the height of the therapist) and temperature-controlled to about 35 °c (95 °f). dry-water massage tables a dry-water massage machine at a shopping mall in fargo, north dakota. a dry-water massage table uses jets of water to perform the massage of the client's muscles. these tables differ from a vichy shower in that the client usually stays dry. two common types are one in which the client lies on a waterbed-like mattress which contains warm water and jets of water and air bubbles and one in which the client lies on a foam pad and is covered by a plastic sheet and is then sprayed by jets of warm water, similar to a vichy shower. the first type is sometimes seen available for use in malls and shopping centers for a small fee. vichy showers a vichy shower is a form of hydrotherapy that uses a series of shower nozzles that spray large quantities of water over the client while they lie in a shallow wet bed, similar to a massage table, but with drainage for the water. the nozzles may usually be adjusted for height, direction, and temperature to suit the client's needs. cremes, lotions, gels, and oils a specially created aroma massage combining technique and aromatherapy oils. many different types of massage cremes, lotions, gels, and oils are used to lubricate and moisturize the skin and reduce the friction between skin (hands of technician and client). massage tools these instruments or devices are sometimes used during massages. some tools are for use by individuals, others by the therapist. tools used by massage therapists calf massage with a bamboo massage tool.instrument-assisted soft-tissue massage can deploy stainless-steel devices to manipulate tissue in a way that augments hands-on work. a body rock is a serpentine-shaped tool, usually carved out of stone. it is used to amplify the therapist's strength and focus pressure on certain areas. it can be used directly on the skin with a lubricant such as oil or corn starch or directly over clothing. bamboo and rosewood tools are also commonly used. they originate from practices in southeast asia, thailand, cambodia, and burma. some of them may be heated, oiled, or wrapped in cloth. cupping massage is often carried out using plastic cups and a manual hand-pump to create the vacuum. the vacuum draws the soft tissue perpendicular to the skin, providing a tensile force, which can be left in one site or moved along the tissue during the massage. tools used by both individuals and massagers hand-held battery-operated massaging and vibrating instruments are available, including devices for massaging the scalp following a haircut. vibrating massage pads come in a range of sizes, some with the option of heating. vibrating massage chairs can provide an alternative for therapy at home. there is a widespread market in erotic massage instruments, including electric dildos and vibrators such as the massage wand. medical and therapeutic use the main professionals that provide therapeutic massage are massage therapists, athletic trainers, physical therapists and practitioners of many traditional chinese and other eastern medicines. massage practitioners work in a variety of medical settings and may travel to private residences or businesses. contraindications to massage include deep vein thrombosis, bleeding disorders or taking blood thinners such as warfarin, damaged blood vessels, weakened bones from cancer, osteoporosis, or fractures, and fever. beneficial effects oil dispersion bath and brush massage peer-reviewed medical research has shown that the benefits of massage include pain relief, reduced trait anxiety and depression, and temporarily reduced blood pressure, heart rate, and state of anxiety. additional testing has shown an immediate increase and expedited recovery periods for muscle performance. theories behind what massage might do include enhanced skeletal muscle regrowth and remodeling, blocking nociception (gate control theory), activating the parasympathetic nervous system, which may stimulate the release of endorphins and serotonin, preventing fibrosis or scar tissue, increasing the flow of lymph, and improving sleep. massage is hindered from reaching the gold standard of scientific research, which includes placebo-controlled and double blind clinical trials. developing a "sham" manual therapy for massage would be difficult since even light touch massage could not be assumed to be completely devoid of effects on the subject. it would also be difficult to find a subject that would not notice that they were getting less of a massage, and it would be impossible to blind the therapist. massage can employ randomized controlled trials, which are published in peer reviewed medical journals. this type of study could increase the credibility of the profession because it displays that purported therapeutic effects are reproducible. single-dose effects mechanical massage chairs pain relief: relief from pain due to musculoskeletal injuries and other causes is cited as a major benefit of massage. a 2015 cochrane review concluded that there is very little evidence that massage is an effective treatment for lower back pain. a meta-analysis conducted by scientists at the university of illinois urbana-champaign failed to find a statistically significant reduction in pain immediately following treatment. weak evidence suggests that massage may improve pain in the short term for people with acute, sub-acute, and chronic lower back pain. state anxiety: massage has been shown to reduce state anxiety, a transient measure of anxiety in a given situation. blood pressure and heart rate: massage has been shown to temporarily reduce blood pressure and heart rate. multiple-dose effects pain relief: massage may reduce pain experienced in the days or weeks after treatment. trait anxiety: massage has been shown to reduce trait anxiety; a person's general susceptibility to anxiety. depression: massage has been shown to reduce subclinical depression. neuromuscular effects massage has been shown to reduce neuromuscular excitability by measuring changes in the hoffman's reflex (h-reflex) amplitude. a decrease in peak-to-peak h-reflex amplitude suggests a decrease in motoneuron excitability. others explain, "h-reflex is considered to be the electrical analogue of the stretch reflex... and the reduction" is due to a decrease in spinal reflex excitability. field (2007) confirms that the inhibitory effects are due to deep tissue receptors and not superficial cutaneous receptors, as there was no decrease in h-reflex when looking at light fingertip pressure massage. it has been noted that "the receptors activated during massage are specific to the muscle being massaged," as other muscles did not produce a decrease in h-reflex amplitude. regulations because the art and science of massage is a globally diverse phenomenon, different legal jurisdictions sometimes recognize and license individuals with titles, while other areas do not. examples are: registered massage therapist (rmt) canada remedial massage therapist (rmt) new zealand certified massage therapist (cmt) new zealand licensed massage practitioner (lmp) licensed massage therapist (lmt) licensed massage and bodywork therapist (lmbt) north carolina therapeutic massage therapist (tmt) south africa in some jurisdictions, practicing without a license is a crime. one such jurisdiction is washington state, where any health professionals practicing without a license can be issued a fine and charged with a misdemeanor offense. canada canadian massage therapist at work. in regulated provinces massage therapists are known as registered massage therapists, in canada six provinces regulate massage therapy: british columbia, ontario, newfoundland and labrador, prince edward island, saskatchewan, and new brunswick. registered massage therapy in british columbia is regulated by the college of massage therapists of british columbia (cmtbc). regulated provinces have, since 2012, established inter-jurisdiction competency standards. quebec is not provincially regulated. massage therapists may obtain a certification with one of the various associations operating. there is the professional association of specialized massage therapists of quebec, also named mon réseau plus, which represents 6,300 massage therapists (including ortho therapist, natural therapists, and others), the quebec federation of massage therapists (fmq), and the association québécoise des thérapeutes naturals; however, none of these are regulated by provincial law. canadian educational institutions undergo a formal accreditation process through the canadian massage therapy council for accreditation (cmtca). china most types of massage, with the exception of some traditional chinese medicine, are not regulated in china. although illegal in china, some of the smaller massage parlors are sometimes linked to the sex industry and the government has taken a number of measures in recent times to curb this. in a nationwide crackdown known as the yellow sweep ("yellow" in mandarin chinese refers to sexual activities or pornographic content), limitations on the design and operation of massage parlors have been placed, going so far as requiring identification from customers who visit massage establishments late at night and logging their visits with the local police. france france requires three years of study and two final exams in order to apply for a license. germany in germany, massage is regulated by the government on a federal and national level. only someone who has completed 3,200 hours of training (theoretical and practical) can use the professional title "masseur und medizinischer bademeister" 'masseur and medical spa therapist'. this person can prolong his training depending on the length of professional experience to a physiotherapist (1 year to 18 months additional training). the masseur is trained in classical massage, myofascial massage, exercise, and movement therapy. during the training, they will study anatomy, physiology, pathology, gynecology, podiatry, psychiatry, psychology, surgery, dermiatry, and orthopedics. they are trained in electrotherapy and hydrotherapy. hydrotherapy includes kneipp, wraps, underwater massage, therapeutic washing, sauna, and steambath. a small part of their training will include special forms of massage which are decided by the local college, for example, foot reflex zone massage, thai massage, etc. finally, a graduate is allowed to treat patients under the direction of a doctor. graduates are regulated by the professional body which regulates physiotherapists. this includes restrictions on advertising and the oath of confidentiality to clients. india in india, massage therapy is licensed by the department of ayurveda, yoga & naturopathy, unani, siddha, and homoeopathy (ayush) under the ministry of health and family welfare (india) in march 1995. massage therapy is based on ayurveda, the ancient medicinal system that evolved around 600 bc. in ayurveda, massage is part of a set of holistic medicinal practices, contrary to the independent massage system popular in some other systems. in siddha, tamil traditional medicine from south india, massage is termed as "thokkanam" and is classified into nine types, each for a specific variety of diseases. japan traditional japanese blind massage