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Issue 3, June 2009 www.terrarosa.com.au Welcome to our third issue of Terra Rosa Bodywork emagazine, our free e-zine dedicated to bodyworkers. It is an exciting full-on 40 pages of information. Economic crisis is looming and has influenced our industry as well. News from an association in Australia indicate the decrease in membership renewal. This crisis will present great challenges, however this is a time to renew and shape our work. Massage has survived many crises, and will continue to be in demand. So be positive. We got a range of great articles from respected authors. Til Luchau on the myofascial techniques for the neck, Anita Boser on neck & shoulder pain. Art Riggs continues his article on the leg. Erik Dalton discusses the latest research and treatment on iliotibial friction syndrome. Richard Gold gives an intro to Thai Massage. We turn to the area of peripersonal space and the latest theory on foot reflexology. A new contraindication of massage by Kristin Osborn and Complex Regional Pain Syndrome by Whitney Lowe. Don’t forget to read Six Questions to Til and Anita. We hope to keep you informed and entertained. If you have something you wish to contribute, drop us an email: terrarosa@ gmail.com. We believe that therapists like you have lots of experiences to share. Thanks for all of your support and enjoy reading.
02 Myofascial Techniques for the Superficial Neck Fascia —Til Luchau 07 Imagery to lengthen the neck 08 The Relationship Between Stress and Neck & Shoulder Pain —Anita Boser 11 An Integrated Approach to Rehabilitation of Leg Injuries. Part II —Art Riggs 19 Deadbeat Diagnosis —Erik Dalton 24 Thai Massage —Richard Gold 28 Peripersonal Space & Bodywork 32 A New Theory on Reflexology 34 De Quervain’s Syndrome 36 A New Contraindication of Massage — Kristin Osborn 37 Complex Regional Pain Syndrome — Whitney Lowe 39 Research Highlights 41 Six Questions to Til Luchau 42 Six Questions to Anita Boser
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Bodywork e-News 1
Myofascial Techniques for the Superficial Neck Fascia
by Til Luchau
Intro In this and subsequent articles, I’ll describe specific techniques that work with some of the most common client issues. I’ll draw on the work taught in AdvancedTrainings.com’s popular “Advanced Myofascial Techniques” workshop series, which for the last 25 years, has been attended by over 2000 practitioners in over a dozen countries. Although I’m at the AdvancedTrainings.com faculty are Certified Advanced Rolfers, and I teach at the Rolf Institute®, rather than writing about structural integration per se, my emphasis in these articles will be on specific and practical techniques that would be useful to any hands-on practitioner. We’ll start by looking at the superficial layers of the neck and preparing the neck and shoulders for deep work. This article is originally published in the Massage and Bodywork magazine, USA. Visit http://www.youtube.com/ user/AdvancedTrainings for a video clip from the 2009 DVD “Advanced Myofascial Techniques for the Neck, Jaw, and Head” from AdvancedTrainings.com.
Figure 1: The superficial fascia of the neck, in green, surrounds the deeper structures like a sleeve or cowl . (Illustration courtesy and copyright Primal Pictures Ltd.)
The Importance of the Superficial Layers
What are the most common complaints you see in your practice? Chances are, neck pain and discomfort are high on the list. Although cervical issues can have many causes, you’ll often see better results if you begin by addressing restrictions in the superficial layers of the neck and shoulders. Whether caused by deep articular fixations, posture and misalignment, habits, stress, injury, or other reasons, neck issues respond quicker and stay away longer when the outer wrappings are released first. As with other parts of the body, many seemingly deeper neck is-
sues resolve when the external layers have been freed. In this article, I’ll describe how to work with these superficial but important layers in order to prepare the neck for working with its deeper structures. The neck’s superficial tissue layers have a great deal of influence on its alignment, mobility and health. These “outer wrappings” encircle the neck and shoulders like an over-large turtleneck sweater, or a surgical collar (Figure 1) Anatomically, these layers include the superficial and deep cervical fascias, as well as the muscles within those fascial layers, such as the Trapezius, Sternocleidomastoid, and the
Bodywork e-News 2
Myofascial techniques for the neck
Platysma (Figure 2). Together, these cowl-like outer layers extend from their upper attachments on the occipital ridge and lower face, to their lower connections with the outer layers of the shoulders, chest, and upper back. Like a sleeve, they encircle the deeper musculoskeletal and visceral structures of the neck’s core. Try this: watch a friend turn his or her head from side to side. Watch what happens with the superficial layers of the neck, shoulders, chest, and back. Are there areas of the torso’s fascia that move along with The superficial layers of the neck the head and have a surprising thickness and neck? Or, do you resilience. When, because of insee lines of tension jury, postural strain, or other and pull appearing Figure 3 Fascial strain visible as "tugging" of the outer layers with movement. reasons, they have lost pliability in the skin and or are adhered to other layers outer layers? Ofand structures, the outside layers ten, these signs of fascial restricperficial layers, you can use your have the ability to restrict movetion will be most visible at the hands to feel for tugs and pulls ment range, disrupt alignment, extremes or end-range of the in the outer layers while your and bind the structures they sur- movement. Look from both the client rotates his or her head. round. Imagine trying to move in front and the back; compare left Whether watching or feeling, a wetsuit that is a size too and right sides for any differnote any areas that don’t have small—the outer layers of the ences. Then, look again as he or smooth, even lengthening of the neck can bind, distort, and conshe gently looks up and down dermis and superficial fascias strain movement in the same (being careful, of course, to avoid when the head moves. way. any posterior cervical compresWe are constructed like onions: sion when looking up). Your layered, from superficial to deep. friend might feel different kinds When testing for fascial tension of restrictions when moving, inSeeing Superficial Restricwith movement, don’t confuse cluding pulls in the deeper mustions movements of deeper structures culature, or catches involving for movement in the superficial neck articulations or the upper fascia. For example, you’ll someribs. For now, we’re going times see the ribcage turning to leave these aside and focus on the outer layers first. along with the head, or a shoulder roll forward, etc. Some of Sometimes superficial fasthis movement is normal; if you cial tension will be visible as see exaggerated or asymmetrical linear patterns “tug” in the movement of the ribcage or skin (Figure 3). In other shoulder, this might be because cases, a whole sheet of fasof deeper restrictions. Make a cia will move or creep along note to check for and address with the rotating or nodthese patterns later, but rememding head. Linear “tug” pat- ber that since these deeper terns are more commonly movements might be caused by seen in the thinner layers of restrictions in the outer layers, the anterior neck and chest, releasing the superficial layers is while the “creep” of whole the logical first step. Unless fascial sheets is seen more you’re working with a scalpel often when looking at the and are cutting right through, Figure 2: The superficial layers of the neck, in thicker posterior layers of you need to gently peel away the cross section. (Illustration courtesy estate of the back. If it is difficult to outer layers to get to the core. John Lodge.) see restrictions in the su-
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Myofascial techniques for the neck
Releasing Superficial Restrictions Once you’ve seen or felt where your client/friend’s outer layers are tugging or creeping along with head and neck movement, you can go to work. A word about sequencing your superficial work on the upper torso: in most cases, you’ll begin by releasing the posterior restrictions of the upper back, and end by working the anterior restrictions. This is the order we’re using in this article. Why this back-tofront progression? Since most of us tend to have our heads forward of the coronal midline, and be narrower across the front of our chest than across our upper back, the anterior fascial layers of the chest and shoulders tend to be shorter than the posterior layers of the shoulders and back. Ending by lengthening the shorter anterior restrictions balances the earlier work on the posterior side, and leaves the client with a greater sense of anterior width, length, and freedom, and so helps with overall alignment. A possible exception to this ordering: if your client has a very flat upper thoracic curve, you may want to reverse the sequence, and end with work on the back to encourage more spinal flexion. work before his or her head starts to feel too full.
Once your client is comfortable, ask him or her to turn the head Figure 4: The "Over-the-Edge" technique for releasing the superficial from layers of the upper back and shoulders. Although relatively safe, side-to- head-down positions are usually contraindicated for clients with unside as controlled high blood pressure, a history or risk of stokes, vertigo, or you acute sinus issues. again watch or movement. Imagine that you’re feel the outer tissue layers, in helping your client lengthen and order to re-check your findings. free herself inside the wetsuitLook again at the up-and-down like outer layers of superficial movements too, again using care fascia. to avoid any neck compression with extension. Often, this prone Alternatively, you can ask your position will make the superficial client to lift and lower the head restrictions even more obvious. (extend and flex the spine) as you lengthen the layers of the The tool we’ll use to release these back inferiorly. You’ll find that restrictions is the flat of our fore- most release will happen on the arm; specifically, the first few eccentric phase of the motion, inches of the ulna just distal to that is, while your client is lowerthe elbow (Figure 5). Use this ing his or her head. tool to gently anchor the inferior margins of the places you saw or Remember, your client will get felt superficial restrictions. We uncomfortable you leave them in 1. Over the Edge Technique don’t use oil or cream, as we’ll be this position for more than a few using friction more than presminutes. Although relatively safe, Ask your client to lie face down sure to contact the layer we want head-down positions are probaon your table, arms at the sides, to release. Also, we won’t be slid- bly contraindicated for clients with his or her head and neck ing much—our client will prowith uncontrolled high blood just over the top edge of the table. vide the movement needed for pressure, a history or risk of The edge of the table should fall release. stokes, vertigo, or acute sinus an inch or two below the top of issues. the sternum. Your client may Once you have the outer layers need to adjust upwards or down- gently anchored with your forewards a bit so that the edge is arm, ask your client to slowly 2.Anterior Neck/Shoulder comfortable. You won’t want to turn his or her head away from Differentiation Technique leave your client like this too the side you’re working. Feel for long, but you’ll usually have at a direction of your pressure that After releasing the posterior releast two or three minutes to gently lengthens the superficial strictions of the back and shoullayers being pulled by the head
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Myofascial techniques for the neck
head. Push with your fingertips, as if straightening out your curled fingers, to encourage superficial release away from the direction of movement. Whether you’re using palm or fingertips, don’t slide along the Figure 5: An open palm or the tips of curled fingers may be surface, and used for the Anterior Neck/Shoulder Differentiation techdon’t dig down nique. to the ribs or intercostals-you want to feel a tug in the ders’ superficial layers, you’ll outer layers, the layers of dermis want to broaden and continue and superficial fascia that lie bethis release by addressing any tween the actual surface of the surface restrictions in the upper skin, and the muscles or bones chest and anterior shoulders. beneath. To release these anterior restrictions, we’ll use either our palms or fingertips to anchor the superMovement: as in the “Over the ficial fascia of the shoulders, Edge” technique, ask you client chest, and anterior neck (Figure to slowly turn his or her head 6). Then we’ll use our client’s away from the side you’re anmovement to release the restricchoring. Find a direction for tions we saw or felt earlier. The your pressure that gently repalm is especially useful where leases the superficial layers beyou saw fascial layer “creep” with head movement. When using your palm, don’t be tempted yet to rub, slide, or massage the deeper layers of pectoralis, etc. Instead, use the broad surface of the palm to catch and gently anchor the outer layers of the chest while your client moves his or her head. In contrast to the broad tool of the palm, your fingertips will allow you to work specific areas, and so are useful where you saw the local “tugs” in the outer layers when your client was moving. When using the fingertips, the fingers are slightly curved rather than straight, and are sensitively “hooking in” to the outer layer you saw or felt moving with the ing pulled by the head movement. Imagine that you’re helping your client lengthen and free him or herself inside the wetsuitlike outer layers of superficial fascia. A further option is to have your client tighten his Platysma muscle, which lies within the superficial fascias that we’re working. Try it yourself as you’re reading this—turn your head, and then grimace or snarl until you feel a tug from your lower lip into the pectoral fascia of your chest. By anchoring the lower end of this tug in the chest, you can snarl and relax repeatedly to release any constriction in the anterior fascia. Having your client tighten and relax the Platysma in this way while you anchor its inferior attachments can help your client focus the release into the tightest areas.
Finishing Once you’ve released the outer layers of the neck and torso from the back, and front, look again as your friend turns his or her head
Figure 6: Active contraction of the Platysma, as in grimacing, can aid in releasing the superficial fascia of the anterior thorax.
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Myofascial techniques for the neck
from side to side. If you’ve been both patient and thorough, you’ll see fewer pulls and tugs in the outer layers, and more than likely, smoother and greater range of motion. Clients report that their movement feels easier, freer, or that their head is lighter and more upright. Now that you’ve released the outer layers, the next step could be deeper work with the neck, ribcage, or spine, either in the same session as these techniques, or the next one. The deeper work will now be easier, more effective, and longer lasting. Or, instead of working deeper right away, first you might want to continue the theme of superficial release by adapting the techniques we’ve just done here to other, complimentary regions of the body, such as the lumbars, limbs, or hips. I’ll write about more about these possibilities in other articles. In the meantime, keep investigating what happens when you take time to release the outer layers of the body. Tips for Effective Work Keep everyone comfortable. You and your client should both be comfortable and able to relax. The pressure, position, or movements you use should never be uncomfortable for either of you. Stay superficial. Even though the tools shown here—forearm, soft fist, palm, finger tips—can be used for deep work, stay in the outer layers of the body at first. You’ll be surprised at how much easier the deeper work will go, and how much longer its effects will last. Use your client’s movement. Instead of pushing tissue around, use your client’s slow, conscious movement to release and reeducate habitual movement patterns. Touch the person, not just the tissue. Remember that your are asking for change from a living, breathing being; not from inanimate compounds like “tissue” or “myofascia.” Balance and integrate. Most clients will feel more balanced if you end with work in the front to counterbalance the back length of the first technique. Be sure to incorporate your local work into an entire-body perspective, rather than just focusing on parts. Visit http://www.youtube.com/ user/AdvancedTrainings for a video clip. Bio Til Luchau is the director and a lead instructor at AdvancedTrainings.com Inc., which offers continuing education seminars and support services for practitioners and schools throughout the USA and abroad. The originator of Skillful Touch Bodywork (the Rolf Institute®'s own training and practice modality), he is a Certified Advanced Rolfer® and a Rolf Institute® faculty member. He welcomes your comments or questions at firstname.lastname@example.org. See also 6 Questions to Til at page .. © 2008, Til Luchau, AdvancedTrainings.com
Advanced Myofascial Techniques
DVDs and Manuals available from www.terrarosa.com.au
Advanced Myofascial Workshops with Til Luchau & Co. in Australia in 2010
For more info: email@example.com
Bodywork e-News 6
Imagery for the Neck
Move your C7 towards your jugular notch! For people with forward head posture, a difficult task for the therapist and the client is to train the client to correct for the wrong posture, move the head back to the neutral position. We usually ask the client to maintain a neutral spine, the head should be stacked over the cervical spine with the shoulders relaxed. The usual exercise we can give is the “chin tuck”. Or we can ask them for a guided imagery of “head lengthening” : Sit tall, imagine that a string is lengthening your neck and pulling your head up towards the ceiling. In Alexander technique, we are instructed to “Allow the head to go forward and up from the spine.” Imagery is quite powerful and acts as a stimulus for developing kinesthetic awareness and producing bodily change. Another simple imagery exercise that I recently learnt is to ask your client to “bring your C7 towards the
Picture courtesy of Primal Pictures
jugular notch of the sternum” (the large notch in the superior margin of the sternum). This is a simple imagery ex-
ercise that is quite powerful in bringing the head back to neutral position. Try it.
Anyone for a Stone massage?
Bodywork e-News 7
The Relationship Between Stress and Neck & Shoulder Pain
by Anita Boser, LMP, CHP
action initiates from the core and translates through the limbs. Functional use of the arms starts from a stable pelvis then transfers through the spine to the scapula, then the arm, hand and fingers. Motions as simple as typing on a keyboard and steering a car follow this pattern. Stress and neck and shoulder tension are interrelated for most people. This article will explain why and show how massage therapists can not only relieve discomfort, but also help our clients be better prepared to handle tumultuous times with resilience. In an optimally functioning body,
This level of performance can be interrupted by restrictions in the rib cage and thoracic spine resulting in dysfunctional movement patterns. When connection to the core is inhibited, the muscles in the arms and neck (especially the trapezius, levator scapula and rhomboids) are overtaxed and develop adhesions
Layers of neck muscles from superficial to deep (from Primal Pictures)
Bodywork e-News 8
Neck & Shoulder Pain
and trigger points. Anxiety is one culprit as it often obstructs breathing and movement of the thoracic spine. Stress creates contraction. The breath becomes shallow with a tendency to hold the inhale. Breathe in this manner and notice what happens. The pelvic floor stiffens. The diaphragm holds tension. The intercostals and thoracic spine erectors and paraspinals stop moving. The natural flow of breathing through the torso becomes frozen, and the muscles eventually fix into this rigid pattern. Now move your arms with this level of tension in the spine. Notice the instant pressure placed on the rotator cuff and neck. Deep breathing can restart the flow, but until the muscles are released the breath will not reach its comfortable maximum. That’s where the massage therapist can help. Release of the myofascia that covers the ribcage is a natural place to start, working from superficial (pectoralis (iliocostalis, longissimus and spinalis) freeing the fibers for individual articulation. To access the deeper muscles (semispinalis, multifidi and rotatores) ask your client to undulate as you work on the interweave of muscles in the laminar groove. When the thoracic spine has regained a level of mobility teach your client to reconnect with fluid movement. Undulations major, trapezius) to deep (the will reduce rigidity and tame intercostals). As the tissues glide, tension. A fluid spine and ample breath naturally becomes easier breath are foundational compoand fuller. nents to shoulder life’s responsiSince most ribs have three atbilities and take the edge off tachments to the thoracic vertestressful situations. brae (See Figure above), improving costal motility will start to cultivate freedom in the spine. Anita Boser, LMP, CHP is the However, the thoracic spine usu- author of Relieve Stiffness and ally does not regain its motion Feel Young Again with Undulawithout specific attention. tion and the audio version, UnThe complexity of muscles that control the spine— the erector spinae overlying the paraspinals—allows for nearly unlimited movement. Work first through the layers of erectors, dulation Exercises. She can be contacted at firstname.lastname@example.org or www.undulationexercise.com.
Feel better fast with Anita Boser’s exercises
Whether you're 16, 36 or 65, an athlete or a couch potato, coordinated or a klutz, Relieve Stiffness and Feel Young Again shows you how just 10 minutes a day can make a difference in how you feel. Boser gives you easy-to-follow guidelines and photographs for 52 simple exercises that will allow you to move better and more comfortably. Try a different exercise every week and by the end of a year, you're sure to feel better. Wherever you ache, undulation will provide relief-naturally, without medication, without equipment, without expense. And you'll have fun, too!
Available from: www.terrarosa.com.au
Bodywork e-News 9
Lomi Lomi Massage Workshop Down Under
With Carrie Rowell
Join Carrie Rowell for a 4-day Workshop, Hawaiian Lomi Lomi Massage, covering an introduction to the principles, and a full body massage routine, complete with joint mobilization and passive stretching. Sydney Workshop, Date: September 24-27, 2009. Location: North Curl Curl at a beach house a few minutes walk from the beach (we can do our hula and Auhea exercises on the sand) • Byron Bay, September 14-17 2009 • New Plymouth, New Zealand ,October 9-11 2009 Approved by AAMT for 20 CPE points.
For over 20 years, Carrie has studied various forms of sacred dance and movement. She applies the beneficial techniques learned from these arts into her bodywork therapy. Carrie practices and teaches bodywork in the US and traveled all over the world teaching Lomi Lomi massage, sacred dance and healing and empowerment workshops for women. For centuries the ancient art of Hawaiian Lomi Lomi massage has been used as a powerful tool for maintaining a healthy way of life. The strokes are long and flowing, using forearms and elbows, and giving the feeling of many hands on the body at once. All seminars incorporate movement and breath exercises, specific Hawaiian Massage techniques and exercises for self care. Practitioners work on each other and switch partners to learn how to apply the techniques to different body types. Individual attention is given by the instructor so that the students learn how utilize their body mechanics in the most efficient way for them. Each day you will learn new exercises and massage techniques designed to harness the power of the elements earth, air, water and fire. To register your interest and get more details email: email@example.com Bodywork e-News 10
AN INTEGRATED APPROACH TO REHABILITATION OF
with Art Riggs
After introducing the importance of a holistic view of knee rehabilitation in order to restore proper gait, the previous article ended with our fingers deep in the IT band. The techniques that were demonstrated began with more superficial work that is appropriate soon after injury or surgery, and progressed to tools for returning flexion mobility. We now turn our attention to treatment strategies to improve full extension to the knee and to a more detailed explanation of the complexities of gait, including techniques to deal with the compensatory reactions in the feet and hips that occur after injury.
Treatment #5 Returning Normal Extension Because of the impossibility of normal gait without full knee extension, I feel that this is the major goal for proper rehabilitation after injury or surgery. Of course tight fascia and muscles, particularly the hamstrings, will prevent full extension, but the therapist should also be skilled in working with the deeper restrictions in the joint itself by using mobilization techniques (shown later) to work with the knee joint. Let’s begin with some of the major muscles that contract after trauma and prevent the knee from straightening. Working with Popliteus and Plantaris One area of caution: You may feel a fairly strong pulse from the popliteal artery, but don’t let this
deter you; just use the usual precautionary techniques to distinguish the muscle tissue from the artery and be precise in your work. Since these are relatively weak flexors of the knee compared to the hamstrings, popliteus and plantaris are often neglected in conventional therapy. Their role in preventing full knee extension is less one of strong muscular resistance than of being “agitators” delegating responsibility to stronger muscles that do the dirty work of preventing knee extension. The body always reacts to pain as a strong dictate of movement, and both these muscles can be sensitive or painful when stretched if they shorten after injury. At the first sign of pain in popliteus and plantaris, they send inhibi-
tory reflexes to the quadriceps inhibiting them from contracting to straighten the knee. They also recruit their allies (agonists?), the hamstrings, to strongly contract and prevent the knee from straightening. Reducing irritation to and lengthening these small muscles is a first step in proper functioning of the larger muscle groups.
Photo # 10-- Popliteus and Plantaris
Note: This article will use the more common usage of the term “leg” to refer to the entire lower extremity as opposed to strict medical terminology where “leg” specifically refers to the portion of the lower extremity between the knee and ankle.
Bodywork e-News 11
Treatment for the Legs
Although most of the examples in this article will recommend working with muscles in a stretched position to effect a release, working in a very sensitive area like the posterior knee is best done with enough flexion to allow easy entry through superficial layers and have popliteus and plantaris relaxed so they are not irritable. As they relax and lengthen with your work, then slowly extend the knee by using a smaller bolster to retrain their stretch receptors to feel safe with more extension. Once these muscles relax, the primary flexors and extensors of the knee can begin to work properly without neurological interference from popliteus and plantaris. Usually popliteus and plantaris are shortened as a protective mechanism rather than from adhesions. Therefore, strokes in a distal direction are most effective to train them to relax and lengthen. Use very soft fingers to sink through superficial tissue to find the tight muscles and very slowly stroke distally, with an intention of simply relaxing and stretching an irritable muscle. The texture and depth of popliteus and plantaris is very similar to what it feels like to work on the scalenes in the anterior neck, so use the same principles. While working on these muscles, it is also a perfect time to begin stretching the more superficial fascia in the posterior knee. Working with the Hamstrings These are the most important muscles to relax and stretch to allow extension. The hamstrings will have learned to contract anytime the knee approaches the painful angle of straightening. You must not only release any fibrous restrictions, but must also train these muscles (and to a much lesser extent, the gastrocnemius which also crosses the joint and is a minor flexor) to relax into a lengthened position. In the prone position refrain from using a bolster under the ankle so the leg can straighten. Hamstring work is almost always beneficial for injured knees, but remember that if the knee is still inflamed and extension is painful in the joint, then it is a natural reflex for these muscles to be short and tight. If the joint is painful in movement or structural barriers such as adhesions are present, then the hamstrings will naturally contract to protect the knee. Extensive work with the hamstrings will always be helpful, but permanent lengthening will only take place after the joint heals. This will sometimes take several weeks or even months, so follow-up visits over an extended period of time are helpful to incrementally lengthen the muscles. Joint mobilization will be very helpful in freeing the joint so the hamstrings will not contract for protection.
Photos #11 & 12 --Facilitated Lengthening Strokes for the Hamstrings Although this may be the most important muscular work you do to return normal function to the knee, luckily, it is relatively simple work without fancy tricks. Notice that if you have your client slide down so that both feet are hanging off the table; comparing the injured knee with the healthy knee is an easy measurement to determine normal extension. In this case, the right knee doesn’t allow full extension, so the right heel is about an inch higher than the left. Use your fingers, knuckles or forearms to slowly stroke distally while visualizing grabbing and stretching the hamstrings. You should continue your intention of lengthening below the knee to the gastrocnemius and soleus. Note the dorsiflexion of the ankle to provide stretch.
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Treatment for the Legs
The largest paradigm shift in my bodywork occurred after I had been practicing for almost 10 years when I took a spinal mechanics class and began working with joints, not only in the spine, but virtually anywhere on the body. I hope that new therapists won’t wait as long as I did. Photo #13 --Anchor and Stretch Techniques for the Hamstrings Not all your work with the hamstrings will be to educate them to lengthen. There may be significant thickening and adhesions in different depths of the muscles or surrounding fascia that need detailed release. Anchor and stretch strokes using precise pressure at fibrosed areas are effective. Visualize that you are placing all of your intention on a knot in a rubber band. Anchor with proximal oblique pressure at adhesions when the knee is flexed and then slowly lower the ankle to extend the knee and focus the stretch at your anchor. Cautionary note: If your client is recovering from anterior cruciate repair, the surgeon may prefer that the knee does not reach full extension. It is advisable to check with the doctor for guidelines about the limits of extension to work for. This caution should also apply to the use of joint mobilization techniques shown in the next section. With the knee, we are primarily working to improve extension, flexion, and a bit of rotation between the femur and the tibia. Anatomists agree that the knee joint is the most complicated in the body, but some relatively simple joint mobilization techniques can be practiced safely and effectively even if you are new to this concept. Although it is tempting to look at the joint as a simple hinge, in reality, when moving from extension to flexion and back, the tibia must slide anterior and posterior and rotate relative to the femur. After knee injury or surgery, tightening muscles that surround the knee can contract and compress the joint from all sides impeding the articulation of the bones. If normal movement between the tibia and femur is not returned within a reasonable period of time, then adhesions form deep in the joint and can permanently restrict joint mobility. Since most therapists are apprised of ways to stretch the knee into flexion, we will concentrate on extension and rotation. Anterior and Posterior Shear of the Tibia and Femur Straightening the knee to full extension requires that there is freedom for the tibia to glide back and forth on the femur (shear) rather than just straightening like a simple hinge. Soon after injury, adhesions begin to form, and even the slightest limitation can impact gait. Most therapists are trained to work on the knee supported by a bolster, but this practice prevents extending the joint into its structural barriers to release them. Early in the recovery process, you may work in supine position with the leg just resting extended on the table as you gain your client’s confidence, but as you begin making progress, place a bolster under the ankle or calf so the knee is suspended in space (“bridging”) as demonstrated in the photo.
Treatment #5--Joint Mobilization Techniques for the Knee
Photos # 14 & 15--Anterior/ Posterior Sheer
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Treatment for the Legs
Remember to place your intention deep in the joint, and that unlike simply stretching the knee into extension as you would if the client is prone, you are applying posterior pressure directly down towards the table and visualizing sliding the tibia and femur in opposite directions. Mobilization can be applied in two ways. First, you can use relatively quick pulsations of pressure with about two pounds of force, repeating the pulsations for a minute or more. It is crucial to move the joint all the way until end range resistance is felt. This is helpful in over-riding conscious soft tissue holding patterns and begins to free up the joint as the bones slide back and forth. Secondly, you can apply a steady pressure downwards with a bit more pressure, but being careful that your client is not too uncomfortable. Sustain the pressure for a minute or two, waiting for a feeling of softening in the joint and a sense that the bones are sliding past each other. In the first photo I am putting pressure on the femur so that it is sliding posterior relative to the tibia. Conversely, by placing your hands below the knee on the tibia, you are now sliding the tibia posterior relative to the femur. As you become adept at these procedures you can expand your effectiveness by experimenting to either compress or traction the joint as you apply anterior/posterior shearing pressure. The key to the success with this and most joint mobilization techniques is to apply enough force to mobilize the joint, but not so much force that your client has pain or is fighting against you. Mobilizing Rotation of the Tibia and the Femur When the knee moves, the tibia actually rotates upon the femur, rotating externally as the knee extends and internally as the knee flexes. If rotation is impaired, then flexion and extension are impaired. The rotation is subtle, but important to work with. Cautionary note: Rotational joint mobilizations should not be performed if there is any question of a torn meniscus or ligaments after injury, but are very helpful after surgical repair of such injuries. Reverse the process as you pull the leg back into full extension by rotating the tibia externally through the range of motion. Of course it can even be more helpful to perform this technique while also stretching tight fascia or muscles, but your primary intention is to be rotating the tibia around the femur. As you flex the knee by helping your client bring her knee to her chest, place steady pressure to rotate the tibia internally. When you reach the end range of comfortable flexion, stay in this position and continue to exert gentle internal rotational force while waiting for softening of resistance
Photos # 18 & 19 —Seated Rotational Mobilization Photos # 16 & 17 —Supine Rotational Mobilization. This technique works well if your client has large or heavy legs or you feel unstable on the table. It
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Treatment for the Legs
has the added advantage of stabilizing the femur during movement and of the natural gravity of the lower leg placing traction the joint while you work. As you have your client flex her knee, rotate the tibia medially and then reverse the rotational direction to external as the knee is extended. Remember that the most release will happen at the end range of movement so hold a sustained pressure at this range of motion for up to a minute. Toe off: This is the important stage of walking that propels the body forward. With limited knee extension, the stride is shortened, approximating the “mincing” steps of very elderly people (I find that working for better knee extension is greatly appreciated by my older clients). If the foot is not far enough behind the body,
UNDERSTANDING MOVEMENT PATTERNS
The treatment suggestions that we have covered so far should provide considerable benefit for your clients who have knee problems and anyone looking for better movement and freedom of the entire leg. As mentioned earlier, a great many people have sustained injuries that persist in compensatory patterns of movement that have been ingrained for decades. A holistic treatment plan that deals with the complicated relationship between the feet, ankles, knees, and hips will be a great boon to your practice and will provide better movement for all your clients, not just with injuries. Now, let’s revisit the chart in Box 1, more detail to discuss the basic kinesiology of walking gait at toe off and heel strike with more attention to the feet, ankle, and hips.
Box 1: In varying degrees, limited knee extension will have the following results in gait, including a short stride. If you can return normal extension to the knee (the primary restriction), then most of the secondary compensations in the foot and hip will improve with minimal intervention. Muscles that are inhibited will need to be strengthened, and any good sports medicine book will have suggestions. These images confine themselves to the pelvis and below, but notice how pelvic tilt is also affected and will have effects up the spine and beyond. If you consider how a tight psoas on the affected side will present side-bending and rotational strain on the lower back, it becomes clear how the effects of injury radiate globally.
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Treatment for the Legs
it loses its power to propel the body forward and energy is expended in lifting the body up instead of forward. The foot ceases to flex at the toe joints (transverse arch) and become immobile causing the plantar fascia to shorten. The ankle remains in a neutral position rather than plantarflexing to push off, so tibialis anterior becomes short and gastrocnemius and soleus become weakened. As previously covered, since the knee won’t extend, the hamstrings, upper gastrocnemius, plantaris, and popliteus become shortened and will all need lengthening work, but don’t forget to work with the superficial fascia, especially behind the knee to stretch this tissue. Perform joint mobilization to return normal flexion, extension and rotation of the joint itself. Many therapists neglect the hip in rehabilitation of the leg. If the leg cannot extend freely to the rear, then rectus femoris and psoas will become short because they don’t need to release to allow the hip to extend for a long stride. They also will become fibrous from overwork, since the leg is not propelled by the foot and ankle to swing forward, rectus femoris and psoas will have to use more energy to lift the leg to overcome inertia. Instead of swinging freely forward, the knee will be lifted at a more vertical angle by the pull of these muscles. Heel Strike: If the knee cannot straighten, then the leg is unable to swing forward in front of the body with ease. Instead of landing on the rear of the heel with the ankle slightly dorsiflexed, the foot lands flat at a more vertical angle, preventing the normal rolling motion from heel to toe that dissipates shock. Gastrocnemius and soleus remain short and will need lengthening so the foot can dorsiflex. The ankle will need to be mobilized in both plantar and dorsiflexion be begin working like a smooth hinge. In addition to being short in the distal portion to prevent knee extension, the hamstrings will also remain tight near the ischial tuberosity as they prevent a full leg swing forward. It is easy to see how working with the hamstrings is the key to rehabilitation. All of these complex feedback loops occur from the simple restriction to knee extension. Remember the chicken/egg relationship with the joint and the muscles. The lack of proper joint movement will cause the muscles to shorten, but these shortened muscles will solidify improper joint movement if the walking pattern becomes ingrained. Be sure to become skilled in joint mobilization techniques on the joint itself to help restore proper mechanics. The best news is that these techniques work equally well for restoring proper movement patterns after injury to the feet, ankles, and hips. Although one can understand these kinesiological principles at a cerebral level, by far the best way to understand what is happening in your client’s body is to feel the sensations in your own deep experience by mimicking the limping pattern. What joints aren’t moving? What muscles are contracting improperly? If you simply concentrate to prevent your knee from straightening, you will experience the profound compensations from the toes up through the hips as you walk. In classes, I actually have students tape their knees to prevent full knee extension, and also have them experiment with placing a pebble in the forefoot or heel of their shoes. This is an excellent way to feel both the joint and muscular adaptations to pain or discomfort, and will enable a strategy for treatment. Treatment #6 Balancing Secondary Compensations Now we can move to some techniques to return proper function to secondary areas that respond to knee dysfunction. Work to satellite areas is extremely important because of their tendency to reinforce limping patterns, but until proper function is returned to the primary site of injury, the secondary compensatory patterns will persist. It is perfectly appropriate to work on secondary compensations throughout your treatments because they often cause discomfort as they adapt. However, your primary goal should be to
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Treatment for the Legs
return the primary injury site to health as soon as possible, and then focus on the feet and hips. the ankle. Use your knuckles or the ulnar surface of your forearm to soften and free this tissue. Anchor in one direction and then mobilize the ankle in any opposing direction to improve freedom. This is an excellent technique after ankle sprains or on virtually anyone who wishes easier ankle movement. Photo #21 Softening the Plantar Fascia and Freeing Dorsiflexion. Improving Hip Mobility
Freeing the Toes, Transverse Arch, and Plantar Fascia With a limping gait, the feet become stiff and inflexible as they land similar to wearing a very stiff-soled shoe that prevents the toes from flexing and providing power on toe off.
can be difficult when the leg is straight. This technique offers the advantage of using your body weight, being able to exert strong pressure to dorsiflex the ankle, and the use of the broad and comfortable tool of your forearm. This technique is also useful to treat plantar fasciitis.
Photo #23 Freeing the Proximal Hamstring for Easier Leg Swing
Photo # 20 Restoring Toe Extension Working in the end range of motion is the key to this technique. With soft fingers, bend the toes as far as possible into an upward dorsiflexed extension. With knuckles or fingers patiently work the area of the metatarsal heads, with both cross-fiber strokes and in the direction of lengthening of tissue. This is also and excellent way work on the plantar fascia for the length of the foot.
Improving Ankle Movement
Photo #22 ---Freeing the Ankle Retinaculum
The biomechanics of stretching the foot into dorsiflexion in either the prone or supine position
The front of the ankle is surrounded by a fibrous retinaculum that can stiffen the ankle joint like an Ace Bandage, limiting both plantarflexion and dorsiflexion and causing torsion on
By flexing the leg with the knee relatively straight, you can place the hamstrings on a nice stretch while releasing any areas with anchor and stretch strokes against the stretch. Don’t strain yourself by holding the leg with your arm if your client is large. You can be inventive and use your shoulder and body to apply stretch to the leg or even have your client apply the stretch by using a strap over the bottom of her foot.
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Treatment for the Legs
Apply pressure with you other hand to extend the hip and work in the direction of stretch working with your fingers for superficial tissue and with you forearm for deep muscular work on the quadriceps. This technique is also useful for working with the psoas in a stretch, but do not over-extend the hip. If the hip is too extended, it becomes difficult to sink through the superficial tissue in the anterior pelvis to contact the psoas. Conclusion I hope that this article have given you insight into the interesting interrelationship of the joints of the legs as well as some specific tools to successfully treat problems, not only to the knees, but to the other joints of the lower extremity. All joints of the leg are inextricably linked together in a complex feedback loop that must be treated in a holistic manner for the best results. Remember that each client will present his or her own unique adaptive mechanisms to injury and that the solutions to solving limping problems rarely are simple or lie in only one area. These considerations are what make our work so interesting and rewarding. Remember that a holistic treatment not only includes a broad view of distant joints and compensations, but should consider the whole person you are working with, including the causative factors of their injury (especially with overuse injuries), their approach to self-help though home programs of stretching and strengthening, and their emotional feelings. Fear, anger, depression, and self-judgment are often associated with injuries. We always treat more than muscle, tendon, and bone. The best therapists’ skills are more of an art than a craft as they provide a hopeful healing environment for their clients with their humanity and contact with the person behind the injury.
Photo #24 Releasing the Rectus Femoris The rectus femoris and front of the pelvis will become short and tight if your client has been walking with a limp that prevents the leg from freely swinging back into extension. Working in the neutral supine position will soften tissue but not stretch enough to open the area. This position allows you to work easily using your own body weight as you stretch the leg into extension. Support your client’s head and neck, and possibly low back with pillows, and have your client pull her opposite leg to her chest to keep the pelvis in a neutral position.
Deep Tissue Massage & Myofascial Release
Best Selling 7 Volume, 11 Hour encyclopedia of advanced massage DVD and a visual guide manual
Available from: www.terrarosa.com.au Art Riggs is planning to travel to Australia in Oct 2010, to register interest for workshop: firstname.lastname@example.org Bodywork e-News 18
by Erik Dalton
The iliotibial band (ITB) syndrome is typically regarded as an overuse injury common in runners and cyclists. Lately, this controversial condition has gained greater attention due recent articles that include my “ITband Friction Fallacy”1; Mark Charrette’s “Lateral Knee Pain and Orthotic Support”2, and Whitney Lowe’s “New Perspectives on ITB Friction Syndrome”.3 Although many researchers and clinicians are convinced that the pathoanatomy of iliotibial band friction syndrome (ITBF) is well known and well understood, the jury is still out on the exact cause (s) of this lateral knee pain condition. Blindly following conventional wisdom may often point good clinicians to the wrong therapeutic path. The following example demonstrates how ‘chasing the pain’ can lead physicians to a linear treatment protocol that results in months of unwarranted pain and unnecessary medical interventions. Case Study Recently, a 44 year old orthopedist, for our purposes will be referred to as Dr. Smith, was referred to me complaining of eight months of debilitating, self-diagnosed, IT-band friction pain. During his history intake, he admitted suffering sporadic foot, hip and low back soreness but dismissed these issues as “unrelated”. A self-described “weekend-warrior”, Dr. Smith’s knee pain flared with excessive running or cycling. Both he and his staff (a physical therapist and physiatrist) had carefully scrutinized the painful knee and arrived at a unanimous diagnosis of ITBF based on results from Ober’s Test (determines the tightness of the ITB), Renne's test (specifies the area of pain during weight bearing) and Noble's test (identifies the area of pain when the leg flexed at a certain angle). To further strengthen their diagnosis, MRI studies showed a thickened iliotibial band over the lateral femoral epicondyle. The summation: diagnosis confirmed….ITband friction syndrome. Case closed. Dr. Smith related that his group’s initial treatment goals focused on relieving the (supposed) inflammation via ice treatments and antiinflammatory medications followed by a series of physical therapy sessions. Sadly, the ‘series’ of physical therapy slowly evolved into months of heartbreaking disappointment. Typical treatment modalities (stretching, ultrasound, electrical stim, cross-fiber frictioning and trigger point work) brought little relief. Discouraged with the lack of progress, Dr. Smith and his physiatrist partner began a more aggressive approach with corticosteroid and proliferation injections (Fig 1). Although many of their ITBF patients responded favorably to this treatment protocol, Dr. Smith did not. Desperate to get back to his biking and running regime, Smith decided to undergo a surgical
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release of the IT-band at the posterior 2 cm where it passes over the lateral epicondyle….but still no relief. So how did eight months of aggressive treatment lead to abysmal failure? Conventional Wisdom ITBF is generally thought to be a multi-factorial, non-traumatic, overuse condition in which the distal aspect of the iliotibial band rubs over the lateral femoral epicondyle during repetitive knee flexion and extension movements (Fig 2). This ultimately leads to irritation of the iliotibial band, bursa and lateral synovial recess. In this popular theoretical model, the deep posterior ITB fibers are more vulnerable to back-and-forth rubbing on the knee’s epicondyle. Several studies 4,5,6 have described a dynamic “impingement zone” at approximately 30° of knee flexion where the ITB is most vulnerable to microfiber tearing and associated inflammation. Therapists who abide by this ‘conventional wisdom’ often seek out the sore spots around the condyle and cross-fiber friction the affected tissue in an effort to break down weak-linked adhesions, enhance fibroblastic activity and encourage tissue remodeling.7 Follow-up treatments often include elbow ‘fasciamashing’ and manual ITB stretching routines. All of these approaches can be effective if ITband fibers truly are damaged. Science vs. Conventional Wisdom In a compelling paper published in the Journal of Science and Medicine in Sport (2007), a prestigious research team led by John Fairclough and seven coauthors8 challenged the idea that excessive friction between the IT band and the lateral femoral epicondyle creates microscopic tears and 'inflames' the tract or a bursa. These researchers found that several basic anatomical ITB principles had been overlooked: (1) the IT band is not a discrete structure but a thickened part of the fascia lata which envelops the thigh, it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands which are not pathological adhesions and, a bursa is rarely present but can be mistaken for the lateral recess of the knee. According to their findings, it appears the ITB is actually prevented from rolling over the epicondyle…partly because of its femoral anchorage…and partly because its fibers are bound tightly to the tough enveloping fascia lata. Although Fairclough and his team were able to induce slight medial-lateral movement across the condyle, they proposed that ITB pain was primarily caused by increased compression of a highly vascularized and innervated layer of fat and loose connective tissue separating the ITB from the epicondyle (Fig 3). Dr. John Fairclough concludes that “ITB syndrome is related to impaired function of hip and leg musculature and its resolution can only be achieved through proper restoration of lower quadrant muscle balance.”
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Myoskeletal Treatment Plan One of the first things that caught my attention while observing Dr. Smith’s gait was the presence of a cavus right foot (high rigid arch) presenting on the same side as his IT-band pain (Fig. 4). With his lower leg stuck in external rotation, it appeared the stiff supinated foot was preventing the tibia from internally rotating during heel strike. This seemed rather unusual since friction or compression of the IT-band is generally thought to result from foot hyperpronation coupled with excessive internal tibial rotation.9 Although gait observations, anatomical landmark assessments and functional testing revealed myoskeletal imbalances through the hips and lumbar spine, I initially decided to address the cavus foot problem. My experience has shown that a cavus foot stresses all myoskeletal structures (foot to lumbar spine) leading to disorders such as peroneus tendinosis, stress fractures, trochanteric bursitis, plantar fasciitis, tibiofibular fixations, and hip/back pain…. but not IT-band friction syndrome Some cavus feet (particularly those with claw toes) do not respond well to manual therapy. Fortunately, Dr. Smith’s foot did regain flexibility as the muscles of the lateral fascial compartment were separated. Once myofascial flexibility improved, rear and forefoot joint mobilization routines helped restore glide to the rigid tarsal bones (navicular, cuboid and cuneiforms) and the talocalcaneal joint. (Fig. 5). Although this myofascial/ joint mob protocol softened the stiff arch, it quickly became apparent that most of the rigidity was coming from Dr. Smith’s severely fix-
ated tibiofibular (ankle) joint. (Fig. 6) I find this oft-neglected tib/fib joint to be the “key lesion” in many lower extremity disorders. Optimum ‘Stirrup Spring System’ functioning (see my Don’t Get Married articles, Massage Today) demands that both ends of the tibia and fibula (proximal and distal), maintain smooth cephalad and caudal movements (Fig. 7). If working properly, the tib/fib articulations should perform as magnificent shock absorbers with their actions enhanced by tibialis anterior and
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that he had suffered a chronic pull a year before the knee began to flare. Therefore, with each step, the injury-shortened biceps femoris tugged on the fibular head causing chronic repetitive microtrauma at the tib/fib articulation. In time, the fibula became posteriorly fixated on the tibia causing joint play loss and lateral knee pain. By applying a simple contract/relax technique (Fig 9) over several sessions, we were able to establish normal ing activities. Rather that chasing the pain, our intent, as always, focused on ‘finding and fixing’ all compensatory kinks along the kinetic chain.
NewslettersOnline/ March_09_Newsletter.htm www.dynamicchiropractic.ca/ mpacms/dc_ca/article.php?id=53550
peroneus longus and kept in sync by a resilient but tough interosseous membrane. The “figure 8” plantar and dorsi flexion technique was used to loosen the fibrotic ankle ligaments and articular cartilages providing better anterior/posterior and superior/inferior glide but the fibular shaft still seemed stuck. Moving up to the proximal fibular head, I tested for A/P glide there. Finally--the ‘main event’ so responsible for months of mysterious lateral knee pain was exposed. With the knee flexed, my fingers and thumb were unable to budge the fibula in an anterior direction. Furthermore, any slight pressure replicated the intense pain previously identified as the source of his problem. (Fig. 8) Summary Runners like Dr. Smith share a high risk for hamstring injuries with the most commonly torn of the group the biceps femoris. When asked about past hamstring problems, Smith related
3 4 J.
Fairclough, K. Hayashi, H. Toumi, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport, Volume 10, Issue 2, Pgs. 74-76 Orchard JW, Fricker PA, Abud AT, et al. Biomechanics of iliotibial band friction syndrome in runners. American Journal of Sports Med, 1996; 24:375-9.
movement to the fixated tib/fib articulation thereby resolving his painful condition. As with many “conventional” protocols, stepping outside the box provided that important distinction to Dr. Smith’s recovery-relying more on accurate identification and restoration of the functional biomechanical deficits in the entire kinetic chain rather than focusing on a specific injured tissue. Incorporating myofascial and skeletal mobilizations to Dr. Smith’s foot, ankle, proximal fibular head, hip and pelvis were key factors allowing his return to normal running and bik-
Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial band strain in runners. Clinical Biomechanics, 2008; 23:1018-25.
Clement DB, Taunton JE, Smart GW, et al. A survey of overuse running injuries. Physical Sports Medicine, 1981; 9:47-58.
7 8 Schwellnus M, Mackintosh L & Mee J. Deep transverse frictions in the treatment of iliotibial band friction syndrome in athletes: a clinical trial. Physiotherapy 1992; 78(8): 564-569.
Ellis R, Hing W & Reid D Iliotibial band friction syndrome – a systematic review, Manual Therapy, 2007; 12: 200208
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Bodywork e-News 23
by Richard Gold
How It Started In Thailand, what is known in the Western world as Thai massage is known as Nuad Bo’Rarn. Nuad is a Thai word that translates as, “to touch with the intention of imparting healing.” Bo’Rarn is a word derived from ancient Sanskrit; it translates as, “something which is ancient and revered.” The same word, Bo’Rarn, is applied to the revered sutras (texts) of Buddhism. Also, in Thailand, Thai massage is recognized as a core component of an entire system of traditional medicine. There are four aspects of traditional Thai medicine: 1) Herbal medicine; 2) Nutrition and food cures; 3) Spiritual practices, including mantras, prayer, incantations and mindfulness meditation; 4) Nuad Bo’Rarn (Thai massage). Historically, Thai massage was not specifically what Westerners consider massage. It was thought of as and utilized as the handson practice of traditional medicine. Thai massage techniques were applied to the treatment of the varied ailments that afflict humanity, including mental and emotional illness. The historical founder of Thai medicine is known as Jivaka Kumar Bhaccha (the father doctor). He is identified by scholars as a close personal associate of the historical Buddha, and was the head physician of the original Sangha, the community of followers that gathered around the Buddha. This would place him as living in India approximately 2,500 years ago. Buddhist monks and followers brought their traditional medicine with them as they made their way from India to what is now modern Thailand, in approximately the second century B.C. For centuries, the traditional medical knowledge was transmitted orally from teacher
Jivaka Kumar Bhaccha
to student. Over the centuries, a distinct tradition evolved that was primarily influenced by the Ayurvedic traditions from India, but also began to incorporate theories and practices from ancient China. In addition, healing practices of the indigenous tribal peoples of the area also became part of the local medical practices. By the time Theravada Buddhism was declared the official religion of the kingdom in approximately 1292 A.D., the traditional medicine was well established in the Buddhist monasteries, known as Wat. Traditionally, the Buddhist monks— and to a lesser extent Buddhist nuns—administered the healing
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work to the people in their villages. How Is It Different?
Today, Thai massage is being Besides the specific hands-on practiced in clinics and spas all techniques, herbs and foods were over the world and has experiutilized in healing; Buddhist phi- enced remarkable growth and losophy pervades the practice of acceptance. In fact, there has medicine in Thailand. Healing even been a dramatic growth of work is understood to be the schools for traditional Thai practical application of metta, or massage in Thailand. It comloving kindness. Metta is under- bines elements of yoga, meditastood to be a core component of tion, acupressure and assisted daily life for each individual seek- stretching to provide a unique ing awareness and fulfillment on and wonderful bodywork experithe path taught by the Buddha. ence. Teachers describe metta as the However, Thai massage does dif“foundation of the world,” essenfer in several ways from Western tial for the peace and happiness of massage. Key distinctions inoneself and others. clude: In Thai Theravada Buddhism, • Thai massage is practiced with significant emphasis is placed on the client fully clothed in loosethe practical application of spirifitting clothing. tual philosophy: that higher ideals be brought into everyday life • No oils or lubricants are utilized and decisions. Accordingly, the in Thai massage. practice of Thai massage demonstrates the practical application of • Thai massage is practiced very the four divine states of mind: 1) slowly.
• Sessions take place on a cotton pad or mat that is placed on the floor or on a low platform. • Thai massage therapists are encouraged to work in a concentrated and meditative state of mind, unencumbered by thought or fantasy. They are supposed to “transmit” this quality of mind through their touch to the client. • Although it is the physical body of the client that is being addressed, the primary focus and intention of the therapy is to bring balance and harmony to the “energetic” body and mind of the recipient.
metta, 2) compassion, 3) vicari• Thai massage is a core compoous joy and 4) mental equanimity nent of an entire traditional (brought to fruition through medical practice (traditional Thai Primacy Of Abdominal Work meditative practice). medicine). Like Indian Ayurvedic and Tradi• The practice emphasizes press- tional Chinese medicine, tradiing, compression and stretching techniques. The rubbing techniques of Western massage (effleurage and petrissage) are absent. • Thai massage practitioners utilize their feet, knees, elbows and forearms, in addition to their hands and fingers extensively during therapy.
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of Thai massage focuses on the abdomen. The practitioner will work with the client to establish an awareness of breathing deeply into the abdomen. Once the client is breathing deeply, the therapist will proceed with a specific series of deep palm compressions, followed by deep thumb presses. All these procedures are designed to intional Thai medicine is based on vigorate the functioning of the an energetic paradigm of the hu- organs and to eliminate enerman body and mind. In the Thai getic blockages and stagnation of blood and lymph. The immedical model, bio-energy (Qi) travels through the body on what proved functioning of the abare designated as Sen lines, which dominal region has positive are somewhat similar to the me- implications for the overall health and vitality of the client. ridians of acupuncture/Chinese medicine theory. Ten primary Sen Going Forward are identified in Thai medicine, which, essentially, originate deep Thai massage offers the pracin the abdominal cavity in the vi- ticing massage therapist a cinity of the navel and connect wonderful new approach to the center of the body to the sen- bodywork and therapeutic sory and excretory orifices and touch. In addition, more and the extremities. Because of this more massage and bodywork esenergetic understanding, the tablishments are receiving repractical, therapeutic application quests from clientele to provide this unique style of therapeutic touch. There are great opportunities to practice Thai massage in spas, clinical settings and resorts around the globe. The learning, practicing and receiving of Thai massage can be a profound, wonderful and joyful life experience.
instructor of the new DVD Mastering Thai Massage produced by Real Bodywork. He is the author of Best Selling Thai Massage book, 2nd edition, published in 2008. He is a founder and current board member of the Pacific College of Oriental Medicine. Additionally, Gold is the president and chairman of the board of the International Professional School of Bodywork (IPSB). He teaches at both institutions. Gold is based in San Diego, and can be reached at: email@example.com.
About the author Richard M. Gold, Ph.D., L.Ac., ABT, has been practicing Asian healing arts and acupuncture since 1978. He is the author and
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Learn the ancient art of Thai Massage with master instructor, Richard Gold. This beautifully filmed DVD features over 3 hours of instruction and over 170 detailed techniques. Each technique is clearly demonstrated showing proper alignment, positioning and proper body mechanics so that pressure can be applied effectively and effortlessly. This DVD includes traditional Thai stretches, work on the Sen energy lines plus abdominal massage. Mastering Thai Massage is one of the most comprehensive programs available! Available from www.terrarosa.com.au
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Peripersonal Space & Energy
When New Age gurus invoke the mysteries of quantum physics to In the book “The Mind Has a Body of Its Own”1, authors Sarah explain the mysterious energy fields and human consciousness, they are essentially explaining one mystery with another mystery. and Matthew Blakeslee described marvelously how the Sandra & Matthew Blakeslee brain maps the body. The brain contains maps of every point in able to use tools or instruments. our limbs. By integrating mulour body, as well as the space When we are playing tennis, the tisensory (visual-auditoryaround the body. An important racquets seems to be part of our tactile) cues around the body, theme of the book is that body hand. When Andre Rieu plays the peripersonal space system maps in the brain can account his violin, he became one with provides information about the for a range of experiences and the instrument. position of objects in the surperception. These recent findrounding environment with reings offer scientific explanations The space around us is real and spect to the body. Research has for many phenomena, including can be sensed. Tai Chi and Qi found that brain cells become phantom limbs, syndromes in Gong practitioners train their active as objects approach the which stroke patients neglect body with their relationship to space around the body. Periperone side of the body, etc. More their peripersonal space, with sonal space can be seen and eximportantly for us, the authors the goal of uniting the mind, suggest the possibility for neuro- perienced in the way that we are body and intention. We can obbiological explanation of many serve that when two people jugalternative therapies, including gle or dance together, they plan aura, Reiki, and energy therapy. and execute their actions together, sharing their periperOur brains and bodies use the sonal space mapped by each maps to translate incoming senother’s brain2. sory signals into meaningful information. To act efficiently, our Scientists never believe the ideas brains need to locate objects in that our bodies are surrounded the space around our bodies, and by the energy fields giving rise to need to hold a constantly upaura, and have never been able dated report on the body's shape to detect this kind of energy. and posture. This requires an However some people could integrated neural representation really experience auras. The of the body (the body schema) Blakeslees hypothesized that and of the space around the body people who can visualize aura is (peripersonal space). Peripera natural construct of the pariesonal space refers to the space tal lobe. People seeing aura is immediately surrounding our believed to be a natural product bodies, which can be reached by
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of cross-wired brain. Auras can be due to a flexible body map and a blending of peripersonal space and colour and any other sense. The fact that our body and peripersonal space are very flexible provides a new scientific understanding of this phenomena. Recent research also suggested that our peripersonal space can be extended into a space where an imagined posture would take us3. There are clear advantages of representing the ‘‘space’’ of an imagined posture. For example, before performing an action, an individual may imagine it to learn about its feasibility (‘‘Can I reach that box on the top shelf?’’). In many movement therapies employing imagery such as Ideokinesis and Alexander technique, guided imagery actually exploited our brain to think of a better posture. The Blakeslees wrote1:
"In traditions of healing touch -shamanic healing, energy healing, universal life energy, Reiki, and scores of other healing practices around the world -- practitioners use a combination of visual imPeripersonal space can be haragery, motor imagery, and gesnessed to treat and cure human tures to merge their own periperillness, which is the basis of many sonal space sense with that of alternative therapies. This idea their patients. It might involve has been accepted in many cullaying on hands, manipulating tures around the world. The flexi- the vitalistic energy fields bebility of our body maps and perip- lieved to suffuse and surround the ersonal space maybe the key to body, or passing magnets or crysunderstanding how various tals over special body points “touch” therapies work. called chakras. The experience,
Sir Wilder Penfield, a Canadian neurosurgeon, in the late 1930s mapped out the areas of the brain involved in sensation and motor activity by stimulating them electrically. In cartoon like drawings Penfield showed the surfaces of the brain and a proportional representation of the external parts of the body. His early sketches have been referred to as Penfield's or motor Homunculus (= little man). Figure "A" is a section through the sensory
cortex (Parietal Lobe) and "B" is a section through the motor cortex (Frontal Lobe). An interesting aspect of this map is that the proportional areas assigned to various body parts on the brain are not to their size, but rather to the sensitivity and complexity of the movements that they can perform. Hence, the areas for the hand and face are especially large compared with those for the rest of the body.
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both for the healers and their patients is quite real: both can often literally feel the shifting of the energetic currents or fields they believe are there.” "The scientific method has never been able to confirm that qi flows or other mystical vital energies are real and present in the mind and body. Yet the experiences of these things are so palpable for so many people that it would be a cop-out to dismiss them out of hand as 'nothing more than' wishful thinking. Perhaps science, having banished these energies from the account of reality, can nonetheless explain the sensory awareness that people have of them. The brain's touch, movement, and peripersonal space maps go far in explaining many key elements of these beliefs and experiences." In various touch modalities, such as Reiki, Therapeutic Touch, Polarity or Craniosacral therapy, we can feel and experience the “energy” from a therapist, the warm sensation, and sometimes can tell where the therapist’s hand (even when the therapists didn’t touch any parts of our skin). This energy can induce powerful sensations in the body, and the sensations we feel are a combination of the flexibility of our body map to reach out to the therapists. It is also due to what we believe is happening. Healing works because the body and mind is flexible and creative. The power of placebos, expectation and belief is related to neural activity in the brain). Using various bodywork modalities, we can actually direct and manipulate this peripersonal space, because the experience is represented also in the brain. Sarah and Matthew Blakeslee hypothesized that using fMRI imaging on the frontal lobes, we might be able to see the effect of Reiki or therapeutic touch. A study by Jeanne Achterberg has investigated the effect of healing in 20055. She and her colleagues recruited 11 healers, each was asked to select a person they had worked with previously with distant intentionality, and with whom they felt an empathic, compassionate bond. Each recipient was placed in a fMRI scanner and was isolated from the healer. a potent form of medicine. Skep- The healers sent forms of distant tics tend to think that this is all intentionality related to their own imaginary. However, since our healing practices (including body maps actually extend out Reiki) at two-minute random ininto the space around us, we tervals that could not be anticiprobably really can sense the per- pated by the recipient. Significant son really close to us doing ener- differences between the experigetic touch.1,2 mental (send) and control (no send) conditions were found. Peripersonal space is physically There are areas of the brain that mapped in the brain’s parietal were activated during the send and frontal lobes. The motor inperiods. This study suggests that tentions are within that space. remote, compassionate, healing Studies using functional MRI intentions can exert measurable (fMRI) imaging technique effects on the recipient, and that showed that parietal and frontal an empathic connection between areas are involved in the reprethe healer and the recipient is a sentation of peripersonal space4. vital part of the process.5 (fMRI is an imaging scan that shows the blood flows response While this study does not suggest
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the effect on peripersonal space, it opens up for neurobiological explanation for many of the alternative therapies. Neurologist V.S. Ramachandran in his book “Phantoms in the Brain” wrote: The message preached by New Age gurus contains important insights into the There are two implications human organism – ones that deof these findings for bodyserve scientific scrutiny…. We workers: first, that there is a should not reject an idea as outpossibility of scientific explanalandish simply because you can’t tion of the mechanism of touch think of a mechanism that extherapies and other energetic plains it…. Finally we should not work from a neurological point of have blind faith in the “wisdom of view. The second is that when we the east” but there are sure to be are working on a body, we are many nuggets of insight in these also working on and affecting ancient practices. Unless we contheir peripersonal space and duct proper “western-style” exmind. periments, we’ll never know The author here does not pretend which ones work and which one doesn’t. to fully understand about the brain and neurology, there’s More importantly the implication probably an oversimplification of of peripersonal space for bodythe matter. However the point is worker is summarised by Keith that we should not get stuck in Eric Grant6: presudoscience explanation of many of the energetic therapy but “There are features and reactions we should try to advance the sci- of the body that are not explicitly ence figuring out the real mecha- physical, but stem from the imnism. mense pattern-matching and mapping processes of our brain. Many mainstream scientists are In some cases, what we perceive also interested in trying to find might be both a mapping of the out the mechanisms of alternative peripersonal space and a maptherapies. Paul Tofts, a professor ping from one sensory mode to in medical imaging, in the book another…. The bottom line is that, “Quantitative MRI of the Brain” as humans, we are neurologically stated: “The Placebo effect is phewired to respond to and be part of nomenon considered very powerthe sensory world immediately ful in medicine, and yet the surrounding us. As massage pracmechanism of action (for alternatitioners, this opens the door to tive treatments) is not fully unhelping our fellow humans cope derstood. With quantitative MRI with transitions and traumas, and we may be in a position to objecfor sharing their joys. Our emotively record responses to such tions map into our body, but just treatments.” as surely, our bodily experiences map into our emotions.” References
S. Blakeslee, M. Blaskeslee. The Mind Has a Body of Its Own. 2007. Random House.
G. Campbell, Brain Science Podcast, Episode #21 Discussion of the book, The Body Has a Mind of Its Own, by Sandra Blakeslee and Matthew Blakeslee. Aired September 22, 2007.
Davoli, R.A. Abrams. Reaching Out With the Imagination. Psychological Science, 20 (2009), 293-295. T.R., Holmes, N.P., & Zohary, E. Is that near my hand? Multisensory representation of peripersonal space in human intraparietal sulcus. Journal of Neuroscience, 27 (2007), 731–740.
Achterberg, K. Cooke, T. Richards, L. Standish, L. Kozak and J. Lake. Evidence for correlations between distant intentionality and brain function in recipients: a functional magnetic resonance imaging analysis, J Altern Complement Med 11 (2005), pp. 965–971. Grant. Mapping Body into Motion. Massage Today June, 2008, Vol. 08, Issue 06.
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A New Theory on Reflexology
A new Japanese study into reflexology has made a significant breakthrough in establishing a scientific link between reflexology areas in the foot and parts of the human brain. The research, which used functional Magnetic Resonance Imaging (fMRI) to measure the brain activity of people undergoing reflexology, is the first study of its kind and offers tantalising proof that differences in the brain can be made by stimulating specific areas of the feet. Although reflexology is believed to be more than 4,000 years old, little is known about how the alternative therapy actually works, as Tracey Smith, Research and Development Manager at the Association of Reflexologists, explains. Although this practice has shown positive effects on the human body in some clinical studies, how reflexology works is not yet fully understood. “One of the major criticisms levelled at reflexology as a therapy is that there has been no proof of any route of connection between the foot and any other representative organ in the body, which is the underlying idea of reflexology,” she said. The fMRI study, which took place at the University of Tohoku, recruited 25 subjects (22 men and 3 women aged 18–41 years). The study investigated three reflex areas relating to the eye, shoulder and small intestine. Brain activity was measured during three sensory stimulation reflex areas, corresponding to the eye, shoulder, and small intestines. The experimenter stimulated each reflex area using a wooden stick with the right hand. A statistical analysis showed that reflexological stimulation of the foot reflex areas corresponding to the eye, shoulder, and small intestine activated not only the somatosensory areas corresponding to the foot, but also the somatosensory areas corresponding to the eye, shoulder, and small intestine or neighboring body parts. These areas of the brain correspond with Penfield’s Homunculus. The authors concluded that the activated area during the stimulation of each reflex area was consistent with the somatotopic representation of the corresponding or neighboring body parts in the somatosensory area. Previous fMRI studies of acupuncture revealed the somatotopical mapping of acupoints on the forearm, hand, leg and foot, and part of the visual processing areas, which were activated when an acupoint related to visual function was stimulated. The results indicated that reflexology had some effects that were not simply sensory stimulation. This new results support that claim and indicate that a neuroimaging approach may be a useful procedure for examining the underlying effects of this alternative medical practice. “Although this particular report is not enough evidence in itself, it does raise interesting questions about our understanding of the human body and shows the potential for alternative therapies to have greater influence on conventional treatment in the future,” Tracey adds. T. Nakamaru, N. Miura, A. Fukushima. and R. Kawashima. Somatotopical relationships between cortical activity and reflex areas in reflexology: A functional magnetic resonance imaging study. Neuroscience Letters 448 (2008), 6-9. Rankin-Box, D., 2009. MRI research sheds new light on reflexology. Complementary Therapies in Clinical Practice 15, 119
Reflex areas for the eye (No. 8), shoulder (No. 10) & small intestine (No. 25)
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Review by Tyraus Farrely, AMT In Good Hands (March 2007 & December 2008) • Excellent quality • Excellent value for money • Invaluable learning resource • Awesome Animated Graphics • Best nerve treatment DVD I have ever seen Overall Rating ***** A must see, highly recommended!
The Best Yoga Collection
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De Quervain’s Syndrome
De Quervain’s syndrome or De Quervain's tenosynovitis, or De Quervain's stenosing tenosynovitis is an inflammation of the sheath or tunnel that surrounds two tendons that control movement of the thumb. It is mainly caused by repetitive movements of the wrist and thumb, which can cause irritation and pressure on an anatomical tunnel known as the first dorsal compartment. Inside the first dorsal compartment run the two tendons of abductor pollicis longus and extensor pollicis brevis. De Quervain’s syndrome is characterized by inflammation of these tendons or their synovial sheath (tenosynovitis). The swelling causes increased restriction of the tendons through the first dorsal tunnel and sets up a chronic cycle of swelling and restriction. The condition is more common in women than in men (a study indicates 5 times more in women). However, some younger women develop symptoms during pregnancy and in the period after birth. It is also referred to as mother's wrist due to the conditions experienced by mothers caused by repeated ulnar deviation while holding their newborn babies. It was also
Grasps the thumb in the palm of the hand and ulnar deviates the thumb and hand. Test positive if it produces sharp pain along the groove of the radial styloid.
Picture courtesy of Primal Pictures
called washerwoman's sprain as it can be caused by wringing motions, such as wringing out a washrag (probably not that common anymore). Recently, it is also related to overuse of thumb from repeated text messaging, referred to as Blackberry Thumb. Although some relate it more with carpal tunnel syndrome. Pain, tenderness and swelling are the major complaint with De Quervain’s syndrome. Some-
Hold the thumb in the palm & ulnar deviate.
times numbness near the base of the thumb. Movements of the wrist and use of the tendons of the thumb exacerbate the pain. A simple test for de Quervain syndrome is called the Finklestein Test. Hold the thumb in the palm, and then ulnar deviated If this causes intense pain over the radial styloid, which disappears if the thumb is released, De Quervain's tenosynovitis is likely. Another variation
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De Quervain’s Syndrome
ening the muscles around the thenar eminence will help. Cold applications may help reduce inflammatory. Transverse friction of the tendon will help mobilize adhesions between the tendon and its sheath. The client’s writs is brought to ulnar deviation to put the tendons into stretch and friction is applied while they are stretched (Lowe, 2003). Several Hyatt Regency Spas in US are now offering Blackberry Thumb Massage for their guests. A hotel news release describes a session; “First, hands are warmed up with soothing rocks and an aroma hot towel. Next, kneading and compressions loosen muscles and warm oil is applied with firm strokes. The therapist then kneads and stretches deltoids, biceps, triceps, flexors and extensors, and uses an acupressure massage technique on hands and arms. The 30-minute treatment culminates with an aroma hot towel cleanse on each hand.” Feels good, but not sure if it will help much with De Quervain syndrome. References Cutler, N. How You Can Help Treat de Quervain’s Tendonitis. http://www.integrativehealthcare.org/mt/ archives/2006/11/ how_you_can_hel.html Lowe, W., 2003. Orthopedic Massage. Elsevier Health.
Custom-made splint to immobilize wrist movement.
is while the thumb is grasped in the palm, extend the thumb with the other fingers resisting. Sharp pain along the tendon indicates likely syndrome. It is very important to rest from the repetitive motions that cause the inflammation. Frequent rest breaks should accompany any tasks that require repetitive use of the wrist and hand. The use of a wrist splint or brace may help to reduce the occurrence of the condition, especially when used at the first sign of a problem. The wrists is immobilized with a splint or brace for part of the day to limit movement while the area is healing. If the area is inflamed, massage is contraindicated. Massage loos-
Cartoon courtesy of Montaz http://www.momtaz.nl/
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A New Contraindication of Massage
It has been bought to my attention recently a new contraindication in Massage which Therapist should be aware of and is currently not being addressed in the Colleges. I practice both Lymphology and Remedial Massage. I have had several patients in my clinic, referred from other Clinics that have performed Remedial Massage on these patients, all within a short period of time from one another, complaining of pain in their legs. This is not so unusual from our daily patient’s complaints except for one thing. The pain turned out to be Superficial Blood Clots. These clots are quite quick to disappear but left untreated will travel into the Deeper Venous System and brings along a different more life threatening problem. All of these patients have some form of either Lymphoedema Or Lipoedema in their legs. These patients cannot have any form of Remedial, Deep Tissue, Trigger Point or Vigorous Massage on their Oedematous limbs because it has and will continue to cause Superficial Blood Clots. How do we know if the Limb/s is oedematous or not? There are some simple tests which you should know. 1. Do your history. You cannot rely on the patient telling you they have a problem because they may not know they have Lymphoedema or Lipoedema. Ask if the patient has had any form of Cancer, now or in the past. Most patients develop their Lymphoedema Secondary due to Cancer node removal and radiation therapy, Mostly 3 – 8 years after the event. If they have had their surgery or radiation recently and there are no signs of oedema that doesn’t mean they haven’t got the start of it. 92% of patients that have had node removal or radiation will get Lymphoedema. There are 8,000 new cases every year reported in Victoria alone. Lipoedema is a genetic disorder of Women. The basic signs of this disease are the top half of the torso is a size 8 and the bottom half a size 14 or thick ankles. If you are in doubt whether or not this person suffers from Lymphoedema or Lipoedema, let the client know that you have a suspicion and leave that limb or limbs out of your session. Effleurage is fine going from distal to proximal, gently and rhythmically. The patient should be told they may have some swelling in their limb, so they can be sent to a Professional Lymphologist for correct diagnosis. Because Only 3% of Doctors know how to correctly diagnose Lymphoedema and even less know about Lipoedema a properly trained Lymphoedema Specialist is the best option to refer to. Much of my work to do this year is to try and rectify this situation. If you have any questions please email me on firstname.lastname@example.org
By Kristin Osborn
2. First Signs of Oedema. Puffiness, Stiffness, Discomfort, Heaviness, Tightness, Heat, Pain, (bursting, shooting, joint), Numbness, Difficulties in putting on Jewellery, Shoes or doing up Pants, An increase in weight for no apparent reason, Increase in skin temperature, Fibrosis and easy Bruising. This can be found in both Arms and Legs. The patient may get 1 or all of these symptoms. Written by Kristin Osborn Dip. R.M., Dip. M.Sc., T.A.A. Lymphologist, Clinician, Writer, Member AMT, ALA and LAV Resources used: Theory and Practice of Lymph Drainage Therapy 2nd Edition 2004
3. Other conditions associated with Lymphoedema. High Blood Pressure, Heart Conditions, Arterial and Venous conditions (Thrombosis and Varicose Veins), Diabetes, Thyroid condition, Inflammation – infections, Auto-Immune Disease, Hormonal Conditions and Pregnancy.
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Complex Regional Pain Syndrome
Pain resulting from nerve entrapment syndromes is a common reason for clients to seek the care of a massage practitioner. However, there are numerous neurological disorders that at first glance might appear to be a nerve entrapment problem, but are an entirely different pathological condition. Complex regional pain syndrome (CRPS) falls into that category. A brief review of fundamental neuroanatomy is helpful to properly understand what occurs in CRPS. The autonomic nervous system has efferent fibers that control activity in various smooth muscles, glands, and cardiac muscle. Within the autonomic system there are two divisions, the sympathetic and parasympathetic. The primary function of the sympathetic branch is to stimulate activity, while signals from the parasympathetic branch serve to inhibit activity. Of these two, the sympathetic branch is more involved in CRPS. The sympathetic nervous system has a vital role in protective reflexes as the body responds to stress. It is in high gear during the “fight or flight” response. However, excess sympathetic system activity can generate and maintain pain states in different regions of the body. It is this excess sympathetic activity that causes the symptoms of CRPS. While there is still not a complete understanding of how excess sympathetic branch activity causes these pain conditions, it appears that there is some spillover of noxious input from the sympathetic efferents into various nociceptors, especially in the extremities. Box 1: Symptoms of CPRS
• • • • • •
By Whitney Lowe
The term complex regional pain syndrome has only recently been added to the medical lexicon. It includes two separate conditions that have similar symptoms but are different in cause. The two conditions were formerly called reflex sympathetic dystrophy (now called CRPS 1) and causalgia (now called CRPS 2).5 The primary difference between them is how they occur. In CRPS 1 (reflex sympathetic dystrophy)
• • • •
Some initiating event, often traumatic, but may be trivial- surgeries, fractures, dislocations, Pain that is disproportionate to the inciting even Allodynia (painful response to a stimulus that is usually not painful) Hyperalgesia (exaggerated sensory response to a stimulus that would ordinarily produce only mild discomfort Allodynia and hyperalgesia in that extends beyond the distribution of a single peripheral nerve Evidence of autonomic dysfunction (edema, alteration in blood flow, sudomotor dysfunction such as excess sweating in the region) Pain is usually described as a burning, searing, or shooting Vascular abnormalities (more common in CRPS 1)—often start vasodilation and skin warming in the early phase and progress to vasoconstriction in later stages Excess edema in the affected extremity Motor impairment including weakness, inability to initiate movement, tremor, muscle spasm, or dystonia Changes in growth patterns of hair and nails on the affected limb Trophic changes in the skin
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symptoms commonly occur as a result of some traumatic incident, but there is no evidence of specific nerve damage. In CRPS 2 (causalgia) there is also some event that initiated excess sympathetic activity, but this condition also involves identifiable damage to the nerve. Most of the symptoms of CRPS 1 & 2 are similar and are included in Box 1. Distinguishing CPRS from other neurological disorders is aided by detailed evaluation of several clinical features in addition to those listed in Box 1. The condition can affect either the upper or lower extremity, but is more common in the upper extremity and the pain is usually aggravated with moving the affected limb. Various myofascial dysfunctions may also accompany the extremity pain.1 Women are affected more often than men with an approximate 3:1 ratio.2 Some degree of depression or psychological dysfunction is common with CRPS. However, it is unclear if this psychological dysfunction is a causative factor or a result of the condition because depression and similar psychological manifestations are common in severe and chronic pain conditions.4 cause myofascial dysfunction is often a part of the array of symptoms, addressing the myofascial component may interrupt the cycle of pain and dysfunction. Rashiq found that in many cases if the myofascial pain condition was properly addressed the whole syndrome may resolve.3 Massage is also likely to be helpful because it is effective at decreasing overall sympathetic system activity. If you have a client that demonstrates signs and symptoms that indicate the possibility of CRPS, it is important to have them properly evaluated by a physician. There are a number of other treatment strategies such as nerve blocks and medications that are effective in addressing the problem and it may be important to start these treatments as early in the rehabilitation process as possible. Notes This article is originally published in massage Today. 1. Allen, G., B. S. Galer, and L. Schwartz. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 80:539-544, 1999. 2. Ghai, B. and G. P. Dureja. Complex regional pain syndrome: a review. J Postgrad Med. 50:300-307, 2004. 3. Rashiq, S. and B. S. Galer. Proximal myofascial dysfunction in complex regional pain syndrome: a retrospective prevalence study. Clin J Pain. 15:151-153, 1999.
4. Walker, S. M. and M. J. Cousins. Complex regional pain syndromes: including "reflex sympathetic dystrophy" and "causalgia". Anaesth Intensive Care. 25:113CRPS can be a debilitating condi- 125, 1997. tion. Because it occurs more often 5. Wasner, G., M. M. Backonja, in the upper extremity it may be and R. Baron. Traumatic neuraleasy to dismiss many of the gias: complex regional pain synsymptoms as arising from a pedromes (reflex sympathetic dysripheral compression neuropathy trophy and causalgia): clinical such as carpal tunnel syndrome. characteristics, pathophysiologiHowever, awareness of the varical mechanisms and therapy. ety of symptoms associated with Neurol Clin. 16:851-868, 1998. CRPS allows the practitioner to Treatment for CRPS varies widely look at a bigger picture and catch but physical therapy is a primary this condition early on, if present, component of most treatment so it can be most effectively protocols. The goal of most physi- treated. cal therapy treatments is to desensitize the area and restore normal function of the affected extremity. Massage may play a fundamental role in this process. Be-
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Neural coding for massage stroke
Researchers have found that some nerves in the skin send 'feel good' signals to the brain when activated by gentle, slow massage stroke. But they only work when the skin is stroked at just the right speed, 1-10 cm per second with an optimal rate around 4 centimetres per second. Rub too fast or too slow, and the nerves are not stimulated. Researchers demonstrated the effect of C-fibres on volunteers using a 'robotic tactile stimulator' – a mechanical arm fitted with soft brush. Sensually caressed by the robot, the volunteers produced C-fibre signals that could be recorded. Professor Francis McGlone said: "If you get a piece of grit in your eye, have a toothache, or bite your tongue, it hurts so much because there are more C fibres there. The research we have been doing is building evidence for another role of C fibres in the skin that are not pain receptors, but are pleasure receptors." He said the findings appear to explain "the pleasant… aspects of touch we are all familiar with, such as when grooming or being cuddled". The nerves are found in skin covered by hair but are absent in the palms of the hands. "We believe this could be Mother Nature's way of ensuring that mixed messages are not sent to the brain when it is in use as a functional tool," said Professor McGlone.
Massage can relieve pain
For those who experience lingering pain following exercise, a relaxing deep massage can help relieve musculoskeletal pain associated with exercise-induced pain, according to research reported in The Journal of Pain. Researchers at the University of Iowa performed a doubleblinded, randomized controlled trial to study the effects of massage on pressure-pain thresholds and perceived pain using delayed muscle soreness following exercise as the pain measurement. Trial participants were divided into three groups: no-treatment (control), superficial touch and deep tissue massage. Pain was assessed before treatment, after exercise and before and after treatment. The authors found that subjects given deep-tissue massage were able to increase their pain thresholds and decrease stretch pain compared with the notreatment group. When combining the deep-tissue massage and light-touch groups, they found that stretch-pain reductions remained significantly better than in the control group although the light-touch treatment was not significantly better than no treatment. The authors concluded that their study demonstrates that softtissue massage can reduce hyperalgesia and pain using a delayed onset muscle soreness model. The findings support use of massage to reduce stretchpain perception and hyperalgesia.
Unique multifidus design contributes to spine stability
Picture courtesy of Real Bodywork
The novel design of a deep muscle along the spinal column called the multifidus muscle may in fact be key to spinal support and a healthy back, according to researchers at the University of California, San Diego School of Medicine. Their findings about the potentially important “scaffolding” role of this poorly understood muscle has been published on line in advance of the January issue of the Journal of Bone and Joint Surgery. “The multifidus muscle was formerly thought to be relatively unimportant based on its fairly small size,” said Richard L. Lieber, Ph.D. “Our research shows that it’s actually the strongest muscle in the back because of its unique design. It’s like a long, skinny pencil packed with millions of tiny fibers.” The researchers discovered that the multifidus has a unique packing design consisting of short fibers arranged within rods,
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and that these fibers are stiffer than any other in the body. Using laser diffraction methods that they developed to measure muscle internal properties during back surgery, they demonstrated that the multifidus’ unique design serves a critical function as a stabilizer of the lumbar spine. These findings could have implications for surgery, according to Steven R. Garfin, M.D. “It is important to identify what each individual muscle does, and this is just a start, showing that the multifidus contributes significantly to spinal stabilization,” said Garfin. “The more we know about what muscles do, the better we can devise therapeutic interventions such as physical therapy to target specific muscles.” new systematic review published in the January issue of Physical Therapy (PTJ). In addition to feeling less pain, patients performing these types of exercises are able to be more physically active and experience positive effects over a longer period of time than those who receive other treatments, according to researchers. ber of massage therapists per 1,000 residents of a state and the life expectancy for that state. As the number of massage therapists per resident increases, the life expectancy tends to increase. A model suggested that with an increase in one therapist per 1000 residents, the life expectancy increases 1.7 years. Hawaii is the state with the greatest number of massage therapists per resident and is the state with the greatest life expectancy as well. Utah and Colorado also place in the top ten in both categories. The states with the lowest concentrations of massage therapists tend to have the lowest life expectancies. Louisiana, Kentucky, Georgia, Mississippi, and Alabama all place in the bottom ten for both number of massage therapists and life expectancy. Certainly encouraging, although drawing a long bow, the author suggests that the higher number of massage therapists meaning more people are getting into massage, and it improves life quality, thus life expectancy!
Motor control exercise, also known as specific stabilization or Core exercise, is a new form of exercise for back pain that has gained the attention of researchers and health practitioners over the past decade. The exercise focuses on regaining control of the trunk muscles, also known as the transversus abdominis and multifidus, which support and control the spine. Previous studies of paGarfin explained that many mus- tients with low back pain have shown they are unable to properly cles get weaker as they are excontrol these muscles. Through tended. But the researchers dismotor control exercise, patients covered that, unlike all other are taught how to isolate and muscles, the multifidus actually becomes stronger as it lengthens, “switch on” these muscles and when the spine flexes. “The length then incorporate these movements into their normal activities. of the sarcomere—the structure within the muscle cell where filaments overlap to produce the “Although the exercises seemed movements required for muscle promising, until now we did not contraction—is shorter in the have clear evidence on whether or multifidus than in any other mus- not they were more effective,” accle cell,” explained study’s first cording to researcher Luciana G author Samuel R. Ward, P.T., Macedo, PT, MSc, a PhD student Ph.D. “But as it gets longer, for at The George Institute for Interinstance as a person leans fornational Health, Sydney Univerward, the multifidus actually sity, Australia. strengthens.”
Motor Control Exercises Re- Massage Therapy & Life Exduce Persistent Lower Back pectancy Pain
A statistical analysis performed by Medical Massage Care indiMotor control exercises, when cates that therapeutic massage performed in conjunction with tends to increase life expectancy. other forms of manual therapy, can significantly reduce pain and Using the data from 50 states in disability in patients with persis- the US, the author found a positent low back pain, according to a tive correlation between the num-
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6 Questions to Til Luchau
1. When and how did you decide to become a bodyworker? My bodywork interest originally came out of my psychological training. In the early 1980’s I was studying Gestalt and other experimental psychotherapies at the Esalen Institute in Big Sur, CA. Gestalt emphasizes the role of the body in psychological growth, and our teacher encouraged us to study a body modality in order to be better therapists. There were great opportunities for studying the work of early bodywork pioneers at Esalen then—several of Ida Rolf’s, Moshe Feldenkrais, Milton Trager, and Randolph Stone’s original students and teachers were in residence there. I enjoyed the body work itself, and got good feedback, so I continued studying and it became a focus of mine. Soon I was teaching at Esalen, then later at the Rolf Institute, where I’d gone to train in 1985. (I also worked for a long time as a body-centered psychotherapist--that part of my work still informs my work as a bodyworker and teacher, and has evolved over the years onto my coaching practice and organizational development work.) 2. What do you find most exciting about bodywork therapy? The one thing? think it is the experience of actually receiving great bodywork. Earlier this year, we had a 9-day retreat in Mexico for a dozen of our (Advanced-Trainings.com’s) faculty and assistants. We traded a lot of work and ideas, and I realized there that we all had one thing in common—a love for the amazing altered state of heightened somatic awareness that comes with skilled bodywork. Bodyworkers classically neglect receiving bodywork themselves. There are exceptions to this of course, and I think those that make sure to stay connected to the actual experience of receiving good work, do much better work, and enjoy it more. Helping people, learning and researching, sharing and teaching, and working together with talented colleagues in a training situation are the things that keep me loving this work. 3. What is your favourite bodywork book? The Encyclopedia Anatomica from Taschen has great photos of gorgeous, anatomically precise wax models that were made for Florentine medical students in the 18th century. Kapandji’s Physiology of the Joints series is an unparalleled source of inspiration and technical insight into how joints function. 4. What is the most challenging part of your work? I find this question particularly challenging! Why can’t I think of a “most challenging part?” It isn't’ for any shortage of difficulties...maybe its just because the good and the “bad” are so intrinsically wrapped together in this work, and that those that make it their path take all that together, that I can’t tease out a challenge that isn’t also a gift. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? I always enjoy it when I get to work with a new therapist who is enthusiastic about the work itself, and who sees this path as one of multi-dimensional development. As a way to make a living, there are a lot of easier and more lucrative ways to go; as a path with “heart,” this is hard to beat. 6. How do you see the future of massage therapy? I don’t know about Australia, but in the USA, the changes in the profession are extreme—the number of practitioners being trained exploded, but now is declining some; the quality of education varies widely; there is a general shift towards the polarized dichotomy of being either treatment-oriented, or relaxation/spa –oriented; there is increasing commoditization of massage and massage education, as businesses consolidate into larger entities, and look to efficiency and volume. The recent economic worries haven’t caused the sky to fall for most established practitioners here, although it has varied region to region, and I do know plenty of stories of folks whose practices have slowed way down. I think there will always be a place for highly-skilled practitioners to be appreciated for their work. Although “Massage Therapy” as a career and profession is undergoing all sorts of changes, us humans have been using skillful touch for longer than we’ve been humans. There is at least 100,000 years of history of bodywork. It isn’t going anywhere.
Til Luchau is the director and a lead instructor at Advanced-Trainings.com Inc., which offers continuing education seminars and support services for practitioners and schools throughout the USA and abroad. The originator of Skillful Touch Bodywork (the Rolf Institute®'s own training and practice modality), he is a Certified Advanced Rolfer® and a Rolf Institute® faculty member.
Bodywork e-News 41
6 Questions to Anita Boser
1. When and how did you decide to become a bodyworker? I was receiving a Hellerwork session, the 7th of the Hellerwork Series, and on the table decided that I would like my life more if I were helping people feel better rather than helping them save money on insurance. It was an odd thought, alternative health care had never occurred to me before, but I considered it from every angle and decided to make the leap. 2. What do you find most exciting about bodywork therapy? That's easy. When my clients get off the table with the experience of less pain, more hope, or new awareness. The transformation feeds my spirit. 6. How do you see the future of massage therapy? Better understood as a diverse therapy with different applications for different intentions. More accepted and widely used. And, continually evolving as we reach new understanding.
Anita Boser, LMP, CHP graduated from the Institute of Structural Medicine and practices Hellerwork Structural Integration in Issaquah, WA, USA. She is the author of Relieve Stiffness and Feel Young Again with Undulation and the audio version, Undulation Exercises. She created a way to make this fundamental movement pattern accessible to people who don't feel like they move well. Her practice as a Hellerwork Structural Integrator includes teaching her clients how to use small movements to melt stuck spots, especially in the back. She accumulated a variety of exercises that transform bodies from stiff and uncomfortable to graceful and at ease. She can be contacted at email@example.com or www.undulationexercise.com.
3. What is your most favourite bodywork book? Oh my, that's not easy. Just one? My latest favorite book is Michael Stanborough's Direct Myofascial Release Techniques. I purchased it last October and haven't made it all the way through yet. There's a lot of information! My all time favorite is probably The Endless Web. I love to read it and get lost in the infinite beauty and connectedness of the body.
4. What is the most challenging part of your work? Detaching myself from the expectation of specific results from my work.
5. What advise you can give to fresh massage therapists who wish to make a career out of it? You can do it!! Remember to ask for help, from other practitioners, from mentors, from your friends, from your clients. You don't have to do it all by yourself.
Bodywork e-News 42