Terra Rosa

E-magazine
Open information for Bodyworkers
No. 17, December 2015
Anatomical drawings by Leonardo da Vinci.
C
Terra Rosa E-magazine, Issue No. 17, December 2015.

ontents

2 Understanding the placebo effectBrian Fulton

10 Myofascial pain syndrome & fibromyalgiaJohn Sharkey
18 Integrating new techniquesArt Riggs
20 Improve your results for clients with persistent pain Rachel Fairweather
28 The importance of joint mobilization Joe Muscolino
40 Easy assessment for massage therapistSean Riehl
46 Type 1 ankle restrictions and plantar fasciitis Til Luchau
54 Manual therapy for lower back painEvidence-based and clinical outcomes
58 Research Highlights
62 6 Questions to Brian Fulton
63 6 Questions to Rachel Fairweather

www.terrarosa.com.au

Be Flexible & Stay Well

Terra Rosa E-mag 1

 Understanding the
Placebo Effect
By Brian Fulton RMT

2 Terra Rosa E-mag


Some therapists shudder at the mention
of the term placebo effect, others are cu-
rious as to what it might be, still others
embrace the concept. Where do you lie
on this spectrum? Sticking ones head in
the sand and denying that it exists in
your treatments is actually not helpful to
you or to the patient, because the pla-
cebo effect has been found to exist in vir-
tually every medical encounter and ap-
pears in virtually almost every drug trial
ever performed.
There is no choice about whether or not to use the
placebo (and nocebo) effects. Those effects are going
on in every medical encounter between patient and
physician. They exist whether we want them to or
not; whether we are consciously exploiting them or
not. The choice is about how we go about using
them: well or poorly, blindly or thoughtfully. 1 Dr.
Howard Brody, Director of the Institute for Medical
Humanities of the University of Texas.
In 2011, the Journal of Manual and Manipulative
Therapy published a peer-reviewed paper pub-
lished by entitled Placebo response to manual ther-
apy: something out of nothing? In it, the authors
look at 94 different research papers on manual
therapy and on the placebo effect and draw some
relevant inferences about the placebo effect in man-
ual therapy. Some of the papers that they looked at
clearly suggested that what you and I think may be
happening isnt exactly what is happening. The evi-
dence points to a strong placebo component in what
we do in the manual therapy professions. The au-
thors state the following:
We suggest that manual therapists conceptualize
placebo not only as a comparative intervention, but
also as a potential active mechanism to partially ac-
count for treatment effects associated with manual
therapy. We are not suggesting manual therapists
include known sham or ineffective interventions in
their clinical practice, but take steps to maximize pla-
cebo responses to reduce pain.2
Another review of evidence is a paper published in
2010 entitled Effectiveness of manual therapies: the
UK evidence report. In this report the authors
looked at 49 recent relevant systematic reviews, 16
evidence-based clinical guidelines, plus an addi-
tional 46 random controlled trials (RCT) that had
not yet been included in systematic reviews and
guidelines. The authors looked at 26 categories of
conditions containing RCT evidence for the use of
manual therapy: 13 musculoskeletal conditions,
four types of chronic headache and nine non-
musculoskeletal conditions. This report, published
in Chiropractic and Manual Therapies (the official
journal of the Chiropractic & Osteopathic College of
Australasia, the European Academy of Chiropractic
and The Royal College of Chiropractors) recognizes
the important role that manual therapy plays in
treating a wide variety of ailments, but even in this
report the authors state:
Additionally, there is substantial evidence to show
that the ritual of the patient practitioner interaction
has a therapeutic effect in itself separate from any
specific effects of the treatment applied. This phe-
Terra Rosa E-mag 3

nomenon is termed contextual effects. The contex-
tual or, as it is often called, non-specific effect of the
therapeutic encounter can be quite different depend-
ing on the type of provider, the explanation or di-
agnosis given, the provider's enthusiasm, and the
patient's expectations. 3
Research interest in this phenomenon has contin-
ued to grow dramatically in this topic. In 2011 Har-
vard created an institute dedicated wholly to the
study of placebos, the Program in Placebo Studies
and the Therapeutic Encounter (PiPS). It is based at
the Beth Israel Deaconess Medical Center and Ted
Kaptchuk, a prominent figure in placebo studies,
was named its director. Its purpose is to bring to-
gether researchers who are examining the placebo
response and the impact of medical ritual, the pa-
tient-physician relationship and the power of imagi-
nation, hope, trust, persuasion, compassion and em-
pathic witnessing in the healing process. PiPS re-
search is multi-disciplinary extremely inclusive
spanning molecular biology, neuroscience and clini-
cal care, as well as interdisciplinary, ranging from
the basic sciences to psychology to the history of
medicine. This certainly gives you an idea of not just
how important the study of the placebo effect is, but
also how complex it is.
If one looks at the money and energy that is now
being invested in understanding the placebo effect,
it is clear that the study of this innate healing phe-
4 Terra Rosa E-mag
The Placebo Effect
nomenon has come of age; and yet the term drags
centuries of baggage along with it. In common lan-
guage people will often say, Oh, thats just a placebo
effect. What people often fail to recognize is that
every time the placebo effect is observed, the body
is healing itself. Is this not our goal as health practi-
tioners? Is it not our primary goal to help create an
environment where the patients body can heal it-
self? I submit that the primary reason for practitio-
ners to understand the placebo effect is so that we
can learn to manage the contextual factors within
the clinical environment that will couple with our
physical intervention to produce an optimal healing
environment.
What is the Placebo Effect?
Admittedly most of our knowledge surrounding the
placebo effect is theory. What is not known vastly
overshadows what is known, but the working the-
ory is that psychosocial cues initiate neurobiological
mechanisms which modulate existing healing re-
sponses, bringing about subjective and objective
(measurable) changes.
--- The Placebo Effect ---
Psychosocial Cues Neurobiological Path-
ways Subjective and Objective Changes
Psychosocial Cues
Cues in the environment and in the patient-
practitioner 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 phe-
nomenon 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, improve-
ment in exercise tolerance, or changes in tissue
quality to name just a few. What are more elusive
and complex are the triggers and the pathways that
bring about this effect. While semantics get raised
every time the placebo is discussed, I suggest that
we not get side-tracked by semantics, but rather
focus on the factors that initiate this healing phe-
nomenon.
The triggers for these healing effects are wide and
varied (as are humans) but there is some agreement
that they can be grouped under one of the following
the headings: conditioning, expectancy, and mean-
ing. Meaning is a very broad topic though that takes
in a large number of concepts. The following is a list
of concepts that I examine in my book, The Placebo
Effect- Improving Clinical Outcomes. Research sup-
porting each concept is examined in the book, and
practical methods are discussed for incorporating
each idea into ones own practice to the end of im-
proving clinical outcomes. 4
Examples of Psychosocial Cues (Contextual Fac-
tors)
Expectancy (Hope, Belief)
Conditioning
Trust in the Practitioner
Motivation and Desire
The Power of Listening
Feelings of Care and Concern from Practitioner
Establishment of a Feeling of Control
Reducing your Patients Anxiety Levels
Receiving Adequate Explanation of the Pathol-
ogy
Acceptance of the Mystery of Healing
Certainty of the Patient
Time Spent By the Practitioner
Use of Ritual
Professionalism
Clinicians Belief System
Confidence of the Practitioner
Competence of the Practitioner
Practitioners Attire
Enthusiasm of Practitioner
Use of Humour
Patients Inner Narrative
Clinical/Healing Environment
Every factor listed above has been shown to inde-
pendently affect clinical outcomes, and there is
likely an additive healing effect from these cues. Be-
coming aware of these elements in your daily prac-
tice 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 rec-
ommend 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 com-
plex mental activity can change body physiology. Psy-
chiatry and psychology, as disciplines investigating
mental events, are at the very heart of the problem,
for they use words and verbal suggestions to influ-
ence 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 re-
cent placebo research is that words and drugs may
use the very same mechanisms and the very same bio-
chemical 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 cor-
tex is brain region is intimately involved in planning
complex cognitive behaviour, personality expres-
sion, decision making, and moderating social behav-
iour. This brain region is considered to be the centre
of orchestration of thoughts and actions in accor-
dance with internal goals. One of the features of Alz-
heimer's disease is the impairment of prefrontal
executive control. Benedetti found a clear disrup-
tion of the placebo response occurred when re-
duced connectivity of the prefrontal lobes with the
rest of the brain was present.6
At least four biological pathways have been pro-
Terra Rosa E-mag 5

posed for facilitating placebo responses.
Endorphin Pathways- Diagnostic equipment now
allows us to look inside of the living brain and see
what is going on. Brain scans show -opioid recep-
tors in the brain being activated by a placebo in
brains of subjects experiencing pain relief from tak-
ing a placebo.7 Clearly the endorphin pathway is
involved in the placebo effect, especially where pain
modulation is happening.
Neuroendocrine Pathway- The neuroendocrine
pathway involves not just the sympathetic and
parasympathetic nervous systems, but also the hy-
pothalamus, pituitary gland and the adrenal glands,
collectively known as the HPA axis. The neural path-
way of the HPA axis signals the adrenal medulla to
release catecholamines (not the least of which is
adrenaline), which are known to increase heart rate,
blood pressure, breathing and metabolic rate. In
addition to these symptoms, our sympathetic nerv-
ous system increases muscle tone, which as you
know can manifest as musculoskeletal pain. Damp-
ening of this pathway (which can be triggered by a
thought or a feeling) could account for placebo suc-
cess with generalized musculoskeletal pain, specific
pain such as headaches, cervical or lumbar pain.
This pathway is also proposed for placebo success
with hypertension, chronic pain and stomach ulcers,
as well as immune system bolstering and normali-
zation of blood sugar levels.
Psychoneuroimmune Pathway- Immune system
cells are studded with receptor sites for neuropep-
tides associated with emotional states. In other
words, your immune system reacts to (among other
things), how you are feeling. There are both afferent
and efferent fibres in this pathway, so there is a lot
of information passing back and forth from the
brain to the immune system allowing for fine-
tuning, checks and balances. Involvement of the hy-
pothalamus and pituitary gland in this loop has
caused some researchers to speculate that there is
an ideal set point for the immune system, to keep it
at a certain level of readiness.8,9 What we have
learned is that conscious intervention can modulate
this immune response, much as it does with respira-
6 Terra Rosa E-mag
The Placebo Effect
tion and blood pressure.
Acute Phase Inflammatory Response- In his book,
Placebo: Mind Over Matter in Modern Medicine, Dy-
lan Evans presents a detailed argument for the
acute phase inflammatory response theory. Evans
states that the conditions where the placebo effect
is most pronounced (pain, swelling, ulcers, depres-
sion anxiety) all involve the acute phase inflamma-
tory response. He reminds us that this response
goes beyond the classic signs of inflammation
(tumor, rubor, calor and dolor), but is now recog-
nized to include a suite of symptoms known as
sickness behaviour. 10 Sickness behaviour includes
lethargy, apathy, loss of appetite and increased sen-
sitivity to pain.
Subjective and Objective Changes
Not only do people experience substantial pain re-
lief from placebo interventions, studies have seen
measurable changes in heart rate, blood pressure,
immune response, endocrine response, and inflam-
mation, which can bring about healing responses
seen in tissue changes, range of motion, pain levels,
exercise tolerance, and even markers such as BMI.
Some examples include:
A wisdom tooth extraction trial using placebo
ultrasound produced reductions in swelling and
healing time.11
Studies have found increase in natural killer cell
function with saline injections when subjects
where first conditioned with adrenalin injec-
tions. 12
Dylan Evans list of conditions most influenced
by placebos includes: inflammation, stomach
ulcers, anxiety, depression and virtually all types
of pain. 13
Investigation into the mechanism of the placebo
effect currently taking place at several medical
universities has documented substantial, meas-
urable physiological changes taking place. 14
A 2011 review of current literature conducted
by Fabrizio Benedetti stated, recent research
 has revealed that these placebo-induced bio-
chemical 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 practitio-
ner/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 pa-
tient, rather than the practitioner. The patient that
takes charge of his or her health is going to see im-
proved outcomes. Making the patient aware that
these amazing healing effects exist within their own
mind and body do not lead to evaporation of the appear to flow out of a healthy patient-practitioner
effect, but to enhancement of healing responses and relationship. Furthermore, placebo effects are real
a personal sense of power over ones health. Finally, and often measureable. Our task as practitioners is
increased professionalism of the practitioner leads to understand and optimize contextual factors
to improved placebo responses. This may be a per- within the clinical environment that can act as trig-
ception issue, since much of the placebo effect ap- gers enhancing the patients innate healing re-
pears to involve the patients perception of their sponse. This can be incorporated ethically and
practitioner, but the way to improve their percep- seamlessly into each and every treatment during
tion of you is by being a more competent profes- assessment, interaction, and treatment of the pa-
sional. So in the end, if you are an ethical profes- tient. Our goal as practitioners should be to become
sional, you have no worries about employing tech- more competent at understanding and managing
niques to encourage healing in your patients. In the complex dynamics known as contextual factors
fact, I recommend reminding your patients that the that come into play in the therapist-practitioner re-
placebo effect is real, and it manifests from their lationship.
own internal healing systems as well as their rela-
References
tionship with you. It is not a minus, but a plus for
1 Using Placebo Responses in Clinical Practice: Is there a there,
the patient to realize the amazing healing potential
there? What do we need to know? Samueli Institute, Jan. 20,
of their own bodies. 2012, pg 15
2 Bialosky, J.E et al. (2011) Placebo response to manual therapy:

Conclusion something out of nothing? J Man Manip Ther. February; 19

I hope that you now see that the placebo effect isnt
quite as mysterious as you may have thought. It
(1): 1119
3 Bronfort, G. et al. (2010) Effectiveness of manual therapies:
the UK evidence report. Chiropr Osteopat. 2010; 18: 3.
4 Fulton, B. (2015) The Placebo Effect in Manual Therapy- Im-

manifests from innate healing mechanisms present proving Clinical Outcomes. Handspring Publishing, Edin-
burgh: 84-246
in the body, and many triggers for this phenomenon

Terra Rosa E-mag 7

 The Placebo Effect
5 Benedetti, F (2012) The placebo response: science versus eth- los Trans R Soc Lond B Biol Sci. Jun 27;366(1572):1808-17.
ics and the vulnerability of the patient. World Psych. 11(2): 15 Benedetti, F., Amanzio, M. (2011). The placebo response: how
7072. words and rituals change the patient's brain. Patient Educ
6 Benedetti, F. et al., (2006) The Biochemical and Neuroendo-
Couns. 2011 84(3):413-9.
crine Bases of the Hyperalgesic Nocebo Effect. Journ Neuro-
sci, 26(46):1201412022
7 Zubieta et al. (2005) Placebo effects mediated by endogenous
Brian Fulton RMT has been a Massage Therapist since
opioid activity on -opioid receptors. The Journal of Neuro-
science 25(34): 7754-7762. 1999. Trained and educated in Ontario, Canada, he has
8 Schwartz, C. (1994). Introduction: old methodological chal- maintained a clinical practice with a distinctly holistic ap-
lenges and new mind-body links in psychoneuroimmunol- proach to healing and disease prevention. As a past Direc-
ogy. Advances in Mind-Body Medicine 10(4): 4-7 tor of the Registered Massage Therapists Association of
9 Barak, Y. (2006). The immune system and happiness. Autoim-
Ontario, he has been actively involved in moving his profes-
munity Reviews 5 (8): 523-527
10 Kent, S., R.-M. Bluthe et al. (1992). Sickness behaviour as a sion forward on all levels.
new target for drug development. Trends in Pharmacologi-
cal Science 13: 24-28
In addition to his private practice, Brian was a health col-
11 Hashish, I., H.K Hai et al. (1986). Reduction of postoperative umnist for a community magazine for over ten years, writ-
pain and swelling by ultrasound treatment: a placebo effect. ing on a broad range of topics from nutrition, exercise,
Pain 33: 303-311 injury management and disease prevention. His current
12 Kirschbaum, C et al. (1992). Conditioning of drug-induced
passion lies in educating health practitioners in becoming
immunomodulation in human volunteers: a European col- more aware of the innate healing mechanisms inside of
laborative study. British Journal of Clinical Psychology 31: their patients. His book, The Placebo Response in Man-
459-472
ual Therapy Improving clinical outcomes in your
13 Evans, Dylan (2004). Placebo: Mind Over Matter in Modern
practice, is a detailed work guiding health professionals in
Medicine. London, England. Harper Collin: 44
14 Benedetti F., Amanzio M. (2013). Mechanisms of the placebo the important area of accessing their patients natural
response. Pulm Pharmacol Ther. Jan 28. pii: S1094-5539(13) healing systems by understanding subtleties in the practi-
00052-7 tioner-patient relationship.
also Pollo A, Carlino E, Benedetti F. (2011) Placebo mechanisms
across different conditions: from the clinical setting to
physical performance. Philos Trans R Soc Lond B Biol Sci. Jun
27;366(1572):1790-8.
also Meissner K. (2011) The placebo effect and the autonomic
nervous system: evidence for an intimate relationship. Phi-

The Placebo Response in Manual Therapy presents a

knowledge-based approach to augmenting your patients
own healing systems.

It explains how to: maximize the placebo response in your

patients, using knowledge from 60 years of research turn
on an individuals inner healing system, even with chal-
lenging patients increase your success rate and your pa-
tients health outcomes within your current methods of
practice .

Available at: www.terrarosa.com.au

8 Terra Rosa E-mag

 Terra Rosa is your source for massage information.
We have the largest & best collection of Massage and bodywork Books in Australia and
in the world.
Over 100 Book titles in stock.

Terra Rosa E-mag 9

 Myofascial Pain Syndrome
and Fibromyalgia
The Myofascial Trigger Point Connection

John Sharkey
Clinical Anatomist (BACA), Exercise Physiologist (BASES), Myofascial Trigger Point Specialist.
MSc., Faculty of Medicine, Dentistry and Clinical Sciences, University of Chester/NTC, Dublin, Ireland

10 Terra Rosa E-mag

Introduction
Myofascial Pain Syndrome (MPS) has been de-
scribed as sensory, motor, and autonomic symp-
toms caused by Myofascial Trigger Points. Most, if
not all, experts on myofascial trigger points de-
scribe 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 palpat-
ing the tissues with their finger tips. People experi-
encing Myofascial Trigger Points present in the
clinical setting complaining of pain, however, this is
only one part of a more accurate story. People suf-
fering 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 accu-
rate information concerning the Etiology and
Pathophysiology of the Myofascial Trigger Point.
Also a focus on changes in sensations will high-
light 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 up-
coming workshops in Sydney next June (2016)
where among other things I will build your knowl-
edge concerning Myofascial Trigger Points, Bioten-
segrity (anatomy for the 21st century) and provide
you with hands-on soft tissue therapeutic applica-
tions that have worked for my chronic pain pa-
tients.
Fibromyalgia and the Myofascial Trigger Point
Fibromyalgia is neither musculoskeletal nor rheu-
matic. 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. Fi-
bromyalgia is the term given to a family of illnesses
that have in common central nervous system sensi-
tisation and chronic diffuse systemic pain. Fi-
bromyalgia 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 dif-
fuse pain all over. Fibromyalgia does not cause lo-
calized pain. If there is localized pain, it is caused by
something else, although Fibromyalgia may also be
present. Often, but not always, localized pain is
caused by one or more Myofascial Trigger Points.
Fibromyalgia is a chronic body wide muscle
(myofascial) soreness syndrome associated with
central and peripheral sensitisations due in no
small part to the body being stuck in a stress re-
sponse. Sleep disturbance, chronic fatigue and vis-
ceral pain syndromes (including irritable bowel
syndrome and interstitial cystitis) regularly accom-
pany Fibromyalgia. Fibromyalgia is characterized
by hyperalgesia (amplified pain) and allodynia
(normally non-painful stimuli such as touch,
sounds, light, and smells all interpreted as intense
pain by the Central Nervous System). It is a critical
point that myofascial pain syndrome is character-
ised by the presence of myofascial trigger points
located in any of the millions of individual muscle
fibers throughout the entire body.1
Peripheral stimuli, such as Myofascial Trigger
Points, may initiate noxious sensations including
pain, nausea or dizziness. Amplified by fibromyal-
gia the pain or other sensations can outlast the
stimulus. Research verifies that the central sensiti-
zation of fibromyalgia can be initiated and/or main-
tained by peripheral pain.2 The referred pain of
myofascial trigger points is itself a manifestation of
central sensitization.3 In fibromyalgia the filters
that protect healthy people from central nervous
system over-stimulation are not working ade-
quately.4 The fibromyalgia patient may not be able
to pinpoint sources of pain, because his or her brain
is totally preoccupied with attempting to handle a
deluge of pain and other stimuli. In uncontrolled
fibromyalgia, anything that can shock the central
nervous systemincluding pain, loud noises, and
any other startling stimulimust be moderated or
avoided. Any central nervous system assault can
lead to fibromyalgia flare. During flare, old symp-
toms worsen and new ones may appear as new
Myofascial Trigger Points activate. Everything is
hypersensitive.
Etiology and Pathophysiology of the Myofascial
Trigger Point
The causes or perpetuation of Myofascial Trigger
Points can include trauma to myofascial tissues,
muscle fibers, intervertebral discs, inflammatory
conditions, myocardial ischemia, non-accustomed
exercise or physical activity, bad posture, fatigue,
inadequate sleep, distress, hormonal influences,
poor nutrition, over-weight or obesity, smoking and
lack of activity. According to research5, Myofascial
Trigger Points can form due to a disruption of the
cell membrane, damage to the sarcoplasmic reticu-
Terra Rosa E-mag 11
lum and subsequent migration of increased levels
of calcium-ions, and disruption of cytoskeletal pro-
teins, such as desmin, titin, and dystrophin. Ragged
red (RR) fibers (also known as moth eaten fibers)
and increased numbers of cytochrome-c-oxidase
(COX) negative fibers are common in patients with
myalgia, which are suggestive of an impaired oxida-
tive metabolism. In any case the key issue at the
cellular level centers around increased levels of cal-
cium ions trapped within the sarcomere. Moving
towards the gross anatomical and physiological lev-
els an energy crisis is witnessed perpetuating the
formation, establishment and maintenance of Myo-
fascial Trigger Points.
Anything that perpetuates a Myofascial Trigger
Point is called a perpetuating factor. Therapists
are fighting a war on pain. The foot soldiers of the
enemy are perpetuating factors including mechani-
cal stressors such as paradoxical breathing, body
disproportions (leg length discrepancy, clavicular
asymmetry or small hemi pelvis), myofascial or
connective tissue abuse, and articular dysfunctions.
Metabolic perpetuating factors include impair-
ments to energy metabolism, coexisting conditions
such as lack of restorative sleep and pain. Environ-
mental perpetuating factors include pollution,
medications, trauma, and infections.
Psychological perpetuating factors are also an im-
portant area to investigate. Lifestyle perpetuating
factors are often the least expensive perpetuating
factors to remedy, but may be among the most diffi-
cult to maintain. To further complicate life, perpetu-
ating factors often have perpetuating factors of
their own. Cognitive therapy and mindfulness can
be useful interventions to help us change the way
our patients/clients and we therapists think about
and perceive pain. What initially activates a Myofas-
cial Trigger Point may be different from what ag-
gravates (worsens) or perpetuates (maintains) it,
but they are all commonly called perpetuating fac-
tors. The key to controlling any symptom is the con-
trol of as many perpetuating factors as possible.
An appropriate medical history will indicate if pain
patterns are stable or evolving. Chronic myofascial
pain (CMP) is not progressive. The development of
satellite Myofascial Trigger Points that worsen
symptoms, or the appearance of new symptoms, are
indicators that there are perpetuating factors at
play. To control symptoms, first identify and control
perpetuating factors. Controlling perpetuating fac-
tors is vital. Perpetuating factors include whatever
impairs muscle function, such as anything diminish-
ing the cells access to oxygen and nutrients, ham-
12 Terra Rosa E-mag
pering removal of cellular wastes, or adversely af-
fecting the metabolism of the neurotransmitter ace-
tylcholine (ACh). Anything that enhances the forma-
tion 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 en-
ergy supply (inadequate nutrition, insulin resis-
tance), sensitizes the Central nervous system (pain,
noise), decreases oxygen supply (congestion), en-
hances 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 sensa-
tions may well be missed.
In 2008, The Concise Book of Neuromuscular Ther-
apy (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 loca-
tion of Myofascial Trigger Points in Upper Trapezius
Central Sensitisation and Control of Perpetuat-
ing Factors
Chronic pain syndromes display significant Neuro-
plastic changes, altered neuron activity, excitability
and adaptations affecting pain matrix structures -
spinal cord, thalamic nuclei, cortical areas, amyg-
dala and periaqueductal gray areas - in essence,
central sensitisation is characterised by an amplifi-
cation of normal neurological activity.6
Continuous bombardment of the dorsal horn by
noxious afferent activity leads to a release of gluta-
mate and substance P, leading to activation of previ-
ously inactive synapses in the wide dynamic neuron
(WDR), leading to central sensitisation. In normal
circumstances, there is a balance between inhibi-
tory and facilitatory neuronal activity in terms of
pain management and control.7 This results in Spi-
nal Segmental Sensitisation (SSS); a hyperactive
state of the dorsal horn caused by constant noxious
afferent bombardment, originating from damaged
or sensitised tissues (e.g. Myofascial Trigger Points
or other soft tissue/connective tissue trauma, or
from visceral structures; e.g. a gall bladder that has
become inflamed due to gall stones). Diagnosis of
Spinal Segmental Sensitisation includes observation
of dermatomal allodynia, hyperalgesia, soft tissue
pain/tenderness upon palpation and Myofascial
Trigger Points.6
Hyper-sensitivity initially occurs at the local seg-
mental level, but through the process of sensitisa-
tion of adjacent spinal segments (spill-over), a state
of wind-up caused by temporal sensory summation
(TSS); an increased rate of nociceptive pulsing at
the dorsal horn, facilitates widespread segmental
Myofascial pain syndrome
Fig. 2 From the Concise Book of Neuromuscular Therapy-a trig-
ger 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 grind-
ing. Proprioceptive dysfunctions include vertigo, nausea and
hearing irregularities such as hypersensitive hearing and tinni-
tus Sharkey, J.
sensitisation, leading to body-wide peripheral pain.8
Temporal sensory summation is caused by in-
creased C-fibre input at the dorsal horn and can
maintain a state of hyperalgesia in chronic pain pa-
tients.9
Stimuli (such as Myofascial Trigger Points) that acti-
vate and sensitise the WDR ascends the spinotha-
lamic tract to reach the higher brain centers, where
the thalamus and limbic system are activated
(anterior cingulate gyrus, insula and amygdala).
The limbic system is involved in modulating muscle
pain, but it also modulates fear, anxiety and distress.
Therefore, increased activity in the limbic system,
influencing the perpetuation of pain syndromes, can
contribute to fear of or emotional stress associated
with chronic pain syndromes.10 The rostral ventral
medulla (RVM), acting as a relay point for descend-
ing activity from the periaqueductal gray (PAG),
contains a number of on and off cells that can in-
crease or decrease levels of pain. In the acute phase
of injury, the on cells provide a protective mecha-
nism - significant pain is evoked, preventing undue
movement/activity that might cause more damage.
In chronic pain mechanisms, on cells remain active
and there appears to be a on cell dominance, rather
than a balance of on and off cells that would main-
Terra Rosa E-mag 13

Fig. 3 Image of a lower limb (anterior view) with skin reflected
showing muscle islands isolated muscles fibers on the deep
aspect of the skin. (Photo Sharkey, J. 2015)
Fig. 4 This image shows muscle fibers running the length of the
tendon (being held in my hand) with the muscle fibers migrat-
ing superficially and deep to the tendon. (Sharkey, J. 2010)
tain a balance between facilitation and inhibition.7
Additionally, normal descending pain inhibiting sig-
nals are disrupted including elevated concentrated
levels of epinephrine, and norepinephrine leading
to a further sensitisation of muscle tissue.10
My dissection investigations have demonstrated
why Myofascial Trigger Points can occur at the site
of a tendon but not in the tendon itself. Tendons do
not house Myofascial Trigger Points. What tendons
often have are isolated islands of muscle fibers
running in series which run past the classical point
of origin or insertion continuing on its kinetic jour-
ney. Careful investigation of Fig 4 reveals a small
0.5cm, or less, of muscle protein, an island. This
island can develop Myofascial Trigger Points giving
the appearance of tendonous trigger points when
palpated.
14 Terra Rosa E-mag
Differentiating the Myofascial Trigger Point from
the numerous variations of pain points is critical for
therapeutic success. Learning to view the skin as a
window to myofascial health deep to and including
the sub cutis will provide the therapists with a new
vision concerning therapeutic interventions. Palpa-
tion skills and excellence in anatomy and clinical
reasoning are called for to provide pinpoint accu-
racy supported by appropriate soft tissue manipu-
lation. I will save the important conversation con-
cerning the relationship between muscle spastic
activity and Myofascial Trigger Points until we meet
at one or more of the planned workshops next June
2016.
Thank you to Terra Rosa for facilitating the work-
shops. I am very excited about returning to Austra-
lia and working with therapists of varying stripes. I
wish everyone success in healing.
References
1 Starlanyl D., Sharkey, J. 2013. "Healing through Trigger Point
Therapy: A Guide to Fibromyalgia, Myofascial Pain and Dys-
function". And Sharkey, J. 2008. Concise Book of Neuromus-
cular Therapy-a trigger point manual. Lotus Publishing/
North Atlantic Press. Staud, R. 2006. Biology and therapy of
fibromyalgia: Pain in fibromyalgia syndrome. Arthritis Res
Ther 8(3):208
2 Gerwin, R. 2010. Myofascial pain syndrome. Here we are,
where we must go? Journal Musculoskeletal Pain 18(4):329
-347
3 Carrilo-de-la-Pena MT et al. 2006. Intensity dependence of
auditory-evoked cortical potentials in fibromyalgia pa-
tients. A test of the generalised hypervigilance hypothesis.
Journal pain 7(7):480-487
4 Larsson B, Bjrk J, Henriksson K, Gerdle B, Lindman R. The
prevalence of cytochrome c oxidase negative and superpo-
sitive fibers and ragged-red fibers in the trapezius muscle of
female cleaners with and without myalgia and of female
healthy controls. Pain. 2000;84:37987.
5 Fogelman, Y & Kent, J 2014 Efficacy of dry needling for treat-
ment of myofascial pain syndrome. J Back Musculoskelet
Rehabil.
6 Gerwin RD, Dommerholt J, Shah J (2004) An expansion of
Simons integrated hypothesis of trigger point formation.
Curr Pain Headache Rep 8:468475
7 Giamberardino MA, Affaitati G, Fabrizio A et al. Effects of
Treatment of Myofascial Myofascial Myofascial Trigger
Points on the Pain of Fibromyalgia. Curr Pain Headache
Rep. 2011 May 5.
8 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.
9 Hsueh TC, Yu S, Kuan TS , Hong CZ. 1998. Association of active
myofascial myofascial Myofascial Trigger Points and cervi-
 Myofascial pain syndrome
John Shakeys 10 Key points for consideration when treating Myofascial Trigger Points:
1. 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 move-
ment, referred pain, autonomic responses.
2. First treat Myofascial Trigger Points that are most superior and medial working inferior and lat-
eral.
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 compres-
sion, 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 Mense, S. 2010 How do muscle lesions such as latent and
active trigger points influence central nociceptive neurons?
J Musculokelet Pain, 18, 348-353.
John Sharkey is a Clinical
Anatomist (BACA), Exercise
Physiologist (BASES), and Myo-
fascial Trigger Point Specialist.
He has an MSc. At the Faculty of
Medicine, Dentistry and Clinical
Sciences, University of Chester/
NTC, Dublin, Ireland. John is a
world renowned presenter and authority in the ar-
eas of anatomy, bodywork and movement thera-
pies. With more than 30 years of clinical experience,
he is now recognised as a leading protagonist of
BioTensegrity (the new anatomy for the 21st cen-
tury) providing new models and paradigm shifts
concerning living movement and anatomy promot-
ing therapeutic interventions for the reduction of
chronic pain . He is a best selling author with titles
on Myofascial Trigger Points and Fibromyalgia. He is
a member of the editorial board of the Journal of
Bodywork and Movement Therapies (JBMT), Inter-
national Journal of Therapeutic Massage and Body-
work and the International Journal of Osteopathic
Medicine.
Correspondence to:
John Sharkey MSc.
University of Chester/National Training Centre
15-16a St Josephs Parade
Dorset St
Dublin 7, Ireland
E-mail address: john.sharkey@ntc.ie
www.johnsharkeyevents.com

Terra Rosa E-mag 15

 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 Myofas-
cial 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 for-
ward to Johns first book (a trigger point manual). Differ-
entiating between neural generated pain and Myofascial
Trigger Point pain is essential in providing the correct
soft tissue interventions for successful therapeutic out-
comes.
The Final Frontier
Working within Endangerment sites, providing
Manual and Movement Techniques to stay mobile
and pain free.
This informative workshop provides therapists with the
necessary anatomical and palpatory excellence to ex-
pertly navigate the holy grails of the human body
(endangerment sites). Providing safe neuromuscular
techniques using digital applications guarantees effec-
tive therapeutic interventions for soft tissue based
chronic pain conditions. Through your newfound ana-
tomical knowledge and unique hands-on clinical pearls
each learner will develop a greater appreciation of local
and global anatomical connections.

The Theory of EverythingBioTensegrity, anatomy for the 21st century

This workshop is ideally suited to the advanced manual and movement therapist with appropriate clinical experience
and a desire to take on fresh new ideas, new models and a new way of thinking. Therapists are warmly encouraged
to demonstrate their current screening, assessments and therapeutic applications with John while he will provide
feedback and suggestions offering a new vision supported by connective tissue techniques for successful manual
and movement interventions for all participants. This workshop provides you, the chronic pain soldier the effective full
body kinetic chain ammunition you need in the war on pain.

John Sharkey MSc is a world renowned presenter and authority in the areas of bodywork and move-
ment therapies. He is a Clinical Anatomist (BACA), Accredited Exercise Physiologist (BASES) and Foun-
der of European Neuromuscular Therapy with more than 30 years of experience gained throughout his
career working alongside his mentors and colleagues Leon Chaitow, David G. Simons, Stephen Levin
MD, Prof. Kevin Sykes. John is recognised as a leading protagonist of BioTensegrity (providing new
models and paradigm shifts concerning living movement and anatomy promoting therapeutic interven-
tions for the reduction of chronic pain.

16 Terra Rosa E-mag

 Register at www.terrarosa.com.au

Sydney, 15-16 October 2016 Sydney, 17-18 October 2016

Fascia of the Pelvic Floor Fascial Toning

Terra Rosa E-mag 17

Sydney, 21 October 2016 Sydney, 22-23 October 2016

Integrating new
techniques
By Art Riggs
Im noticing an interesting conflict in the massage profes-
sion. 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 try-
ing 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 be-
cause 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 straight-
jacket?
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 disap-
pointed and that my long-time regular clients would wonder if
an imposter had taken over my practice. Nothing could be fur-
ther 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-and-
potato people will never appreciate nouveau cuisine, some peo-
ple might resist new bodywork. However, I think that the ad-
vantages 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 evi-
dence enough. It is far easier to draw clientele who return be-
cause they appreciate your work than to try to fit your work to
18 Terra Rosa E-mag
your guesses about client tastes. Many therapists project their
ownsometimes incorrectassumptions about what clients
expect. Some therapists assume any work that approaches in-
tensity may be considered strange. Many mistakenly assume
that clients dont want to be bothered in the midst of their
headrest snooze to be moved for side-lying work, for example,
or that a client will be unhappy if the session doesnt leave all
parts of the body equally covered with excess lubrication. In
reality, almost all clients will be grateful for skillful work that
pays attention to their particular needs, instead of conforming
to cookie-cutter convention.
The key to transitioning to a more creative bodywork style is
communication with, and education of, your clients. A former
student got in touch with me a few weeks after taking a deep-
tissue class to say that after languishing for many months at a
spa waiting for walk-ins, he is now booked every shift. The
techniques he learned were certainly useful, but the main rea-
son for his success was that he took the time before and during
the massage to talk to clients to find out what they wanted to
improve in their bodies. He went on to explain to them the
benefits of spot work, working slowly and deeply in problem-
atic areas, scheduling longer massages to get full-body cover-
age, and taking enough time to also focus on specific areas. Its
important to find your own sincere way of communicating and
transitioning to the ways of working that excite you most. Fol-
lowing are a few suggestions.
Gradually transition to your new way of working. For regular
clients, simply say you have some great new things youd like to
try to improve the massage. For new clients, build your confi-
dence and communication skills with those whom you feel a
good connection and suspect may be relaxed and open to ex-
panding their experience, instead of on every newcomer who
comes through the door.

Spend a few minutes getting to know your clients. Explain that
the meter isnt running until you start the bodywork. Educate
them about how you work and learn about their needs. The
session will be more rewarding for both of you because some
connection will have been established, rather than abruptly
diving into the massage.
Find a peer therapist to trade with and refine your skills. A fear
that clients wont like your new work can be more than just
projections about their preferences. Sometimes the culprit is
simply lack of confidence due to lack of practice.
Integrating new techniques
Art Riggs is the author of Deep Tissue Mas-
sage: a Visual Guide to Techniques (North
Atlantic Books, 2007), which has been
translated into seven languages, and the
DVD series Deep Tissue Massage and Myo-
fascial Release: A Video Guide to Tech-
niques. He just release a new DVD series Deep Tissue Massage: An
Integrated Full Body Approach which demonstrates how to inter-
grate and coordinate Deep Tissue and Myofascial Release into a
Fluid Bodywork Session.

Develop your expertise slowly, instead of overnight. Review

your training and specialize on one technique with those clients
who you feel may benefit most. When comfortable, introduce
that technique to a broader array of clientele. In the end, its
important to remember that not every client will see you as the
answer to his or her perfect massage. And thats OK. But with
good client communication and a desire to do the work you
love, your practice will thrive with clients who see value in your
more specialized work.

Deep Tissue Massage

An Integrated Full Body Approach
Coordinating Deep Tissue and Myofascial Release into a Fluid
Bodywork Session
This extensive new set (seven DVDs totalling over 9 hours) was created by Art Riggs
after countless requests from therapists who loved the first set, Deep Tissue Massage
and Myofascial Release but were having trouble working the therapeutic philosophy
and techniques into a fluid deep tissue massage, especially in a spa setting. We cover the
whole body in a common sequence of beginning in prone, moving to supine with a whole
segment devoted to the important side-lying position. The focus is upon smooth mas-
sage, but still provide a huge number of specific nuts and bolts techniques.

Available now at www.terrarosa.com.au

Deep Tissue Massage by Art Riggs

DVDs and Book
The original 7 DVD set Deep Tissue Massage and Myofascial Release.
The DVD set is designed as a full study clinical training course for mas-
sage therapists wishing to expand their skills. It has great details on
biomechanics, anatomy, with plenty of working strategies and tech-
niques.

Terra Rosa E-mag 19

 Improve your results
for clients with persistent pain
Top tips for effective client self care

Rachel Fairweather

20 Terra Rosa E-mag

 Theres only one corner of the Universe you can be certain of improving and
thats your own self. -Aldous Huxley

Client self care: Does it work?
As a manual therapist it is tempting to think that
getting effective results is all about your hands on work.
After all the use of those awesome healing hands is our
prime raison d'tre and many of us devote a lifetime to
pursuing the massage Holy Grail in other words, the
latest technique or modality that will best help our
clients out of pain. As a result, client self care is often
pushed to the back burner; a desultory 5 minutes at the
end of the session where you give a photocopy of a few
stretches
Yet what if you were missing a trick? What if spending
time teaching your client self care suggestions was one
of the biggest single cost and time effective ways to
improve your results with chronic musculo-skeletal
pain conditions? Research suggests that devoting some
thought to incorporating self- care as part of an overall
treatment plan is a wonderful way to quickly improve
your results. Conditions as diverse as herniated disc
pain, whiplash, headaches and nagging sporting
injuries all respond to a healthy dose of self care and
who better to support this than a friendly massage
therapist? Massage and self care are wonderful bed
fellows; outcomes for low back pain are improved if
combined with self care and exercise (Furlan 2002)
and studies also suggest that receiving bodywork makes
people more likely to carry out self care suggestions
(Long 2009)
The psychology of self care: Power to the
People!
To understand why self -care can be so powerful we
need to look at the psychology behind it the so- called
locus of control. You will know from your own
experience that the world tends to be divided into 2
types of people: those that believe they can alter their
circumstances by their actions and those who believe
they are at the mercy of outside forces such as chance,
fate or the whims of authority. Psychologist Julian
Rotter (1966) came up with the concept of locus of
control to explain this tendency. People with an
internal locus of control believe 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. 1). Crucially the sense of locus of
control is not fixed and can be altered through
education or experience.
So what does this sense of control have to do with
helping your clients persistent bad back? Actually
everything, as research shows that the locus of control
is highly correlated with successful treatment
outcomes. For example headache sufferers with a high
internal locus of control respond better to treatment
and are less disabled by their pain (Nicholson 2007).
On the other hand, believing that relief from low back
pain is determined by factors outside of individual
control (such as chance or the interventions of health

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 .

Terra Rosa E-mag 21

Fig. 2. Unlike this client, studies show that as many as 70% of
physiotherapy clients do not do their prescribed exercises

care professionals) is related to higher levels of

disability and poorer quality of life (Sengul 2010).

Following the logic of this research suggests that if we

are able to empower our clients to believe they have
some control over their pain condition then we are
more likely to achieve better treatment outcomes. This
is why self care approaches can be so effective as clients
are literally taking back some of the responsibility for
healing into their own hands a true case of power to
the people!
Doctor Doctor what are the best exercises to
do?
Patient: Doctor Doctor, what are the best exercises to
do.
Fig. 3. For effective results, put time aside in your treatment
to set self care goals with your client
simply telling them. Unsurprisingly, research has
shown that some of these strategies are very similar to
the motivational tools used in business or personal
training. DeSilva (2011) drew out 3 key features of
initiating successful self management of
musculoskeletal pain conditions:

Doctor: The ones that you do.
This old joke neatly summarises the best approach to
prescribing self care. The truth is that the best exercises
to suggest are the ones that your client will actually do.
There can be a big gap between knowing what is good
for you and actually doing it and studies show that as
many as 70% of physiotherapy clients do not do their
prescribed exercises (Beinart 2013) (Fig. 2). Therapists
often get cross and blaming about clients who dont
help themselves; you know - those pesky people who
dont do their exercises. (Totally unlike our good
selves who never sit and eat cake or watch TV as we are
busy spending every moment in unrelenting self-
improvement. Hang on a minute while I turn off the
mung bean stew so I can go and meditate..).
The point here is that motivating your clients to
become involved in their recovery is an art in itself and
requires a number of skills and strategies beyond
22 Terra Rosa E-mag
Agenda setting: Jointly setting health goals with your
client
Goal setting: Clients choosing their own small and
achievable goals
Goal follow up: Proactive follow up is vital to
maintain momentum and provide engagement and
support.
So if you really want to get results with your client self
care exercises you will need to look at setting time aside
within your treatment to set goals, review and most
importantly- cheer-lead! (Fig. 3)
Understanding the biopsychosocial model of
pain
To properly get to grips with the art and science of
prescribing self care it is vital to understand what is

Fig. 4. In the biopsychosocial model, pain is seen to be a com-
bination of biological, psychological and social factors
really going on in musculo-skeletal pain. The most
accepted model of pain is the Biopsychosocial model
a bit of a mouthful hence commonly abbreviated to
BPS. If you find the word makes you want to glaze over
just substitute the concept of holistic as this pretty
much means the same thing!
In a nutshell the BPS model (Engel 1977, 1980).
suggests that pain is due not just to biological issues
(the bio bit) but also psychological and social factors
(Fig. 4). In other words, our experience of pain can be
increased by:
Psychological factors: unhelpful thoughts, feelings
or attitudes such as catastrophising (jumping to the
worst possible scenario about the pain condition
see Fig. 5)
Social context: wider factors such as being unhappy
in a job or a relationship
Conversely, positive thoughts and beliefs or a
supportive social context generally leads to the pain
signals being turned down by the brain.
For effective self care it is important to gain some idea
of how each of these 3 areas is contributing to your
clients pain situation so that you can target your
suggestions accordingly. The hands on portion of the
treatment can address any issues in the tissues such
as trigger points or fascial adhesions that may be
contributing to the ongoing pain. However the
psychological and social factors can only properly be
addressed via self-management suggestions.
Client self care
Fig. 5. Unhelpful thoughts can in themselves increase pain
levels .
The Jing method: The MAPS approach to self
care
Choosing the most appropriate self care suggestions for
a particular client or condition can seem like a
minefield so, as with most things, it is helpful to have a
map to guide you through the process.
The MAPS approach to self care (Fairweather 2015) is a
simple mnemonic to help you think about the most
useful self care suggestions for a particular client and
their condition. Most self care suggestions can be
grouped under 4 major headings as laid out below. All
of these areas have a strong research base to support
their use in the management of persistent
musculoskeletal pain
Movement and exercise
Research shows that most types of exercise can be
helpful to pain conditions. These include:
General aerobic exercise: For example running,
cycling, swimming, walking.
Advice and education
Advice and education is a key area that can help change
unhelpful beliefs that may be perpetuating the clients
pain state. Self care approaches that fall within this
category include:
Terra Rosa E-mag 23
Fig. 6. Take time to educate your client about the causes of their pain.

Education and information about the pain Site specific interventions

condition: reassurance that most acute pain
Self care interventions that are targeted at the area of
situations get better in a matter of days or weeks.
pain can include:
(Fig. 6)
Self trigger point treatment (Fig. 8)
Advice on managing and returning to desired
activities Application of hot and cold
Help with goal setting, action planning and reviews Specific exercise targetted to help the area of pain.
through structured treatment plans For example stretching, mobilisation or rehab
exercises for the low back (Fig 9).
Advice and referral to classes that would be helpful
e.g. yoga, Pilates or Tai chi Quite simply your self- care suggestions should draw
on each of these categories for a full all round
Psycho-social
biopsychosocial approach to treatment.
Research has shown that practices that help to change
Using the MAPS approach for acute herniated
unhelpful psychological mind- sets or give mechanisms
disc
for dealing with stress can be extremely useful. This is
especially the case in chronic pain situations. Useful As an example of using the MAPS self care process for a
evidence based approaches include: client with pain from a herniated disc we might look at
approaches that include:
Relaxation, meditation or mindfulness practices
(Fig. 7 ) Movement based self care: This could be as simple
as encouraging walking to work a few times a week
CBT based self help approaches that aim to reduce
unhelpful beliefs such as catastrophising. Advice and reassurance: Reassuring your client that
most disc problems heal within 4-6 weeks and do
Reflecting back to the client any social factors that may
not lead to long term problems. This is because the
be perpetuating the pain condition. Common themes in
disc can shrink back from the nerve that it is
this category include being unhappy in a job or
pressing on and that more importantly our brain
relationship. It is not your job to sort this out but
can learn to turn down the pain signals (and that
helping the client identify these factors as being
there are many things they can do to help this
relevant can be very powerful.
24 Terra Rosa E-mag

Fig. 7. Research has shown that simple meditation and
breathing exercises can be extremely helpful in reducing
persistent pain
Fig. 8. Site specific self care interventions can include self
trigger point treatment, stretching or rehab exercises.
Client self care
process)
Psychological: Teaching a simple breathing exercise
to help your client cope with stress and feel in
control of any pain they are experiencing
Site specific interventions: Teaching some simple
mobilisation exercise or stretches for the low back.
It is important not to overwhelm your client with too
many suggestions at once we usually recommend
between 1-3 exercises a session depending on
complexity. Self care suggestions should be reviewed at
every treatment to see how successful the client has
been at carrying them out and can be built on, week by
week.
A 21st century approach to massage therapy
For massage therapists to move forward in the 21st
century it is important that we embrace all the aspects
of our great profession. Long before the coining of the
term biopsychosocial, complementary therapists had
a core belief in holism defined by the dictionary as
The treating of the whole person, taking into account
mental and social factors, rather than just the physical
symptoms of a disease. In the holistic approach,
clients are seen as active agents in their path towards
healing with the practitioner role being that of a
facilitator towards this aim; client and therapist work
as an alliance towards mutual goals. Self care has
always been an integral part of this approach. With our
modern knowledge of how psychology can influence
pain states, now is the time to reclaim self- care as a
vital part of a successful treatment.
Using the biopsychosocial model as a basis gives us a
clear map to navigate different self care options to
prescribe the most useful approaches for our clients.
Remember that the MAPS (Movement, Advice, Psycho-
social aspects and site specific interventions) process
helps to ensure that your self care suggestions are
addressing all aspects of your clients pain condition:.
Ensure you set aside enough time in your hands on
sessions to goal set and review successful outcomes
with your clients. Motivate, inspire, encourage and
watch your results increase!
Further reading and Freebies for Terra Rosa
readers
Our philosophy around self care is part of an overall
approach to excellence in soft tissue therapy for chronic
pain as pioneered through our book Massage Fusion;
the Jing method for the treatment of chronic pain. For
Terra Rosa E-mag 25

Fig. 9. Teaching self stretching is an effective intervention targeted at the area of
pain
Fig. 10. Head over to the Jing website www.jingmassage.com for some great free
self care handouts for your clients
further reading on the subject hit
chapter 11 of the book.
For some great FREE self care
resources head over to our website
http://www.jingmassage.com/
category/self-care-resources-for-
massage-therapists/ where you will
find loads of self care handouts that
you can print out and give directly
to your clients. From mindfulness
to mobilisations, advice to active
isolated stretching, feel free to print
out, enjoy and share with your
26 Terra Rosa E-mag
clients and other therapists. (Fig.
10)
References
Beinart, N.A. et al., 2013. Individual
and intervention-related factors
associated with adherence to home
exercise in chronic low back pain: a
systematic review. The spine journal:
official journal of the North American
Spine Society, 13(12), pp.194050.
De Silva, D. (The Health Foundation
2011) No Evidence: Helping people help
themselves A review of the evidence
considering whether it is worthwhile to
support self-management,
Engers, A. et al., 2008. Individual
patient education for low back pain.
The Cochrane database of systematic
reviews, (1), p.CD004057.
Fairweather, R (2015): The MAPS
approach to self care; Jing Advanced
massage
Furlan, A.D. et al., 2002. Massage for
low back pain. The Cochrane database
of systematic reviews, (2), p.CD001929.
Long, A.F., 2009. The potential of
complementary and alternative
medicine in promoting well-being and
critical health literacy: a prospective,
observational study of shiatsu. BMC
complementary and alternative
medicine, 9, p.19.
Rotter, J. B. (1966). Generalized
expectancies for internal versus
external control of reinforcement:
Psychological Monographs: General &
Applied 80(1) 1966, 1-28.
Nicholson, R.A. et al., 2007.
Psychological risk factors in headache.
Headache, 47(3), pp.41326.
Sengul, Y., Kara, B. & Arda, M.N., 2010.
The relationship between health locus
of control and quality of life in patients
with chronic low back pain. Turkish
neurosurgery, 20(2), pp.1805.
About Rachel Fairweather and
Jing Advanced Massage
Rachel Fairweather is author of the
best selling book for passionate
massage therapists Massage
Fusion: The Jing Method for the
treatment of chronic pain. She is
also the dynamic Co-founder and
Director of Jing Advanced Massage
Training (www.jingmassage.com), a
company providing degree level,
hands-on and online training for all
who are passionate about massage.
Rachel has over 25 years experience
in the industry working as an
 Client self care
advanced therapist and trainer, first in New York and Rachel holds a degree in Psychology, a Postgraduate
now throughout the UK. Due to her extensive Diploma in Social Work, an AOS in Massage Therapy
experience, undeniable passion and intense dedication, and is a licensed massage therapist.
Rachel is a sought after international guest lecturer,
writes regularly for professional trade magazines, and
has twice received awards for outstanding achievement
in her field.

Massage Fusion is an essential companion for any manual therapist interested in

treating common pain issues. Acclaimed teachers and therapists, Rachel Fair-
weather and Meghan Mari offer a practical and dynamic step-by-step approach to
gaining results with persistent client problems such as low back pain, neck pain,
headaches, carpal tunnel syndrome, TMJ disorders, stress-related conditions and
stubborn sporting injuries. The book outlines a clear and evidence-based ration-
ale to treatment using a clinically tried and tested combination of advanced mas-
sage techniques including myofascial work, trigger point therapy, acupressure,
stretching and client self-care suggestions.

Available at: www.terrarosa.com.au

Terra Rosa E-mag 27

 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 be-
tween 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

28 Terra Rosa E-mag

Many factors are important for
musculoskeletal health. Arguably,
the two most important factors
are flexibility of soft tissue and
strength of musculature. Al-
though strength of musculature is
often beyond the scope of mas-
sage therapy, massage therapists
excel at increasing soft tissue
flexibility. In this regard, massage
therapy holds an extremely im-
portant place in the world of
clinical orthopedic manual ther-
apy.
Often the key to remedying a cli-
ents musculoskeletal condition is
loosening tight soft tissues that
directly cause pain and/or de-
crease the clients range of mo-
tion (ROM). Unfortunately, for
many years, the field of massage
therapy has limited its effective-
ness by focusing only on tight
musculature. With the recent un-
derstanding and acceptance of
the importance of fascia and the
role that fascial adhesions (and
fascial contraction) can play in a
clients condition, the field of
massage therapy has been ex-
panding its focus. This is an excel-
lent step forward for manual
therapy.
Intrinsic Fascial Tissue
However, this increased focus on
fascial tissue has largely limited
itself to myo-fascial tissue (via
Myers work with myofascial me-
ridians/anatomy trains) and sub-
cutaneous fascia (via the Stecco
family work on superficial fascial
tissue/membranes). As a result,
most massage therapists still
Joint mobilization is actually quite simple to per-
form. 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 tech-
nique.
ignoring intrinsic fascial joint tissue may be an ex-
cellent job halfway-done; and may likely be the reason
for limited success when treating a clients muscu-
loskeletal condition.
largely ignore an incredibly im-
portant fascial tissue component
of the body: joint capsules and
their associated intrinsic joint
ligaments. After all, tautness in
any soft tissue will decrease mo-
tion and impact the quality of the
clients life. This is true whether
the taut soft tissue is muscle myo-
fascia, 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 muscu-
loskeletal condition.
The province of intrinsic fascial
tissues has been largely left to
chiropractic and osteopathic phy-
sicians. Yet, if massage therapy is
to take its rightful place as the
preeminent manual therapy for
clinical orthopedic manual treat-
ment of soft tissue musculoskele-
tal/myofascial conditions, then
learning how to treat intrinsic
joint tissues needs to become a
part of the treatment strategy.
Toward this end, joint mobiliza-
tion, specifically Grade IV joint
mobilization, can be an extremely
important technique to incorpo-
rate into the treatment strategy
for our clients. And when prop-
erly learned, is effective and safe.
Joint Mobilization
Joint mobilization is actually
quite simple to perform. It in-
volves pinning/stabilizing one
bone at a joint, and then moving/
mobilizing the adjacent bone
relative to it. In effect, joint mobi-
lization is identical to a treatment
method that is already prevalent
in the world of massage therapy:
pin-and-stretch technique. Pin-
and-stretch as it is performed
involves pinning within the belly
of a muscle and then stretching
one of the muscles attachments
away from the pinned point. This
has the effect of focusing the
stretch to the part of that muscle
that is located between the
pinned point and the attachment
that is moved. With joint mobili-
zation technique the therapist
instead pins one bone at a joint,
and then moves the other bone of
the joint away from it, thereby
focusing the stretch to the intrin-
sic capsular/ligamentous tissue
(as well as any deep intrinsic
musculature) located between
those two bones (Figure 1). Both
techniques involve pinning and
stretching, in other words, pin-
ning and mobilizing. With typical
pin-and-stretch we focus our mo-
bilization on muscular tissue;
with Grade IV joint mobilization
we focus our mobilization on in-
trinsic joint fascial tissue.
Technique Guidelines
As with any technique, there are
guidelines for the efficient and
safe employment of joint mobili-
Terra Rosa E-mag 29
zation.
Most typically, the proximal
bone is pinned and the distal
bone is stabilized.
When placing the pin to stabi-
lize the bone, it is important to
find a bony surface that is as
broad and flat as possible; this
ensures that the bone is se-
curely and comfortably held.
It is important to also find a
broad and flat surface on the
bone that is being mobilized so
that it is securely and com-
fortably contacted.
It is usually optimal to contact
each bone as close to the joint
surface as possible. This is es-
pecially important for nonaxial
motion joint mobilization.
If the skin and other overlying
soft tissue is loose, a soft tissue
pull might be necessary. A soft
tissue pull is accomplished by
first contacting the client
proximal to the desired stabili-
zation point and then pulling
the skin and subcutaneous fas-
cia toward that point. This en-
sures that any soft tissue slack
is removed so that your grasp
is secure on the underlying
bone.
First adding traction to the
joint adds to the efficiency of
the mobilization.
The actual mobilization is usu-
ally done by performing 3-5
oscillations.
The oscillation motion is per-
formed slowly; a fast thrust is
never involved.
The excursion of the oscilla-
tion is very small, usually only
a few millimeters.
Each oscillation is held for a
fraction of a second and then
released.
30 Terra Rosa E-mag
Grading Joint Mobilization
The term joint mobilization is actually a broad term that may be de-
fined in many ways. One classification of joint mobilization divides it
into five grades.
Grade I: Slow, small-amplitude movement performed at the beginning
of a joints active/passive ROM.
Grade II: Slow, large-amplitude movement performed through the
joints active ROM.
Grade III: Slow, large-amplitude movement performed to the limit of
the joints passive ROM.
Grade IV: Slow, small-amplitude movement performed at the limit of a
joints passive ROM, and into resistance (joint play) (see accompany-
ing Figure).
Grade V: Fast, small-amplitude movement performed at the limit of a
joints passive ROM, and into resistance/joint play.
In this grading system, Grade I is any beginning ROM at a joint; Grade
II is the clients active ROM; and Grade III is a typical stretch that is
performed by a therapist on a client (or a self-care stretch performed
by the client himself/herself) to the end of passive range of motion.
Grade IV is joint mobilization as the term is used in this article. It in-
volves stretching the soft tissues at a joint such that the joint is chal-
lenged to move past its passive ROM into the range of motion that is
known as joint play.
Note: It should be pointed out that Grade V joint mobilization is a chi-
ropractic/osteopathic high-velocity (fast thrust) manipulation that is
not within the scope of practice for massage therapy.
Indications/Contraindications Motion Palpation Assessment
The indication for joint mobiliza- Joint hypomobility or hyper-
tion is simple. Given that the goal mobility is determined by an as-
of this technique is to increase sessment technique known as
motion at a joint, the indication is motion palpation. Motion palpa-
joint hypomobility: if the joints tion assessment is performed in
motion is decreased as a result of an identical manner to joint mo-
taut intrinsic joint tissues, joint bilization treatment technique; in
mobilization is indicated. The other words the joint is chal-
contraindication to joint mobili- lenged to move into its joint play
zation is joint hypermobility: if ROM at the end of its passive
the joints motion is excessive ROM, and the quality of the end-
due to slackened tissue or if the feel motion is felt. If the end-feel
integrity of the tissue is compro- is hard and abrupt and the mo-
mised or unstable, joint mobiliza- tion is felt to be restricted, the
tion is contraindicated. joint is hypomobile and joint mo-
bilization is indicated. If the end-
feel is mushy and the joint exhib-
its excessive motion, the joint is
 Joint mobilization
hypermobile and joint mobiliza-
tion is contraindicated. A gentle
bounce or spring to the end-feel
is optimal and indicates a healthy
joint. In this case, joint mobiliza-
tion is neither indicated nor con-
traindicated, but may be per-
formed 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 tech-
nique, practice and focused atten-
tion are the keys to becoming
skilled at motion palpation as-
sessment and joint mobilization
treatment techniques.
Axial and Nonaxial Motions
The type of motion that is per-
formed during the mobilization
can be an axial, nonaxial, or a Fig. 1 Joint mobilization is performed by pinning one bone and mobilizing the adjacent
combination of the two. Thera- bone relative to it, thereby stretching the intrinsic soft tissues located between them.
pists 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 ad-
duction 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 hume-
rus moving in a circular manner
around an axis of rotation that
passes through the joint. How-
ever, underlying most axial mo-
tions such as flexion or abduction
are more fundamental compo-
nent motions called roll, glide,
and spin. To perform joint mobili-
zation, these fundamental mo- Fig. 2 Fundamental motions of roll, glide, and spin. A, Roll. B, Glide. C, Spin. (Figure
tions of roll, glide, and spin must reproduced with permission from Elsevier, Kinesiology, The Skeletal System and Mus-
first be understood (Figure 2). cle Function, 2nd Edition, JE Muscolino)

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-
ogy to a car tire. Roll motion
would be equivalent to a tire that
is rolling along the road. Glide
motion is equivalent to a tire that
is skidding along the road. And
spin is the tire spinning in place
on the surface of the road (Figure
3).
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 mo-
bilize the nonaxial glide compo-
nent 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)
kinematics simply means motion;
in the world of kinesiology, it re-
fers to joint motion. Convex/
concave kinematics refers to the
motion pattern that occurs at a
joint wherein one bone has a con-
vex shape and the other bone has
a concave shape.
At many joints, the proximal bone
is concave and the distal bone is
convex. Examples include the
glenohumeral (GH) and hip
joints. Looking more closely at
the GH joint, the proximal bone,
the glenoid fossa of the scapula, is
concave; and the distal bone, the
head of the humerus, is seen to be
convex. At other joints, the proxi-
mal bone is convex and the distal
bone is concave. Examples in-
clude the metacarpophalangeal
(MCP) and metatarsophalangeal
32 Terra Rosa E-mag
(MTP) joints. Looking more
closely at the MCP joint, the
proximal bone, the head of the
metacarpal, is convex and the dis-
tal bone, the base of the proximal
phalanx, is concave (Figure 4).
When the convex bone moves
relative to the concave bone, we
have convex on concave kinemat-
ics; and when the concave bone
moves relative to the convex
bone, we have concave on convex
kinematics. Given that most joint
motions are standard open-chain
motions in which the distal end of
the extremity is free to move and
the proximal end is more stable,
convex on concave kinematics or
concave on convex kinematics is
usually determined by the shape
of the distal bone at the joint.
Fig. 4 Convex and concave joint
surfaces. A, The glenohumeral
(GH) joint. B, The metacarpo-
phalangeal (MCP) joint.
(Figure modeled from Elsevier,
Kinesiology, The Skeletal Sys-
tem and Muscle Function, 2nd
Edition, JE Muscolino)
Roll and Glide Kinematics
Now lets apply roll and glide mo-
tions to convex/concave kinemat-
ics. When a convex-shaped bone
begins to roll on a concave-
shaped bone, it rolls along the
concave bones articular surface,
much like the tire in Figure 3A
rolled along the road. However,
whereas a tire has unlimited road
to roll along, the path of the con-
cave joint surface is limited. So if
the convex bone were to roll too
far, it would roll right off the con-
cave joint surface and dislocate
(Figure 5). Joints are designed to
operate optimally when the op-
posing articular surfaces are cen-
tered on one another, a concept
that is often referred to as centra-
tion. Therefore, it is important for
 Joint mobilization

Fig. 5 Excessive roll motion of the convex
bone upon the concave bone would result
in dislocation.
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 mas-
sage therapy .
Further, it is critical that you understand, study, and practice Grade
IV joint mobilization technique carefully before attempting to use it
with your clients. The steps of joint mobilization are actually quite
simple, and this article provides an excellent conceptual framework
and set of guidelines for performing this technique. However, the
challenge lies in practicing the technique sufficiently to develop a
refined sense of joint motion before using it with your clients. For
this reason, it is strongly recommended to attend in-person work-
shops with experienced continuing education instructors before in-
corporating this technique into your practice.
Any technique that has the power to help also has the power to do
harm, and joint mobilization is an extremely powerful technique.
Joint mobilization, when applied inappropriately, can cause serious
harm to the client. Inappropriate application of joint mobilization
technique includes applying joint mobilization to a condition for
which it is contraindicated, most likely an unstable/hypermobile
joint or to tissue that does not have sufficient integrity. It also in-
cludes applying joint mobilization to a condition for which its use is
indicated, but executing the technique incorrectlyfor example,
performing it too forcefully.

location, but here the compensa- able. With an understanding of

Fig. 6 Kinematics of roll and glide. A, Con-
vex 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 accompa-
nied by glide of the concave bone in the
same direction.
the bones to stay centered in
proper alignment with each
other. This is where glide is
needed to accompany roll. As the
convex bone rolls along the con-
cave bone in one direction,
nonaxial glide must occur in the
opposite direction so that centra-
tion is maintained (Figure 6A). If
instead we look at a concave bone
moving along a convex bone, the
kinematics change. Excessive roll
of the concave bone on the con-
vex bone would also result in dis-
tory glide is different. Now the
glide must be in the same direc-
tion as the roll to maintain the
centration of the joint (Figure
6B).
Thus, with convex on concave
kinematics, roll in one direction is
accompanied by glide in the op-
posite direction; and with con-
cave on convex kinematics, roll in
one direction is accompanied by
glide in the same direction. In ei-
ther case, if adhesions within the
intrinsic fascial tissues of the
joint restrict the nonaxial glide
component of joint motion, cen-
tration cannot be maintained,
thereby increasing the chance of
limited motion (joint dysfunc-
tion) and injury.
The fundamental kinematics of
joint motion may seem theoreti-
cal, but are actually quite valu-
joint kinematics, the therapist can
critically reason how motion
should occur at a joint. This em-
powers the therapist to be able to
critically think how to apply joint
mobilization treatment technique
to their clients condition instead
of memorizing cookbook treat-
ment routines. Critical thinking is
the key determinant of an excel-
lent clinical orthopedic manual
therapist, and can make the dif-
ference between mediocre and
excellent results.
Joint Mobilization Examples
To ground this theory in actual
practice, the following examples
demonstrate joint mobilization
technique performed at joints of
the upper extremity, lower ex-
tremity, and axial skeleton. In
each example, the steps to be per-
formed are outlined.
Terra Rosa E-mag 33
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 cli-
ents are often concerned by the presence of joint
crepitus, it seldom indicates a serious condition
and rarely contraindicates joint mobilization tech-
nique. 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 pre-
sent 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 intro-
duced into the joint. Note: Although a joint re-
lease may occur during Grade IV mobilization, it
should not be the intended goal of this mobiliza-
tion 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 tempo-
rarily stuck, often along a bumpy contour of un-
derlying bone. The continued application of force
34 Terra Rosa E-mag
can then move the joint past this restriction, re-
sulting 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 mobili-
zation should be performed when crepitus oc-
curs 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 hyper-
mobility. Because joint hypermobility contraindi-
cates joint mobilization technique, joint mobili-
zation 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 rub-
bing 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 con-
traindicates 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 help-
ful toward mobilizing a joint that otherwise can-
not be moved without pain.

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 pha-
lanx. (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 con-
cave on convex kinematics. Flex-
ion is composed of an anterior/
palmar roll of the phalanx accom-
panied by a palmar glide of the
phalanx. And extension is com-
posed of a posterior/dorsal roll of
the phalanx accompanied by a
dorsal glide of the phalanx.
Therefore, palmar glide mobiliza-
tion is needed to optimize flexion
range of motion; and dorsal glide
mobilization is needed to opti-
mize extension range of motion.
Following are the steps to per-
form palmar and dorsal glide mo-
bilizations of the MCP joint:
Use one hand to pin/stabilize
the distal end of the metacarpal
on its dorsal and palmar sur-
faces (Figure 7A).
Add traction to the joint by
gently pulling the phalanx
away from the metacarpal
(Figure 7B).
Challenge the phalanx to glide
in the palmar direction until
tissue tension is reached; and
then gently increases the pal-
mar glide force to mobilize the
joint (Figure 7C). Three to
five gentle mobilization oscilla-
tions are performed, each one
performed slowly with an ex-
cursion of only a few millime-
ters and held for a fraction of a
second.
Challenge the phalanx to glide
in the dorsal direction until
tissue tension is reached; and
then gently increases the dor-
sal glide force to mobilize the
joint (Figure 7D). Three to
five gentle mobilization oscilla-
Joint mobilization
tions are performed, each one
performed slowly with an ex-
cursion of only a few millime-
ters and held for only a fraction
of a second.
Example 2: Talocrural Joint Trac-
tion
Long axis traction of the ankle
(talocrural) joint. This is a fairly
simple example of nonaxial joint
mobilization in which the talus is
tractioned away from the tibia
and fibula.
Following are the steps to per-
form this mobilization:
Use both hands (middle finger
reinforced over middle finger) to
contact the dorsal surface of the
talus immediately distal to the
tibia/fibula (Figure 8A). No stabi-
lization hand is needed because
the clients body weight serves to
stabilize the rest of the body, in-
Terra Rosa E-mag 35

Fig. 8 Traction mobilization of ankle (talocrural) joint. A, Contacting the talus. B, Trac-
tion mobilization of the talus.
cluding the tibia and fibula.
Add traction to the joint by gently
pulling the talus away from the
tibia/fibula until tissue tension is
reached; and then gently in-
creases the traction force to mo-
bilize the joint (Figure 8B).
Three to five gentle mobilization
oscillations are performed; each
one is performed slowly with an
excursion of only a few millime-
ters and held for only a fraction of
a second.
Example 3: Glenohumeral Joint
Roll and Glide
Frontal plane roll and glide mobi-
lization of GH joint abduction in-
volves convex on concave kine-
36 Terra Rosa E-mag
matics. Abduction involves a su-
perior roll of the humeral head
accompanied by an inferior glide
of the humeral head. This roll and
glide mobilization is performed
from the starting position of
ninety degrees of humeral abduc-
tion.
Following are the steps to per-
form this mobilization:
Place one hand on the medial
surface of the distal humerus
and the other hand on lateral
surface of the proximal hume-
rus (Figure 9A). Note: It is lo-
gistically difficult to use ones
hands to stabilize the scapula
for this mobilization. Instead,
when applying the force to mo-
bilize the humerus into inferior
glide, the slack of scapular
depression motion needs to be
first taken out. When pressing
inferiorly on the humeral head,
the shoulder girdle will move
(depress) with the humerus.
Keep pressing on the humerus
until shoulder girdle depres-
sion reaches the end of its mo-
tion.
Some traction can be added to
the GH joint by pulling the hu-
merus laterally away from the
glenoid fossa with the hand
that is placed on the distal hu-
merus. This is facilitated by the
placement of the thumb on the
anterior surface of the elbow
(see Figure 9B).
Challenge the humerus to roll
into further abduction with the
distal hand as the proximal
hand glides the humerus inferi-
orly until tissue tension is
reached. (Note: As stated, the
slack of scapular depression
first had to be removed with
this motion.)
Now gently add to the force
with both hands, focusing pri-
marily on the proximal hand
increasing the inferior glide
mobilization of the humeral
head (Figure 9C). Three to
five gentle mobilization oscilla-
tions are performed, each one
performed slowly with an ex-
cursion of only a few millime-
ters and held for only a fraction
of a second.
Example 4: Mobilization of the
cervical spine
Joint mobilization of the spine
involves mobilization of the facet
joints which are planar (flat), so
convex/concave kinematics are
not involved.
Following are the steps to per-
form mobilization of the C4-C5
joint into right lateral flexion.
Fig. 9 Abduction with inferior glide mobilization of glenohumeral (GH) joint in the frontal plane: A, Contact the distal and proxi-
mal 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)

Comfortably and securely place
the clients head in your left hand
(Figure 10A). Note: Rotating the
clients head/neck to the left ap-
proximately 45 degrees helps to
facilitate this protocol.
Contact and pin (stabilize) the
right-side facet (articular proc-
ess) of C5 with the radial side of
the proximal phalanx of your in-
dex finger (Figure 10B). Thumb
pad or finger pad contacts are
also possible but are not as com-
fortable or strong. Note: The fac-
ets are shown in Figure 10C.
Bring the clients head and neck
into right lateral flexion until tis-
sue tension is reached at the end
of passive range of motion of C4
on C5 (be sure to maintain your
pin/stabilization contact on the
facet of C5) (Figure 10D).
Mobilization is performed by gen- Note: The mobilization can also
tly increasing the right lateral be done by instead holding the
flexion of the head and neck with head and neck pinned with the
the left hand while the right hand left hand and then gently increas-
contact maintains the pin on the ing the pressure against the facet
facet of C5. This results in right of C5 to move it relative to C4. It
lateral flexion mobilization of C4 can also be performed by moving
on C5 (Figure 10E). Three to five both of your hands in concert: the
gentle mobilization oscillations left hand increases the right lat-
are performed, each one per- eral flexion of the head (and con-
formed slowly with an excursion sequently C1-C4) while the right
of only a few millimeters and held hand presses on the facet of C5.
for only a fraction of a second.
With an understanding of joint kinematics, the thera-
pist can critically reason how motion should occur at a
joint. This empowers the therapist to be able to criti-
cally think how to apply joint mobilization treatment
technique to their clients condition instead of memo-
rizing 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 cli-
ents 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.

Integrating Joint Mobilization into your Massage Session

Because joint mobilization is effectively a type of stretching, its integration into a massage session should
be done when regular (Grade III) stretching would be done; that is after the associated soft tissues have
first been warmed up with either heat or soft tissue manipulation/massage. If regular stretching is also
being done during the session, then Grade IV joint mobilization could be done either before or after the
stretching. The ideal approach is usually to first free up intrinsic adhesions and restrictions by performing
joint mobilization and then perform stretching. But as with all clinical orthopedic work, the exact ap-
proach should be determined on a case-by-case basis.

38 Terra Rosa E-mag

 Clinical Orthopedic
Massage Therapy
with Dr. Joe Muscolino
Sydney, July 2016
www.terrarosa.com.au

This workshop covers the major clinical ortho- This workshop covers major clinical orthopedic
pedic assessment and treatment techniques assessment and treatment techniques for the
(soft tissues & Joint mobilization) for the neck. lower extremity

8-9 July 2016, Sydney 10-11 July 2016, Sydney

ATMS, AMT, Approved CPE/CEU

Points
Dont miss this unique experience to
train with Dr. Joe Muscolino.
"Joe Muscolino is a master of his profession! His broad
knowledge on the human body and extensive experience
made the workshops interesting and engaging. I would
Terra Rosa e-magazine, No. 11 (Decemberhighly
2012) Terra to
recommend his workshops Rosa
any E-mag 39 I,
body-worker.
myself, can't wait for the next one!" Zuzana G, North Syd-
ney.
 Easy Assessment for
Massage Therapist
By Sean Riehl, LMT

40 Terra Rosa E-mag

 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 dramati-
cally 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 com-
plaint 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 re-
quirements, 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.
The Spa Challenge
Many of my students reflect that people who come
to spas don't want any testing. I contend that every
human wants to be listened to deeply. We listen to
our clients when they tell us where they hurt. We
can listen to them with our eyes when we notice
one shoulder is higher than the other. We can listen
to them with our touch when we flex their wrists,
elbows or shoulders and notice restriction. To
spend 90 seconds to go through some tests that re-
veal major holding patterns usually is met with ex-
citement by clients. Therapists that can engage with
their clients, and focus on what is needed, are the
therapists that are successful. The fact that 99% of
therapists don't do any testing before the session
means that there is a huge potential for massage
therapists to create even more value for their cli-
ents.
Start with the wrists
When someone enters the session, after you have
listened to the reason they are there. Ask them is
you can run through a quick full body evaluation. I
like to start this by touching them, since it puts the
clients at ease. Grasp both of their hands, bring
them up towards you and flex and extend each
wrist. Notice if one side doesn't move as far as the
other. Comparing the sides is an easy way to notice
if there is restriction, and is much easier than
memorizing the correct number of degrees a joint is
supposed to move. When you do all these tests, give
a little extra pressure, springing into the end of the
range. A hard end-feel reveals that the restriction is
in the ligaments. A soft or springy end feel reveals
that the restriction is from muscle tension.
Now make sure both elbows are at their sides, and
supinate and pronate both wrists and compare each
side. Notice if there is any restriction on either side.
You will be surprised by how many people have a
little restriction in some wrist motion on one side.
Terra Rosa E-mag 41
When you find some restriction, smile and tell you
client look at that, you have a little restriction here
in this wrist. Ask them if they can feel it. Have a
playful attitude with no judgement. Don't say wow,
you're really restricted!, or That's really bad!. All
of this is done with a light spirit. The idea is to raise
your awareness about areas that you can help, and
raise the clients awareness about restrictions in
their body.

Shoulder assessment

There are hundreds of shoulder evaluations to dis-

tinguish joint capsule issues as opposed to muscle
issues. We are not going to worry about that too
much right now. First we will test general external
rotation. With the client's elbows at their sides, have
them externally rotate their shoulder, which will
look like them rotating their arms out to their sides
as far as they can. Notice if one side goes further
than the other.

To test internal rotation, we would do the opposite

motion, but if we do that the arms run into the
body... so another way to do this is to have the client
put one have behind their back and inch their hand
up their back as far as they can go. You should mark
with your finger where they reach on their upper
back. Then the relax and try the other hand up their
back. The side that doesn't go as high up is the re-
stricted side. This tests for the ability to internally
rotate and extend the shoulder joint.

It is very difficult to test for the length of the shoul-

der abductors, so instead we will test for function.
Have the client bring their arms overhead. As they
do so, watch to see if both sides move equally, and if
once raised, both are equally straight up. Pain or
hesitation indicates muscle weakness in the abduc-
tors, and if one side can't quite make it all the way
vertical, it could be from restriction below the joint,
or weakness again in the abductors.
Next have the client relax, arms at their sides. Notice
if one hand is more forward over the thigh than the
other. This indicates a forward shoulder, because
when the shoulder moves forward it brings the hand
forward too. Now look at the shoulder that is for-
ward. Is it higher or lower than the other shoulder?
If it is higher, it indicates the serratus anterior is
tight. If it is lower, it indicates the pectoralis minor is
tight. This is a big distinction to make, since both
these muscles pull the shoulder forward, but only
Fig. 1. Assessment for the wrist: flexion & supination.
the pectoralis minor pulls it forward and down.
Neck assessment
To perform the neck assessment, have your client
rotate their head to the right and then the left. Notice
if they don't move as far on one side. Limited neck
rotation is very common, and incredibly easy to help.
It is one of the most satisfying evaluations that you
can do, since the clients will usually experience a big
improvement after the session.
Next have your client laterally flex- bring their ear to
their shoulder. Have them do this several times, and

42 Terra Rosa E-mag

 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 flex-

ion or extension of the neck. The reason is that most
of the muscles that perform these motions also per-
form 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 nor-
mally. 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 exter-
nal rotators. Feet pointing inward can indicate ten-
sion in the internal hip rotators. If we want to ad-
dress the lower back and hips, we can get confirma-
tion 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 verte-

brae 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 be-
tween 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, Exter-

nal rotation & Shoulder height assessment.

Terra Rosa E-mag 43

possibility of a tight quadratus lumborum on the left.

More Tests

There are so many tests, and this is just a few. We

have also skipped a few joints that either don't need
to be assessed every time, or are best assessed with
the client on the table. The few that I have shown
here give us a great amount of information before
the session starts.

Massage is powerful work. We as therapists have a

great sensitivity in our hands to feel areas of tension.
There is no reason, however, for us not to use our
eyes and motion evaluation to really understand our
clients. With the simple steps I have outlined here,
we can reveal all types of restrictions. Once we bring
these restrictions to the attention of our client, we
are in a much better position to help them during the
session, and for planning future session. I invite the
massage community to adopt these simple and pow-
erful techniques, so we can help our clients even
more.

Sean Riehl has been teaching massage therapy for

over 20 years. He has authored and produced over 40
massage training DVDs and is the president of Real
Bodywork. This article is based on his newest work,
Structural Massage. You can find more of his work
at www.realbodywork.com

Fig. 3. Assessment for the neck: rotation & lateral flexion .

www.terrarosa.com.au

44 Terra Rosa E-mag

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

Terra Rosa E-mag 45

Fig.1. There is a continuous line of connection from the gastrocnemius/soleus to the plantar fascia (whose fibrous aponeuro-
ses 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.

46 Terra Rosa E-mag

 Type 1 Ankle Restrictions
and Plantar Fasciitis
By Til Luchau

Ankles bend, ankles straighten. Why is this impor- tibia and fibula (such as the extensor retinacula, in-
tant? Try walking without bending your ankles. If terosseous membrane and tibiofibular ligaments)
you have ever attempted to walk in ski boot, you will can prevent these two bones from normal widening
be aware of the awkwardness and stiffness that around the wedge-shaped talus .
comes with a loss of ankle motion.
These two types of restrictions can occur together,
Ankles bend in two sagittal directions plantarflex- but often one type will be the primary or most obvi-
ion (from the Latin plantaris flectere, sole bent), ous restriction. In general, Type 2 is more common
and dorsiflexion (bent towards the dorsal or upper when there is very limited dorsiflexion (as in the
side of the foot). While plantarflexion gives a power- person on the right in Fig. 3), though this is variable.
ful push-off to each stride and adds spring to a jump,
In this article, I will begin by discussing a number of
the complementary motion of dorsiflexion is at least
ways to work with a Type 1 restriction to help the
as important. Squatting, kneeling, lunging, running,
soft tissues in the back of the lower limb to lengthen
and landing from a jump all require dorsiflexion, as
and be as responsive as possible. Type 2 restrictions
do many other crucial functions related to our ability
a fixed relationship between the tibia and fibula
to get around and function freely. Dorsiflexion, when
is discussed fully in Chapter. 5 of the Advanced Myo-
lost, limits more than just ankle movement it limits
fascial Techniques Vol. 1 book (Luchau, 2015, Hand-
our overall mobility and adaptability.
spring Publishing)
There are two main types of structural restrictions
Dorsiflexion test
that can limit standing dorsiflexion1. We will refer to
them as Type 1 and Type 2: We can assess the amount of dorsiflexion available
and identify the primary type of restriction by asking
Type 1: Dorsiflexion will be limited if the soft
our client to do a deep knee bend with parallel feet.
tissue structures on the posterior side of the leg and
Look at the angle of the lower leg in relationship to
foot resist lengthening. These structures include the
the foot (Figs. 2 and 3). How deep can the knee bend
gastrocnemius, soleus, superficial and deep fascias,
go before the available dorsiflexion is used up and
the long toe flexors, and the plantar fascia.
the heels have to come off the ground?
Type 2: Inelastic connective tissues joining the
In general, the more dorsiflexion, the better, even for
1 The contributing causes of both types of restrictions can include soft tissue shortening, hardening, or scarring from overuse, pos-
tural 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.

Terra Rosa E-mag 47

people with frontal plane ankle instabilities, such as
pronation, supination, or a tendency toward ankle
sprains. (Having greater adaptability in the sagittal
plane can reduce the lateral forces that cause ankle
turns or over-pronation.)

Once you have assessed the amount of dorsiflexion,

you will need to determine where to work. Your cli-
ent will usually be able to direct you to the predomi-
nant restriction. At the full limit of dorsiflexion, ask:
What stops you from going further? Where exactly
do you feel that? The most common answers are a
stretch or tightness in the back of the calf, sometimes
including the sole of the foot (a Type 1 restriction), Fig. 2. Dorsiflexion refers to the angle between the tibia and the
or a jamming, crunching, or pinching at the anterior talus.
fold of the ankle (indicating a Type 2 restriction)2.
We will now look at two techniques that will help
address the first type of restriction: shortness in the
posterior leg and/or foot.

Ankle mobility techniques

The soft fist

Both of the techniques in this chapter use the practi-

tioners soft fist as a tool. This has several advan-
tages over using a palm, fingers, or other parts of the
hand as traditionally used in soft-tissue manual ther-
apy:

Once you are accustomed to using a soft fist,

you will find that it allows you to address particular
structures and tissue layers with greater specificity
and less work as, by keeping your wrist aligned with
the metacarpals of your hand, you can transmit pres-
Fig. 3. In the Dorsiflexion Test, look for the degree of ankle dor-
sure with almost no muscular effort.
siflexion possible before the heels lift off the floor. In addition to
The neutral position of the wrist keeps the car- the angle between the foot and the tibia, compensations such as
turning the feet out (seen in the person on the left), foot prona-
pal tunnel open, preventing the neurovascular com-
tion, lifting the arms forward for balance, or leaning forward at
pression and overuse injuries that can accompany the hips (as the person on the right is doing), are all possible
frequent or habitual wrist extension. signs of limited dorsiflexion.

2 Sometimes clients will report a straining or cramping in the front of the shin, instead of a stretching in the back or jamming sensa-
tion in the front. If they seem to be referring to the tibialis anterior area, this is usually related to Type II restriction, which is dis-
cussed 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 lim-
ited dorsiflexion (see Fig. 5).

48 Terra Rosa E-mag

The keys to a sensitive, comfortable,
soft fist are to keep your wrist
straight, your hand open, and let the
knuckles of the middle fingers do
the work.

Gastrocnemius/Soleus Technique

As the strongest and largest muscle

group on the back of the leg, the gas-
trocnemius/soleus complex is the
most obvious place to work when
you see limited dorsiflexion. Injuries
or strains of the gastrocnemius and
soleus are common, especially with
activities such as racquet sports,
basketball, skiing, or running. Tissue
shortening resulting from injury, or
Fig. 4. Using a soft fist combined with assisted dorsiflexion via the practitioners leg,
simply from normal use, can reduce
in the Gastrocnemius Technique.
the ankles ability to dorsiflex.

With your client prone and with his

or her feet off the end of the table,
use your soft fist to anchor the stock-
ing-like outer layers of fascia (the
superficial and crural fascias). We
will work with one layer at a time,
releasing each before going deeper.
Ask your client for slow, deliberate
ankle movement (plantar- and dorsi-
flexion). Use the lengthening effects
of dorsiflexion to release any short-
ened or tighter lines of tissue (Fig. 4),
as you apply a slight cephalad (head-
ward) resistance to the tissues under
your touch.

Although your touch will slide

slightly, let your clients active ankle
dorsiflexion initiate and pace your
movement. Once you have felt the
outer layers lengthen, feel into the Fig. 5. Use the Gastrocnemius Technique all the way to the gastrocnemii origins on
deeper Achilles tendon and the con- the posterior side of the distal femur (left edge of image). Also visible in this view
joined heads of the gastrocnemius are the peroneus longus and brevis (transparent), which like the gastrocnemius/
soleus complex, can also limit dorsiflexion
and soleus itself. Continue the active
movement, as you gradually work
deeper on each pass. Check in fre-
quently with your client about the

Terra Rosa E-mag 49

Key Points: Gastrocnemius/Soleus
Technique
Indications include:
* Type I dorsiflexion restriction
* Achilles Tendon or calf pain
* Plantar Fasciitis.
Purpose
* Increase layer differentiation and tissue adapta-
bility.
* Prepare outer layers of the lower leg for deeper
work.
Instructions
Use gentle friction and tension to feel for and re-
lease any restrictions in outer layers of the lower
leg.
pace and depth of this movement. As postural mus-
cles that are always engaged when standing, the
gastrocnemius complex can be particularly tender,
especially at deeper levels.
Since the long toe flexors can also restrict dorsiflex-
ion, ask for active toe extension in combination with
dorsiflexion. This lengthens and structurally differ-
entiates the flexor hallicus longus and flexor digito-
rum longus from each other, and from their
neighbors. Since these are the deepest structures in
the calf, this makes this technique even more effec-
tive.
As long as your client is comfortable and able to re-
lax into the work, you can incorporate an additional
measure of passive gastrocnemius stretch with your
leg (Fig. 4). Use your soft fist or gentle finger pres-
sure to work all the way to the proximal origins of
the medial and lateral gastrocnemius heads on the
posterior femur (Fig. 5), being cautious around the
nerves in the popliteal fossa at the back of the knee.
50 Terra Rosa E-mag
Plantar Fascia Technique
See video of the Plantar Fascia Technique at http://
advanced-trainings.com/v/ld05.html
The sole of the foot has alternating layers of broad
connective tissue strata, short strong muscles, and
long cord-like tendons and ligaments. Shortness in
any of these layers can limit dorsiflexion through
their collective continuity with the gastrocnemius/
soleus complex, as seen in Fig. 1. The plantar fascia
is a strong, fibrous layer covering the entire sole,
lying superficial to the short toe flexors and just
deep to the subcutaneous fat of the heel. Plantar
fasciitis is a common inflammatory condition of this
layer, characterized by heel and mid-foot pain, and
most often with point tenderness at the plantar fas-
cias insertion on the distal and inferior surfaces of
the calcaneus. Contributive factors include im-
proper foot and leg biomechanics, overuse, and fas-
cial shortness in the calf or hamstrings.
Direct work with the plantar surface of the foot, in-
cluding the plantar fascia, is indicated when clients
report a stretch or pain in the sole with the Dorsi-
flexion Test. Local plantar pain, cramping, and stiff-
ness are also indications for using this technique, as
is plantar fasciitis.
Because plantar fasciitis involves tissue inflamma-
tion, the conventional wisdom is to avoid working
directly on the most painful areas (usually the
proximal attachments on the calcaneus). Although
some practitioners report good results by carefully
working directly on the most painful areas, the most
cautious approach would be to lengthen, release,
and ease the entire plantar surface around (rather
than at) the points of greatest tenderness. If you are
not getting the results you want from the indirect
approach, you might want to discuss using a direct
approach with your client, making sure he or she is
aware of the risk of experiencing increased inflam-
mation afterwards as a possible result of working
directly on the inflamed tissues. If your client re-
ports less discomfort in the days after your session,
even if the relief was transitory, you are on track. If
there was a worsening of the symptoms, or if no
change was evident afterwards, return to
working globally rather than locally.

Recalcitrant, or stubborn, plantar fasciitis

is treated surgically by
releasing (partially severing) the plantar
fascia, with the aim of relieving the strain
on the inflamed attachments. Our intention
is similar, though our methods are differ-
ent instead of severing the fascia, feel for
a lengthening release in both of the tech-
niques described here. In combination with
hamstring or peroneal work, clients often
show tangible improvements in the degree
of plantar tenderness within one or two
sessions. A longer series of sessions is of- Fig. 6. The Plantar Fascia Technique combines the soft fist with active or pas-
ten necessary for chronic sufferers, as is sive toe extension. In Plantar Fasciitis, avoid direct pressure on the most ten-
regular stretching, a change in usage pat- der areas so as not to further aggravate the inflammation. Instead, lengthen
and release the tissue distal to the inflamed points.
terns, and improved biomechanics (via
methods like structural integration, or-
thotics, movement instruction, or im-
proved footwear).

To work with the plantar fascia, we use the

middle knuckles of a soft fist (Fig. 6). As in
the Gastrocnemius Technique, start with
the superficial layers, releasing first the
skin, then the subcutaneous layers, then
the plantar fascia. Use active or passive toe
extension to move the tissue layers under
your touch. Be sensitive, thorough, and
slow. Remember, you are releasing your
clients nervous system as well their con-
nective tissue, so be sure to allow time for
your client to breathe, release, and relax
into the work.

The techniques covered in this section

serve as ideal preparation for the deeper
work described in the next chapter, where
our focus will be on the second type of
dorsiflexion restriction: a fixation of the
tibia and fibula around the talus.

This article is an extract from the Book Ad-
vanced Myofascial Techniques , Vol. 1.
Shoulder, Pelvis, Leg and Foot by Til Lu-
chau, Handspring Publishing, 2015.
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).

Terra Rosa E-mag 51

Key Points: Plantar Fascia Technique The son of a mathemati-
cian and an artist, Til Lu-
Indications include: chau delights in combining
* Restricted plantarflexion or toe flexion the technical and the beau-
* Shin splints tiful in his manual therapy
* Type II dorsiflexion restriction (preparation). articles, which have ap-
peared in magazines and
Purposes professional journals
* Increase myofascial differentiation and adaptabil- around the world. A Certi-
ity of anterior lower leg. fied Advanced Rolfer and
* Preparation for the Interosseous Membrane Tech- former Faculty Coordinator of the Rolf Institutes
nique. Foundations of Rolfing Structural Integration pro-
gram, where in the early 1990s he originated Skill-
Instructions ful Touch Bodywork (the Rolf Institutes own train-
Use slow gliding of a soft fist or forearm on myofas- ing and practice modality), his company (Advanced-
cia of anterior lower leg, feeling for tissue lengthen- Trainings.com) offers in-person and at-a-distance
ing on eccentric (plantarflexion or toe flexion) professional continuing education. Originally
phase. trained as a psychotherapist, Tils ability to connect
interdisciplinary, big-picture ideas to practical, real-
Movements world applications has made his trainings popular
Active ankle plantarflexion and dorsiflexion; active worldwide.
toe flexion and extension.

Advanced Myofascial Techniques, Volume 1

is information-packed guides to highly ef-
fective manual therapy techniques. Focus-
ing on conditions of the shoulder, wrist,
pelvis, sacrum, leg, and foot, Volume 1 pro-
vides a variety of tools for addressing some
of the most commonly encountered com-
plaints. With clear step-by-step instructions
and spectacular illustrations, each volume
is a valuable collection of hands-on ap-
proaches for restoring function, refining
proprioception, and decreasing pain.
Available at www.terrarosa.com.au

52 Terra Rosa E-mag

 Image Advanced-Trainings.com

Advanced Myofascial Techniques:

Whiplash
With Til Luchau, Advanced-Trainings.com
25-26 September 2016, Sydney
Learn advanced myofascial and neurological techniques that dramatically improve your abil-
ity to work safely and effectively with whiplash and related trauma.

Preparation: completion of our "Neck Jaw & Head" course (via seminar or DVD) is recommended (though not required) preparation for this course.

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 knowl-
edge, 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 tech-
niques book (Handspring Publishing).
Terra Rosa E-mag 53

More Info at: www.terrarosa.com.au

 Manual Therapy for
Lower Back Pain
Evidence-Based and Clinical Outcomes
A research was recently published in Journal of the American
Medical Association JAMA, October 2015 issue by researchers
from University of Utah. The study titled Early Physical Ther-
apy vs Usual Care in Patients With Recent-Onset Low Back Pain,
A Randomized Clinical Trial evaluated whether early physical
therapy (spinal manipulation and exercise) is more effective
than usual care in improving disability for patients with low
back pain (LBP). The study assigned 108 people to receive early
physical therapy (four treatment sessions over 3 weeks starting
soon after symptoms began), and randomly selected another
112 people to stick with usual care (no physical therapy treat-
ment).
The results showed that among adults with recent-onset LBP,
early physical therapy resulted in statistically significant im-
provement in disability after three months, but the improve-
ment was modest. There wasnt a significant difference be-
tween the groups after one year.
What was reported in the media can have different interpreta-
tion:
Reuters Health published Early physical therapy might help
ease lower back pain ,
Meanwhile, the blog at NYTimes wrote Physical Therapy May
Not Benefit Back Pain
The Inquisitr reported New study shows acute lower back pain
may not require physical therapy.
And NPR website reported Physical Therapy May Help For
Back Pain, But Time Works Best
So is physical therapy is not beneficial for acute low back pain
and it is better to wait as time heals?
A Recent Cochrane Review on Massage for low-back pain, has a
similar conclusion: We have very little confidence that massage
is an effective treatment for LBP. Acute, sub-acute and chronic
LBP had improvements in pain outcomes with massage only in
the short-term follow-up. Functional improvement was observed
in participants with sub-acute and chronic LBP when compared
with inactive controls, but only for the short-term follow-up.
54 Terra Rosa E-mag
There were only minor adverse effects with massage.
So does that mean massage or manual therapy is no effective
for lower back pain? It seems that a short-term relief of pain is
considered to be non-significant from a medical point of view. I
would contend if there is any therapy that can provide a long-
term relief of pain.
While we know that massage cannot fix everything, it can at
least provide a short-term relief, which is much needed, follow-
ing an onset of back pain.
We asked some expert manual therapists on their view on this
issue.
John Sharkey MSc:
This paper is not dissimilar to a recent randomized clinical trial
published in Spine entitled Comparison of Spinal Manipulation
Methods and Usual Medical Care for Acute and Subacute Low
Back Pain (Schneider et al 2015). Both papers used similar
procedures in design and methods. The Schneider paper
showed a statistically significant advantage of manual-thrust
manipulation at 4 weeks compared to usual medical care.
Based on the past forty years of research we can say with au-
thority that back pain resolution has not statistically improved.
In fact, research has demonstrated an increase in the preva-
lence of chronic back pain. Low back pain is multi-factorial with
numerous circular relationships (Richmond 2012). It would be
wise to provide treatment that is also multi-factorial. A recent
systematic review of systematic reviews by Kumar, Beaton
and Hughes found some evidence to support the effectiveness
of massage therapy for treatment of non-specific low back pain
in the short term. Massage therapists combine soft tissue ma-
nipulation techniques with other effective therapeutic interven-
tions including positional release, soft tissue release (aka:
START, ART, Connective tissue massage) myofascial trigger
point therapy, muscle energy techniques and others to great
effect. Massage therapists deal with a ludicrous number of vari-
ables when treating clients. It is the combined therapeutic effect
that leads to the significant results we see every day in clinical
practice globally.
Joe Muscolino, DC:

I find the entire premise of this research study to be invalid. I do

not see how manual therapy or any therapy, other than pain
medication, can be evaluated on how it affects low back pain. We
do not treat low back pain. We treat the underlying mechanisms
that cause low back pain. And given the many neuro-myo-fascio-
skeletal conditions that can cause low back pain, I dont see how
they can all be lumped into one study. I think this study both
misses the point of clinical orthopedic manual therapy care and
furthers the incorrect belief that if there is not a demonstrable
lesion on MRI or X-Ray, that all soft tissue problems can be
lumped into non-specific low back pain.

Regarding the lack of long term improvement, I will say that I
view most manual therapy as a passive means of creating tem-
porary improvement on the part of the client. Once this is
achieved, to maintain this improvement, movement therapy
such as Pilates, yoga, or fitness training is needed. In other
words, we can likely get people well, but we cannot necessarily
keep them well. For that, they need strengthening and stretching
to create strong musculature and maintain soft tissue flexibility,
and regain/maintain proper neural control.
Joanne Avison:
intervention. I am not at all sure that the question raised here,
upon which the study was based, makes sense of the issue or
how the body works; much less justifies suggesting massage
doesnt help, based upon the short term only.
References
Fritz, J. M., Magel, J. S., McFadden, M., Asche, C., Thackeray, A.,
Meier, W., & Brennan, G. 2015. Early Physical Therapy vs Usual
Care in Patients With Recent-Onset Low Back Pain: A Random-
ized Clinical Trial. JAMA,314(14), 1459-1467.

Time, timing and accumulation might also play a role in acquir-
ing and managing (and overcoming) Lower Back Pain. Whatever
the cause of lower back pain, be it the insult of poor posture or
injury or otherwise, there is known to be a cumulative effect in
the tissues; be they compensatory or self-protective, for exam-
ple. The connective tissue (particularly the Thoraco-lumbar Fas-
cia and other myofascial aspects that might contribute to Low
Back Pain), like all fascial tissues, is now known to respond to its
loading history (see Schleip, 2003) over various time-frames.
Since the fascia is ubiquitous and invested through every muscle,
joint and aspect of the body - including the lower back - it might
be misleading to suggest that any therapy can be sufficiently
judged after only early intervention. Surely a chronic or trau-
matised pattern would not have sufficient time to respond to
treatment? If chronic conditions, by definition, have taken
time to accumulate - then perhaps we should consider efficacy of
palpation (under any discipline) once it has taken time to accu-
mulate? That is after consistent, repeated treatments that can
allow the body to adapt over time, to more optimal patterns.
(This is a known purpose and common achievement after such
practices as Structural Integration, Neuromuscular Therapy and
many others). The response time of specifically training the fas-
cial aspect of the tissues in performance, for example, is 12-24
months, vs. the much faster response time of training in muscu-
lar-based programmes. (See article by Schleip in Terra Rosa).
Furlan, A.D., Giraldo, M., Baskwill, A., Irvin, E. and Imamura, M.,
2015. Massage for low-back pain (Review). Cochrane Database
of Systematic Reviews 2015, Issue 9. Art. No.: CD001929. doi:
10.1002/14651858.CD001929.pub3
Schleip, R., 2003. Fascial plasticitya new neurobiological expla-
nation: Part 1. Journal of Bodywork and Movement Therapies, 7
(1): 11-19.
Schneider, M., Haas, M., Glick, R., Stevens, J., Landsittel, D. 2015.
Comparison of Spinal Manipulation Methods and Usual Medical
Care for Acute and Subacute Low Back Pain A Randomized Clini-
cal Trial. Spine. 40(4): 209-217.
Richmond, J. 2012. Multi-factorial causative model for back pain
management; relating causative factors and mechanisms to in-
jury presentations and designing time- and cost effective treat-
ment thereof. Med Hypotheses. Aug; 79 (2):232-40. doi:
10.1016/j.mehy.2012.04.047. Epub May 31.
Kumar, S., Beaton, K., Hughes, T. 2013. The effectiveness of mas-
sage therapy for the treatment of nonspecific low back pain: a
systematic review of systematic reviews. International Journal of
General Medicine. 6: 733741.

Perhaps short term may be the key to lack of significant

change, through massage - perhaps it only addresses the muscu-
lar aspect in such a short time. Is it plausible that in the long
term, the fascial tissues would have the chance to accumulate a
more optimal loading history? I would be most interested to see
such research based upon 24 months of continued therapeutic

Terra Rosa E-mag 55

 Maximise Oxygenation

CORE MYOFASCIAL THERAPY

with George Kousaleos
Sydney, November 2016
"George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success. His amazing
CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the hu-
man body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapy - James Waslaski LMT;
Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage

CORE Myofascial Therapy Certification CORE Sports and Performance Bodywork

Sydney Sydney 19,20,21 November 2016

CORE Myofascial Therapy 1: 11,12,13 November 2016
CORE Myofascial Therapy 2: 14,15,16 November 2016
An intermediate to advanced, six-day workshop designed to
give practicing massage therapists in-depth knowledge and
hands-on experience in full-body myofascial treatment proto-
cols. With this knowledge and skill, you will be able to improve
your clients structural body alignment and increase their physi-
cal performance.
This 3-day seminar will examine the basic styles of performance
inherent in all athletic disciplines. Utilizing structural integra-
tion and myofascial therapy theories and techniques that are
appropriate for each style of performance, we will focus on de-
veloping training and event protocols for endurance, sprint,
power, and multi-skilled athletes.
Getting the basic Myofascial Spreading done on my
first day resulted in a dramatic improvement of my
body alignment Mic, Townsville

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
For more information & Registration
Your Source for Massage Information
Visit www.terrarosa.com.au
AMT , ATMS, IRMA, MAA Approved CEs.
 Functional Fascial Taping
with Ron Alexander
Evidence-Based Pain Relief

This workshop teaches a fast and simple way for clinicians to reduce
pain, improve function, encourage normal movement patterns and
rehabilitation of musculoskeletal pathologies in a pain-free environ-
ment.
FFT has been shown to have a significant effect on Non-Specific
Low Back Pain in a randomised double-blind PhD study. FFT is a
non-invasive, immediate, functional and an objective way to de-
crease musculoskeletal pain.

Presenter: A great way to encourage

Ron Alexander
STT [Musculoskeletal],
FFT Founder and Teacher

Sydney 9-10 April 2016,

Melbourne 16-17 April 2016

Register Now at:

www.terrarosa.com.au

Terra Rosa E-mag 57

Research Highlights
Compiled By Jeff Tan
Evidence of Anatomy Trains myofascial meridi-
ans
The anatomy trains concept is quite popular for body-
workers, but currently there is no scientific evidence
yet. A group of researchers from Goethe University in
Frankfurt, Gemany looked for the evidence on the exis-
tence of six myofascial meridians proposed by Myers
(1997) based on anatomical dissection studies.
They looked for relevant articles published between
1900 and December 2014 were searched in scholarly
publication databases. Peer-reviewed human anatomi-
cal dissection studies reporting morphological continu-
ity between the muscular constituents of the examined
meridians were included. If no study demonstrating a
structural connection between two muscles was found,
papers on general anatomy of the corresponding body
region were targeted. A continuity between two mus-
cles was only documented if two independent investi-
gators agreed that it was reported clearly.
The literature search identified 6589 articles. Of these,
62 papers met the inclusion criteria. The studies re-
viewed suggest strong evidence for the existence of
three myofascial meridians: the superficial back line
(all three transitions verified, based on 14 studies), the
back functional line (all three transitions verified, 8
studies) and the front functional line (both transitions
verified, 6 studies). Moderate to strong evidence is
available for parts of the spiral line (five of nine verified
transitions, 21 studies) and the lateral line (two of five
verified transitions, 10 studies).
However no evidence exists for the superficial front line
(no verified transition, 7 studies).
The authors suggested that the practical relevance is
twofold. First, the existence of myofascial meridians
might help to explain the phenomenon of referred pain.
For example, myofascial trigger points of the calf have
been shown to elicit pain that radiates to the sole of the
foot and to the dorsal thigh. A second aspect relates to
therapy and training of the musculoskeletal system.
Treatment according to myofascial meridians could be
effective in reducing back pain. Several studies have
shown that low back pain patients display reduced
hamstring flexibility.
Overload injuries in competitive sports represent an-
other entity of pathologies which possibly occur due to
the presence of myofascial meridians. Recent studies
indicate that tightness of the gastrocnemius and the
hamstrings are associated with plantar fasciitis. Groin
58 Terra Rosa E-mag
pain or athletic pubalgia is suggested to be provoked by
a tight adductor longus and a weak rectus abdominis.
The study was published in of Archives of Physical
Medicine and Rehabilitation.
Shoe insoles are not effective for the prevention
and treatment of low back pain
An intervention of foot orthoses or insoles has been
suggested to reduce the risk of developing Low Back
Pain (LBP) and be an effective treatment strategy for
people suffering from LBP. However, despite the com-
mon usage of orthoses and insoles, there is a lack of
clear guidelines for their use in relation to LBP. The
aim of this review is to investigate the effectiveness of
foot orthoses and insoles in the prevention and treat-
ment of non specific LBP.
A systematic search of MEDLINE, CINAHL, EMBASE
and The Cochrane Library was conducted in May 2013.
Two authors independently reviewed and selected rele-
vant randomised controlled trials.
Results identified eleven trials : five trials investigated
the treatment of LBP (n=293) and six trials examined
the prevention of LBP (n=2379) through the use of
foot orthoses or insoles. Meta-analysis showed no sig-
nificant effect in favour of the foot orthoses or insoles
for either the treatment trials or the prevention trials.
The authors concluded that there is insufficient evi-
dence to support the use of insoles or foot orthoses as
either a treatment for LBP or in the prevention of LBP.
Does nerve growth factor cause more pain in
muscle or fascia?
Nerve growth factor (NGF) is known to greatly induce
hyperalgesia (heightened sensitivity to pain). Research-
ers from Heidelberg University and Mannheim, Ger-
many explored patterns of NGF sensitization in muscle
and fascia of distal and paraspinal sites. The study was
published in Muscle and Nerve Journal.
The researchers compared the effects of injecting nerve
growth factor (an agent that causes sensitization to me-
chanical stimuli) to 8 subjects, to the tibialis anterior
and erector spinae muscles and their fasciae.
The spatial extent of pressure sensitization, pressure
pain threshold, and mechanical hyperalgesia was as-
sessed at days 0.25, 1, 3, 7, 14, and 21. Chemical sensiti-
 Research Highlights
zation was also explored.
The results showed that the time-course and magni-
tude of nerve growth factor injection-induced sensitiza-
tion 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 me-
chanical sensitization in the tibialis anterior muscula-
ture was larger in the fascia than in the muscle and dis-
played a tendency to peak at 3 days post-
injection. 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 sensiti-
zation differs between muscle and fascia. Thoracolum-
bar 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 treat-
ment you've been given has no medical value, research
has concluded.
A study, published in The Journal of Pain, was con-
ducted by a team from the University of Colorado Boul-
der (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 apply-
ing 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 Vase-
line 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 associ-
ated 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 sug-
gests 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.
What we think now is that they require both belief in
the power of the treatment and experiences that are
consistent with those beliefs. Those experiences make
the brain learn to respond to the treatment as a real
event. After the learning has occurred, your brain can
still respond to the placebo even if you no longer be-
lieve in it."
The research could be useful in helping treat drug ad-
diction, such as patients in severe pain who have taken
strong and potentially addictive painkillers. "If a
child has experience with a drug working, you could
wean them off the drug, or switch that drug a placebo,
and have them continue taking it," said Schafer in the
statement.
Effect of a Brief Massage on Pain, Anxiety, and
Satisfaction With Pain Management in Postop-
erative Orthopaedic Patients
A new study by the nurses at the Orthopedic Unit of
The William W. Backus Hospital in Norwich,
CT evaluated the impact of a brief massage intervention
in conjunction with analgesic administration on pain,
anxiety, and satisfaction with pain management in
postoperative orthopaedic inpatients.
Postoperative orthopaedic patients was studied during
two therapeutic pain treatments with an oral analgesic
medication. A pre-test, post-test, randomized, con-
trolled trial study design, with crossover of subjects,
was used to evaluate the effect of a 5-minute hand and
arm massage at the time of analgesic administration.
Each patient received both treatments (analgesic ad-
ministration alone [control]; analgesic administration
with massage) during two sequential episodes of post-
operative pain. Prior to administration of the analgesic
medication, participants rated their level of pain and
anxiety with valid and reliable tools. Immediately after
analgesic administration, a study investigator provided
the first, randomly assigned treatment. Pain and anxi-
ety were rated by the participant 5 and 45 minutes after
medication administration. Satisfaction with pain man-
agement was also rated at the 45-minute time point.
Study procedures were repeated for the participant's
next requirement for analgesic medication, with the
participant receiving the other randomly assigned
treatment.
Twenty-five postoperative patients were studied during
two sequential episodes of pain, which required analge-
sic medication administration (N = 25 analgesic alone;
N = 25 analgesic with massage). Patient ages ranged
from 32 to 86 years. Pain and anxiety scores after
medication administration decreased in both groups,
with no significant differences found between the anal-
gesic alone or analgesic with massage treatments. How-
ever patient satisfaction with pain management was
higher for pain treatment with massage than medica-
tion only.
The authors concluded that the addition of a 5-minute
massage treatment at the time of analgesic administra-
tion significantly increased patient satisfaction with
pain management.
Terra Rosa E-mag 59
 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 Bi- "What is intriguing about the illusion is its specificity,"
ology and the Journal of Biomechanics examined how says Antje Gentsch, also of the University College Lon-
the iliotibial band stores and releases elastic energy to don. "We found the illusion to be strongest when the
make walking and running more efficient. stroking was applied intentionally and according to the
We found that the human IT band has the capacity to optimal properties of the specialized system in the skin
store 15 to 20 times more elastic energy per body mass for receiving affective touch."
than its much-less-developed precursor structure in a This system typically responds to slow, gentle stroking
chimp, We looked at the IT bands capacity to store found in intimate relationships and encodes the pleas-
energy during running, and we found its energy-storage ure of touch, Gentsch explains. In other words, this
capacity is substantially greater during running than "social softness illusion" in the mind of the touch-giver
walking, and thats partly because running is a much is selective to the body parts and the stroking speeds
springier gait. We dont know whether the IT band that are most likely to elicit pleasure in the receiver.
evolved for running or walking; it could have evolved for "The illusion reveals a largely automatic and uncon-
walking and later evolved to play a larger role in run- scious mechanism by which 'giving pleasure is receiving
ning. pleasure' in the touch domain," Fotopoulou says.
The notion that the IT band acts as a spring to aid in In fact, social touch plays a powerful role in human life,
locomotion runs counter to the decades-old belief that
from infancy to old age, with beneficial effects on physi-
its primary function is to stabilize the hip during walk- cal and mental health. Many studies have focused on the
ing. benefits of touch for the person receiving it. For in-
Unlike many clinicians and anatomists, we use the lens stance, premature infants benefit greatly from time
of evolution to think about how humans are adapted not spent in direct physical contact with their mothers. Yet,
just for walking, but also for running, so we look at the Fotopoulou and her colleagues say, remarkably little is
IT band from a totally different perspective, Lieberman known about the psychological benefits of actively
said. When we looked at the difference between a touching others.
chimp and a human, we saw this big elastic band, and Earlier studies showed that softness and smoothness
the immediate idea that leapt out at us was that the IT
stimulate parts of the brain associated with emotion and
band looked like another elastic structure, like the
reward. Therefore, this "illusion" that other people are
Achilles tendon, that might be important in saving en- softer ensures that reaching out and touching another
ergy during locomotion, especially running. person comes as its own reward.
The findings, Biewener said, will have key importance This rewarding illusion acts as a kind of "social glue,"
for basic science and clinical studies that seek to inte-
bonding people to each other. For example, touching a
grate the role of this key fascial structure into programs baby in a gentle manner seems to give the mother tactile
of sports-exercise training and gait rehabilitation. pleasure, the researchers say, over and above any other
To understand what role the IT band plays in locomo- thoughts or feelings the mother may have in the mo-
tion, the researchers developed a computer model to ment.
estimate how much it stretched and by extension,
how much energy it stored during walking and run-
ning. Researchers have very little confidence that
massage is an effective treatment for Lower
One part of the IT band stretches as the limb swings
Back Pain
backward, Eng explained, storing elastic energy. That
stored energy is then released as the leg swings forward A systematic review on massage effects on non-specific
during a stride, potentially resulting in energy savings. low back pain in 2009, out of 13 trials, it was concluded
that Massage might be beneficial for patients with
Its like recycling energy, Eng said. Replacing muscles subacute and chronic nonspecific low back pain, espe-
with these passive rubber bands makes moving more
cially when combined with exercises and education.
economical. There are a lot of unique features in human
limbs like long legs and large joints that are adap- However, in a updated 2015 review by the same authors,
tations for bipedal locomotion, and the IT band just
out of 25 trialsthe conclusion was quite the opposite.
stood out as something that could potentially play a role
The Cochrane Review concluded that: "We have very
in making running and possibly even walking more eco-
little confidence that massage is an effective treatment
nomical. for LBP.Acute, sub-acute and chronic LBP had improve-
ments in pain outcomes with massage only in the short-
term follow-up. Functional improvement was observed
When it comes to touch, to give is to receive
in participants with sub-acute and chronic LBP when
In a series of studies led by Aikaterini Fotopoulou of the compared with inactive controls, but only for the short-
University College London, participants consistently term follow-up. There were only minor adverse ef-
rated the skin of another person as being softer than fects with massage."
their own, whether or not it really was softer. The re-
searchers suggest that this phenomenon may exist to
60 Terra Rosa E-mag
 Research Highlights
The authors further added that "The quality of the evi- gram and the Touch, Caring and Cancer Project, which
dence for all comparisons was graded "low " or "very is sponsored by the National Cancer Institute. Accord-
low" which means that we have very little confidence in ing to Terhune, it is comfort-oriented, rather than a
these results. This is because most of the included stud- therapeutically oriented series of techniques with safety
ies were small and had methodological flaws." precautions and the full consent of the patient's medical
team.
Despite this, as reported in Massage and Fit-
There are depth, pressure, positioning, timing and
ness magazine:
movement considerations that are individual by patient.
We should not discount the research, even if it doesn't
Students are trained to work with nursing staff to un-
run much in our favour. Massage if we're talking derstand what those are and how they should be taken
about rubbing is a management tool, explained Beret
into consideration for each patient so as not to compro-
Kirkeby, RMT, LMT, of Body Mechanics Orthopaedic
mise the patient's care or wellbeing, said Terhune.
Massage in New York City. As far as what massage
therapists should get out of reading the paper, they Studies have shown that decreased nausea, anxiety, fa-
should be relieved. Short-term effects are still effects. I tigue and depression are among the benefits of utilizing
think a lot of therapists out there are secretly frustrated of specific acupressure points and a series of massages
at why they can't fix people permanently. People get over time.
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. The effectiveness of soft-tissue therapy for the
management of musculoskeletal disorders and
Besides the actual hands-on work, communication with injuries of the upper and lower extremities
clients and patients is also another factor that could in- Thats the title of a review recently published in
fluence their pain outcome. [Communication] also the Manual Therapy Journal by a group of researchers
opens the door to talking about sound reasons to return, at the Canadian Memorial Chiropractic College. The
rather than you won't get better if you do not come in, authors conducted a Systematic Review by searching six
Kirkeby emphasized. If massage therapists step up to databases from 1990 to 2015. They screened 9869 arti-
the plate and change their verbiage or website to mas- cles and critically appraised seven; six had low risk of
sage positive messages reflecting the truth, such as we bias.
can help you manage rather than we correct or treat,
they are far more likely to have returning clients based The review found that:
on the idea that the clients understand it's not a one- * Localized relaxation massage provides added benefits
time show and have less disappointment when their to multimodal care immediately post-intervention for
financial commitment did not fix them. carpal tunnel syndrome.
* Movement re-education (contraction/passive stretch-
ing) provides better long-term benefit than one corticos-
Comfort to cancer patients through Hand Mas- teroid injection for lateral epicondylitis.
sage Program
* Myofascial release improves outcomes compared to
For those undergoing chemotherapy, the Hand Massage sham ultrasound for lateral epicondylitis. Diacutaneous-
Program run by the Integrative Medicine Oncology Ini- fibrolysis (DF) or sham DF leads to similar outcomes in
tiative may ease the experience. pain intensity for subacromial impingement syndrome.
Trained students and faculty are providing hand mas- * Trigger point therapy may provide limited or no addi-
sages in the infusion suites of the Ambulatory Care Cen- tional benefit when combined with self-stretching for
tre at University Massachusetts Memorial Medical Cen- plantar fasciitis; however, myofascial release to the gas-
ter for interested patients undergoing infusion proce- trocnemius,soleus and plantar fascia is effective.
dures. The massages are about 5 minutes per hand and
several different techniques are used with patient feed- The authors concluded that: Our review clarifies the
back as a guide. Medical students, graduate students role of soft-tissue therapy for the management of upper
and faculty from the School of Medicine and the Gradu- and lower extremity musculoskeletal disorders and inju-
ate School of Nursing are serving as volunteers in the ries. Myofascial release therapy was effective for treat-
program. ing lateral epicondylitis and plantar fasciitis. Movement
re-education was also effective for managing lateral epi-
Relaxation, comfort and support are some of the key condylitis. Localized relaxation massage combined with
benefits for patients, said Bambi P. Mathay, an oncol- multimodal care may provide short-term benefit for
ogy massage therapist and Reiki master practitioner treating carpal tunnel syndrome.
at Dana Farber. More and more people are using mas-
sage for medical issues, to support and improve health
and are valuing it for its role in well-being. It is increas-
ingly being recognized as part of comprehensive and
continuum of care, not as
a treatment, because massage cannot cure cancer.
The curriculum and training for the hand massage pro-
gram is based on the Dana Farber Hands on Care Pro-

Terra Rosa E-mag 61

1. When and how did you decide to become a body-
worker?
I entered the world of bodywork after turning 40. I had
spent the first half of my working life in a family business
making money and pumping out products. I wanted the
second half of my working life to be a part of the solu-
tion, both from a human and a global perspective. When
I considered massage therapy as a career, I immediately
realized that it would not require me to compromise any
of my beliefs in any manner, allowing me to help others
lead healthier lives. I also feel that it is a perfect fit with
my personality. Massage therapy also happens to capital-
ize on my strengths, and allows for a lot of personal
growth and professional development.
2. What do you find most exciting about bodywork ther-
apy?
What I really love about bodywork is its pure simplicity. I
believe that manual therapy can be distilled down to
three elements- your head, your heart and your hands.
You need your head for the knowledge base, your heart
as a caring compass, and of course, you need your hands
for the physical intervention. The body is incredibly com-
plex and mysterious, but it is always amazing to see that
a physical, human intervention can often make a big dif-
ference in a patients life.
3. What is your favourite bodywork book?
I have a book written by Leon Chaitow back in 1987 enti-
tled Soft-Tissue Manipulation: A Practitioner's Guide to the
Diagnosis and Treatment of Soft-Tissue Dysfunction and
Reflex Activity. I found this to be an extremely helpful
reference manual during my schooling years and in my
early years of practice as well. Leon continues to be a
hero of mine, so I was elated when he agreed to write the
foreword to my book.
4. What is the most challenging part of your work?
Without a doubt, it is paperwork. I love working on peo-
ple, and solving problems. I love reading and learning
about anything health-related. I enjoy blogging and writ-
ing about health topics; but when it comes to the paper-
work involved in being self-employed I really have to
62 Terra Rosa E-mag
push myself. I dont think that I am alone in this area. I
think that it is truly the bane of most self-employed per-
sons.
5. What advice you can give to fresh manual therapists
who wish to make a career out of it?
Like any career, I suggest that a person must have a deep
interest and a passion before embarking on the journey.
If you love what you do, then it will never be work.
There are many bumps along the road to ones career,
and they come from any and every direction. If you love
what you do, then you will keep forging ahead. If you
dont love what you do, these bumps will appear to be
roadblocks. If that passion is not there, then I suggest
pursuing a career for which you do have a passion.
6. How do you see the future of manual therapy?
I think that the foreseeable future of manual therapy is
(unfortunately) on the sidelines of health care delivery.
This is due to existing government funding models and
the power of many corporations profiting from the exist-
ing model. What I would propose is that we be advocates
for a new model that employs knowledge that we already
have. Well-established practice guidelines within medical
literature call for lifestyle change as the first line of ther-
apy[1]and yet this important step is missing from the
present medical model. This message ties in with the
theme of my book, and that is that the patients body al-
ready has the power to heal itself. To quote lifestyle
medicine physician, Michael Greger, The best-kept se-
cret in medicine is that, given the right conditions, the
body heals itself.[2] Our job as manual therapists is not
just to provide a physical intervention, but to advise our
patients on lifestyle factors that are impeding their heal-
ing, and to advise them on lifestyle factors that need to be
incorporated to help create the right conditions for their
body to heal itself. The future for our patients can change
if we reveal the best-kept secret in medicine. The future
for our profession could change if we were to remind
policymakers that these practice guidelines already exist.
However, the medical profession will not be able to fol-
low this guideline unless the funding model is changed.
1. When and how did you decide to become a
bodyworker?
I would love to be able to say that I had some exis-
tential experience that gave me a sign from the Uni-
verse to become a bodyworker but the truth is I
was just bored! I was working as a social worker in
my late twenties and looking around for other ac-
tivities to keep me interested in the evenings - I had
tried drumming, car maintenance and a host of
other evening classes - none of which I was particu-
larly talented at or grabbed my interest further. So
an introductory massage class was another one on
the list - yet that first time I touched someone with
focus and respect I truly did have a Disney mo-
ment. Stardust seemed sprinkled across the room
and cartoon bluebirds tweeted! ! Ive never stopped
loving bodywork since that moment!
2. What do you find most exciting about body-
work therapy?
I find EVERYTHING exciting about bodywork ther-
apy - the theories, the practice, the thrill of putting
my hands on someone and tuning into the tissues
and the connection with the mind-body. The ability
to truly connect with someone through touch will
never lose its appeal for me.
3. What is your favourite bodywork book?
Ha ha - hard one as I have millions and am famous
for taking big textbooks to the beach when I am on
holiday. Although I read loads of technical nerdy
stuff, probably some of my favourite books are the
ones that inspired me when I first started. I have a
lovely little paperback called Massage and Medita-
tion by George Dowling that is probably now out
of print but is beautiful in its simplicity of convey-
ing the art of massage as a meditation - an ethos
that has continued to be at the heart of my work.
4. What is the most challenging part of your
work?
The most challenging part of my work is not having
enough time to do all the things I want to do
with bodywork! I create courses, teach, write, have
a practice and love to go on courses but there is just
not enough time to immerse myself fully in all those
areas of my work as I would like. As a good friend
of my says This lifetime will not be enough for us .
I really hope that I come back as a bodyworker so I
can pick up where I left off!
5. What advise you can give to fresh manual
therapists who wish to make a career out of it?
Love it, Live it, do it. To be successful at massage
you really have to immerse yourself fully. Go on
loads of training. Read tons of books. Most impor-
tantly find yourself a community of passionate
therapists to connect with - that is what Meg and I
have created at Jing and it sustains me every day.
And most importantly, keep on keeping on and
dont give up.
6. How do you see the future of manual therapy?
The future is bright! Manual therapy has been
around for thousands of years and has never waned
in popularity. The need to be touched with rever-
ence lies at our core as human beings. The rise of
interest and research around fascia is particularly
exciting as this has the potential to explain many
things that manual therapists have felt for years.
Research is important but we must also be careful
not to lose the artistry of bodywork = our aim at
Jing is to inspire and teach beautiful exquisite body-
work that unites the head, the heart and the hands.
Terra Rosa E-mag 63