Terra Rosa E-Magazine Issue 13 (December 2013) | Breathing | Blood

Terra Rosa

E-Magazine
Open information for massage therapists & bodyworkers No. 13, December 2013

Terra Rosa e-magazine, No. 13 (December 2013)

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Terra Rosa E-Magazine, No. 13, December 2013

Inside this Issue
3 7 11 Anatomy in Clay — Joe Muscolino An interview with Antonio Stecco Maximise Body Oxygenation — Patrick McKeown Functional Fascial Taping® Research — Ron Alexander Tendinopathy: What about the pain? — Ebonie Rio & Prof. Jill Cook The Intrinsic Spiral — George Kousaleos Distal Vs. Proximal — Art Riggs John Wayne, Marilyn Monroe, and Goldilocks — Til Luchau Erection During Massage Acupressure and Myofascial Therapy: A Unified Approach — John Kirkwood What Dooms Working Relationship? — Don Quinn Research Highlights 6 Questions to John Kirkwood 6 Questions to Ron Alexander

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Cover Feature
Jo Phee is a senior trainer in the mindfulness practice of Yin Yoga. Her teachings are a blend of meditative, long holds, static yoga postures with the theories of Chinese Medicine. She travels around the world offering teacher trainings and workshops in Yin Yoga, Functional Anatomy and Chinese Medicine. www.yinspiration.org http://www.facebook.com/jophee.yinyoga

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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. Terra Rosa e-magazine, No. 13 (December 2013) 2

Anatomy in Clay
By Joe Muscolino
“The mind does not forget what the hands have learned.”
It can be argued that the fundamental basis for all clinical orthopedic manual and movement therapies is a solid understanding of anatomy. After all, if you know anatomy (structure), you can figure out physiology (function). And if you know physiology, you can understand what pathophysiology (altered physiology of a condition) is. And if you know pathophysiology, you can figure out how to assess that condition. And if you know assessment, you can critically think to determine what treatment is appropriate for that condition. In other words, knowing anatomy can be the key that allows for the critical thinking that empowers you to creatively apply the appropriate treatment techniques for the condition with which your client presents. The irony is that most students look at anatomy as a course that must be endured and passed in order to move on to the more “important” courses on assessment and treatment. To many students, anatomy is nothing more than a dry and abstract subject that is an exercise in putting Latin-derived names on all the many structures of the body. As a result, they do not learn their anatomy well. And much of what they do learn is soon forgotten after leaving school. Not knowing anatomy then requires them to have to work much harder in their physiology, pathophysiology, assessment, and treatment technique classes because, without the fundamental basis of anatomy, instead of learning to understanding the content, they must memorize it. This results in them having to memorize cookbook routines instead of learning how to critically think and appropriately apply treatment techniques to best treat the various orthopedic conditions with which their clients present. So why do so many students resist spending the time and effort to learn anatomy? The problem is often twofold. First, their instructor probably did not apply the concepts of anatomy to the conditions that they would encounter once they are out in practice, so they were not taught to see how fundamentally important anatomy is to clinical massage. Second, the manner in
Terra Rosa e-magazine, No. 13 (December 2013)

which they were taught anatomy was likely dry and abstract, often auditory lecture at best supplemented with visual illustrations. This is unfortunate because the body is a threedimensional marvel of engineering; and teaching and learning the structure of the body, especially the muscles, should stem from an appreciation of the beauty of its architecture. This beauty can be best appreciated if the teaching approach is dynamic and kinesthetic. Massage therapy, and indeed every manual and movement therapy, is a kinesthetic field, and for this reason attracts students and therapists who learn best with kinesthetic methods. One such method that is effective for teaching muscles (and all myofascial tissues) is palpation. Being taught how to palpate the muscles as they are being learned can make the learning process more accessible. However, as excellent as palpation is, it is still a somewhat indirect way to learn the muscles of the body. After all, the muscles must be palpated through the skin, making a true sense of their location challenging to appreciate; this is especially true for the deeper muscles. A much more direct and creative kinesthetic approach for learning muscles is a system called Anatomy in Clay™. Anatomy in Clay™ involves actually creating in clay the muscles (and other myofascial tissues) that are being learned, and then placing them on a 29 inch-high model skeleton that was designed by Jon Zahourek, the creator of the Anatomy in Clay™ system. By doing this, the student becomes both an artist and engineer as he or she designs and forms each muscle by hand and places it on the skeleton. This method of learning is more time intensive, but the time spent is not wasted. Rather, taking time to work with each muscle creates an enriching experience that enhances familiarity with and knowledge of the muscles of the body.

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Anatomy in Clay

Step One: Forming the Muscle First, by creating and forming a muscle from clay, the student comes to understand and appreciate its shape. Is the muscle round or flat? Is it strap-shaped, square, or triangular? Is it thick or thin? What is its width and length? Working with these factors creates an intimacy with the three-dimensional structure of the muscle that cannot be gained from auditory lecture, flat twodimensional illustrations, or even palpation. And this intimate knowledge of the muscle’s form will enhance the student’s/therapist’s ability to assess and treat the muscle in their practice. Step Two: Placing the Muscle on the Skeleton After the muscle is formed, it must then be placed on the skeleton. This requires the student to work with and learn the actual bony attachments of the muscle. It also allows for a deeper understanding of where and how the muscle crosses the joint. Does it cross the joint anteriorly, posteriorly, laterally, or medially? Is it oriented vertically or horizontally? This is the fundamental knowledge needed to reason out the joint actions of the muscle and understand its role in posture and movement. Step Three: Placing Successive Muscles on the Skeleton Third, as successive muscles are formed and placed on the skeleton, the student begins to see the relationship between the sizes, shapes, and locations of these muscles. Having to fit a second muscle on the skeleton next

“Massage therapy, and indeed every manual and movement therapy, is a kinaesthetic field, and for this reason attracts students and therapists who learn best with kinaesthetic methods.”
to the one placed before it also often brings to light errors made in the creation of the first or second muscle. For example, one of the muscles might have been formed too large, not allowing sufficient space to fit the other muscle. Or perhaps one of the muscles was formed too small, leaving too much space between the two muscles. This then better informs the student about the size and shape of the muscles being formed, requiring the student to revisit and amend them. Placing muscles next to each other on the skeleton also allows for a deeper appreciation of the myofascial meridian continuities from one muscle to another because the student can blend the fibrous attachments of adjacent muscles into each other. This results in a richer and deeper appreciation of the structure of the myofascial system of the body. Based on the logistics of the Anatomy in Clay™ system, the muscles of the body must be created and placed on the skeleton from deep to superficial. Therefore the muscular system is recreated from the inside out. This results in more attention being placed on learning the deeper muscles of the body. Deeper muscles are often poorly taught and learned in lecture-format classes because lecture classes usually begin by teaching and spending their time on the larger superficial muscles, often relegating the smaller deeper muscles to the last few minutes of class. Deeper muscles also tend to be more poorly learned because they are not seen in superficial illustrations of the body, and their contours are not visible or palpable through the skin. Given the crucial role of these deeper muscles in stabilizing joints, focusing on them from the outset as is done with Anatomy in Clay ™ is especially valuable. The Anatomy in Clay™ system is also beneficial for a number of other reasons. Jon Zahourek designed many different model skeletons, each one in a different posture so that the student can gain an appreciation of the placement and location of muscles in various postures of the body. Also, when creating the muscles in clay and placing them on the skeleton, students can work cooperatively in groups. This fosters camaraderie, dialogue, and an exchange of ideas, further enriching the learning experience. It also tends to create a unified class
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“… knowing anatomy can be the key that allows for the critical thinking that empowers you to creatively apply the appropriate treatment techniques for the condition with which your client presents.”
Terra Rosa e-magazine, No. 13 (December 2013)

Anatomy in Clay

Photos of Maniken (R) with full permission by and attribution to Jon Zahourek.

experience in which students circulate around the classroom to view the other students’ skeleton models and discuss and compare how their muscles look. Anatomy in clay is also a creative process. Accessing creativity while learning the science of anatomy can help to blend linear and nonlinear thought, marrying together proverbial right-brain and left-brain thinking. And last but not least, it is fun!

Given the kinesthetic nature of manual and movement therapies, and the importance of learning anatomy, it only makes sense that teaching and learning anatomy should not be confined to the classroom lecture format. For a deeper and fuller appreciation of the musculature of the body, kinesthetic learning methods should be included. Jon Zahourek understood that working with one’s hands to create and place the muscles on the skeleton is the most direct way for the student or therapist to truly learn the muscles. He is fond of saying: “The mind does not forget what the hands have learned.” Whether you are a manual or movement therapy student, or a seasoned therapist, Anatomy in Clay™ This article is modified from the article “Learning can enrich your knowledge and understanding of the Muscles from Clay” published in Massage Therapy musculoskeletal system. Journal.

“…the body is a threedimensional marvel of engineering; and teaching and learning the structure of the body, especially the muscles, should stem from an appreciation of the beauty of its architecture.”

Terra Rosa e-magazine, No. 13 (December 2013)

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Anatomy in Clay & Clinical Orthopedic Manual Therapy
with Dr. Joe Muscolino
Sydney & Gold Coast February 2014
Anatomy in Clay®
Sydney
14 February 2014, Muscle Palpation as an assessment tool for Orthopedic Massage 15-16 February 2014, COMT: Neck 17-18 February 2014, COMT: Lower Back & Pelvis Dr. Joe Muscolino is presenting this workshop for learning muscles by building them in clay, which is the ultimate kinaesthetic experience for deepening the knowledge of the skeletal muscles of pelvic tilt and shoulder girdle. We are Users of Anatomy in Clay®, a Creation of Zahourek Systems

Sydney

Gold Coast

8 February 2014, Anatomy in Clay® Muscles of the Pelvic Girdle/ Powerhouse 9 February 2014, Anatomy in Clay® Muscles of the Shoulder Girdle

21-22 February 2014,COMT: Lower Back & Pelvis 23 February 2014 , Advanced Joint Mobilisation

Clinical Orthopedic Manual Therapy (COMT)
The focus of these workshops is to learn how to work clinically utilising deep pressure, basic and advanced stretching, and joint mobilisation techniques; and to do so more efficiently by working from the core with less effort so you do not hurt yourself. In effect, how to work smarter instead of harder! Working clinically and efficiently can be done simply by learning a few basic guidelines of proper technique that Dr. Joe Muscolino will show you. An invaluable workshop for anyone who does sports, clinical, and/or rehab. work! The workshop will cover body mechanics for deep tissue work, muscle palpation assessment, orthopaedic assessment testing , and stretching. It will also has focuses on advanced stretching (CR, AC, and CRAC stretching), motion palpation and assessment of joint, and how to safely perform joint mobilisation.

About Dr. Joe Muscolino
Dr. Joe Muscolino is a licensed chiropractic physician and has been a massage therapy educator for more than 25 years, with extensive experience in teaching kinesiology and musculoskeletal assessment and technique classes. Dr. Muscolino has authored 8 major publications with Mosby of Elsevier Science, including "The Muscle and Bone Palpation Manual, with Trigger Points, Referral Patterns, and Stretching" "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.” Anita S., Hornsby.

ATMS, AMT, AAMT Approved CPE/CEU Points Don’t 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 highly recommend his workshops to any body-worker. I, myself, can't wait for the next one!" Zuzana G, North Sydney.

Terra Rosa e-magazine, No. 13 (December 2013)

Book Early as Places are Limited

To register your interest & for more information, visit www.terrarosa.com.au/joe

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An Interview with Antonio Stecco
Dr. Antonio Stecco is a graduate in Medicine and Surgery, and specialized in Physics Medicine and Rehabilitation at the University of Padua, Italy. His scientific and clinical interests are anatomy of the fascia corporis via dissections and histological studies, including immunohistochemical and molecular biology; study and clinical application of hyaluronic acid; and myofascial syndrome. Following the techniques developed by his father, Luigi Stecco, PT, Dr. Stecco co-authored with his sister, Carla Stecco, MD Fascial Manipulation for Musculoskeletal Pain (Piccin, 2004). Dr. Stecco was recently elected Assistant-President in the Cabinet of the International Society of Physical Medicine and Rehabilitation. He is also the author of 20 articles in journals, all relating to the category of disciplinary scientific sector MED/34, presentation at international conferences, including one Best Poster Award and three chapters in English textbooks. Can you tell us a bit about your work. I am a physiatrist and have been working more than 10 years in the department Human Anatomy and Physiology in University of Padova, Italy. My work tries to understand the anatomy and morphology of fascia, particularly the relationship between fascia and muscle. With this fundamental research and discoveries, we are able to find out fascia involved in musculoskeletal disorder and pain, and also able to explain neuropathic pain, or what is usually called myofascial pain. What is the relationship between fascia and pain? Myofascial pain syndrome (MPS) is usually described as symptoms on the muscle, sensory, motor, and autonomic nervous system caused by stimulation of myofascial trigger points. Its cause is still a mystery, and the role of fascia in this syndrome has often been neglected. Now let us look into the anatomy of fascia first. The
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term deep fascia, we intend any dense fibrous sheath that interpenetrates and surrounds the muscles, bones, nerves, and blood vessels of the body, binding all these structures together into a firm compact mass. Over bones, it is called periosteum, around tendons, it forms the paratendon, around vessels and nerves, it forms the neurovascular sheath. Around joints, it strengthens the capsules and ligaments. Deep fascia (such as fascia lata, brachial fascia, crural fascia) is not a single structure, but a multilayer structure composed of 2 to 3 layers of dense connective tissue (collagen type 1, 3, elastin fibres), and several layers of loose connective tissue (adipose tissue, GAG, and HA). The dense connective tissue has a function to transmit force, proximally to distally and vice versa,
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Antonio Stecco
and to help the coordination of muscles. Now, we know that about 30% of the muscle insertions are not in the tendon, but in the deep fascia. All of these fascial insertions provide an excellent illustration of how the thickness and strength of fasciae is a precise mirror of the forces generated by muscular action. When these muscles contract, not only do the bones move, they also stretch the deep fascia. Meanwhile the loose connective Figure 1. Cross-section from the skin to musculature, showing fascial membranes and rtetinacula tissue is structured so that they cutis fibres. Illustration by Giovanni Rimasti, modelled from an illustration by Luigi Stecco. (From Muscolino, 2012, Used with permission). are independent of each other, each layer have a particular direction of collagen fibre that follow the muscle fibre. It pen. In overuse or repetitive use syndrome, isometric allows gliding between each layer and between the contraction for a long time can increase the viscosity of layer and the muscle. the HA, causing an increase stiffness. Deep fascia is also innervated with many mechanoreceptors (such as Ruffini, Pacini, free ending nerves). Research from Heidelberg led by Siegfried Mense also described that fascia is innervated with nociceptors. Fascia is therefore important in proprioception and pain generation. It is possible that the viscoelasticity of fascia can modify activation of the nervous receptors within fascia For example, if the viscosity of the connective tissue change, the gliding between the layers of fascia can be affected (decreased). If a decrease between layers of the deep fascia, they will start to experience stiffness. This will cause hyperactivation or irritation of the mechanoreceptors, free ending nerves, and eventually pain. This pain experience, however, will not show up in any x-ray or MRI because it is not a morphological change that caused the pain, but the alteration of the viscosity of connective tissues. In an experiment using ultrasound, we showed that neck pain is proportional to the fascial thickness of the sternal ending of the sternocleidomastoid and medial scalene muscles. After FM treatment, the results showed a significant decrease in loose connective tissue thickness. There are now different studies using an instrument that can stretch the fascia in the lab. Initially the fascia from a cadaver is very stiff, but after several stretching cycles the stiffness begins to decrease. This is like a ‘warm up’ exercise. In human, the opposite could hapTerra Rosa e-magazine, No. 13 (December 2013)

What is the Role of Hyaluronic Acid (HA) in pain generation? HA is a large, remarkably simple, straight chain carbohydrate polymer of the extracellular matrix (ECM). This is in marked contrast with all other GAGs that are attached to core proteins. High molecular size HA in the body acts as a hydrating, space filling polymer. We have confirmed that HA is located in considerable amounts at the interface between deep fascia and the surface of muscle. This provides a lubricant for the fascia to glide over neighbouring muscle. The viscoelasticity of the fascial tissue and associated HA shapes the dynamic response of the mechanoreceptors. The normal sliding lubricating function of HA can decrease with increased viscosity. When the HA becomes adhesive rather than lubricating, the distribution of lines of force within the fascia become altered. With increase viscosity, the receptors within the fascia can send a pain message even when it is stretched within the physiological range.

How does manual therapy able to help? Therefore an important component of manual therapy is to reverse these changes in HA. From clinical and lab experiments, we demonstrate that with deep pressure, friction and gliding, we are able to create an increase in temperature in the deep fascia. That’s why in Fascial Manipulation® (FM®) we keep the pressure and cre8

Antonio Stecco
ate a gliding in a particular spot because it increases the temperature. In the lab we showed that when we reach over 40 degree Celsius, we are able to break down the chains by inter- and intra-molecular water bonds of HA, and thus can decrease viscosity. The decrease of the viscosity enables restoration of normal gliding and normalizes the activation of the mechano-receptors in that area. The HA fragmentation reactions also promote inflammation that help to restore the normal physiology of the area. Our idea in Fascial Manipulation® is that with deep pressure, we warm up the area, catalyse inflammatory reaction, restore the fluidity (from gel to sol) of HA, and thus restore normal gliding. The real efficacy of the ma- trunk) and extremities restore the normal tension of the nipulation of deep tissue lies in its role as a catalyst for fascia restoration the correct motility and function of resolving the inflammatory reaction. the organ. Our approach is related at the tensile structure of our body that allow us to work out the body to How does fascia relate to proprioception? effect inside the body. The perspective of the body in space now it is a very popular concept, but twenty years ago when we said that What is your current work? fascia is an organ for proprioception people are surNow, we are doing research in anatomy and physiology prised and find it difficult to digest. The fascia is inner- of fascial, with collaborations of University of Padova, vated, surrounds the muscle and it can “feel” the elonga- Rehab. Centre in Sao Paulo and other places. I am using tion and changes in the muscles. When we use our mus- ultrasound techniques to objectively show the effect of cles, whether moving, elongation, contraction, we pull treatment on the changes in fascia and improvement of through the myofascial insertion, a particular area of the the fascia gliding. fascia. Because fascia is innervated, the mechanoreceptors in the area will be stretched, and activated. The I am also travelling all over the world (this year I have CNS will have a “map” of the mechanorecteors through- travelled to New York, Las Vegas, Houston, Washington out the body. So if a particular area is activated, the CNS DC, Los Angeles, Manila, Hong Kong, Beijing, Dubai, will know that a particular region of the body is affected Tokyo and Europe) teaching Fascial Manipulation®. or moving in space. Muscles, fascia, nerves, CNS work The FM book is now translated in Japanese, Korean, together to perceive the movement in space. Chinese, Portuguese, English, Polish, France, Italian, Spanish and German. We want to popularise FM for Can you tell us about FM for Internal Dysfunceverybody because it is a relatively cheap, fast, and eftions fective method to treat musculoskeletal pain. The government in Israel now recognised FM as one of the 3 The Level III of Fascial Manipulation is indicated for visceral pain and symptoms as constipation, dysmenor- best manual therapies. In the US, private health insurance looks for treatments that can show improvement rhea, reflex and all the other symptoms of the organs after three treatments, and FM is a perfect method for when the imaging do not show any morphological alteration. FM for internal dysfunctions evaluate also the this. The treatment is easy to teach, even to Medical alteration of the superficial fascia as oedema, alteration Doctors, and they found it is easy to restore the function of the superficial vein system, skin alteration etc. with a and pain. different modality of treatment and a new type of manuality. The points that we treat are almost the same (we have added only some points), but the combination and the modality of the approach is completely different. This allow the therapist to asses and treat symptoms that, most of the time, were difficult to interpret. We teach how the manipulation of the container (fasciae of the
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Fascial Manipulation Diploma - in Australia!
Fascial Manipulation is a manual therapy that has been developed by Luigi Stecco, an Italian physiotherapist from the north of Italy. It focuses on the fascia, in particular the deep muscular fascia, including the epimysium and the retinacula and considers that the myofascial system is a three-dimensional continuum. In recent years, via collaboration with the Anatomy Faculties of the René Descartes University, Paris, France and the University of Padova in Italy, Dr. Carla Stecco and Dr. Antonio Stecco have carried out extensive research into the anatomy and histology of the fascia via dissection of unembalmed cadavers. The Fascial Manipulation technique presents a complete biomechanical model that assists in deciphering the role of fascia in musculoskeletal disorders. The mainstay of this manual technique lies in the identification of a specific, localised area of the fascia in connection with a specific limited movement. Once a limited or painful movement is identified, then a specific point on the fascia is implicated and, through the appropriate manipulation of this precise part of the fascia, movement can be restored. The team at PhysioWISE are bringing Fascial Manipulation to Australia in March 2014 with courses in Melbourne and Sydney. The instructor is Julie Ann Day who has worked closely with the Stecco's over the years and has translated their work into English - it's as close to being taught directly by the Stecco's without having to learn Italian first! Registration for these courses is through the Australian Institute of Advanced Training (www.AIAT.com.au).

The complete collection of Fascial Manipulation Available at www.terrarosa.com.au

Terra Rosa e-magazine, No. 13 (December 2013)

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Maximise Body Oxygenation
By Patrick McKeown
Quick Reference Normal breathing volume during rest is 4 to 6 litres of air per minute. Breathing a volume which is in excess of normal causes a loss of the gas carbon dioxide. This in turn leads to a number of events including the following:  The bond between the red blood cells and oxygen becomes more ‘sticky’ leading to reduced delivery of oxygen to tissues and organs Smooth muscle surrounding blood vessels and airways constrict, causing reduced blood circulation and increased breathlessness pH of the blood changes towards alkaline affecting our immune system and more However, by doing so, they are in fact limiting improvements to their performance. It is no wonder that regardless of how hard some athletes train, they still find it extremely difficult to improve their fitness levels beyond a certain point. It is also not surprising that many elite athletes experience sickness and poor health soon after they retire. Carbon Dioxide: Not just a waste gas! The concentration of carbon dioxide in the atmosphere is very low, and therefore this gas is not carried into the lungs when we breathe. Instead we produce it in the tissue cells during the process of converting food and oxygen into energy. Maintaining a normal breathing volume ensures that the correct amount of carbon dioxide remains in the lungs, blood, tissues and cells. So what are the negative effects of creating an increased sensitivity to carbon dioxide when we over-breathe?     Carbon dioxide performs a number of vital functions in the human body, including: the delivery of oxygen from the blood to the muscles and organs the opening and closing of smooth muscles surrounding the airways and blood vessels the regulation of blood pH

You may be thinking at this point, "My breathing is fine, so why change it?" In fact, whenever a stranger asks my wife what I do for a living she replies, "He helps people breathe," to which the reaction is usually laughter or disbelief. Yes, breathing is natural and involuntary. Luckily, we don’t have to remember to take each breath or we would have ceased living a long time ago. But while breathing is the most natural thing in our lives, many factors of modern life negatively affect our breathing, such as: Stress, Sitting at a desk all day, Excessive talking, Processed foods, and Stuffy environments. The commonly held belief that it's good to take deep breaths. During a presentation to a group of runners who were due to compete in the Dublin city marathon the following day, I posed the following question: “Who here believes that taking a large breath into the lungs during rest will increase oxygen content of the blood?” Immediately, 95% of the runners raised their arms, and I have found that such a belief is endemic throughout the world of physical exercise. Ironically, it is exactly the wrong thing to do if you want more oxygen and more endurance. Based on this belief, many athletes adopt the practice of intentionally taking deep breaths during times of rest, during training and especially when the going is hard.
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Delivery of oxygen from the blood to the muscles and organs One of the fundamental elements of the OxyAdvantage technique is to understand the so-called Bohr effect – the way in which oxygen is released from red blood cells and delivered to the muscles. This exchange forms the core of unlocking your body's true potential when it comes to sport and exercise, allowing you to raise your game and achieve the results you really want. The Bohr effect was discovered in 1904 by the Danish physiologist Christian Bohr (father of Niels Bohr, the Nobel Prize winner physicist—and footballer). In the words of Christian Bohr, “The carbon dioxide pressure of the blood is to be regarded as an important factor in the inner respiratory metabolism. If one uses carbon dioxide in appropriate amounts, the oxygen that was taken up can be used more effectively throughout the
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Maximise Oxygenation

body”.2 Over-breathing is detrimental to the release of oxygen from the blood, and in turn affects how well our muscles are able to work. Author of the book “Respiratory Physiology”, John West tells us that "an exercising muscle is hot and generates carbon dioxide, and it benefits from increased unloading of O2 [oxygen] from its capillaries."3 In simple terms: haemoglobin is a protein found in the blood, and one of its functions is to carry oxygen from the lungs to the tissues and cells. The crucial point to remember is that haemoglobin releases oxygen when in the presence of carbon dioxide. When we over-breathe, too much carbon dioxide is washed from the lungs, blood, tissues and cells. This condition is called hypocapnia and strengthens the bond between oxygen and haemoglobin, resulting in reduced oxygen release and therefore reduced delivery of oxygen to tissues and organs. With less oxygen delivered to the muscles, they cannot work as effectively as we might like them to. The urge to take bigger, deeper breaths when we hit 'the wall' during exercise does not provide the muscles with more oxygen but effectively reduces oxygenation. In contrast, when breathing volume remains nearer to normal levels, the pressure of carbon dioxide in the blood is higher, loosening the bond between haemoglobin and oxygen, meaning that there is a greater delivery of oxygen to the muscles. The better we can fuel our muscles with oxygen during activity, the longer and harder they can work, and the lower lactic acid levels will be. The Bohr effect can be illustrated using the oxygen disassociation curve above, which plots blood oxygen saturation on the vertical axis against the amount of oxygen in the blood on the horizontal axis. Within the red cells are proteins known as haemoglobin which contain iron. One of the functions of haemoglobin is to carry oxygen from the lungs to the tissues and cells of the body where it is released in order to burn nutrients for the production of energy. Oxyhaemoglobin saturation on the vertical axis refers to the percentage amount of haemoglobin which is occupied with oxygen. The normal saturation of haemoglobin with oxygen is between 95 to 99%, attributable to silent and barely
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noticeable breathing during rest. When you breathe more than your body requires, carbon dioxide pressure is reduced, which in turn causes pH to change towards alkaline. This alteration shifts the S-shaped curve on the graph to the left and results in oxygen sticking to haemoglobin. With less oxygen being released, the percentage saturation of oxygen in the blood is higher. Dilation and constriction of airways and blood vessels Breathing too much can also cause reduced blood flow. For the vast majority of people, two minutes of heavy breathing is enough to reduce blood circulation throughout the body, including the brain. In general, blood flow to the brain reduces by 2% for every 1mmHg decrease in carbon dioxide.4 (a normal level is 40mmHg). A study by Gibbs to assess arterial constriction induced by hyperventilation found that blood vessel diameter reduced in some individuals by as much as 50%.5 Most people will have experienced constriction of blood flow to the brain resulting from a period spent overbreathing. It doesn’t take very long to feel the onset of dizziness and light-headedness from taking a few big breaths in and out, breathing heavily through the mouth. Similarly, many individuals who sleep with their mouths open may find it difficult to get going in the morning. Regardless of the amount of time spent
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Maximise Oxygenation
place. Interestingly, individuals without asthma also experienced better breathing.13 The feeling of chest tightness, excessive breathlessness and the inability to take a satisfying breath is experienced by many athletes, including those without a prior history of asthma. Later on in this book, I will further explore the relationship between breathing volume and exercise-induced narrowing of the airways, and, more importantly, I will provide you with the tools to help prevent asthma symptoms. This is an area of considerable importance to me, having spent years gasping for breath from even the slightest of exercise. Little did I know that my continuous mouth breathing and gulping of air into my lungs was in fact worsening my asthma. For the past twelve years, I have helped thousands of children and adults get to the root of their asthma, providing them with lifelong tools to keep it to a minimum. For those who suffer from asthma or have relatives or friends with asthma, they can find a whole program to end asthma without drugs at my website: www.AsthmaCare.info The regulation of blood pH In addition to determining how much oxygen is released into your tissues and cells, Carbon dioxide also plays a central role in regulating the pH of the bloodstream, how acidic or alkaline your blood is. Normal pH is 7.365 and this level must remain within a tightly defined range or the body is forced to compensate. For example, when the pH becomes more alkaline, breathing reduces to allow carbon dioxide levels to rise and restore pH. Conversely, if pH of the blood is too acidic, as it is during the over-consumption of processed foods, breathing increases in order to offload carbon dioxide as acid, allowing pH to normalise. Maintaining normal blood pH is vital to our survival. If pH is too acidic and drops below 6.8, or too alkaline and rises above 7.8, the result can be fatal.14 The scientific evidence clearly points to the fact that carbon dioxide is an essential element in regulating our breathing, optimising blood flow and releasing oxygen to the muscles, and maintaining correct pH levels – all of which are essential for improving sporting performance, endurance and strength. We have also seen how over-breathing can negatively affect the amount of CO2, which can in turn limit our ability to exercise effectively and, in some cases, lead to health issues and injury. Knowing how your respiratory system works, and the important role carbon dioxide plays in its efficiency, allows you to maximise your potential when exercising. Case study: 37 year old competitive cyclist Eamon is 37 years old and has been an avid cyclist since his late teens. His usual training regime amounts to two 150km cycles per week. Despite his years of regular training, Eamon came to me because he was experiencing excessive breathlessness and a desperate need for air even while cycling at a moderate pace. He also complained of temporary blackouts during a 150 km cycle. He had visited his doctor and a consultant,
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sleeping, they are still tired and groggy for the first few hours after waking. It is well documented that habitual mouth breathing during waking and sleeping hours results in fatigue, poor concentration, reduced productivity and a bad mood.6-12 Hardly an ideal recipe for quality living. The same can also be true of individuals whose occupations involve considerable talking, such as school teachers or salespeople, who are only too aware of how tired they feel following a day of work. This is not necessarily due to mental or physical stimulation, but is more likely due to the effect of increased breathing during excessive talking. Increased breathing without a proportionate increase in metabolic activity results in a loss of carbon dioxide and reduced blood flow. Depending on genetic predisposition, the loss of carbon dioxide in the blood can also cause the smooth muscles of the airways to constrict, resulting in wheezing and breathlessness. A study by Dr van den Elshout from the Department of Pulmonary Diseases, University of Nijmegen, The Netherlands explored the effect on airway resistance when there is an increase of carbon dioxide (hypercapnia) or a decrease (hypocapnia).13 Altogether, 15 healthy people and 30 with asthma were involved. The study found that an increase of carbon dioxide resulted in a “significant fall” in airway resistance in both normal and asthmatic subjects. This simply means that the increase of carbon dioxide opened the airways to allow a better oxygen transfer to take
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Maximise Oxygenation

who both ruled out asthma. When I met Eamon, he showed signs of habitual mouth breathing which culminated in excessive breathing movements from the upper chest. Following two weeks of the OxyAdvantage program, Eamon's breathlessness was markedly reduced and he experienced no more blackouts. In this case, the cause of his breathlessness and blackouts was chronic hyperventilation. Eamon’s irregular and over-laboured breathing during resting periods translated into heavy breathing during exercise. His over-breathing during cycling caused an excessive loss of carbon dioxide, which resulted in a reduction of blood flow to the brain and the temporary blackouts. Of course, not everyone with reduced carbon dioxide experiences blackouts, as the effect will depend on genetic predisposition, but in all cases there will be some negative symptom to be found. As the late Cardiologist Claude Lum explains: "Hyperventilation presents a collection of bizarre and often apparently unrelated symptoms, which may affect any part of the body, and any organ or any system."15

8. Ohki M, Usui N, Kanazawa H, Hara I, Kawano K. Relationship between oral breathing and nasal obstruction in patients with obstructive sleep apnea.Acta Otolaryngol Suppl. 1996;523:228-30. 9. Lee SH, Choi JH, Shin C, Lee HM, Kwon SY, Lee SH.How does open-mouth breathing influence upper airway anatomy? Laryngoscope. 2007 Jun;117(6):1102-6. 10.Scharf MB, Cohen AP Diagnostic and treatment implications of nasal obstruction in snoring and obstructive sleep apnea. Ann Allergy Asthma Immunol. 1998 Oct;81(4):279-87; quiz 287-90. 11.Wasilewska J, Kaczmarski M Obstructive sleep apnea-hypopnea syndrome in children [Article in Polish] Wiad Lek. 2010;63(3):201 -12. 12.Rappai M, Collop N, Kemp S, deShazo R. The nose and sleepdisordered breathing: what we know and what we do not know. Chest. 2003 Dec;124(6):2309-23. 13.van den Elshout F.J.J.; van Herwaarden CL; Folgering H.T.M. Effects of hypercapnia and hypocapnia on respiratory resistance in normal and asthmatic subjects. Thorax.1991;(46):28-32 14.Casiday Rachel, Frey Regina. Blood, Sweat, and Buffers: pH Regulation During Exercise Acid-Base Equilibria Experiment . http:// www.chemistry.wustl.edu/~edudev/LabTutorials/Buffer/ Buffer.html (accessed 20th August 2012). 15.Lum, C. "Hyperventilation: The tip and the iceberg", J Psychosom Res, VOL 19, 1975, 375-383.

References and Notes
1. Cheung S. Advanced environmental exercise physiology . 1st ed. Human Kinetics; 2009 2. Bohr Chr., Hasselbalch K., Krogh A. Concerning a Biologically Important Relationship - The Influence of the Carbon Dioxide Content of Blood on its Oxygen Binding. http://www.udel.edu/ chem/white/C342/Bohr%281904%29.html 3. West J.B. Respiratory Physiology: The Essentials. Philadelphia: Lippincott Williams and Wilkins, 1995 4. Magarian GJ, Middaugh DA, Linz DH. Hyperventilation syndrome: a diagnosis begging for recognition. West J Med.1983 ; (May; 138(5)):733–736 5. Gibbs, D. M. (1992). Hyperventilation-induced cerebral ischemia in panic disorder and effects of nimodipine. American Journal of Psychiatry, 149, 1589–1591. 6. Kim EJ, Choi JH, Kim KW, Kim TH, Lee SH, Lee HM, Shin C, Lee KY, Lee SH. The impacts of open-mouth breathing on upper airway space in obstructive sleep apnea: 3-D MDCT analysis.Eur Arch Otorhinolaryngol. 2010 Oct 19. 7. Kreivi HR, Virkkula P, Lehto J, Brander P.Frequency of upper airway symptoms before and during continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome. Respiration. 2010;80(6):488-94.

Patrick McKeown was accredited as a Buteyko breathing practitioner by the late Dr Konstantin Buteyko in 2002. Having suffered from asthma, rhinitis and sleep-disordered breathing for over 20 years, Patrick is able to offer both theoretical knowledge and his own experiences to help clients to overcome similar challenges. To date, Patrick has written seven books and produced two DVD sets on the Buteyko Method, including three bestsellers: Close Your Mouth, Asthma-Free Naturally, and Anxiety Free: Stop Worrying and Quieten your Mind. The Buteyko DVD is available at www.terrarosa.com.au Patrick recently collaborated in a clinical trial investigating the Buteyko Method as a treatment of rhinitis in asthma with the University of Limerick. Results from a three-month follow-up with participants showed a 70% reduction of nasal symptoms including snoring, inability to get a satisfying breath, nasal congestion and more. An abstract of the trial was published in the April 2013 Journal Otolaryngology.

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Functional Fascial Taping Research
By Ron Alexander
FFT® Est. Since 1994 Distract Tissue and Apply Load.
FFT® is a rapid and effective way to decrease pain, assist function and allow rehabilitation to commence in a pain free environment. Clinically, FFT can be used to determine Soft Tissue Dysfunction in the musculoskeletal conditions with a high degree of accuracy. This article will discuss the overview and results of a research project on the effects of FFT on non-specific low back pain which was the subject of Shu-Mei Chen’s PhD at Deakin University and was supervised by Professors Jill Cook and Sing Ky Lo. Shu-Mei Chen and Ron Alexander were the clinical investigators and the outcome assessor was Shu-Mei. This study was published in the Journal of Clinical Rehabilitation October 2012(1). Background Non-specific Low Back Pain (NSLBP) is a common musculoskeletal disorder with a high lifetime prevalence and high rate of recurrence.(2) Pain can hinder movement and disturb neuromuscular activity and motor control and thus affect function.(3) Individuals with chronic pain can experience further disability due to psycho-social problems that result in personal and societal economic burdens.(4) Limiting pain in magnitude and time is therefore likely to minimize or reverse the negative consequences of NSLBP. After an acute low back episode 90% of people will get better after 6 weeks regardless of treatment, 10% will go on to have pain for 12months. Patients cannot be given a clear diagnosis and do not present with signs on imaging. Eighty-five percent of back pain patients fall within this group.

®

How is FFT different to other taping techniques? The taping has 2 components - Assessment and Application (5). The assessment procedure follows the standard clinical processes of test, intervene and re-test. This procedure is guided by the patient’s symptoms and allows for continual reassessment as symptoms decrease. This test has pain specific direction variability. The assessment intervention is performed in the pain provocative position and is determined by the optimal direction of ease. It is a systematic process distracting the skin and underlying tissue, with a graded tangential force directly over the pain. This is similar to the approach of Andrew Taylor Still (1828-1917), the founder of Osteopathy. Then whilst still in that range and with positive change, we observe if an increase in range is possible. The right direction takes in a number of factors and multiple vectors can be used. Tape application aims to create a graded load (tension) to tissues and employs a gathering technique to directly tighten the skin and the tissue below to change the tissue slack and to possibly affect the deeper structures. The rigid tape width is half the standard size of 38mm, halving it makes the tape tighter. This comes about by decreasing area, which increases force and creates more pressure, in this case the pressure is tension. Resulting in greater load on the tissues, this aims to offer a specific vector force away from the pain, in the direction predetermined by the assessment. The application may sound like it may decrease range of motion, however it does not, and it actually has a fascilitory effect on range in most cases. After these 2 stages are performed patients/athletes have pain relief and tension/ load to tissues during daily activities or exercise for an extended and predetermined period of time.
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FFT Research
Research Methods This pilot study design was a randomised, placebocontrolled trial comparing the effect of FFT with Sham Taping or Control Group during a 2-week intervention with 2, 6, and 12 week follow-up. Forty three participants were recruited from the general population, with a flexion deficit. All baseline characteristics were similar within and between the groups FFT (n = 21) and Sham/Control (n = 22). We used what is considered to be the best prognostic measures for investigating Low Back Pain (LBP) which was the result of a systematic review conducted by Shu-Mei and later confirmed from a presentation by LBP expert Professor Bogduk at a Melbourne Conference. The study had 2 people in both groups drop out in the first 2 weeks and a further 2 in the FFT group within 6 weeks. The treatment procedure was standard between the 2 groups except for how the rigid tape was applied. Lumbar flexion exercises were given in the 2nd week and a manual for skin care was provided to all participants. Both groups were treated 4 times over a 2 week period. Patients were to keep the tape on and was tightened daily. After 2 weeks the tape was removed. In treatment sessions 2, 3 and 4, the patients in both groups went into trunk flexion, in the pain provocative position and the same tape procedures as in session 1 were applied. The results from the study are far too detailed for this article, so an overview will be provided. Results We used a statistical analysis called ANOVA (Analysis of Variance), to observe the results of a number of the prognostic indicators for LBP. The analysis looked at 5 repeated measures to detect change in pain and funcSham/Control, Session 1 - Sit, pain provocative position. - Measure pain region, sham calculations performed, patients potentially thought the procedure looked technical. - Apply white and rigid tape, by placing tape over the measured area. Rigid Tape ½ width wide. FFT Group, Session 1 - Sit, pain provocative position. - Assessed tissue directionally specific. - Apply white and rigid tape ½ width wide, FFT gathering technique. - 2nd week flexion exercises. Terra Rosa e-magazine, No. 13 (December 2013)

tion, within and between the treatment groups, over the duration of the study, expressed as an effect size and compared with baseline (start of the project). The measures were used so we can confirm our findings/ data a number of times. The results from the study showed the FFT group demonstrated significantly greater reduction in worst pain compared to the control group after the 2 week intervention. The study was set so that the p-value had to show less than a 0.05 for clinical significance (meaning that there is less than 5% probability of getting a no effect). At the end of the trial the p-value result was 0.02. This number indicates that 2% of the time change may have occurred through chance with a 98% certainty that it was the intervention (FFT) that had created change. The study was also set to show a greater than 0.5 effect size (a measure of the strength of the treatment) for clinical significance. The result was 0.74 which means that the effect from FFT is very large and a powerful treatment. There were an additional 2 measures to test our findings, both of which confirmed that FFT was clinically significant for reducing worst pain. The same ANOVA analysis was applied to the modified Oswestery disability index questionnaire [mODI] to observe change in function. Although the data showed higher numbers in the FFT group, it was not clinically significant. The results from this data may have been underpowered at this stage due to the dropouts. If we had better adherence to treatment or if we had higher number of participants, we believe that greater change would have occurred and been detected. There were no significant differences between the 2 groups in relation to average pain at any time periods. The study also looked at pain intensity, function and used a calculation called Minimal Clinical Important Difference (MCID). Although the name uses the word ‘minimal’, it’s actually an important calculation and used in various research projects. For example, if a patient presents with 7/10 pain and after treatment the symptoms are reduced by more than 2, so less than 5/10, this means that they have attained MCID, i.e. intense pain reduced to comfortable pain. In order to confirm clinical relevance the study had to show less than 0.05 p-value. The data showed that in the FFT Group, 17 people attained and 4 did not attain MCID. Within the control group, 9 attained and 11 did not. Therefore a higher proportion of patients in FFT group attained MCID in worst pain [0.007 p-value] and function [0.007 p-value] than did those in the control group after the 2-week intervention.

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FFT Research

FFT treatment group in session 2.

Sham treatment group in session 2.

Why did the 4 dropouts occur in the FFT Group? One patient had soft tissue pain reduction which revealed an underlying osseous pathology which required surgery. One person thought they were in the placebo/ sham group and dropped out and 2 patients got better. These 2 learnt how to apply FFT and dropped out. The Principal Supervisor Jill Cook, explained that their data was to be recorded as a nil result and had to stay in the data. This was because the intention to treat analysis had been used, which meant that anyone who enters the study and drops out for any reason must be recorded as nil or no result from either taping group. On the day that the 4th person, dropped out (2nd pain free patient), I went for a nice long walk. Taking the focus away from patient compliance for a moment and looking at those who remained in the study, we can look at what was truly happening. Of the people who stayed in the study, we had in the FFT group 17 people out of 17, or 100% who attained positive MCID. The result for the control group was 50%. Even with the dropouts we have still shown an amazing result at 0.007 p-values for both pain intensity and function. This score means that if the project was repeated 1000 times then a similar result would be achieved for 993 times. Clinically for practitioners this indicates that by decreasing pain we increase function. We can confidently state that this was a real effect and not simply a matter of chance . Over the following weeks the patients within the FFT Group continued to show the same consistent results, however the control group started to show improvement. This can be the natural occurring effect due to patient expectation to treatment. Even with the tape being placed on the body we would have proprioceptive input and subtle load, especially when they moved into truck flexion. (For
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more information about the role of placebos in research, see an article by Bianca Nogrady, Placebos more effective than mere sugar pills. www.abc.net.au/ health/features/stories/2013/11/11/3888346.htm) Discussion In clinical practice we know that NSLBP is a complex musculoskeletal condition and that it can be multifactorial in nature. As clinicians we need to know if individual treatments are effective as well as when to use these. In this study, we looked at FFT and trunk flexion, in a normal practice, of course, you would be using other treatments and thus potentially achieve better results. Numerous reasons can contribute to NSLBP such as computer set up, smoking and psychosocial factors etc. Whilst NSLBP evidence based treatments are lacking(6), massage(7,8) has been shown to be effective however this is limited to the hands on session. FFT allows the treatment to work for a longer period of time. I am definitely not saying that we don’t ever need to do massage/soft tissue work, however clinicians can be more effective by incorporating FFT as it can be left on for hours and reapplied for days or weeks if need be. The data from this study demonstrates that a window of opportunity is created by the use of FFT. The patient experiences a rapid decrease in pain and an increase in function, the patient is encouraged to go back into the previous pain range and this potentially creates decreased apprehension of pain. This elevates the patient’s mood and speeds recovery because you can start rehabilitation earlier than is usually the case. An additional benefit is that the rehabilitation is being performed in a pain free environment. It may also now provide an opportunity to refer patients who have other contributing factors that are out of the scope of Manual
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FFT Research
Therapists, as the patient may be more receptive to change. What could be happening to the body? It is still not a thorough understanding of the mechanism by which any taping technique creates change(9). Our hypothesis for this study was limited to what could be taking place physiologically. The FFT assessment procedure has pain specific direction variability, which may indicate the Neuro-Fascial Interface. This may stimulate large-diameter afferent fibres and then modulate nociceptor input (Gate control mechanism). The load from tape could potentially change the sliding of fascial tissues relative to tissues next to them. The load from the tape may also potentially affect the skin and/or remodel the internal architecture of connective tissue(9,10), this may include changing mechanoreceptor activation(11). This hypothesis was supported by a paper on Motor Synchronisation that investigated the knee (12), the same principles can be translated to the back. Further research to investigate the potential mechanisms of how FFT could affect pain perception is required. We conducted an interesting experiment this year at the AAMT conference. Let me explain as some of you may have taken part and not realized it. I presented FFT at the AAMT conference in Adelaide, May 2013. I also presented twice a 3 hr workshop at the Conference and we had 60 people in each. I presented a lecture, followed by a demonstration and then taught everyone the elementary steps of the technique. I then had participants do an unbiased neural tension test in the arm, because not everyone is going to have a positive neural tension test and I wanted them perform an objective exercise. Most therapists are Neuro-Fascially tight in the arms because of the way they work. From experience I know that this test produces some pretty obvious Neural-Fascial Symptoms, in asymptomatic people and we can observe a decrease in pain and an increase in range. If anyone didn’t have discomfort doing this they were to choose an area in their hypermobile body (one or two in every crowd) that either produced pain or was uncomfortable. Each person had 20 minutes to perform the assessment and tape application. After the second workshop, 120 people had performed the exercise. Of these 120 people, 100% had experienced a decrease in symptoms and an increase range of motion. This exercise was repeated at the World Congress on Low Back and Pelvic Pain, in Dubai October 2013, on 48 people with 100% result. Our data from our RCT on FFT for NSLBP supports what we had observed at the 2 Conferences and is confirmed at almost all FFT workTerra Rosa e-magazine, No. 13 (December 2013)

shops. These consistent results indicate that the effect from FFT is predictable, in that you can have an effect in a large number of cases. Although there are situations where it doesn’t work, it is evidence-based, it is a relatively simple technique and it provides immediate results. References
1. Chen SM, Alexander R, Sing KL,Cook J. Efficacy of Functional Fascial Taping on Pain and Function in Patients with Non-Specific Low Back Pain: A Randomised Controlled Trial. 2012. Pub Clin Rehab Oct 2012 Vol 26, No. 10. 924-933. 2. Pengel LH, Herbert RD, Maher CG, et al. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327: 323. 3. Swinkels-Meewisse IE, Roelofs J, Verbeek AL, et al. Fear avoidance beliefs, disability, and participation in workers and non-workers with acute low back pain. Clin J Pain2006; 22: 45 –54. 4. Penny KI, Purves AM, Smith BH, et al. Relationship between the chronic pain grade and measures of physical, social and psychological well-being. Pain 1999; 79: 275–279. 5. Alexander R. Functional Fascial Taping. 5th International Olympic Committee World Congress on Sport Sciences with the Annual Conference of Science and Medicine in Sport 1999 Sydney. Book of Abstracts P 36. 6. Beurskens A.J, De Vet HC, Van der Heijden GJ, Knipschild PG, Köke A.J, Lindeman E, Regtop W. Efficacy of traction for nonspecific low back pain: a randomised clinical trial. The Lancet 1995 Vol 346, Iss 8990, 1596–1600. 7. Tsao JCI. Effectiveness of massage therapy for chronic, nonmalignant pain: A review. 2007. Vol 04,2,165-179. 8. Kumar S, Beaton K, Hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: A systematic review of systematic reviews. 2013, Int J Gen Med. Sep 4;6:733-741. 9. Ingber DE. 2008. Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol. 97:163-179. 10. Langevin HM, Storch KN, Snapp RR, et al. Tissue stretch induces nuclear remodeling in connective tissue fibroblasts. Histochem Cell Biol 2010; 133: 405–415. 11. Grigg P and Del Prete Z. Stretch sensitivity of cutaneous afferent neurons. Behav Brain Res 2002; 135: 35 –41. 12. Macgregor K, Gerlach S, Mellor R, Hodges PW. 2005. Motor synchronisation. Cutaneous stimulation from patella tape causes a differential increase in vasti muscle activity in people with patellofemoral pain. J Orthopaed Res. 23:351-358.

Ron Alexander is the Director/Founder of the Functional Fascial Taping Institute. FFT was refined over eight years service as the Principal Soft Tissue Therapist [Musculoskeletal] for The Australian Ballet. During this time he was awarded the Lady Southey Scholarship for Excellence from the Australian Ballet Foundation. More recently he was a coinvestigator of Randomised Double Blind Placebo Controlled Trial of FFT for Non-Specific Low Back Pain (PhD) Deakin University, Melbourne, Australia. Ron has an interest in chronic pathologies, continues to research the effects of FFT. Read 6 Questions to Ron on page 50.
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Functional Fascial Taping® ® FFT
with Ron Alexander Sydney, Melbourne, Adelaide May 2014 Sydney & Gold Coast
February 2014 Distract Tissue and Apply Tension
FFT® is a unique way to assess and apply tape for musculoskeletal pathologies creating an immediate analgesic effect and increase in range of motion. This innovative technique can complement most treatments of musculoskeletal pathologies. This workshop teaches the FFT method which is ideal for those therapists who need to instantly control their patients pain to reduce muscle inhibition and allow you to proceed with your treatment. FFT can have a fast and dramatic effect on musculoskeletal pain. FFT has been supported by randomised double blind placebo controlled clinical trial. The technique has shown it is significantly better than placebo in reducing Non-Specific Low Back Pain. This study was published in a peer review journal, Clinical Rehabilitation Oct 2012.

Sydney: 3-4 May 2014 Melbourne: 10-11 May 2014 Adelaide: 17-18 May 2014

Ron Alexander
FFT® was founded and refined by Ron Alexander in 1994 during eight years service for The Australian Ballet. The Australian Ballet award Ron in 1997, The Lady Southey Scholarship for Excellence. This included a 6-week study tour of Europe. Ron's passion for tape was further encouraged by Dr Karim Khan, Dr Ken Crichton and Physiotherapists Jan Smith (PhD candidate) and Susan Mayes. He was a Co-investigator of a Randomised Double Blind Placebo Controlled Study [PhD] at Deakin University, Melbourne Australia. ‘I witnessed the benefits of this method in many of our dancers…. I would commend this method as a further addition to treatments that are beneficial in the management of dance & sporting injuries’. Ken Crichton. Sports Physician, Deputy Chief Medical Officer, 2000 Olympic Games. Medical Director for the Australian Ballet . "A simple way to decrease pain and increase range allowing you to start rehabilitation. This method offers the clinician a wonderful addition to their treatment toolbox." Professor Jill Cook. PhD, Head of the Musculoskeletal Research Unit Department Deakin University

The Workshop: Through lecture, demonstration and
hands-on guidance clinicians will learn an innovative systematic objective assessment procedure and tape application, which allows for therapeutic load and rehabilitation in a pain free environment. The first day covers the spine and upper quadrant and the second day covers the lower quadrant. The second stage teaches new principles and advanced concepts for dynamic movement, predetermined load taping and functional restrictive taping. Providing the clinician with a far broader range of conditions that can be treated with FFT.

AMT, AAMT Approved CPE/CEU Points
"FFT is definitely the most efficient course I've done. Often, the simplest concepts prove to be among the most effective, and this is certainly true of FFT. It's clinical application is direct and easily accessible. We're using it with great results in our physiotherapy and pilates clinic...I believe it should be a tool in every physiotherapy and sports clinic.”

To register your interest & for more information, visit www.terrarosa.com.au/fft
Terra Rosa e-magazine, No. 13 (December 2013)

Or email: terrarosa@gmail.com

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Tendinopathy: What about the pain?
By Ebonie Rio & Prof. Jill Cook
Tendinopathy is the clinical syndrome of pain and dysfunction in a tendon. It is a common and often chronic condition that continues to baffle both scientists and clinicians. The drivers of tendon pain and modulation by the central nervous system are poorly understood. These limitations affect our ability to effectively treat people with tendon pain – we don’t know where the pain comes from. Many features of tendon pain are consistent with tissue disruption - the pain is well localised, persistent and specifically associated with tendon loading, whereas others are not, however investigations do not always match symptoms and painless tendons can be catastrophically degenerated and even rupture. This review will briefly summarise the clinical features, current research into pain drivers and central nervous system contribution. Exercise based rehabilitation remains the most potent method of stimulating the tendon matrix and new evidence indicates certain types of exercise can also provide acute pain relief. Note: Tendonitis is not a commonly accepted term as no inflammatory cells have been demonstrated and the changes appear to be a cell driven response. Tendinopathy is the term that is accepted and refers to a continuum of pathological change with pain. Note that collagen tearing has not been shown to be a primary event. What are the clinical features of tendon pain? The clinical presentation of tendinopathy includes localised tendon pain with loading [1], tenderness to palpation [2] and impaired function [3, 4]. The tendons most commonly affected by tendon pain include the patellar, Achilles, lateral elbow, adductor and gluteus
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Figure 1. Patellar tendon pain is most commonly felt at the inferior pole.

medius. Pain defines the clinical presentation, regardless of the degree of tendon pathology. In fact, tendon pathology can be present (ie changes on ultrasound) without the tendon being the cause of symptoms in the presentation. Tendinopathy, despite being an umbrella term, is usually limited to intra-tendinous presentations, with more specific terminology being applied to pathology in surrounding tissue with different disease processes, such as peritendinitis. These also require a different treatment approach, thus differential diagnosis is key. Tendon pain has an on/off nature linked to loading, and excessive energy storage and release in the tendon most commonly precedes symptoms [5, 6]. For example, the pain in patellar tendinopathy is most commonly at the inferior pole (Figure 1) and activities that require energy storage and release in this tendon, such as jumping are both painful and impaired. Pain is rarely experienced at rest or during low load tendon activities; for example, a person with patellar tendi20

Tendinopathy
nopathy will describe jumping as exquisitely painful yet not experience pain with cycling due to the different demands on the musculotendinous unit. A further characteristic pain pattern is that the tendon “warms up”, becoming less painful over the course of an activity, only to become very painful at variable times after exercise [7]. Modern concepts of pain Physiological or ‘nociceptive’ pain reflects activation of primary nociceptors following actual or impending tissue damage or in association with inflammation. Pathophysiological pain is associated with functional changes within the nervous system making it resistant to tissue-based treatments. The distinction between these is important clinically as they may require different approaches. However, it is important to remember that pain is an output and modulation by the central nervous system, it occurs even with clear physiological input. Some aspects of tendinopathy fit more clearly into pathophysiological pain. Painful tendons can have little pathology [8, 9] and pain can persist for years [10]. Furthermore, pain during tendon rehabilitation exercises has been encouraged [11-14] and may not be deleterious [15], demonstrating that tendon pain does not necessarily equate with tissue damage. Furthermore, overuse tendon injury does not involve an inflammatory process with a clear end point that underpins most physiological pain. However, other aspects of tendinopathy fit more clearly into physiological pain - pain remains confined to the tendon and is closely linked temporally to tissue loading [16]. A clinical presentation that fails to be explained by either pain state classification is the rupture of a pathological yet pain free tendon, where nociceptive input would have been advantageous. Local nociception Tendon pathology results in cell activation and proliferation, matrix change (collagen disorganisation and increased large PG) and neovascularisation, in various combinations and severity [8, 17, 18] as well as changes to biochemical substances present. Change in collagen structure is the most obvious candidate for nociception because it is the load bearing structure in tendon, but loss of collagen integrity does not correlate with tendon pain [8]. There are few afferent nerves within tendon, and innervation patterns do not change with pathology [19, 20]. New vessels primarily bring autonomic vasomotor (and
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Cells Nerves

Pain threshold

Normal

Reactive

Degenerative

Reactive on degeneration

Figure 2. Tendon pain throughout different stages of the continuum of tendinopathy.

some sensory) nerves but neovascularisation is not present in every painful tendon. Neovascularisation (new vessels) has been associated with degenerative tendinopathy but is not a feature of early pathology [8]. Not all painful tendons have increased vascularity [8, 21] and vice versa [8], therefore the vessels or the nerves and receptors on vessel walls fail to explain tendon pain across all pathological presentations. There are many biochemical changes in tendinopathy, none of which can fully explain tendon pain. Bioactive substances and their receptors may be important in pain behaviour. Neuropeptides and neurotransmitters, formerly attributed only to neurons, are now known to also be produced by tenocytes, however their actions and interactions are poorly understood. A key change is the increase in lactate [22], which decreases tissue pH and it is likely to alter cell activity, communication and ion channel expression of both tendons and nerves. Ion channels are important as they communicate the nociceptive message. The cause of local source of nociception is currently unknown and pain is experienced across a range of clinical presentations. Theoretically, in reactive (early stage) tendinopathy (as described by Cook & Purdam 2009 [33]) there may be increased expression of nociceptive substances because of cell activation and proliferation, but no change in innervation. In degenerative tendinopathy (end stage) there may be little expression of nociceptive substances due to cell inactiva21

Tendinopathy
tion or death but greater innervation. At both ends of the spectrum pain is possible because the threshold is reached (Figure 2.). The painfree tendon may have substantial matrix disorganisation and cell compromise, but insufficient production of nociceptive substances and /or the neural network to reach a threshold to cause pain. Central Nervous System Tendon pain aims to protect the injured tendon from overload. Sustained peripheral nociceptive activity may lead to the development of central sensitisation [23]. Although central sensitisation accounts for widespread pain and hyperalgesia/allodynia in chronic pain patients, excessive pain response is not a clinical feature of tendon pain regardless of symptom chronicity. This may be explained by the on/off nature of tendon pain (that is, tendons rarely hurt at rest so the pain is not sustained in nature), reducing the likelihood of neural upregulation, or local saturation of the receptor that would then fail to stimulate the afferent nerve. Few studies have examined if central pain processes are involved in tendon pain states [24, 25]. Tendinopathy pain would seem a unique chronic pain because pain generally occurs during loading, and although there is more pain with increasing load it disappears once the load is removed. Spreading of pain (for example secondary hyperalgesia) is not a common clinical feature of tendinopathy, especially in the lower limb. For example, pain in patellar tendinopathy, usually at the inferior pole, does not refer and is localised to this location regardless of the length of time of symptoms. However, developing symptoms on the other side is common and this mirroring is often attributed to bilateral loading patterns, although CNS neuroimmune mechanisms may be possible. A study by Årøen et al. (2004) [33] suggests that patients with an Achilles tendon rupture have increased risk of a contralateral tendon rupture, as well. This may be due to high bilateral loads or genetic factors, but may also indicate central drivers to pathology and /or pain or systemic. Study on bilateral shoulder tendinopathy in both the pitching and unloaded limb of baseball pitchers also support this [26]. This view is further strengthened by data from an animal model where bilateral cell changes were observed in unilaterally loaded rabbits [27] and a unilateral chemically induced model of tendinopathy in horses [28]. Tendon pain has been associated with local sensory change such as increased mechanical sensitivity (pain
Terra Rosa e-magazine, No. 13 (December 2013) Figure 3. Isometric muscle contractions decrease tendon pain. Standing calf raise in inner range for Achilles tendon insertion.

with activity and tendon pressure) [29, 30], hyperalgesia and bilateral changes to pressure pain thresholds [31] and bilateral changes to thermal sensitivity [32]. However, another study in tendons demonstrated no differences in cold and heat pain, cold and warm detection thresholds [25]. Reducing tendon pain An emerging area of interest for clinicians is the use of isometric exercise to reduce tendon pain. Research has shown that isometric contractions can reduce pressure pain thresholds in normal participants and have also been shown to reduce pain in patellofemoral pain syndrome and osteoarthritis. Isometric contractions reduce tendon pain immediately and for at least forty five minutes in patellar tendinopathy (Rio et al, 2013 [35]) and thus may have an important role in pain modulation to allow rehabilitation. Clinically, we have applied them to tendinopathy in the gluteus medius, patellar, Achilles, tendons of the elbow, hamstrings and the adductors. The aim is to build up the length of time of the contraction to greater than 45 seconds, using high loads without muscle fasciculation. Ideally they should be completed isolated muscle function in a range where the tendon is uncompressed, and should be repeated five times several times per day if necessary, depending upon the length of time of relief. An example for the Achilles tendon insertion is inner range calf raise holds (Figure 3). Summary The question of the pain of tendinopathy, physiological or pathophysiological, remains unanswered; however there is evidence for both; tendon based nociceptive contributions and extensive mechanisms within the periphery and the CNS that may up or down regulate
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Tendinopathy
the experience of pain. It may be different for different tendons or vary depending upon the context around loading and the effect of this on the pain experience, for example work related elbow tendon pain versus sport related patellar tendon pain could have vastly different modulation. Importantly for clinicians, tendon pain is complex and requires thorough assessment of both musculoskeletal and neural contributors. The use of isometric exercise to reduce tendon pain is an easily accessible technique that is efficacious. For a full discussion on this topic, please read The Pain of Tendinopathy: Physiological or Pathophysiological? Sports Medicine (September 2013) [35], available at: http://www.bodyinmind.org/wp-content/uploads/ Rio2013.pdf Ebonie Rio was awarded a post-graduate scholarship at the Australian Institute of Sport and has completed her Masters in Sports Physiotherapy. She is currently working with the Victorian Institute of Sport, Paralympic table tennis and wheelchair rugby teams whilst undertaking a PhD in tendon injuries. Prof. Jill Cook is a Principal Research Fellow at the Faculty of Medicine, Nursing & Health Sciences at Monash University. Her research interests is in tendon injury, tendon pathology, sports injuries, and musculoskeletal injuries. and patellar tendinopathies. Best practice & research Clinical rheumatology. 2007 Apr;21(2):295-316. 8. Cook JL, Feller JA, Bonar SF, Khan KM. Abnormal tenocyte morphology is more prevalent than collagen disruption in asymptomatic athletes' patellar tendons. J Orthop Res. 2004 Mar;22(2):334-8. 9. Malliaras P, Cook J. Patellar tendons with normal imaging and pain: change in imaging and pain status over a volleyball season. Clin J Sport Med. 2006 Sep;16(5):388-91. 10. Cook JL, Khan KM, Harcourt PR, Grant M, Young DA, Bonar SF. A cross sectional study of 100 athletes with jumper's knee managed conservatively and surgically. The Victorian Institute of Sport Tendon Study Group. Br J Sports Med. 1997 Dec;31(4):332-6. 11. Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study. Br J Sports Med. 2005 Nov;39(11):847-50. 12. Young MA, Cook JL, Purdam CR, Kiss ZS, Alfredson H. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med. 2005 Feb;39(2):102-5. 13. Ohberg L, Alfredson H. Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Knee Surg Sports Traumatol Arthrosc. 2004 Sep;12(5):465-70. 14. Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):327-33. 15. Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a painmonitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007 Jun;35(6):897-906. 16. Wilson JJ, Best TM. Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician. 2005 Sep 1;72(5):811-8. 17. Jozsa L, Reffy A, Kannus P, Demel S, Elek E. Pathological alterations in human tendons. Arch Orthop Trauma Surg. 1990;110(1):15-21. 18. Alfredson H, Ohberg L, Forsgren S. Is vasculoneural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):334-8. 19. Bjur D, Alfredson H, Forsgren S. The innervation pattern of the human Achilles tendon: studies of the normal and tendinosis tendon with markers for general and sensory innervation. Cell Tissue Res. 2005 Apr;320(1):201-6.
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References 1. Cook JL, Purdam CR. Rehabilitation of lower limb tendinopathies. Clin Sports Med. 2003 Oct;22 (4):777-89. 2. Ramos LA, Carvalho RT, Garms E, Navarro MS, Abdalla RJ, Cohen M. Prevalence of pain on palpation of the inferior pole of the patella among patients with complaints of knee pain. Clinics (Sao Paulo). 2009;64 (3):199-202. 3. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the "tendinitis" myth. Bmj. 2002 Mar 16;324(7338):626-7. 4. Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Full symptomatic recovery does not ensure full recovery of muscle-tendon function in patients with Achilles tendinopathy. Br J Sports Med. 2007 Apr;41 (4):276-80; discussion 80. 5. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Man Ther. 2002 Aug;7(3):121-30. 6. Ferretti A. Epidemiology of jumper's knee. Sports Med. 1986 Jul-Aug;3(4):289-95. 7. Kountouris A, Cook J. Rehabilitation of Achilles
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20. Ackermann PW, Li J, Finn A, Ahmed M, Kreicbergs A. Autonomic innervation of tendons, ligaments and joint capsules. A morphologic and quantitative study in the rat. J Orthop Res. 2001 May;19(3):372-8. 21. Cook JL, Khan KM, Harcourt PR, Kiss ZS, Fehrmann MW, Griffiths L, et al. Patellar tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian Institute of Sport Tendon Study Group. Clin J Sport Med. 1998 Apr;8(2):73-7. 22. Alfredson H, Bjur D, Thorsen K, Lorentzon R, Sandstrom P. High intratendinous lactate levels in painful chronic Achilles tendinosis. An investigation using microdialysis technique. J Orthop Res. 2002 Sep;20(5):934-8. 23. Butler D. The Sensitive Nervous System. Adelaide: Noigroup Publications; 2009. 24. Slater H, Gibson W, Graven-Nielsen T. Sensory responses to mechanically and chemically induced tendon pain in healthy subjects. Eur J Pain. 2011 Feb;15 (2):146-52. 25. van Wilgen CP, Konopka KH, Keizer D, Zwerver J, Dekker R. Do patients with chronic patellar tendinopathy have an altered somatosensory profile? - A Quantitative Sensory Testing (QST) study. Scand J Med Sci Sports. 2011 Sep 13. 26. Miniaci A, Mascia AT, Salonen DC, Becker EJ. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med. 2002 Jan-Feb;30(1):66-73. 27. Andersson G, Forsgren S, Scott A, Gaida JE, Stjernfeldt JE, Lorentzon R, et al. Tenocyte hypercellularity and vascular proliferation in a rabbit model of tendinopathy: contralateral effects suggest the involvement of central neuronal mechanisms. Br J Sports Med. 2011 Apr;45(5):399-406. 28. Williams IF, McCullagh KG, Goodship AE, Silver IA. Studies on the pathogenesis of equine tendonitis following collagenase injury. Res Vet Sci. 1984 May;36 (3):326-38. 29. Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med. 2003 Jan;13(1):11-5. 30. Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med. 2003 Oct;22(4):703-10. 31. Fernandez-Carnero J, Fernandez-de-las-Penas C, Sterling M, Souvlis T, Arendt-Nielsen L, Vicenzino B. Exploration of the extent of somato-sensory impairment in patients with unilateral lateral epicondylalgia. J Pain. 2009 Nov;10(11):1179-85. 32. Ruiz-Ruiz B, Fernandez-de-Las-Penas C, OrtegaSantiago R, Arendt-Nielsen L, Madeleine P. Topographical pressure and thermal pain sensitivity mapping in patients with unilateral lateral epicondylalgia. J Pain. 2011 Oct;12(10):1040-8. 33. Årøen, A., Helgø, D., Granlund, O. G., Bahr, R. Contralateral tendon rupture risk is increased in individuals with a previous Achilles tendon rupture. Scandinavian journal of medicine & science in sports. 2004; 14(1), 30-33. 34. Cook, J. L., & Purdam, C. R. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine. (2009); 43(6), 409-416. 35. Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., Pearce, A. J., Jaberzadeh, S., Cook, J. The Pain of Tendinopathy: Physiological or Pathophysiological? Sports Medicine. (2013) Sep; 1-15.

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The Intrinsic Spiral
By George Kousaleos
Since 1978, I have looked at and worked with the structural alignment of countless thousands of human bodies. I have also studied with some of the early masters of structural integration and pondered the theories of the great thinkers and creators of this dynamic discipline. Every clinical experience and every lesson led me to the realization that every person’s structural contour has a unique circular pattern that often resembles a clockwise spiral. The “intrinsic spiral” Studying under Bill Williams, Ph.D., founder of the SOMA Institute of Neuromuscular Integration, I learned that some 70% of the population had a similar pattern. This pattern, often called the “typical random body”, is distinguishable by an anterior and inferior placement of the ASIS of the left ilium. Generally there is more lateral rotation of the right leg, providing strong hyperextension of the same knee. This same leg often holds 65% of the weight of the body. There is generally increased elevation of the left shoulder, with a more compressed lateral thorax of the right ribcage. This often is accompanied by a stronger medial rotation of the left shoulder, and a slight rotation, or lateral flexion of the neck and head to the right. This pattern is more obvious in those who are strongly right hand dominant, but can also be seen on more ambidextrous individuals, and even in some who are left hand dominant. The powerful sense of this spiral pattern is how the whole body seems to more effortlessly turn to the right. Even when standing still, it is easy to observe the clockwise rotation of most body regions. Having been taught of the importance of the tensile strength that the collagen molecule provides all fascia, and knowing that it shares the clockwise orientation of its triple helix with the double helix of DNA, I have concluded that the clock-wise spiral is natural, indeed intrinsic, to human structure and function. How many other forces in nature rely on a structural orientation similar to DNA and collagen? I know that trees grow in an ever-expanding circular pattern. I remembered that Einstein believed that the Milky Way constituted a giant, clockwise spiral, and that even some of the long bones in our body grow in a clockwise orientation. And artists from every culture (we’ll excuse
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the ancient Egyptians for now) created sculptures, frescoes, and paintings that continually show the same dominant, spiral pattern in most human forms. So is it the responsibility of the structural bodyworker to seek symmetry and eliminate the spiral pattern, or is it to find the right combination of techniques that brings awareness of balance, power, and energy to this human spring? The CORE techniques are designed to lengthen, open, and balance this spiral pattern. Clients often comment that they feel longer, larger, looser, and lighter. They perceive that they are using less energy for simple movements, creating a state of “effortless effort”. But more importantly they have increased their neurosomatic awareness, and they understand the benefits of balancing their structure. These clients have been empowered to rethink their day-to-day behaviours that
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Intrinsic Spiral
include chronic structural and functional habits. They have gained the ability to find options that serve their neuromuscular and neuro-sensory systems in a more efficient way. The existence of the “intrinsic spiral” is simply a theory that can allow the structural body worker a vision of how overexertion, underuse, repetitive strain, or trauma can force the body into a more rigid compression that lacks the full ease and fluidity of optimal health. For 10 years it has been the goal of CORE Somatic Therapies to provide a foundation of information and clinical strategies that support the integration of structure and function. The “intrinsic spiral” is an important part of this foundational knowledge. George Kousaleos founded the CORE Institute in 1990 after teaching for the SOMA Institute for 10 years. George was the first chair of the National Certification Council and was an officer and trustee of the Massage Therapy Foundation in USA. As General Manager of the 1996 British Olympic Preparation Camp Sports Massage Team and as Co-Director of the 2004 Athens Health Services Sports Massage Team, he has supported the inclusion of massage therapy at the highest levels of international sports. George teaches throughout the world and has given keynote and motivational presentations to national and international organisations. He will visit Australia in SeptemberOctober 2014 and conduct CORE Myofascial Therapy Courses and Certification program.

The Secret of Success One of the proven successful applications of CORE myofascial sports therapy program is working together with Florida State University's football team. The US football team’s success was the implementation of massage therapy for all players. Jake Pfeil, the Associate Director of Sports Medicine and Head Football Athletic Trainer at Florida State University said: “Along with the team's overall success in 2013 fall, we experienced a drastic reduction in lower extremity soft tissue injuries. I think this can be attributed to several changes in our overall training and recovery models, but the introduction of massage therapy for the majority of our team has definitely been a significant factor. “ While the team has previously employed massage therapy to work with injured athletes, the other athletes complained and would like to get a massage as well. However the cost and availability of therapists become

an issue to implement for the whole football team. Th team then reached out to the CORE Institute. New massage therapy graduates from the institute wanted to gain more experience working athletes, and the team needed more massage therapists. The match was made. Jake said: “By building our relationship with the CORE Institute, we were able to offset the common issues of excessive costs and feasibility of having enough therapists for our athletes. Because of the successful results we have experienced so far, we look forward to continuing the program and exploring the possibility of incorporating it into the recovery needs of other Seminole teams as well.” Abridged from Recovered and Ready by Jake Pfeil, published in Training & Conditioning, May/June 2013. http://www.training-conditioning.com/2013/05/19/ recovered_and_ready/index.php

CORE Myofascial Therapy:
Myofascial Spreading & Back Specific Routine
This CORE Myofascial Therapy DVD includes the protocols for the two most-used treatments that are taught in the CORE Myofascial Therapy Certification Program. The video also includes the theories, specific techniques, and client-education strategies of CORE Myofasical Therapy. Available from www.terrarosa.com.au

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CORE Myofascial Therapy
with George Kousaleos
CORE Myofascial Therapy Certification program
Sydney, 26,27,28 September 2014: CORE Myofascial Therapy 1 29,30 Sept- 1 Oct 2014: CORE Myofascial Therapy 2
An advanced, six-day workshop designed to give practicing massage therapists in-depth knowledge and hands-on experience in full-body Myofascial treatment protocols. With this knowledge and skill, you will be able to improve your clients’ structural body alignment and increase their physical performance.
CORE Myofascial Therapy was used as the premier treatment for the British Olympic Team at their 1995 and 1996 Olympic Training Camps held at Florida State University. Techniques and Skills you will learn and be able to apply to your practice immediately:  Myofascial Spreading- the foundation technique for full-body treatment  Back Specific- a comprehensive routine for the deep musculature of the Para spinal, shoulder, and hip regions.  CORE Release- intrinsic techniques for balancing the pelvic structures  Arthrokinetics- arm and leg joint techniques that reduce ligament tension and holding  End Work- a series of techniques that stimulate the parasympathetic response at the close of a session  Neurosomatic Awareness Exercises  How to combine both passive and active movements into your session for greater results  Specific techniques to address and theories of common structural and functional client issues.  Ultimately how to eliminate pain, restore movement and limited function, and get long term results.

CORE Sports and Performance Bodywork
Sydney, 3,4,5 October 2014
This 3-day seminar will examine the four basic styles of performance inherent in all athletic disciplines. Utilizing structural integration and myofascial therapy theories and techniques that are appropriate for each style of performance, participants will focus on developing training and event protocols for endurance, sprint, power, and multi-skilled athletes. Presentations on performance mechanics, somatotypes, and the balancing of the autonomic nervous system will highlight a comprehensive study of advanced therapies for the athletic performer.

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 been a leader in the massage therapy field over his 30-year career. He helped bring sports massage to the 2000 and 2004 Summer Olympic Games, and is a past president of the Massage Therapy Foundation. He is the General Manager of the 1996 British Olympic Preparation Camp Sports Massage Team and as Co-Director of the 2004 Athens Health Services Sports Massage Team he has supported the inclusion of massage therapy at the highest levels of international sports.
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George teaches throughout the world and has given keynote and motivational presentations to national and international organisations. His website is at www.coreinstitute.com

Distal Vs. Proximal
Q&A with Art Riggs

Q

DEAR ART, You and several other teachers demonstrate strokes moving in a direction away from the heart. I was taught to always work toward the heart and don’t feel comfortable working in the opposite direction. Can you please explain your rationale? Is your direction really safe? —WHICH WAY TO GO?

the best of many different philosophies and apply them in varying degrees with each client, as the need arises. Here’s a passage from one of my favourite anatomy teachers, Gil Hedley, that reinforces what I’ve heard from every medical and anatomy expert I’ve checked with regarding the safety of working distally: “From an anatomical perspective, you can do damage in any direction with bad work, and you can do good in any direction with appropriate contact. If you are a machine programmed to touch, like one of those massage chairs, that might be a case where it would be best to set the program in a particular direction, as the power to discriminate is absent. But in a conscious practitioner, working with a generally healthy client, the direction that’s best to work in is the direction that gets results.” Although there are, indeed, many reasons for working in a proximal direction, there are many other benefits when it comes to not limiting yourself with hard and fast rules. It’s really pretty simple: I often get excellent results working distally. Most of the problems that our clients present with are a result of short and tight muscles that cause pain or prevent proper movement. It just doesn’t make sense to bunch these muscles by always pushing them into further shortening. Especially for deep work, it just plain feels better to work in a distal direction. Here are some of the advantages of thoughtful, distal stroke direction:  Since most muscles attach proximally, in order to exert force proximally, working distally lengthens short muscle fibres and fascia for lasting relief from contraction which limits joint function and causes discomfort.  It frees and lengthens nerves that have shortened along with the muscles.  It decompresses joints and releases tight ligaments for better osseous function.
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DEAR WHICH WAY,

Early in my education, I learned that any test question that used the word always was most likely a red light to mark the answer false or to choose another option. Your question illustrates a common theme that arises in this column. I will address the tendency of unquestioning adherence to inflexible rules in a future column, but will say now that we all need to constantly examine our techniques and belief systems in light of new information, or we risk stagnation, boredom, and less effective work. The common knowledge you mention is due to the emphasis early Swedish massage had on moving superficial venous blood and lymph in its normal direction of flow. Although this is indeed a good reason, some teachers imply that working in the other direction is harmful, thereby scaring their students from doing any distal work. Yet, working distally is very beneficial in implementing the goals of other bodywork systems, such as therapeutic/medical massage, structural work for posture or improved joint function, and even in subtle work to help the flow of energy outward from the core. What’s necessary is a clear understanding of your therapeutic goals. An excellent bodyworker will take
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Distal vs. Proximal
 Possibly the most important benefit is that working distally helps train our clients to override protective holding and reprograms movement patterns as they release in the direction of lengthening and relaxation. So, by all means, continue working proximally with clear goals, but rest assured that you can also safely work in the opposite direction to achieve additional benefits. As with all of our work, the key to effective therapy— and the fun of Image 1: Extending the arm above the head while lengthening the triceps away from its origin can creative thinking—is to provide decompression of the shoulder, as well as free abduction. If joint mobility is limited, you can support the arm with a pillow . let the needs of our clients dictate our therapeutic practice.

Art Riggs is the author of Deep Tissue Massage: A Visual Guide to Techniques (North Atlantic Books, 2007), which has been translated into seven languages, and the seven-volume DVD series Deep Tissue Massage and Myofascial Release: A Video Guide to Techniques. Visit his website at ww.deeptissuemassagemanual.com.

Image 2: Both practitioners and clients love this technique because it lengthens the entire leg and decompresses the hip. Very little effort is used to sink deeply into the hamstrings by leaning with your body weight (it also works fine for quadriceps and the iliotibial band). After sinking, all the energy is directed by pushing the right leg in a distal direction, while the left hand applies force downstream at the ankle or lower leg. This affords a great stretch all the way down from the quadratus lumborum to the ankle, while decompressing the hip, knee, and ankle. Terra Rosa e-magazine, No. 13 (December 2013) 29

John Wayne, Marilyn Monroe, and Goldilocks:
Assessing Pelvis Movement in Walking By Til Luchau

Image 1 :Leonardo da Vinci’s sketches of lower limb anatomy illustrate his inquiry into how the pelvis balances on the femur, and schematically illustrate how the soft tissues stabilize this relationship. Here he compares the role of hip abductors in a quadruped and a human, where they play an even greater role in lateral support for the pelvis/femur function.

Stand on one leg. You’ll need to get up from wherever you’re sitting, but give it a try. Once you’re standing on one leg, ask yourself – how did you move from two legs, to one? A complex set of shifts, stabilizations, compensations, and contractions allowed you to stand on just one leg. This movement is familiar to our bodies, even if we are a bit wobbly at first. Most of us do it hundreds or thousands of times per day – every time we take a step. However briefly, walking involves standing on one leg. Let’s focus on weight shift for a moment. Our pelvis and torso are supported by our legs – balanced on our femurs, if you will (Image 1). When we step, we shift our body weight over the supporting leg, balancing on just one femur. In order to do this, we must transfer our center of gravity over the standing leg. Try walking without shifting your weight laterally, and you’ll see how important side-to-side shift is. There are two predominant methods for laterally shifting one’s center of gravity over the standing leg. Each
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pattern corresponds to one of the major centers of the torso’s mass: the shoulder girdle or the pelvic girdle. The Shoulder Shift In the shoulder shift, the shoulder girdle and upper body shift over the standing leg to allow the swinging leg to be lifted. The exaggerated version of this pattern is John Wayne’s stiffhipped gunfighter swagger. (Image 2) In this way of walking, the hips don’t have to shift much, so it is a common adaptation for people who have limited
Image 2: John Wayne’s top -heavy swagger involved laterally shifting his shoulder girdle more than his pelvic girdle when walking. 30

Pelvis Movement

Image 3: Triathlete Sarah Reinertsen creatively adapts to limited hip shift by shifting her shoulder girdle to the supporting side.

ability to control lateral hip shift, including amputees (Image 3) and those with cerebral palsy. The Hip Shift In contrast to upper-body shift, the second method for getting the center of gravity over the standing leg relies on laterally shifting the lower center of gravity, the pelvis, over the standing leg. For the purposes of our conversation, we’ll refer to this lateral translation of the entire pelvis as “hip shift”. The overstated archetype of this pattern is Marilyn Monroe, sashaying down the catwalk. (Image 4)

Image 5: Marilyn Monroe with a copy of Mabel Ellsworth Todd’s “The Thinking Body,” classic study of physiology and the psychology of movement. Somatic therapy pioneers who also cited this book as an influence included Moshe Feldenkrais and Ida Rolf.

Marilyn Monroe’s signature hip sway was apparently something she worked at. Ralph Roberts, Monroe’s bodyguard, chauffeur, and massage therapist, related this story the year of her death: "Back in the days when Marilyn first decided she wanted to be an actress rather than a star, she got a book, The Thinking Body, by Mabel Ellsworth Todd. From it Marilyn got the basic exercise called the pelvic girdle and she developed the walk that made her famous. She always carried a copy of that book with her."(1) Manual therapy teacher Erik Dalton shared a story with me that he heard from the “Rat Pack’s” Peter Lawford: in order to get more of a “Mae West” walk, Marilyn had an inch cut off one heel to make her hip on that side shift even more laterally. Once that hip had loosened up some, she switched the shorter heel to the other side. She continued to swap the short heel from one side to the other, until she’d developed the mobility required for her larger-than-life hip shift. If Monroe had lived longer, this exaggerated pattern may have
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Image 4: Marilyn Monroe’s trademark walk coupled hip shift with contralateral hip drop. In the movie “Gentlemen Prefer Blondes,” Monroe (on the left) was cast opposite Jane Russell (on the right), who demonstrates the complementary pattern of shoulder girdle shift, a pattern which usually involves less hip drop than hip shift does. Terra Rosa e-magazine, No. 13 (December 2013)

Pelvis Movement

Image 6: The hip abductors of gluteus medius and minimus, together with the lateral gluteus maximus, tensor fascia lata, iliotibial tract, and their fascial extensions (not pictured), inhibit lateral hip shift when they resist eccentric lengthening.

come with unintended consequences. Presumably due to their generally wider pelvic structure, women are already prone to genu valgum and other knee issues, as well as piriformis syndrome (six times more frequent in Image 7: If overly active during hip flexion, the lumbar erecwomen than in men)(2). Exaggerated lateral hip move- tors (together with quadratus lumborum, etc.) cause hip hikment could exacerbate these tendencies. ing. If you were to see this pattern after asking your client to Men have their own problems, of course, and at least a few of these may be related to the tight-hipped John Wayne swagger that indicates restricted hip abductors and limited lumbar mobility. Lumbar disk issues are twice as common in men as women(3); inguinal hernias (conceivably related to compression and lack of adaptability in the visceral space) are seven times as likely in men(4); men are also more prone to sacroiliac joint degeneration than women.(5) It appears that an exaggerated pattern of shifting primarily with the shoulders also takes a toll on the body. As mentioned, leg amputees often use shoulder-shift in lieu of hip-shift. According to the gait expert, prosthetic engineer, and MIT professor Hugh Herr, 70% of amputees have hip and back problems. (6) So, some hip-shift with hip flexion is desirable; without it, the pelvis/lumbar complex can’t adapt to the changing demands of walking, balance, and weight-bearing, which can put strain on the lumbars and hip joints.
raise his left knee, he would benefit from work that helped him maintain length in the left side of his lumbar space during hip flexion.

Hip Shift Test In my manual therapy practice, I assess hip shift whenever a client complains of hip, lumbar, sciatic, or sacroiliac pain, and in the context of working with larger gait or balance issues. To assess hip shift, ask your standing client to lift one knee high. (If balance is difficult, have your client face a wall so that he or she can reach forward for balance. If the wall is to the side, he or she will reach sideways, which will affect shift and obscure your results.) When your client lifts the knee, ask yourself: Does the pelvic girdle shift laterally over the standing leg, or does only the shoulder girdle shift, causing the torso to lean? (You’ll likely observe other movements and compensations, such as rotation and tilt of the entire pelvis, but for the purposes of this discussion, we’ll focus primarily on lateral translation of the entire pelvis, or “hip shift”.)
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Image 9: Michelangelo’s David shows both rightside hip and shoulder shift, along with left hip drop, demonstrating eccentric lengthening of the right hip’s abductors, and an ability to allow the sacrum to sidebend left, away from the supporting leg. David’s upper body shift, coupled with hip drop, suggests a supple strength at rest, in contrast to the tentative shyness of upper body shift without hip drop in Image 7 left.

Image 8: Asymmetrical hip-shift and hip-drop patterns in one of Eadweard Muybridge’s nineteenth-century studies of human movement. In the first image (left), note the pronounced rightward shoulder girdle shift, limited rightward pelvic girdle shift, and slight hip-hiking on the left. In the second image (right), notice the model's greater right-side hip-hiking and more pronounced leftward hip shift (visible via the umbilicus/ ankle plumb line). Although some of the apparent asymmetry may be due to the left leg’s external rotation in preparation for turning, these differences suggest restricted right-side hip abductors, along with tighter right-side lumbar soft tissues.

1. 2.

The abductors on the supporting side almost certainly don't release when weight shifts; 2. Possibly, the sacrum could be fixed in sidebending away from the supporting side (see Image 9).

Compare what happens when the left and right knees are lifted. The shoulders will typically shift farther to the side of the more restricted hip abductors; so if there is a marked shoulder girdle shift without hip shift, work the hip abductors and the lateral line on that same side of the body, and then re-test. For example, if you see shoulders that shift more to the right than the hips do (as in Image 8), we’d expect to find tighter abductors on the right, as hip shift involves eccentrically lengthening the same-side abductors. Pain or guarding elsewhere, such as lumbar disk pain, ankle instability, or knee pain, can also cause a tendency towards greater shoulder shift (and thus, diminished hip shift). Leg-length differences can also be a factor in asymmetrical hip shift. As Peter Lawford’s story about Marilyn Monroe’s high heels illustrates, a shorter leg will cause increased hip shift to the same side. Barring these issues, if hip shift is diminished, one or both of these is possible:

To rule out #1 (non-releasing abductors), work with your client in a side-lying position, using gentle pressure into the abductors with your forearm or soft fist. Ask for active participation, first using active hip and knee flexion and extension, and then active hip abduction and adduction. Your goal is to increase the ability of the lateral hip structures to eccentrically lengthen. So, as you ask for movement, use your pressure to encourage release in the gluteus medius, minimus, and lateral gluteus maximus, as well as in the tensor fascia lata, iliotibial tract, and their related fascial extensions. Coach your client to initiate movement slowly and smoothly, allowing the structures being worked to stay as long as possible, even in active movement. Then retest. If there is still a left/right difference in hip shift after releasing the restricted side’s abductors, check for sacral sidebending fixations, per factor #2 above. There are several ways of doing this, ranging from a subtle pelvic lift, to more active sacral nutation assessment and release. Describing these manipulations is beyond our scope here, but Dr. Dalton’s Myoskeletal work, as well as our own Advanced Myofascial Techniques courses, cover these and other approaches for assessing
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and balancing sacral motion. Non-lengthening abductors per #1 will usually be present in any case, whether or not the sacrum is fixed in sidebending. Hip Dropping and Hip Hiking In addition to the hips shifting laterally when a knee is raised, the entire pelvis will often laterally flex or sidebend (tilt in the coronal plane), either dropping on the un-weighted side (as David does in Image 9), or hiking up (as in Image 8, right). If there is excessive hip-drop (“Trendelenburg’s sign”), it can signal weakness or lack of participation by the abductors. If there is excessive hip-hiking on the same side as the lifted knee, it indicates that the lumbar muscles (quadratus lumborum and the lumbar erectors) are probably overly active in hip flexion. Although there are differing models of normal hip motion, most people benefit from learning how to flex the hip without over-recruiting these back muscles. Clients who show hip-hiking will benefit from softtissue work that encourages length in the shortened space between the ribcage and pelvis during same-side hip flexion. hip flexion, without the pronounced trunk leaning associated with shoulder-girdle shift. As our Marilyn Monroe and John Wayne examples show, shoulder and hip-shift patterns have strong gender connotations. Structural differences between men and women play a part: women’s wider pelvises, and men’s wider shoulders, favor their respective shift patterns. An example of how this difference in width affects function: a gorilla has a very narrow pelvis compared to a human, and has even greater side-to-side shoulder-shift when walking upright. Biologically, it could be that a female’s hip sway advertises a pelvic structure wide enough for childbearing; or a male’s shoulder-swagger might be drawing attention to the upper-body strength and prowess that are presumably biologically advantageous in a mate.

In addition to the more objective structural, biomechanical, and technical aspects of these patterns, there is also a subjective aspect – the lived experience of one’s own gait. A person’s walk is an expression of their personality, identity, and their individual style. What would a gender-bending drag queen do without her The psoas’ role as a hip flexor and lumbar side-bender slinky walk? How credible would a bar-bouncer be would suggest that it plays a role in hip hiking when the without his tough-guy swagger? Besides gait, the face is knee is raised. Dr. Ida Rolf, the originator of Rolfing® perhaps the only other place in the body where we, as structural integration, maintained that the psoas allows body therapists, have this much impact on someone’s the lumbar space to maintain its length, and that a com- subjective identity and presentation to the world. The pressed lumbar space indicates the need for greater often-quoted phrase in Rolf Movement® work is, “The psoas involvement. Although somewhat counterintuiway one walks through the room is the way one walks tive from a conventional kinesiological perspective, in- through the world.” When we work with gait, we affect creased client awareness of the psoas in hip flexion does our clients’ very experience and expression of being, seem to correspond to the ability to leave the lumbar from the inside out. space long while raising one knee, perhaps because psoas activation inhibits the antagonistic contraction of Article (c) 2013 by Til Luchau. An earlier version of this the lumbar erectors. article appeared as a chapter in “Dynamic Body” edited by Erik Dalton. Goldilocks’ Mean Til Luchau is a member of the AdHow much pelvic movement is the right amount? We vanced-Trainings.com faculty, which can use the “Three Bears” approach: like Goldilocks, we offers distance learning and indon’t want too much of Papa Bear’s tough -guy hip stiffperson seminars throughout the ness, nor Mama Bear’s exaggerated side-to-side hip world. He is a Certified Advanced movement. The shoulder-shifter needs more pelvic Rolfer. Advanced-Trainings.com will adaptability. The hip-swinger needs the whole-picture travel to Australia in October 2014. stability of integrated shoulder/pelvis coordination: Contact him via info@advancedupper and lower moving together. Both extremes are trainings.com or Advanced-Trainings.com’s Facebook inefficient in terms of kinetic energy recycling: trunk page for more information. rigidity prevents the spiralling and sidebending that allows for kinetic uptake; hip hypermobility doesn’t provide the resilience needed to store gait energy and release it into the next step. We’re looking for the “justright” combination of a moderate amount of hip shift in
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Notes 1. Hyams, Joe. “Marilyn was open, happy like flower.” Chronicle Telegram, Elyria, Ohio, September 22, 1962 http://www.ralphlroberts.com/articles/ ChronicleTelegramtext.htm, accessed Nov 2013. 2. Carol L. Otis, M.D., http://www.sportsdoctor.com/ articles/sciatica3.html, accessed March 2010. 3. “Males are affected by lumbar disk problems approximately twice as often as females, except in the adolescent group where there is a small female preponderance, probably due to earlier skeletal maturity.” – “Interactive Spine” version 1.66, Primal Pictures Ltd. 2009. 4. Professional Guide to Diseases (Eighth Edition), 2005. 5. Ribeirol et al., “Sacroiliac dysfunction”, Acta Ortopédica Brasileira, vol. 11 no. 2 São Paulo April/June 2003. 6. Hugh Herr, quoted by Paul Hochman in “Super Human,” Fast Company magazine, Feb. 2010 142:83. 7. Rolf, Ida P. Rolfing: The Integration of Human Structures, NY: Harper & Row, 1977, p. 112.
Til Luchau’s technique videos on the Pelvis is available at www.terrarosa.com.au. Free clips available at AdvancedTrainings.com’s YouTube channel: http:// www.youtube.com/user/AdvancedTrainings

Image credits:
Images 1, 2, and 4 are in the public domain. Image 3: Photo of Sarah Reinertsen used by permission. Sarah is the author of the book, In a Single Bound; her website is www.alwaystri.com Image 5: Copyright Primal Pictures Ltd. Used by permission. Image 6: Photo of Marilyn Monroe on the set of “Clash By Night” in 1952 by Ernest Bachrach. Image 7: Sculpture and photo by artists Helmut Hillenkamp and Christy Hengst, used by permission. Their website is www.iron-to-live-with.com Image 8: Source images from Eadweard Muybridge, “Woman walking down stairs,” 1887. Images are in the public domain. Image 9: by Rico Heil, used by permission under GNU Free Documentation License.

Advanced Myofascial Techniques
DVDs and Manuals available from www.terrarosa.com.au

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Erection during massage
An article published in Massage and Bodywork August 2013 issue discussed erection during therapeutic massage: “The topic of erections is not only complicated, but also rarely addressed. During therapeutic massage, erections can be annoying, embarrassing, and sometimes ridiculous.” This topic is indeed taboo, although it is discussed briefly in schools; it is not an easy and simple problem to deal with. Here we asked the opinions from some therapists and teachers. Is it common? According to Carrie Rowell, a Lomi Lomi massage teacher, it is not uncommon for an erection to occur during a massage and most of the time it is not a sexual arousal response but a relaxation response. “I generally tell students and clients not to worry about it unless someone becomes aggressive or starts asking for additional services". According to Shari Auth, founder of the Auth Method, she never experienced it after 19 years of practice. However she often met female massage therapists who complain about their male clients getting erections or hitting on them. Although there may be a scientific discussion about erections being part of a relaxation response it’s important to remember that erections can be personal and that a client who is consciously or unconsciously looking for a sexual massage will prey on therapists with boundary issues. How and why does it happen? Louis Schultz in his book “Out in the Open” wrote: “Erections were a sign of relaxation of the man’s body and had nothing to do with the therapists’ persona. He considered 2 types of erections: one is resulting from erotic stimulation and the other is associated with relaxation and sensual feelings about himself. Men can have several erections during sleep that have nothing to do with the need to urinate (the pressure of a full bladTerra Rosa e-magazine, No. 13 (December 2013)

der can also cause an erection). Some men are so insensitive to their bodily sensations that they were not aware of having an erection when relaxed.” Advanced Rolfer®, Art Riggs agrees that erections may simply occur during relaxation in massage and have very little connection with sexual attraction between a client and therapist. “I’d hate to think that some of the embarrassing moments in 8th grade that most young lads experience sitting in class would imply some unconscious sexual attraction to algebra or grammar.” But he also expresses discomfort with the “either/or” explanation of deep relaxation or chemical reactions in the body to separate sexual and non-sexual as an example of classic “mind/body” dichotomies that simplify the subject. “Most of us accept the complex feelings such as sadness or tears, release of anxiety or anger, laughter and other emotions are a natural reaction that may occur during bodywork. It seems to me that sexual energy is a natural part of life, and the nurture and close bond between a therapist and client is a continuum and can’t be simply repressed or classified to exclude this energy because we are uncomfortable that it doesn’t fit into our definitions of professionalism. This is where guilt enters into the equation. The denial of
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Erection
The Anatomy of Erection
The usual explanation on erection is that the arteries dilate causing the corpora cavernosa of the penis to be filled with blood . However there is no biomechanical explanation of how why it happen, and why it doesn’t bend. So Diane Kelly undertook a PhD dissertation to find out the anatomical structure of mammalian penis. Diane hypothesised that mammalian penis was much like the hydrostatic skeletons of earth worms. A hydrostatic skeleton has two key elements; pressurized fluids and wall in tension. Penis has this hallmark; its central portion is made of spongy tissue which fills with blood, and it is surrounded by a wall of tissue rich in collagen. The collagenous wall in hydroskeleton is usually arranged in a cross helical structure, which enable reinforcement and wiggle movement such as bending, compression and extension, but this is not observed in an erect penis. So Kelly investigated the wall tissues of erect penis. She found that mammals have evolved an array of collagen fibres that are arranged perpendicular to each other. In other words, the collagen fibre is arranged in multiple layers that alternate between fibres that are horizontal (zero degree to the long axis of the penis) and fibres that are vertical (at 90 degree to the long axis). The collagen fibers are highly crimped in the flaccid penis, but straighten upon erection. This arrangement allows the structure to become larger when erect, and harder to bend. Watch Dr. Diane Kelly ‘s TED talk : What we didn't know about penis anatomy

reality can actually create a tension that increases sexual energy rather than letting it naturally dissipate if we don’t focus on it. Of course the absolute key is the integrity and safety to know that neither person will act improperly.” Of course, it will be great to have a scientific explanation. But the science behind erection itself is quite complex. One of the many possible links is the so-called Love Hormone, Oxytocin. It has been found that massage increases oxytocins in the body (and decreases adrenocorticotropin hormone ACTH, nitric oxide NO, and beta-endorphin BE) (Morhenn et al., 2012). Oxytocin is a hormone known to facilitate social bonding, and touch can release this hormone. Neuroeconomist Paul Zak believes that oxytocin (which he called “the moral molecule”) is responsible for trust, empathy, and other feelings that help build a stable society (Watch his TED talk). However according to behavioural scientist Roy Levin, Oxytocin, ADH (antidiuretic hormone), and prolactin are also released from the posterior pituitary during human sexual arousal. K.-E. Andersson further described it more technically at Pharmacological Reviews:

“Erection is basically a spinal reflex that can be initiated by recruitment of penile afferents, both autonomic and somatic, and supraspinal influences from visual, olfactory, and imaginary stimuli. Several central transmitters are involved in the erectile control. Dopamine, acetylcholine, nitric oxide (NO), and peptides, such as oxytocin and adrenocorticotropin/α-melanocytestimulating hormone, have a facilitatory role, whereas serotonin may be either facilitatory or inhibitory, and enkephalins are inhibitory. The balance between contractant and relaxant factors controls the degree of contraction of the smooth muscle of the corpora cavernosa (CC) and determines the functional state of the penis.” What shall I do? Louis Schultz wrote that when a client get aroused during a Rolfing session and is aware of it, he may ask its significance and Louis usually responded “oh, yes” and asked the client to enjoy the feelings. The erections are usually not lasting. “I also say that I don’t take their condition personally, which puts humour into the situation.” Carrie Rowell said “I have directed clients to use the energy for healing and repairing the body by con37

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Erection
sciously by circulating the energy up the spine and down the front of the body, then expanding out through the limbs. When the focus is taken off the genitals and spread through the body it usually dissipates quickly and people feel safe and honoured rather than dirty and ashamed. When you attach shame and guilt to sexuality it turns a natural reaction into a negative one and does not serve the client or therapist. However if someone arrives with a sexual intention and uses the massage as an excuse to try to get off that is another story. I generally vet people ahead of a session and tell therapists it is their right to terminate a session at anytime if they feel uncomfortable or threatened.” Til Luchau, the Director of Advanced-Trainings.com, also warned the potential vulnerability or shame men when erection is unwanted. On the other side, many women therapists feel vulnerable as well, unwanted sexuality was the single-most commonly reported concern in a poll he conducted a couple years ago. What’s your experience? A massage therapist who blogs at The Real Rub—Life as a Massage Therapist wrote, “I get asked about erections regularly by both men and women. Fear of getting an erection [during massage] is a powerful deterrent for men. Some aren’t comfortable getting massage from a man because they’re afraid ‘it will move,’ and some simply won’t get massages at all for the same reason.” Toni, a massage therapist from Barcaldine QLD said “When it happened, the only thing I can try to do is make my client at ease. I don’t point it out, if they happen to comment or need to adjust their friend, you let them. They are probably more embarrassed them you are. I just reassure them it’s human nature, we all like or want human touch at some point. It's not only men who get that reaction, women can experience it as well. It's just that women can hide their reaction a little better. This is of course on the view that it’s not sexual. When I have a gut feeling that something isn’t right, I will either stop the massage or make it known that I am a professional Massage Therapist and nothing more will come of it. They have the choice to continue or walk out. Most will continue.” Shari Auth, Founder of the Auth Method said “When I started doing massage at age 23, I was concerned about my work being misconstrued by male consumers. I went to great lengths to ensure that my male clients take me and massage therapy seriously. I dressed and spoke professionally using correct anatomical terminology and favoured massage techniques that were theraTerra Rosa e-magazine, No. 13 (December 2013) 38

peutic and deep, over light and sensual. If I felt the client had questionable intentions any attempts to discuss my personal life were side-stepped, usually by changing the subject or reminding them that they are here to relax and encouraging them to focus on their breathing. One time a man requested that I massage his inner thigh and I did, with deep pressure, let’s just say I don’t think it was what he was looking for. In the end these kinds of clients don’t return if they don’t get what they want and this is a good thing. Or perhaps they discovered something better than what they originally were looking for, i.e. the therapeutic benefits of massage. Respect yourself, be clear on what kind of practice you want to create, keep your boundaries and most importantly know that your therapeutic work has great value.”

References Louis Schultz. Out in the Open: The Complete Male Pelvis. North Atlantic Books. Sarah A. Ryan-Knox. Let's Talk About ... Um ... Erections. How to Respond Appropriately and Professionally. Massage and Bodywork, July/August 2013. R. Levin, Is Prolactin the Biological ‘Off Switch’ for Human Sexual Arousal? Sexual & Relationship Therapy 18, no. 2 (2003): 237. K.-E. Andersson. Mechanisms of Penile Erection and Basis for Pharmacological Treatment of Erectile Dysfunction. Pharmacological Reviews December 2011 vol. 63 no. 4, 811-859. http:// pharmrev.aspetjournals.org/ content/63/4/811.full#title98

Acupressure and Myofascial Therapy: A Unified Approach
By John Kirkwood, BA, DRM
Qi as the Ground of Healing Over the last three decades, myofascial work has become widespread in the field of bodywork. This has happened because it has proved to be a very effective approach to healing the body. But what is the actual healing mechanism underlying this work? In this article I propose that even though myofascial work appears to be working simply with the physical tissue structure, it is actually working with the energetic field of the body. I further propose that this energy field is more fundamental than physical structure, and is where the deepest healing occurs. I suggest that it is actually the field of Qi (or energy) that is fundamentally affected by myofascial therapies. What has led me to this place is my understanding of the profound interrelationships between the fascial network and the meridian and acupuncture point system, which maps the energy field of the body. The practice of acupuncture is not accessible to most bodyworkers. However, acupressure, which uses the hands, in particular finger pressure on the acupuncture points, provides a vehicle which bridges the structural and the energetic systems. Acupressure provides an interface between soft tissue modalities and energetic medicine. Thus the knowledge of acupressure makes It possible to significantly expand the healing capacity of myofascial work. It allows us to intelligently track and work with the flows of energy as they are affected by tissue manipulation, and to greatly facilitate, understand and direct the healing flow of Qi.
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A number of recent landmark publications and research studies, as well as the writings of an ancient Chinese physician, have noted interrelationships between tissue manipulation and Qi. An overview of these publications follows. After that I present a case study which shows not just that the two systems are interrelated, but that myofascial work creates profound healing shifts in the client’s energetic field. Trigger points and acu-points Mark Seem’s 1993 work provided an exploration of this interface between the meridians of acupuncture and bodywork. He boldly asserted, “Acupuncture from a meridian perspective is primarily a myofascial, musculoskeletal therapy.”(1). While it also produces improvements in internal systems, it does this by treating the body surface of the myofascial body fabric. Much of Seem’s work looked at the close relationship between the acupuncture meridian system and the trigger point system developed by Dr. Janet Travell in the 1940’s. She defined a trigger point as “a highly irritable localized spot of exquisite tenderness in a nodule in a palpable taut band of muscle tissue.” (2) Travell had no knowledge of Chinese medicine, yet her trigger point map corresponds closely to the acupuncture points. How can we explain this close correspondence? It appears that Travell had rediscovered an ancient system first espoused by Sun Simiao in the 7th century. That venerable Chinese physician discovered that tender points on the body, what he called a-shi points, were accumulations of congested, stagnant Qi. While modern maps of the meridians can provide precise anatomical locations of acupuncture points, these
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Acupressure
locations are merely a guide to the areas where the tender a-shi points may be found. When the communist government in China resurrected the lost art of acupuncture in the 1950’s, they created a system that could be strictly codified and taught in colleges and which moreover had a western medical slant. Point location became a theoretical exercise and the concept of the a-shi points was overlooked. However, this method of palpating for tender points remains alive and well in Japan where acupuncturists are far more willing to use their palpation skills to find points. Mark Seem wanted to restore this myofascial perspective to acupuncture. “To me, unblocking the qi through acupuncture is identical to myofascial release … Classical acupuncture and modern myofascial perspectives have much to offer each other.” (3) Myofascial chains and trains The concept of trigger points was taken a step further by BJ Headley who, in treating myofascial pain, identified strings of related trigger points which form myofascial chains (4). The work with patients with low back pain traced myofascial chains down the back and legs in a pattern that bears a remarkable similarity to the pathways of the Bladder and Gall Bladder meridians. The ground breaking work of Thomas Myers’ Anatomy Trains took this concept of myofascial chains to another level. He identified 9 of these myofascial networks which he called myofascial meridians. “Muscles operate across functionally integrated body-wide continuities within the fascial webbing. These sheets and lines follow the warp and weft of the body’s connective tissue fabric, forming traceable “meridians” of myofascia.”(5) Myers took time to explain that the myofascial meridians are not acupuncture meridians. Yet to those with a knowledge of acupuncture meridians, the similarity is immediately obvious. Others have taken the trouble to investigate the correspondence. Peter Dorcher’s study of Myers’ nine myofascial meridians revealed that, “In 8 of 9 comparisons, there was substantial overlap in the distributions of the anatomically derived myofascial meridians with those of the acupuncture Principal Meridian distributions.”(6) In addition the ninth could be described as a combination of two acupuncture meridians. Dorsher concluded that, “The marked degree of correspondence noted in this qualitative study between the distributions of the anatomically derived myofascial
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meridians to those of acupuncture Principal Meridians is unlikely to be coincidental.” More generally, scientists and practitioners alike have noted the close correspondence between the meridians and the fascial network. John Barnes, developer of Myofascial Release Therapy asserts that, “The acupuncture meridians lie within the fascial system. Recent research has shown that each acupuncture point is a fascial structure.”(7) One such piece of research was that by Langevin and Yandow which mapped acupuncture points in serial gross anatomical sections through the human arm. “We found an 80% correspondence between the sites of acupuncture points and the location of intermuscular or intramuscular connective tissue planes in postmortem tissue sections.” (8) To return to Dorsher, he believes that sufferers of myofascial pain can benefit from either acupuncture or myofascial techniques. “I think it is fair to say that the myofascial pain tradition represents an independent rediscovery of the healing principles of traditional Chinese medicine.” (9) Under the Bonnet While these studies undoubtedly point to a correspondence between myofascial structures and meridians, I believe that it is the system of Qi flow that underpins all physical structures including the fascia and organs. With a knowledge of the acupuncture meridians we can work directly with the underlying Qi, thereby not simply achieving myofascial pain relief, but affecting qualitative changes in our clients at the levels of organs, sys40

Acupressure
tems, psyche and emotions. Let me give an example of a recent case. My client presented with neck and jaw tightness, a feeling of being stuck in her head, worrying excessively, feeling tight and sore in the gut and feeling out of touch with her legs and feet. I used standard myofascial techniques in her jaw, neck and upper chest. The Stomach meridian flows through all these areas. The myofascial work not only softened the tissue, but released blocked Qi in the upper part of the Stomach meridian, allowing a free flow of Qi through the lower part of the meridian, that is the abdomen, legs and feet. As these changes happened, I supported and enhanced them by holding some Stomach meridian points on her legs. The client noticed healing that went far beyond the immediate effects of the myofascial work. She felt more balance between the upper and lower body, her stomach relaxed and there was a sense of ease in the abdomen. Such were the physical changes. But in addition there were significant emotional and energetic effects. There was a qualitative shift in how she experienced herself internally. She felt grounded and centered mentally, emotionally became much less worried, and overall had a feeling of equanimity. Her pulses also changed, reflecting a balancing of the Stomach meridian, as well as other meridians. These changes were all in alignment with harmonizing of the Stomach meridian and the field of Qi. All these healings came about as a result of releasing the fascia, but more fundamentally from a balancing of the Qi flow in the body. Conclusion As bodyworkers, we are uniquely placed to bring these two systems, one ancient, the other modern, into an integrated whole. Working with the fascia of an area of the body releases the congested Qi in the acupuncture points in that area, and also in distant parts of the relevant meridian or meridians. Understanding both systems allows us to intelligently facilitate shifts in both the fascial network and the energy body, thus healing not just the tissues, but also the organs, the psyche and the emotions. John Kirkwood, BA, DRM, has been practicing and teaching the healing arts for almost 30 years. He trained extensively in California in Five Element Acupressure, Jin Shin Do, Deep Tissue Work & Myofascial Release, and had a successful private practice in the San Francisco area for over 18 years. He now teaches around Australia and practises in the Adelaide Hills. He is deeply committed to facilitating and teaching healing at all levels – physical, energetic, emotional and spiritual. Email John at: john@acupuressure.com.au, or visit his website www.acupressure.com.au Read 6 Questions to John on page 49.

NOTES 1. 2. 3. 4. M Seem, A new American acupuncture, Blue Poppy 1993, p. 6. C Davies, The trigger point therapy workbook 2nd edition, New Harbinger 2004, p. 19. Seem p. 17. BJ Headley, “EMG and myofascial pain”, Clinical Management, Vol 10, No. 4, July/August 1990, p. 43-46. TW Myers, Anatomy trains, Churchill Livingstone 2001, p. 1. PT Dorsher, Myofascial meridians as anatomical evidence of acupuncture channels”, Medical Acupuncture, Vol 21, No. 2, 2009, p. 1. JF Barnes, “Acupuncture and myofascial release”, Massage, January 21, 2008, viewed 20 November 2013 <http://www.massagemag.com> HM Langevin & JA Yandow, “Relationship of acupuncture points and meridians to connective tissue planes”, The Anatomical Record, 2002, p. 257. “Acupuncture and myofascial trigger therapy treat the same pain areas”, Science Daily, 14 May, 2008, viewed 20 November 2013 <http:// www.sciencedaily.com>

5. 6.

7.

8.

9.

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Become the Healer you’ve dreamed you could be

Acupressure
For Massage Therapists
with John Kirkwood, DRM Sydney, April 30, May 1,3&4, 2014

Acupressure is a very effective method of
healing. Like acupuncture, acupressure works with the blocked energies that have led to illness, releasing and harmonising them to allow health and wellness. Acupressure can be used by itself to great effect, and it is also extremely versatile. You can significantly enhance your ability to heal by combining it with other bodywork modalities such as remedial massage, sports massage and myofascial release.

The Teacher
John Kirkwood, DRM, has been practicing and teaching the healing arts for almost 30 years. He trained extensively in California in Five Element Acupressure, Jin Shin Do, Deep Tissue Work & Myofascial Release, and had a successful private practice in the San Francisco area for over 18 years. He now teaches around Australia and practises in the Adelaide Hills. He is deeply committed to facilitating and teaching healing at all levels – physical, energetic, emotional and spiritual. “I enjoyed John’s informative relaxed style of teaching immensely and have already incorporated acupressure into my Myofascial and Craniosacral treatments with ease and have received good feed back from clients, and also good results. Acupressure fits well with these two modalities which I have been practising for 20 years. As a TCM practitioner, Integrated Acupressure has added another dimension to diagnosis and treatments. Thank you John.” – Anne Jordan “I really enjoyed John’s acupressure courses. He creates a great atmosphere and supportive environment to learn. He is an expert in his field, approachable and knowledgeable. If you’re interested in this area I would definitely recommend doing John’s Acupressure courses.” – Ann Stevens

Benefits
spective

 Solve health problems in ways not available with  other massage therapies  Assess you clients from a whole body energy per Understand patterns of imbalance not obvious by  other methods  Develop you sensitivity to bio-energy in both yourself  Easily incorporate acupressure into your current  style of work  Practice a gentle technique that is easy on your body

and your clients

To Register go to: http://www.craniosacraltherapy.com.au and select “Specialty Courses” Or call the CSTA: 0438 584 123 or 1800 101 105 (free call) For Further Info: john@acupressure.com.au or call John 041 779 159
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What Dooms Working Relationship?
By Don Quinn
All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.— Arthur Schopenhauer Practitioner working agreements offer tremendous opportunity. For the practitioner-turned-practice broker/ employer - expansion of hours and services, a scaling of delivery-of-care costs, and the opportunity to profit from established reputation and location. For the contractor/employee practitioner – overflow clients/ patients, reputation and location as well as operating systems and marketing campaigns established, and no requirement for large capital expenditures up front to launch a business. So with all the potential, why do so many go sour? Unsustainable Models and Poor Accountancy. The time- and labour-intensive nature of bodywork in particular limits a practitioner’s ability to provide care beyond part-time hours yet they often require a fulltime wage. Practitioners and massage business owners blame each other for insufficient income from their respective labours, yet the real culprit is the applied business model. Practitioners should consider securing secondary sources of income or employing sustainable business models to increase capacity to provide care and therefore decreasing wear and tear on their own bodies. Isolation. Self-employed, sole providers work alone, limited in opportunity to engage and learn from others in the field…hence they are constantly reinventing the wheel. Practitioners may be employed in a myriad of business models – spa, rehab, human performance / workplace wellness or CAM – all with different compensation models and working arrangements. Decisions are frequently made with limited information or
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consultation with peers. Poor positioning or Leverage within Mainstream Health Care. Without the researched evidence-based practices and degree-level education enjoyed by gatekeeper health care professionals, the massage profession does not have the same credibility and funding. Our access to funding is limited at best - precluded at worst. Insufficient Collaboration. Without collaboration between providers, educational institutions, professional associations and regulatory bodies, practitioners appear incompetent and disorganized in the marketplace and are easily exploited by the profiteers of massage popularity. In large part, a practitioner's working opportunities are cultivated by the economic environment created by collaboration between these various agencies. In feeble interstitial fluid, even the most vigorous cells will die! Build Your Working Relationship on Solid Ground Historically agreements could be sealed with a handshake…before the increasingly litigious nature of society eroded our inherent trust in such agreements. Un43

Working Relationship
Contractor practitioners want an opportunity to grow, and perhaps even ownership. If you’re a practitionerturned-practice broker, consider premising the agreement on a trial basis with overt rewards for productivity and adding value to the business. The hard-working practitioners will rise to the next level, so offer them bonuses, incentives and health benefits to retain them. Percentage agreements over long-term actually force out your best candidates while retaining the less productive ones…a very dumb business model! The best of your candidates may rise to the next level – partnership or succession. Make it hard for your best people to leave, and easy for the less desirable ones to go!
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/massage_therapist_practice.htm

derstandably, practitioners may find creating agreements, with the small print and legalese, complicated and contentious. The practitioner may settle for an agreement that is less favourable for the sake of saving the relationship or the opportunity. But there are ways to assess the quality of an agreement without giving away the farm. What constitutes a good working agreement? Respondents commonly reference its financial terms and provisions - percentages, base rates and caps, and who is responsible for providing equipment, linen service, lubricants, advertising, etc. However without putting value on the relationship – what each party brings to the table – these figures cannot be representative of a fair agreement. The business owner must calculate actual operating costs of bringing on an associate (including profit margin) and valuating location and reputation in their equation of the ideal rent. Contracting practitioners need to sell their assets – experience, established practice, work ethic – to move the terms in their favour.

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Research Highlights
Compiled By Jeff Tan
Human touch extends down to the nano-level While we all know that massage therapist's hand and finger have developed a high sensitivity, it needs scientists to prove it. The recent finding is that the human finger is so sensitive it can detect bumps as small as a few nanometres in height, according to a new study. (Note: 1 nanometer is a millionth of a milimeter). The finding, publish in the journal Scientific Reports, Lead researcher Professor Mark Rutland says until recently touch was a relatively unknown sense. (Really?? That's why scientists never learn about palpation). Previous studies have shown that there are three main 'dimensions' used to describe touch - rough-smooth, hard-soft and sticky-slippery. Rutland's team, which included material scientists and psychologists, developed a test to measure how sensitive the human finger is at differentiating between rough and smooth surfaces. They constructed a set of 16 polymer surfaces that had a series of parallel ridges across its surface. The distance between each peak known as wavelength - ranged from 300 nanometres up to 90 micrometres, and the height of the peaks were from 7 nanometres up to 4.5 micrometres. A blank surface with no ridges was also used. Twenty volunteers were then blindfolded and presented with two surfaces at a time and asked to run their index finger over each one. They then rated how similar, or dissimilar, each pair was. To Rutland's surprise, the results showed that the group was able to sense wrinkles at the nano-scale. "The participants could distinguish a surface which had a 13-nanometre average amplitude from a smooth surface," So at least it is now confirmed that our senses are just an illusion. Achilles pain & poor gluteus muscles control A link might exist between pain in and around the Achilles tendon and how the gluteus muscles fire when you run, suggests a study that was published in Medicine & Science in Sports & Exercise. Australian researchers gathered two groups of male runners who were similar except that one group had been free of Achilles problems for at least the last year, while the runners in the other group had Achilles tendon pain when they ran and did other activities. While the men did short runs at about 6:40 per mile pace, the researchers measured the runners' neuromuscular control of the glutes--that is, when the muscles were activated, and for how long. In the men with Achilles pain, glute activation in relation to heel strike occurred later than in the pain-free men, and glute activation lasted for a shorter time. The researchers note that it's unclear from their study whether the runners' Achilles pain caused a change in their glute muscle activation, or vice versa. Still, they write, retraining glute muscles, including by strengthening, should be considered for runners with Achilles injuries. Joe Muscolino commented “let's look at the biomechanics: The glutes create a force of lateral rotation of the thigh at the hip joint; this prevents the thigh from excessively medially rotating, which will occur if the foot overpronates (overpronation leads to medial rotation of the talus, which leads to medial rotation of the tibia because the ankle joint does not allow rotation, which leads to medial rotation of the femur because the knee joint does not allow rotation when it is extended). So, if the glutes don't fire, they cannot prevent overpronation of the foot. Overpronation will place a stress on the Achilles tendon. “

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Research Highlights
Fibromyalgia Mystery Solved? Researchers have found the main source of pain in Fibromyalgia patients, and contrary to what many believe, it does not stem from the brain. The findings mark the end of a decades-old mystery about the disease, which many doctors believed was conjured in patients’ imaginations. Up until recently, many physicians thought that the disease was “imaginary” or psychological, but scientists have now revealed that the main source of pain stems from a most unlikely placeexcess blood vessels in the hand. To solve the Fibromyalgia mystery, researchers zeroed in on the skin from the hand of one patient who had a lack of the sensory nerve fibers, causing a reduced reaction to pain. They then took skin samples from the hands of Fibromyalgia patients and were surprised to find an extremely excessive amount of a particular type of nerve fiber called arteriole-venule (AV) shunts. Up until this point scientists had thought that these fibres were only responsible for regulating blood flow, and did not play any role in pain sensation, but now they’ve discovered that there is a direct link between these nerves and the widespread body pain that Fibromyalgia sufferers feel. The breakthrough also could solve the lingering question of why many sufferers have extremely painful hands as well as other “tender points” throughout the body, and why cold weather seems to aggravate the symptoms. In addition to feeling widespread deep tissue pain, many Fibromyalgia patients also suffer from debilitating fatigue. Neuroscientist Dr. Frank L. Rice explained: “We previously thought that these nerve endings were only involved in regulating blood flow at a subconscious level, yet here we had evidences that the blood vessel endings could also contribute to our conscious sense of touch… and also pain,” Rice said. “This mismanaged blood flow could be the source of muscular pain and achiness, and the sense of fatigue which are thought to be due to a build-up of lactic acid and low levels of inflammation fibromyalgia patients. This, in turn, could contribute to the hyperactivity in the brain.” Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and moTerra Rosa e-magazine, No. 13 (December 2013)

bilisation are considered for its treatment. A review was conducted to assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis. The researchers searched for relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the shortterm effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and mid-term effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found. Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis. Br J Sports Med. 2013 May 24. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Treatment effects of massage therapy in depressed people A systematic review was done to investigate the treatment effects of massage therapy in depressed people by incorporating data from recent studies. A meta-analysis of randomized controlled trials (RCTs) of massage therapy in depressed people was conducted using published studies. The authors finally included 17 studies containing 786 persons from 246 retrieved references. Trials with other intervention, combined therapy, and massage on infants or pregnant women were excluded.
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Research Highlights
The data showed that all trials showed positive effect of massage therapy on depressed people. Seventeen RCTs were of moderate quality, with a mean quality score of 6.4 (SD = 0.85). The pooled data indicated significant effectiveness in the treatment group compared with the control group. The authors concluded that massage therapy is significantly associated with alleviated depressive symptoms. However, standardized protocols of massage therapy, various depression rating scales, and target populations in further studies are suggested. Hou WH, Chiang PT, Hsu TY, Chiu SY, Yen YC The Journal of Clinical Psychiatry [2010, 71(7):894-901] The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. Massage may often be perceived as a safe therapeutic modality without any significant risks or side effects. However, despite its popularity, there continues to be ongoing debate on the effectiveness of massage in treating nonspecific low back pain. With a rapidly evolving research evidence base and access to innovative means of synthesizing evidence, it is time to reinvestigate this issue. evidence, albeit small, that supports the effectiveness of massage therapy for the treatment of non-specific low back pain in the short term. Due to common methodological flaws in the primary research, which informed the systematic reviews, recommendations arising from this evidence base should be interpreted with caution. Kumar, S., Beaton, K., & Hughes, T. (2013). The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. International journal of general medicine, 6, 733. The evolution of throwing Humans are the only species that are able to throw objects incredibly fast and with great accuracy. Darwin noted that the unique throwing abilities of humans, which were made possible when bipedalism emancipated the arms, enabled foragers to hunt effectively using projectiles. Researchers from George Washington University and Harvard University, led by Neil Roach investigated when, how and why humans evolved the ability to generate high-speed throws. Their study was published in the June 2013 edition of Nature.

Using experimental studies of humans throwing projecResearchers from University of South Australia, with a tiles the authors showed that our throwing capabilities funding provided by AAMT, conducted a systematic, largely result from several derived anatomical features step-by-step approach, underpinned by best practice in that enable the storing and releasing energy in the tenreviewing the literature. A systematic search was condons and ligaments crossing the shoulder. This energy is ducted in the several databases, investigating systematic used to catapult the arm forward, creating the fastest reviews and meta-analyses from January 2000 to Demotion the human body can produce, and resulting in cember 2012, and restricted to English-language docu- very rapid throws. ments. Methodological quality of included reviews was undertaken using the Centre for Evidence Based Medi- The authors showed that this ability to store energy in the shoulder is made possible by three critical changes cine critical appraisal tool. in our upper bodies that occurred during human evoluNine systematic reviews were found. The methodologi- tion: the expansion of the waist, a lower positioning of cal quality of the systematic reviews varied (from poor the shoulders on the torso, and the twisting of the huto excellent) although, overall, the primary research in- merus. All of these key evolutionary changes first appear forming these systematic reviews was generally consid- together approximately 2 million years ago in the speered to be weak quality. The findings indicate that mas- cies Homo erectus. sage may be an effective treatment option when comRoach, N. T., Venkadesan, M., Rainbow, M. J., & Lieberpared to placebo and some active treatment options (such as relaxation), especially in the short term. There man, D. E. (2013). Elastic energy storage in the shoulder and the evolution of high-speed throwing in is conflicting and contradictory findings for the effecHomo. Nature, 498(7455), 483-486. tiveness of massage therapy for the treatment of nonspecific low back pain when compared against other From: http://cashp.gwu.edu/ntroach/the-evolution-ofmanual therapies (such as mobilization), standard throwing/ medical care, and acupuncture. The authors concluded that there is an emerging body of
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New DVD Collection
Motion is Lotion
Each day our bodies “dry up” a bit, get a little shorter and hurt more. But motion is lotion, and nothing brings back the ‘juice’ like good bodywork and corrective exercise. Join Erik Dalton and his special guest Paul Kelly, as they bring on the “lotion" to restore ‘motion’ to stuck fascial layers, adhesive joint capsules, and injured ligaments. Your clients will love this work!

Fascia and Sports Medicine
Fascia & Sports Medicine is a 5 DVD set devoted to these two “fascianating” topics and how they influence and interact with each other. Featuring an array of 23 sports medicine, fascial, orthopaedic, and bio-mechanical experts! Fascia & Sports Medicine features 10 hours of video lectures from the Connect 2013 Conference on Connective Tissue and Sports Medicine.

Buteyko Clinic DVD Set
Buteyko Method is a breathing training program which may provide significant improvement of symptoms for many people with asthma, sleep disordered breathing and other breathing-related conditions. This DVD set allows you to view and apply the complete instruction of the Buteyko Method . Lifestyle factors including diet, sleeping and physical exercise are also addressed. The DVD is accompanied by a detailed twenty minute CD and 130 page book.

Psoas Major: A Guide for Manual & Movement Therapists
"Perhaps no muscles are more misunderstood and have more dysfunction attributed to them than the psoas muscles." Psoas Major is one of the most important muscles in the body. Dr. Joe Muscolino will guide you to the anatomy, palpation, assessment, soft tissue manipulation, Self care stretches for clients, Corrective Rest Position, and yoga asanas .

Fascia Academy II
Fascia Academy II is a 4 DVD set containing lectures from 10 international anatomy, fascia, and bio-mechanical experts! The presentations are from the Fascia Summer School at Ulm University, Germany in September 2012. The latest research shows the anatomy and mechanical properties of fascia, the secret life of water, back pain generation of lumbarfascia, fascial contributions to the lumbopelvic control, and more. Speakers include Robert Schleip, Leon Chaitow, Paul Hodges, Jean-Claude Guimberteau, and more.
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6 Questions to John Kirkwood
1. When and how did you decide to become a bodyworker? In 1985 I was living in England and attended a presentation of Jin Shin Do acupressure. As part of the demonstration the teacher held points on each of the attendees. When he pressed into my shoulders at GB 21 I felt an intense surge of energy through my body which really got my attention. I signed up for his 8 week workshop and was hooked from the start. A couple of years later I went to California to study with Jin Shin Do founder Iona Teeguarden to an advanced level, then set up a practice in the San Francisco Bay Area. After that I studied other forms of bodywork including NeoReichian massage and myofascial therapies, but acupressure has always remained the hub of my work. 2. What do you find most exciting about bodywork therapy? When you practice a number of modalities and can see a person from a different perspectives, the work always remains interesting. If you are really open to the person as a whole being and not just a biomechanical structure, there is never anything rote or repetitive about a session. Everyone is unique of course, but also when you see a person repeatedly, they are in a unique place each time you work with them 3. What is your most favourite bodywork book? It’s quite old now, but I think I’d go for Iona Teeguarden’s The Joy of Feeling which was such an influential book in my early years as an acupressure therapist. This was a great contribution to the field of psycho-emotional bodywork. 4. What is the most challenging part of your work? Being perfectly present to the client. I have all kinds of
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things going on in my mind while I am working. Thoughts, feelings, reactions, memories and so on. This is normal. The challenge is to regard each treatment as a meditation, to not push away these things but to be absolutely present with everything that is happening while neither engaging with it nor being taken away by it. This state of presence is what most facilitates Qi flow in myself and my client. 5. What advice can you give to fresh massage therapists who wish to make a career out of it? Close your eyes and look through your hands. When I was training as a massage therapist, one of the most useful teaching tools was to give a massage while blindfolded. This really sensitises the sense of touch. Also I would suggest learning your anatomy and physiology well so you can “see” the internal structures with your fingers. Visualisation is a tremendous tool as it gives substance to your intention. 6. How do you see the future of massage therapy? I see that it is becoming more and more inclusive. New modalities are becoming more and more integrated. I would like to see the term bodywork begin to replace the word massage which is quite limited and historically tainted. Bodywork seems a clearer description of what we are about.

6 Questions to Ron Alexander
1. When and how did you decide to become a bodyworker? In my early 20's I had back pain from playing Aussie Rules Football [Country League] so 'running it out' was the treatment of choice by the coach but now I know that this was not the answer and my posture needed attention. I saw a Doctor and he recommend NSAID's and I knew that other older guys at the club were using them for a long time and they still had their pain condition. My mother suggested a Naturopath who worked out of a caboose in Tarnagulla Central Victoria and had legendary stories of amazing results. She treated my back and neck, with techniques that were similar to what I later learnt to be like Bowen Techniques. This completely changed my discomfort and I was light headed from the treatment or from the painful experience. She was talking about massage, that you can make a career out of helping people, athletes and work with sports clubs. It sounded really interesting and after doing more research, I enrolled 3 months later in a two year course at the Southern School of Natural Therapies. 2. What do you find most exciting about bodywork therapy? There are numerous things. One of them is the various experiences that you can have in this profession such as working for athletes and performers. When I worked for the Australian Ballet, I got to travel and was part of an excellent Sports Medical Team. This was a great learning experience as knowledge was shared so I was exposed to a world bigger than massage, which gave me a much greater understanding of the body and how to treat it. The sheer volume of dancers and the environment provided the impetus to experiment with treatments to get the dancers out on stage and this where FFT came from. So being able to develop something new was very exciting and I am still excited by that today. A patient can present with something that sounds very complicated and has been there for a long time and no-one else has changed the condition that I am able to affect it with FFT. This still excites after all these years and it keeps me motivated. 3. What is your most favourite bodywork book? Sorry I cannot choose just one, but I can limit it to two. Years ago Job’s Body by Juhan. It gave me a great understanding of how the fascia has a big role to play in the body and should be used as one of the basic texts for all Bodywork courses. In more recent years Explain Pain, by Butler and Mosely. It is written in simple language, although it discusses quite comTerra Rosa e-magazine, No. 13 (December 2013) plicated concepts and can even be given to chronic pain patients. So you should have more than 1 copy! 4. What is the most challenging part of your work? Long flights to present FFT. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? Be good to your patients, be good to your referrals and you will do alright. Dream, believe, achieve, and succeed. It works. 6. How do you see the future of massage therapy? Where we have come from and where we are at now, the transformation is amazing. The Australian Bureau of Statistcs has identified massage as a growing industry. Over time it will become an even greater part of mainstream medicine. This translates to more people being able to make good careers within the industry. I think we have started to evolve into the medical model and thank God away from the sex industry. I think the Medical model is also changing and some accepted that they are not able to provide all the answers and are willing to try alternatives. I think people in this digital world are exposed to so much information and so quickly, that not only are we more informed as practitioners but so are the public and that can have great benefits. For example making more insurance companies change policy to suit customer preferences. This combined with pressure from Massage Associations has had a big influence on us as an industry. I also see evidence based massage becoming the way forward. I think as we increasingly value education and make efforts to improve the quality of education, research will follow. We need to more closely align ourselves with Universities in order for this to happen. As the Quality research is very important for our industry as it will give credibility to what we know clinically to be true. This will translate to publishing findings, not just in peer review journals but ones widely read by other industries. This will be one of our greatest ways of having the biggest impact. However as far as research goes if we stay doing what we are currently doing we will still be at the same place in 10 years. Our RCT is only the 2nd in Australia's history within our industry to be completed and published. I find this very surprising in such a progressive country as Australia. 50

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