Terra Rosa E-magazine Issue #10 by Terra Rosa

Terra Rosa E-Magazine Open information for massage therapists & bodyworkers Terra Rosa e-magazine, No. 10 (June 2012)

No. 10, June 2012 www.terrarosa.com.au www.massage-research.com

Terra Rosa E-Magazine, No. 10, June 2012

Cover Feature

How Do We Know What We Know?—Joe Muscolino

The Effectiveness of Massage Therapy—AAMT Report

From the 3rd Fascia Congress — David Lesondak

Pelvic Organ Prolapse— Walt Fritz

What is Deep Tissue Massage — Art Riggs

Spontaneous Movement Body work

Tom Ockler on MET

Practitioner & Owner: ―Straight Percentage Agreements Work Best‖ —Don Dillon

Postural Assessment— Jane Johnson

3D Anatomy for Manual Therapists

Research Highlights

42 43 44

6 Questions to David Lesondak 6 Questions to Jane Johnson 6 Questions to Walt Fritz

Welcome to our tenth issue of Terra Rosa e-magazine. In this issue, we have some focus on research and what it can do for us. We are quite fond of new research that came out continuously, as proven by our Massage News Update that has continuously running the latest research on massage and bodyworks since March 2007. Joe in his latest article discusses how we may acquire (new) knowledge. Most in the massage world would fall into the authority model, where we believe in what the teacher said. We must be aware that most of the knowledge in early massage teaching is now proven not to be valid, e.g. flushing out toxins. Then we have the research world, that recently becomes popular. However we also not fall into the trap of the evidence-based medicine goes extreme and become a sceptic. Now there are few blogs that supposedly provoke critical thinking in bodywork, start to turn into sceptics and to attack on alternative treatment: acupuncture is a sham, stretching is useless, fascia research is overrated and so on. We should not forget that bodywork is much of an art than science, that's why people are enjoying massage. As Joe stated that ‗most every technique must have something valid within it, if not many things; otherwise, it would not last very long in the world of manual and movement therapies. However, if every technique were as effective as its proponents state, why isn‘t everyone doing that technique?‘ An article posted in the Pain Treatment Topics by Stewart Leavitt: ".. as with many other CAM approaches, the problem of validity may be due to our lack of understanding and/or ability to adequately assess effectiveness, rather than with the modality itself. Considering the multitude of patients worldwide who have benefitted from acupuncture in one way or another, it still appears premature to broadly dismiss it as being of little or no value for pain relief." In this issue, we also cover other exciting articles from a selection of well-known bodyworkers. David Lesondak reported on the third Fascia Congress in Vancouver. Art Riggs answers What is Deep Tissue Massage. Walt Fritz on Pelvic Organ Prolapse, Jane Johnson on Postural Assessment. Thanks for reading and Stay Healthy Sydney, June 2012

Disclaimer: The publisher of this e-magazine disclaims any responsibility and liability for loss or damage that may result from articles in this publication.

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Cover Feature The cover of this magazine features a picture of lumbodorsal and gluteal fascia. (Thanks to Robert Schleip for permission to use.) The picture is part of the Fascia Posters produced by Robert Schleip. The project of illustrating fascia took more than 3 years to complete. The idea of illustrating fascia comes from the demand from bodyworkers who got tired of seeing the same muscular or skeletal posters hanging on their wall. There is also never an illustration of connective tissue as a whole in the body. Robert and colleagues collected hundreds of illustrations and photographs of fascia and connective tissues from old and new literatures. They fed those pictures into a computer program to recreate a 3-D illustration. With hours and days of trial and error they try to provide not only an anatomically correct representation but also convey a sense of the unified harmony. Finally with consultations with anatomy experts, they produced these set of posters that beautifully convey without words the unity of the fascial net from the most superficial layers all the way to the endomysium. More than just another anatomical chart, they are also fine art in their own right. Robert hoped that future development will create a 3-D computer model showing the layers and connectivity of fascia. Watch Robert Schleip talking about the challenge of illustrating fascia http://youtu.be/I8H0MwyQIi0 These posters are available from www.terrarosa.com.au

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How Do We Know What We Know? Joe Muscolino This may seem like a strange question. After all, most of us are probably more concerned with the knowledge that we acquire rather than how we acquire it. But, examining this question is not just an exercise in abstraction; it can improve our client practice skills because it helps us choose what techniques we want to learn and place into our toolbox of treatment techniques. Our approaches to acquiring knowledge can be divided into four models. They are: 1. knowledge imparted by an authority, 2. gleaning knowledge from research, 3. testing the new knowledge in our practice, and 4. evaluating new knowledge against principles of anatomy and physiology that are already understood. Authority model The authority model rests upon knowledge being imparted by an individual who we respect and place in a position of authority. This is probably the most common approach to learning. It begins in school, where as empty vessels, we sit and try to absorb as much as possible of the knowledge of the teachers who are assigned to our classes. This method of learning is often called sage on the stage because the teacher is the sage standing on the stage in front of us. We also place the authors of our textbooks as sages that we learn from. The authority model of learning usually continues after graduation. As practicing therapists, we subscribe to magazines devoted to our field and read articles by more sages. And we further our knowledge base by attending continuing education workshops where continuing education instructors are sages who present their techniques for us to learn. The authority model rests upon the idea that wisdom is passed from mentor to pupil and we are enriched. However, there is a three-fold danger to this model. First, this model assumes that each authority is truly a knowledgeable and wise expert; this is not always the

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case. As brilliant as some sages might be, there might be some aspects to their knowledge base that are lacking; or the perspective they present might not fully encompass the entirety of the knowledge area that is being taught. They might even hold some beliefs that simply are not true, and therefore present some incorrect information. But how are we to know? How do we choose which pieces of information are pearls of wisdom that we should hold onto and use with our clients, and which pieces would best be discarded? This dilemma lies at the heart of the second problem, which is that the authority model often discourages independent and creative thought. Instead of critically thinking through the information given to us, the authority model often presents cookbook recipes that are to be followed. We trust the information because we believe in the infallibility of the authority. This is especially true in the world of continuing education where charismatic instructors might not explain the anatomic and physiologic basis for their technique protocols and might offer only their successful case studies as validity of their technique. A good maxim might be: Beware of case studies. Anyone who has been in practice for a few years can cherry pick out a handful of miracle case study success stories from all the clients they have seen. And the third problem is likely the most vexing of all. What do we do when two (or more) authorities we trust disagree with each other? And looking at the world of continuing education, it does seem that many authorities are convinced of the superiority of his/her own technique over the techniques of others. Who do we choose to trust more when this occurs? Research model The second approach to learning is to look to research for our answers. Research is based on the scientific method, which relies on a very simple and logical concept: if something works, it should be reproducible. It would seem that the research model might be the solution to the problem with the authority model. For example, if an authority states that a certain treatment

What We Know? technique helps low back pain, and they back this up by describing two or three case studies, scientific research applies their treatment technique to a large group of people who have low back pain, to see if their treatment is as effective as they state. The results for this treatment group are compared to a large control group which did not receive the treatment (usually the control group receives what is called a placebo or sham treatment that is known/considered to be ineffective). A comparison is then made to see if the clients in the treatment group fared better than those in the control group. If they did, then the proposed treatment is effective and valid. Alternatively, the proposed treatment could be compared to another treatment that is recognized and accepted to see which one is more effective. Certainly, trusting research is a lot safer than blindly trusting an authority. The very essence of research is to put the ideas of authorities to the test. But relying too much on research can also have its dangers. The efficacy of a research study depends upon it being designed and carried out correctly, which is not always the case. Research study design can be complicated, and errors are sometimes made. Further, incorrect interpretations and conclusions of the research data can occur.

―...the day before the apple fell on Newton‘s head, it did not mean that gravity did not exist, we simply did not yet have a scientific formula to explain it.‖ people included who also exercise or meditate or engage in some other activity that might affect the study? The very essence of a research study is that we try to study just one parameter, the proposed treatment. But so many factors affect health that it is virtually impossible to do this. Therefore, we try our best to identify all of these factors and then make sure that they are equally represented in both the treatment and control groups. If this is achieved, then we assume that any difference between the two groups is due to the proposed treatment technique. However, accounting for all of these factors and then distributing them evenly is not always successfully achieved. Isolation versus wholistic approach

Study population First of all, an effective research study involves working with a large number of people (the number of people in a study is referred to as ―n‖). Whereas a single case study (n of 1) or a few case studies (an n of 2 or 3) might make the proposed treatment technique seem effective, perhaps these results are not reflective of the entire client population. If n is large enough, we can better trust that the technique is representative of the entire client population that we might treat, and therefore will work for us with our clients. For a research study to be effective it usually means that that tens, if not hundreds or thousands, of people need to be involved. This can be expensive and these types of large studies are not always available.

In fact, this points to the larger conceptual difficulty of research. A research study, by design, is meant to evaluate the effectiveness of just one parameter. In other words, a research study, to be valid, must isolate this one parameter and then decide it is effective in improving one‘s health. However, the concept of wholistic health involves the realization that no one parameter works in a vacuum. Good health is often attained only when a number of treatments are administered in conjunction with each other. For example, the best treatment for a client with low back pain might be to use massage, heat, and stretching together, not to mention advising the client about postures, stress, and diet amongst other things. These multi-faceted treatment approaches are inherently difficult to evaluate with scientific research models. Treatment administration: validity and bias

Inclusion and exclusion factors Next, we have to make sure that the inclusion and exclusion factors are carefully chosen. As these names imply, inclusion factors are those factors/parameters that we want included in the study; exclusion factors are those that we want excluded. Continuing with our example, if the study is evaluating the effectiveness of the proposed treatment on clients with low back pain, do we include all people with low back pain, or do we pick and choose which ones are to be part of the study? For example, we might want to include all people with muscle spasms, strains, and strains; but exclude all people with herniated discs or severe degenerative joint disease. The idea of inclusion and exclusion factors becomes more complicated when we start to consider all the other parameters that might affect the study. Are

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Another consideration is whether the treatment was administered correctly. This may seem to be a given, but is not always the case. It is not uncommon for treatment to be administered by people who are not experts in that technique. This is especially true with touch/massage research where the people administering the care are often nurses or family members. A valid question is: If the treatment was not administered by experts, can we trust the results? Ironically, if experts are used to administer the treatment, because of their interest in seeing their technique succeed, bias may creep in. To prevent bias, it is important that the therapists are not the same people who chart the progress of the participants in the study. In this way, the people who chart the progress are blinded in their knowledge of who is in each group.

What We Know?

FIGURE 1A. Ulnar deviating the hand at the wrist joint has little or no effect at stretching the brachioradialis because it does not cross the wrist joint. 1B. Placing the forearm in full extension at the elbow joint and full pronation at the radioulnar joints are the most effective forearm positions to stretch the brachioradialis.

Client bias and hands-on placebo treatment In fact, even the participants may be biased and want so much to improve that they bias the study. This is why it is important to design the study to include a sham placebo treatment so that the participants do now know whether they are in the treatment group or the control group that received the placebo; in other words, they are also blinded. This brings up a problem that is particularly challenging when conducting research in the world of manual therapy: it is difficult if not impossible to create a valid hands-on placebo treatment for the control group. In the world of prescription drug research, both groups receive the same little white pill so they cannot know which group they are in. But in the world of massage and other manual therapies, clients know whether hands-on massage is being given to them. Therefore, an ineffective placebo hands-on treatment must be devised. But this is extremely difficult. After all, doesn‘t all touch involve some therapeutic healing? Interpretations and conclusions And on top of all this, the final conclusions at the end of a research study may be open to interpretation, so it is important to read carefully the entire paper to see if you agree with the conclusions drawn by the authors of the study. Yet, most therapists do not read the entire research paper that is published; rather they read only the short abstract or conclusion; or worse yet, read or listen to someone else‘s conclusion about the study.

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―Our client did not sign up to be part of a research study; he or she came for effective treatment and it is our responsibility to administer it.‖ Not all research is in Which brings us to our last challenge when relying on the research model for what we know. Because valid research is expensive and takes time, there are not always research studies available to prove or disprove the value of every treatment technique. However, we cannot always wait for all the studies to be conclusively done; our clients need treatment now. In the meantime, it is important to remember that the absence of research does not prove that a technique is not valid. When someone states: ―There is no proof that treatment X works,‖ it does not necessarily mean that there is proof that treatment X does not work. To make a comparison, the day before the apple fell on Newton‘s head, it did not mean that gravity did not exist, we simply did not yet have a scientific formula to explain it. In the absence of definitive proof, we need to be openminded. For more information on reading and understanding research papers, see Anatomy of a Research Article on the Articles page on Joe‘s website (www.learnmuscles.com)

What We Know?

Figure 2A. Stretching the vastus musculature of the quadriceps femoris group is accomplished by flexing the knee joint. B and C, the thigh is laterally rotated and medially rotated at the hip joint respectively. These motions do not stretch the vastus musculature because the vastus muscles do not cross the hip joint.

Testing New Knowledge Model In the face of not blindly trusting an authority, and also not having conclusive valid research upon which to rely, we can always try testing the knowledge/ technique in our own practice. For example, on Monday morning, we can practice on our clients whatever we learn in a continuing education workshop over the weekend. However, this can also be problematic for many reasons. In effect, we would be conducting our own limited research study; and we might not be designing and executing it very well. We might not yet be proficient with the treatment technique to implement it correctly; we might not have enough clients to test it on to determine if it is effective; and if we are administering other techniques at the same time, how do we know which one was responsible for a client‘s improvement, if any? Beyond all this, there are literally tens if not hundreds of techniques being marketed to manual and movement therapists. Do we need to test them all? And if we did just try out a technique for a reasonable period of time, and it did not prove to be effective, didn‘t we just waste our client‘s time and money? Our client did not sign up to be part of a research study; he or she came for effective treatment and it is our responsibility to administer it. Evaluating new knowledge against anatomy and physiology principles We can see that the authority model of learning requires trust that the authority is infallible; definitely problematic. Relying on the research model requires clear and conclusive valid research to already be done;

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―Be open-minded, but don‘t be so openminded that your brains fall out.‖

often problematic. And relying upon the model of testing all new knowledge in our practice is logistically problematic, as well as potentially unfair to our clients. Where does this leave us? Are we back to being openminded and trusting our sages on the stage? We usually think of being open-minded as being a good thing, but there is another old saying that goes: ―Be open-minded, but don‘t be so open-minded that your brains fall out.‖ This is where our fourth model of learning, that is, evaluating new knowledge against principles of anatomy and physiology, is so valuable. Essentially, evaluating new knowledge against principles of anatomy and physiology allows us to critically think through the mechanics of a new technique that is being proposed, and determine for ourselves if the basis for this technique makes sense given what we know about anatomy and physiology. Certainly, not all of anatomy and physiology is known and understood, but we do have some very well established principles about how the human body functions. And if we apply that knowledge to a new technique, we are empowered to critically think through the likelihood of how effective that technique will be. It also empowers us to determine when to apply the technique.

What We Know?

FIGURE 3. Deep stroking massage functions to increase arterial blood circulation to the trigger point (TrP). If done along the direction of the taut band of the TrP, it also helps to stretch and physically break the cross-bridges of the TrP.

―...if the time is spent to learn and understand anatomy, physiology can be figured out. If physiology is understood, then pathophysiology can be figured out. If the mechanics of pathophysiology are understood, then assessment can be figured out. And if assessment is known, then treatment can be figured out. It all stems from spending the time to first truly learn anatomy.‖

For example, by knowing anatomy and physiology, we can reason what stretches for a muscle would and would not be correct. We do not need to trust an authority; we do not need to wait for a research study to be done; and we do not have to subject our clients to be guinea pigs as we test every stretch that is proposed. We understand that stretching a muscle involves making it longer, which is accomplished by simply doing the opposite of the muscle‘s joint actions. This makes sense because if the actions of a muscle bring it to its shortened state, then doing the opposite of the actions would make the muscle longer, thereby stretching it. (One addendum to this idea is that it might be ex-

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panded to include actions at other joints if myofascial continuity across these other joints is considered.) So, we think of the joint actions that the target muscle to be stretched can do and we compare that knowledge to the stretch that is offered by the authority. If the knowledge matches, we can trust that the stretch will, in fact, be effective and we can begin employing it in our practice; if it does not, we can choose to not embrace it. For example, given that the brachioradialis does not cross the wrist joint, why would moving the hand into ulnar deviation at the wrist joint add to its stretch as is often recommended by authorities (Figure 1a)? Could it be that the increased stretch that is felt by the client is occurring in the nearby extensors carpi radialis longus and brevis, which do cross the wrist joint and are stretched with ulnar deviation of the hand? And given that the end forearm position when the brachioradialis is maximally contracted and shortened is halfway between full pronation and full supination (at the radioulnar joints), why would we want to place the forearm in that position as is often recommended? Making a muscle longer to stretch it is not accomplished by placing it in the position of its actions, it is accomplished by doing the opposite of its actions. Wouldn‘t full pronation (or even full supination) of the forearm make more sense because this position brings the attachments farther apart, therefore the muscle is lengthened (Figure 1b)? Looking at a stretching example in the lower extremity, why is it recommended by many authorities to change the position of the hip joint when stretching the vastus musculature of the quadriceps femoris group? If the

What We Know?

Figure 4A. When engaging the brachioradialis to palpate it, resistance should be placed against the client‘s distal forearm, not hand. 4B, If the client attempts to radially deviate the hand at the wrist joint, the extensors carpi radialis longus and brevis would contract, making it difficult to palpate and discern the brachioradialis from these muscles.

vastus muscles do not cross the hip joint, then other than flexing the hip joint to slacken the rectus femoris and knock it out of the stretch (so it does not limit stretching the vastus musculature), what are we trying to accomplish by altering the position of the hip joint (Figure 2)? If it has to do with myofascial meridian continuity, then a specific position should be determined based on the adjacent muscle/myofascial units that are in the meridian; does the recommended change in the hip joint make sense when compared with this information? Using trigger point (TrP) treatment as another example, if a TrP is understood to be due to local ischemia in the tissues, does it make sense to create any further ischemia with prolonged pressure? And if deep pressure is administered, does it make sense to hold it for a prolonged time? What are we trying to accomplish and are we accomplishing it as effectively as possible? Given that ischemia is the problem (because it causes a decrease in blood supply that then causes a decrease in ATP molecules that are needed to break the actinmyosin cross-bridges that create the contraction), then wouldn‘t a stroking technique that increases local blood supply be more efficient? Therefore, mightn‘t multiple short deep effleurage strokes be more effective when treating TrPs than holding sustained compression? These are the kinds of questions that can be asked and answered without benefit of authority, research studies, and months of testing in your practice (Figure 3). Evaluating new knowledge against principles of anatomy and physiology can also improve our assessment skills as well. Continuing with the brachioradialis as the

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Perhaps the most effective way to become a more effective clinical orthopedic massage therapist is not to continually frequent continuing education workshops, not to continually read every research study that is published, and not to spend hundreds of hours testing new techniques on our clients, but to spend more time going over the basics of anatomy and then critically thinking from there.

example, if we want to assess it through palpation and we need to make it contract to engage it and locate it, it makes sense that we want to contract the brachioradialis and only the brachioradialis if we want to discern it from the adjacent musculature. This requires an isolated contraction. So we ask the client to place their forearm in a position that is halfway between full pronation and full supination (the best position for it to effectively contract, given its actions), and then flex the forearm against our resistance. It is crucially important that our resistance is placed against their distal forearm, not their hand. If we add our resistance to the client‘s hand, their radial deviators (extensors carpi radialis longus and brevis) will engage, making it harder

What We Know?

―...if every technique were as effective as its proponents state, why isn‘t everyone doing that technique?‖

to discern the brachioradialis from these adjacent muscles (Figure 4). By understanding basic principles of anatomy and physiology, we can reason through how to most effectively palpate and assess our clients. The essence of evaluating new knowledge against established principles of anatomy and physiology is that we are empowered by critical thinking. Of course, this requires first learning anatomy, which is often not as well taught and learned as might be desirable. But, if the time is spent to learn and understand anatomy, physiology can be figured out. If physiology is understood, then pathophysiology can be figured out. If the mechanics of pathophysiology are understood, then assessment can be figured out. And if assessment is known, then treatment can be figured out. It all stems from spending the time to first truly learn anatomy. Perhaps the most effective way to become a more effective clinical orthopedic massage therapist is not to continually frequent continuing education workshops, not to continually read every research study that is published, and not to spend hundreds of hours testing new techniques on our clients, but to spend more time going over the basics of anatomy and then critically thinking from there.

therapies. However, if every technique were as effective as its proponents state, why isn‘t everyone doing that technique? A logical conclusion might be that each technique has something to offer, but does not offer the solution to every problem for every client. Therefore, our role is to learn as many techniques as possible, adding the elements of each one to our tool box of therapies. Then, with the wise judgment that comes from experience, we can learn how to reason through which combination of assessment and treatment tools to use in each case for the best improvement of the client who is on our table. This Article is reprinted with permission from AMTA Massage Therapy Journal, Summer 2011 www.amtamassage.org/mtj ―For more information on reading and understanding research papers, see Anatomy of a Research Article on the Articles page on Joe‘s website (www.learnmuscles.com)

FIGURE CREDITS: Figures 1a, 2b and 2c: Illustrated by Giovanni Rimasti Figures 1b, 2a, 4a, and 4b from Muscolino JE: The Muscle and Bone Palpation Manual, with Trigger Points, Referral Patterns, and Stretching. 2009, St. Louis, Elsevier / Photography by Yanik Chauvin. Figure 3 reprinted from understanding and working with myofascial trigger points, body mechanics column article, mtj, spring 2008 issue. Illustrated by Jeannie Robertson

Conclusion This article could be construed as being negative on educators and authors, given their role as authorities. I as the author of this article am fully aware of the irony of being the authority as you read this. However, it is not the knowledge or the authority that is the danger; most authorities fervently believe in what they are teaching and have an extensive knowledge base. The danger comes when we place blind trust in them. When we treat them as a sage on the stage, or perhaps a sage on the page. Similarly, this article should not be construed as being against scientific research; I am also a firm advocate for research. But we need to be aware of the limitations of relying too heavily on research when making treatment choices; if for no other reason because research is rarely complete. And certainly, there is nothing wrong with being creative in our practice by introducing and trying new treatment techniques, we just need to be mindful to not constantly subject our clients to the newest technique that is the flavor of the month. Most every technique must have something valid within it, if not many things; otherwise, it would not last very long in the world of manual and movement

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Clinical Orthopedic Massage Therapy (COMT) The focus of these workshops is to learn how to work clinically utilising deep pressure, basic and advanced stretching, and joint mobilisation techniques; and to do so more efficiently by working from the core with less effort so you do not hurt yourself. In effect, how to work smarter instead of harder! Working clinically and efficiently can be done simply by learning a few basic guidelines of proper technique that Dr. Joe Muscolino will show you. An invaluable workshop for anyone who does sports, clinical, and/or rehab. work! Each workshop delivers 8 hours of instruction every day (9am—6pm). The workshop will cover body mechanics for deep tissue work, muscle palpation assessment, orthopaedic assessment testing , and stretching. It will also has focuses on advanced stretching (CR, AC, and CRAC stretching), motion palpation and assessment of joint, and how to safely perform joint mobilisation.

Sydney 1-2 May 2013, COMT: Upper Extremity 6-7 May 2013, COMT: Lower Extremiy

Gold Coast

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

“Joe has inspired me to dig deeper into the knowledge I already have and to pursue more information about the body in further study. I have been to many courses in the past which were unable to do more than pass on a few interesting techniques, many of which were not easy for the therapist to perform unless they were a 6 foot male with arms twice the length of mine. It is a true gift to be able to inspire your students, especially those who have been in the field for a few years and are unaccustomed to learning. The class challenged me and my way of thinking without belittling the areas I am weak in. The content was thorough yet simple to understand with Joe's wonderful way of teaching. His immense technical knowledge of the body has shown me how effective we can be as therapists if we apply all of the resources that are available to us.” Anita Schmidt, Hornsby

11-12 May 2013, COMT: Neck

"Joe Muscolino is a master of his profession! His broad knowledge on the human body and extensive experience made the workshops interesting and engaging. I would highly recommend his workshops to any body-worker. I, myself, can't wait for the next one!" Zuzana Gaalova, Queenscliff, NSW.

Book Early as Places are Limited Terra Rosa e-magazine, No. 10 (June 2012)

To register your interest & for more11 information, visit www.terrarosa.com.au/joe

The Effectiveness of Massage Therapy The Australian Association of Massage Therapists (AAMT) in 2008 commissioned a research report into finding the research evidence on the effectiveness of Massage Therapy. The research report was conducted Dr Kenny CW Ng, a Member Australian Association of Massage Therapy in collaboration with Professor Marc Cohen, School of Health Sciences, RMIT University. This article is a summary of The Effectiveness of Massage Therapy Report which was first published in October 2011. Massage here was defined as â&#x20AC;&#x2022;manual soft tissue manipulation, and includes holding, causing movement, and/or applying pressure to the body. Massage therapy is the practice of massage by accredited professionals to achieve positive health and well-being (physical, functional, and psychological outcomes) in clients. The research reviewed includes systematic reviews, randomised controlled trials, comparative studies, case -series/studies and cross-sectional studies in academic research papers, published between 1978 and 2008. It covers a range of massage therapy techniques , include acupressure, Bowen therapy, lymphatic drainage, myo-

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fascial release, reflexology, Rolfing, shiatsu, Swedish massage, sports massage, infant massage, tuina and trigger point therapies/modalities. More than 740 studies from 5 reputable databases were reviewed. The studies were grouped into 5 categories based on their study quality and clinical significance. (see table below). The grades of recommendation are: A Body of evidence can be trusted to guide practice B Body of evidence provides moderate support to guide practice in most situations C Body of evidence provides limited support for recommendation(s) and care should be taken in its application D Body of evidence is weak and any recommendation must be applied with caution E Body of evidence is insufficient to provide recommendation

The Effectiveness of Massage Therapy The report found a growing research studies in the effectiveness of massage therapy (Figure 1). There is also a growing body of research supports massage therapy as being an evidence-based therapeutic modality, which is summarised in Figure 2. In particular, massage has been found effective for:  Acupressure Management of Nausea and Vomiting. There is strong evidence supporting acupressure management of nausea and vomiting  Managing anxiety, stress and promoting relaxation. Multiple studies provided good evidence supporting the effectiveness of massage therapy in managing anxiety, stress and promoting relaxation.  Subacute and chronic low back pain. Seven reviews were in unison concluding that massage therapy for subacute and chronic low back pain to be more effective than placebo.

The report concluded Massage Therapy as a safe and effective treatment option. The report reinforces that: There is consistent and conclusive evidence that massage therapy is safe. However, the importance of qualified massage therapists adhering to appropriate scopes of practice, safety guidelines and ethical procedures is stressed. There is a growing evidence base to aid clinicians in recommending massage as an evidence-based therapeutic modality. Clinicians are encouraged to collaborate with professional massage practitioners for best practice management of patients who may benefit from massage therapy. The full report can be downloaded at www.aamt.com.au

This is a summary of the research report „The Effectiveness of Massage Therapy‟ by Ng (2011), reproduced with permission from AAMT.

 Pain reduction, quality of life, improved sleep, reduced depressive symptoms. Positive outcomes reported following massage therapy include pain reduction, better quality of life, improved sleep and function as well as reduced depressive symptoms.  Infant distress, newborn growth, mother-infant interaction, post-natal depression. Studies into the benefits of massage therapy for maternal and infant care reported a reduction in infant distress, significant newborn growth and development, improved mother-infant interaction and reduced symptoms of post-natal depression.

Figure 1. Growth of published studies on the effectiveness of massage. therapy . After Ng (2011) TEMT Report, AAMT.

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The Effectiveness of Massage Therapy

Figure 2. Summary of systematic reviews on the effectiveness of massage therapy. After Ng (2011) TEMT Report, AAMT.

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From the 3 International Fascia Research Congress 28 28--30 March 2012, Vancouver

David Lesondak It‘s no lie, being behind the camera at the Third International Fascia Research Congress is a pretty sweet gig. But it‘s also about multitasking, constantly taking notes on each presenter. Every time they change a slide writing down the exact time, noting when the slide has an animation, when they skip a slide or accidentally jump ahead. When there‘s a technical failure and we have to wait. Adjusting for sudden volume changes or lighting issues.

First up in the panel was Wayne Diamond, MD from Wayne State University who presented data on the high incident of post-surgical adhesions following pelvic surgeries. Even with a relatively non-invasive procedure like a laparotomy or a laparoscopy the average of how many patients develop post-operative adhesions is a very surprising 70%.

All of this gets written down so that when I am editing this footage (which I am doing now) – it goes a lot smoother and faster.

Following the film was Hal Brown, a DO from Vancouver who presented an overview of prolotherapy to treat scars and adhesions. He uses a neural therapy model, injecting local anaesthetic to depolarize the nerve tissue around the scars. In the skin there are billions of sympathetic nerve fibres, all tightly packed together. The signals from these nerves travel at about 400 kilometres per hour making for instantaneous communication throughout the body. Anytime there is a cut, tear, surgery or sufficient trauma, these fibres are torn asunder. Without intervention the repair is very chaotic to the nerves near the affected area, which will fire in aberrant and send signals to other parts of the body with no rhyme or reason.

It‘s all very multi-tasking, and makes it hard to absorb all of the information being presented. I left the Congress my head aswirl and agoggle with so many things but overall I was left with the strong, unshakable sense that: This is real. There was a lot here to be real about. The first day began with keynotes involving repetitive motion disorders and ended with a panel discussion on scar tissue and adhesions that played like a superb four movement symphony.

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Next up – the Shaman/Showman of Bordeaux, France – tendon transplant surgeon Jean-Claude Guimberteau wowed us with his latest endoscopic film. This time he brought to life the reality of the stresses to the tissues beneath the skin where scarring and adhesions are present. It was actually a bit like a horror movie. Or if you prefer a different genre, as the narrator of the film put it, ―a fibular apocalypse‖. Graciously, Dr. Guimberteau has allowed us to use 3 minutes of this film in the final Fascia Congress DVD.

3rd Fascia Congress

Think of these nerve impulses as cars on a superfast highway who have to detour around an accident, but in this case the accident is never cleared from the roadway.

Dr. Gerald Pollack

So back to the injections. When the anaesthetic wears off in the injected areas, the nerve repolarizes and the nerves membrane potential is restored to normal around the area and functionality returns. Dr. Brown presented several compelling case studies dramatically showing the success of this approach. The panel ended with the dynamic Susan Chapelle, RMT from Squamish, British Columbia. Squamish is a community of about 17,000 people , unique because of it‘s climate which allows you to both ski and mountain bike in same day, not to mention kayak and rock climb. Many Olympic athletes train there. She described it as an ―epicentre of orthopaedic injuries‖. In this environment, people get their surgeries and need to get back to their sports before the injury fully heals. This has lead to an environment where complementary therapists communicate freely with allopathic doctors and where early manual interventions are showing beneficial results. Susan was also involved in a ground-breaking adhesion study, partnering with Geoffrey Bove DC, PhD from Maine to study the effects of manual therapy of adhesions. Now, I need a drink of water because Day 2 was all about fluid flow. As bodyworkers, so much of our focus on fascia seems to be on it‘s load bearing, structural component. Dr. Rolf K Reed challenged us to think about its role as a regulator of fluid flow and Gerald Pollack challenged us to rethink what we know about water itself. It seems that Dr Pollack has discovered a 4th state of water. The defining characteristic of this fourth state of water, which has been heavily researched, is that it is a liquid crystal. It is a thicker, more viscous water that

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also seems to have a energy-producing capacity. And what unlocks this capacity? Radiant energy – the sun! E=H2O according to Pollack, claiming that radiant energy drives blood, lymph and fluid flow throughout the body. And don‘t quote me on this yet, but I believe that in the Fluid Dynamics Panel that ensued it was posited that the water content of our fascia may be about 50% this ―fourth state‖ water. All of this points to possible explanations for everything from cold lasers to energy work, not to mention a walk on a sunny day, but as always – more research is needed. And speaking of research I need to go research that mention about the amount of fourth state water in our fascia. That means I need to get back to editing video. I‘m on a deadline you see, to get those videos finished and get this article finished for your enjoyment before I get on a plane to shoot more video at the BodyWisdom Spain Congress. Which I will surely write about too. There was so much more that happened in Vancouver: the multi-media night, Carla Stecco and Jay Shah just

3rd Fascia Congress bringing it all home Friday morning with two stunning back-to-back lectures on fascial anatomy and myofascial trigger points respectively, but somehow I keep going further back in time.

David Lesondak, BCSI, KMI, LMT is an Allied Health Member in the Department of Family and Community Medicine at the University of Pittsburgh Medical Center (UPMC). He practices Structural Integration at UPMC‟s Center for Integrative Medicine. David‟s keen I can remember being in the back of the room at the interest in the emerging science of fascia coupled with first Fascia Congress at Harvard in 2007. No camera a previous career in the video arts led him to collabothat time, just feeling lucky to even be in the room, rate with Thomas Myers‟s to produce and direct the 3 – amazed that it was even happening and trying not to get DVD set “Anatomy Trains Revealed” a video compantoo geeky about meeting my heroes (look! It‘s Donald ion to Myers‟ popular book. He has also worked on Ingber!) whose work I had been inspired by for years. various video projects with Robert Schleip and a series of technique videos for the Gebauer company. Move 4½ years into the future to the Sheraton Wall Center in Vancouver. A world-class hotel. A conference He is an NCBTMB approved continuing education proroom big enough hold over 800 people from 37 counvider and teaches fascially-oriented workshops intertries. And everyone happy, connecting, confabbing, oc- nationally. casionally contesting and setting new collaborations. David is currently editing the videos from the Third This is real. International Fascia Research Congress, which will be made into a DVD set available in July 2012. In his spare time, he tries to find spare time. David can be reached at lesondakda@upmc.edu. Read also 6 questions to David on page 42.

Will be Available Soon.. rd The 3 International Fascia Research Congress on DVD

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Pelvic Organ Prolapse Thorough Evaluation and Myofascial Release

Walt Fritz Referrals for myofascial release treatment can come from a wide variety of sources for an even wider variety of conditions. When questions come in regarding if I can help with a certain condition, I am optimistic . Therapists may have their comfort level, depending on their training and licensure, which can actually limit the referrals that come their way. Treatment of women‘s health conditions has always been a strong part of my practice. Even for common conditions, such as lower back pain, women are often faced with a different set of causative factors than men, especially in the United States, where pelvic surgeries are all too common. The role that scar tissue can play with pelvic pain/dysfunction is huge, and we can play a significant role in helping this population. Pelvic organ prolapse is a common referral to a physical therapist, with pelvic floor musculature strengthening the most common intervention. But there are other views on causative factors, as well as treatment approaches. I recently connected with Sherrie Palm, who heads the Association for Pelvic Organ Prolapse Support, Inc. Sherrie has recognized the role that myofascial release treatment can play in pelvic organ prolapse. While pelvic organ prolapse may seem an obscure disorder, consider the following: POP SYMPTOMS AND CAUSES Half of all women over the age of 50 suffer from at least one type of pelvic organ prolapse (there are 5 types), many women in their 30‘s and 40‘s have POP as well. Although POP is not extremely common in women in their 20‘s, it can occur in this age bracket. The 5 types of pelvic organ prolapse are cystyocele (bladder), rectocele (large bowel), enterocele (intestines), vaginal vault (vagina caves in on itself after uterus is removed-

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hysterectomy), and uterine (uterus). When the PC or pelvic floor muscles weaken or become damaged, one or more of these organ/tissue areas shift in the pelvic cavity beyond their normal positions. Each of these 5 types of POP has its own symptoms, but in general symptoms can include: (Use with permission from Sherrie Palm. http:// pelvicorganprolapsesupport.org/pop_basics/ pop_symptoms_and_causes)          

Pressure, pain, or fullness in vagina, rectum, or both. Feeling like your ―insides are falling out‖ or like you are sitting on a ball. Urinary incontinence. Urine retention (you have to (urinate), you just can‘t get it to come out). Fecal incontinence. Constipation. Back/abdominal pain. Lack of sexual sensation. Painful intercourse. Can‘t keep a tampon in.

There are multiple causes of POP; it is likely that most women have more than one cause that fits their health pocket and lifestyle. The most common causes of POP are: Vaginal childbirth - complications from large birth weight babies, forceps or suction deliveries, multiple childbirths, improperly repaired episiotomies. (It is also possible for women who have never given birth to have POP; there are many non-childbirth related causes.) Menopause - age related muscle loss due to drop in estrogen level; this impacts strength, elasticity, and

Pelvic Organ Prolapse density of muscle tissue. Chronic constipation - IBS (irritable bowel syndrome), poor diet, lack of exercise can all cause constipation. Chronic coughing - smoking, allergies, bronchitis, and emphysema can create chronic coughing. Heavy lifting - lifting children, repetitive heavy lifting at work, weight trainers. Joggers, marathon runners - constant downward pounding of internal structures Abdominal surgeries - structural weakness from surgery or myofascial restrictions and scar tissue can lead to POP Diastasis Rectus Abdominus (DRA) - a separation in the two bellies of the rectus abominus muscle during pregnancy may predispose women to a weakness in core support which can lead to POP issues. When one researches pelvic organ prolapse on the major Internet medical sites, muscular weakness is an oft repeated cause for many prolapse issues. Weakness of the musculature or overstretching of lower pelvis soft tissue can certainly be at the root of prolapse and should not be discounted. Weakness is said to result from childbirth, including cesarean section, as well as a myriad of other pelvic surgeries. What is missing from these explanations is the profound tightness that can develop secondary to surgeries and childbirth, especially scar tissue tightness. It can be this tightness that FORCES an organ to move from its original position. While traditional strengthening, including various types of electrical stimulation, can improve certain issues, often the treatment is incomplete. Unless the tightness is addressed, an increase in tightness may be the result. Myofascial release is an accepted therapeutic modality practiced by physical therapist, occupational therapists, and massage therapists. Having a bit of an education regarding the most effective types of myofascial release is in order, as there are many variations. Both direct and indirect myofascial release have been used for decades, first by osteopaths and eventually therapists. Direct myofascial release involves a deeper, more forceful type of pressure that is typically short in duration. Indirect myofascial release is gentler and is typically sustained for a longer time period. While I was trained in both methods, I find that the indirect approach is both better tolerated and also provides more lasting results. A trained myofascial release therapist will be proficient in evaluating and treating a wide variety of pelvic pain and dysfunction syndromes. A GoogleScholar.com

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Female reproductive organ anatomy. From: http:// commons.wikimedia.org/wiki/File:Female_anatomy.svg

search will give you a large number of examples of myofascial release being used effectively in the treatment of pelvic organ prolapse. Particular attention should be paid to any and all scar tissue in the lower abdominal and pelvic regions. Scar tissue evaluation should be a regular part of all therapeutic treatments. Assessing the tissue quality of superficial to deep soft tissue of the lower abdomen/pelvis, as well as the lumbosacral regions, and connecting that tightness to their pain or dysfunction, closes the loop. This loop is an important part of our role. If, during evaluation, we can reproduce their pain/dysfunction, whether local or distant to the pain, this creates a positive feedback loop between what we feel may be at fault, connects it to their pain, and feeds back the information to the therapist. The therapist now has a firm place to begin treatment and the client has trust that the therapist understands and acknowledges their pain/dysfunction. As I travel, teaching my Foundations in Myofascial Release Seminars, I find that many therapists feel that evaluation time is time wasted from the session. They relate an assumption from their clients that they expect the full amount of hands-on time. Here is where education, of both the therapist-intraining as well as their clients, is crucial. Without a thorough evaluation, one is really treating blindly. As a physical therapist, clients are often confused when they walk into my office for the first time. They expect to see the typical array of exercise machines, modalities machines, etc. But what they find is a simple treatment

Pelvic Organ Prolapse table. I explain to them that the weakness model of pain or dysfunction has its place, but I find that not everyone responds to the traditional sort of intervention. We then proceed with the evaluation where, hopefully, I am able to connect their symptoms with my findings. Clients may wonder what myofascial release treatment is like? While all therapists evaluate and treat in different ways, there should be some commonality. After a thorough history taking, your therapist may perform a head to toe evaluation, in standing, sitting face up and face down. This is an important aspect of myofascial release, as tightness, injury, or surgery in other areas of the body can influence the pelvis. They will then narrow the scope of their evaluation to the area of dysfunction. Gentle pressure into the lower abdomen will often reveal a great deal of information to both the therapist as well as to you. You may be surprised as to how easily your therapist can reproduce familiar sensations of tightness, pain, or pelvic organ dysfunction with just a small amount of pressure placed into very specific area. (It is important to note that in certain circumstances it may be necessary for your therapist to perform evaluation and/or treatment vaginally or rectally. Individual regional licensure laws vary. Physical therapists are often permitted to perform internal examination and treatment. It is important to note that internal treatment is NOT always needed to successfully resolve pelvic organ prolapse issues. Your therapist should exhaust external treatment before proceeding further and only with your consent. In my experience it is only occasionally necessary to treat internally. If you feel pressured by your therapist in any way, find another therapist.)

To find a qualified myofascial release therapist near you, please refer to the Myofascial Release Therapist page on this website: http://pelvicorganprolapsesupport.org/ health_care_connections/ myofascial_release_therapists You may also email me at walt@myofascialpainrelief.com or check the therapist listings at www.FoundationsinMFR.com. ÂŠ 2012 Walt Fritz, PT

Walt Fritz, PT has been a physical therapist since 1985 and has been teaching Myofascial Release to physical therapists, massage therapists, and occupational therapists since 1995. His Foundations in Myofascial Release Seminars were developed in 2006 and have been taught across the United States. Working from the strengths of his predecessors, Walt emphasizes the straightforward effectiveness of Myofascial Release without the hype. In his Foundations in Myofascial Release Seminars, Walt brings an approachable, easy to understand style of teaching, one that can easily be assimilated into your treatment regime. Evaluation is a strong component of his teaching style, in order to create a logical progression from evaluation to treatment. Read 6 questions to Walt on page 44. Look for his videos on the WaltFritzPT YouTube Channel. Walt also owns the Pain Relief Center, a physical therapy private practice in Rochester, NY, with a specialty in treating pain conditions.

Treatment with indirect myofascial release involves the therapist placing mild to moderate pressure into an area of tightness and maintaining that pressure for time frames up to or exceeding five minutes per technique. Typical sessions last an hour. Frequency of treatment can vary, but your therapist may wish to see you more often for the first few sessions. Trying to predict the necessary length of treatment is difficult, but when working with a well-trained and experienced myofascial release therapist, one can expect to notice lasting, positive changes in as little as three sessions. While it may take longer than three sessions to find full relief, you should be able to determine in a short length of time whether myofascial release is working for you. Your therapist will also recommend home stretching to allow you to continue to progress.

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What is Deep Tissue Massage Art Riggs Question: “My spa/clinic offers “Deep Tissue Massage” as a separate massage category and at a higher price than regular massage, but I can‟t seem to get a clear answer on what the difference is. I‟ve also heard that it can be painful. Can you explain why it costs more and how it is different?” Answer: Although I think there is a perception that the increased charge is because the therapist is working ―harder,‖ any extra charge for deep tissue massage should be because the practitioner has taken advanced courses to learn new skills. We will get into some specifics of the differences between deep tissue and ―regular‖ massage in a bit, but it is helpful to first dispel some misconceptions: Deep Tissue Massage is painful: This comes from the ―No Pain, No Gain‖ fallacy, and there is a big difference between working deeply and working hard. The emphasis is simply on sinking to deeper levels of stress in the layers of the body with a bit more emphasis upon therapeutic results while using some of the tools that I will explain later. Relaxation massage is for enjoyment while deep tissue work is for specific problems: There are two misconceptions here: Relaxation massage is much more than just ―enjoyment‖ or ―feel good‖ and is very therapeutic for many reasons, including specific benefits to the muscles themselves through increased circulation, and many health benefits that result from releasing general tension levels in the body due to the stresses of life. Conversely, many people find deep work extremely gratifying and enjoyable, not just for the long lasting benefits or improvement of performance in activities or sports, but because it actually feels good! Deep Tissue Massage can be risky because of overwork, not only being unpleasant but not entirely safe: Actually, proper training in deep tissue skills goes into much more detail about contraindications and safely working than initial trainings and is quite safe.

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There are many different variations in how practitioners perform Deep Tissue Massage with the therapeutic goals for the work and also with how it is practiced: GOALS Treatment of injuries or conditions: Both for treatment and prevention of soft tissue problems, deep tissue massage releases adhesions, improves muscle function for better alignment of muscles to help improve joint mobility or proper function. Improvement of performance in activities: Whether in sports, dance, yoga and everyday activities, the stresses of life result in short and tight muscles that limit mobility and cause pain or discomfort. Deep Tissue Massage places more emphasis upon grabbing and stretching

Deep Tissue Massage be less intense than when the therapist works too hard to overcome the slipperyness of excess lubrication. Deep tissue massage does, indeed, work with deeper layers of the body by sinking though superficial layers. This does not mean that substantially more pressure is needed as the therapist sinks vertically until she senses the layer of tension and then moves obliquely to lengthen short muscles and fascia at this layer.

short muscles and fascia that hinder performance instead of sliding over and compressing tissue as more general massage that uses a lot of lubrication. Improved posture: This particular facet of Deep Tissue Massage, sometimes called structural integration, focus upon careful analysis and a systematic and structured plan to lengthen short muscles and fascia that adversely affect posture so that people can stand or sit erect and move more freely. Emotional/psychological freedom: Some theories of the personality emphasize the integration of the physical and emotional components of health. Under stress or when not feeling safe, many people tighten or armour their muscles into habitual patterns that reinforce emotional patterns. As these physical restraints are released, many people report a profound emotional response. THE TOOLS The proper application of pressure necessitates a broader range of tools than those used in conventional relaxation massage. Some people assume that if an elbow is used, that it must be intense, but the elbow often allows your therapist to use proper mechanics in her body so she is not straining and is relaxed which allows for much more enjoyable sensations instead of straining. To sink through superficial layers to deeper tension, she may use focused and precise tools such as knuckles or an elbow. For large muscles that require more pressure, she may choose to use the forearm or a fist to focus attention on a broader surface. HOW DEEP TISSUE MASSAGE IS PRACTICED The first thing you may notice will be that much less lubrication is used. Just as trying to turn a doorknob with slippery hands is difficult, it is difficult to grab and stretch short tissue if too much lubrication is used. This may be the biggest distinction between ―regular‖ and deep tissue massage. Light lubrication requires less pressure to grip tissue, so profound work may actually

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Strokes will be considerably slower and possibly shorter as the therapist waits for a slow release of tension and may move quickly or even skip some areas so that more time can be spent on specific areas of need. Clients are often asked to be actively engaged in the process by moving to positions that stretch muscles and joints to affect a release. A session may not cover the entire body. Doing ―spot work‖ allows for meticulous and careful attention to problem areas rather than spreading the work ―too thin.‖ Although it should not be painful, work may be more intense and utilize active cooperation of the client to consciously release areas of holding. However, a deep tissue massage, whether full body or for spot work should not attempt to coerce the body into submission. The line between a deep tissue massage and relaxation massage is not a sharp one. A good relaxation massage should slow down and pay particular attention to specific areas of restriction, and a good deep tissue massage should also have relaxation and pleasure as a major goal. As in all bodywork, the key to a gratifying experience is largely a function of good communication and clarification of objectives. The following pages is an example of a brochure made by Art explaining what is deep tissue massage, you can print and use as an information for your client .

International presenter Art Riggs became enthralled with bodywork after a meandering career in academia. He was certified by the Rolf Institute in 1987 and teaches deep tissue massage, myofascial release and Rolf workshops in the US and abroad. He also maintains a private bodywork practice in Oakland. Art is the author of the textbook, Deep Tissue Massage: a Visual Guide to Techniques and the acclaimed seven volume DVD series, Deep Tissue Massage and Myofascial Release: A Video Guide to Techniques.

Therapeutic Deep Tissue Massage and Myofascial Release

Your therapist has taken extensive continuing education training in Deep Tissue Massage and Myofascial Release. The fee for this bodywork is based upon the expertise required to provide the most enjoyable, effective, and safe experience for you-not because more effort is required. Because the work is performed much more slowly and often requires additional time to release holding in certain areas, it is highly recommended that you choose a longer time period to enable you to integrate the work at a pace that is easy for your body. Longer sessions allow proper time to address your needs and will provide a more enjoyable, profound, and longerlasting improvements to your well -being.

Deep Tissue Massage offers the same relaxing and enjoyable experience as conventional massage, but with the added emphasis of releasing deeply held tension in muscles and fascia to provide a more therapeutic release to troublesome or painful areas of your body. Our therapists are specially trained in therapeutic Deep Tissue Massage and Myofascial Release to offer you profound, long-lasting benefits that are specially tailored to your individual needs.

What is Deep Tissue Massage Most problems in tissue are caused by a buildup of tension and adhesions due to injury, overuse, or postural habits that are not specifically addressed in conventional massage. Rather than simply kneading muscles, your Deep Tissue bodyworker places emphasis upon the therapeutic benefits of actually stretching and freeing short and fibrous restrictions.

What to Expect Not all of the work will be deeper than what you are used to in relaxation-based massage. Deep Tissue therapy can be performed in an integrated full body massage with specific deep focus upon a single or possibly several troublesome areas. However, you may choose a few particular areas without covering the entire body.

Your Role in the Session Your therapist is trained to locate areas of tension, but it is recommended that you take a few minutes to discuss your needs so that the session will provide you with an integrated, therapeutic, and pleasant experience. Although more pressure may be applied, the release of tension should not be painful, and you may want to be more involved in communicating your experience and needs than in conventional relaxation massage. Please feel free to ask our staff if you have any additional questions ... and enjoy your massage!

How is Deep Tissue Performed? While carefully sinking to deeper layers of the body, your therapist will work with slow and relaxing strokes to actually lengthen muscles, and free them where they are "stuck.' Most of the massage will be performed with the hands, but in certain areas, the use of more broad and powerful tools such as knuckles, forearms, fists, and elbows will prevent the discomfort that is sometimes felt if too much pressure is applied with fingers. Body positioning to stretch muscles will provide more flexibility of joints, release of painful restrictions, and a gratifying sense of deep relaxation.

Join Art Riggs for a unique experience in Deep Tissue Massage Workshop Sydney, October 2012 Register now at www.terrarosa.com.au/art

Cultivating a powerful and soft touch: Strategies for Treatment with Deep Tissue Massage and Myofascial Release 27-28 October, Sydney This 2-day workshop focuses on proper use of biomechanics to allow therapists to remain healthy and conserve energy, and refine skills for deep tissue massage and myofascial release. We will learn how to work with a powerful but soft touch, with proper use of knuckles, fists, elbows and forearms. The emphasis is on the layers of the body and myofascial skills to stretch and release tissue restrictions rather than just sliding over superficial layers.

Working with Common Injuries and Complaints in a Bodywork Practice 30-31 October, Sydney This workshop covers most all of the injuries and complaints that are encountered in a therapeutic bodywork practice. In addition to therapeutic techniques to help resolve problems, we will also provide information to work safely around injured areas and what not to do, so both the client and practitioner can feel confident and safe. We will cover: • The feet and lower leg: plantar fasciitis, Achilles tendinitis, sprains • The knee: patella-femoral pain, surgery rehabilitation, providing proper function of the joint from an holistic viewpoint • Back pain, sciatica including piriformis syndrome (psoas work if time permits) and mobilising ‘stuck’ ribs • Shoulder girdle and rotator cuff • Arm and wrist problems including RSI • Whiplash

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Spontaneous Movement Most bodywork and movement therapy instructed the client to perform movement which can facilitate simple patterns of activation and release. However there are various bodywork and movement therapy that utilise the bodyâ&#x20AC;&#x2DC;s own inherent movement for therapy and relieving pain. Usually these therapies initiate unconscious or automatic movements in the clientâ&#x20AC;&#x2DC;s body. Here we listed several bodywork and movement works that used these approaches. And we try to explain rationally how these spontaneous movements can occur. We can classify them broadly as bodywork, movement therapy, and spiritual movements. Bodywork Fascial Unwinding Fascial or myofascial unwinding is a specific technique of bodywork that is used to release fascial restriction by encouraging the body or parts of the body to move into areas of ease. It involves constant feedback to the practitioner who is passively moving a portion of the patientâ&#x20AC;&#x2DC;s body in response to the sensation of movement. The unwinding process usually involves a therapist inducing the movement to a client, and is followed by a spontaneous reaction: parts of the body bend, rotate, twitch or twist, sometimes in a rhythmic or chaotic pattern. It is taught and used in myofascial release and craniosacral therapy. Although unwinding is usually induced by a therapist, the client can also experience self unwinding.

fort to impose forces, but to listen and follow this inherent movement, and encourage its greater expression. This technique explicitly uses ideomotor action (ideomotion) as a form of therapy. Non-Directed Body Movements http:// marvinsolit.site.aplus.net/pgs/health/ndbm_mb.htm Non-Directed Body Movement (NDBM) is a method developed by Dr. Marvin Solit for unwinding defense and control patterns that have accumulated in the body's tissues. Dr. Solit was one of the earliest Rolfers trained by Dr. Rolf. NDBM is based on an idea that is diametrically opposed to the common sense dictates of our culture - that pain, illness, negative emotions and injury are not bad things to be avoided or fixed. NDBM started by asking the client to stand and focus on what you feel in your body without any intention to understand, change or fix anything. When these feelings, emotions and thoughts arise, it is important not to act on them, but just to continue to pay attention to them, most particularly attending to what they feel like as a physical sensation. Then, just track the sensations, where they go, how they change, how your body responds. They are usually slow and subtle, taking a part or the whole of the body into a rotation, a bend, lifting up or pulling down. By staying with it long enough, it eventually releases and the pattern that was under it, which I was defending myself against, comes to consciousness in some way.

Simple Contact

Muscle repositioning (http:// musclerepositioning.blogspot.com/)

Created by Barrett Dorko, a physical therapist from the USA in the early 2000s. The basis is that the body naturally and perpetually moves in a way that promotes health and optimal function (called inherent movement). The practitioners use their hands not in an ef-

A contemporary technique created by Luiz Fernando Bertolucci, a physician and Rolfer from San Paolo, Brazil. It is a type of myofascial release characterized by integrating body segments during touch, condition as-

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Spontaneous Movement

sociated with the occurrence of various sorts of motor reflexes. Luiz explained this spontaneous movement as a form of pandiculation, the involuntary stretching of the soft tissues, which occurs in most animals and is associated with transitions between cyclic biological behaviours, especially the sleep-wake rhythm. Movement Therapy Movement therapy refers to a broad range of movement approaches used to promote physical, mental, emotional, and spiritual well-being. There are various approaches to movement therapy, and there are some approaches encourage spontaneous movement. Some approaches emphasize alignment with gravity and specific movement sequences, some approaches are primarily concerned with increasing the ease and efficiency of bodily movement. Some approaches emphasize awareness and attention to inner sensations. Other approaches use movement as a form of psychotherapy, expressing and working through deep emotional issues. The following are some movement works that encourage spontaneous movements. Hanna Somatic Education (http://www.somatics.com) also known as Hanna Somatics, founded by Thomas Hanna in the 1970s. Hanna Somatics is a system of neuromuscular education which helps one to enjoy freedom from pain and more comfortable movement. It

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teaches one to recognize, release, and reverse chronic pain patterns resulting from injury, stress, repetitive motion strain, or habituated postures. The experience of â&#x20AC;&#x2022;conscious embodimentâ&#x20AC;&#x2013; can be developed through a process of movement exercises, direct touch from a skilled teacher or therapist, and the study of the body itself through the life cycle. One of the forms of somatic education used in Hanna somatics is pandiculation. Pandiculation is the act of yawning and stretching simultaneously, it is an instinctual behaviour that cleanses residual tension from the neuromuscular system and arouses the sensory-motor nervous system. Pandiculation is found among all vertebrates, the action commonly precedes moving from rest into activity, commonly manifested as stretching. The practitioner helps the beginner through a process called assisted pandiculation, which involves the client contracting the affected area while the therapist provides resistance. This teaches the body how to correctly perform the action. Afterward, the therapist instructs the client on self-pandiculation to obtain relief from pain and stress. See also an article on Pandiculation from Issue 8 of this e-magazine. Continuum (http://www.continuummovement.com) Founded by Emily Conrad, a dancer who studied AfroHaitian dance and ballet, in the late 1960s. After witnessing and experiencing undulating wave movements

Spontaneous Movement prayer rituals in Haiti, she found that fluid undulating movements are the essentials for human being. Emily developed Continuum Movement as a form of movement education that is based in the concept of the body being made up of mostly fluids. This gentle therapy includes breathing techniques, sound, and imagery to create subtle (mircro) and dynamic movements. The emphasis is upon unpredictable, spontaneous or spiral movements rather than a linear movement pattern. Authentic movement (AM) http:// www.authenticmovementcommunity.org/ Started in 1950s by Mary Starks Whitehouse as "movement in depth". AM is based on her understanding of dance, movement, and depth psychology. There is no movement instruction in AM, simply a mover and a witness. The mover waits and listens for an impulse to move and then follows or "moves with" the spontaneous movements that arise. These movements may or may not be visible to the witness. The movements may be in response to an emotion, a dream, a thought, pain, joy, or whatever is being experienced in the moment. The witness serves as a compassionate, non judgmental mirror and brings a "special quality of attention or presence." At the end of the session the mover and witness speak about their experiences together. Subud (http://www.subud.org/) A spiritual movement developed in Java, Indonesia in the 1920s founded by Muhammad Subuh Sumohadiwidjojo. The basis of Subud is a spiritual exercise called ―latihan kejiwaan‖ or simply ―latihan‖ which was said to represent guidance from "the Power of God" or "the Great Life Force". This exercise is not thought about, learned or trained for; it is totally unique for each person and the ability to 'receive' it is passed on by formal contact with another practicing member at the 'opening'. The experience takes place in a room or a hall with open space, after a period of sitting quietly, the members are typically asked to stand and relax. Members are advised to surrender to the Divine and follow what arises from within, not expecting anything in advance. They will find themselves making involuntarily movement, walking around, dancing, jumping, laughing, crying or whatever. The experience varies for different people, but the practitioner is wholly conscious throughout and frees to stop the exercise at any time. Taiji wuxi gong (http://www.taijiwuxigong.com/) Is a type of Tai Chi movement which has a goal to achieve self-healing and self-regulation using sponta-

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“I can‟t tell you how it works. I know that the intention of the therapist has a lot to do with it. Also the less guarded the patient is, the quicker it will work. “ John E. Upledger, 1987

neous movement. Spontaneous movement can be induced using a special body posture. The practitioners stand in a certain position so that the centre of gravity becomes more central in the body, in the ―Dantian‖, the energy centre in the lower abdomen. After a while practitioners start moving by themselves in standing position. It is about letting the body decide itself what movement it needs to restore inner movement in an area that is blocked. It is believed that this posture allows the practitioner to connect to a vibrational force from the earth, and this force is used to activate the Dantian, and the activated Dantian creates spontaneous movements. There are also other more rigorous spontaneous QiGong exercise of Five Animal System (http:// dangerofchi.org/videos/videos.html) Trance dance (http://www.trancedance.com/) is a contemporary blend of body movement, healing sounds, dynamic percussive rhythms, transformational breathing technique stimulating a 'trance' state that promotes spiritual awakenings, mental clarity, physical stamina and emotional well-being. Spiritual Spontaneous Body Movements Spontaneous body movements can also occur in many forms with spiritual connotation. In meditation, spontaneous movement can occur as shaking, the head moving, twitches and all sorts of other body movements. Kundalini yoga, an active form of yoga designed to awaken the kundalini (spiritual energy located at the base of the spine). The main work is called a kriya, which is a prescribed sequence of poses that focuses on a specific area of the body. Kriya may consist of rapid, repetitive movements done with breath or holding a pose while breathing in a particular way. It can involve intense involuntary, jerking movements of the body, including shaking, vibrations, spasm and contraction. It is believed that this happened when an intense en-

Spontaneous Movement ergy moves through the body and clears out physiological blocks. As deeply held armouring and blockages to the smooth flow of energy are released, the person may re-access memories and emotions associated with past trauma and injury. (From: http://www.lifeenthusiast.com/ormus/orm_kundalini.htm) See examples video: http://www.youtube.com/watch? v=z2NifkVq5RE, or http://www.youtube.com/watch? v=zCQFSwkvwUc Spontaneous movement or Ideomotor action is also part of some spiritual practices, which is called a class of innate bodily manifestations of spirit: (after Stuart Sovatsky http://www.cit-sakti.com/kundalini/sahajaspontaneous-yoga.htm). The examples are:  

      

Spontaneous spinal rockings prayer in Judaism as davening and Islam as zikr Autonomic quaking and shaking or ‗Quaker‖ and ―Shaker‖ or the "taken-over" gyrations of gospel ―holy ghost‖ shaking and dancing and charismatic/pentacostal ―mani-festations‖ Dionysian "revel" Shamanic trance-dance Raja-Yoga‘s effortless ―straight back‖ (uju-kaya) meditation Tibetan yoga‘s Tumo heat Reichian full-bodied, spontaneous ―orgasm reflex‖ Yoga kriyas Spontaneous QiGong

No doubt there are other bodywork and movement works that share similar characteristics. To understand how spontaneous movement occurs, first we need to understand about movement. According to André Bernard in Ideokinesis, movement may be defined as a neuromusculoskeletal event. This means that in order for movement to take place, all three of the systems alluded to in this definition—nervous, muscular, and skeletal—must be involved. Each system has its own specific role to play; the nervous system is the messenger, that is, it transmits impulses or messages to the muscles to contract or release; the muscle system is the workhorse or the motor system; the skeletal system is the support system that is moved by the work of the muscles. The nervous system is more than just a simple messenger. It also organizes the muscle pattern, and it does this on a level below consciousness. It is the complex of muscles that perform a desired movement: organizing the muscle pattern is a highly complex and sophisticated task. Our conscious role in movement is to focus on the movement, because the nervous system, in orga-

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nizing the muscle pattern, is responding to the clarity of one‘s concept of what the movement is. If the movement is not done well, it means the muscle pattern is poor, and the muscle pattern is poor because the ―wrong‖ message (a faulty concept of the movement) has been sent to the muscles. This wrong message is the result of either a lack of clarity about what the movement is or a previously established poor muscle pattern associated with the movement. The objective of movement work is to change the message—that is, to rethink the movement in order to change the poor muscle pattern. This rethinking the movement can be formed into an image and used as a means to change the muscle pattern. However in spontaneous movement, the inherent subconscious movement is used to correct the muscle pattern. The whole class of involuntary and automatic movement, can be considered as ideomotor action or ideomotion. Ideomotion is a movement that occurs as a result of mental activity, but independently of conscious volition. These involuntary movements can happen spontaneously or can be stimulated by various ways. The stimulus can be tactile and proprioceptive stimuli, or simply by thought, emotion, verbal suggestion. Barrett Dorko argued that ideomotor movements that accompany pain can be corrective. When pain of mechanical origin occurs, our brain automatically produce motor commands to reduce pain . However the corrective movements produced by pain are often inhibited by other mental activity. Thus ideomotion can be used as corrective movements that have become inhibited. (See also http:// www.bettermovement.org/2011/ideomotion-part-three -how-to-elicit-corrective-movement/) This is a work in progress. Feel free to provide comments by emailing terrarosa@gmail.com

Tom Ockler on MET Tom, can you briefly explain what is MET? What is the difference with stretching. MET stands for Muscle Energy Technique. It is an Osteopathic-based method that does not use manipulation to correct asymmetry and hypo-mobilities in the body. Since it relies on the muscle spindles, it actually has advantages over stretching because it is theorized to reset the muscle spindle to actually lengthen the muscle and not just stretch it. Usually we learn MET for lengthening muscles, but in your books and DVDs you also focused on joints, ribs and vertebrae. Why and what's the benefit for bodyworkers to learn these techniques There are two main types of Muscle Energy Techniques: One technique for large muscle groups and one for articular restrictions / hypo-mobility. So often, smaller muscles can get reset and pull / restrict bones and joints, thus creating pain and lack of range of motion. Having these two techniques in your "bag of tools" can effectively treat just about any somatic asymmetry and hypo-mobility you find. In your book, you mentioned 'Bone is the Slave to Muscle'? Yes, this is an Osteopathic phrase to remind us that the bones / joints are not stuck out of place by some physiologic glue but rather, held out of place by muscles that have too much tone and have been "re-set" to be too short and too sensitive to stretch. Therefore, since a manipulation may produce an analgesic effect to temporarily reduce pain, Muscle Energy, when done properly, is designed to correct the problem and not just cover up the pain. In other words, since the problem is in the muscle, why spend your time treating the joint.

It takes about 3-4 full seconds to reset the muscle spindle back to normal. That is just about the amount of time it takes to take a nice breath in and out. Also, and perhaps even more importantly, deep breathing is known to have a direct synaptic connection to inhibit the gamma motor neuron cell body that is located in the anterior horn of the spinal cord. Therefore the deep breath assists in the actual resetting of the muscle spindle by inhibiting firing of the gamma motor neuron and thus the interfusal fibres of the muscle spindle itself. One more thing, we don't breathe well and good deep breaths are very healthy for all of us. Why do you need to 'treat' the ribs? Since deep breathing is such a big help to doing muscle energy as well as reversing and preventing so many diseases, if the ribs are painful and don't expand well, you have difficulty breathing. Once a pattern of shallow or belly breathing is learned and maintained, we begin our slow downward spiral of ill health and hasten our death. As you may know, Joseph Pilates was very big on breathing. So by treating rib restrictions you can get proper breathing back on track and really improve the life expectancy or what I like to call the "thrife expectancy." In other words, how long you actually thrive, not just how long you live. You also have a passion on Alternative Medicine, we obviously don't feel that Alternative Medicine should only be used as a last resort. I'm in favour of anything natural and simple that keeps us healthy. In most cases, that is in direct opposition to our current, income-based conveyor belt form of medicine. Unfortunately, in the USA, our health care system is the number one cause of death. Time to change that system.

You also stressed a lot on breathing in your work, can you tell us the importance of correct breathing, and how bodywork can help.

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MET What tips can you give to massage therapists to prolong their career?

by several physiotherapists, oesteoplaths and massage therapists to come over and teach but so far, no one has taken the lead to get it done. I would love to come over No matter what type of body worker you are, your hands to Australia to teach. Who knows, It just might happen and shoulders are your most important tools. some day soon. Learn how to breathe; keep your core strong and keep balance in your body's musculoskeletal system. Tom Ockler P.T. has extensive teaching experience throughout the United States, Canada, England What are your interests these days? and Australia. As a teacher, Tom has earned the nickname "The Currently researching and writing two chapters for a Patch Adams of Physical Therapy" textbook on chronic pain. One of the chapters is about due to his unique style of injecting MET, the other is about EFT. humour into complicated subjects. He has developed teaching methods that explain very How and where can we learn more about MET? complicated subjects in easily understandable formats. His two books and DVDs Muscle Energy Technique for Taking a course from an experienced practitioner and Lower Extremities, Pelvis, Sacrum, and Lumbar Spine teacher is the best way. Buying the corresponding and Muscle Energy Techniques for the Thoracic Spine, manuals and DVDs is also a good start. Ribs, Shoulder and Cervical Spine have been hailed by students as the most user friendly and useful Muscle Are you planning to come and teach in AustraEnergy manuals ever. lia? I taught in Australia for a month way back in the late 80s and have not been back since. I have been contacted

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Practitioner & Owner: “Straight Percentage Agreements Work Best”

Don Dillon Massage practitioner agreement terms frequently feature a straight percentage of earnings. The contracting practitioner receives fee for service then remits a percentage of those fees to the business owner or manager. For short-term locum (maternity leave/limited-time) or as a trial to ensure practitioner and workplace are a good fit, straight percentage agreements work well. For long-term relationships built on trust, loyalty and respect, they are problematic. A straight percentage creates a variable rent, typically covering operating expenses incurred in some, but not all, months. Early in the working relationship, the business owner frequently supplements the contractor‘s expenses in the hope the investment will result in a long-term relationship and eventually a profit. In effect, the owner shoulders the risk of the associate‘s success.

The above illustration depicts the rent a business owner receives from a contracting practitioner over six months in a straight percentage agreement. Operating expenses are estimated by the business owner to be $950 / month. Note the variance of the rent paid to the clinic. In only two months does the business make a profit above operating expenses in exchange for brokering a work opportunity for the associate. In the other four months, the business does not receive adequate rent to cover operating expenses incurred by the associate. In those four months, the business owner must cover the shortfall with her or his own money. It‘s worth re-stating the obvious. With a percentage agreement, whenever the associate does not work at adequate capacity to meet expenses, the business owner dips into his or her own pocket to make up the difference. Percentage-only agreements are not good for contracting practitioners either. When starting out, paying a portion seems reasonable. However, when the contractor's practice is booming, the rent can seem disproportionately high. A straight percentage agreement provides a disincentive to long-term working relationships because it penalizes the associating practitioner for working more! Having to relocate because the rent becomes too high is expensive and practice-killing. For long-term relationships, we need accountability and opportunity for financial reward on both sides. I suggest a model that encourages fairness and accountability for both parties - a percentage agreement with a base and cap rate. The base rate guarantees cash -flow for the business owner to offset business expenses borne on behalf of the associate. The cap rate creates incentive for the associate to work hard and maximize

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Straight Percentage What about the municipal government – do I ask them to scale back my property taxes? Of course not. I incur expenses regardless of if I‘m home or not. Businesses do, too. Caveat: As a business owner and manager, make sure you know your average monthly and seasonal business expenses before you set the terms of your agreement. Don't forget to build in a profit margin for contingency, expansion and reward for shouldering the risk and responsibility of running the business. In my opinion, straight percentage agreements have some benefits, but have unacceptable disadvantages in long-term working relationships.

Partners in Profit But Without Risk Are Not Partners! her/his yield. In my experience, the base rate motivates contracting practitioners to try harder, to focus their efforts and challenge themselves. The cap rate assures them the rent will not become unreachable. In my dealings with associates, I found it effective to set a base rate for the first six months, then raise the base rate for the second six months, followed by a move to a flat rent (set at the cap rate) at one year. It allowed the associates time to get their practice up and running without excessive financial pressure. And, it ensured that, as business manager, I could expect a progressive return on investment in my budding associate. It also pushed me to get my associates as productive as possible quickly. "I'm away....why should I pay?" Some contracting practitioners argue they shouldn't bear expense when on vacation or away from the office. Their logic, "I'm not working or using any resources...why should I pay?" I recall a month when both my associates were away for a good portion, one married and the other on a training course. Because we had straight percentage terms, their low productivity that month meant low cash flow for me. I had to cover much of the operating expenses myself which meant I didn't have enough take-home pay for myself. As a result, I incurred debt. Consider this analogy. I am going on vacation and won‘t be home for two weeks. Can I call the mortgage company and ask them to suspend my mortgage for two weeks because I won‘t be using my house? Or the phone, hydro and gas companies and ask for a reduction because I‘m not using their services for two weeks?

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Sometimes, practitioners-turned-business managers allow an associate under their wing in a collective partnership. True partners share the potential for profit as well as risk of loss. Partnerships are problematic when risk is not borne equally by all partners. Consider a business owner who agrees to divide the expenses for business operation equally between herself or himself and three associates, without incorporating any profit margin. The business owner is wearing two hats - practitioner and manager - but did not factor in a salary for the extra administrative work required. If two associates leave, the owner and the remaining associate must now double their rent (and their business duties) to cover all expenses until they find two more ―partners.‖ Are all partners willing to bear the risk of loss as the business owner must? If not, don't make them partners! Partners should buy in/invest with their own capital and have the responsibility of finding a replacement or selling their share should they wish to leave the partnership. A business manager who bears the operating expenses and risk of loss should be paid for it.

"Without a straight percentage agreement, will I fail to attract candidates?" If you have an established location and reputation you have a valuable asset. Associates will jockey for the opportunity to be part of your business. During prospective associate interviews, I openly dis-

Straight Percentage close what it costs to run my business (profit margin in), and clearly set my expectations for the candidate. In setting up expectations in advance, I am less likely to encounter problems with the associate later on. If your business has high value – a well-established reputation and location – you will attract better candidates.

Intuition versus Doing the Math In my seminars, I ask business owners, ―How did you arrive at the financial terms for your agreement?‖ The typical response: The terms ―seemed fair,‖ or ―felt right.‖ Further, ―If I figure my actual expenses and a profit margin into my terms, my associates will leave and take all the business with them. I can‘t raise the rent!‖ This is what I believed as a business owner and manager and for years tried to increase my income through other means before I finally questioned my own beliefs. I had allowed professional myths and misinformation to determine my terms, rather than basic math. I had paid handily for these beliefs and not until I admitted the reality of my business costs and lack of business experience did I resolve my dilemma. After examining my financial position and talking with my accountant, I put together a fact sheet with the actual costs of the business and scheduled a meeting with my associates to present the financial facts. The associates at first were apprehensive – a natural response to being asked for more money. But after discussion and reflection, the associates fully accepted the new terms. They were as reliant as I on seeing the business continue. While intuition is an important faculty for the practitioner providing care, do not forget to do the math when it comes to forming a contractual agreement. Make sure your agreement is based on financial facts, not opinions or unhelpful beliefs.

Don Dillon, RMT is the author of Massage Therapist Practice: Start. Sustain. Succeed. and the self-study workbook Charting Skills for Massage Therapists. Don has lectured in seven Canadian provinces and over 60 of his articles have appeared in massage industry publications in Canada, the United States and Australia. Don is the recipient of several awards from the Ontario Massage Therapist Association, and is one of the founding members of Massage Therapy Radio www.massagetherapyradio.com. His website, www.MTCoach.com, provides a variety of resources for massage therapists. This excerpt is reprinted from Massage Therapist Practice: Start. Sustain. Succeed. Available from Terra Rosa http:// www.terrarosa.com.au/book/

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Postural Assessment Jane Johnson When used in the context of therapy – physiotherapy, massage therapy, osteopathy or chiropractic, for example – the term posture more precisely describes the relationships among various parts of the body, their anatomical arrangement and how well they do or do not fit together. Bodyworkers have become familiar with postural terms such as scoliosis and genu valgum, which are used to describe a congenital, inherited position, plus used to describe a position assumed through habit, such as increased thoracic kyphosis resulting from prolonged sitting in a hunched position. Of course, the postures we assume provide clues to not only the condition of our bodies – traumas and injuries old and new, and mild or more serious pathologies – but also how we feel about ourselves – our confidence (or lack of it), how much energy we have (or are lacking), how enthusiastic (or unenthusiastic) we feel, or whether we feel certain and relaxed (or anxious and tense). Intriguingly, we all almost always adopt the same postures in response to the same emotions.

Why should I perform a postural assessment? The main reasons for carrying out a postural assessment are to acquire information, save time, establish a baseline, and treat holistically.

Working with the general population, you have your fair share of clients suffering from back and neck pain. Many clients believe that their ‗terrible posture‘ is due to the sedentary nature of their work, the long hours they spend slumped at a desk or driving. It would be helpful to know whether a client‘s pain does indeed stem from the adoption of habitual postures, or whether it might be due to something else. By distinguishing among various causes, you are more likely to be able to determine whether a change in working posture might be beneficial. Example 2 Assessing a 49-year-old woman for worsening shoulder pain, you notice a decrease in shoulder muscle bulk during the postural assessment. One possible explanation for atrophy of the shoulder muscles (accompanied by a progressive decrease in range of movement) in a client with no history of trauma is adhesive capsulitis. The information you have gained from your observation has contributed to the formulation of your diagnosis, which may later be substantiated or refuted with the appropriate tests.

First, and most important, performing a postural assessment gives you more information about your client. Here are two examples to illustrate this point:

It is important to remember that postural assessment is only one component of the assessment procedure, and that to make a diagnosis of any condition, all components of the assessment procedure need to be considered, along with current guidelines. For example, to support a diagnosis of adhesive capsulitis, you may follow guidelines such as those set out by Hanchard and colleagues (2011).

Example 1

The postural assessment is also an opportunity to clar-

i) Acquire information

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Postural Assessment ify observations about marks on the skin such as scars from significant operations (such as appendectomies or treatment for fractures in childhood) that clients may have forgotten to mention. ii) Save time A postural assessment may save time in the long run by revealing facts that are pertinent to the client‘s problem that might otherwise have taken longer to establish. The relationships among body parts are more difficult to assess when someone is lying down to receive a treatment, but suddenly become obvious when they stand. Example You are a sports massage therapist treating a typist who is normally fit and healthy. She is complaining of right-side anterior shoulder pain. Performing both the standing and sitting postural assessments, you observe that your client has a considerably protracted right scapula, something you had not noticed when your client was in the prone position, a position in which both scapulae naturally protract. iii) Establish a baseline A postural assessment helps you to establish a baseline – a marker by which you might judge the effectiveness of your treatment. If your client has muscular pain in the low back resulting from the position of the pelvis, and you prescribe exercises and stretches to correct this posture, you will no doubt need to reassess the client at some stage to determine whether there has been any change in the pain and whether this can be attributed to an alteration in the position of the pelvis. If we suspect that a problem is the result of poor posture, we need to identify whether we have made any impact (directly with massage and movement, or indirectly with prescribed exercises and stretches) on the client‘s upper body posture. iv) Treat holistically Finally, it could be argued that by including an analysis of posture as part of our assessment, we are offering a more complete service, in keeping with the idea of treating people holistically, not compartmentalising them as a bad knee, a frozen shoulder, or whiplash. We keep records of clients‘ states of health and physical activities, so it seems logical that we also keep a record of their postures.

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Who should have a postural assessment? Ideally, you should perform a postural assessment on all clients presenting for sports or remedial massage, physiotherapy or osteopathy treatments. If you are working as a fitness professional with one of your aims being to strengthen weak muscles, or as a teacher of yoga aiming perhaps to lengthen muscles, you too will find postural assessment beneficial because it will help you identify muscle imbalances and you can therefore design the most effective exercises and postures for your clients. However, with some clients, a postural assessment may not be appropriate, such as the following:  An anxious client  A client unable to stand because of pain or illness  A client who is unstable when standing or when getting to or from the standing position  A client who does not understand the purpose of the assessment or who does not give consent to having one performed  A client with a condition that would benefit from a different form of assessment When working with an anxious client, you may want to postpone a postural assessment while you develop a rapport. Once that is established, you can carry out a more thorough assessment, including that of posture. It would be inappropriate to assess the posture of a client who is unable to stand because of pain or illness. Remember, you can still assess a client in a seated position. In some cases a postural assessment is warranted but must be performed with care. For example, you may want to assess an elderly person who has suddenly become unbalanced when using a regular walking aid. In this case you need to assess the patient standing with the aid, yet you must also ensure safety. Similar caution needs to be taken when assessing a client with a recent injury. With such patients – particularly those with injury in the lumbar spine, pelvis or lower limbs – weight bearing or a change in posture may aggravate discomfort. Some clients may be unsettled by how close you are to them during a postural assessment; with such clients, you should clearly explain your intention and the purpose behind the assessment.

Postural Assessment Factors affecting posture

Structural or anatomical

Age Physiological

Pathological

Occupational

Scoliosis in all or part of the spine. Discrepancy in the length of the long bones in the upper or lower limbs. Extra ribs. Extra vertebrae. Increased elastin in tissues (decreasing the rigidity of ligaments). Posture changes considerably as we grow into our adult forms, with postures in children being markedly different at different ages. Posture changes temporarily in a minor way when we feel alert and energised compared to when we feel subdued and tired. Pain or discomfort may affect posture as we adopt positions to minimise discomfort. This may be temporary or could result in long-term postural change if the position is maintained. Physiological changes that accompany pregnancy are temporary (e.g., low backache before or after childbirth), but sometimes result in more permanent, compensatory postural change. Illness and disease affect our postures especially when bones and joints are involved. Osteomalacia may show up as genu varum; arthritic changes are often revealed when joints in the limbs are observed. Pain can lead to altered postures as we attempt to minimise discomfort (for example, following a whiplash injury a client may hunch the shoulders protectively; abdominal pain may lead to spinal flexion). Malalignment in the healing of fractures may sometimes be observed as a change in bone contour. Certain conditions may lead to an increase or a decrease in muscle tone. For example, someone who has suffered a stroke may have increased tone in some limbs but decreased tone in others. As elderly adults, we tend to lose height as a result of osteoporotic changes and so develop stooped postures; postmenopausal women may develop a dowagerâ&#x20AC;&#x2DC;s hump. Consider the postural differences between a manual worker and an office worker, and between someone active and someone sedentary.

Recreational

Consider the postural differences between someone who plays regular racket sports and someone who is a committed cyclist.

Environmental

When people feel cold they adopt a different posture to that when they feel warm.

Social and cultural

People who grow up sitting cross-legged or squatting develop postures that are different from those of people who grow up sitting on chairs.

Emotional

Usually, the posture we subconsciously adopt to match certain moods is temporary, but in some cases it persists if the emotional state is habitual. Consider the posture of a person who is grieving, or the muscle tone of a person who is angry. Clients who fear pain may adopt protective postures.

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Postural Assessment with neck pain may subconsciously elevate their shoulder protectively in an attempt to reduce their discomfort.

Examples of postural assessment

This woman is standing ‗relaxed‘. Observe how she holds her right arm. She has suffered neck pain in the past, but at the time this photograph was taken, and for many months previous to that, she was pain free. Would you agree that her right shoulder is elevated? Can you see also how her neck is also laterally flexed and slightly rotated to the right?

Please note that these examples form just two parts of a full body assessment and are for illustrative purposes only. Shoulder height

Abdomen

When looking at your client‘s shoulders, note whether they are level, or if one appears higher than the other.

An area that sometimes gets overWhat your findings mean looked in posShortening in levator scapulae and the upper fibres of tural assessthe trapezius may contribute to one shoulder appearing ment is the higher than the other. If a scapula is elevated, you would abdomen. expect the inferior angle of that scapula to be superior to How does the the inferior angle of the scapula on the opposite side. abdomen of your client Here is an interesting question: How do you know appear - is it whether one shoulder is truly higher or the other is flat or protrudlower? Ask the client to try this simple exercise: shrug ing? In a northeir shoulders, elevating their scapulae; then relax. mal, healthy Now depress their shoulders; then relax. Which moveperson, the ment did they find easier, elevation or depression? Most abdomen people find that shrugging the shoulders is easier than should be flat. depressing them. It seems reasonable to assume that if your client‘s right shoulder appears higher, muscles on The photothe right are shorter and tighter than the corresponding graphs on the muscles on the left. An exception to this might be if you opposite page demonstrate the variety in the shape and were assessing someone with a neurological condition position of the abdomen when a person is viewed later(for example, having suffered a stroke) and she had a ally. Does an abdomen protrude because the person is dropped shoulder as a result of low tone on one side of overweight or pregnant, or it is the result of the person‘s her body. overall standing posture and an anteriorly tilted pelvis? Therapists have observed that, for many people, the dominant shoulder is naturally depressed and slightly protracted. If right-handed, the right shoulder may be slightly lower and more protracted than the left. Clients

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Is there increased tension in the abdomen perhaps corresponding to a posteriorly tilted pelvis and a decreased curve in the lumbar spine?

Postural Assessment

What your findings mean Protrusion of the abdomen could be a natural consequence of pregnancy or the result of increased lumbar lordosis, or it could simply be excess adipose tissue because the client is overweight. Clients with restrictions in the muscles and fascia of the chest sometimes appear to have a protruding abdomen, quite a distinct change in shape from the chest area, which is tight and depressed.

Postural Assessment is available from www..terrarosa.com.au

Jane Johnson MSc, is co-director of the London Massage Company, England. As a chartered physiotherapist and sport massage therapist, she has been carrying out postural assessments for many years. She is renowned for her teaching, enthusiasm and dynamism. Her track record in the industry spans over 17 years References working both as a practitioner/instructor and as course director of her own company and other successHanchard N, Goodchild L, Thompson J, Oâ&#x20AC;&#x2DC;Brien T, ful massage schools. She has a deep interest in muscuRichardson C, Davison D, Watson H, Wragg M, Mtopo S loskeletal anatomy and how newly qualified therapists and Scott M (2011). Evidence-based clinical guidelines can be better educated in this subject. She also is interfor the diagnosis, assessment and physiotherapy manested in the relationship between emotions and posagement of contracted (frozen) shoulder, Standard ture. In her spare time, Johnson enjoys taking her dog Physiotherapy 1:3. Endorsed by the Chartered Society of for long walks, practicing wing chun kung fu, and visPhysiotherapy. iting museums. She resides in London. Read also 6 questions to Jane on page 43 This excerpt is based on excerpts from Postural Assessment, by Jane Johnson, published in December 2011 by Human Kinetics. This article was first published in International Therapist (Issue 99, January 2012), the membership journal of the Federation of Holistic Therapists.

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3D Anatomy for Manual Therapies Having used Primal software for many years in her teaching, renowned massage therapist and educator Judith DeLany proposed a new Primal Pictures product specifically designed for manual practitioners, with a focus on massage techniques. This proposal became a reality in 2012 with the publication of 3D Anatomy for Manual Therapies. The aims of the product are to introduce the students, as well as professional practitioners, to a wide range of techniques and modalities, to clarify anatomy and functional movements, and to provide instructors with exceptional, easy to use tool, to guarantee success within this substantial, worldwide market. Manual therapy practitioners use their hands to locate, assess and treat myofascial tissues. The clearer the anatomy knowledge, the more precisely placed and safely executed the treatment. Knowledge of neurovascular and lymphatic structures is necessary in order to avoid endangerment sites and to focus treatment toward relieving muscular impingement of those structures. Using clear anatomy visuals, created by Primal Pictures, provides the level of detail needed in an engaging and easy to use format. The 3D anatomy models were accurately built using MRI and CT scan data and cadaveric material. For many of our 3D models we used the Visible Human

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Project data produced by University of Michigan. The imaging data is delivered as 2D cross-sectional slices, and then each slice goes through a segmentation process. This involves outlining individual tissue, by hand, and tracking the contours of each anatomical feature through successive slices, which are then built into a 3D model using advanced graphics techniques. All Primal anatomy models are verified by an in house team of qualified anatomists and by a team of external experts. Judith DeLany and Primal Pictures worked with a team of the top names in massage and manual therapy, including: Timothy Agnew, Sandra K Anderson, JeanPierre Barral DO MRO(F) PT, Leon K Chaitow ND DO, Bruno Chikly MD DO, Alain Croibier DO MRO(F), Johnette du Rand ,Sandy Friedland, Richard M Gold PhD L.Ac, Alison Harvey DC CST-D, Dawn Langnes BS LMT, Whitney W Lowe, Vimala McClure, Mike McGillicuddy, Joseph E Muscolino DC, Thomas Myers, Carole Osborne, Sharon Puszko PhD LMT, Susan G Salvo B Ed LMT NTS CI NCTMB, John E Upledger DO OMM John M Upledger CEO, Ed Wilson LMT, Cert Reflexology, Robert A Wuttke LMT NSCA-CPT BMO, James Waslaski AA LMT CPT (NASM), Linda Beach, Iris Burman LMT CNMT, Susan Kay Hillman, ATC, PT Beside anatomy, the DVD-ROM also covered 27 manual therapy techniques, include: Active isolated stretch-

ing, Orthopedic massage, Aquatic bodywork, PNF stretching, Body wraps and scrubs, Positional release, Craniosacral therapy, Prenatal massage, Hospice-based massage therapy, Reflexology, Hot/cold stone therapy, Shiatsu/acupressure, Infant massage, Sports massage, Kinesiotaping, Spray and stretch, Lymph drainage therapy, Structural integration, Massage for the elderly, Swedish massage, Muscle energy techniques, Thai massage, Neural manipulation, Trigger point release, Neuromuscular therapy (NMT), Visceral manipulation, Oncology massage. 3D Anatomy for Manual Therapies is now available from www.terrarosa.com.au

Postural Assessment offers students and practitioners of massage therapy, physical therapy, osteopathy, chiropractic, sports medicine, athletic training, and fitness instruction a guide to determining muscular or fascial imbalance and whether that imbalance contributes to pain or dysfunction. Now available at www.terrarosa.com.au

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Research Highlights Massage Therapy Attenuates Inflammatory Signalling After Exercise-Induced Muscle Damage Although there is evidence that massage may relieve pain in injured muscle, how massage affects cellular function remains unknown. The discovery provides strong evidence that massage merits further study as a treatment for injuries and chronic disorders, said Dr. Mark Tarnopolsky, a researcher at McMaster University in Ontario, Canada. The authors administered either massage therapy or no treatment to separate quadriceps of 11 young male participants after exercise-induced muscle damage. Tarnopolsky, who has studied the cellular effects of exercise for decades, performed muscle biopsies in both quadriceps (vastus lateralis) of healthy young men before and after they'd undergone strenuous exercise, and then a third time after massaging just one leg in each individual. Comparing tissues from each subject's massaged leg with tissues from his unmassaged leg, Tarnopolsky and his team found that massage therapy reduced exerciserelated inflammation by dampening activity of a protein called NF-kB. Massage also seemed to help cells recover by boosting amounts of another protein called PGC-1alpha, which spurs production of new mitochondria â&#x20AC;&#x201D; tiny organelles inside cells that are crucial for muscle energy generation and adaptation to endurance exercise. Other proteins with similar roles were influenced by massage as well. The study was published in the journal Science Translational Medicine. Pleasant Human Touch is Represented in the Brain Touch massage (TM) is a form of pleasant touch stimulation used as treatment in clinical settings and found to improve well-being and decrease anxiety, stress, and pain. Emotional responses reported during and after TM have been studied, but the underlying mechanisms are still largely unexplored. In the study conduced by Swedish scientists, the authors used functional magnetic resonance (fMRI) to test the hypothesis that the combination of human touch (i.e. skin-to-skin contact) with movement is eliciting a specific response in brain areas coding for pleasant sensations. The design included four different touch conditions; human touch with or without movement and rubber glove with or without movement. The pleasantness of the four different touch stimulations was rated on a visual analog scale (VAS-scale) and human touch was rated as most pleasant, particularly in combination with movement. The fMRI results revealed that TM stimulation most strongly activated the pregenual anterior cingulate cor-

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tex (pgACC.) These results are consistent with findings showing pgACC activation during various rewarding pleasant stimulations. This area is also known to be activated by both opioid analgesia and placebo. Together with these prior results, the finding furthers the understanding of the basis for positive TM treatment effects. The study was published in Neuroimage. Massage Therapy for Osteoarthritis of the Knee A group of medical scientists from the US in 2006, reported results of a pilot study of massage therapy for osteoarthritis (OA) of the knee. Subjects with OA of the knee were randomized to biweekly (4 weeks), then weekly (4 weeks) Swedish massage (1 hour sessions) or wait list. Subjects receiving massage therapy demonstrated significant improvements in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), pain, stiffness, and physical functional disability domains and visual analog pain scale, compared to usual care. Notably, the benefits persisted up to 8 weeks following the cessation of massage. In a new trial, the scientists now want to identify the optimal dose of massage within an 8-week treatment regimen and to further examine durability of response. Participants were 125 adults with OA of the knee, randomized to one of four 8-week regimens of a standardized Swedish massage regimen (30 or 60 min weekly or biweekly) or to a Usual Care control. Their results showed that the WOMAC Global scores improved significantly in the 60-minute massage groups compared to Usual Care at the primary endpoint of 8-weeks. WOMAC subscales of pain and functionality, as well as the visual analog pain scale also demonstrated significant improvements in the 60minute doses compared to usual care. No significant differences were seen in range of motion at 8-weeks, and no significant effects were seen in any outcome measure at 24-weeks compared to usual care. A doseresponse curve based on WOMAC Global scores shows increasing effect with greater total time of massage, but with a plateau at the 60-minute/week dose. The authors concluded that Given the superior convenience of a once-weekly protocol, cost savings, and consistency with a typical real-world massage protocol, the 60-minute once weekly dose was determined to be optimal, establishing a standard for future trials. The research was published in PLoS.

Research Highlights The Role of Massage in Scar Management Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly. Scientists from Ohio conducted a review on the efficacy of scar massage. The review was published in Dermatology Surgery Journal. After searching through a large scientific database, ten studies including 144 patients who received scar massage were examined in the review. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment protocols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from one treatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score. However the authors concluded that although there are several studies showing the effectiveness, the evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it. Neural Correlates of a Single-session Massage Treatment A recent study from Canada investigated the immediate neurophysiological effects of different types of massage in healthy adults using functional magnetic resonance imaging (fMRI). The study suggested that that qualitatively different aspects of massage, such as the nature of human touch, can selectively modulate the activity of certain brain regions. The researchers looked at the problem from, the resting state of the brain, which has been referred to as the default mode network and has received much attention for its importance in the generation of consciousness. These regions (i.e. insula, posterior and anterior cingulate, inferior parietal and medial prefrontal cortices) have been postulated to be involved in the neural correlates of consciousness, specifically in arousal and awareness. The researchers posit that massage would modulate these same regions given the benefits and pleasant affective properties of touch. Healthy participants were randomly assigned to one of four conditions: 1. Swedish massage, 2. reflexology, 3. massage with an object or 4. a resting control condition. The right foot

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was massaged while each participant performed a cognitive association task in the scanner. They found that the Swedish massage treatment activated the subgenual anterior and retrosplenial/ posterior cingulate cortices. This increased blood oxygen level dependent (BOLD) signal was maintained only in the former brain region during performance of the cognitive task. Interestingly, the reflexology massage condition selectively affected the retrosplenial/posterior cingulate in the resting state, whereas massage with the object augmented the BOLD response in this region during the cognitive task performance. The most robust fMRI changes were observed with the Swedish massage treatment, which involves long and smooth strokes with an applied pressure geared towards relaxation. The impact of reflexology, which is focused upon applying pressure to specific reflex points to invoke a beneficial response at distant body regions, was restricted to the RSC/PCC brain region. In contrast, the massage with a wooden object, which involved pressure and strokes along the same areas of the foot as applied in the Swedish massage, had no significant effect on the BOLD signal in either of the brain regions. This latter finding is particularly noteworthy since it suggests the possibility that the human touch component (as opposed to the same pattern of massage with an object) had a profound influence upon the impact of the treatment. These findings should have implications for better understanding how alternative treatments might affect resting state neural activity and could ultimately be important for devising new targets in the management of mood disorders. The study was published in Brain Imaging and Behavior.

6 Questions to David Lesondak 1. When and how did you decide to become a bodyworker?

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

It was in 1989. Bodywork and massage were always something I had been doing since my early teens and into my young adulthood. I had tried a number of different careers but nothing really took off. Putting my hands on people and affecting them was the one constant in my life. It seemed like a good way to earn a living while I was figuring out what I wanted to do with my life – and here I am 23 years later so I guess I figured it out.

Follow your passion and shape your practice in a way that feeds you, and by that I mean not physically, but in a way that feeds your soul. Stay curious, keep learning new things, keep your sense of wonder alive and never, ever tell a client or patient that they're "a mess" or "you have the tightest traps in the universe" – give them information about their bodies that they can use to make a difference.

2. What do you find most exciting about bodywork therapy? That here is so much to discover. That there are so many potential applications that haven't been tried. That after 20 years my patients are still surprising me about what they're capable of doing. And if it doesn't sound too grandiose, helping the disenfranchised find hope.

6. How do you see the future of bodywork and massage therapy? I think the sky's the limit. The research is finally starting to prove what we've seen clinically for a very, very long time. It's vindicating and opening new doors to us. As we walk through them we must remember to be humble and learn from everyone we meet. And to look for opportunities to teach what we know. And do both these things in a spirit of collaboration and openness.

3. What is your most favourite bodywork book? Well, It' s not exactly a bodywork book per se, but "Energy Medicine – The Scientific Basis" by Jim Oschman gets read every year for continued inspiration. I am also a big fan of Dr. Atul Gawande and his book "Complications: A Surgeon's Notes of an Imperfect Science." It's just a beautiful book that I recommend to all my students and surprisingly applicable to our field. 4. What is the most challenging part of your work? Having to tell somebody "I can't help you," and taking time for myself to rest, recharge and revitalize – but as I approach 50 I'm getting better at this.

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6 Questions to Jane Johnson 1. When and how did you decide to become a bodyworker? It wasn't a conscious decision at all. At school I liked to sort thingsâ&#x20AC;&#x201D;shells, seeds, stones, whatever I could get my hands onâ&#x20AC;&#x201D; and so studying the human body came naturally as I viewed it simply as something that could be sorted. It could be sorted into systems (respiratory, digestive, nervous, etc.), and aspects of those systems could themselves be categorized (flexor muscles/ extensor muscles, arteries/veins, etc). Of course we all appreciate the interrelationship between systems and between these and the mind, but back then it seemed an easy way to help me learn human anatomy when I was studying biology. The more I learned the more I became interested. From training as a fitness instructor I moved into massage, sports massage, exercise physiology, exercise psychology, and physiotherapy. I'm a lifelong learner and so forget to see myself as a 'bodyworker' because I continue on the journey of learning and understanding so have not yet 'become'anything! 2. What do you find most exciting about bodywork therapy? The fact that I pretty much learn something new on a daily basis. Within the last two days I've come across three people each with unusual presentations: paralysis of the long thoracic nerve due to a single cough whilst resting, oedema to the face with no apparent cause, and an unusual hip pathology. I find it fascinating and intriguing to find the best ways to help each client, knowing that all treatments need to be tailored. So because every client is different I feel that I am myself always growing and expanding in knowledge and awareness and that's a very satisfying feeling. I'm actually also really excited by the fact they the profession attracts new people all of the time, who come bringing their own ideas and experiences. I'm a total fan of diversity and the more people who join the profession the better it becomes. 3. What is your most favourite bodywork book? Well, its not actually a book for bodyworkers, its one of the Thieme Flexibooks called Colour Atlas and Textbook of Human Anatomy, Volume 1: Locomotor System by Werner Platzer. Its a superb anatomy book, small, compact, with fantastically clear illustrations. I discovered it years ago when working for a publishing company and return to it time and time again. 4. What is the most challenging part of your work? Ensuring that the last treatment of the day is as good as the first. This may sound obvious but I often work as a locum physiotherapist, in roles that require massage. I recently completed a contract with a clinic specializing in whiplash and saw 17 patients day,

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each of 30 minutes, all of whom had various whiplash associated disorders. Its a real skill to make every client feel special and not simply like a number on a conveyor belt and whilst longer treatment times and fewer patients are preferable, this is not always possible when working for other people. I actually enjoy the challenge of working this way and endeavour to be absolutely the best bodyworker I can possibly be to each and every client, to help them manage their condition effectively so that they leave feeling positive and uplifted. It also requires considerable diagnostic and treatment skill to be able to work in this manner, which I truly believe can be done with experience. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? Be yourself. Explore different ways of working and, more than anything, follow your instincts. There is no one way to do anything. There is no one therapy that should be employed. Different techniques work for different clients with the same conditions, and different types of bodywork suit different therapists. All bodyworkers have something to contribute to the field. All bodyworkers have the opportunity to make a difference. If you help but one client to feel better about themselves, to help reduce their pain or anxiety or to improve their function, it has all been worth it. Though not necessarily advice, one thing I would wish for is for any therapist to find ways to share their experiences. The value of sharing cannot be overstated. It's not just useful its crucial. Magazines, conferences, workshops, chat rooms, books, newsletters, these are all superb ways to gain knowledge and skills and also to share knowledge and skills. Continue to ask questions. I owe a tremendous debt of gratitude to the hundreds of therapists I have helped to train because they have asked questions which have kept me on my toes for many years. Sharing is everything. 6. How do you see the future of bodywork and massage therapy? I'm not sure of the situation in other countries, but I can tell you that in the UK I'm sensing more and more physiotherapists and osteopaths exploring massage as postgraduate training. At the same time, after training and working as bodyworkers, some therapists crave additional stimulation so go on to study physiotherapy or osteopathy. There is definitely a growth in our appreciation of fascia and the role that it plays. There are also a growing number of therapists wanting access to cadaveric specimens so that they can view the body structures they have learnt about and work with. Having some physiotherapists provide massage has helped this therapy to become more acceptable to some people and this is a good thing because people who have received massage and benefited from it are more likely to seek out practitioners whether these practitioners are physiotherapists or not.

6 Questions to Walt Fritz 1. When and how did you decide to become a bodyworker? After failing miserably as an engineering major in college, I shifted my sights toward physical therapy. While in theory, physical therapy is bodywork; there was often little resemblance to what I do now. After moving through a variety of job situations for 10 years, I began my first few continuing education seminars in MFR and CST and I was hooked. I was so impressed at the changes that I could make in my clients, even after only one weekend seminar. I took all of the classes I could and spent the next ten years instructing at myofascial release seminars for another teacher. After a parting of ways, I began my own line of myofascial release seminars (Foundations in Myofascial Release Seminars) in 2006. 2. What do you find most exciting about bodywork therapy? Simply put, it is being able to help those who others were not able to help. I love being able to positively influence the lives of others, whether it is my clients or the therapists that I teach. 3. What is your most favourite bodywork book? Netter‘s Atlas of Human Anatomy. The artistry is magnificent and every time I pick it up I am amazed just how well we function. It is also my favorite teaching tool for clients. 4. What is the most challenging part of your work?

Second, as a physical therapist I have many obstacles to overcome in dealing with stereotypes of just what physical therapy is. In many ways, massage therapists have it easier. A bodywork-centered approach is what new clients expect, even though the modality may vary. Mention physical therapy to the average person and their vision of that is very different than the way I practice. It is a pleasant surprise to most new clients, as they are not used to being touched and given so much one-on-one treatment by their physical therapist. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? Find your passion. I discovered mine 20 years ago and continue to love what I do to this day. How many people can say this? Whether it is my choice, myofascial release, or any of the other excellent modalities available, find a teacher who matches your style and pursue the work. Fill your toolbox with skills that will allow you to meet the needs of your dream client. I believe specialization is key to success in our professions. Be very good at something and word will spread. 6. How do you see the future of bodywork and massage therapy? I believe that the science-based approach to bodywork will continue to spread, replacing unfounded modalities and approaches. Therapists will need to keep up with the changes or get left behind. Massage schools will need to better address this science and continuing education will need to keep pace as well. ―Because it works‖ will no longer be good enough.

Two things come to mind. One is trying to ignore the garbage that continues to exist in the therapy community when it comes to myofascial release. The science is quickly emerging and evolving, thanks in no small part to the Fascia Research Congress. There is no need to continue pursuing alternative explanations that bring no credence to our field. However, there is money to be made in continuing to push this agenda onto unsuspecting therapists.

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