates the parasympathetic system, and the patient feels less pain causing increased patient comfort and outcomes.

Risks

The risks are limited with adding heat to a massage practice but acknowledging risks and setting a standard for best practice is very important.  The main risks with using heat are pathology based and indicated in the contraindications below.

One of the risks with using hot stones is burning your hands and your patient. This risk has been significantly reduced when using hot stone heaters, where it is very easy to control the temperature of the water. Having Ice water beside the heater will also help to reduce stone temperature. With constant check in’s with client on temperature.

With hot stones we can do stationary stones and stones with movement. Moving the stones decreases chance of burns as the heat is dissipated across a wide surface area. Stationary stones dissipate heat into a single area which increases the chance of burns. To lower the risk when doing stationary stones there has to be a barrier between the stone and the skin, and verbal check in’s with the patient.

Contraindications

-       Acute injuries (you are allowed to use heat on the injury itself but with very little to no pressure, just the weight of the hot stone, then following with cold stones so the blood does not remain stagnant in the muscle. (Dehghan (2014).)

-       Pregnancy (due to the increased blood)

-       Acute Asthma

-       Acute Cyctic (bladder)

-       Acute Edema

-       Heat rash or Sun burn

-       Hot Flashes (menopause)

-       Acute Diabetes

-       Contagious Infections

-       High Blood Pressure

-       Hormone or Antidepressants

-       Anti-coagulant medications

Precautions

-       Cancer

-       Varicose Veins

-       Burn scars

-       Acute inflammatory conditions

-       Kidney dysfunction

-       Inflammatory condition secondary to infection

-       Rheumatoid arthritis

Cold Stone Therapy

Because heat brings blood flow to the area and increases the circulation, but it can create stagnate blood that will take a while to circulate back to the heart (this has yet to be proven dangerous when talking about an isolated area of the body), the cold stones will vasoconstrict the blood vessels, pumping stagnate blood out and encouraging new blood to come back in. This is also known as contrast therapies. There are two main cold stones utilized in massage, these two are Marble (as it is a naturally colder stone at room temperature) and Jade Stone. Cold stones are not as comfortable for the patient and it has the potential increases the parasympathetic system and turn on the sympathetic system. However, we can use this to our advantage. There are multiple uses for cold stones during massage, a couple major ones I would like to highlight are,

1.     Trigger point therapy with cold stones

2.     Flushing the area to decrease swelling naturally created from adding heat

3.     Working with acute injuries

4.     Temporarily reduce inflammation and blood flow

5.     To create “Heat Response” the body will heat itself in the localized area and bring new blood in

6.     Less pain and stiffness after blood is flushed out.

7.     Some therapists have used cooling agents such as mint oil in replacement for cold. The cooling agents do not change the temperature of the skin therefore there are no physiological changes (Malanga, G.,,2014). What peppermint oil actually does is send signals to the brain that there is cold on the skin therefore your brain thinks it is cold, but there is no physiological changes to the skin (Malanga, G.,,2014). Peppermint oil is great to use after the massage to make it feel like it feels better in a local area but cannot replace cold stones.

8.     During the acute (inflammation) phase of a soft tissue injury, the goal is to stop the internal bleeding or control it. This phase will last 6 hours up to 1 week post injury. Using the cold stones lightly on the injured area will benefit the healing. (Soft Tissue Healing. (n.d.).) After 6 weeks the remolding phase of the injury should be over and we can introduce heat and realigning fibers (Soft Tissue Healing. (n.d.).)

9.     The cold creates a vasoconstriction reaction to the veins therefore the blood leaves the cell and is pumped back to the heart. (Alba, B., 2019).

10.  Some studies have stated that cold can increase tissue healing and faster strength recovery, but this statement has yet to be proven with consistent results. (Nemet, D, 2009)

11.  Less pain and stiffness after blood is flushed out. (Nelson, M. 2011)

Summary

Hot and Cold Stones are a valuable tool for massage therapists. We have seen versions of this modality utilized in past generations dating back to 5000 years ago. Heat is very important in aiding to muscle recovery, down regulation of parasympathetic system, taking stress off massage therapists’ hands, and increases client comfort and outcomes. The risks are very manageable and limited. The goals of stone therapy are the same as massage therapy, and potentially more efficient in achieving these goals based on the recent research. I have attached the articles I have read when writing these findings. Thank you for reading thus far.

Written and researched by Alix Sutherland RMT, BKin, BEd

Alix Sutherland owns the copyright to this essay.

Citations (APA format)

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Bleakley & Costello, (2013) Do thermal agents affect range of movement and mechanical properties in soft tissues? A systematic review. Retrieved December 05, 2020, from https://pubmed.ncbi.nlm.nih.gov/22885279/

Body Mechanics for Massage Therapists: Massage Therapy Journal. American Massage Therapy Association. (2014, March 7). https://www.amtamassage.org/publications/massage-therapy-journal/work-smarter-not-harder/. 

Chou R;Côté P;Randhawa K;Torres P;Yu H;Nordin M;Hurwitz EL;Haldeman S;Cedraschi C;. (2018). The Global Spine Care Initiative: Applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. Retrieved December 05, 2020, from https://pubmed.ncbi.nlm.nih.gov/29460009/

Clinic Staff, M. (2018, January 30). First aid for burns. Mayo Clinic. https://www.mayoclinic.org/first-aid/first-aid-burns/basics/art-20056649.

Dehghan, M., & Farahbod, F. (2014, September). The efficacy of thermotherapy and cryotherapy on pain relief in patients with acute low back pain, a clinical trial study. Retrieved December 05, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225921/

Ghavami, H., Shamsi, S., Abdollahpoor, B., Radfar, M., & Khalkhali, H. (2019, August 28). Impact of hot stone massage therapy on sleep quality in patients on maintenance hemodialysis: A randomized controlled trial. Retrieved December 05, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734672/

JM;, H. (2020, July). Combining cooling or heating applications with exercise training to enhance performance and muscle adaptations. Retrieved December 05, 2020, from https://pubmed.ncbi.nlm.nih.gov/32644914/

Kim, J. H., Lee, H. S., & Park, S. W. (2015, August). Effects of the active release technique on pain and range of motion of patients with chronic neck pain. Journal of physical therapy science. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4563290/

Kim, J., Sung, D., & Lee, J. (2017, February 28). Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: Mechanisms and practical application. Retrieved January 28, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331993/

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