Terra Rosa E-mag #17

Terra Rosa E-magazine

Open information for Bodyworkers No. 17, December 2015

Anatomical drawings by Leonardo da Vinci.

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Terra Rosa E-magazine, Issue No. 17, December 2015.

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ontents

Understanding the placebo effect—Brian Fulton

10 Myofascial pain syndrome & fibromyalgia—John Sharkey 18 Integrating new techniques—Art Riggs 20 Improve your results for clients with persistent pain — Rachel Fairweather 28 The importance of joint mobilization— Joe Muscolino 40 Easy assessment for massage therapist—Sean Riehl 46 Type 1 ankle restrictions and plantar fasciitis — Til Luchau 54 Manual therapy for lower back pain—Evidence-based and clinical outcomes 58 Research Highlights 62 6 Questions to Brian Fulton 63 6 Questions to Rachel Fairweather www.terrarosa.com.au

Be Flexible & Stay Well

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Understanding the Placebo Effect

By Brian Fulton RMT

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In 2011, the Journal of Manual and Manipulative Therapy published a peer-reviewed paper published by entitled ‘Placebo response to manual therapy: something out of nothing?’ In it, the authors look at 94 different research papers on manual therapy and on the placebo effect and draw some relevant inferences about the placebo effect in manual therapy. Some of the papers that they looked at clearly suggested that what you and I think may be happening isn’t exactly what is happening. The evidence points to a strong placebo component in what we do in the manual therapy professions. The authors state the following: “We suggest that manual therapists conceptualize placebo not only as a comparative intervention, but also as a potential active mechanism to partially account for treatment effects associated with manual therapy. We are not suggesting manual therapists include known sham or ineffective interventions in their clinical practice, but take steps to maximize placebo responses to reduce pain.”2

Some therapists shudder at the mention of the term placebo effect, others are curious as to what it might be, still others embrace the concept. Where do you lie on this spectrum? Sticking one’s head in the sand and denying that it exists in your treatments is actually not helpful to you or to the patient, because the placebo effect has been found to exist in virtually every medical encounter and appears in virtually almost every drug trial ever performed.

“There is no ‘choice’ about whether or not to ‘use’ the placebo (and nocebo) effects. Those effects are going on in every medical encounter between patient and physician. They exist whether we want them to or not; whether we are consciously exploiting them or not. The ‘choice’ is about how we go about using them: well or poorly, blindly or thoughtfully.” 1 – Dr. Howard Brody, Director of the Institute for Medical Humanities of the University of Texas.

Another review of evidence is a paper published in 2010 entitled Effectiveness of manual therapies: the UK evidence report. In this report the authors looked at 49 recent relevant systematic reviews, 16 evidence-based clinical guidelines, plus an additional 46 random controlled trials (RCT) that had not yet been included in systematic reviews and guidelines. The authors looked at 26 categories of conditions containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine nonmusculoskeletal conditions. This report, published in Chiropractic and Manual Therapies (the official journal of the Chiropractic & Osteopathic College of Australasia, the European Academy of Chiropractic and The Royal College of Chiropractors) recognizes the important role that manual therapy plays in treating a wide variety of ailments, but even in this report the authors state: “Additionally, there is substantial evidence to show that the ritual of the patient practitioner interaction has a therapeutic effect in itself separate from any specific effects of the treatment applied. This pheTerra Rosa E-mag 3

The Placebo Effect nomenon has come of age; and yet the term drags centuries of baggage along with it. In common language people will often say, “Oh, that’s just a placebo effect.” What people often fail to recognize is that every time the placebo effect is observed, the body is healing itself. Is this not our goal as health practitioners? Is it not our primary goal to help create an environment where the patient’s body can heal itself? I submit that the primary reason for practitioners to understand the placebo effect is so that we can learn to manage the contextual factors within the clinical environment that will couple with our physical intervention to produce an optimal healing environment.

What is the Placebo Effect? nomenon is termed contextual effects. The contextual or, as it is often called, non-specific effect of the therapeutic encounter can be quite different depending on the type of provider, the explanation or diagnosis given, the provider's enthusiasm, and the patient's expectations”. 3 Research interest in this phenomenon has continued to grow dramatically in this topic. In 2011 Harvard created an institute dedicated wholly to the study of placebos, the Program in Placebo Studies and the Therapeutic Encounter (PiPS). It is based at the Beth Israel Deaconess Medical Center and Ted Kaptchuk, a prominent figure in placebo studies, was named its director. Its purpose is to bring together researchers who are examining the placebo response and the impact of medical ritual, the patient-physician relationship and the power of imagination, hope, trust, persuasion, compassion and empathic witnessing in the healing process. PiPS research is multi-disciplinary extremely inclusive spanning molecular biology, neuroscience and clinical care, as well as interdisciplinary, ranging from the basic sciences to psychology to the history of medicine. This certainly gives you an idea of not just how important the study of the placebo effect is, but also how complex it is.

If one looks at the money and energy that is now being invested in understanding the placebo effect, it is clear that the study of this innate healing phe4 Terra Rosa E-mag

Admittedly most of our knowledge surrounding the placebo effect is theory. What is not known vastly overshadows what is known, but the working theory is that psychosocial cues initiate neurobiological mechanisms which modulate existing healing responses, bringing about subjective and objective (measurable) changes.

--- The Placebo Effect --Psychosocial Cues ⇒ Neurobiological Pathways ⇒ Subjective and Objective Changes

Psychosocial Cues Cues in the environment and in the patientpractitioner relationship appear to trigger placebo effects. A common term that you have undoubtedly encountered for these cues is contextual factors.

This is a very useful term as it alludes to what might be going on. Another term used to describe this phenomenon is non-specific effects however, not only does this term lack any real description or hint as to what is going on; it is actually misleading. A far cry from non-specific, the ‘effects’ of this phenomenon can be amazingly specific: from blood pressure changes, changes in immune response, improvement in exercise tolerance, or changes in tissue

quality to name just a few. What are more elusive and complex are the triggers and the pathways that bring about this effect. While semantics get raised every time the placebo is discussed, I suggest that we not get side-tracked by semantics, but rather focus on the factors that initiate this healing phenomenon.

The triggers for these healing effects are wide and varied (as are humans) but there is some agreement that they can be grouped under one of the following the headings: conditioning, expectancy, and meaning. Meaning is a very broad topic though that takes in a large number of concepts. The following is a list of concepts that I examine in my book, The Placebo Effect- Improving Clinical Outcomes. Research supporting each concept is examined in the book, and practical methods are discussed for incorporating each idea into one’s own practice to the end of improving clinical outcomes. 4 Examples of Psychosocial Cues (Contextual Factors)                      

Expectancy (Hope, Belief) Conditioning Trust in the Practitioner Motivation and Desire The Power of Listening Feelings of Care and Concern from Practitioner Establishment of a Feeling of Control Reducing your Patients’ Anxiety Levels Receiving Adequate Explanation of the Pathology Acceptance of the Mystery of Healing Certainty of the Patient Time Spent By the Practitioner Use of Ritual Professionalism Clinician’s Belief System Confidence of the Practitioner Competence of the Practitioner Practitioner’s Attire Enthusiasm of Practitioner Use of Humour Patient’s Inner Narrative Clinical/Healing Environment

Every factor listed above has been shown to independently affect clinical outcomes, and there is likely an additive healing effect from these cues. Becoming aware of these elements in your daily practice and consciously improving your skills in these areas will yield benefits for the patient. Ultimately these contextual factors are what we need to focus on is we want to manage placebo triggers in the clinical environment. A complete article could easily be devoted to every one of these contextual factors.

For more information on each of these topics I recommend reading ‘The Placebo Effect in Manual Therapy-Improving Clinical Outcomes’.

Pathways and Mechanisms “On the basis of these recent insights, it is clear that the placebo response represents an excellent model to understand mind-body interactions, whereby a complex mental activity can change body physiology. Psychiatry and psychology, as disciplines investigating mental events, are at the very heart of the problem, for they use words and verbal suggestions to influence the course of a disease. Psychiatry, for example, has in its hands at least two therapeutic tools: words and drugs. Interestingly, what has emerged from recent placebo research is that words and drugs may use the very same mechanisms and the very same biochemical pathways.”5 - Fabrizio Benedetti (Professor of Physiology and Neuroscience at the University of Turin Medical School) What is known for sure about placebo pathways is that if an individual lacks prefrontal control, there is limited to no placebo response. The prefrontal cortex is brain region is intimately involved in planning complex cognitive behaviour, personality expression, decision making, and moderating social behaviour. This brain region is considered to be the centre of orchestration of thoughts and actions in accordance with internal goals. One of the features of Alzheimer's disease is the impairment of prefrontal executive control. Benedetti found a clear disruption of the placebo response occurred when reduced connectivity of the prefrontal lobes with the rest of the brain was present.6 At least four biological pathways have been proTerra Rosa E-mag 5

The Placebo Effect posed for facilitating placebo responses.

tion and blood pressure.

Endorphin Pathways- Diagnostic equipment now allows us to look inside of the living brain and see what is going on. Brain scans show µ-opioid receptors in the brain being activated by a placebo in brains of subjects experiencing pain relief from taking a placebo.7 Clearly the endorphin pathway is involved in the placebo effect, especially where pain modulation is happening.

Acute Phase Inflammatory Response- In his book, Placebo: Mind Over Matter in Modern Medicine, Dylan Evans presents a detailed argument for the acute phase inflammatory response theory. Evans states that the conditions where the placebo effect is most pronounced (pain, swelling, ulcers, depression anxiety) all involve the acute phase inflammatory response. He reminds us that this response goes beyond the classic signs of inflammation (tumor, rubor, calor and dolor), but is now recognized to include a suite of symptoms known as ‘sickness behaviour’. 10 Sickness behaviour includes lethargy, apathy, loss of appetite and increased sensitivity to pain.

Neuroendocrine Pathway- The neuroendocrine pathway involves not just the sympathetic and parasympathetic nervous systems, but also the hypothalamus, pituitary gland and the adrenal glands, collectively known as the HPA axis. The neural pathway of the HPA axis signals the adrenal medulla to release catecholamines (not the least of which is adrenaline), which are known to increase heart rate, blood pressure, breathing and metabolic rate. In addition to these symptoms, our sympathetic nervous system increases muscle tone, which as you know can manifest as musculoskeletal pain. Dampening of this pathway (which can be triggered by a thought or a feeling) could account for placebo success with generalized musculoskeletal pain, specific pain such as headaches, cervical or lumbar pain.

This pathway is also proposed for placebo success with hypertension, chronic pain and stomach ulcers, as well as immune system bolstering and normalization of blood sugar levels.

Psychoneuroimmune Pathway- Immune system cells are studded with receptor sites for neuropeptides associated with emotional states. In other words, your immune system reacts to (among other things), how you are feeling. There are both afferent and efferent fibres in this pathway, so there is a lot of information passing back and forth from the brain to the immune system allowing for finetuning, checks and balances. Involvement of the hypothalamus and pituitary gland in this loop has caused some researchers to speculate that there is an ideal ‘set point’ for the immune system, to keep it at a certain level of readiness.8,9 What we have learned is that conscious intervention can modulate this immune response, much as it does with respira6 Terra Rosa E-mag

Subjective and Objective Changes Not only do people experience substantial pain relief from placebo interventions, studies have seen measurable changes in heart rate, blood pressure, immune response, endocrine response, and inflammation, which can bring about healing responses seen in tissue changes, range of motion, pain levels, exercise tolerance, and even markers such as BMI. Some examples include: 

A wisdom tooth extraction trial using placebo ultrasound produced reductions in swelling and healing time.11

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Studies have found increase in natural killer cell function with saline injections when subjects where first conditioned with adrenalin injections. 12

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Dylan Evans’ list of conditions most influenced by placebos includes: inflammation, stomach ulcers, anxiety, depression and virtually all types of pain. 13

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Investigation into the mechanism of the placebo effect currently taking place at several medical universities has documented substantial, measurable physiological changes taking place. 14

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A 2011 review of current literature conducted

by Fabrizio Benedetti stated, “recent research

has revealed that these placebo-induced biochemical and cellular changes in a patient's brain are very similar to those induced by drugs.”15 Ethical Considerations When one thinks of using placebos, deception often comes to mind, since this is how they have often been used in the past. However in my investigation of contextual effects that elicit the placebo response in the clinical environment, I have found that the exact opposite is true. As I began writing my book I began to see several themes emerge. The first theme is the importance of trust in the practitioner/patient relationship. Anything that enhances this trust will tend to enhance healing responses (and vice versa). Clearly deception will not enhance trust. Secondly, improved healing responses are seen when the locus of control lies with the patient, rather than the practitioner. The patient that takes charge of his or her health is going to see improved outcomes. Making the patient aware that these amazing healing effects exist within their own mind and body do not lead to evaporation of the effect, but to enhancement of healing responses and a personal sense of power over one’s health. Finally, increased professionalism of the practitioner leads to improved placebo responses. This may be a perception issue, since much of the placebo effect appears to involve the patient’s perception of their practitioner, but the way to improve their perception of you is by being a more competent professional. So in the end, if you are an ethical professional, you have no worries about employing techniques to encourage healing in your patients. In fact, I recommend reminding your patients that the placebo effect is real, and it manifests from their own internal healing systems as well as their relationship with you. It is not a minus, but a plus for the patient to realize the amazing healing potential of their own bodies.

Conclusion I hope that you now see that the placebo effect isn’t quite as mysterious as you may have thought. It manifests from innate healing mechanisms present in the body, and many triggers for this phenomenon

appear to flow out of a healthy patient-practitioner relationship. Furthermore, placebo effects are real and often measureable. Our task as practitioners is to understand and optimize contextual factors within the clinical environment that can act as triggers enhancing the patient’s innate healing response. This can be incorporated ethically and seamlessly into each and every treatment during assessment, interaction, and treatment of the patient. Our goal as practitioners should be to become more competent at understanding and managing the complex dynamics known as contextual factors that come into play in the therapist-practitioner relationship.

References 1 Using

Placebo Responses in Clinical Practice: Is there a there, there? What do we need to know? Samueli Institute, Jan. 20, 2012, pg 15 2 Bialosky, J.E et al. (2011) Placebo response to manual therapy: something out of nothing? J Man Manip Ther. February; 19 (1): 11–19 3 Bronfort, G. et al. (2010) Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010; 18: 3.

4 Fulton, B. (2015) The Placebo Effect in Manual Therapy- Improving Clinical Outcomes. Handspring Publishing, Edinburgh: 84-246

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The Placebo Effect Benedetti, F (2012) The placebo response: science versus ethics and the vulnerability of the patient. World Psych. 11(2): 70–72.

6 Benedetti, F. et al., (2006) The Biochemical and Neuroendocrine Bases of the Hyperalgesic Nocebo Effect. Journ Neurosci, 26(46):12014–12022 7 Zubieta et al. (2005) Placebo effects mediated by endogenous opioid activity on µ-opioid receptors. The Journal of Neuroscience 25(34): 7754-7762.

8 Schwartz, C. (1994). Introduction: old methodological challenges and new mind-body links in psychoneuroimmunology. Advances in Mind-Body Medicine 10(4): 4-7 9 Barak, Y. (2006). The immune system and happiness. Autoimmunity Reviews 5 (8): 523-527 10 Kent, S., R.-M. Bluthe et al. (1992). Sickness behaviour as a new target for drug development. Trends in Pharmacological Science 13: 24-28 11 Hashish, I., H.K Hai et al. (1986). Reduction of postoperative pain and swelling by ultrasound treatment: a placebo effect.

Pain 33: 303-311 12 Kirschbaum, C et al. (1992). Conditioning of drug-induced immunomodulation in human volunteers: a European collaborative study. British Journal of Clinical Psychology 31: 459-472 13 Evans, Dylan (2004). Placebo: Mind Over Matter in Modern Medicine. London, England. Harper Collin: 44 14 Benedetti F., Amanzio M. (2013). Mechanisms of the placebo response. Pulm Pharmacol Ther. Jan 28. pii: S1094-5539(13) 00052-7 also Pollo A, Carlino E, Benedetti F. (2011) Placebo mechanisms across different conditions: from the clinical setting to physical performance. Philos Trans R Soc Lond B Biol Sci. Jun 27;366(1572):1790-8. also Meissner K. (2011) The placebo effect and the autonomic nervous system: evidence for an intimate relationship. Phi5

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los Trans R Soc Lond B Biol Sci. Jun 27;366(1572):1808-17.

Benedetti, F., Amanzio, M. (2011). The placebo response: how words and rituals change the patient's brain. Patient Educ Couns. 2011 84(3):413-9.

Brian Fulton RMT has been a Massage Therapist since 1999. Trained and educated in Ontario, Canada, he has maintained a clinical practice with a distinctly holistic approach to healing and disease prevention. As a past Director of the Registered Massage Therapists’ Association of Ontario, he has been actively involved in moving his profession forward on all levels.

In addition to his private practice, Brian was a health columnist for a community magazine for over ten years, writing on a broad range of topics from nutrition, exercise, injury management and disease prevention. His current passion lies in educating health practitioners in becoming more aware of the innate healing mechanisms inside of their patients. His book, The Placebo Response in Manual Therapy – Improving clinical outcomes in your practice, is a detailed work guiding health professionals in the important area of accessing their patients’ natural healing systems by understanding subtleties in the practitioner-patient relationship.

The Placebo Response in Manual Therapy presents a knowledge-based approach to augmenting your patients’ own healing systems.

It explains how to: maximize the placebo response in your patients, using knowledge from 60 years of research “turn on” an individual’s inner healing system, even with challenging patients increase your success rate and your patients’ health outcomes within your current methods of practice .

Available at: www.terrarosa.com.au

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Terra Rosa is your source for massage information.

We have the largest & best collection of Massage and bodywork Books in Australia and in the world.

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Myofascial Pain Syndrome and Fibromyalgia The Myofascial Trigger Point Connection John Sharkey Clinical Anatomist (BACA), Exercise Physiologist (BASES), Myofascial Trigger Point Specialist.

MSc., Faculty of Medicine, Dentistry and Clinical Sciences, University of Chester/NTC, Dublin, Ireland

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Introduction Myofascial Pain Syndrome (MPS) has been described as sensory, motor, and autonomic symptoms caused by Myofascial Trigger Points. Most, if not all, experts on myofascial trigger points describe them “as exquisitely tender spots in discrete taut bands of hardened muscle producing local and/ or referred pain”. Several terms including “knots” or “contraction knots with a nodular feel” have been used to describe what the therapist feels on palpating the tissues with their finger tips. People experiencing Myofascial Trigger Points present in the clinical setting complaining of pain, however, this is only one part of a more accurate story. People suffering the consequences of Myofascial Trigger Points also suffer “changes in sensations” (Fig 2).

This fact can be overlooked, forgotten or simply not appreciated by qualified therapists and health care providers. This short article aims to provide accurate information concerning the Etiology and Pathophysiology of the Myofascial Trigger Point.

Also a focus on “changes in sensations” will highlight the need for therapists to include this term in advertising or promotional materials. Finally, this article will offer general guidelines for the effective treatment and /or management of myofascial pain.

I invite readers to join me at one or all of my upcoming workshops in Sydney next June (2016) where among other things I will build your knowledge concerning Myofascial Trigger Points, Biotensegrity (anatomy for the 21st century) and provide you with hands-on soft tissue therapeutic applications that have worked for my chronic pain patients.

Fibromyalgia and the Myofascial Trigger Point Fibromyalgia is neither musculoskeletal nor rheumatic. Fibromyalgia does not cause aching muscles.

It does not cause numbness or tingling. Patients with fibromyalgia can have these and many other symptoms, but those symptom origins have been widely misunderstood and so have the patients. Fibromyalgia is the term given to a family of illnesses that have in common central nervous system sensitisation and chronic diffuse systemic pain. Fibromyalgia is systemic, not local. A person cannot have fibromyalgia only in the hands or in the back or in one foot. The central nervous system is the brain and spinal cord becoming the peripheral nervous system touching every cell in the soma.

Fibromyalgia affects the whole body, causing a diffuse pain all over. Fibromyalgia does not cause localized pain. If there is localized pain, it is caused by something else, although Fibromyalgia may also be

present. Often, but not always, localized pain is caused by one or more Myofascial Trigger Points.

Fibromyalgia is a chronic body wide muscle (myofascial) soreness syndrome associated with central and peripheral sensitisations due in no small part to the body being stuck in a stress response. Sleep disturbance, chronic fatigue and visceral pain syndromes (including irritable bowel syndrome and interstitial cystitis) regularly accompany Fibromyalgia. Fibromyalgia is characterized by hyperalgesia (amplified pain) and allodynia (normally non-painful stimuli such as touch, sounds, light, and smells all interpreted as intense pain by the Central Nervous System). It is a critical point that myofascial pain syndrome is characterised by the presence of myofascial trigger points located in any of the millions of individual muscle fibers throughout the entire body.1 Peripheral stimuli, such as Myofascial Trigger Points, may initiate noxious sensations including pain, nausea or dizziness. Amplified by fibromyalgia the pain or other sensations can outlast the stimulus. Research verifies that the central sensitization of fibromyalgia can be initiated and/or maintained by peripheral pain.2 The referred pain of myofascial trigger points is itself a manifestation of central sensitization.3 In fibromyalgia the filters that protect healthy people from central nervous system over-stimulation are not working adequately.4 The fibromyalgia patient may not be able to pinpoint sources of pain, because his or her brain is totally preoccupied with attempting to handle a deluge of pain and other stimuli. In uncontrolled fibromyalgia, anything that can shock the central nervous system—including pain, loud noises, and any other startling stimuli—must be moderated or avoided. Any central nervous system assault can lead to fibromyalgia “flare.” During flare, old symptoms worsen and new ones may appear as new Myofascial Trigger Points activate. Everything is hypersensitive.

Etiology and Pathophysiology of the Myofascial Trigger Point The causes or perpetuation of Myofascial Trigger Points can include trauma to myofascial tissues, muscle fibers, intervertebral discs, inflammatory conditions, myocardial ischemia, non-accustomed exercise or physical activity, bad posture, fatigue, inadequate sleep, distress, hormonal influences, poor nutrition, over-weight or obesity, smoking and lack of activity. According to research5, Myofascial Trigger Points can form due to a disruption of the cell membrane, damage to the sarcoplasmic reticuTerra Rosa E-mag 11

lum and subsequent migration of increased levels of calcium-ions, and disruption of cytoskeletal proteins, such as desmin, titin, and dystrophin. Ragged red (RR) fibers (also known as moth eaten fibers) and increased numbers of cytochrome-c-oxidase (COX) negative fibers are common in patients with myalgia, which are suggestive of an impaired oxidative metabolism. In any case the key issue at the cellular level centers around increased levels of calcium ions trapped within the sarcomere. Moving towards the gross anatomical and physiological levels an energy crisis is witnessed perpetuating the formation, establishment and maintenance of Myofascial Trigger Points.

Anything that perpetuates a Myofascial Trigger Point is called a “perpetuating factor.” Therapists are fighting a war on pain. The foot soldiers of the enemy are perpetuating factors including mechanical stressors such as paradoxical breathing, body disproportions (leg length discrepancy, clavicular asymmetry or small hemi pelvis), myofascial or connective tissue abuse, and articular dysfunctions.

Metabolic perpetuating factors include impairments to energy metabolism, coexisting conditions such as lack of restorative sleep and pain. Environmental perpetuating factors include pollution, medications, trauma, and infections.

Psychological perpetuating factors are also an important area to investigate. Lifestyle perpetuating factors are often the least expensive perpetuating factors to remedy, but may be among the most difficult to maintain. To further complicate life, perpetuating factors often have perpetuating factors of their own. Cognitive therapy and mindfulness can be useful interventions to help us change the way our patients/clients and we therapists think about and perceive pain. What initially activates a Myofascial Trigger Point may be different from what aggravates (worsens) or perpetuates (maintains) it, but they are all commonly called perpetuating factors. The key to controlling any symptom is the control of as many perpetuating factors as possible.

An appropriate medical history will indicate if pain patterns are stable or evolving. Chronic myofascial pain (CMP) is not progressive. The development of satellite Myofascial Trigger Points that worsen symptoms, or the appearance of new symptoms, are indicators that there are perpetuating factors at play. To control symptoms, first identify and control perpetuating factors. Controlling perpetuating factors is vital. Perpetuating factors include whatever impairs muscle function, such as anything diminishing the cells’ access to oxygen and nutrients, ham12 Terra Rosa E-mag

pering removal of cellular wastes, or adversely affecting the metabolism of the neurotransmitter acetylcholine (ACh). Anything that enhances the formation of Myofascial Trigger Points is a perpetuating factor. For instance, anything that constricts the flow of blood to the area will lessen its supply of oxygen and nutrients, adding to the energy crisis. A perpetuating factor can be anything that increases energy demand (trauma, overwork), decreases energy supply (inadequate nutrition, insulin resistance), sensitizes the Central nervous system (pain, noise), decreases oxygen supply (congestion), enhances release of sensitizing substances (allergies, infections), or increases endplate noise (increased ACh release, reduced acetylcholinesterase).

New recommendation versus the old In the original and now infamous big red books “Myofascial Pain and Dysfunction-the trigger point manual”, written by Janet Travel, David G, Simons and Lois Simons, the use of an “X” was used to mark the location of the Myofascial Trigger Point (Fig 1) Several years before the passing of my mentor David G Simons, on April 5, 2010, David and I spoke at length regarding the appropriateness and accuracy of using the “X” as a method to identify the location of Myofascial Trigger Points. As a Clinical Anatomist and Exercise Physiologist I argued that the notion that Myofascial Trigger Points only formed in the centre of the gastor or as described in the big red books “near the middle of each fibre, midway between its attachments” was not reflected in clinical practice nor by my anatomical dissection investigations. While the integrated trigger point hypothesis postulates that “in myofascial pain motor endplates release excessive acetylcholine evidenced histopathologically by the presence of sarcomere shortening”.2 it is worth noting that endplates are positioned in varied locations requiring excellent palpation skills from the therapist. If the therapist only investigates the middle of any muscle gastor and finds no palpable nodule or taught band the true source of a patient’s pain and changes in sensations may well be missed.

In 2008, The Concise Book of Neuromuscular Therapy (Sharkey, J) included artwork showing the pain referral pattern of the Myofascial Trigger Point and comments on changes in sensations and for the first time all without the use of the “X”. (Fig 2)

Myofascial pain syndrome

Fig. 1 The “X’ in this example was provided to identify the location of Myofascial Trigger Points in Upper Trapezius

Central Sensitisation and Control of Perpetuating Factors Chronic pain syndromes display significant Neuroplastic changes, altered neuron activity, excitability and adaptations affecting pain matrix structures spinal cord, thalamic nuclei, cortical areas, amygdala and periaqueductal gray areas - in essence, central sensitisation is characterised by an amplification of normal neurological activity.6 Continuous bombardment of the dorsal horn by noxious afferent activity leads to a release of glutamate and substance P, leading to activation of previously inactive synapses in the wide dynamic neuron (WDR), leading to central sensitisation. In normal circumstances, there is a balance between inhibitory and facilitatory neuronal activity in terms of pain management and control.7 This results in Spinal Segmental Sensitisation (SSS); a hyperactive state of the dorsal horn caused by constant noxious afferent bombardment, originating from damaged or sensitised tissues (e.g. Myofascial Trigger Points or other soft tissue/connective tissue trauma, or from visceral structures; e.g. a gall bladder that has become inflamed due to gall stones). Diagnosis of Spinal Segmental Sensitisation includes observation of dermatomal allodynia, hyperalgesia, soft tissue pain/tenderness upon palpation and Myofascial Trigger Points.6 Hyper-sensitivity initially occurs at the local segmental level, but through the process of sensitisation of adjacent spinal segments (spill-over), a state of ‘wind-up’ caused by temporal sensory summation (TSS); an increased rate of nociceptive pulsing at the dorsal horn, facilitates widespread segmental

Fig. 2 From the Concise Book of Neuromuscular Therapy-a trigger point manual. Sharkey, J. 2008 “Myofascial Trigger Points in the muscle temporalis can cause myogenic (“tension”) headache. This aching pain can extend to the upper teeth and include hypersensitivity to cold, heat, and pressure. The teeth may not meet correctly and there may be uncoordinated chewing when opening and closing the jaw.

These Myofascial Trigger Points can contribute to teeth grinding. Proprioceptive dysfunctions include vertigo, nausea and hearing irregularities such as hypersensitive hearing and tinnitus” Sharkey, J.

sensitisation, leading to body-wide peripheral pain.8 Temporal sensory summation is caused by increased C-fibre input at the dorsal horn and can maintain a state of hyperalgesia in chronic pain patients.9 Stimuli (such as Myofascial Trigger Points) that activate and sensitise the WDR ascends the spinothalamic tract to reach the higher brain centers, where the thalamus and limbic system are activated (anterior cingulate gyrus, insula and amygdala).

The limbic system is involved in modulating muscle pain, but it also modulates fear, anxiety and distress.

Therefore, increased activity in the limbic system, influencing the perpetuation of pain syndromes, can contribute to fear of or emotional stress associated with chronic pain syndromes.10 The rostral ventral medulla (RVM), acting as a relay point for descending activity from the periaqueductal gray (PAG), contains a number of ‘on’ and ‘off’ cells that can increase or decrease levels of pain. In the acute phase of injury, the ‘on’ cells provide a protective mechanism - significant pain is evoked, preventing undue movement/activity that might cause more damage.

In chronic pain mechanisms, ‘on’ cells remain active and there appears to be a ‘on’ cell dominance, rather than a balance of ‘on’ and ‘off’ cells that would mainTerra Rosa E-mag 13

Differentiating the Myofascial Trigger Point from the numerous variations of pain points is critical for therapeutic success. Learning to view the skin as a window to myofascial health deep to and including the sub cutis will provide the therapists with a new vision concerning therapeutic interventions. Palpation skills and excellence in anatomy and clinical reasoning are called for to provide pinpoint accuracy supported by appropriate soft tissue manipulation. I will save the important conversation concerning the relationship between muscle spastic activity and Myofascial Trigger Points until we meet at one or more of the planned workshops next June 2016.

Fig. 3 Image of a lower limb (anterior view) with skin reflected showing “muscle islands” isolated muscles fibers on the deep aspect of the skin. (Photo Sharkey, J. 2015)

Thank you to Terra Rosa for facilitating the workshops. I am very excited about returning to Australia and working with therapists of varying stripes. I wish everyone success in healing.

References 1 Starlanyl

D., Sharkey, J. 2013. "Healing through Trigger Point Therapy: A Guide to Fibromyalgia, Myofascial Pain and Dysfunction". And Sharkey, J. 2008. Concise Book of Neuromuscular Therapy-a trigger point manual. Lotus Publishing/ North Atlantic Press. Staud, R. 2006. Biology and therapy of fibromyalgia: Pain in fibromyalgia syndrome. Arthritis Res Ther 8(3):208

2 Gerwin,

R. 2010. Myofascial pain syndrome. Here we are, where we must go? Journal Musculoskeletal Pain 18(4):329 -347

Fig. 4 This image shows muscle fibers running the length of the tendon (being held in my hand) with the muscle fibers migrating superficially and deep to the tendon. (Sharkey, J. 2010)

tain a balance between facilitation and inhibition.7 Additionally, normal descending pain inhibiting signals are disrupted including elevated concentrated levels of epinephrine, and norepinephrine leading to a further sensitisation of muscle tissue.10 My dissection investigations have demonstrated why Myofascial Trigger Points can occur at the site of a tendon but not in the tendon itself. Tendons do not house Myofascial Trigger Points. What tendons often have are isolated “islands of muscle fibers” running in series which run past the classical point of origin or insertion continuing on its kinetic journey. Careful investigation of Fig 4 reveals a small 0.5cm, or less, of muscle protein, “an island”. This island can develop Myofascial Trigger Points giving the appearance of tendonous trigger points when palpated.

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3

Carrilo-de-la-Pena MT et al. 2006. Intensity dependence of auditory-evoked cortical potentials in fibromyalgia patient’s. A test of the generalised hypervigilance hypothesis.

Journal pain 7(7):480-487

4

Larsson B, Björk J, Henriksson K, Gerdle B, Lindman R. The prevalence of cytochrome c oxidase negative and superpositive fibers and ragged-red fibers in the trapezius muscle of female cleaners with and without myalgia and of female healthy controls. Pain. 2000;84:379–87.

5

Fogelman, Y & Kent, J 2014 Efficacy of dry needling for treatment of myofascial pain syndrome. J Back Musculoskelet Rehabil.

6

Gerwin RD, Dommerholt J, Shah J (2004) An expansion of Simons’ integrated hypothesis of trigger point formation.

Curr Pain Headache Rep 8:468–475

7

Giamberardino MA, Affaitati G, Fabrizio A et al. Effects of Treatment of Myofascial Myofascial Myofascial Trigger Points on the Pain of Fibromyalgia. Curr Pain Headache Rep. 2011 May 5.

8

Hsieh, YL, Chou, LW, Joe, YS & Hong, CZ 2011 Spinal cord mechanism involving the remote effects of dry needling on the irritability of myofascial trigger spots in rabbit skeletal muscle. Archives of Physical Medicine and Rehabilitation, 92, 1098- 1105.

9

Hsueh TC, Yu S, Kuan TS , Hong CZ. 1998. Association of active myofascial myofascial Myofascial Trigger Points and cervi-

Myofascial pain syndrome John Shakey’s 10 Key points for consideration when treating Myofascial Trigger Points: 1.

Differentiate the Myofascial Trigger Point from pain points using the cardinal signs which must include; palpable nodule and taught band, jump sign, twitch response, painful end range of movement, referred pain, autonomic responses.

2.

First treat Myofascial Trigger Points that are most superior and medial working inferior and lateral.

3.

The deltoid seldom develops its own active Myofascial Trigger Points. Instead most are “baby” or “satellite” Myofascial Trigger Points so treat associated muscles within its functional unit first.

4.

Upper trapezius is “grand central station” of Myofascial Trigger Points and is a major contributor to neck, shoulder, upper back and head pain.

5.

Active Myofascial Trigger Points, when irritated by a competent therapist, will result in referred pain or changes in sensation that the patient recognises.

6.

Latent Myofascial Trigger Points generally result in pain or change in sensations that the patient does not recognise. These Myofascial Trigger Points may be contributing to but are not the true source of a patient’s problem.

7.

Myofascial Trigger Points can form in any muscle fiber (11) and not just in the center of a muscle or where the “X” marks the spot on so many Myofascial Trigger Point charts-this is misleading.

Identify and remove/change the perpetuating factor/s.

8.

Excellent palpation skills are required to locate and treat Myofascial Trigger Points.

9.

Upper or lower limb tension tests should be provided to rule out nerve insults including compression, adhesion and/or inflammation.

10.

Any patient suffering with unresolved pain or changes in sensations should have the possibility of Myofascial Trigger Point involvement ruled out as a primary or secondary cause or contributor. cal disc lesions. J Formos Med Assoc 97(3):174-180.

10

Mense, S. 2010 How do muscle lesions such as latent and active trigger points influence central nociceptive neurons?

J Musculokelet Pain, 18, 348-353.

John Sharkey is a Clinical Anatomist (BACA), Exercise Physiologist (BASES), and Myofascial Trigger Point Specialist.

He has an MSc. At the Faculty of Medicine, Dentistry and Clinical Sciences, University of Chester/ NTC, Dublin, Ireland. John is a world renowned presenter and authority in the areas of anatomy, bodywork and movement therapies. With more than 30 years of clinical experience, he is now recognised as a leading protagonist of BioTensegrity (the new anatomy for the 21st century) providing new models and paradigm shifts concerning living movement and anatomy promoting therapeutic interventions for the reduction of

chronic pain . He is a best selling author with titles on Myofascial Trigger Points and Fibromyalgia. He is a member of the editorial board of the Journal of Bodywork and Movement Therapies (JBMT), International Journal of Therapeutic Massage and Bodywork and the International Journal of Osteopathic Medicine.

Correspondence to: John Sharkey MSc. University of Chester/National Training Centre 15-16a St Joseph’s Parade Dorset St Dublin 7, Ireland E-mail address: john.sharkey@ntc.ie www.johnsharkeyevents.com

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A N A T O M Y F O R T H E 2 1 S T C E N T U RY

BIOTENSEGRITY with John Sharkey Sydney, June 2016 Myofascial Trigger Points (MtPs) Versus Neuropathies A unique integrated neuromuscular approach for the treatment of unresolved pain due to MtPs or nerve insults.

This is that one stop workshop that covers everything you need to know about identifying and treating Myofascial Trigger Points and nerve injury. David G Simons (Travel and Simons), the farther of Myofascial Trigger Points was mentor to John Sharkey and wrote the forward to John’s first book (a trigger point manual). Differentiating between neural generated pain and Myofascial Trigger Point pain is essential in providing the correct soft tissue interventions for successful therapeutic outcomes.

The Final Frontier Working within Endangerment sites, providing Manual and Movement Techniques to stay mobile and pain free.

This informative workshop provides therapists with the necessary anatomical and palpatory excellence to expertly navigate the holy grails of the human body (endangerment sites). Providing safe neuromuscular techniques using digital applications guarantees effective therapeutic interventions for soft tissue based chronic pain conditions. Through your newfound anatomical knowledge and unique hands-on clinical pearls each learner will develop a greater appreciation of local and global anatomical connections.

The Theory of Everything—BioTensegrity, anatomy for the 21st century This workshop is ideally suited to the advanced manual and movement therapist with appropriate clinical experience and a desire to take on fresh new ideas, new models and a new way of thinking. Therapists are warmly encouraged to demonstrate their current screening, assessments and therapeutic applications with John while he will provide feedback and suggestions offering a new vision supported by connective tissue techniques for successful manual and movement interventions for all participants. This workshop provides you, the chronic pain soldier the effective full body kinetic chain ammunition you need in the war on pain.

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

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Register at www.terrarosa.com.au

Sydney, 15-16 October 2016

Sydney, 17-18 October 2016

Fascia of the Pelvic Floor

Fascial Toning

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Sydney, 21 October 2016

Sydney, 22-23 October 2016

Integrating new techniques

By Art Riggs I’m noticing an interesting conflict in the massage profession. On one side, continuing education credit requirements and the desire of therapists to expand and excel in their skills have greatly expanded the number and quality of advanced workshops. On the other side, the proliferation of spa work has many massage schools primarily teaching “generic” massage routines that are actually defining the public’s perception of massage.

I’ve recently had several therapists express difficulties in trying to implement their new knowledge with established private clients or the general public in spa settings. Here is a typical example: “I took a great workshop of advanced techniques that I was very excited about but I'm hesitant to try anything because I work at a spa and I'm afraid that the clients will think the new work is strange and not like it. I'm already forgetting a lot from the workshop. How do I escape from this straightjacket?”

It is amazing how often I hear concern that trying new work will send clients scurrying to more conventional therapists. As a Rolfer, I had the same thing happen when I studied craniosacral techniques and more subtle work. I worried that people who expected sharpened elbows and knuckles would be disappointed and that my long-time regular clients would wonder if an imposter had taken over my practice. Nothing could be further from the truth; my clients loved the new skills, just as yours will appreciate your new techniques, in addition to the relaxation work you may normally do. Just as some meat-andpotato people will never appreciate nouveau cuisine, some people might resist new bodywork. However, I think that the advantages of showing an increasingly discerning public your newfound skills far outweighs any downside; the rebookings from happy clients and word-of-mouth referrals will be evidence enough. It is far easier to draw clientele who return because they appreciate your work than to try to fit your work to

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your guesses about client tastes. Many therapists project their own—sometimes incorrect—assumptions about what clients expect. Some therapists assume any work that approaches intensity may be considered strange. Many mistakenly assume that clients don’t want to be bothered in the midst of their headrest snooze to be moved for side-lying work, for example, or that a client will be unhappy if the session doesn’t leave all parts of the body equally covered with excess lubrication. In reality, almost all clients will be grateful for skillful work that pays attention to their particular needs, instead of conforming to cookie-cutter convention.

The key to transitioning to a more creative bodywork style is communication with, and education of, your clients. A former student got in touch with me a few weeks after taking a deeptissue class to say that after languishing for many months at a spa waiting for walk-ins, he is now booked every shift. The techniques he learned were certainly useful, but the main reason for his success was that he took the time before and during the massage to talk to clients to find out what they wanted to improve in their bodies. He went on to explain to them the benefits of spot work, working slowly and deeply in problematic areas, scheduling longer massages to get full-body coverage, and taking enough time to also focus on specific areas. It’s important to find your own sincere way of communicating and transitioning to the ways of working that excite you most. Following are a few suggestions.

Gradually transition to your new way of working. For regular clients, simply say you have some great new things you’d like to try to improve the massage. For new clients, build your confidence and communication skills with those whom you feel a good connection and suspect may be relaxed and open to expanding their experience, instead of on every newcomer who comes through the door.

Integrating new techniques Spend a few minutes getting to know your clients. Explain that the meter isn’t running until you start the bodywork. Educate them about how you work and learn about their needs. The session will be more rewarding for both of you because some connection will have been established, rather than abruptly diving into the massage.

Find a peer therapist to trade with and refine your skills. A fear that clients won’t like your new work can be more than just projections about their preferences. Sometimes the culprit is simply lack of confidence due to lack of practice.

Art Riggs is the author of Deep Tissue Massage: a Visual Guide to Techniques (North Atlantic Books, 2007), which has been translated into seven languages, and the DVD series Deep Tissue Massage and Myofascial Release: A Video Guide to Techniques. He just release a new DVD series Deep Tissue Massage: An Integrated Full Body Approach which demonstrates how to intergrate and coordinate Deep Tissue and Myofascial Release into a Fluid Bodywork Session.

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

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

Available now at www.terrarosa.com.au

Deep Tissue Massage by Art Riggs DVDs and Book The original 7 DVD set “Deep Tissue Massage and Myofascial Release”.

The DVD set is designed as a full study clinical training course for massage therapists wishing to expand their skills. It has great details on biomechanics, anatomy, with plenty of working strategies and techniques.

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

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“There’s only one corner of the Universe you can be certain of improving and that’s your own self.” -Aldous Huxley

Client self care: Does it work?

As a manual therapist it is tempting to think that getting effective results is all about your hands on work.

After all the use of those awesome healing hands is our prime raison d'être and many of us devote a lifetime to pursuing the massage ‘Holy Grail’ –in other words, the latest technique or modality that will best help our clients out of pain. As a result, client self care is often pushed to the back burner; a desultory 5 minutes at the end of the session where you give a photocopy of a few stretches Yet what if you were missing a trick? What if spending time teaching your client self care suggestions was one of the biggest single cost and time effective ways to improve your results with chronic musculo-skeletal pain conditions? Research suggests that devoting some thought to incorporating self- care as part of an overall treatment plan is a wonderful way to quickly improve your results. Conditions as diverse as herniated disc pain, whiplash, headaches and nagging sporting injuries all respond to a healthy dose of self care – and who better to support this than a friendly massage therapist? Massage and self care are wonderful bed fellows; outcomes for low back pain are improved if combined with self care and exercise (Furlan 2002) and studies also suggest that receiving bodywork makes people more likely to carry out self care suggestions (Long 2009)

The psychology of self care: Power to the People!

To understand why self -care can be so powerful we need to look at the psychology behind it – the so- called “locus of control”. You will know from your own experience that the world tends to be divided into 2 types of people: those that believe they can alter their circumstances by their actions and those who believe they are at the mercy of outside forces such as chance, fate or the whims of authority. Psychologist Julian Rotter (1966) came up with the concept of locus of control to explain this tendency. People with an internal locus of control believe they can control events that happen to them whereas those with an external locus of control believe they are powerless to control outside events. (Fig. 1). Crucially the sense of locus of control is not fixed and can be altered through education or experience.

So what does this sense of control have to do with helping your client’s persistent bad back? Actually everything, as research shows that the locus of control is highly correlated with successful treatment outcomes. For example headache sufferers with a high internal locus of control respond better to treatment and are less disabled by their pain (Nicholson 2007).

On the other hand, believing that relief from low back pain is determined by factors outside of individual control (such as chance or the interventions of health

Fig. 1. Locus of Control. People with an internal locus of control believe that they can control events that happen to them whereas those with an external locus of control believe they are powerless to control outside events .

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

care professionals) is related to higher levels of disability and poorer quality of life (Sengul 2010).

Following the logic of this research suggests that if we are able to empower our clients to believe they have some control over their pain condition then we are more likely to achieve better treatment outcomes. This is why self care approaches can be so effective as clients are literally taking back some of the responsibility for healing into their own hands– a true case of “power to the people!”

Doctor Doctor what are the best exercises to do?

Patient: “Doctor Doctor, what are the best exercises to do.”

Doctor: “The ones that you do.”

This old joke neatly summarises the best approach to prescribing self care. The truth is that the best exercises to suggest are the ones that your client will actually do.

There can be a big gap between “knowing” what is good for you and actually doing it and studies show that as many as 70% of physiotherapy clients do not do their prescribed exercises (Beinart 2013) (Fig. 2). Therapists often get cross and blaming about clients who “don’t help themselves”; you know - those pesky people who “don’t do their exercises”. (Totally unlike our good selves who never sit and eat cake or watch TV as we are busy spending every moment in unrelenting selfimprovement. Hang on a minute while I turn off the mung bean stew so I can go and meditate…..).

The point here is that motivating your clients to become involved in their recovery is an art in itself and requires a number of skills and strategies beyond

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Fig. 3. For effective results, put time aside in your treatment to set self care goals with your client

simply “telling them”. Unsurprisingly, research has shown that some of these strategies are very similar to the motivational tools used in business or personal training. DeSilva (2011) drew out 3 key features of initiating successful self management of musculoskeletal pain conditions:  Agenda setting: Jointly setting health goals with your client  Goal setting: Clients choosing their own small and achievable goals  Goal follow up: Proactive follow up is vital to maintain momentum and provide engagement and support.

So if you really want to get results with your client self care exercises you will need to look at setting time aside within your treatment to set goals, review and – most importantly- cheer-lead! (Fig. 3) Understanding the biopsychosocial model of pain To properly get to grips with the art and science of prescribing self care it is vital to understand what is

Client self care

Fig. 4. In the biopsychosocial model, pain is seen to be a combination of biological, psychological and social factors

really going on in musculo-skeletal pain. The most accepted model of pain is the Biopsychosocial model – a bit of a mouthful hence commonly abbreviated to BPS. If you find the word makes you want to glaze over just substitute the concept of ‘holistic” as this pretty much means the same thing!

In a nutshell the BPS model (Engel 1977, 1980). suggests that pain is due not just to biological issues (the bio bit) but also psychological and social factors (Fig. 4). In other words, our experience of pain can be increased by:  Psychological factors: unhelpful thoughts, feelings or attitudes such as ‘catastrophising’ (jumping to the worst possible scenario about the pain condition – see Fig. 5)  Social context: wider factors such as being unhappy in a job or a relationship Conversely, positive thoughts and beliefs or a supportive social context generally leads to the pain signals being “turned down” by the brain.

For effective self care it is important to gain some idea of how each of these 3 areas is contributing to your client’s pain situation so that you can target your suggestions accordingly. The hands on portion of the treatment can address any “issues in the tissues” such as trigger points or fascial adhesions that may be contributing to the ongoing pain. However the psychological and social factors can only properly be addressed via self-management suggestions.

Fig. 5. Unhelpful thoughts can in themselves increase pain levels .

The Jing method: The MAPS approach to self care Choosing the most appropriate self care suggestions for a particular client or condition can seem like a minefield so, as with most things, it is helpful to have a map to guide you through the process.

The MAPS approach to self care (Fairweather 2015) is a simple mnemonic to help you think about the most useful self care suggestions for a particular client and their condition. Most self care suggestions can be grouped under 4 major headings as laid out below. All of these areas have a strong research base to support their use in the management of persistent musculoskeletal pain Movement and exercise Research shows that most types of exercise can be helpful to pain conditions. These include:  General aerobic exercise: For example running, cycling, swimming, walking.

Advice and education Advice and education is a key area that can help change unhelpful beliefs that may be perpetuating the client’s pain state. Self care approaches that fall within this category include:

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Fig. 6. Take time to educate your client about the causes of their pain.

 Education and information about the pain condition: reassurance that most acute pain situations get better in a matter of days or weeks.

(Fig. 6)  Advice on managing and returning to desired activities  Help with goal setting, action planning and reviews through structured treatment plans  Advice and referral to classes that would be helpful e.g. yoga, Pilates or Tai chi Psycho-social Research has shown that practices that help to change unhelpful psychological mind- sets or give mechanisms for dealing with stress can be extremely useful. This is especially the case in chronic pain situations. Useful evidence based approaches include:  Relaxation, meditation or mindfulness practices (Fig. 7 )  CBT based self help approaches that aim to reduce unhelpful beliefs such as catastrophising.

Reflecting back to the client any social factors that may be perpetuating the pain condition. Common themes in this category include being unhappy in a job or relationship. It is not your job to “sort this out” but helping the client identify these factors as being relevant can be very powerful.

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Site specific interventions Self care interventions that are targeted at the area of pain can include:  Self trigger point treatment (Fig. 8)  Application of hot and cold  Specific exercise targetted to help the area of pain.

For example stretching, mobilisation or rehab exercises for the low back (Fig 9).

Quite simply your self- care suggestions should draw on each of these categories for a full all round biopsychosocial approach to treatment.

Using the MAPS approach for acute herniated disc As an example of using the MAPS self care process for a client with pain from a herniated disc we might look at approaches that include:  Movement based self care: This could be as simple as encouraging walking to work a few times a week  Advice and reassurance: Reassuring your client that most disc problems heal within 4-6 weeks and do not lead to long term problems. This is because the disc can shrink back from the nerve that it is pressing on and that more importantly our brain can learn to “turn down” the pain signals (and that there are many things they can do to help this

Client self care process)  Psychological: Teaching a simple breathing exercise to help your client cope with stress and feel in control of any pain they are experiencing  Site specific interventions: Teaching some simple mobilisation exercise or stretches for the low back.

It is important not to overwhelm your client with too many suggestions at once – we usually recommend between 1-3 exercises a session depending on complexity. Self care suggestions should be reviewed at every treatment to see how successful the client has been at carrying them out and can be built on, week by week.

A 21st century approach to massage therapy

Fig. 7. Research has shown that simple meditation and breathing exercises can be extremely helpful in reducing persistent pain

For massage therapists to move forward in the 21st century it is important that we embrace all the aspects of our great profession. Long before the coining of the term “biopsychosocial”, complementary therapists had a core belief in holism – defined by the dictionary as “The treating of the whole person, taking into account mental and social factors, rather than just the physical symptoms of a disease”. In the holistic approach, clients are seen as active agents in their path towards healing with the practitioner role being that of a facilitator towards this aim; client and therapist work as an alliance towards mutual goals. Self care has always been an integral part of this approach. With our modern knowledge of how psychology can influence pain states, now is the time to reclaim self- care as a vital part of a successful treatment.

Using the biopsychosocial model as a basis gives us a clear map to navigate different self care options to prescribe the most useful approaches for our clients.

Remember that the MAPS (Movement, Advice, Psychosocial aspects and site specific interventions) process helps to ensure that your self care suggestions are addressing all aspects of your clients pain condition:.

Ensure you set aside enough time in your hands on sessions to goal set and review successful outcomes with your clients. Motivate, inspire, encourage and watch your results increase!

Further reading and Freebies for Terra Rosa readers

Fig. 8. Site specific self care interventions can include self trigger point treatment, stretching or rehab exercises.

Our philosophy around self care is part of an overall approach to excellence in soft tissue therapy for chronic pain as pioneered through our book “Massage Fusion; the Jing method for the treatment of chronic pain”. For

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themselves A review of the evidence considering whether it is worthwhile to support self-management, Engers, A. et al., 2008. Individual patient education for low back pain.

The Cochrane database of systematic reviews, (1), p.CD004057.

Fairweather, R (2015): The MAPS approach to self care; Jing Advanced massage Furlan, A.D. et al., 2002. Massage for low back pain. The Cochrane database of systematic reviews, (2), p.CD001929.

Fig. 9. Teaching self stretching is an effective intervention targeted at the area of pain

Long, A.F., 2009. The potential of complementary and alternative medicine in promoting well-being and critical health literacy: a prospective, observational study of shiatsu. BMC complementary and alternative medicine, 9, p.19.

Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement: Psychological Monographs: General & Applied 80(1) 1966, 1-28.

Nicholson, R.A. et al., 2007.

Psychological risk factors in headache.

Headache, 47(3), pp.413–26.

Sengul, Y., Kara, B. & Arda, M.N., 2010.

The relationship between health locus of control and quality of life in patients with chronic low back pain. Turkish neurosurgery, 20(2), pp.180–5.

Fig. 10. Head over to the Jing website www.jingmassage.com for some great free self care handouts for your clients

further reading on the subject hit chapter 11 of the book.

clients and other therapists. (Fig. 10)

For some great FREE self care resources head over to our website http://www.jingmassage.com/ category/self-care-resources-formassage-therapists/ where you will find loads of self care handouts that you can print out and give directly to your clients. From mindfulness to mobilisations, advice to active isolated stretching, feel free to print out, enjoy and share with your

References

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Beinart, N.A. et al., 2013. Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. The spine journal : official journal of the North American Spine Society, 13(12), pp.1940–50.

De Silva, D. (The Health Foundation 2011) No Evidence: Helping people help

About Rachel Fairweather and Jing Advanced Massage Rachel Fairweather is author of the best selling book for passionate massage therapists – ‘Massage Fusion: The Jing Method for the treatment of chronic pain”. She is also the dynamic Co-founder and Director of Jing Advanced Massage Training (www.jingmassage.com), a company providing degree level, hands-on and online training for all who are passionate about massage.

Rachel has over 25 years experience in the industry working as an

Client self care advanced therapist and trainer, first in New York and now throughout the UK. Due to her extensive experience, undeniable passion and intense dedication, Rachel is a sought after international guest lecturer, writes regularly for professional trade magazines, and has twice received awards for outstanding achievement in her field.

Rachel holds a degree in Psychology, a Postgraduate Diploma in Social Work, an AOS in Massage Therapy and is a licensed massage therapist.

Massage Fusion is an essential companion for any manual therapist interested in treating common pain issues. Acclaimed teachers and therapists, Rachel Fairweather and Meghan Mari offer a practical and dynamic step-by-step approach to gaining results with persistent client problems such as low back pain, neck pain, headaches, carpal tunnel syndrome, TMJ disorders, stress-related conditions and stubborn sporting injuries. The book outlines a clear and evidence-based rationale to treatment using a clinically tried and tested combination of advanced massage techniques including myofascial work, trigger point therapy, acupressure, stretching and client self-care suggestions.

Available at: www.terrarosa.com.au

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The Importance of Joint Mobilization

By Joe Muscolino “Critical thinking is the key determinant of an excellent clinical orthopedic manual therapist, and can make the difference between mediocre and excellent results.�

Before practicing any new modality or technique, check with your massage therapy association to ensure that it is within the defined scope

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Many factors are important for musculoskeletal health. Arguably, the two most important factors are flexibility of soft tissue and strength of musculature. Although strength of musculature is often beyond the scope of massage therapy, massage therapists excel at increasing soft tissue flexibility. In this regard, massage therapy holds an extremely important place in the world of clinical orthopedic manual therapy.

Often the key to remedying a client’s musculoskeletal condition is loosening tight soft tissues that directly cause pain and/or decrease the client’s range of motion (ROM). Unfortunately, for many years, the field of massage therapy has limited its effectiveness by focusing only on tight musculature. With the recent understanding and acceptance of the importance of fascia and the role that fascial adhesions (and fascial contraction) can play in a client’s condition, the field of massage therapy has been expanding its focus. This is an excellent step forward for manual therapy.

Intrinsic Fascial Tissue However, this increased focus on fascial tissue has largely limited itself to myo-fascial tissue (via Myers’ work with myofascial meridians/anatomy trains) and subcutaneous fascia (via the Stecco family work on superficial fascial tissue/membranes). As a result, most massage therapists still

“…ignoring intrinsic fascial joint tissue may be an excellent job halfway-done; and may likely be the reason for limited success when treating a client’s musculoskeletal condition.” largely ignore an incredibly important fascial tissue component of the body: joint capsules and their associated intrinsic joint ligaments. After all, tautness in any soft tissue will decrease motion and impact the quality of the client’s life. This is true whether the taut soft tissue is muscle myofascia, subcutaneous fascia, or intrinsic capsular/ligamentous fascial tissue. Therefore, if our goal is to increase soft tissue flexibility, loosening muscles and their associated myofascial and subcutaneous fascial tissues while ignoring intrinsic fascial joint tissue may be an excellent job halfway-done; and may likely be the reason for limited success when treating a client’s musculoskeletal condition.

The province of intrinsic fascial tissues has been largely left to chiropractic and osteopathic physicians. Yet, if massage therapy is to take its rightful place as the preeminent manual therapy for clinical orthopedic manual treatment of soft tissue musculoskeletal/myofascial conditions, then learning how to treat intrinsic joint tissues needs to become a part of the treatment strategy.

Toward this end, joint mobilization, specifically Grade IV joint mobilization, can be an extremely

“Joint mobilization is actually quite simple to perform. It involves pinning/stabilizing one bone at a joint, and then moving/mobilizing the adjacent bone relative to it. In effect, joint mobilization is identical to a treatment method that is already prevalent in the world of massage therapy: pin-and-stretch technique.”

important technique to incorporate into the treatment strategy for our clients. And when properly learned, is effective and safe.

Joint Mobilization Joint mobilization is actually quite simple to perform. It involves pinning/stabilizing one bone at a joint, and then moving/ mobilizing the adjacent bone relative to it. In effect, joint mobilization is identical to a treatment method that is already prevalent in the world of massage therapy: pin-and-stretch technique. Pinand-stretch as it is performed involves pinning within the belly of a muscle and then stretching one of the muscle’s attachments away from the pinned point. This has the effect of focusing the stretch to the part of that muscle that is located between the pinned point and the attachment that is moved. With joint mobilization technique the therapist instead pins one bone at a joint, and then moves the other bone of the joint away from it, thereby focusing the stretch to the intrinsic capsular/ligamentous tissue (as well as any deep intrinsic musculature) located between those two bones (Figure 1). Both techniques involve pinning and stretching, in other words, pinning and mobilizing. With typical pin-and-stretch we focus our mobilization on muscular tissue; with Grade IV joint mobilization we focus our mobilization on intrinsic joint fascial tissue.

Technique Guidelines As with any technique, there are guidelines for the efficient and safe employment of joint mobiliTerra Rosa E-mag 29

zation.  Most typically, the proximal

bone is pinned and the distal bone is stabilized.  When placing the pin to stabi-

lize the bone, it is important to find a bony surface that is as broad and flat as possible; this ensures that the bone is securely and comfortably held.

 It is important to also find a

broad and flat surface on the bone that is being mobilized so that it is securely and comfortably contacted.

Grading Joint Mobilization The term joint mobilization is actually a broad term that may be defined in many ways. One classification of joint mobilization divides it into five grades.

Grade I: Slow, small-amplitude movement performed at the beginning of a joint’s active/passive ROM. Grade II: Slow, large-amplitude movement performed through the joint’s active ROM. Grade III: Slow, large-amplitude movement performed to the limit of the joint’s passive ROM. Grade IV: Slow, small-amplitude movement performed at the limit of a joint’s passive ROM, and into resistance (joint play) (see accompanying Figure).

 It is usually optimal to contact

Grade V: Fast, small-amplitude movement performed at the limit of a joint’s passive ROM, and into resistance/joint play.

 If the skin and other overlying

In this grading system, Grade I is any beginning ROM at a joint; Grade II is the client’s active ROM; and Grade III is a typical stretch that is performed by a therapist on a client (or a self-care stretch performed by the client himself/herself) to the end of passive range of motion.

Grade IV is joint mobilization as the term is used in this article. It involves stretching the soft tissues at a joint such that the joint is challenged to move past its passive ROM into the range of motion that is known as joint play.

each bone as close to the joint surface as possible. This is especially important for nonaxial motion joint mobilization. soft tissue is loose, a soft tissue pull might be necessary. A soft tissue pull is accomplished by first contacting the client proximal to the desired stabilization point and then pulling the skin and subcutaneous fascia toward that point. This ensures that any soft tissue slack is removed so that your grasp is secure on the underlying bone.

 First adding traction to the

joint adds to the efficiency of the mobilization.  The actual mobilization is usu-

ally done by performing 3-5 oscillations.

 The oscillation motion is per-

formed slowly; a fast thrust is never involved.  The excursion of the oscilla-

tion is very small, usually only a few millimeters.  Each oscillation is held for a

fraction of a second and then released.

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Note: It should be pointed out that Grade V joint mobilization is a chiropractic/osteopathic high-velocity (fast thrust) manipulation that is not within the scope of practice for massage therapy.

Indications/Contraindications

Motion Palpation Assessment

The indication for joint mobilization is simple. Given that the goal of this technique is to increase motion at a joint, the indication is joint hypomobility: if the joint’s motion is decreased as a result of taut intrinsic joint tissues, joint mobilization is indicated. The contraindication to joint mobilization is joint hypermobility: if the joint’s motion is excessive due to slackened tissue or if the integrity of the tissue is compromised or unstable, joint mobilization is contraindicated.

Joint hypomobility or hypermobility is determined by an assessment technique known as motion palpation. Motion palpation assessment is performed in an identical manner to joint mobilization treatment technique; in other words the joint is challenged to move into its joint play ROM at the end of its passive ROM, and the quality of the endfeel motion is felt. If the end-feel is hard and abrupt and the motion is felt to be restricted, the joint is hypomobile and joint mobilization is indicated. If the endfeel is mushy and the joint exhibits excessive motion, the joint is

Joint mobilization hypermobile and joint mobilization is contraindicated. A gentle bounce or spring to the end-feel is optimal and indicates a healthy joint. In this case, joint mobilization is neither indicated nor contraindicated, but may be performed proactively to maintain healthy joint motion. Palpating for the quality of end-feel motion can be subtle and challenging to discern at first. As with any technique, practice and focused attention are the keys to becoming skilled at motion palpation assessment and joint mobilization treatment techniques.

Axial and Nonaxial Motions The type of motion that is performed during the mobilization can be an axial, nonaxial, or a combination of the two. Therapists often think of joint motion only in terms of axial motion. For example, the glenohumeral joint motions that are usually taught are flexion and extension in the sagittal plane, abduction and adduction in the frontal plane, and lateral and medial rotations in the transverse plane. All of these motions are described as axial because they involve the humerus moving in a circular manner around an axis of rotation that passes through the joint. However, underlying most axial motions such as flexion or abduction are more fundamental component motions called roll, glide, and spin. To perform joint mobilization, these fundamental motions of roll, glide, and spin must first be understood (Figure 2).

Roll, Glide, and Spin Spin and roll are axial motions, but roll must occur in conjunction with glide, which is a nonaxial motion. It is this nonaxial glide motion that joint mobilization is usually focused on. To visualize these three fundamental motions, it can be helpful to make an anal-

Fig. 1 Joint mobilization is performed by pinning one bone and mobilizing the adjacent bone relative to it, thereby stretching the intrinsic soft tissues located between them.

Fig. 2 Fundamental motions of roll, glide, and spin. A, Roll. B, Glide. C, Spin. (Figure reproduced with permission from Elsevier, Kinesiology, The Skeletal System and Muscle Function, 2nd Edition, JE Muscolino)

ogy to a car tire. Roll motion would be equivalent to a tire that is rolling along the road. Glide motion is equivalent to a tire that is skidding along the road. And spin is the tire spinning in place on the surface of the road (Figure 3).

Convex/Concave Kinematics Now that roll and glide motions are understood, let’s apply this knowledge to convex/concave kinematics. This will allow us to determine how to assess and mobilize the nonaxial glide component of joint motion to improve the ROM of the joint. The term Terra Rosa E-mag 31

Fig. 3 Roll, glide, and spin motions: tire analogy. A, Tire that is rolling along the road. B, Tire that is gliding/skidding along the road.

C, Tire that is spinning in place on the road. (Figure reproduced with permission from Elsevier, Kinesiology, The Skeletal System and Muscle Function, 2nd Edition, JE Muscolino)

Fig. 4 Convex and concave joint surfaces. A, The glenohumeral (GH) joint. B, The metacarpophalangeal (MCP) joint.

(Figure modeled from Elsevier, Kinesiology, The Skeletal System and Muscle Function, 2nd Edition, JE Muscolino)

kinematics simply means motion; in the world of kinesiology, it refers to joint motion. Convex/ concave kinematics refers to the motion pattern that occurs at a joint wherein one bone has a convex shape and the other bone has a concave shape.

At many joints, the proximal bone is concave and the distal bone is convex. Examples include the glenohumeral (GH) and hip joints. Looking more closely at the GH joint, the proximal bone, the glenoid fossa of the scapula, is concave; and the distal bone, the head of the humerus, is seen to be convex. At other joints, the proximal bone is convex and the distal bone is concave. Examples include the metacarpophalangeal (MCP) and metatarsophalangeal 32 Terra Rosa E-mag

(MTP) joints. Looking more closely at the MCP joint, the proximal bone, the head of the metacarpal, is convex and the distal bone, the base of the proximal phalanx, is concave (Figure 4).

When the convex bone moves relative to the concave bone, we have convex on concave kinematics; and when the concave bone moves relative to the convex bone, we have concave on convex kinematics. Given that most joint motions are standard open-chain motions in which the distal end of the extremity is free to move and the proximal end is more stable, convex on concave kinematics or concave on convex kinematics is usually determined by the shape of the distal bone at the joint.

Roll and Glide Kinematics Now let’s apply roll and glide motions to convex/concave kinematics. When a convex-shaped bone begins to roll on a concaveshaped bone, it rolls along the concave bone’s articular surface, much like the tire in Figure 3A rolled along the road. However, whereas a tire has unlimited road to roll along, the path of the concave joint surface is limited. So if the convex bone were to roll too far, it would roll right off the concave joint surface and dislocate (Figure 5). Joints are designed to operate optimally when the opposing articular surfaces are centered on one another, a concept that is often referred to as centration. Therefore, it is important for

Joint mobilization

CAUTION Before practicing any new modality or technique, check with your state’s or province’s massage therapy regulatory authority to ensure that it is within the defined scope of practice for massage therapy.

Grade IV joint mobilization is within the scope of practice for massage therapy .

Fig. 5 Excessive roll motion of the convex bone upon the concave bone would result in dislocation.

Further, it is critical that you understand, study, and practice Grade IV joint mobilization technique carefully before attempting to use it with your clients. The steps of joint mobilization are actually quite simple, and this article provides an excellent conceptual framework and set of guidelines for performing this technique. However, the challenge lies in practicing the technique sufficiently to develop a refined sense of joint motion before using it with your clients. For this reason, it is strongly recommended to attend in-person workshops with experienced continuing education instructors before incorporating this technique into your practice.

Any technique that has the power to help also has the power to do harm, and joint mobilization is an extremely powerful technique.

Joint mobilization, when applied inappropriately, can cause serious harm to the client. Inappropriate application of joint mobilization technique includes applying joint mobilization to a condition for which it is contraindicated, most likely an unstable/hypermobile joint or to tissue that does not have sufficient integrity. It also includes applying joint mobilization to a condition for which its use is indicated, but executing the technique incorrectly—for example, performing it too forcefully.

Fig. 6 Kinematics of roll and glide. A, Convex on concave kinematics: Roll of the convex (upper bone) in one direction is accompanied by glide of the convex bone in the opposite direction. A, Concave on convex kinematics: Roll of the concave (upper) bone in one direction is accompanied by glide of the concave bone in the same direction.

the bones to stay centered in proper alignment with each other. This is where glide is needed to accompany roll. As the convex bone rolls along the concave bone in one direction, nonaxial glide must occur in the opposite direction so that centration is maintained (Figure 6A). If instead we look at a concave bone moving along a convex bone, the kinematics change. Excessive roll of the concave bone on the convex bone would also result in dis-

location, but here the compensatory glide is different. Now the glide must be in the same direction as the roll to maintain the centration of the joint (Figure 6B).

Thus, with convex on concave kinematics, roll in one direction is accompanied by glide in the opposite direction; and with concave on convex kinematics, roll in one direction is accompanied by glide in the same direction. In either case, if adhesions within the intrinsic fascial tissues of the joint restrict the nonaxial glide component of joint motion, centration cannot be maintained, thereby increasing the chance of limited motion (joint dysfunction) and injury.

The fundamental kinematics of joint motion may seem theoretical, but are actually quite valu-

able. With an understanding of joint kinematics, the therapist can critically reason how motion should occur at a joint. This empowers the therapist to be able to critically think how to apply joint mobilization treatment technique to their client’s condition instead of memorizing cookbook treatment routines. Critical thinking is the key determinant of an excellent clinical orthopedic manual therapist, and can make the difference between mediocre and excellent results.

Joint Mobilization Examples To ground this theory in actual practice, the following examples demonstrate joint mobilization technique performed at joints of the upper extremity, lower extremity, and axial skeleton. In each example, the steps to be performed are outlined.

Terra Rosa E-mag 33

Joint Crepitus When performing joint mobilization, it is common to hear or feel a sound emanating from the joint.

Any sound that occurs during joint motion is termed joint crepitus. Although therapists and clients are often concerned by the presence of joint crepitus, it seldom indicates a serious condition and rarely contraindicates joint mobilization technique. In fact, joint crepitus may be an indicator that mobilization should be performed.

To determine whether joint crepitus indicates or contraindicates joint mobilization technique, it is important to determine the mechanism/cause of the crepitus because it can occur for many reasons.

(Keep in mind that whether joint crepitus is present or not, the two most important criteria for the indication/contraindication of joint mobilization technique are the mobility of the joint and the structural integrity of the joint tissues.)

Following are the most common causes of joint crepitus: Joint release: This is the sound that is heard when a chiropractic manipulation is performed. A joint release sounds similar to the popping noise that a cork makes when it is removed from a bottle of champagne. Unlike other types of joint crepitus, a joint release cannot occur multiple times in succession at the same joint as other forms of crepitus can. This is a good criterion to use to determine if the joint crepitus you hear is a joint release. If a joint release does occur, there is no need for concern. In fact, it is likely a good sign because it shows that motion has been introduced into the joint. Note: Although a joint release may occur during Grade IV mobilization, it should not be the intended goal of this mobilization technique).

Taut soft tissue restriction: Joint crepitus is most often caused by a hypomobility of the joint due to a taut band of soft tissue. As a joint moves through its range of motion, it might reach a point where the taut band of soft tissue restricts its further motion. In effect, it becomes temporarily stuck, often along a bumpy contour of underlying bone. The continued application of force

34 Terra Rosa E-mag

can then move the joint past this restriction, resulting in a clicking type of noise, as the taut band rubs (twangs) over the underlying bony contour. This type of crepitus would be assessed by the presence of decreased motion, in other words, a joint hypomobility. Joint hypomobility indicates joint mobilization technique, so mobilization should be performed when crepitus occurs for this reason because it can serve to gradually loosen the taut soft tissue.

Excessively loose soft tissue: A hypermobile joint that has excessively loose soft tissue can also cause joint crepitus. This occurs as the excessive motion allows bands of soft tissue to rub/twang along bumps on the underlying bones. This type of crepitus would be assessed by the presence of excessive motion, in other words, joint hypermobility. Because joint hypermobility contraindicates joint mobilization technique, joint mobilization should not be performed when crepitus occurs for this reason.

Degenerative joint surface: If there is degeneration of the articular cartilage surfaces of the joint (indicative of degenerative joint disease [DJD], also known as osteoarthritis [OA]), mobilization of the joint can cause the rough surfaces to grind along each other, creating joint crepitus. This type of joint crepitus sounds/feels similar to rubbing sandpaper along a surface. Unlike other causes of joint crepitus, this type of crepitus is often accompanied by pain or discomfort deep in the joint. This type of joint crepitus usually contraindicates joint mobilization because it would cause further irritation to the joint. However, if traction can be added to the mobilization so that the joint surfaces do not grind along each other, mobilization can be performed and may be helpful toward mobilizing a joint that otherwise cannot be moved without pain.

Joint mobilization

Fig. 7 Mobilization of metacarpophalangeal (MCP) joint glides in the sagittal plane. A, Stabilization of the metacarpal. B, Traction of the proximal phalanx. C, Palmar glide mobilization of the proximal phalanx. D, Dorsal glide mobilization of the proximal phalanx. (Figure reproduced with permission from Joseph E. Muscolino)

Example 1: Metacarpophalangeal Joint Glide Sagittal plane glide motions of the metacarpophalangeal (MCP) joint of the index finger involve concave on convex kinematics. Flexion is composed of an anterior/ palmar roll of the phalanx accompanied by a palmar glide of the phalanx. And extension is composed of a posterior/dorsal roll of the phalanx accompanied by a dorsal glide of the phalanx.

Therefore, palmar glide mobilization is needed to optimize flexion range of motion; and dorsal glide mobilization is needed to optimize extension range of motion.

Following are the steps to perform palmar and dorsal glide mobilizations of the MCP joint:  Use one hand to pin/stabilize

the distal end of the metacarpal on its dorsal and palmar sur-

faces (Figure 7A).  Add traction to the joint by

gently pulling the phalanx away from the metacarpal (Figure 7B).  Challenge the phalanx to glide

in the palmar direction until tissue tension is reached; and then gently increases the palmar glide force to mobilize the joint (Figure 7C). – Three to five gentle mobilization oscillations are performed, each one performed slowly with an excursion of only a few millimeters and held for a fraction of a second.  Challenge the phalanx to glide

in the dorsal direction until tissue tension is reached; and then gently increases the dorsal glide force to mobilize the joint (Figure 7D). – Three to five gentle mobilization oscilla-

tions are performed, each one performed slowly with an excursion of only a few millimeters and held for only a fraction of a second.

Example 2: Talocrural Joint Traction Long axis traction of the ankle (talocrural) joint. This is a fairly simple example of nonaxial joint mobilization in which the talus is tractioned away from the tibia and fibula.

Following are the steps to perform this mobilization: Use both hands (middle finger reinforced over middle finger) to contact the dorsal surface of the talus immediately distal to the tibia/fibula (Figure 8A). No stabilization hand is needed because the client’s body weight serves to stabilize the rest of the body, inTerra Rosa E-mag 35

bilize the humerus into inferior glide, the “slack” of scapular depression motion needs to be first taken out. When pressing inferiorly on the humeral head, the shoulder girdle will move (depress) with the humerus.

Keep pressing on the humerus until shoulder girdle depression reaches the end of its motion.  Some traction can be added to

the GH joint by pulling the humerus laterally away from the glenoid fossa with the hand that is placed on the distal humerus. This is facilitated by the placement of the thumb on the anterior surface of the elbow (see Figure 9B).  Challenge the humerus to roll

into further abduction with the distal hand as the proximal hand glides the humerus inferiorly until tissue tension is reached. (Note: As stated, the slack of scapular depression first had to be removed with this motion.)  Now gently add to the force Fig. 8 Traction mobilization of ankle (talocrural) joint. A, Contacting the talus. B, Traction mobilization of the talus.

cluding the tibia and fibula.

Add traction to the joint by gently pulling the talus away from the tibia/fibula until tissue tension is reached; and then gently increases the traction force to mobilize the joint (Figure 8B). – Three to five gentle mobilization oscillations are performed; each one is performed slowly with an excursion of only a few millimeters and held for only a fraction of a second.

Example 3: Glenohumeral Joint Roll and Glide Frontal plane roll and glide mobilization of GH joint abduction involves convex on concave kine36 Terra Rosa E-mag

matics. Abduction involves a superior roll of the humeral head accompanied by an inferior glide of the humeral head. This roll and glide mobilization is performed from the starting position of ninety degrees of humeral abduction.

Following are the steps to perform this mobilization:  Place one hand on the medial

surface of the distal humerus and the other hand on lateral surface of the proximal humerus (Figure 9A). Note: It is logistically difficult to use one’s hands to stabilize the scapula for this mobilization. Instead, when applying the force to mo-

with both hands, focusing primarily on the proximal hand increasing the inferior glide mobilization of the humeral head (Figure 9C). – Three to five gentle mobilization oscillations are performed, each one performed slowly with an excursion of only a few millimeters and held for only a fraction of a second.

Example 4: Mobilization of the cervical spine Joint mobilization of the spine involves mobilization of the facet joints which are planar (flat), so convex/concave kinematics are not involved.

Following are the steps to perform mobilization of the C4-C5 joint into right lateral flexion.

Fig. 9 Abduction with inferior glide mobilization of glenohumeral (GH) joint in the frontal plane: A, Contact the distal and proximal arm. B, Traction added. C, Further abduction with inferior glide until tissue tension is reached. D, Inferior glide mobilization of the head of the humerus. (Figure reproduced with permission from Joseph E. Muscolino)

Comfortably and securely place the client’s head in your left hand (Figure 10A). Note: Rotating the client’s head/neck to the left approximately 45 degrees helps to facilitate this protocol.

Contact and pin (stabilize) the right-side facet (articular process) of C5 with the radial side of the proximal phalanx of your index finger (Figure 10B). Thumb pad or finger pad contacts are also possible but are not as comfortable or strong. Note: The facets are shown in Figure 10C. Bring the client’s head and neck into right lateral flexion until tissue tension is reached at the end of passive range of motion of C4 on C5 (be sure to maintain your pin/stabilization contact on the facet of C5) (Figure 10D).

Mobilization is performed by gently increasing the right lateral flexion of the head and neck with the left hand while the right hand contact maintains the pin on the facet of C5. This results in right lateral flexion mobilization of C4 on C5 (Figure 10E). Three to five gentle mobilization oscillations are performed, each one performed slowly with an excursion of only a few millimeters and held for only a fraction of a second.

Note: The mobilization can also be done by instead holding the head and neck pinned with the left hand and then gently increasing the pressure against the facet of C5 to move it relative to C4. It can also be performed by moving both of your hands in concert: the left hand increases the right lateral flexion of the head (and consequently C1-C4) while the right hand presses on the facet of C5.

“With an understanding of joint kinematics, the therapist can critically reason how motion should occur at a joint. This empowers the therapist to be able to critically think how to apply joint mobilization treatment technique to their client’s condition instead of memorizing cookbook treatment routines.”

Terra Rosa E-mag 37

Fig.10 Mobilization of the cervical spine into right lateral flexion. A, Support the client’s head in your left hand. Note that the client’s head and neck are rotated to the left. B, Index finger contact on right-side facet of C5. C, Facets of the cervical spine. D, The head and neck are brought into right lateral flexion until tension is reached at the C4-C5 level. F, Mobilization of C4 on C5.

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

38 Terra Rosa E-mag

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

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

This workshop covers major clinical orthopedic assessment and treatment techniques for the lower extremity

8-9 July 2016, Sydney

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Terra Rosa e-magazine, No.

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Easy Assessment for Massage Therapist

By Sean Riehl, LMT

40 Terra Rosa E-mag

Easy Assessment Only a small fraction of massage therapists use any assessment testing in their practice. Although most massage training includes some type of kinesiology and assessment tests, therapists quickly forget this information and rely only on their touch. Touch is powerful, and because of this, most therapists don't find a need for any assessment testing. I believe that adding a few simple assessment tests can dramatically enhance the massage experience.

The problem with assessment The problem with testing is that there are too many tests. Even after making many DVDs on orthopedic testing, even I can't remember them all. Also, in a normal massage practice, muscle tension dominates the client's complaints, and so a therapist with good palpation skills can easily find the areas of complaint and relieve them. Finally, many clients don't expect to have any testing done. What we really need is a simple set of tests that we can do quickly that will reveal restrictions to both the therapist and client.

What assessment can bring Due to the complexity of all the orthopedic tests, we need some simple tests that can be done quickly, and are applied to every client every session. Range of motion testing is the perfect answer to these requirements, especially since we are working with muscles, which control the joints. By performing a quick full body range of motion testing sequence, we can see where someone is restricted. This tells the therapist where to work, but just as importantly, alerts the client to an area that needs attention. This can create a goal that the therapist and client can work towards. Tension is the precursor to injury, and restricted range of motion is an indication of tension and dysfunctional movement. By revealing these areas to a client, we can design session that will not just get them out of pain now, but make them healthier in the future.

The Spa Challenge Many of my students reflect that people who come to spas don't want any testing. I contend that every human wants to be listened to deeply. We listen to our clients when they tell us where they hurt. We can listen to them with our eyes when we notice one shoulder is higher than the other. We can listen to them with our touch when we flex their wrists, elbows or shoulders and notice restriction. To spend 90 seconds to go through some tests that reveal major holding patterns usually is met with excitement by clients. Therapists that can engage with their clients, and focus on what is needed, are the therapists that are successful. The fact that 99% of therapists don't do any testing before the session means that there is a huge potential for massage therapists to create even more value for their clients.

Start with the wrists When someone enters the session, after you have listened to the reason they are there. Ask them is you can run through a quick full body evaluation. I like to start this by touching them, since it puts the clients at ease. Grasp both of their hands, bring them up towards you and flex and extend each wrist. Notice if one side doesn't move as far as the other. Comparing the sides is an easy way to notice if there is restriction, and is much easier than memorizing the correct number of degrees a joint is supposed to move. When you do all these tests, give a little extra pressure, springing into the end of the range. A hard end-feel reveals that the restriction is in the ligaments. A soft or springy end feel reveals that the restriction is from muscle tension.

Now make sure both elbows are at their sides, and supinate and pronate both wrists and compare each side. Notice if there is any restriction on either side.

You will be surprised by how many people have a little restriction in some wrist motion on one side.

Terra Rosa E-mag 41

When you find some restriction, smile and tell you client “look at that, you have a little restriction here in this wrist”. Ask them if they can feel it. Have a playful attitude with no judgement. Don't say “wow, you're really restricted!”, or “That's really bad!”. All of this is done with a light spirit. The idea is to raise your awareness about areas that you can help, and raise the clients awareness about restrictions in their body.

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

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

It is very difficult to test for the length of the shoulder abductors, so instead we will test for function.

Have the client bring their arms overhead. As they do so, watch to see if both sides move equally, and if once raised, both are equally straight up. Pain or hesitation indicates muscle weakness in the abductors, and if one side can't quite make it all the way vertical, it could be from restriction below the joint, or weakness again in the abductors.

Next have the client relax, arms at their sides. Notice if one hand is more forward over the thigh than the other. This indicates a forward shoulder, because when the shoulder moves forward it brings the hand forward too. Now look at the shoulder that is forward. Is it higher or lower than the other shoulder?

If it is higher, it indicates the serratus anterior is tight. If it is lower, it indicates the pectoralis minor is tight. This is a big distinction to make, since both these muscles pull the shoulder forward, but only 42 Terra Rosa E-mag

Fig. 1. Assessment for the wrist: flexion & supination.

the pectoralis minor pulls it forward and down.

Neck assessment To perform the neck assessment, have your client rotate their head to the right and then the left. Notice if they don't move as far on one side. Limited neck rotation is very common, and incredibly easy to help.

It is one of the most satisfying evaluations that you can do, since the clients will usually experience a big improvement after the session.

Next have your client laterally flex- bring their ear to their shoulder. Have them do this several times, and

Easy assessment as they do, notice if the motion is happening in the upper neck(C1-C3), or lower neck. It is very common for the lower neck to be almost immobile, and all the motion happening in the upper neck. Note where there is restriction.

You may be wondering why we don't perform flexion or extension of the neck. The reason is that most of the muscles that perform these motions also perform rotation, so we can get most of what we need by looking at rotation. Once rotation is restored, any limited flexion or extension usually resolves itself.

Hip Next have the client take a few steps in place without looking down. Then have them stop and stand normally. Look at the position of their feet. Notice if one foot is pointing out, or if one is pointing in. If the feet are pointing out, it indicates tension in the hip external rotators. Feet pointing inward can indicate tension in the internal hip rotators. If we want to address the lower back and hips, we can get confirmation of this initial assessment once the client is on the table.

Torso At this point we have the client sit on the edge of the massage table, cross their hands in front of their chest and rotate to each side. This will tell us about the ability of the thoracic vertebrae to move. Notice if one side is more restricted than the other.

Next we can look at the ability of the lumbar vertebrae to side-bend, which will tell us something about the health of the spine. Still with hands crossed over their chest, have them side bend to each side. Watch their torso and ignore shoulder or neck motion.

Really note what type of motion is happening between the bottom of the ribs and the top of the ilium.

Restriction bending to the right indicates a strong

Fig. 2. Assessment for the shoulder: Internal rotation, External rotation & Shoulder height assessment.

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possibility of a tight quadratus lumborum on the left.

More Tests There are so many tests, and this is just a few. We have also skipped a few joints that either don't need to be assessed every time, or are best assessed with the client on the table. The few that I have shown here give us a great amount of information before the session starts.

Massage is powerful work. We as therapists have a great sensitivity in our hands to feel areas of tension.

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

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

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

www.terrarosa.com.au

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Real Bodywork offers a variety of high quality massage DVDs and massage videos. All of the DVDs are finely crafted by Sean Riehl and colleagues with great techniques that you can apply immediately in your massage practice.

Available as hardcopy DVDs and Online Videos at www.terrarosa.com.au

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Fig.1. There is a continuous line of connection from the gastrocnemius/soleus to the plantar fascia (whose fibrous aponeuroses are shown here in salmon). A lack of resilience anywhere in the chain will restrict ankle dorsiflexion, and may contribute to Achilles tendon irritation or plantar fasciitis.

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Type 1 Ankle Restrictions and Plantar Fasciitis

By Til Luchau Ankles bend, ankles straighten. Why is this important? Try walking without bending your ankles. If you have ever attempted to walk in ski boot, you will be aware of the awkwardness and stiffness that comes with a loss of ankle motion.

tibia and fibula (such as the extensor retinacula, interosseous membrane and tibiofibular ligaments) can prevent these two bones from normal widening around the wedge-shaped talus .

These two types of restrictions can occur together, Ankles bend in two sagittal directions – plantarflex- but often one type will be the primary or most obviion (from the Latin plantaris flectere, “sole bent”), ous restriction. In general, Type 2 is more common and dorsiflexion (bent towards the dorsal or upper when there is very limited dorsiflexion (as in the side of the foot). While plantarflexion gives a power- person on the right in Fig. 3), though this is variable. ful push-off to each stride and adds spring to a jump, In this article, I will begin by discussing a number of the complementary motion of dorsiflexion is at least ways to work with a Type 1 restriction – to help the as important. Squatting, kneeling, lunging, running, soft tissues in the back of the lower limb to lengthen and landing from a jump all require dorsiflexion, as and be as responsive as possible. Type 2 restrictions do many other crucial functions related to our ability – a fixed relationship between the tibia and fibula – to get around and function freely. Dorsiflexion, when is discussed fully in Chapter. 5 of the Advanced Myolost, limits more than just ankle movement – it limits fascial Techniques Vol. 1 book (Luchau, 2015, Handour overall mobility and adaptability. spring Publishing) There are two main types of structural restrictions Dorsiflexion test that can limit standing dorsiflexion1. We will refer to them as Type 1 and Type 2: We can assess the amount of dorsiflexion available • Type 1: Dorsiflexion will be limited if the soft tissue structures on the posterior side of the leg and foot resist lengthening. These structures include the gastrocnemius, soleus, superficial and deep fascias, the long toe flexors, and the plantar fascia.

•

Type 2: Inelastic connective tissues joining the

and identify the primary type of restriction by asking our client to do a deep knee bend with parallel feet.

Look at the angle of the lower leg in relationship to the foot (Figs. 2 and 3). How deep can the knee bend go before the available dorsiflexion is used up and the heels have to come off the ground?

In general, the more dorsiflexion, the better, even for

1 The contributing causes of both types of restrictions can include soft tissue shortening, hardening, or scarring from overuse, postural habit, surgery, or injury, as well as neurological conditions such as cerebral palsy. The contractures from these conditions will usually respond well to the work presented in these articles. Restrictions from joint abnormalities or bone spurs are also possible, and although the work described here may be helpful, additional measures and care by other professionals is usually indicated.

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

Once you have assessed the amount of dorsiflexion, you will need to determine where to work. Your client will usually be able to direct you to the predominant restriction. At the full limit of dorsiflexion, ask: “What stops you from going further? Where exactly do you feel that?” The most common answers are a stretch or tightness in the back of the calf, sometimes including the sole of the foot (a Type 1 restriction), Fig. 2. Dorsiflexion refers to the angle between the tibia and the or a jamming, crunching, or pinching at the anterior talus. fold of the ankle (indicating a Type 2 restriction)2.

We will now look at two techniques that will help address the first type of restriction: shortness in the posterior leg and/or foot.

Ankle mobility techniques The soft fist Both of the techniques in this chapter use the practitioner’s “soft fist” as a tool. This has several advantages over using a palm, fingers, or other parts of the hand as traditionally used in soft-tissue manual therapy: • Once you are accustomed to using a soft fist, you will find that it allows you to address particular structures and tissue layers with greater specificity and less work as, by keeping your wrist aligned with the metacarpals of your hand, you can transmit presFig. 3. In the Dorsiflexion Test, look for the degree of ankle dorsure with almost no muscular effort.

• The neutral position of the wrist keeps the carpal tunnel open, preventing the neurovascular compression and overuse injuries that can accompany frequent or habitual wrist extension.

siflexion possible before the heels lift off the floor. In addition to the angle between the foot and the tibia, compensations such as turning the feet out (seen in the person on the left), foot pronation, lifting the arms forward for balance, or leaning forward at the hips (as the person on the right is doing), are all possible signs of limited dorsiflexion.

Sometimes clients will report a straining or cramping in the front of the shin, instead of a stretching in the back or jamming sensation in the front. If they seem to be referring to the tibialis anterior area, this is usually related to Type II restriction, which is discussed in Chapter 5. If the more lateral peroneals seem to be the source of the sensation, those will usually respond to direct work at the site of discomfort, combined with active dorsiflexion and plantarflexion, as the peroneals themselves can contribute to limited dorsiflexion (see Fig. 5).

2

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

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

With your client prone and with his or her feet off the end of the table, use your soft fist to anchor the stocking-like outer layers of fascia (the superficial and crural fascias). We will work with one layer at a time, releasing each before going deeper.

Ask your client for slow, deliberate ankle movement (plantar- and dorsiflexion). Use the lengthening effects of dorsiflexion to release any shortened or tighter lines of tissue (Fig. 4), as you apply a slight cephalad (headward) resistance to the tissues under your touch.

Although your touch will slide slightly, let your client’s active ankle dorsiflexion initiate and pace your movement. Once you have felt the outer layers lengthen, feel into the deeper Achilles tendon and the conjoined heads of the gastrocnemius and soleus itself. Continue the active movement, as you gradually work deeper on each pass. Check in frequently with your client about the

Fig. 5. Use the Gastrocnemius Technique all the way to the gastrocnemii origins on the posterior side of the distal femur (left edge of image). Also visible in this view are the peroneus longus and brevis (transparent), which like the gastrocnemius/ soleus complex, can also limit dorsiflexion

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Key Points: Gastrocnemius/Soleus Technique Indications include: * Type I dorsiflexion restriction * Achilles Tendon or calf pain * Plantar Fasciitis.

Purpose * Increase layer differentiation and tissue adaptability. * Prepare outer layers of the lower leg for deeper work.

Instructions Use gentle friction and tension to feel for and release any restrictions in outer layers of the lower leg. pace and depth of this movement. As postural muscles that are always engaged when standing, the gastrocnemius complex can be particularly tender, especially at deeper levels.

Since the long toe flexors can also restrict dorsiflexion, ask for active toe extension in combination with dorsiflexion. This lengthens and structurally differentiates the flexor hallicus longus and flexor digitorum longus from each other, and from their neighbors. Since these are the deepest structures in the calf, this makes this technique even more effective.

As long as your client is comfortable and able to relax into the work, you can incorporate an additional measure of passive gastrocnemius stretch with your leg (Fig. 4). Use your soft fist or gentle finger pressure to work all the way to the proximal origins of the medial and lateral gastrocnemius heads on the posterior femur (Fig. 5), being cautious around the nerves in the popliteal fossa at the back of the knee.

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Plantar Fascia Technique See video of the Plantar Fascia Technique at http:// advanced-trainings.com/v/ld05.html The sole of the foot has alternating layers of broad connective tissue strata, short strong muscles, and long cord-like tendons and ligaments. Shortness in any of these layers can limit dorsiflexion through their collective continuity with the gastrocnemius/ soleus complex, as seen in Fig. 1. The plantar fascia is a strong, fibrous layer covering the entire sole, lying superficial to the short toe flexors and just deep to the subcutaneous fat of the heel. Plantar fasciitis is a common inflammatory condition of this layer, characterized by heel and mid-foot pain, and most often with point tenderness at the plantar fascia’s insertion on the distal and inferior surfaces of the calcaneus. Contributive factors include improper foot and leg biomechanics, overuse, and fascial shortness in the calf or hamstrings.

Direct work with the plantar surface of the foot, including the plantar fascia, is indicated when clients report a stretch or pain in the sole with the Dorsiflexion Test. Local plantar pain, cramping, and stiffness are also indications for using this technique, as is plantar fasciitis.

Because plantar fasciitis involves tissue inflammation, the conventional wisdom is to avoid working directly on the most painful areas (usually the proximal attachments on the calcaneus). Although some practitioners report good results by carefully working directly on the most painful areas, the most cautious approach would be to lengthen, release, and ease the entire plantar surface around (rather than at) the points of greatest tenderness. If you are not getting the results you want from the indirect approach, you might want to discuss using a direct approach with your client, making sure he or she is aware of the risk of experiencing increased inflammation afterwards as a possible result of working directly on the inflamed tissues. If your client reports less discomfort in the days after your session, even if the relief was transitory, you are on track. If there was a worsening of the symptoms, or if no

change was evident afterwards, return to working globally rather than locally.

“Recalcitrant”, or stubborn, plantar fasciitis is treated surgically by “releasing” (partially severing) the plantar fascia, with the aim of relieving the strain on the inflamed attachments. Our intention is similar, though our methods are different – instead of severing the fascia, feel for a lengthening release in both of the techniques described here. In combination with hamstring or peroneal work, clients often show tangible improvements in the degree of plantar tenderness within one or two sessions. A longer series of sessions is often necessary for chronic sufferers, as is regular stretching, a change in usage patterns, and improved biomechanics (via methods like structural integration, orthotics, movement instruction, or improved footwear).

Fig. 6. The Plantar Fascia Technique combines the soft fist with active or passive toe extension. In Plantar Fasciitis, avoid direct pressure on the most tender areas so as not to further aggravate the inflammation. Instead, lengthen and release the tissue distal to the inflamed points.

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

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

This article is an extract from the Book Advanced Myofascial Techniques , Vol. 1.

Shoulder, Pelvis, Leg and Foot by Til Luchau, Handspring Publishing, 2015.

Fig. 7. The plantar fascia is a broad layer of tough connective tissue covering the sole of the foot. Within it are bands of mostly longitudinal fibers (the plantar aponeuroses, in orange). The proximal end of the plantar fascia lies deep to the thick calcaneal fat pad (transparent).

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Key Points: Plantar Fascia Technique Indications include: * Restricted plantarflexion or toe flexion * Shin splints * Type II dorsiflexion restriction (preparation).

Purposes * Increase myofascial differentiation and adaptability of anterior lower leg. * Preparation for the Interosseous Membrane Technique.

Instructions Use slow gliding of a soft fist or forearm on myofascia of anterior lower leg, feeling for tissue lengthening on eccentric (plantarflexion or toe flexion) phase.

Movements Active ankle plantarflexion and dorsiflexion; active toe flexion and extension.

The son of a mathematician and an artist, Til Luchau delights in combining the technical and the beautiful in his manual therapy articles, which have appeared in magazines and professional journals around the world. A Certified Advanced Rolfer® and former Faculty Coordinator of the Rolf Institute’s Foundations of Rolfing Structural Integration program, where in the early 1990’s he originated Skillful Touch Bodywork (the Rolf Institute’s own training and practice modality), his company (AdvancedTrainings.com) offers in-person and at-a-distance professional continuing education. Originally trained as a psychotherapist, Til’s ability to connect interdisciplinary, big-picture ideas to practical, realworld applications has made his trainings popular worldwide.

Advanced Myofascial Techniques, Volume 1 is information-packed guides to highly effective manual therapy techniques. Focusing on conditions of the shoulder, wrist, pelvis, sacrum, leg, and foot, Volume 1 provides a variety of tools for addressing some of the most commonly encountered complaints. With clear step-by-step instructions and spectacular illustrations, each volume is a valuable collection of hands-on approaches for restoring function, refining proprioception, and decreasing pain.

Available at www.terrarosa.com.au 52 Terra Rosa E-mag

Image ŠAdvanced-Trainings.com

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

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

Til Luchau is the Director of Advanced-Trainings.com. A legend around the USA for his thorough, student-focused approach to trainings, Til brings more than 25 years of knowledge, talent and enthusiasm to these programs. He has trained thousands of practitioners in over a dozen countries on five continents. He is the author of the Advanced Myofascial techniques book (Handspring Publishing).

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More Info at: www.terrarosa.com.au

Manual Therapy for Lower Back Pain Evidence-Based and Clinical Outcomes A research was recently published in Journal of the American Medical Association JAMA, October 2015 issue by researchers from University of Utah. The study titled ” Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain, A Randomized Clinical Trial” evaluated whether early physical therapy (spinal manipulation and exercise) is more effective than usual care in improving disability for patients with low back pain (LBP). The study assigned 108 people to receive early physical therapy (four treatment sessions over 3 weeks starting soon after symptoms began), and randomly selected another 112 people to stick with usual care (no physical therapy treatment).

The results showed that among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability after three months, but the improvement was modest. There wasn’t a significant difference between the groups after one year.

What was reported in the media can have different interpretation: Reuters Health published “Early physical therapy might help ease lower back pain” , Meanwhile, the blog at NYTimes wrote “Physical Therapy May Not Benefit Back Pain” The Inquisitr reported “New study shows acute lower back pain may not require physical therapy”.

And NPR website reported “Physical Therapy May Help For Back Pain, But Time Works Best” So is physical therapy is not beneficial for acute low back pain and it is better to wait as time heals?

A Recent Cochrane Review on Massage for low-back pain, has a similar conclusion: “We have very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up.

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There were only minor adverse effects with massage.”

So does that mean massage or manual therapy is no effective for lower back pain? It seems that a short-term relief of pain is considered to be non-significant from a medical point of view. I would contend if there is any therapy that can provide a longterm relief of pain.

While we know that massage cannot fix everything, it can at least provide a short-term relief, which is much needed, following an onset of back pain.

We asked some expert manual therapists on their view on this issue.

John Sharkey MSc: This paper is not dissimilar to a recent randomized clinical trial published in Spine entitled “Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute and Subacute Low Back Pain” (Schneider et al 2015). Both papers used similar procedures in design and methods. The Schneider paper showed a statistically significant advantage of manual-thrust manipulation at 4 weeks compared to usual medical care.

Based on the past forty years of research we can say with authority that back pain resolution has not statistically improved.

In fact, research has demonstrated an increase in the prevalence of chronic back pain. Low back pain is multi-factorial with numerous circular relationships (Richmond 2012). It would be wise to provide treatment that is also multi-factorial. A recent “systematic review of systematic reviews” by Kumar, Beaton and Hughes found some evidence to support the effectiveness of massage therapy for treatment of non-specific low back pain in the short term. Massage therapists combine soft tissue manipulation techniques with other effective therapeutic interventions including positional release, soft tissue release (aka: START, ART, Connective tissue massage) myofascial trigger point therapy, muscle energy techniques and others to great effect. Massage therapists deal with a ludicrous number of variables when treating clients. It is the combined therapeutic effect that leads to the significant results we see every day in clinical practice globally.

Joe Muscolino, DC: I find the entire premise of this research study to be invalid. I do not see how manual therapy or any therapy, other than pain medication, can be evaluated on how it affects low back pain. We do not treat low back pain. We treat the underlying mechanisms that cause low back pain. And given the many neuro-myo-fascioskeletal conditions that can cause low back pain, I don’t see how they can all be lumped into one study. I think this study both misses the point of clinical orthopedic manual therapy care and furthers the incorrect belief that if there is not a demonstrable lesion on MRI or X-Ray, that all soft tissue problems can be lumped into “non-specific low back pain.”

Regarding the lack of long term improvement, I will say that I view most manual therapy as a passive means of creating temporary improvement on the part of the client. Once this is achieved, to maintain this improvement, movement therapy such as Pilates, yoga, or fitness training is needed. In other words, we can likely get people well, but we cannot necessarily keep them well. For that, they need strengthening and stretching to create strong musculature and maintain soft tissue flexibility, and regain/maintain proper neural control.

Joanne Avison: Time, timing and accumulation might also play a role in acquiring and managing (and overcoming) Lower Back Pain. Whatever the cause of lower back pain, be it the insult of poor posture or injury or otherwise, there is known to be a cumulative effect in the tissues; be they compensatory or self-protective, for example. The connective tissue (particularly the Thoraco-lumbar Fascia and other myofascial aspects that might contribute to Low Back Pain), like all fascial tissues, is now known to respond to its loading history (see Schleip, 2003) over various time-frames.

Since the fascia is ubiquitous and invested through every muscle, joint and aspect of the body - including the lower back - it might be misleading to suggest that any therapy can be sufficiently judged after only “early intervention”. Surely a chronic or traumatised pattern would not have sufficient time to respond to treatment? If chronic conditions, by definition, have taken time to accumulate - then perhaps we should consider efficacy of palpation (under any discipline) once it has taken time to accumulate? That is after consistent, repeated treatments that can allow the body to adapt over time, to more optimal patterns.

(This is a known purpose and common achievement after such practices as Structural Integration, Neuromuscular Therapy and many others). The response time of specifically training the fascial aspect of the tissues in performance, for example, is 12-24 months, vs. the much faster response time of training in muscular-based programmes. (See article by Schleip in Terra Rosa).

intervention. I am not at all sure that the question raised here, upon which the study was based, makes sense of the issue or how the body works; much less justifies suggesting massage doesn’t help, based upon the short term only.

References Fritz, J. M., Magel, J. S., McFadden, M., Asche, C., Thackeray, A., Meier, W., & Brennan, G. 2015. Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain: A Randomized Clinical Trial. JAMA,314(14), 1459-1467.

Furlan, A.D., Giraldo, M., Baskwill, A., Irvin, E. and Imamura, M., 2015. Massage for low-back pain (Review). Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD001929. doi: 10.1002/14651858.CD001929.pub3 Schleip, R., 2003. Fascial plasticity–a new neurobiological explanation: Part 1. Journal of Bodywork and Movement Therapies, 7 (1): 11-19.

Schneider, M., Haas, M., Glick, R., Stevens, J., Landsittel, D. 2015.

Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute and Subacute Low Back Pain A Randomized Clinical Trial. Spine. 40(4): 209-217.

Richmond, J. 2012. Multi-factorial causative model for back pain management; relating causative factors and mechanisms to injury presentations and designing time- and cost effective treatment thereof. Med Hypotheses. Aug; 79 (2):232-40. doi: 10.1016/j.mehy.2012.04.047. Epub May 31.

Kumar, S., Beaton, K., Hughes, T. 2013. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. International Journal of General Medicine. 6: 733–741.

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

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Maximise Oxygenation

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

CORE Myofascial Therapy Certification

CORE Sports and Performance Bodywork

Sydney

Sydney 19,20,21 November 2016

CORE Myofascial Therapy 1: 11,12,13 November 2016 CORE Myofascial Therapy 2: 14,15,16 November 2016

This 3-day seminar will examine the basic styles of performance inherent in all athletic disciplines. Utilizing structural integration and myofascial therapy theories and techniques that are appropriate for each style of performance, we will focus on developing training and event protocols for endurance, sprint, power, and multi-skilled athletes.

An intermediate to advanced, six-day workshop designed to give practicing massage therapists in-depth knowledge and hands-on experience in full-body myofascial treatment protocols. With this knowledge and skill, you will be able to improve your clients’ structural body alignment and increase their physical performance.

“Getting the basic Myofascial Spreading done on my first day resulted in a dramatic improvement of my body alignment “ Mic, Townsville

George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has practiced and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years.

George has served as a member of the Florida Board of Massage Therapy and was Co-Director of the International Sports Massage Team for the 2004 Athens Olympics.

Terra Rosa 56 Terra Rosa E-mag Your Source for Massage Information AMT , ATMS, IRMA, MAA Approved CEs.

For more information & Registration Visit www.terrarosa.com.au

Functional Fascial Taping with Ron Alexander

“Evidence-Based Pain Relief” This workshop teaches a fast and simple way for clinicians to reduce pain, improve function, encourage normal movement patterns and rehabilitation of musculoskeletal pathologies in a pain-free environment.

FFT has been shown to have a significant effect on Non-Specific Low Back Pain in a randomised double-blind PhD study. FFT is a non-invasive, immediate, functional and an objective way to decrease musculoskeletal pain.

Presenter:

A great way to encourage

Ron Alexander— STT [Musculoskeletal], FFT Founder and Teacher

Sydney 9-10 April 2016, Melbourne 16-17 April 2016 Register Now at: www.terrarosa.com.au

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Research Highlights Compiled By Jeff Tan Evidence of Anatomy Trains myofascial meridians

pain or athletic pubalgia is suggested to be provoked by a tight adductor longus and a weak rectus abdominis.

The anatomy trains concept is quite popular for bodyworkers, but currently there is no scientific evidence yet. A group of researchers from Goethe University in Frankfurt, Gemany looked for the evidence on the existence of six myofascial meridians proposed by Myers (1997) based on anatomical dissection studies.

The study was published in of Archives of Physical Medicine and Rehabilitation.

They looked for relevant articles published between 1900 and December 2014 were searched in scholarly publication databases. Peer-reviewed human anatomical dissection studies reporting morphological continuity between the muscular constituents of the examined meridians were included. If no study demonstrating a structural connection between two muscles was found, papers on general anatomy of the corresponding body region were targeted. A continuity between two muscles was only documented if two independent investigators agreed that it was reported clearly.

The literature search identified 6589 articles. Of these, 62 papers met the inclusion criteria. The studies reviewed suggest strong evidence for the existence of three myofascial meridians: the superficial back line (all three transitions verified, based on 14 studies), the back functional line (all three transitions verified, 8 studies) and the front functional line (both transitions verified, 6 studies). Moderate to strong evidence is available for parts of the spiral line (five of nine verified transitions, 21 studies) and the lateral line (two of five verified transitions, 10 studies).

However no evidence exists for the superficial front line (no verified transition, 7 studies).

The authors suggested that the practical relevance is twofold. First, the existence of myofascial meridians might help to explain the phenomenon of referred pain.

For example, myofascial trigger points of the calf have been shown to elicit pain that radiates to the sole of the foot and to the dorsal thigh. A second aspect relates to therapy and training of the musculoskeletal system.

Treatment according to myofascial meridians could be effective in reducing back pain. Several studies have shown that low back pain patients display reduced hamstring flexibility.

Overload injuries in competitive sports represent another entity of pathologies which possibly occur due to the presence of myofascial meridians. Recent studies indicate that tightness of the gastrocnemius and the hamstrings are associated with plantar fasciitis. Groin

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Shoe insoles are not effective for the prevention and treatment of low back pain An intervention of foot orthoses or insoles has been suggested to reduce the risk of developing Low Back Pain (LBP) and be an effective treatment strategy for people suffering from LBP. However, despite the common usage of orthoses and insoles, there is a lack of clear guidelines for their use in relation to LBP. The aim of this review is to investigate the effectiveness of foot orthoses and insoles in the prevention and treatment of non specific LBP. A systematic search of MEDLINE, CINAHL, EMBASE and The Cochrane Library was conducted in May 2013.

Two authors independently reviewed and selected relevant randomised controlled trials.

Results identified eleven trials : five trials investigated the treatment of LBP (n = 293) and six trials examined the prevention of LBP (n = 2379) through the use of foot orthoses or insoles. Meta-analysis showed no significant effect in favour of the foot orthoses or insoles for either the treatment trials or the prevention trials.

The authors concluded that there is insufficient evidence to support the use of insoles or foot orthoses as either a treatment for LBP or in the prevention of LBP. Does nerve growth factor cause more pain in muscle or fascia?

Nerve growth factor (NGF) is known to greatly induce hyperalgesia (heightened sensitivity to pain). Researchers from Heidelberg University and Mannheim, Germany explored patterns of NGF sensitization in muscle and fascia of distal and paraspinal sites. The study was published in Muscle and Nerve Journal.

The researchers compared the effects of injecting nerve growth factor (an agent that causes sensitization to mechanical stimuli) to 8 subjects, to the tibialis anterior and erector spinae muscles and their fasciae.

The spatial extent of pressure sensitization, pressure pain threshold, and mechanical hyperalgesia was assessed at days 0.25, 1, 3, 7, 14, and 21. Chemical sensiti-

Research Highlights zation was also explored.

The results showed that the time-course and magnitude of nerve growth factor injection-induced sensitization to mechanical stimuli were generally similar across muscle and fascia. They were also mostly similar across two different muscle groups (the tibialis anterior and lumbar erectors). However, the spatial extent of mechanical sensitization in the tibialis anterior musculature was larger in the fascia than in the muscle and displayed a tendency to peak at 3 days postinjection. Pressure pain thresholds were lower, tonic pressure pain ratings, and citrate buffer evoked pain higher in fascia than in muscle.

The authors concluded that Spatial mechanical sensitization differs between muscle and fascia. Thoracolumbar fasciae appear more sensitive than tibial fasciae and may be major contributors to low back pain, but the temporal sensitization profile is similar between paraspinal and distal sites.

The placebo effect can still work, even if people know it's a placebo "The placebo effect is real – even if you know the treatment you've been given has no medical value, research has concluded.

A study, published in The Journal of Pain, was conducted by a team from the University of Colorado Boulder (UCB). In it, a ceramic heating element was applied to the forearms of participants, hot enough to cause pain but not too hot that it burned their skin.

The lead researcher, UCB graduate student Scott Schafer, then applied what the participants thought was an analgesic gel, used to relieve pain before applying the heating element on the skin again. In reality, though, the gel was nothing more than Vaseline with blue food coloring, and Schafer simply turned down the heat when it was applied. Each participant was asked medical questions and given information on the drugs to help the illusion. Regular Vaseline, without blue food colouring, was used as a control.

When Schafer set the heat on ‘medium,’ participants reported less pain when they were given the blue Vaseline as opposed to the regular Vaseline – despite the heat remaining constant. After one session, some were told that it was a placebo, and Schafer found that it no longer worked.

However, for those that went four sessions with the blue Vaseline before being told it was a placebo, it was remarkably still effective. It appears that they associated the blue Vaseline with the reduced pain so much that they trusted its effects over Schafer telling them it wasn't real, having felt the benefits regularly. It suggests people can be trained to believe that a placebo works as well as a drug.

"We're still learning a lot about the critical ingredients of placebo effects,” Tor Wager of UCB, senior author on the study, said in a statement.

consistent with those beliefs. Those experiences make the brain learn to respond to the treatment as a real event. After the learning has occurred, your brain can still respond to the placebo even if you no longer believe in it."

The research could be useful in helping treat drug addiction, such as patients in severe pain who have taken strong – and potentially addictive – painkillers. "If a child has experience with a drug working, you could wean them off the drug, or switch that drug a placebo, and have them continue taking it," said Schafer in the statement.

Effect of a Brief Massage on Pain, Anxiety, and Satisfaction With Pain Management in Postoperative Orthopaedic Patients A new study by the nurses at the Orthopedic Unit of The William W. Backus Hospital in Norwich, CT evaluated the impact of a brief massage intervention in conjunction with analgesic administration on pain, anxiety, and satisfaction with pain management in postoperative orthopaedic inpatients.

Postoperative orthopaedic patients was studied during two therapeutic pain treatments with an oral analgesic medication. A pre-test, post-test, randomized, controlled trial study design, with crossover of subjects, was used to evaluate the effect of a 5-minute hand and arm massage at the time of analgesic administration.

Each patient received both treatments (analgesic administration alone [control]; analgesic administration with massage) during two sequential episodes of postoperative pain. Prior to administration of the analgesic medication, participants rated their level of pain and anxiety with valid and reliable tools. Immediately after analgesic administration, a study investigator provided the first, randomly assigned treatment. Pain and anxiety were rated by the participant 5 and 45 minutes after medication administration. Satisfaction with pain management was also rated at the 45-minute time point.

Study procedures were repeated for the participant's next requirement for analgesic medication, with the participant receiving the other randomly assigned treatment.

Twenty-five postoperative patients were studied during two sequential episodes of pain, which required analgesic medication administration (N = 25 analgesic alone; N = 25 analgesic with massage). Patient ages ranged from 32 to 86 years. Pain and anxiety scores after medication administration decreased in both groups, with no significant differences found between the analgesic alone or analgesic with massage treatments. However patient satisfaction with pain management was higher for pain treatment with massage than medication only.

The authors concluded that the addition of a 5-minute massage treatment at the time of analgesic administration significantly increased patient satisfaction with pain management.

“What we think now is that they require both belief in the power of the treatment and experiences that are

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Research Highlights Iliotibial band stores and releases elastic energy ensure that humans are motivated to build social bonds during running through touch.

A New study published in Journal of Experimental Biology and the Journal of Biomechanics examined how the iliotibial band stores and releases elastic energy to make walking and running more efficient.

“We found that the human IT band has the capacity to store 15 to 20 times more elastic energy per body mass than its much-less-developed precursor structure in a chimp,” “We looked at the IT band’s capacity to store energy during running, and we found its energy-storage capacity is substantially greater during running than walking, and that’s partly because running is a much springier gait. We don’t know whether the IT band evolved for running or walking; it could have evolved for walking and later evolved to play a larger role in running.”

The notion that the IT band acts as a spring to aid in locomotion runs counter to the decades-old belief that its primary function is to stabilize the hip during walking.

"What is intriguing about the illusion is its specificity," says Antje Gentsch, also of the University College London. "We found the illusion to be strongest when the stroking was applied intentionally and according to the optimal properties of the specialized system in the skin for receiving affective touch."

This system typically responds to slow, gentle stroking found in intimate relationships and encodes the pleasure of touch, Gentsch explains. In other words, this "social softness illusion" in the mind of the touch-giver is selective to the body parts and the stroking speeds that are most likely to elicit pleasure in the receiver.

"The illusion reveals a largely automatic and unconscious mechanism by which 'giving pleasure is receiving pleasure' in the touch domain," Fotopoulou says.

In fact, social touch plays a powerful role in human life, from infancy to old age, with beneficial effects on physical and mental health. Many studies have focused on the benefits of touch for the person receiving it. For in“Unlike many clinicians and anatomists, we use the lens stance, premature infants benefit greatly from time of evolution to think about how humans are adapted not spent in direct physical contact with their mothers. Yet, just for walking, but also for running, so we look at the Fotopoulou and her colleagues say, remarkably little is IT band from a totally different perspective,” Lieberman known about the psychological benefits of actively said. “When we looked at the difference between a touching others. chimp and a human, we saw this big elastic band, and Earlier studies showed that softness and smoothness the immediate idea that leapt out at us was that the IT stimulate parts of the brain associated with emotion and band looked like another elastic structure, like the reward. Therefore, this "illusion" that other people are Achilles tendon, that might be important in saving ensofter ensures that reaching out and touching another ergy during locomotion, especially running.” person comes as its own reward.

The findings, Biewener said, “will have key importance for basic science and clinical studies that seek to integrate the role of this key fascial structure into programs of sports-exercise training and gait rehabilitation.”

To understand what role the IT band plays in locomotion, the researchers developed a computer model to estimate how much it stretched ― and by extension, how much energy it stored — during walking and running.

One part of the IT band stretches as the limb swings backward, Eng explained, storing elastic energy. That stored energy is then released as the leg swings forward during a stride, potentially resulting in energy savings.

This rewarding illusion acts as a kind of "social glue," bonding people to each other. For example, touching a baby in a gentle manner seems to give the mother tactile pleasure, the researchers say, over and above any other thoughts or feelings the mother may have in the moment.

Researchers have very little confidence that massage is an effective treatment for Lower Back Pain

A systematic review on massage effects on non-specific low back pain in 2009, out of 13 trials, it was concluded that “Massage might be beneficial for patients with “It’s like recycling energy,” Eng said. “Replacing muscles subacute and chronic nonspecific low back pain, espewith these passive rubber bands makes moving more cially when combined with exercises and education.” economical. There are a lot of unique features in human limbs — like long legs and large joints — that are adap- However, in a updated 2015 review by the same authors, tations for bipedal locomotion, and the IT band just —out of 25 trials—the conclusion was quite the opposite. stood out as something that could potentially play a role The Cochrane Review concluded that: "We have very in making running and possibly even walking more ecolittle confidence that massage is an effective treatment nomical.” for LBP.Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the shortterm follow-up. Functional improvement was observed When it comes to touch, to give is to receive in participants with sub-acute and chronic LBP when In a series of studies led by Aikaterini Fotopoulou of the compared with inactive controls, but only for the shortUniversity College London, participants consistently term follow-up. There were only minor adverse efrated the skin of another person as being softer than fects with massage." their own, whether or not it really was softer. The researchers suggest that this phenomenon may exist to

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Research Highlights The authors further added that "The quality of the evidence for all comparisons was graded "low " or "very low" which means that we have very little confidence in these results. This is because most of the included studies were small and had methodological flaws."

Despite this, as reported in Massage and Fitness magazine: We should not discount the research, even if it doesn't run much in our favour. “Massage — if we're talking about rubbing— is a management tool,” explained Beret Kirkeby, RMT, LMT, of Body Mechanics Orthopaedic Massage in New York City. “As far as what massage therapists should get out of reading the paper, they should be relieved. Short-term effects are still effects. I think a lot of therapists out there are secretly frustrated at why they can't “fix” people — permanently. People get ‘better’ for a lot of reasons, and it's was always highly unlikely that a passive activity, like getting a massage, is the magic bullet for back pain.”

Besides the actual hands-on work, communication with clients and patients is also another factor that could influence their pain outcome. “[Communication] also opens the door to talking about sound reasons to return, rather than you won't get better if you do not come in,” Kirkeby emphasized. “If massage therapists step up to the plate and change their verbiage or website to massage positive messages reflecting the truth, such as ‘we can help you manage’ rather than we ‘correct’ or ‘treat,’ they are far more likely to have returning clients based on the idea that the clients understand it's not a onetime show and have less disappointment when their financial commitment did not ‘fix’ them.”

Comfort to cancer patients through Hand Massage Program

gram and the Touch, Caring and Cancer Project, which is sponsored by the National Cancer Institute. According to Terhune, it is comfort-oriented, rather than a therapeutically oriented series of techniques with safety precautions and the full consent of the patient's medical team.

“There are depth, pressure, positioning, timing and movement considerations that are individual by patient.

Students are trained to work with nursing staff to understand what those are and how they should be taken into consideration for each patient so as not to compromise the patient's care or wellbeing,” said Terhune.

Studies have shown that decreased nausea, anxiety, fatigue and depression are among the benefits of utilizing of specific acupressure points and a series of massages over time.

The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities That’s the title of a review recently published in the Manual Therapy Journal by a group of researchers at the Canadian Memorial Chiropractic College. The authors conducted a Systematic Review by searching six databases from 1990 to 2015. They screened 9869 articles and critically appraised seven; six had low risk of bias.

The review found that: * Localized relaxation massage provides added benefits to multimodal care immediately post-intervention for carpal tunnel syndrome. * Movement re-education (contraction/passive stretching) provides better long-term benefit than one corticosteroid injection for lateral epicondylitis.

* Myofascial release improves outcomes compared to For those undergoing chemotherapy, the Hand Massage sham ultrasound for lateral epicondylitis. DiacutaneousProgram run by the Integrative Medicine Oncology Ini- fibrolysis (DF) or sham DF leads to similar outcomes in tiative may ease the experience. pain intensity for subacromial impingement syndrome.

Trained students and faculty are providing hand mas* Trigger point therapy may provide limited or no addisages in the infusion suites of the Ambulatory Care Cen- tional benefit when combined with self-stretching for tre at University Massachusetts Memorial Medical Cen- plantar fasciitis; however, myofascial release to the gaster for interested patients undergoing infusion procetrocnemius,soleus and plantar fascia is effective. dures. The massages are about 5 minutes per hand and several different techniques are used with patient feed- The authors concluded that: “Our review clarifies the role of soft-tissue therapy for the management of upper back as a guide. Medical students, graduate students and faculty from the School of Medicine and the Gradu- and lower extremity musculoskeletal disorders and injuries. Myofascial release therapy was effective for treatate School of Nursing are serving as volunteers in the ing lateral epicondylitis and plantar fasciitis. Movement program. re-education was also effective for managing lateral epi“Relaxation, comfort and support are some of the key condylitis. Localized relaxation massage combined with benefits for patients,” said Bambi P. Mathay, an oncol- multimodal care may provide short-term benefit for ogy massage therapist and Reiki master practitioner treating carpal tunnel syndrome.” at Dana Farber. “More and more people are using massage for medical issues, to support and improve health and are valuing it for its role in well-being. It is increasingly being recognized as part of comprehensive and continuum of care, not as a treatment, because massage cannot cure cancer.”

The curriculum and training for the hand massage program is based on the Dana Farber Hands on Care Pro-

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1. When and how did you decide to become a bodyworker?

I entered the world of bodywork after turning 40. I had spent the first half of my working life in a family business making money and pumping out products. I wanted the second half of my working life to be a part of ‘the solution’, both from a human and a global perspective. When I considered massage therapy as a career, I immediately realized that it would not require me to compromise any of my beliefs in any manner, allowing me to help others lead healthier lives. I also feel that it is a perfect fit with my personality. Massage therapy also happens to capitalize on my strengths, and allows for a lot of personal growth and professional development.

2. What do you find most exciting about bodywork therapy?

What I really love about bodywork is its pure simplicity. I believe that manual therapy can be distilled down to three elements- your head, your heart and your hands.

You need your head for the knowledge base, your heart as a caring compass, and of course, you need your hands for the physical intervention. The body is incredibly complex and mysterious, but it is always amazing to see that a physical, human intervention can often make a big difference in a patient’s life.

3. What is your favourite bodywork book?

I have a book written by Leon Chaitow back in 1987 entitled Soft-Tissue Manipulation: A Practitioner's Guide to the Diagnosis and Treatment of Soft-Tissue Dysfunction and Reflex Activity. I found this to be an extremely helpful reference manual during my schooling years and in my early years of practice as well. Leon continues to be a hero of mine, so I was elated when he agreed to write the foreword to my book.

4. What is the most challenging part of your work?

Without a doubt, it is paperwork. I love working on people, and solving problems. I love reading and learning about anything health-related. I enjoy blogging and writing about health topics; but when it comes to the paperwork involved in being self-employed I really have to

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push myself. I don’t think that I am alone in this area. I think that it is truly the bane of most self-employed persons.

5. What advice you can give to fresh manual therapists who wish to make a career out of it?

Like any career, I suggest that a person must have a deep interest and a passion before embarking on the journey.

If you love what you do, then it will never be ‘work’.

There are many bumps along the road to one’s career, and they come from any and every direction. If you love what you do, then you will keep forging ahead. If you don’t love what you do, these bumps will appear to be roadblocks. If that passion is not there, then I suggest pursuing a career for which you do have a passion.

6. How do you see the future of manual therapy?

I think that the foreseeable future of manual therapy is (unfortunately) on the sidelines of health care delivery.

This is due to existing government funding models and the power of many corporations profiting from the existing model. What I would propose is that we be advocates for a new model that employs knowledge that we already have. Well-established practice guidelines within medical literature call for lifestyle change as the first line of therapy[1]and yet this important step is missing from the present medical model. This message ties in with the theme of my book, and that is that the patient’s body already has the power to heal itself. To quote lifestyle medicine physician, Michael Greger, “The best-kept secret in medicine is that, given the right conditions, the body heals itself.”[2] Our job as manual therapists is not just to provide a physical intervention, but to advise our patients on lifestyle factors that are impeding their healing, and to advise them on lifestyle factors that need to be incorporated to help create ‘the right conditions’ for their body to heal itself. The future for our patients can change if we reveal the best-kept secret in medicine. The future for our profession could change if we were to remind policymakers that these practice guidelines already exist.

However, the medical profession will not be able to follow this guideline unless the funding model is changed.

1. When and how did you decide to become a bodyworker?

I would love to be able to say that I had some existential experience that gave me a sign from the Universe to become a bodyworker but the truth is I was just bored! I was working as a social worker in my late twenties and looking around for other activities to keep me interested in the evenings - I had tried drumming, car maintenance and a host of other evening classes - none of which I was particularly talented at or grabbed my interest further. So an introductory massage class was another one on the list - yet that first time I touched someone with focus and respect I truly did have a ‘Disney moment”. Stardust seemed sprinkled across the room and cartoon bluebirds tweeted! ! I’ve never stopped loving bodywork since that moment!

2. What do you find most exciting about bodywork therapy?

I find EVERYTHING exciting about bodywork therapy - the theories, the practice, the thrill of putting my hands on someone and tuning into the tissues and the connection with the mind-body. The ability to truly connect with someone through touch will never lose its appeal for me.

3.

What is your favourite bodywork book?

Ha ha - hard one as I have millions and am famous for taking big textbooks to the beach when I am on holiday. Although I read loads of technical nerdy stuff, probably some of my favourite books are the ones that inspired me when I first started. I have a lovely little paperback called “Massage and Meditation” by George Dowling that is probably now out of print but is beautiful in its simplicity of conveying the art of massage as a meditation - an ethos

that has continued to be at the heart of my work.

4. What is the most challenging part of your work?

The most challenging part of my work is not having enough time to do all the things I want to do with bodywork! I create courses, teach, write, have a practice and love to go on courses but there is just not enough time to immerse myself fully in all those areas of my work as I would like. As a good friend of my says” This lifetime will not be enough for us” .

I really hope that I come back as a bodyworker so I can pick up where I left off!

5. What advise you can give to fresh manual therapists who wish to make a career out of it?

Love it, Live it, do it. To be successful at massage you really have to immerse yourself fully. Go on loads of training. Read tons of books. Most importantly find yourself a community of passionate therapists to connect with - that is what Meg and I have created at Jing and it sustains me every day.

And most importantly, keep on keeping on and don’t give up.

6.

How do you see the future of manual therapy?

The future is bright! Manual therapy has been around for thousands of years and has never waned in popularity. The need to be touched with reverence lies at our core as human beings. The rise of interest and research around fascia is particularly exciting as this has the potential to explain many things that manual therapists have felt for years.

Research is important but we must also be careful not to lose the artistry of bodywork = our aim at Jing is to inspire and teach beautiful exquisite bodywork that unites the head, the heart and the hands.

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