E-magazine
ontents
Understanding the
Placebo Effect
By Brian Fulton RMT
--- The Placebo Effect --Psychosocial Cues Neurobiological Pathways Subjective and Objective Changes
Psychosocial Cues
Cues in the environment and in the patientpractitioner relationship appear to trigger placebo
effects. A common term that you have undoubtedly
encountered for these cues is contextual factors.
This is a very useful term as it alludes to what might
be going on. Another term used to describe this phenomenon is non-specific effects however, not only
does this term lack any real description or hint as to
what is going on; it is actually misleading. A far cry
from non-specific, the effects of this phenomenon
can be amazingly specific: from blood pressure
changes, changes in immune response, improvement in exercise tolerance, or changes in tissue
Every factor listed above has been shown to independently affect clinical outcomes, and there is
likely an additive healing effect from these cues. Becoming aware of these elements in your daily practice and consciously improving your skills in these
areas will yield benefits for the patient. Ultimately
these contextual factors are what we need to focus
on is we want to manage placebo triggers in the
clinical environment. A complete article could easily
be devoted to every one of these contextual factors.
For more information on each of these topics I recommend reading The Placebo Effect in Manual
Therapy-Improving Clinical Outcomes.
Pathways and Mechanisms
On the basis of these recent insights, it is clear that
the placebo response represents an excellent model to
understand mind-body interactions, whereby a complex mental activity can change body physiology. Psychiatry and psychology, as disciplines investigating
mental events, are at the very heart of the problem,
for they use words and verbal suggestions to influence the course of a disease. Psychiatry, for example,
has in its hands at least two therapeutic tools: words
and drugs. Interestingly, what has emerged from recent placebo research is that words and drugs may
use the very same mechanisms and the very same biochemical pathways.5 - Fabrizio Benedetti (Professor
of Physiology and Neuroscience at the University of
Turin Medical School)
What is known for sure about placebo pathways is
that if an individual lacks prefrontal control, there is
limited to no placebo response. The prefrontal cortex is brain region is intimately involved in planning
complex cognitive behaviour, personality expression, decision making, and moderating social behaviour. This brain region is considered to be the centre
of orchestration of thoughts and actions in accordance with internal goals. One of the features of Alzheimer's disease is the impairment of prefrontal
executive control. Benedetti found a clear disruption of the placebo response occurred when reduced connectivity of the prefrontal lobes with the
rest of the brain was present.6
At least four biological pathways have been proTerra Rosa E-mag 5
has revealed that these placebo-induced biochemical and cellular changes in a patient's brain
are very similar to those induced by drugs.15
Ethical Considerations
When one thinks of using placebos, deception often
comes to mind, since this is how they have often
been used in the past. However in my investigation
of contextual effects that elicit the placebo response
in the clinical environment, I have found that the
exact opposite is true. As I began writing my book I
began to see several themes emerge. The first
theme is the importance of trust in the practitioner/patient relationship. Anything that enhances
this trust will tend to enhance healing responses
(and vice versa). Clearly deception will not enhance
trust. Secondly, improved healing responses are
seen when the locus of control lies with the patient, rather than the practitioner. The patient that
takes charge of his or her health is going to see improved outcomes. Making the patient aware that
these amazing healing effects exist within their own
mind and body do not lead to evaporation of the
effect, but to enhancement of healing responses and
a personal sense of power over ones health. Finally,
increased professionalism of the practitioner leads
to improved placebo responses. This may be a perception issue, since much of the placebo effect appears to involve the patients perception of their
practitioner, but the way to improve their perception of you is by being a more competent professional. So in the end, if you are an ethical professional, you have no worries about employing techniques to encourage healing in your patients. In
fact, I recommend reminding your patients that the
placebo effect is real, and it manifests from their
own internal healing systems as well as their relationship with you. It is not a minus, but a plus for
the patient to realize the amazing healing potential
of their own bodies.
Conclusion
I hope that you now see that the placebo effect isnt
quite as mysterious as you may have thought. It
manifests from innate healing mechanisms present
in the body, and many triggers for this phenomenon
15
Introduction
Myofascial Pain Syndrome (MPS) has been described as sensory, motor, and autonomic symptoms caused by Myofascial Trigger Points. Most, if
not all, experts on myofascial trigger points describe them as exquisitely tender spots in discrete
taut bands of hardened muscle producing local and/
or referred pain. Several terms including knots or
contraction knots with a nodular feel have been
used to describe what the therapist feels on palpating the tissues with their finger tips. People experiencing Myofascial Trigger Points present in the
clinical setting complaining of pain, however, this is
only one part of a more accurate story. People suffering the consequences of Myofascial Trigger
Points also suffer changes in sensations (Fig 2).
This fact can be overlooked, forgotten or simply not
appreciated by qualified therapists and health care
providers. This short article aims to provide accurate information concerning the Etiology and
Pathophysiology of the Myofascial Trigger Point.
Also a focus on changes in sensations will highlight the need for therapists to include this term in
advertising or promotional materials. Finally, this
article will offer general guidelines for the effective
treatment and /or management of myofascial pain.
I invite readers to join me at one or all of my upcoming workshops in Sydney next June (2016)
where among other things I will build your knowledge concerning Myofascial Trigger Points, Biotensegrity (anatomy for the 21st century) and provide
you with hands-on soft tissue therapeutic applications that have worked for my chronic pain patients.
Fibromyalgia and the Myofascial Trigger Point
Fibromyalgia is neither musculoskeletal nor rheumatic. Fibromyalgia does not cause aching muscles.
It does not cause numbness or tingling. Patients
with fibromyalgia can have these and many other
symptoms, but those symptom origins have been
widely misunderstood and so have the patients. Fibromyalgia is the term given to a family of illnesses
that have in common central nervous system sensitisation and chronic diffuse systemic pain. Fibromyalgia is systemic, not local. A person cannot
have fibromyalgia only in the hands or in the back
or in one foot. The central nervous system is the
brain and spinal cord becoming the peripheral
nervous system touching every cell in the soma.
Fibromyalgia affects the whole body, causing a diffuse pain all over. Fibromyalgia does not cause localized pain. If there is localized pain, it is caused by
something else, although Fibromyalgia may also be
pering removal of cellular wastes, or adversely affecting the metabolism of the neurotransmitter acetylcholine (ACh). Anything that enhances the formation of Myofascial Trigger Points is a perpetuating
factor. For instance, anything that constricts the
flow of blood to the area will lessen its supply of
oxygen and nutrients, adding to the energy crisis. A
perpetuating factor can be anything that increases
energy demand (trauma, overwork), decreases energy supply (inadequate nutrition, insulin resistance), sensitizes the Central nervous system (pain,
noise), decreases oxygen supply (congestion), enhances release of sensitizing substances (allergies,
infections), or increases endplate noise (increased
ACh release, reduced acetylcholinesterase).
New recommendation versus the old
In the original and now infamous big red books
Myofascial Pain and Dysfunction-the trigger point
manual, written by Janet Travel, David G, Simons
and Lois Simons, the use of an X was used to mark
the location of the Myofascial Trigger Point (Fig 1)
Several years before the passing of my mentor
David G Simons, on April 5, 2010, David and I spoke
at length regarding the appropriateness and
accuracy of using the X as a method to identify the
location of Myofascial Trigger Points. As a Clinical
Anatomist and Exercise Physiologist I argued that
the notion that Myofascial Trigger Points only
formed in the centre of the gastor or as described in
the big red books near the middle of each fibre,
midway between its attachments was not reflected
in clinical practice nor by my anatomical dissection
investigations. While the integrated trigger point
hypothesis postulates that in myofascial pain motor
endplates release excessive acetylcholine evidenced
histopathologically by the presence of sarcomere
shortening.2 it is worth noting that endplates are
positioned in varied locations requiring excellent
palpation skills from the therapist. If the therapist
only investigates the middle of any muscle gastor
and finds no palpable nodule or taught band the
true source of a patients pain and changes in sensations may well be missed.
In 2008, The Concise Book of Neuromuscular Therapy (Sharkey, J) included artwork showing the pain
referral pattern of the Myofascial Trigger Point and
comments on changes in sensations and for the first
time all without the use of the X. (Fig 2)
Fig. 1 The X in this example was provided to identify the location of Myofascial Trigger Points in Upper Trapezius
Fig. 2 From the Concise Book of Neuromuscular Therapy-a trigger point manual. Sharkey, J. 2008
Myofascial Trigger Points in the muscle temporalis can cause
myogenic (tension) headache. This aching pain can extend to
the upper teeth and include hypersensitivity to cold, heat, and
pressure. The teeth may not meet correctly and there may be
uncoordinated chewing when opening and closing the jaw.
These Myofascial Trigger Points can contribute to teeth grinding. Proprioceptive dysfunctions include vertigo, nausea and
hearing irregularities such as hypersensitive hearing and tinnitus Sharkey, J.
Thank you to Terra Rosa for facilitating the workshops. I am very excited about returning to Australia and working with therapists of varying stripes. I
wish everyone success in healing.
References
1 Starlanyl
2 Gerwin,
Fig. 4 This image shows muscle fibers running the length of the
tendon (being held in my hand) with the muscle fibers migrating superficially and deep to the tendon. (Sharkey, J. 2010)
Fogelman, Y & Kent, J 2014 Efficacy of dry needling for treatment of myofascial pain syndrome. J Back Musculoskelet
Rehabil.
Hsieh, YL, Chou, LW, Joe, YS & Hong, CZ 2011 Spinal cord
mechanism involving the remote effects of dry needling on
the irritability of myofascial trigger spots in rabbit skeletal
muscle. Archives of Physical Medicine and Rehabilitation,
92, 1098- 1105.
Differentiate the Myofascial Trigger Point from pain points using the cardinal signs which must
include; palpable nodule and taught band, jump sign, twitch response, painful end range of movement, referred pain, autonomic responses.
2.
First treat Myofascial Trigger Points that are most superior and medial working inferior and lateral.
3.
The deltoid seldom develops its own active Myofascial Trigger Points. Instead most are baby or
satellite Myofascial Trigger Points so treat associated muscles within its functional unit first.
4.
Upper trapezius is grand central station of Myofascial Trigger Points and is a major contributor
to neck, shoulder, upper back and head pain.
5.
Active Myofascial Trigger Points, when irritated by a competent therapist, will result in referred
pain or changes in sensation that the patient recognises.
6.
Latent Myofascial Trigger Points generally result in pain or change in sensations that the patient
does not recognise. These Myofascial Trigger Points may be contributing to but are not the true
source of a patients problem.
7.
Myofascial Trigger Points can form in any muscle fiber (11) and not just in the center of a muscle
or where the X marks the spot on so many Myofascial Trigger Point charts-this is misleading.
Identify and remove/change the perpetuating factor/s.
8.
Excellent palpation skills are required to locate and treat Myofascial Trigger Points.
9.
Upper or lower limb tension tests should be provided to rule out nerve insults including compression, adhesion and/or inflammation.
10.
Any patient suffering with unresolved pain or changes in sensations should have the possibility of
Myofascial Trigger Point involvement ruled out as a primary or secondary cause or contributor.
cal disc lesions. J Formos Med Assoc 97(3):174-180.
10
A N A T O M Y F O R T H E 2 1 S T C E N T U RY
BIOTENSEGRITY
with John Sharkey
Sydney, June 2016
Myofascial Trigger Points (MtPs) Versus
Neuropathies
A unique integrated neuromuscular approach for the
treatment of unresolved pain due to MtPs or nerve
insults.
This is that one stop workshop that covers everything
you need to know about identifying and treating Myofascial Trigger Points and nerve injury. David G Simons
(Travel and Simons), the farther of Myofascial Trigger
Points was mentor to John Sharkey and wrote the forward to Johns first book (a trigger point manual). Differentiating between neural generated pain and Myofascial
Trigger Point pain is essential in providing the correct
soft tissue interventions for successful therapeutic outcomes.
Register at www.terrarosa.com.au
Fascial Toning
Integrating new
techniques
By Art Riggs
Im noticing an interesting conflict in the massage profession. On one side, continuing education credit requirements
and the desire of therapists to expand and excel in their skills
have greatly expanded the number and quality of advanced
workshops. On the other side, the proliferation of spa work has
many massage schools primarily teaching generic massage
routines that are actually defining the publics perception of
massage.
Ive recently had several therapists express difficulties in trying to implement their new knowledge with established private
clients or the general public in spa settings. Here is a typical
example: I took a great workshop of advanced techniques that
I was very excited about but I'm hesitant to try anything because I work at a spa and I'm afraid that the clients will think
the new work is strange and not like it. I'm already forgetting a
lot from the workshop. How do I escape from this straightjacket?
It is amazing how often I hear concern that trying new work
will send clients scurrying to more conventional therapists. As a
Rolfer, I had the same thing happen when I studied craniosacral
techniques and more subtle work. I worried that people who
expected sharpened elbows and knuckles would be disappointed and that my long-time regular clients would wonder if
an imposter had taken over my practice. Nothing could be further from the truth; my clients loved the new skills, just as
yours will appreciate your new techniques, in addition to the
relaxation work you may normally do. Just as some meat-andpotato people will never appreciate nouveau cuisine, some people might resist new bodywork. However, I think that the advantages of showing an increasingly discerning public your
newfound skills far outweighs any downside; the rebookings
from happy clients and word-of-mouth referrals will be evidence enough. It is far easier to draw clientele who return because they appreciate your work than to try to fit your work to
Art Riggs is the author of Deep Tissue Massage: a Visual Guide to Techniques (North
Atlantic Books, 2007), which has been
translated into seven languages, and the
DVD series Deep Tissue Massage and Myofascial Release: A Video Guide to Techniques. He just release a new DVD series Deep Tissue Massage: An
Integrated Full Body Approach which demonstrates how to intergrate and coordinate Deep Tissue and Myofascial Release into a
Fluid Bodywork Session.
Theres only one corner of the Universe you can be certain of improving and
thats your own self. -Aldous Huxley
Fig. 1. Locus of Control. People with an internal locus of control believe that they can control events that happen to them
whereas those with an external locus of control believe they are powerless to control outside events .
Fig. 4. In the biopsychosocial model, pain is seen to be a combination of biological, psychological and social factors
Fig. 6. Take time to educate your client about the causes of their pain.
Fig. 10. Head over to the Jing website www.jingmassage.com for some great free
self care handouts for your clients
References
The Importance of
Joint Mobilization
By Joe Muscolino
Critical thinking is the key determinant of an excellent clinical
orthopedic manual therapist, and can make the difference between mediocre and excellent results.
Before practicing any new modality or technique, check with your massage therapy association to ensure that it is within the defined
scope
ignoring intrinsic fascial joint tissue may be an excellent job halfway-done; and may likely be the reason
for limited success when treating a clients musculoskeletal condition.
largely ignore an incredibly important fascial tissue component
of the body: joint capsules and
their associated intrinsic joint
ligaments. After all, tautness in
any soft tissue will decrease motion and impact the quality of the
clients life. This is true whether
the taut soft tissue is muscle myofascia, subcutaneous fascia, or
intrinsic capsular/ligamentous
fascial tissue. Therefore, if our
goal is to increase soft tissue
flexibility, loosening muscles and
their associated myofascial and
subcutaneous fascial tissues
while ignoring intrinsic fascial
joint tissue may be an excellent
job halfway-done; and may likely
be the reason for limited success
when treating a clients musculoskeletal condition.
The province of intrinsic fascial
tissues has been largely left to
chiropractic and osteopathic physicians. Yet, if massage therapy is
to take its rightful place as the
preeminent manual therapy for
clinical orthopedic manual treatment of soft tissue musculoskeletal/myofascial conditions, then
learning how to treat intrinsic
joint tissues needs to become a
part of the treatment strategy.
Toward this end, joint mobilization, specifically Grade IV joint
mobilization, can be an extremely
Joint mobilization is actually quite simple to perform. It involves pinning/stabilizing one bone at a
joint, and then moving/mobilizing the adjacent bone
relative to it. In effect, joint mobilization is identical
to a treatment method that is already prevalent in the
world of massage therapy: pin-and-stretch technique.
zation.
Most typically, the proximal
Note: It should be pointed out that Grade V joint mobilization is a chiropractic/osteopathic high-velocity (fast thrust) manipulation that is
not within the scope of practice for massage therapy.
Indications/Contraindications
The indication for joint mobilization is simple. Given that the goal
of this technique is to increase
motion at a joint, the indication is
joint hypomobility: if the joints
motion is decreased as a result of
taut intrinsic joint tissues, joint
mobilization is indicated. The
contraindication to joint mobilization is joint hypermobility: if
the joints motion is excessive
due to slackened tissue or if the
integrity of the tissue is compromised or unstable, joint mobilization is contraindicated.
Joint mobilization
hypermobile and joint mobilization is contraindicated. A gentle
bounce or spring to the end-feel
is optimal and indicates a healthy
joint. In this case, joint mobilization is neither indicated nor contraindicated, but may be performed proactively to maintain
healthy joint motion. Palpating
for the quality of end-feel motion
can be subtle and challenging to
discern at first. As with any technique, practice and focused attention are the keys to becoming
skilled at motion palpation assessment and joint mobilization
treatment techniques.
Axial and Nonaxial Motions
The type of motion that is performed during the mobilization
can be an axial, nonaxial, or a
combination of the two. Therapists often think of joint motion
only in terms of axial motion. For
example, the glenohumeral joint
motions that are usually taught
are flexion and extension in the
sagittal plane, abduction and adduction in the frontal plane, and
lateral and medial rotations in
the transverse plane. All of these
motions are described as axial
because they involve the humerus moving in a circular manner
around an axis of rotation that
passes through the joint. However, underlying most axial motions such as flexion or abduction
are more fundamental component motions called roll, glide,
and spin. To perform joint mobilization, these fundamental motions of roll, glide, and spin must
first be understood (Figure 2).
Roll, Glide, and Spin
Spin and roll are axial motions,
but roll must occur in conjunction
with glide, which is a nonaxial
motion. It is this nonaxial glide
motion that joint mobilization is
usually focused on. To visualize
these three fundamental motions,
it can be helpful to make an anal-
Fig. 1 Joint mobilization is performed by pinning one bone and mobilizing the adjacent
bone relative to it, thereby stretching the intrinsic soft tissues located between them.
Fig. 2 Fundamental motions of roll, glide, and spin. A, Roll. B, Glide. C, Spin. (Figure
reproduced with permission from Elsevier, Kinesiology, The Skeletal System and Muscle Function, 2nd Edition, JE Muscolino)
Convex/Concave Kinematics
Now that roll and glide motions
are understood, lets apply this
knowledge to convex/concave
kinematics. This will allow us to
determine how to assess and mobilize the nonaxial glide component of joint motion to improve
the ROM of the joint. The term
Terra Rosa E-mag 31
Fig. 3 Roll, glide, and spin motions: tire analogy. A, Tire that is rolling along the road. B, Tire that is gliding/skidding along the road.
C, Tire that is spinning in place on the road. (Figure reproduced with permission from Elsevier, Kinesiology, The Skeletal System
and Muscle Function, 2nd Edition, JE Muscolino)
Joint mobilization
CAUTION
Before practicing any new modality or technique, check with your
states or provinces massage therapy regulatory authority to ensure
that it is within the defined scope of practice for massage therapy.
Grade IV joint mobilization is within the scope of practice for massage therapy .
Fig. 6 Kinematics of roll and glide. A, Convex on concave kinematics: Roll of the
convex (upper bone) in one direction is
accompanied by glide of the convex bone
in the opposite direction. A, Concave on
convex kinematics: Roll of the concave
(upper) bone in one direction is accompanied by glide of the concave bone in the
same direction.
Joint Crepitus
When performing joint mobilization, it is common
to hear or feel a sound emanating from the joint.
Any sound that occurs during joint motion is
termed joint crepitus. Although therapists and clients are often concerned by the presence of joint
crepitus, it seldom indicates a serious condition
and rarely contraindicates joint mobilization technique. In fact, joint crepitus may be an indicator
that mobilization should be performed.
To determine whether joint crepitus indicates or
contraindicates joint mobilization technique, it is
important to determine the mechanism/cause of
the crepitus because it can occur for many reasons.
(Keep in mind that whether joint crepitus is present or not, the two most important criteria for the
indication/contraindication of joint mobilization
technique are the mobility of the joint and the
structural integrity of the joint tissues.)
Following are the most common causes of joint
crepitus:
Joint release: This is the sound that is heard when a
chiropractic manipulation is performed. A joint
release sounds similar to the popping noise that
a cork makes when it is removed from a bottle of
champagne. Unlike other types of joint crepitus,
a joint release cannot occur multiple times in
succession at the same joint as other forms of
crepitus can. This is a good criterion to use to
determine if the joint crepitus you hear is a joint
release. If a joint release does occur, there is no
need for concern. In fact, it is likely a good sign
because it shows that motion has been introduced into the joint. Note: Although a joint release may occur during Grade IV mobilization, it
should not be the intended goal of this mobilization technique).
Taut soft tissue restriction: Joint crepitus is most
often caused by a hypomobility of the joint due
to a taut band of soft tissue. As a joint moves
through its range of motion, it might reach a
point where the taut band of soft tissue restricts
its further motion. In effect, it becomes temporarily stuck, often along a bumpy contour of underlying bone. The continued application of force
can then move the joint past this restriction, resulting in a clicking type of noise, as the taut
band rubs (twangs) over the underlying bony
contour. This type of crepitus would be assessed
by the presence of decreased motion, in other
words, a joint hypomobility. Joint hypomobility
indicates joint mobilization technique, so mobilization should be performed when crepitus occurs for this reason because it can serve to
gradually loosen the taut soft tissue.
Excessively loose soft tissue: A hypermobile joint
that has excessively loose soft tissue can also
cause joint crepitus. This occurs as the excessive
motion allows bands of soft tissue to rub/twang
along bumps on the underlying bones. This type
of crepitus would be assessed by the presence of
excessive motion, in other words, joint hypermobility. Because joint hypermobility contraindicates joint mobilization technique, joint mobilization should not be performed when crepitus
occurs for this reason.
Degenerative joint surface: If there is degeneration
of the articular cartilage surfaces of the joint
(indicative of degenerative joint disease [DJD],
also known as osteoarthritis [OA]), mobilization
of the joint can cause the rough surfaces to grind
along each other, creating joint crepitus. This
type of joint crepitus sounds/feels similar to rubbing sandpaper along a surface. Unlike other
causes of joint crepitus, this type of crepitus is
often accompanied by pain or discomfort deep in
the joint. This type of joint crepitus usually contraindicates joint mobilization because it would
cause further irritation to the joint. However, if
traction can be added to the mobilization so that
the joint surfaces do not grind along each other,
mobilization can be performed and may be helpful toward mobilizing a joint that otherwise cannot be moved without pain.
Joint mobilization
Fig. 7 Mobilization of metacarpophalangeal (MCP) joint glides in the sagittal plane. A, Stabilization of the metacarpal. B, Traction
of the proximal phalanx. C, Palmar glide mobilization of the proximal phalanx. D, Dorsal glide mobilization of the proximal phalanx. (Figure reproduced with permission from Joseph E. Muscolino)
Example 1: Metacarpophalangeal
Joint Glide
Sagittal plane glide motions of the
metacarpophalangeal (MCP) joint
of the index finger involve concave on convex kinematics. Flexion is composed of an anterior/
palmar roll of the phalanx accompanied by a palmar glide of the
phalanx. And extension is composed of a posterior/dorsal roll of
the phalanx accompanied by a
dorsal glide of the phalanx.
Therefore, palmar glide mobilization is needed to optimize flexion
range of motion; and dorsal glide
mobilization is needed to optimize extension range of motion.
Following are the steps to perform palmar and dorsal glide mobilizations of the MCP joint:
Use one hand to pin/stabilize
Fig. 9 Abduction with inferior glide mobilization of glenohumeral (GH) joint in the frontal plane: A, Contact the distal and proximal arm. B, Traction added. C, Further abduction with inferior glide until tissue tension is reached. D, Inferior glide mobilization
of the head of the humerus. (Figure reproduced with permission from Joseph E. Muscolino)
With an understanding of joint kinematics, the therapist can critically reason how motion should occur at a
joint. This empowers the therapist to be able to critically think how to apply joint mobilization treatment
technique to their clients condition instead of memorizing cookbook treatment routines.
Terra Rosa E-mag 37
Fig.10 Mobilization of the cervical spine into right lateral flexion. A, Support the clients head in your left hand. Note that the clients head and neck are rotated to the left. B, Index finger contact on right-side facet of C5. C, Facets of the cervical spine. D, The
head and neck are brought into right lateral flexion until tension is reached at the C4-C5 level. F, Mobilization of C4 on C5.
Clinical Orthopedic
Massage Therapy
with Dr. Joe Muscolino
Sydney, July 2016
www.terrarosa.com.au
This workshop covers the major clinical orthopedic assessment and treatment techniques
(soft tissues & Joint mobilization) for the neck.
Easy Assessment
Only a small fraction of massage therapists use any
assessment testing in their practice. Although most
massage training includes some type of kinesiology
and assessment tests, therapists quickly forget this
information and rely only on their touch. Touch is
powerful, and because of this, most therapists don't
find a need for any assessment testing. I believe that
adding a few simple assessment tests can dramatically enhance the massage experience.
The problem with assessment
The problem with testing is that there are too many
tests. Even after making many DVDs on orthopedic
testing, even I can't remember them all. Also, in a
normal massage practice, muscle tension dominates
the client's complaints, and so a therapist with good
palpation skills can easily find the areas of complaint and relieve them. Finally, many clients don't
expect to have any testing done. What we really
need is a simple set of tests that we can do quickly
that will reveal restrictions to both the therapist
and client.
What assessment can bring
Due to the complexity of all the orthopedic tests, we
need some simple tests that can be done quickly,
and are applied to every client every session. Range
of motion testing is the perfect answer to these requirements, especially since we are working with
muscles, which control the joints. By performing a
quick full body range of motion testing sequence,
we can see where someone is restricted. This tells
the therapist where to work, but just as importantly,
alerts the client to an area that needs attention. This
can create a goal that the therapist and client can
work towards. Tension is the precursor to injury,
and restricted range of motion is an indication of
tension and dysfunctional movement. By revealing
these areas to a client, we can design session that
will not just get them out of pain now, but make
them healthier in the future.
Easy assessment
as they do, notice if the motion is happening in the
upper neck(C1-C3), or lower neck. It is very common
for the lower neck to be almost immobile, and all the
motion happening in the upper neck. Note where
there is restriction.
You may be wondering why we don't perform flexion or extension of the neck. The reason is that most
of the muscles that perform these motions also perform rotation, so we can get most of what we need
by looking at rotation. Once rotation is restored, any
limited flexion or extension usually resolves itself.
Hip
Next have the client take a few steps in place without
looking down. Then have them stop and stand normally. Look at the position of their feet. Notice if one
foot is pointing out, or if one is pointing in. If the feet
are pointing out, it indicates tension in the hip external rotators. Feet pointing inward can indicate tension in the internal hip rotators. If we want to address the lower back and hips, we can get confirmation of this initial assessment once the client is on
the table.
Torso
At this point we have the client sit on the edge of the
massage table, cross their hands in front of their
chest and rotate to each side. This will tell us about
the ability of the thoracic vertebrae to move. Notice
if one side is more restricted than the other.
Next we can look at the ability of the lumbar vertebrae to side-bend, which will tell us something about
the health of the spine. Still with hands crossed over
their chest, have them side bend to each side. Watch
their torso and ignore shoulder or neck motion.
Really note what type of motion is happening between the bottom of the ribs and the top of the ilium.
Restriction bending to the right indicates a strong
Fig. 2. Assessment for the shoulder: Internal rotation, External rotation & Shoulder height assessment.
www.terrarosa.com.au
Real Bodywork offers a variety of high quality massage DVDs and massage videos. All of the
DVDs are finely crafted by Sean Riehl and colleagues with great techniques that you can apply
immediately in your massage practice.
Available as hardcopy DVDs and Online Videos at www.terrarosa.com.au
Fig.1. There is a continuous line of connection from the gastrocnemius/soleus to the plantar fascia (whose fibrous aponeuroses are shown here in salmon). A lack of resilience anywhere in the chain will restrict ankle dorsiflexion, and may contribute
to Achilles tendon irritation or plantar fasciitis.
tibia and fibula (such as the extensor retinacula, interosseous membrane and tibiofibular ligaments)
can prevent these two bones from normal widening
around the wedge-shaped talus .
1 The contributing causes of both types of restrictions can include soft tissue shortening, hardening, or scarring from overuse, postural habit, surgery, or injury, as well as neurological conditions such as cerebral palsy. The contractures from these conditions will
usually respond well to the work presented in these articles. Restrictions from joint abnormalities or bone spurs are also possible,
and although the work described here may be helpful, additional measures and care by other professionals is usually indicated.
The neutral position of the wrist keeps the carpal tunnel open, preventing the neurovascular compression and overuse injuries that can accompany
frequent or habitual wrist extension.
siflexion possible before the heels lift off the floor. In addition to
the angle between the foot and the tibia, compensations such as
turning the feet out (seen in the person on the left), foot pronation, lifting the arms forward for balance, or leaning forward at
the hips (as the person on the right is doing), are all possible
signs of limited dorsiflexion.
Sometimes clients will report a straining or cramping in the front of the shin, instead of a stretching in the back or jamming sensation in the front. If they seem to be referring to the tibialis anterior area, this is usually related to Type II restriction, which is discussed in Chapter 5. If the more lateral peroneals seem to be the source of the sensation, those will usually respond to direct work
at the site of discomfort, combined with active dorsiflexion and plantarflexion, as the peroneals themselves can contribute to limited dorsiflexion (see Fig. 5).
2
Fig. 5. Use the Gastrocnemius Technique all the way to the gastrocnemii origins on
the posterior side of the distal femur (left edge of image). Also visible in this view
are the peroneus longus and brevis (transparent), which like the gastrocnemius/
soleus complex, can also limit dorsiflexion
Fig. 6. The Plantar Fascia Technique combines the soft fist with active or passive toe extension. In Plantar Fasciitis, avoid direct pressure on the most tender areas so as not to further aggravate the inflammation. Instead, lengthen
and release the tissue distal to the inflamed points.
Fig. 7. The plantar fascia is a broad layer of tough connective tissue covering
the sole of the foot. Within it are bands of mostly longitudinal fibers (the
plantar aponeuroses, in orange). The proximal end of the plantar fascia lies
deep to the thick calcaneal fat pad (transparent).
Image Advanced-Trainings.com
Til Luchau is the Director of Advanced-Trainings.com. A legend around the USA for
his thorough, student-focused approach to trainings, Til brings more than 25 years of knowledge, talent and enthusiasm to these programs. He has trained thousands of practitioners in
over a dozen countries on five continents. He is the author of the Advanced Myofascial techniques book (Handspring Publishing).
Terra Rosa E-mag 53
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Sydney
George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy
and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has practiced
and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years.
George has served as a member of the Florida Board of Massage Therapy and was Co-Director of the
International Sports Massage Team for the 2004 Athens Olympics.
Terra
Rosa
56 Terra Rosa E-mag
Your Source for Massage Information
AMT , ATMS, IRMA, MAA Approved CEs.
Presenter:
Ron Alexander
STT [Musculoskeletal],
FFT Founder and Teacher
Research Highlights
Compiled By Jeff Tan
Evidence of Anatomy Trains myofascial meridians
The anatomy trains concept is quite popular for bodyworkers, but currently there is no scientific evidence
yet. A group of researchers from Goethe University in
Frankfurt, Gemany looked for the evidence on the existence of six myofascial meridians proposed by Myers
(1997) based on anatomical dissection studies.
Research Highlights
zation was also explored.
The results showed that the time-course and magnitude of nerve growth factor injection-induced sensitization to mechanical stimuli were generally similar across
muscle and fascia. They were also mostly similar across
two different muscle groups (the tibialis anterior and
lumbar erectors). However, the spatial extent of mechanical sensitization in the tibialis anterior musculature was larger in the fascia than in the muscle and displayed a tendency to peak at 3 days postinjection. Pressure pain thresholds were lower, tonic
pressure pain ratings, and citrate buffer evoked pain
higher in fascia than in muscle.
The authors concluded that Spatial mechanical sensitization differs between muscle and fascia. Thoracolumbar fasciae appear more sensitive than tibial fasciae
and may be major contributors to low back pain, but
the temporal sensitization profile is similar between
paraspinal and distal sites.
The placebo effect can still work, even if people
know it's a placebo
"The placebo effect is real even if you know the treatment you've been given has no medical value, research
has concluded.
A study, published in The Journal of Pain, was conducted by a team from the University of Colorado Boulder (UCB). In it, a ceramic heating element was applied
to the forearms of participants, hot enough to cause
pain but not too hot that it burned their skin.
The lead researcher, UCB graduate student Scott
Schafer, then applied what the participants thought
was an analgesic gel, used to relieve pain before applying the heating element on the skin again. In reality,
though, the gel was nothing more than Vaseline with
blue food coloring, and Schafer simply turned down the
heat when it was applied. Each participant was asked
medical questions and given information on the drugs
to help the illusion. Regular Vaseline, without blue food
colouring, was used as a control.
When Schafer set the heat on medium, participants
reported less pain when they were given the blue Vaseline as opposed to the regular Vaseline despite the
heat remaining constant. After one session, some were
told that it was a placebo, and Schafer found that it no
longer worked.
However, for those that went four sessions with the
blue Vaseline before being told it was a placebo, it was
remarkably still effective. It appears that they associated the blue Vaseline with the reduced pain so much
that they trusted its effects over Schafer telling them it
wasn't real, having felt the benefits regularly. It suggests people can be trained to believe that a placebo
works as well as a drug.
"We're still learning a lot about the critical ingredients
of placebo effects, Tor Wager of UCB, senior author on
the study, said in a statement.
Research Highlights
Iliotibial band stores and releases elastic energy ensure that humans are motivated to build social bonds
during running
through touch.
A New study published in Journal of Experimental Biology and the Journal of Biomechanics examined how
the iliotibial band stores and releases elastic energy to
make walking and running more efficient.
We found that the human IT band has the capacity to
store 15 to 20 times more elastic energy per body mass
than its much-less-developed precursor structure in a
chimp, We looked at the IT bands capacity to store
energy during running, and we found its energy-storage
capacity is substantially greater during running than
walking, and thats partly because running is a much
springier gait. We dont know whether the IT band
evolved for running or walking; it could have evolved for
walking and later evolved to play a larger role in running.
The notion that the IT band acts as a spring to aid in
locomotion runs counter to the decades-old belief that
its primary function is to stabilize the hip during walking.
Research Highlights
The authors further added that "The quality of the evidence for all comparisons was graded "low " or "very
low" which means that we have very little confidence in
these results. This is because most of the included studies were small and had methodological flaws."
Despite this, as reported in Massage and Fitness magazine:
We should not discount the research, even if it doesn't
run much in our favour. Massage if we're talking
about rubbing is a management tool, explained Beret
Kirkeby, RMT, LMT, of Body Mechanics Orthopaedic
Massage in New York City. As far as what massage
therapists should get out of reading the paper, they
should be relieved. Short-term effects are still effects. I
think a lot of therapists out there are secretly frustrated
at why they can't fix people permanently. People get
better for a lot of reasons, and it's was always highly
unlikely that a passive activity, like getting a massage,
is the magic bullet for back pain.
Besides the actual hands-on work, communication with
clients and patients is also another factor that could influence their pain outcome. [Communication] also
opens the door to talking about sound reasons to return,
rather than you won't get better if you do not come in,
Kirkeby emphasized. If massage therapists step up to
the plate and change their verbiage or website to massage positive messages reflecting the truth, such as we
can help you manage rather than we correct or treat,
they are far more likely to have returning clients based
on the idea that the clients understand it's not a onetime show and have less disappointment when their
financial commitment did not fix them.
Comfort to cancer patients through Hand Massage Program