E-Magazine
Open information for massage therapists & bodyworkers
Terra Rosa e-magazine, No. 10 (June 2012)
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Cover Feature How Do We Know What We Know?Joe Muscolino The Effectiveness of Massage TherapyAAMT Report From the 3rd Fascia Congress David Lesondak Pelvic Organ Prolapse Walt Fritz What is Deep Tissue Massage Art Riggs Spontaneous Movement Body work Tom Ockler on MET Practitioner & Owner: Straight Percentage Agreements Work Best Don Dillon Postural Assessment Jane Johnson 3D Anatomy for Manual Therapists Research Highlights 6 Questions to David Lesondak 6 Questions to Jane Johnson 6 Questions to Walt Fritz
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Welcome to our tenth issue of Terra Rosa e-magazine. In this issue, we have some focus on research and what it can do for us. We are quite fond of new research that came out continuously, as proven by our Massage News Update that has continuously running the latest research on massage and bodyworks since March 2007. Joe in his latest article discusses how we may acquire (new) knowledge. Most in the massage world would fall into the authority model, where we believe in what the teacher said. We must be aware that most of the knowledge in early massage teaching is now proven not to be valid, e.g. flushing out toxins. Then we have the research world, that recently becomes popular. However we also not fall into the trap of the evidence-based medicine goes extreme and become a sceptic. Now there are few blogs that supposedly provoke critical thinking in bodywork, start to turn into sceptics and to attack on alternative treatment: acupuncture is a sham, stretching is useless, fascia research is overrated and so on. We should not forget that bodywork is much of an art than science, that's why people are enjoying massage. As Joe stated that most every technique must have something valid within it, if not many things; otherwise, it would not last very long in the world of manual and movement therapies. However, if every technique were as effective as its proponents state, why isnt everyone doing that technique? An article posted in the Pain Treatment Topics by Stewart Leavitt: ".. as with many other CAM approaches, the problem of validity may be due to our lack of understanding and/or ability to adequately assess effectiveness, rather than with the modality itself. Considering the multitude of patients worldwide who have benefitted from acupuncture in one way or another, it still appears premature to broadly dismiss it as being of little or no value for pain relief." In this issue, we also cover other exciting articles from a selection of well-known bodyworkers. David Lesondak reported on the third Fascia Congress in Vancouver. Art Riggs answers What is Deep Tissue Massage. Walt Fritz on Pelvic Organ Prolapse, Jane Johnson on Postural Assessment. Thanks for reading and Stay Healthy Sydney, June 2012
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Disclaimer: The publisher of this e-magazine disclaims any responsibility and liability for loss or damage that may
result from articles in this publication.
Cover Feature
The cover of this magazine features a picture of lumbodorsal and gluteal fascia. (Thanks to Robert Schleip for permission to use.) The picture is part of the Fascia Posters produced by Robert Schleip. The project of illustrating fascia took more than 3 years to complete. The idea of illustrating fascia comes from the demand from bodyworkers who got tired of seeing the same muscular or skeletal posters hanging on their wall. There is also never an illustration of connective tissue as a whole in the body. Robert and colleagues collected hundreds of illustrations and photographs of fascia and connective tissues from old and new literatures. They fed those pictures into a computer program to recreate a 3-D illustration. With hours and days of trial and error they try to provide not only an anatomically correct representation but also convey a sense of the unified harmony. Finally with consultations with anatomy experts, they produced these set of posters that beautifully convey without words the unity of the fascial net from the most superficial layers all the way to the endomysium. More than just another anatomical chart, they are also fine art in their own right. Robert hoped that future development will create a 3-D computer model showing the layers and connectivity of fascia. Watch Robert Schleip talking about the challenge of illustrating fascia http://youtu.be/I8H0MwyQIi0 These posters are available from www.terrarosa.com.au
What We Know?
technique helps low back pain, and they back this up by describing two or three case studies, scientific research applies their treatment technique to a large group of people who have low back pain, to see if their treatment is as effective as they state. The results for this treatment group are compared to a large control group which did not receive the treatment (usually the control group receives what is called a placebo or sham treatment that is known/considered to be ineffective). A comparison is then made to see if the clients in the treatment group fared better than those in the control group. If they did, then the proposed treatment is effective and valid. Alternatively, the proposed treatment could be compared to another treatment that is recognized and accepted to see which one is more effective. Certainly, trusting research is a lot safer than blindly trusting an authority. The very essence of research is to put the ideas of authorities to the test. But relying too much on research can also have its dangers. The efficacy of a research study depends upon it being designed and carried out correctly, which is not always the case. Research study design can be complicated, and errors are sometimes made. Further, incorrect interpretations and conclusions of the research data can occur.
...the day before the apple fell on Newtons head, it did not mean that gravity did not exist, we simply did not yet have a scientific formula to explain it.
people included who also exercise or meditate or engage in some other activity that might affect the study? The very essence of a research study is that we try to study just one parameter, the proposed treatment. But so many factors affect health that it is virtually impossible to do this. Therefore, we try our best to identify all of these factors and then make sure that they are equally represented in both the treatment and control groups. If this is achieved, then we assume that any difference between the two groups is due to the proposed treatment technique. However, accounting for all of these factors and then distributing them evenly is not always successfully achieved. Isolation versus wholistic approach
Study population First of all, an effective research study involves working with a large number of people (the number of people in a study is referred to as n). Whereas a single case study (n of 1) or a few case studies (an n of 2 or 3) might make the proposed treatment technique seem effective, perhaps these results are not reflective of the entire client population. If n is large enough, we can better trust that the technique is representative of the entire client population that we might treat, and therefore will work for us with our clients. For a research study to be effective it usually means that that tens, if not hundreds or thousands, of people need to be involved. This can be expensive and these types of large studies are not always available.
In fact, this points to the larger conceptual difficulty of research. A research study, by design, is meant to evaluate the effectiveness of just one parameter. In other words, a research study, to be valid, must isolate this one parameter and then decide it is effective in improving ones health. However, the concept of wholistic health involves the realization that no one parameter works in a vacuum. Good health is often attained only when a number of treatments are administered in conjunction with each other. For example, the best treatment for a client with low back pain might be to use massage, heat, and stretching together, not to mention advising the client about postures, stress, and diet amongst other things. These multi-faceted treatment approaches are inherently difficult to evaluate with scientific research models. Treatment administration: validity and bias
Inclusion and exclusion factors Next, we have to make sure that the inclusion and exclusion factors are carefully chosen. As these names imply, inclusion factors are those factors/parameters that we want included in the study; exclusion factors are those that we want excluded. Continuing with our example, if the study is evaluating the effectiveness of the proposed treatment on clients with low back pain, do we include all people with low back pain, or do we pick and choose which ones are to be part of the study? For example, we might want to include all people with muscle spasms, strains, and strains; but exclude all people with herniated discs or severe degenerative joint disease. The idea of inclusion and exclusion factors becomes more complicated when we start to consider all the other parameters that might affect the study. Are
Another consideration is whether the treatment was administered correctly. This may seem to be a given, but is not always the case. It is not uncommon for treatment to be administered by people who are not experts in that technique. This is especially true with touch/massage research where the people administering the care are often nurses or family members. A valid question is: If the treatment was not administered by experts, can we trust the results? Ironically, if experts are used to administer the treatment, because of their interest in seeing their technique succeed, bias may creep in. To prevent bias, it is important that the therapists are not the same people who chart the progress of the participants in the study. In this way, the people who chart the progress are blinded in their knowledge of who is in each group.
What We Know?
FIGURE 1A. Ulnar deviating the hand at the wrist joint has little or no effect at stretching the brachioradialis because it does not cross the wrist joint. 1B. Placing the forearm in full extension at the elbow joint and full pronation at the radioulnar joints are the most effective forearm positions to stretch the brachioradialis.
Client bias and hands-on placebo treatment In fact, even the participants may be biased and want so much to improve that they bias the study. This is why it is important to design the study to include a sham placebo treatment so that the participants do now know whether they are in the treatment group or the control group that received the placebo; in other words, they are also blinded. This brings up a problem that is particularly challenging when conducting research in the world of manual therapy: it is difficult if not impossible to create a valid hands-on placebo treatment for the control group. In the world of prescription drug research, both groups receive the same little white pill so they cannot know which group they are in. But in the world of massage and other manual therapies, clients know whether hands-on massage is being given to them. Therefore, an ineffective placebo hands-on treatment must be devised. But this is extremely difficult. After all, doesnt all touch involve some therapeutic healing? Interpretations and conclusions And on top of all this, the final conclusions at the end of a research study may be open to interpretation, so it is important to read carefully the entire paper to see if you agree with the conclusions drawn by the authors of the study. Yet, most therapists do not read the entire research paper that is published; rather they read only the short abstract or conclusion; or worse yet, read or listen to someone elses conclusion about the study.
Our client did not sign up to be part of a research study; he or she came for effective treatment and it is our responsibility to administer it.
Not all research is in Which brings us to our last challenge when relying on the research model for what we know. Because valid research is expensive and takes time, there are not always research studies available to prove or disprove the value of every treatment technique. However, we cannot always wait for all the studies to be conclusively done; our clients need treatment now. In the meantime, it is important to remember that the absence of research does not prove that a technique is not valid. When someone states: There is no proof that treatment X works, it does not necessarily mean that there is proof that treatment X does not work. To make a comparison, the day before the apple fell on Newtons head, it did not mean that gravity did not exist, we simply did not yet have a scientific formula to explain it. In the absence of definitive proof, we need to be openminded. For more information on reading and understanding research papers, see Anatomy of a Research Article on the Articles page on Joes website (www.learnmuscles.com)
What We Know?
Figure 2A. Stretching the vastus musculature of the quadriceps femoris group is accomplished by flexing the knee joint. B and C, the thigh is laterally rotated and medially rotated at the hip joint respectively. These motions do not stretch the vastus musculature because the vastus muscles do not cross the hip joint.
Testing New Knowledge Model In the face of not blindly trusting an authority, and also not having conclusive valid research upon which to rely, we can always try testing the knowledge/ technique in our own practice. For example, on Monday morning, we can practice on our clients whatever we learn in a continuing education workshop over the weekend. However, this can also be problematic for many reasons. In effect, we would be conducting our own limited research study; and we might not be designing and executing it very well. We might not yet be proficient with the treatment technique to implement it correctly; we might not have enough clients to test it on to determine if it is effective; and if we are administering other techniques at the same time, how do we know which one was responsible for a clients improvement, if any? Beyond all this, there are literally tens if not hundreds of techniques being marketed to manual and movement therapists. Do we need to test them all? And if we did just try out a technique for a reasonable period of time, and it did not prove to be effective, didnt we just waste our clients time and money? Our client did not sign up to be part of a research study; he or she came for effective treatment and it is our responsibility to administer it. Evaluating new knowledge against anatomy and physiology principles We can see that the authority model of learning requires trust that the authority is infallible; definitely problematic. Relying on the research model requires clear and conclusive valid research to already be done;
often problematic. And relying upon the model of testing all new knowledge in our practice is logistically problematic, as well as potentially unfair to our clients. Where does this leave us? Are we back to being openminded and trusting our sages on the stage? We usually think of being open-minded as being a good thing, but there is another old saying that goes: Be open-minded, but dont be so open-minded that your brains fall out. This is where our fourth model of learning, that is, evaluating new knowledge against principles of anatomy and physiology, is so valuable. Essentially, evaluating new knowledge against principles of anatomy and physiology allows us to critically think through the mechanics of a new technique that is being proposed, and determine for ourselves if the basis for this technique makes sense given what we know about anatomy and physiology. Certainly, not all of anatomy and physiology is known and understood, but we do have some very well established principles about how the human body functions. And if we apply that knowledge to a new technique, we are empowered to critically think through the likelihood of how effective that technique will be. It also empowers us to determine when to apply the technique.
What We Know?
FIGURE 3. Deep stroking massage functions to increase arterial blood circulation to the trigger point (TrP). If done along the direction of the taut band of the TrP, it also helps to stretch and physically break the cross-bridges of the TrP. panded to include actions at other joints if myofascial continuity across these other joints is considered.) So, we think of the joint actions that the target muscle to be stretched can do and we compare that knowledge to the stretch that is offered by the authority. If the knowledge matches, we can trust that the stretch will, in fact, be effective and we can begin employing it in our practice; if it does not, we can choose to not embrace it. For example, given that the brachioradialis does not cross the wrist joint, why would moving the hand into ulnar deviation at the wrist joint add to its stretch as is often recommended by authorities (Figure 1a)? Could it be that the increased stretch that is felt by the client is occurring in the nearby extensors carpi radialis longus and brevis, which do cross the wrist joint and are stretched with ulnar deviation of the hand? And given that the end forearm position when the brachioradialis is maximally contracted and shortened is halfway between full pronation and full supination (at the radioulnar joints), why would we want to place the forearm in that position as is often recommended? Making a muscle longer to stretch it is not accomplished by placing it in the position of its actions, it is accomplished by doing the opposite of its actions. Wouldnt full pronation (or even full supination) of the forearm make more sense because this position brings the attachments farther apart, therefore the muscle is lengthened (Figure 1b)? Looking at a stretching example in the lower extremity, why is it recommended by many authorities to change the position of the hip joint when stretching the vastus musculature of the quadriceps femoris group? If the
...if the time is spent to learn and understand anatomy, physiology can be figured out. If physiology is understood, then pathophysiology can be figured out. If the mechanics of pathophysiology are understood, then assessment can be figured out. And if assessment is known, then treatment can be figured out. It all stems from spending the time to first truly learn anatomy.
For example, by knowing anatomy and physiology, we can reason what stretches for a muscle would and would not be correct. We do not need to trust an authority; we do not need to wait for a research study to be done; and we do not have to subject our clients to be guinea pigs as we test every stretch that is proposed. We understand that stretching a muscle involves making it longer, which is accomplished by simply doing the opposite of the muscles joint actions. This makes sense because if the actions of a muscle bring it to its shortened state, then doing the opposite of the actions would make the muscle longer, thereby stretching it. (One addendum to this idea is that it might be ex-
What We Know?
Figure 4A. When engaging the brachioradialis to palpate it, resistance should be placed against the clients distal forearm, not hand. 4B, If the client attempts to radially deviate the hand at the wrist joint, the extensors carpi radialis longus and brevis would contract, making it difficult to palpate and discern the brachioradialis from these muscles.
vastus muscles do not cross the hip joint, then other than flexing the hip joint to slacken the rectus femoris and knock it out of the stretch (so it does not limit stretching the vastus musculature), what are we trying to accomplish by altering the position of the hip joint (Figure 2)? If it has to do with myofascial meridian continuity, then a specific position should be determined based on the adjacent muscle/myofascial units that are in the meridian; does the recommended change in the hip joint make sense when compared with this information? Using trigger point (TrP) treatment as another example, if a TrP is understood to be due to local ischemia in the tissues, does it make sense to create any further ischemia with prolonged pressure? And if deep pressure is administered, does it make sense to hold it for a prolonged time? What are we trying to accomplish and are we accomplishing it as effectively as possible? Given that ischemia is the problem (because it causes a decrease in blood supply that then causes a decrease in ATP molecules that are needed to break the actinmyosin cross-bridges that create the contraction), then wouldnt a stroking technique that increases local blood supply be more efficient? Therefore, mightnt multiple short deep effleurage strokes be more effective when treating TrPs than holding sustained compression? These are the kinds of questions that can be asked and answered without benefit of authority, research studies, and months of testing in your practice (Figure 3). Evaluating new knowledge against principles of anatomy and physiology can also improve our assessment skills as well. Continuing with the brachioradialis as the
Perhaps the most effective way to become a more effective clinical orthopedic massage therapist is not to continually frequent continuing education workshops, not to continually read every research study that is published, and not to spend hundreds of hours testing new techniques on our clients, but to spend more time going over the basics of anatomy and then critically thinking from there.
example, if we want to assess it through palpation and we need to make it contract to engage it and locate it, it makes sense that we want to contract the brachioradialis and only the brachioradialis if we want to discern it from the adjacent musculature. This requires an isolated contraction. So we ask the client to place their forearm in a position that is halfway between full pronation and full supination (the best position for it to effectively contract, given its actions), and then flex the forearm against our resistance. It is crucially important that our resistance is placed against their distal forearm, not their hand. If we add our resistance to the clients hand, their radial deviators (extensors carpi radialis longus and brevis) will engage, making it harder
What We Know?
therapies. However, if every technique were as effective as its proponents state, why isnt everyone doing that technique? A logical conclusion might be that each technique has something to offer, but does not offer the solution to every problem for every client. Therefore, our role is to learn as many techniques as possible, adding the elements of each one to our tool box of therapies. Then, with the wise judgment that comes from experience, we can learn how to reason through which combination of assessment and treatment tools to use in each case for the best improvement of the client who is on our table. This Article is reprinted with permission from AMTA Massage Therapy Journal, Summer 2011 www.amtamassage.org/mtj For more information on reading and understanding research papers, see Anatomy of a Research Article on the Articles page on Joes website (www.learnmuscles.com)
...if every technique were as effective as its proponents state, why isnt everyone doing that technique?
to discern the brachioradialis from these adjacent muscles (Figure 4). By understanding basic principles of anatomy and physiology, we can reason through how to most effectively palpate and assess our clients. The essence of evaluating new knowledge against established principles of anatomy and physiology is that we are empowered by critical thinking. Of course, this requires first learning anatomy, which is often not as well taught and learned as might be desirable. But, if the time is spent to learn and understand anatomy, physiology can be figured out. If physiology is understood, then pathophysiology can be figured out. If the mechanics of pathophysiology are understood, then assessment can be figured out. And if assessment is known, then treatment can be figured out. It all stems from spending the time to first truly learn anatomy. Perhaps the most effective way to become a more effective clinical orthopedic massage therapist is not to continually frequent continuing education workshops, not to continually read every research study that is published, and not to spend hundreds of hours testing new techniques on our clients, but to spend more time going over the basics of anatomy and then critically thinking from there. Conclusion This article could be construed as being negative on educators and authors, given their role as authorities. I as the author of this article am fully aware of the irony of being the authority as you read this. However, it is not the knowledge or the authority that is the danger; most authorities fervently believe in what they are teaching and have an extensive knowledge base. The danger comes when we place blind trust in them. When we treat them as a sage on the stage, or perhaps a sage on the page. Similarly, this article should not be construed as being against scientific research; I am also a firm advocate for research. But we need to be aware of the limitations of relying too heavily on research when making treatment choices; if for no other reason because research is rarely complete. And certainly, there is nothing wrong with being creative in our practice by introducing and trying new treatment techniques, we just need to be mindful to not constantly subject our clients to the newest technique that is the flavor of the month. Most every technique must have something valid within it, if not many things; otherwise, it would not last very long in the world of manual and movement
FIGURE CREDITS: Figures 1a, 2b and 2c: Illustrated by Giovanni Rimasti Figures 1b, 2a, 4a, and 4b from Muscolino JE: The Muscle and Bone Palpation Manual, with Trigger Points, Referral Patterns, and Stretching. 2009, St. Louis, Elsevier / Photography by Yanik Chauvin. Figure 3 reprinted from understanding and working with myofascial trigger points, body mechanics column article, mtj, spring 2008 issue. Illustrated by Jeannie Robertson
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Sydney
1-2 May 2013, COMT: Upper Extremity 6-7 May 2013, COMT: Lower Extremiy
Gold Coast
11-12 May 2013, COMT: Neck
Joe has inspired me to dig deeper into the knowledge I already have and to pursue more information about the body in further study. I have been to many courses in the past which were unable to do more than pass on a few interesting techniques, many of which were not easy for the therapist to perform unless they were a 6 foot male with arms twice the length of mine. It is a true gift to be able to inspire your students, especially those who have been in the field for a few years and are unaccustomed to learning. The class challenged me and my way of thinking without belittling the areas I am weak in. The content was thorough yet simple to understand with Joe's wonderful way of teaching. His immense technical knowledge of the body has shown me how effective we can be as therapists if we apply all of the resources that are available to us. Anita Schmidt, Hornsby
"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 highly recommend his workshops to any body-worker. I, myself, can't wait for the next one!" Zuzana Gaalova, Queenscliff, NSW.
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This is a summary of the research report The Effectiveness of Massage Therapy by Ng (2011), reproduced with permission from AAMT.
Figure 1. Growth of published studies on the effectiveness of massage. therapy . After Ng (2011) TEMT Report, AAMT.
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Figure 2. Summary of systematic reviews on the effectiveness of massage therapy. After Ng (2011) TEMT Report, AAMT.
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David Lesondak
Its no lie, being behind the camera at the Third International Fascia Research Congress is a pretty sweet gig. But its also about multitasking, constantly taking notes on each presenter. Every time they change a slide writing down the exact time, noting when the slide has an animation, when they skip a slide or accidentally jump ahead. When theres a technical failure and we have to wait. Adjusting for sudden volume changes or lighting issues. All of this gets written down so that when I am editing this footage (which I am doing now) it goes a lot smoother and faster. Its all very multi-tasking, and makes it hard to absorb all of the information being presented. I left the Congress my head aswirl and agoggle with so many things but overall I was left with the strong, unshakable sense that: This is real. There was a lot here to be real about. The first day began with keynotes involving repetitive motion disorders and ended with a panel discussion on scar tissue and adhesions that played like a superb four movement symphony. First up in the panel was Wayne Diamond, MD from Wayne State University who presented data on the high incident of post-surgical adhesions following pelvic surgeries. Even with a relatively non-invasive procedure like a laparotomy or a laparoscopy the average of how many patients develop post-operative adhesions is a very surprising 70%. Next up the Shaman/Showman of Bordeaux, France tendon transplant surgeon Jean-Claude Guimberteau wowed us with his latest endoscopic film. This time he brought to life the reality of the stresses to the tissues beneath the skin where scarring and adhesions are present. It was actually a bit like a horror movie. Or if you prefer a different genre, as the narrator of the film put it, a fibular apocalypse. Graciously, Dr. Guimberteau has allowed us to use 3 minutes of this film in the final Fascia Congress DVD. Following the film was Hal Brown, a DO from Vancouver who presented an overview of prolotherapy to treat scars and adhesions. He uses a neural therapy model, injecting local anaesthetic to depolarize the nerve tissue around the scars. In the skin there are billions of sympathetic nerve fibres, all tightly packed together. The signals from these nerves travel at about 400 kilometres per hour making for instantaneous communication throughout the body. Anytime there is a cut, tear, surgery or sufficient trauma, these fibres are torn asunder. Without intervention the repair is very chaotic to the nerves near the affected area, which will fire in aberrant and send signals to other parts of the body with no rhyme or reason.
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Think of these nerve impulses as cars on a superfast highway who have to detour around an accident, but in this case the accident is never cleared from the roadway. So back to the injections. When the anaesthetic wears off in the injected areas, the nerve repolarizes and the nerves membrane potential is restored to normal around the area and functionality returns. Dr. Brown presented several compelling case studies dramatically showing the success of this approach. The panel ended with the dynamic Susan Chapelle, RMT from Squamish, British Columbia. Squamish is a community of about 17,000 people , unique because of its climate which allows you to both ski and mountain bike in same day, not to mention kayak and rock climb. Many Olympic athletes train there. She described it as an epicentre of orthopaedic injuries. In this environment, people get their surgeries and need to get back to their sports before the injury fully heals. This has lead to an environment where complementary therapists communicate freely with allopathic doctors and where early manual interventions are showing beneficial results. Susan was also involved in a ground-breaking adhesion study, partnering with Geoffrey Bove DC, PhD from Maine to study the effects of manual therapy of adhesions. Now, I need a drink of water because Day 2 was all about fluid flow. As bodyworkers, so much of our focus on fascia seems to be on its load bearing, structural component. Dr. Rolf K Reed challenged us to think about its role as a regulator of fluid flow and Gerald Pollack challenged us to rethink what we know about water itself. It seems that Dr Pollack has discovered a 4th state of water. The defining characteristic of this fourth state of water, which has been heavily researched, is that it is a liquid crystal. It is a thicker, more viscous water that
also seems to have a energy-producing capacity. And what unlocks this capacity? Radiant energy the sun! E=H2O according to Pollack, claiming that radiant energy drives blood, lymph and fluid flow throughout the body. And dont quote me on this yet, but I believe that in the Fluid Dynamics Panel that ensued it was posited that the water content of our fascia may be about 50% this fourth state water. All of this points to possible explanations for everything from cold lasers to energy work, not to mention a walk on a sunny day, but as always more research is needed. And speaking of research I need to go research that mention about the amount of fourth state water in our fascia. That means I need to get back to editing video. Im on a deadline you see, to get those videos finished and get this article finished for your enjoyment before I get on a plane to shoot more video at the BodyWisdom Spain Congress. Which I will surely write about too. There was so much more that happened in Vancouver: the multi-media night, Carla Stecco and Jay Shah just
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There are multiple causes of POP; it is likely that most women have more than one cause that fits their health pocket and lifestyle. The most common causes of POP are: Vaginal childbirth - complications from large birth weight babies, forceps or suction deliveries, multiple childbirths, improperly repaired episiotomies. (It is also possible for women who have never given birth to have POP; there are many non-childbirth related causes.) Menopause - age related muscle loss due to drop in estrogen level; this impacts strength, elasticity, and
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search will give you a large number of examples of myofascial release being used effectively in the treatment of pelvic organ prolapse. Particular attention should be paid to any and all scar tissue in the lower abdominal and pelvic regions. Scar tissue evaluation should be a regular part of all therapeutic treatments. Assessing the tissue quality of superficial to deep soft tissue of the lower abdomen/pelvis, as well as the lumbosacral regions, and connecting that tightness to their pain or dysfunction, closes the loop. This loop is an important part of our role. If, during evaluation, we can reproduce their pain/dysfunction, whether local or distant to the pain, this creates a positive feedback loop between what we feel may be at fault, connects it to their pain, and feeds back the information to the therapist. The therapist now has a firm place to begin treatment and the client has trust that the therapist understands and acknowledges their pain/dysfunction. As I travel, teaching my Foundations in Myofascial Release Seminars, I find that many therapists feel that evaluation time is time wasted from the session. They relate an assumption from their clients that they expect the full amount of hands-on time. Here is where education, of both the therapist-intraining as well as their clients, is crucial. Without a thorough evaluation, one is really treating blindly. As a physical therapist, clients are often confused when they walk into my office for the first time. They expect to see the typical array of exercise machines, modalities machines, etc. But what they find is a simple treatment
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Walt Fritz, PT has been a physical therapist since 1985 and has been teaching Myofascial Release to physical therapists, massage therapists, and occupational therapists since 1995. His Foundations in Myofascial Release Seminars were developed in 2006 and have been taught across the United States. Working from the strengths of his predecessors, Walt emphasizes the straightforward effectiveness of Myofascial Release without the hype. In his Foundations in Myofascial Release Seminars, Walt brings an approachable, easy to understand style of teaching, one that can easily be assimilated into your treatment regime. Evaluation is a strong component of his teaching style, in order to create a logical progression from evaluation to treatment. Read 6 questions to Walt on page 44. Look for his videos on the WaltFritzPT YouTube Channel. Walt also owns the Pain Relief Center, a physical therapy private practice in Rochester, NY, with a specialty in treating pain conditions.
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There are many different variations in how practitioners perform Deep Tissue Massage with the therapeutic goals for the work and also with how it is practiced: GOALS Treatment of injuries or conditions: Both for treatment and prevention of soft tissue problems, deep tissue massage releases adhesions, improves muscle function for better alignment of muscles to help improve joint mobility or proper function. Improvement of performance in activities: Whether in sports, dance, yoga and everyday activities, the stresses of life result in short and tight muscles that limit mobility and cause pain or discomfort. Deep Tissue Massage places more emphasis upon grabbing and stretching
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short muscles and fascia that hinder performance instead of sliding over and compressing tissue as more general massage that uses a lot of lubrication. Improved posture: This particular facet of Deep Tissue Massage, sometimes called structural integration, focus upon careful analysis and a systematic and structured plan to lengthen short muscles and fascia that adversely affect posture so that people can stand or sit erect and move more freely. Emotional/psychological freedom: Some theories of the personality emphasize the integration of the physical and emotional components of health. Under stress or when not feeling safe, many people tighten or armour their muscles into habitual patterns that reinforce emotional patterns. As these physical restraints are released, many people report a profound emotional response. THE TOOLS The proper application of pressure necessitates a broader range of tools than those used in conventional relaxation massage. Some people assume that if an elbow is used, that it must be intense, but the elbow often allows your therapist to use proper mechanics in her body so she is not straining and is relaxed which allows for much more enjoyable sensations instead of straining. To sink through superficial layers to deeper tension, she may use focused and precise tools such as knuckles or an elbow. For large muscles that require more pressure, she may choose to use the forearm or a fist to focus attention on a broader surface. HOW DEEP TISSUE MASSAGE IS PRACTICED The first thing you may notice will be that much less lubrication is used. Just as trying to turn a doorknob with slippery hands is difficult, it is difficult to grab and stretch short tissue if too much lubrication is used. This may be the biggest distinction between regular and deep tissue massage. Light lubrication requires less pressure to grip tissue, so profound work may actually
International presenter Art Riggs became enthralled with bodywork after a meandering career in academia. He was certified by the Rolf Institute in 1987 and teaches deep tissue massage, myofascial release and Rolf workshops in the US and abroad. He also maintains a private bodywork practice in Oakland. Art is the author of the textbook, Deep Tissue Massage: a Visual Guide to Techniques and the acclaimed seven volume DVD series, Deep Tissue Massage and Myofascial Release: A Video Guide to Techniques.
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Your therapist has taken extensive continuing education training in Deep Tissue Massage and Myofascial Release. The fee for this bodywork is based upon the expertise required to provide the most enjoyable, effective, and safe experience for you-not because more effort is required. Because the work is performed much more slowly and often requires additional time to release holding in certain areas, it is highly recommended that you choose a longer time period to enable you to integrate the work at a pace that is easy for your body. Longer sessions allow proper time to address your needs and will provide a more enjoyable, profound, and longerlasting improvements to your well -being.
Deep Tissue Massage offers the same relaxing and enjoyable experience as conventional massage, but with the added emphasis of releasing deeply held tension in muscles and fascia to provide a more therapeutic release to troublesome or painful areas of your body. Our therapists are specially trained in therapeutic Deep Tissue Massage and Myofascial Release to offer you profound, long-lasting benefits that are specially tailored to your individual needs.
What to Expect
Not all of the work will be deeper than what you are used to in relaxation-based massage. Deep Tissue therapy can be performed in an integrated full body massage with specific deep focus upon a single or possibly several troublesome areas. However, you may choose a few particular areas without covering the entire body.
Join Art Riggs for a unique experience in Deep Tissue Massage Workshop Sydney, October 2012
Register now at www.terrarosa.com.au/art
Cultivating a powerful and soft touch: Strategies for Treatment with Deep Tissue Massage and Myofascial Release
27-28 October, Sydney
This 2-day workshop focuses on proper use of biomechanics to allow therapists to remain healthy and conserve energy, and refine skills for deep tissue massage and myofascial release. We will learn how to work with a powerful but soft touch, with proper use of knuckles, fists, elbows and forearms. The emphasis is on the layers of the body and myofascial skills to stretch and release tissue restrictions rather than just sliding over superficial layers.
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Spontaneous Movement
Most bodywork and movement therapy instructed the client to perform movement which can facilitate simple patterns of activation and release. However there are various bodywork and movement therapy that utilise the bodys own inherent movement for therapy and relieving pain. Usually these therapies initiate unconscious or automatic movements in the clients body. Here we listed several bodywork and movement works that used these approaches. And we try to explain rationally how these spontaneous movements can occur. We can classify them broadly as bodywork, movement therapy, and spiritual movements. Bodywork Fascial Unwinding Fascial or myofascial unwinding is a specific technique of bodywork that is used to release fascial restriction by encouraging the body or parts of the body to move into areas of ease. It involves constant feedback to the practitioner who is passively moving a portion of the patients body in response to the sensation of movement. The unwinding process usually involves a therapist inducing the movement to a client, and is followed by a spontaneous reaction: parts of the body bend, rotate, twitch or twist, sometimes in a rhythmic or chaotic pattern. It is taught and used in myofascial release and craniosacral therapy. Although unwinding is usually induced by a therapist, the client can also experience self unwinding. Simple Contact Created by Barrett Dorko, a physical therapist from the USA in the early 2000s. The basis is that the body naturally and perpetually moves in a way that promotes health and optimal function (called inherent movement). The practitioners use their hands not in an effort to impose forces, but to listen and follow this inherent movement, and encourage its greater expression. This technique explicitly uses ideomotor action (ideomotion) as a form of therapy. Non-Directed Body Movements http:// marvinsolit.site.aplus.net/pgs/health/ndbm_mb.htm Non-Directed Body Movement (NDBM) is a method developed by Dr. Marvin Solit for unwinding defense and control patterns that have accumulated in the body's tissues. Dr. Solit was one of the earliest Rolfers trained by Dr. Rolf. NDBM is based on an idea that is diametrically opposed to the common sense dictates of our culture - that pain, illness, negative emotions and injury are not bad things to be avoided or fixed. NDBM started by asking the client to stand and focus on what you feel in your body without any intention to understand, change or fix anything. When these feelings, emotions and thoughts arise, it is important not to act on them, but just to continue to pay attention to them, most particularly attending to what they feel like as a physical sensation. Then, just track the sensations, where they go, how they change, how your body responds. They are usually slow and subtle, taking a part or the whole of the body into a rotation, a bend, lifting up or pulling down. By staying with it long enough, it eventually releases and the pattern that was under it, which I was defending myself against, comes to consciousness in some way. Muscle repositioning (http:// musclerepositioning.blogspot.com/) A contemporary technique created by Luiz Fernando Bertolucci, a physician and Rolfer from San Paolo, Brazil. It is a type of myofascial release characterized by integrating body segments during touch, condition as-
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Spontaneous Movement
sociated with the occurrence of various sorts of motor reflexes. Luiz explained this spontaneous movement as a form of pandiculation, the involuntary stretching of the soft tissues, which occurs in most animals and is associated with transitions between cyclic biological behaviours, especially the sleep-wake rhythm. Movement Therapy Movement therapy refers to a broad range of movement approaches used to promote physical, mental, emotional, and spiritual well-being. There are various approaches to movement therapy, and there are some approaches encourage spontaneous movement. Some approaches emphasize alignment with gravity and specific movement sequences, some approaches are primarily concerned with increasing the ease and efficiency of bodily movement. Some approaches emphasize awareness and attention to inner sensations. Other approaches use movement as a form of psychotherapy, expressing and working through deep emotional issues. The following are some movement works that encourage spontaneous movements. Hanna Somatic Education (http://www.somatics.com) also known as Hanna Somatics, founded by Thomas Hanna in the 1970s. Hanna Somatics is a system of neuromuscular education which helps one to enjoy freedom from pain and more comfortable movement. It
teaches one to recognize, release, and reverse chronic pain patterns resulting from injury, stress, repetitive motion strain, or habituated postures. The experience of conscious embodiment can be developed through a process of movement exercises, direct touch from a skilled teacher or therapist, and the study of the body itself through the life cycle. One of the forms of somatic education used in Hanna somatics is pandiculation. Pandiculation is the act of yawning and stretching simultaneously, it is an instinctual behaviour that cleanses residual tension from the neuromuscular system and arouses the sensory-motor nervous system. Pandiculation is found among all vertebrates, the action commonly precedes moving from rest into activity, commonly manifested as stretching. The practitioner helps the beginner through a process called assisted pandiculation, which involves the client contracting the affected area while the therapist provides resistance. This teaches the body how to correctly perform the action. Afterward, the therapist instructs the client on self-pandiculation to obtain relief from pain and stress. See also an article on Pandiculation from Issue 8 of this e-magazine. Continuum (http://www.continuummovement.com) Founded by Emily Conrad, a dancer who studied AfroHaitian dance and ballet, in the late 1960s. After witnessing and experiencing undulating wave movements
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Spontaneous Movement
prayer rituals in Haiti, she found that fluid undulating movements are the essentials for human being. Emily developed Continuum Movement as a form of movement education that is based in the concept of the body being made up of mostly fluids. This gentle therapy includes breathing techniques, sound, and imagery to create subtle (mircro) and dynamic movements. The emphasis is upon unpredictable, spontaneous or spiral movements rather than a linear movement pattern. Authentic movement (AM) http:// www.authenticmovementcommunity.org/ Started in 1950s by Mary Starks Whitehouse as "movement in depth". AM is based on her understanding of dance, movement, and depth psychology. There is no movement instruction in AM, simply a mover and a witness. The mover waits and listens for an impulse to move and then follows or "moves with" the spontaneous movements that arise. These movements may or may not be visible to the witness. The movements may be in response to an emotion, a dream, a thought, pain, joy, or whatever is being experienced in the moment. The witness serves as a compassionate, non judgmental mirror and brings a "special quality of attention or presence." At the end of the session the mover and witness speak about their experiences together. Subud (http://www.subud.org/) A spiritual movement developed in Java, Indonesia in the 1920s founded by Muhammad Subuh Sumohadiwidjojo. The basis of Subud is a spiritual exercise called latihan kejiwaan or simply latihan which was said to represent guidance from "the Power of God" or "the Great Life Force". This exercise is not thought about, learned or trained for; it is totally unique for each person and the ability to 'receive' it is passed on by formal contact with another practicing member at the 'opening'. The experience takes place in a room or a hall with open space, after a period of sitting quietly, the members are typically asked to stand and relax. Members are advised to surrender to the Divine and follow what arises from within, not expecting anything in advance. They will find themselves making involuntarily movement, walking around, dancing, jumping, laughing, crying or whatever. The experience varies for different people, but the practitioner is wholly conscious throughout and frees to stop the exercise at any time. Taiji wuxi gong (http://www.taijiwuxigong.com/) Is a type of Tai Chi movement which has a goal to achieve self-healing and self-regulation using sponta-
I cant tell you how it works. I know that the intention of the therapist has a lot to do with it. Also the less guarded the patient is, the quicker it will work. John E. Upledger, 1987
neous movement. Spontaneous movement can be induced using a special body posture. The practitioners stand in a certain position so that the centre of gravity becomes more central in the body, in the Dantian, the energy centre in the lower abdomen. After a while practitioners start moving by themselves in standing position. It is about letting the body decide itself what movement it needs to restore inner movement in an area that is blocked. It is believed that this posture allows the practitioner to connect to a vibrational force from the earth, and this force is used to activate the Dantian, and the activated Dantian creates spontaneous movements. There are also other more rigorous spontaneous QiGong exercise of Five Animal System (http:// dangerofchi.org/videos/videos.html) Trance dance (http://www.trancedance.com/) is a contemporary blend of body movement, healing sounds, dynamic percussive rhythms, transformational breathing technique stimulating a 'trance' state that promotes spiritual awakenings, mental clarity, physical stamina and emotional well-being. Spiritual Spontaneous Body Movements Spontaneous body movements can also occur in many forms with spiritual connotation. In meditation, spontaneous movement can occur as shaking, the head moving, twitches and all sorts of other body movements. Kundalini yoga, an active form of yoga designed to awaken the kundalini (spiritual energy located at the base of the spine). The main work is called a kriya, which is a prescribed sequence of poses that focuses on a specific area of the body. Kriya may consist of rapid, repetitive movements done with breath or holding a pose while breathing in a particular way. It can involve intense involuntary, jerking movements of the body, including shaking, vibrations, spasm and contraction. It is believed that this happened when an intense en-
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Spontaneous Movement
ergy moves through the body and clears out physiological blocks. As deeply held armouring and blockages to the smooth flow of energy are released, the person may re-access memories and emotions associated with past trauma and injury. (From: http://www.lifeenthusiast.com/ormus/orm_kundalini.htm) See examples video: http://www.youtube.com/watch? v=z2NifkVq5RE, or http://www.youtube.com/watch? v=zCQFSwkvwUc Spontaneous movement or Ideomotor action is also part of some spiritual practices, which is called a class of innate bodily manifestations of spirit: (after Stuart Sovatsky http://www.cit-sakti.com/kundalini/sahajaspontaneous-yoga.htm). The examples are: Spontaneous spinal rockings prayer in Judaism as davening and Islam as zikr Autonomic quaking and shaking or Quaker and Shaker or the "taken-over" gyrations of gospel holy ghost shaking and dancing and charismatic/pentacostal mani-festations Dionysian "revel" Shamanic trance-dance Raja-Yogas effortless straight back (uju-kaya) meditation Tibetan yogas Tumo heat Reichian full-bodied, spontaneous orgasm reflex Yoga kriyas Spontaneous QiGong nizing the muscle pattern, is responding to the clarity of ones concept of what the movement is. If the movement is not done well, it means the muscle pattern is poor, and the muscle pattern is poor because the wrong message (a faulty concept of the movement) has been sent to the muscles. This wrong message is the result of either a lack of clarity about what the movement is or a previously established poor muscle pattern associated with the movement. The objective of movement work is to change the messagethat is, to rethink the movement in order to change the poor muscle pattern. This rethinking the movement can be formed into an image and used as a means to change the muscle pattern. However in spontaneous movement, the inherent subconscious movement is used to correct the muscle pattern. The whole class of involuntary and automatic movement, can be considered as ideomotor action or ideomotion. Ideomotion is a movement that occurs as a result of mental activity, but independently of conscious volition. These involuntary movements can happen spontaneously or can be stimulated by various ways. The stimulus can be tactile and proprioceptive stimuli, or simply by thought, emotion, verbal suggestion. Barrett Dorko argued that ideomotor movements that accompany pain can be corrective. When pain of mechanical origin occurs, our brain automatically produce motor commands to reduce pain . However the corrective movements produced by pain are often inhibited by other mental activity. Thus ideomotion can be used as corrective movements that have become inhibited. (See also http:// www.bettermovement.org/2011/ideomotion-part-three -how-to-elicit-corrective-movement/) This is a work in progress. Feel free to provide comments by emailing terrarosa@gmail.com
No doubt there are other bodywork and movement works that share similar characteristics. To understand how spontaneous movement occurs, first we need to understand about movement. According to Andr Bernard in Ideokinesis, movement may be defined as a neuromusculoskeletal event. This means that in order for movement to take place, all three of the systems alluded to in this definitionnervous, muscular, and skeletalmust be involved. Each system has its own specific role to play; the nervous system is the messenger, that is, it transmits impulses or messages to the muscles to contract or release; the muscle system is the workhorse or the motor system; the skeletal system is the support system that is moved by the work of the muscles. The nervous system is more than just a simple messenger. It also organizes the muscle pattern, and it does this on a level below consciousness. It is the complex of muscles that perform a desired movement: organizing the muscle pattern is a highly complex and sophisticated task. Our conscious role in movement is to focus on the movement, because the nervous system, in orga-
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MET
What tips can you give to massage therapists to prolong their career? by several physiotherapists, oesteoplaths and massage therapists to come over and teach but so far, no one has taken the lead to get it done. I would love to come over No matter what type of body worker you are, your hands to Australia to teach. Who knows, It just might happen and shoulders are your most important tools. some day soon. Learn how to breathe; keep your core strong and keep balance in your body's musculoskeletal system. Tom Ockler P.T. has extensive teaching experience throughout the United States, Canada, England What are your interests these days? and Australia. As a teacher, Tom has earned the nickname "The Currently researching and writing two chapters for a Patch Adams of Physical Therapy" textbook on chronic pain. One of the chapters is about due to his unique style of injecting MET, the other is about EFT. humour into complicated subjects. He has developed teaching methods that explain very How and where can we learn more about MET? complicated subjects in easily understandable formats. His two books and DVDs Muscle Energy Technique for Taking a course from an experienced practitioner and Lower Extremities, Pelvis, Sacrum, and Lumbar Spine teacher is the best way. Buying the corresponding and Muscle Energy Techniques for the Thoracic Spine, manuals and DVDs is also a good start. Ribs, Shoulder and Cervical Spine have been hailed by students as the most user friendly and useful Muscle Are you planning to come and teach in AustraEnergy manuals ever. lia? I taught in Australia for a month way back in the late 80s and have not been back since. I have been contacted
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Straight Percentage
What about the municipal government do I ask them to scale back my property taxes? Of course not. I incur expenses regardless of if Im home or not. Businesses do, too. Caveat: As a business owner and manager, make sure you know your average monthly and seasonal business expenses before you set the terms of your agreement. Don't forget to build in a profit margin for contingency, expansion and reward for shouldering the risk and responsibility of running the business. In my opinion, straight percentage agreements have some benefits, but have unacceptable disadvantages in long-term working relationships.
Partners in Profit But Without Risk Are Not Partners! her/his yield. In my experience, the base rate motivates contracting practitioners to try harder, to focus their efforts and challenge themselves. The cap rate assures them the rent will not become unreachable. In my dealings with associates, I found it effective to set a base rate for the first six months, then raise the base rate for the second six months, followed by a move to a flat rent (set at the cap rate) at one year. It allowed the associates time to get their practice up and running without excessive financial pressure. And, it ensured that, as business manager, I could expect a progressive return on investment in my budding associate. It also pushed me to get my associates as productive as possible quickly. "I'm away....why should I pay?" Some contracting practitioners argue they shouldn't bear expense when on vacation or away from the office. Their logic, "I'm not working or using any resources...why should I pay?" I recall a month when both my associates were away for a good portion, one married and the other on a training course. Because we had straight percentage terms, their low productivity that month meant low cash flow for me. I had to cover much of the operating expenses myself which meant I didn't have enough take-home pay for myself. As a result, I incurred debt. Consider this analogy. I am going on vacation and wont be home for two weeks. Can I call the mortgage company and ask them to suspend my mortgage for two weeks because I wont be using my house? Or the phone, hydro and gas companies and ask for a reduction because Im not using their services for two weeks? Sometimes, practitioners-turned-business managers allow an associate under their wing in a collective partnership. True partners share the potential for profit as well as risk of loss. Partnerships are problematic when risk is not borne equally by all partners. Consider a business owner who agrees to divide the expenses for business operation equally between herself or himself and three associates, without incorporating any profit margin. The business owner is wearing two hats - practitioner and manager - but did not factor in a salary for the extra administrative work required. If two associates leave, the owner and the remaining associate must now double their rent (and their business duties) to cover all expenses until they find two more partners. Are all partners willing to bear the risk of loss as the business owner must? If not, don't make them partners! Partners should buy in/invest with their own capital and have the responsibility of finding a replacement or selling their share should they wish to leave the partnership. A business manager who bears the operating expenses and risk of loss should be paid for it.
"Without a straight percentage agreement, will I fail to attract candidates?" If you have an established location and reputation you have a valuable asset. Associates will jockey for the opportunity to be part of your business. During prospective associate interviews, I openly dis-
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Straight Percentage
close what it costs to run my business (profit margin in), and clearly set my expectations for the candidate. In setting up expectations in advance, I am less likely to encounter problems with the associate later on. If your business has high value a well-established reputation and location you will attract better candidates.
Intuition versus Doing the Math In my seminars, I ask business owners, How did you arrive at the financial terms for your agreement? The typical response: The terms seemed fair, or felt right. Further, If I figure my actual expenses and a profit margin into my terms, my associates will leave and take all the business with them. I cant raise the rent! This is what I believed as a business owner and manager and for years tried to increase my income through other means before I finally questioned my own beliefs. I had allowed professional myths and misinformation to determine my terms, rather than basic math. I had paid handily for these beliefs and not until I admitted the reality of my business costs and lack of business experience did I resolve my dilemma. After examining my financial position and talking with my accountant, I put together a fact sheet with the actual costs of the business and scheduled a meeting with my associates to present the financial facts. The associates at first were apprehensive a natural response to being asked for more money. But after discussion and reflection, the associates fully accepted the new terms. They were as reliant as I on seeing the business continue. While intuition is an important faculty for the practitioner providing care, do not forget to do the math when it comes to forming a contractual agreement. Make sure your agreement is based on financial facts, not opinions or unhelpful beliefs. Don Dillon, RMT is the author of Massage Therapist Practice: Start. Sustain. Succeed. and the self-study workbook Charting Skills for Massage Therapists. Don has lectured in seven Canadian provinces and over 60 of his articles have appeared in massage industry publications in Canada, the United States and Australia. Don is the recipient of several awards from the Ontario Massage Therapist Association, and is one of the founding members of Massage Therapy Radio www.massagetherapyradio.com. His website, www.MTCoach.com, provides a variety of resources for massage therapists. This excerpt is reprinted from Massage Therapist Practice: Start. Sustain. Succeed. Available from Terra Rosa http:// www.terrarosa.com.au/book/
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Postural Assessment
Jane Johnson
When used in the context of therapy physiotherapy, massage therapy, osteopathy or chiropractic, for example the term posture more precisely describes the relationships among various parts of the body, their anatomical arrangement and how well they do or do not fit together. Bodyworkers have become familiar with postural terms such as scoliosis and genu valgum, which are used to describe a congenital, inherited position, plus used to describe a position assumed through habit, such as increased thoracic kyphosis resulting from prolonged sitting in a hunched position. Of course, the postures we assume provide clues to not only the condition of our bodies traumas and injuries old and new, and mild or more serious pathologies but also how we feel about ourselves our confidence (or lack of it), how much energy we have (or are lacking), how enthusiastic (or unenthusiastic) we feel, or whether we feel certain and relaxed (or anxious and tense). Intriguingly, we all almost always adopt the same postures in response to the same emotions. Working with the general population, you have your fair share of clients suffering from back and neck pain. Many clients believe that their terrible posture is due to the sedentary nature of their work, the long hours they spend slumped at a desk or driving. It would be helpful to know whether a clients pain does indeed stem from the adoption of habitual postures, or whether it might be due to something else. By distinguishing among various causes, you are more likely to be able to determine whether a change in working posture might be beneficial. Example 2 Assessing a 49-year-old woman for worsening shoulder pain, you notice a decrease in shoulder muscle bulk during the postural assessment. One possible explanation for atrophy of the shoulder muscles (accompanied by a progressive decrease in range of movement) in a client with no history of trauma is adhesive capsulitis. The information you have gained from your observation has contributed to the formulation of your diagnosis, which may later be substantiated or refuted with the appropriate tests. It is important to remember that postural assessment is only one component of the assessment procedure, and that to make a diagnosis of any condition, all components of the assessment procedure need to be considered, along with current guidelines. For example, to support a diagnosis of adhesive capsulitis, you may follow guidelines such as those set out by Hanchard and colleagues (2011). The postural assessment is also an opportunity to clar-
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Postural Assessment
ify observations about marks on the skin such as scars from significant operations (such as appendectomies or treatment for fractures in childhood) that clients may have forgotten to mention. ii) Save time A postural assessment may save time in the long run by revealing facts that are pertinent to the clients problem that might otherwise have taken longer to establish. The relationships among body parts are more difficult to assess when someone is lying down to receive a treatment, but suddenly become obvious when they stand. Example You are a sports massage therapist treating a typist who is normally fit and healthy. She is complaining of right-side anterior shoulder pain. Performing both the standing and sitting postural assessments, you observe that your client has a considerably protracted right scapula, something you had not noticed when your client was in the prone position, a position in which both scapulae naturally protract. iii) Establish a baseline A postural assessment helps you to establish a baseline a marker by which you might judge the effectiveness of your treatment. If your client has muscular pain in the low back resulting from the position of the pelvis, and you prescribe exercises and stretches to correct this posture, you will no doubt need to reassess the client at some stage to determine whether there has been any change in the pain and whether this can be attributed to an alteration in the position of the pelvis. If we suspect that a problem is the result of poor posture, we need to identify whether we have made any impact (directly with massage and movement, or indirectly with prescribed exercises and stretches) on the clients upper body posture. iv) Treat holistically Finally, it could be argued that by including an analysis of posture as part of our assessment, we are offering a more complete service, in keeping with the idea of treating people holistically, not compartmentalising them as a bad knee, a frozen shoulder, or whiplash. We keep records of clients states of health and physical activities, so it seems logical that we also keep a record of their postures.
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Postural Assessment
Factors affecting posture
Structural or anatomical
Age Physiological
Pathological
Occupational Recreational
Scoliosis in all or part of the spine. Discrepancy in the length of the long bones in the upper or lower limbs. Extra ribs. Extra vertebrae. Increased elastin in tissues (decreasing the rigidity of ligaments). Posture changes considerably as we grow into our adult forms, with postures in children being markedly different at different ages. Posture changes temporarily in a minor way when we feel alert and energised compared to when we feel subdued and tired. Pain or discomfort may affect posture as we adopt positions to minimise discomfort. This may be temporary or could result in long-term postural change if the position is maintained. Physiological changes that accompany pregnancy are temporary (e.g., low backache before or after childbirth), but sometimes result in more permanent, compensatory postural change. Illness and disease affect our postures especially when bones and joints are involved. Osteomalacia may show up as genu varum; arthritic changes are often revealed when joints in the limbs are observed. Pain can lead to altered postures as we attempt to minimise discomfort (for example, following a whiplash injury a client may hunch the shoulders protectively; abdominal pain may lead to spinal flexion). Malalignment in the healing of fractures may sometimes be observed as a change in bone contour. Certain conditions may lead to an increase or a decrease in muscle tone. For example, someone who has suffered a stroke may have increased tone in some limbs but decreased tone in others. As elderly adults, we tend to lose height as a result of osteoporotic changes and so develop stooped postures; postmenopausal women may develop a dowagers hump. Consider the postural differences between a manual worker and an office worker, and between someone active and someone sedentary. Consider the postural differences between someone who plays regular racket sports and someone who is a committed cyclist. When people feel cold they adopt a different posture to that when they feel warm.
Environmental
People who grow up sitting cross-legged or squatting develop postures that are different from those of people who grow up sitting on chairs. Usually, the posture we subconsciously adopt to match certain moods is temporary, but in some cases it persists if the emotional state is habitual. Consider the posture of a person who is grieving, or the muscle tone of a person who is angry. Clients who fear pain may adopt protective postures.
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Postural Assessment
with neck pain may subconsciously elevate their shoulder protectively in an attempt to reduce their discomfort. This woman is standing relaxed. Observe how she holds her right arm. She has suffered neck pain in the past, but at the time this photograph was taken, and for many months previous to that, she was pain free. Would you agree that her right shoulder is elevated? Can you see also how her neck is also laterally flexed and slightly rotated to the right?
Abdomen
An area that sometimes gets overWhat your findings mean looked in posShortening in levator scapulae and the upper fibres of tural assessthe trapezius may contribute to one shoulder appearing ment is the higher than the other. If a scapula is elevated, you would abdomen. expect the inferior angle of that scapula to be superior to How does the the inferior angle of the scapula on the opposite side. abdomen of your client Here is an interesting question: How do you know appear - is it whether one shoulder is truly higher or the other is flat or protrudlower? Ask the client to try this simple exercise: shrug ing? In a northeir shoulders, elevating their scapulae; then relax. mal, healthy Now depress their shoulders; then relax. Which moveperson, the ment did they find easier, elevation or depression? Most abdomen people find that shrugging the shoulders is easier than should be flat. depressing them. It seems reasonable to assume that if your clients right shoulder appears higher, muscles on The photothe right are shorter and tighter than the corresponding graphs on the muscles on the left. An exception to this might be if you opposite page demonstrate the variety in the shape and were assessing someone with a neurological condition position of the abdomen when a person is viewed later(for example, having suffered a stroke) and she had a ally. Does an abdomen protrude because the person is dropped shoulder as a result of low tone on one side of overweight or pregnant, or it is the result of the persons her body. overall standing posture and an anteriorly tilted pelvis? Therapists have observed that, for many people, the dominant shoulder is naturally depressed and slightly protracted. If right-handed, the right shoulder may be slightly lower and more protracted than the left. Clients Is there increased tension in the abdomen perhaps corresponding to a posteriorly tilted pelvis and a decreased curve in the lumbar spine?
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Postural Assessment
What your findings mean Protrusion of the abdomen could be a natural consequence of pregnancy or the result of increased lumbar lordosis, or it could simply be excess adipose tissue because the client is overweight. Clients with restrictions in the muscles and fascia of the chest sometimes appear to have a protruding abdomen, quite a distinct change in shape from the chest area, which is tight and depressed.
Jane Johnson MSc, is co-director of the London Massage Company, England. As a chartered physiotherapist and sport massage therapist, she has been carrying out postural assessments for many years. She is renowned for her teaching, enthusiasm and dynamism. Her track record in the industry spans over 17 years References working both as a practitioner/instructor and as course director of her own company and other successHanchard N, Goodchild L, Thompson J, OBrien T, ful massage schools. She has a deep interest in muscuRichardson C, Davison D, Watson H, Wragg M, Mtopo S loskeletal anatomy and how newly qualified therapists and Scott M (2011). Evidence-based clinical guidelines can be better educated in this subject. She also is interfor the diagnosis, assessment and physiotherapy manested in the relationship between emotions and posagement of contracted (frozen) shoulder, Standard ture. In her spare time, Johnson enjoys taking her dog Physiotherapy 1:3. Endorsed by the Chartered Society of for long walks, practicing wing chun kung fu, and visPhysiotherapy. iting museums. She resides in London. Read also 6 questions to Jane on page 43 This excerpt is based on excerpts from Postural Assessment, by Jane Johnson, published in December 2011 by Human Kinetics. This article was first published in International Therapist (Issue 99, January 2012), the membership journal of the Federation of Holistic Therapists.
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ing, Orthopedic massage, Aquatic bodywork, PNF stretching, Body wraps and scrubs, Positional release, Craniosacral therapy, Prenatal massage, Hospice-based massage therapy, Reflexology, Hot/cold stone therapy, Shiatsu/acupressure, Infant massage, Sports massage, Kinesiotaping, Spray and stretch, Lymph drainage therapy, Structural integration, Massage for the elderly, Swedish massage, Muscle energy techniques, Thai massage, Neural manipulation, Trigger point release, Neuromuscular therapy (NMT), Visceral manipulation, Oncology massage. 3D Anatomy for Manual Therapies is now available from www.terrarosa.com.au
Postural Assessment offers students and practitioners of massage therapy, physical therapy, osteopathy, chiropractic, sports medicine, athletic training, and fitness instruction a guide to determining muscular or fascial imbalance and whether that imbalance contributes to pain or dysfunction. Now available at www.terrarosa.com.au
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Research Highlights
Massage Therapy Attenuates Inflammatory Signalling After Exercise-Induced Muscle Damage Although there is evidence that massage may relieve pain in injured muscle, how massage affects cellular function remains unknown. The discovery provides strong evidence that massage merits further study as a treatment for injuries and chronic disorders, said Dr. Mark Tarnopolsky, a researcher at McMaster University in Ontario, Canada. The authors administered either massage therapy or no treatment to separate quadriceps of 11 young male participants after exercise-induced muscle damage. Tarnopolsky, who has studied the cellular effects of exercise for decades, performed muscle biopsies in both quadriceps (vastus lateralis) of healthy young men before and after they'd undergone strenuous exercise, and then a third time after massaging just one leg in each individual. Comparing tissues from each subject's massaged leg with tissues from his unmassaged leg, Tarnopolsky and his team found that massage therapy reduced exerciserelated inflammation by dampening activity of a protein called NF-kB. Massage also seemed to help cells recover by boosting amounts of another protein called PGC-1alpha, which spurs production of new mitochondria tiny organelles inside cells that are crucial for muscle energy generation and adaptation to endurance exercise. Other proteins with similar roles were influenced by massage as well. The study was published in the journal Science Translational Medicine. Pleasant Human Touch is Represented in the Brain Touch massage (TM) is a form of pleasant touch stimulation used as treatment in clinical settings and found to improve well-being and decrease anxiety, stress, and pain. Emotional responses reported during and after TM have been studied, but the underlying mechanisms are still largely unexplored. In the study conduced by Swedish scientists, the authors used functional magnetic resonance (fMRI) to test the hypothesis that the combination of human touch (i.e. skin-to-skin contact) with movement is eliciting a specific response in brain areas coding for pleasant sensations. The design included four different touch conditions; human touch with or without movement and rubber glove with or without movement. The pleasantness of the four different touch stimulations was rated on a visual analog scale (VAS-scale) and human touch was rated as most pleasant, particularly in combination with movement. The fMRI results revealed that TM stimulation most strongly activated the pregenual anterior cingulate cortex (pgACC.) These results are consistent with findings showing pgACC activation during various rewarding pleasant stimulations. This area is also known to be activated by both opioid analgesia and placebo. Together with these prior results, the finding furthers the understanding of the basis for positive TM treatment effects. The study was published in Neuroimage. Massage Therapy for Osteoarthritis of the Knee A group of medical scientists from the US in 2006, reported results of a pilot study of massage therapy for osteoarthritis (OA) of the knee. Subjects with OA of the knee were randomized to biweekly (4 weeks), then weekly (4 weeks) Swedish massage (1 hour sessions) or wait list. Subjects receiving massage therapy demonstrated significant improvements in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), pain, stiffness, and physical functional disability domains and visual analog pain scale, compared to usual care. Notably, the benefits persisted up to 8 weeks following the cessation of massage. In a new trial, the scientists now want to identify the optimal dose of massage within an 8-week treatment regimen and to further examine durability of response. Participants were 125 adults with OA of the knee, randomized to one of four 8-week regimens of a standardized Swedish massage regimen (30 or 60 min weekly or biweekly) or to a Usual Care control. Their results showed that the WOMAC Global scores improved significantly in the 60-minute massage groups compared to Usual Care at the primary endpoint of 8-weeks. WOMAC subscales of pain and functionality, as well as the visual analog pain scale also demonstrated significant improvements in the 60minute doses compared to usual care. No significant differences were seen in range of motion at 8-weeks, and no significant effects were seen in any outcome measure at 24-weeks compared to usual care. A doseresponse curve based on WOMAC Global scores shows increasing effect with greater total time of massage, but with a plateau at the 60-minute/week dose. The authors concluded that Given the superior convenience of a once-weekly protocol, cost savings, and consistency with a typical real-world massage protocol, the 60-minute once weekly dose was determined to be optimal, establishing a standard for future trials. The research was published in PLoS.
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Research Highlights
The Role of Massage in Scar Management Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly. Scientists from Ohio conducted a review on the efficacy of scar massage. The review was published in Dermatology Surgery Journal. After searching through a large scientific database, ten studies including 144 patients who received scar massage were examined in the review. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment protocols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from one treatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score. However the authors concluded that although there are several studies showing the effectiveness, the evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it. Neural Correlates of a Single-session Massage Treatment A recent study from Canada investigated the immediate neurophysiological effects of different types of massage in healthy adults using functional magnetic resonance imaging (fMRI). The study suggested that that qualitatively different aspects of massage, such as the nature of human touch, can selectively modulate the activity of certain brain regions. The researchers looked at the problem from, the resting state of the brain, which has been referred to as the default mode network and has received much attention for its importance in the generation of consciousness. These regions (i.e. insula, posterior and anterior cingulate, inferior parietal and medial prefrontal cortices) have been postulated to be involved in the neural correlates of consciousness, specifically in arousal and awareness. The researchers posit that massage would modulate these same regions given the benefits and pleasant affective properties of touch. Healthy participants were randomly assigned to one of four conditions: 1. Swedish massage, 2. reflexology, 3. massage with an object or 4. a resting control condition. The right foot was massaged while each participant performed a cognitive association task in the scanner. They found that the Swedish massage treatment activated the subgenual anterior and retrosplenial/ posterior cingulate cortices. This increased blood oxygen level dependent (BOLD) signal was maintained only in the former brain region during performance of the cognitive task. Interestingly, the reflexology massage condition selectively affected the retrosplenial/posterior cingulate in the resting state, whereas massage with the object augmented the BOLD response in this region during the cognitive task performance. The most robust fMRI changes were observed with the Swedish massage treatment, which involves long and smooth strokes with an applied pressure geared towards relaxation. The impact of reflexology, which is focused upon applying pressure to specific reflex points to invoke a beneficial response at distant body regions, was restricted to the RSC/PCC brain region. In contrast, the massage with a wooden object, which involved pressure and strokes along the same areas of the foot as applied in the Swedish massage, had no significant effect on the BOLD signal in either of the brain regions. This latter finding is particularly noteworthy since it suggests the possibility that the human touch component (as opposed to the same pattern of massage with an object) had a profound influence upon the impact of the treatment. These findings should have implications for better understanding how alternative treatments might affect resting state neural activity and could ultimately be important for devising new targets in the management of mood disorders. The study was published in Brain Imaging and Behavior.
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