Terra Rosa E-magazine Issue #11 by Terra Rosa

Terra Rosa E-Magazine

Open information for massage therapists & bodyworkers No. 11, December 2012 www.terrarosa.com.au www.massage-research.com

Terra Rosa e-magazine, No. 11 (December 2012) 1

Terra Rosa E-Magazine, No. 11, December 2012

Working with Rib Restrictions — Til Luchau

First Rib Mobilization using an Indirect Technique — Marita Louw

Mobilizing the Frst Rib — Art Riggs

Fascia as a Communication Organ — Robert Schleip

10 Steps towards Fascial Fitness— Sol Petersen

Research on Cupping — Romy Lauche

Massage Tools

Joint Mobilization of the Thoracic Region— Joe Muscolino

“Core” Matters — Josephine Key

Research Highlights

6 Questions to Greg Polins

6 Questions to Josephine Key

Welcome to our eleventh issue of Terra Rosa e-magazine. Do you ever wonder where our food come from and how it was produced. In this urbanised world, we often forget the food that we eat is grown from our soil. Most of the soil in the city has been under concrete, luckily we still have some gardens and parks. Soil has been much used and abused when we produced food. A rather vicious farming system has continually cultivated the soil and squeezed out the nutrients to produce our food. This caused much land been degraded. We often take granted of soil, but it is the most fundamental non-renewable resource we need to grow food. In a recent symposium in Sydney, a call has been made to focus on Soil Security. How to secure our fragile natural resources so we can sustainably produce food. Prime Minister of Australia, Julia Gillard recently gave a speech: “Australia should be a supplier of choice for agricultural solutions like technologies to increase yields, reduce water use and lessen environmental degradation; soil management systems; and improving feed sustainability for marine aquaculture. In the Asian Century, our production and exports will expand, but our soil and water resources remain finite. As Prime Minister, I recognise you (farmers) as frontline caretakers of our greatest assets – our soils, our water, and our biodiversity. Soil is the very basis of our survival. Clean air and water; food and fibre; and our unique biodiversity all rely on protecting our soil.” So next time, we step and look on our land, remember where it all begins. Take care of our soil much as we take take of our body. In this issue, we cover other exciting articles from a selection of well-known bodyworkers. A series of articles on ribs by Til Luchau, Marita Louw and Art Riggs. Joe Muscolino on mobilizing the thoracic region. On the research front, Robert Schleip discusses the importance of fascia as a communication organ. And Romy Lauche discusses some of the latest research on Cupping. Thanks for reading, happy holiday, and Stay Healthy. Looking forward to a successful new year in 2013. Sydney, November 2012

Cover picture: The Art of Balancing by Art Riggs

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

Terra Rosa e-magazine, No. 11 (December 2012)

Working with Rib Restrictions Til Luchau Take a breath. How much did your ribcage move, and where? Take another breath, this time without moving your ribs quite as much. The unpleasant, hard-tobreathe sensation? That’s what restricted rib motion feels like, whether the restrictions are from connective tissue constriction, pain, posture, or habit. Breath efficacy affects a wide range of functions, from metabolic processes, to our energy level, alertness, and mood. Since we take approximately 24,000 breaths in a day, even small changes in our respiratory efficiency will have cumulative and far-reaching body-mind effects. Fortunately, this multiplying effect works both ways: not only can breath resections make us feel bad, but even small, incremental improvements in rib freedom can improve well-being on many levels. Restricted rib motion can arise from the usual things that cause us to loose mobility: stress, postural and habitual stance, inactivity, disease, pain, or injury. No matter what the cause, skilled hands-on work can be an effective way to help re-establish lost motion. I’ll discuss four techniques for restoring ribcage mobility, taken from Advanced-Trainings.com’s Advanced Myofascial Techniques series. We’ll begin with the back. Erector technique Your work with rib restrictions will be more effective if you take time to release the larger, more superficial rib structures first. Within the erector spinae group, the iliocostalis and longissimus thoracis connect ribs to other structures, and will restrict breath mobility when tight (and both connective tissue tightness and high muscle tone are common here). You will also find it easier to assess the movement of the ribs themselves in the subsequent techniques if you release the erector spinae group first. The forearm tool (Image 2) is an effective way to work with the erectors. Without using oil (which would eliminate the slight friction necessary to differentiate individual layers), use your forearm to apply a bit of caudal (downward) pressure on the erectors, feeling for their lateral edge. At first, feel for variations tissue density, rather than attempting to release or change any-

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Images 1 & 2: Use the flat portion of your forearm to gently release the iliocostalis group (orange), the most lateral of the erector spinae. Image 1 courtesy Primal Pictures; Image 2 courtesy Advanced-Trainings.com.

Working with the ribs Whichever position or assessment method you choose, be sure you’re feeling for the boney hardness of the rib itself, and not getting distracted by any remaining tightness in the soft tissues over the ribs or in the laminar groove. Each rib should give slightly when you put anterior pressure on it. An unyielding rib or particular tenderness with the test reveals an issue with that rib’s costovertebral joints. Test all ribs, using caution and using very little pressure on the lowest two pairs of floating ribs.

Image 3: Applying gentle, steady pressure to encourage to a restricted rib in the release phase of the Costovertebral Joint Technique. Image courtesy Advanced-Trainings.com.

thing. Keep your other, non-working hand on your client, close to your forearm. This will help your body position be more stable, and give you a bigger “footprint” in your client’s awareness, which will help him or her to relax into your touch. Allow the slow release of the tissue to set the pace for your gradual gliding movement down the back. Begin with moderate pressure, in order to prepare and warm up the superficial layers. Once they’ve released, on your successive passes feel deeper into the back’s myofascia, working slowly, layer by layer. You might ask your client to gently let the breath expand under your touch, releasing from the inside the same places you’re working from the outside. Work the entire length of the erectors, but be extra-sensitive over the lower floating ribs and the lumbars. Costovertebral joint technique One of the most commonly overlooked places that ribs loose mobility is at the costovertebral joints, where the ribs articulate with the spine. Deep to the erectors, the area around these key joints is filled with ligaments and small muscles, which when shortened or hard, can bind the ribs and vertebrae together into an immobile mass. Free costovertebral joints allow the ribs to change their angle in relation to the spine, lifting with inhalation, and dropping with exhalation. Since the costovertebral joints are obliquely arranged, with the rib lying anterolateral to the transverse processes of the vertebra (Image 3), these joints also allow a small amount of anterior rib movement as well; this anterior movement is an indicator of freedom at this joint. Assess this anterior mobility after you’ve the erectors with the previous technique. With your client prone, use what manual therapy teacher Art Riggs calls the “piano key” method: using either your fingers, thumbs, palm, or forearm (as in the Erector Technique, Image 2), check each rib’s anterior mobility in turn. Each rib can be palpated just lateral to the muscle mass of the erectors, or on the upper ribs, just medial to the scapula. A variation is to reach under your supine client, and with your fingertips, lift each rib from underneath.

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Once you’ve identified which costovertebral joints are restricted, position your client on his or her side, with the restricted joint on the upper side (e.g., for rightside restrictions, your client would lie on her left side). Curl your client into a tight fetal position, with hips and spine in flexion, knees to the chest, and chin tucked. This position will give you a head start by creating a bit more space between adjacent vertebral transverse processes, opening them away from the neck of the restricted rib. Using the flat section of your ulna just distal to your elbow, apply pressure (in an anterior and slightly medial direction) to the back (posterior angle) of the restricted ribs (Image 3). Usually it is most effective to approach at a low angle, almost parallel to the table. Tune the direction of your pressure until you feel the rib itself; then, lean on it, check with your client about their comfort, and wait for a release. You can invite your client to breath into his or her back, which will fill the area you’re working with and encourage the spine to move slightly posteriorly. You can monitor this slight posterior motion of the spine with your non-working hand. The key here is patience; stay comfortable in your own body so that you can sustain the pressure for several breaths, giving the ligaments around the joints time to respond. You’ll feel the rib become subtly but tangibly mobile if you wait long enough. When you’ve released the restrictions on one side, turn your client over and work the restrictions on his or her other side, so that you’re again working the upper side. Or, before your client turns over, check another dimension of that side’s rib mobility with the Bucket Handle Technique. Intercostal space technique Once you’ve addressed restrictions at the costovertebral joints, you can proceed around the rib’s shaft to check for the ribs’ cranial/caudal motion. Since the ribs articulate at their posterior and anterior ends, ribcage expansion causes their most lateral part to rise on inhalation, much like a bucket handle pivots on its fastened ends when lifted. This motion depends on the mobility not only of the costovertebral joints, but on the ability of the intercostal structures to lengthen and allow separation between the ribs. To check the ribs’ ability to separate, position yourself behind your side-lying client, facing the foot of the table. Your client should no longer be in the tight fetal position of the Costovertebral Joint Technique, but in-

Working with the ribs

Images 4 & 5: Stabilizing a rib against the lift of active inhalation allows the intercostal spaces to open like an accordion. Image 4 courtesy Advanced-Trainings.com; Image 5 courtesy Zero Gravity under GFDL.

Images 6 & 7: stabilizing a rib against the downward pull of exhalation in the reversed Intercostal Space Technique. Image 6 courtesy Advanced-Trainings.com; Image 7 courtesy Primal Pictures, used by permission.

stead, lying with the spine straight, that is, neither flexed nor extended. Use a broad open hand to check for expansion between the ribs as you direct your client to take a full breath (Image 4). When the ribs are free, youâ&#x20AC;&#x2122;ll feel each intercostal space expand on inhalation, much like the pleats of an accordion expand (Image 5) Note any rib spaces that expand less than others. Most of us have restrictions here; for example, on women, the spaces at the level of a bra-strap can become bound

together by restricted fascia, and move all together, instead of as individual bones.

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To address any restricted intercostal spaces you find, use the base of your forefinger at the edge of your hand to apply gentle caudal (inferior) pressure to the upper edge of the rib, below the restricted intercostal space (Image 6). For example, if the intercostal space between ribs four and five is restricted, apply inferior

Working with the ribs release will be clear to both your client and to you when you get it right. COSTAL ARCH/DIAPHRAGM TECHNIQUE The diaphragm is the largest rib muscle, attaching to seven of our twelve pairs of our ribs, as well as to three of the five lumbar vertebrae and to the sternum. Besides its central role in breathing, the diaphragm can be a contributor lumbar pain, particularly when there is tendency towards lumbar lordosis.

Images 8 & 9: Use gentle pressure on the rim of the costal arch to open the diaphragm and lower ribs. Because of the proximity to the liver and other organs, don’t try to work inside the costal arch without specialized training. Image 8 courtesy Advanced-Trainings.com; Image 9 courtesy Primal Pictures, used by permission.

pressure to the upper edge of rib five, thus encouraging the restricted space to opening with direct but gentle pressure. Actually, your pressure itself will not open the space, as much as your client’s breath will. Once your hands are in position, ask your client to “inhale above this place,” as you resist the tendency of the lower rib to lift with inspiration. It may take your client a few attempts to discover how to lift the ribs above your stabilizing hands. Patiently coach your client to be specific with their in-breath, “inhaling from here up.” This motion will actively separate the ribs, and open restricted intercostal spaces. Depending on your client’s tendency towards exhalation- or inhalation-fixation, sometimes it is more effective to reverse the technique, stabilizing a rib superiorly while the client actively exhales below that level (Image 7). In this version, the contraction of the abdomen and internal intercostals in forcible exhalation pulls the ribs downward. When combined with your gentle upwards pressure on the rib just above the restricted space, you can use the exhalation (instead of an inhalation) to open a restricted intercostal space. If one variation does not seem particular effective with your client’s intercostal restrictions, try the opposite approach. The

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Since the diaphragm wraps around the liver, stomach, pancreas, and spleen, its close relationship with these delicate structures makes direct manipulation of the diaphragm inadvisable without specialized in-person training. However, you can use the boney edge of the costal arch to “open up” the diaphragm in a very effective way, without ever having to endanger the delicate and fragile viscera that it surrounds. Begin by standing at your supine client’s side at the level of his or her hips. Palpate the edge of the costal arch on the opposite side of the body (Image 8). Don't attempt to dig under the edge of the costal arch where the diaphragm’s actual attachments are. Instead, stay on the boney lower (inferomedial) edge of the costal arch, using a broad, firm, but soft touch to apply gently outward (superolateral) pressure. By reaching across the body, the angle of your pressure encourages the lower ribs to widen laterally. Wait for your client’s breath, and follow the natural widening of the inhalation to open and slightly flattening the dome-shaped diaphragm. Then, when exhalation begins, gently hold the costal arch in this widened position against the pull of the diaphragm from inside. This gently stretches the diaphragm wider as you resist the narrowing of the lower ribcage with exhalation. Working the diaphragm in this way is extremely effective, while being noninvasive and comfortable. The techniques described provide a good start towards restoring lost rib mobility. You’ll also want to assess how the diaphragm, chest, shoulder, and abdomen might be inhibiting ribcage mobility. Rib pain considerations The techniques described here are effective in reducing many kinds of rib pain, including mild rib displacements or fixations. It important to keep in mind that in addition to soft tissue or articular restrictions, rib pain can accompany other issues, including these:  Bruised, cracked, or fractured ribs; or costochondritis (inflammation of the sternal cartilage, usually painful but benign) often respond best to rest and the passage of time. Once healed, these can leave behind tissue and movement restrictions that these techniques can help relieve.  Pleurisy (inflamed linings of the lung cavity) should be considered when breathing is painful. Referral to a physician is indicated when pleurisy is suspected.  Cardiac issues can also cause chest pain. In the most cautious approach, unexplained chest pain should

Working with the ribs be considered an emergency until cardiac issues can be ruled out.  Osteoporosis (a bone disease that increases the risk of fracture) initially has few signs or symptoms unless a fracture has already occurred, and is difficult to detect without screening. Both men and women can be affected. Bone density screening is recommended when three or more of these risk factors are present: being over age 65, Caucasian or Asian, female, low body weight, or a family history of osteoporosis. Play it safe and avoid excessive pressure on the ribs or spine when you suspect any risk of osteoporosis.  Boney movement, like the ribs’ movement in breathing, is often not the main focus in a soft-tissue practice. By assessing and releasing the ribs’ articulations and tissues, we broaden our effectiveness and increase the contribution we make towards our clients’ overall wellbeing.

Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the US and abroad. He is also a Certified Advanced Rolfer™ and teaches for the Rolf Institute® of Structural Integration. Til will travel to Australia in 2013 to conduct workshops on Advanced Myofascial Techniques. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page. Visit www.Advanced-Trainings.com for video of this article’s techniques, and free eLetter.

A condensed version of this article first appeared in Massage and Bodywork magazine. Images © Advanced-Trainings.com or Primal Pictures (used by permission)

Advanced Myofascial Techniques Available from www.terrarosa.com.au

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First Rib Mobilization using an Indirect Technique Marita Louw, PT Clients with cervicothoracic postural dysfunction may present with a hypomobile or elevated first rib.and hypertonic upper trapezius muscle.(1). The hypertonicity may make it difficult to mobilize the first rib and maintain mobility once mobilized. This technique combines passive muscle shortening of the upper trapezius with facilitation of the ipsilateral lower trapezius. Rationale Passively shortening a muscle decreases afferent discharge from the muscle spindle. Decreasing motorneuron firing favours lengthening or relaxation of muscles (2). Muscle imbalance patterns are well documented. Increased activity in the upper trapezius will lead to inhibition and weakness of the scapula stabilizers, especially the lower trapezius (1),(3) . Sher-

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rington's law of reciprocal innervation states that when one set of muscles is stimulated, muscles working against the activity of the first will be inhibited. Method Base on (4) (described for a right side dysfunction): 1. Client supine with arms resting at side. Therapist stands at the patient’s head, supporting patient’s neck with right hand. 2. Therapist asks the patient to “make a fist with your right hand and reach down to your right foot.” Client actively sidebends his neck and trunk to right while therapist maintains neck sidebending. As the client to actively reach down, the scapular stabilizers, including

Mobilizing the 1st Rib the lower trapezius, are activated. 3. Therapist places her left hand on top of patient’s left shoulder and resists left shoulder elevation by asking client to “Push up into my hand and hold”. Resisting elevation on the contralateral side helps the client coordinate the movement of sidebending on the ipsilateral side. Ensure shoulder is moving cephalad and not being protracted. Maintain the position. 4. The client is then asked to take a deep breath and hold the breath along with step 2 and 3. 5. Release all three actions after 6‐10 seconds. 6. Repeat sequence 2‐3 times and reassess upper trapezius tone and first rib mobility.

References 1. Janda, V: Muscles and motor control in Cervicogenic Disorders: Assessment and Management In Grant,R (ed): Physical Therapy of the Cervical and Thoracic Spine (2nd ed). Clinics in Physical Therapy, Churchill Livingstone, New York, 1994

3. Sahrman, SA: Diagnosis and treatment of Movement Impairment Syndromes, Mosby, St. Louis, 2002 4. Myofascial Release. Course notes as part of completion of Master in Health Science, Krannert School of Physical Therapy, University of Indianapolis.

Marita Louw graduated with a Bachelor’s in Science degree in Physiotherapy from the University of Stellenbosch, South Africa in 1989. She have worked in medical centres in South Africa, England and since 1993, in the USA. She completed the Kaiser Hayward Orthopedic Residency in Advanced Orthopedic Medicine in 1996 as well as earned my Master degree in Health Science in Physical Therapy from the University of Indianapolis in 1999. She has a special interest in orthopaedic manual therapy and am a Fellow of the American Academy of Orthopaedic Manual Therapists. She is currently working as a Physical Therapist in San Jose, California.

2. Deig, Denise: Positional Release Techniques Manual. 1994

The first rib (in green). Pictures courtesy of Primal Pictures, Used with permission.

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Mobilizing the First Rib Art Riggs Many new students only focus on tight muscles and have never been taught to work with the vertebrae and ribs. And yet, it is essential for the therapist to direct attention to the mobility of the osseous components of the spine in addition to the muscular and soft tissue components. Providing mobility to ribs will often enable the adjacent muscles that are in spasm to relax. This can be accomplished by focusing rotational, anterior/posterior, and other mobilizing efforts to individual vertebrae rather than larger segments of the spine. Experimenting with varying degrees of flexion/ extension and rotation when positioning the body will also aid in freeing vertebral fixations. Imagine the ribs as the keys of a piano; pay attention to the ease with which you can depress each of the “keys” with vertical pressure and how they are able to move up or down with the breath. See if you can notice areas of restriction or immobility. Sometimes neck problems are actually the result of lack of mobility in the thoracic vertebrae and the ribs. The first rib is particularly vulnerable; it may be immobile, rotated, or pulled up and compressing nerves against the clavicle. The good news is that it is fairly easy to help restore balance to the first rib. The best way to learn is to have someone who is experienced work on your first rib so that you can know what it feels like. Many workshops that cover neck work automatically teach protocols for mobilizing ribs. Almost always, rib problems are a result of immobility rather than instability. They become slightly rotated or in some other way deviate from normal position, and the tissue at their articulations becomes hard and inflexible in an attempt to prevent further deviation. Particular ribs then become “stuck.”

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Mobilizing the First Rib Palpate the first ribs with your thumbs immediately in front of the trapezius muscle. Notice if one rib is elevated more than the other, but most important, determine if one rib is more mobile than the other. Determine if a rib is rotated by feeling for a sharp edge rather than the flat surface you would expect with a normal rib position. Try to create balance in freedom of movement by applying steady pressure directly on the rib itself and waiting for tissue to soften and for a slight improvement in the mobility of the rib.

Mobilizing the 1st Rib Side-Bending Mobilization of the First Rib After determining which side needs more work, work unilaterally. Side-bend the client’s head towards the side you are working and with your thumb, gently depress the head of the rib next to the transverse process of the first thoracic vertebra. Initially, a steady pressure will be all that is required, but if you do not feel movement, try side-bending your client’s head slightly more and experiment with a slow, pulsating pressure. Do not try to force a rib into movement; work gently and slowly with small adjustments in neck rotation, flexion/ extension, and side-bending.

This is an excerpt from Deep Tissue Massage: A Visual Guide to Techniques by Art Riggs. North Atlantic Books.

Build your own Spine model Recently, Art Riggs travelled down under and taught workshops in Sydney. He proudly showed us his ‘home-made’ spine model. It is just simple: using woods, and foams, you can create your own spine model!

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Fascia as an organ of communication Robert Schleip More than twenty years ago, I was involved in a dispute between instructors of the Feldenkrais Method of somatic education and teachers of the Rolfing Method of Structural Integration. Advocates of the second group had claimed that many postural restrictions are due to pure mechanical adhesions and restrictions within the fascial network, whereas the leading figures of the first group suggested that “it's all in the brain”, i.e., that most restrictions are due to dysfunctions in sensorimotor regulation. They cited a story by Milton Trager, which deals with an old man in a hospital whose body was very stiff and rigid (Trager, 1987). But under anaesthesia his muscle tonus got lowered and he was as limber and soft as a young baby. As soon as his consciousness returned he got stiff and rigid again. Subsequently, a small ‘experiment’ was set up involving several representatives of those two schools, in which three patients undergoing orthopaedic knee. I was given a consent to do some passive joint range of motion testing with the 3 patients before and during anaesthesia. With the patient in a supine position I elevated the arms superiorly above the head and noticed the freedom of movement in this direction. With one of the patients, the elbow dropped all the way to the table above the head before the anaesthesia, and this was no different after he lost consciousness. However, with the other 2 patients I could not elevate their elbows all the way in their normal state, i.e. their elbows kept hanging somewhere in the air above the head. Five minutes later, when they had lost consciousness I again elevated their arms above the head and to my surprise, their elbows dropped all the way down to the table - no restrictions whatsoever, they just dropped! Additionally, I dorsiflexed the feet of all 3 patients. Here I could not detect any increased joint mobility during anaesthesia. (I used my subjective comparison only, without any measuring devices). I must say that I was quite shocked by the result of my tests. From my Rolfer's point of view I had expected that remaining fascial restrictions would prevent the arms dropping all the way under anaesthesia. (I was

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not surprised by the unchanged mobility of the ankle joint, since none of the 3 patients seemed to have any limitations there that would concern me as a Rolfer). Given the limited scientific rigour of this preliminary investigation, the result nevertheless convinced me that what had been perceived as mechanical tissue fixation may at least be partially due to neuromuscular regulation. The ongoing interdisciplinary dispute after this event led to a rethinking of traditional concepts of myofascial therapies, and several years later a first neurologically oriented model was published as a proposed explanatory model for the effects of myofascial manipulation (Cottingham 1985), later expanded by many others in the field (Schleip 2003) (Figure 1). The body-wide network of fascia is assumed to play an essential role in our posture and movement organization. It is frequently referred to as our organ of form. However for decades, ligaments, joint capsules, and other dense fascial tissues have been regarded as mostly inert tissues and have primarily been considered for their mechanical properties. Nonetheless, in the 1990s advances were being made in recognizing the proprioceptive nature of ligaments, which subsequently influenced the guidelines for knee and other joint injury surgeries. Similarly, the fascia has been shown to contribute to the sensorimotor regulation of postural control in standing. It is now recognized that fascial network is one of our richest sensory organs. The surface area of this network is endowed with millions of endomysial sacs and other membranous pockets with a total surface area that by far surpasses that of the skin or any other body tissues. Interestingly, compared with muscular tissue’s innervation with muscle spindles, the fascial element of it is innervated by approximately 6 times as many sensory nerves than its red muscular counterpart. Additionally even the spindle receptors in the muscles are themselves found primarily only in areas with force transfer from muscle to connective tissues. This includes many different types of sensory receptors, including the usu-

Fascia as a communication organ

Figure 1. Stimulation of mechanoreceptors leads to a lowered tonus of skeletal motor units, which are mechanically linked to the tissue under the practitioner’s hand. The involved intrafascial mechanoreceptors are most likely Ruffini endings, Pacinian corpuscles (with more rapid manipulations), some of the interstitial receptors, and possibly some intrafascial Golgi receptors. ally myelinated proprioceptive endings such as Golgi, Pacini, and Ruffini endings, but also a myriad of tiny unmyelinated 'free' nerve endings, which are found almost everywhere in fascial tissues, but particularly in periosteum, in endomysial and perimysial layers, and in visceral connective tissues. If we include these smaller fascial nerve endings in our calculation, then the amount of fascial receptors may possibly be equal or even superior to that of the retina, so far considered as the richest sensory human organ. However, for the sensorial relationship with our own body - whether it consists of pure proprioception, nociception or the more visceral interoception – fascia provides definitely our most important perceptual organ. While fascial stretch therapies and manual fascial therapies often seem to have positive effects on palpatory tissue stiffness as well as on passive joint mobility, it is still unclear which exact physiological processes may be underlying these responses. Some of the potential mechanisms may be due to dynamic changes in water content of the ground substance, to altered link proteins in the matrix, to an altered activity of fascial fibroblasts, as well as other factors. However, today an increasing number of practitioners bases their concepts to some extent on the mechanosensory nature of the fascial net and its assumed ability to respond to skilful stimulation of its various sensory receptors. The question then is: what do we really know about the sensory capacity of fascia? And what specific physiological responses can we expect to elicit in response to stimulation of various fascial receptors?

pertains to the stimuli that originate from outside the body, and interoception pertains to how one perceives the sensation related to the physiological needs of the body. Fascial tissues are important for our sense of proprioception (Van der Wal, 2012). While, in the past, much emphasis was placed on joint receptors (being located in joint capsules and associated ligaments), more recent investigations indicate that more superficially placed mechanoreceptors, particularly in the transitional area between the fascia profunda and the fascia superficialis, seem to be endowed with an exceptionally rich density of proprioceptive nerve endings. Fascia as a network extends throughout the whole body and numerous muscular expansions maintain it in a basal tension. Thus, it was hypothesized that during a muscular contraction these expansions could also transmit the effect of the stretch to a specific area of the fascia, stimulating the proprioceptors in that area (Stecco et al., 2007). While this may be relevant for the practice (and often profound beneficial effects) of skin taping in sports medicine -as well as for other therapeutic fields - further research is necessary to clarify how stimulation of this superficial fascial layer influences proprioceptive regulation in healthy as well as pathological conditions.

Fascia has important roles in proprioception, interoception, and nociception. Proprioception is the kinaesthetic sense that enables us to sense the relative position of the parts of the body, posture, balance, and motion. It is usually distinguished from exteroception with

A newly rediscovered field is fascial interoception, which relates to mostly subconscious signalling from free nerve endings in the body’s viscera - as well as other tissues - informing the brain about the physiological state of the body and relates it to our need for maintaining homeostasis (Schleip and Jäger, 2012). While sensations from proprioceptive receptors are usually projected via their somatomotor cortex, signalling from interoceptive endings is processed via the insula region in the brain, and is usually associated with an emotional or motivational component. This field also promises interesting implications for the un-

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Fascia as a communication organ

derstanding and treatment of disorders with a somatoemotional component, such as irritable bowel syndrome or essential hypertension. The sensory nature of fascia includes also its potential for nociception (nociception is the ability to feel pain, caused by stimulation of a nociceptor). Researchers from Heidelberg University (Hoheisel et al., 2012) have conducted research about the nociceptive potential of the lumbar fascia. Their choice of investigating the lumbar fascia is not accidental. While some cases of lower back pain are definitely caused by deformations of spinal discs, several large magnetic resonance imaging studies clearly revealed that for the majority of lower back pain cases the origin may be elsewhere in the body, as the discal alterations are often purely incidental. Based on this background, a new hypothetical explanation model for lower back pain was proposed by Panjabi (2006) and subsequently elaborated on by others (Langevin & Sherman 2007; Schleip et al. 2007). According to these authors, microinjuries in lumbar connective tissues may lead to nociceptive signalling and further downstream effects associated with lower back pain. The new findings from the Heidelberg group showed the nociceptive potential of the lumbar fascia; in patients with nonspecific lower back pain their fascial tissue maybe a more important pain source than the lower back muscles or other soft tissues. The findings have potentially huge implications for the diagnosis and treatment of lower back pain. As this is a newly emerging field, their research will definitely trigger further research investigations into this important field within modern health care. These exciting new topics from research might lead to new insights to clinical applications. They are fully discussed in the book Fascia: The Tensional Network of the Human Body. The Science and Clinical Applications in Manual and Movement Therapy. Edited By Robert Schleip, Thomas W. Findley, Leon Chaitow, Peter A. Huijing. See http://www.tensionalnetwork.com/ for more information.

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References Cottingham JT 1985 Healing through Touch â&#x20AC;&#x201C; A History and a Review of the Physiological Evidence. Rolf Institute Publications, Boulder CO. Hoheisel, U., Taguchi, T., Mense, S., 2012. Nociception: The thoracolumbar fascia as a sensory organ. In: Fascia: The Tensional Network of the Human Body. (Eds: Schleip, Findley, Chaitow, and Huijing), pp. 95 -101. Churchill Livingstone. Langevin, H.M., Sherman, K.J., 2007. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med. Hypotheses 68, 74-80. Panjabi, M.M., 2006. A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur. Spine J. 15, 668-767. Schleip, R., 2003. Fascia1 plasticity-a new neurobiological explanation. Part 1. J. Bodyw. Mov. Ther. 7, 11-19. Schleip, R., Vleeming, A., Lehmann-Horn, F., Klingler, W., 2007. Letter to the Editor concerning "A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction" (M. Panjabi). Eur. Spin. J . 16, 1733-1735. Schleip, R., Jager, H., 2012. Interoception: A new correlate for intricate connections between fascial receptors, emotion and self recognition. In: Fascia: The Tensional Network of the Human Body. (Eds: Schleip, Findley, Chaitow, and Huijing), pp. 89-94. Churchill Livingstone. Stecco, C., Gagey, O., Belloni, A., Pozzuoli, A., Porzionato, A., Macchi, V., Aldegheri, R., De Caro, R., Delmas, V., 2007. Anatomy of the deep fascia of the upper limb. Second part: study of innervation. Morphologie 91, 38-43. Trager, M., Guadagno-Hammond, C., Turnley Walker, T., 1987. Trager mentastics: movement as a way to agelessness. Station Hill Press, Barrytown. Van Der Wal J.C., 2012. Proprioception. In: Fascia: The Tensional Network of the Human Body. (Eds: Schleip, Findley, Chaitow, and Huijing), pp.81-87. Churchill Livingstone.

Robert Schleip PhD, is an International Rolfing Instructor and Fascial Anatomy Teacher. Robert has been an enthusiastic certified Rolfer since 1978. He holds on M.A. degree in psychology and is a Certified Feldenkrais Teacher since 1988. He earned his Ph.D. with honours in 2006 and shortly thereafter established the Fascia Research Project at Ulm University and has a lab of his own. He was coinitiator and organizer of the first Fascia Research Congress at the Harvard Medical School in Boston, USA in 2007.

10 Steps towards

Fascial Fitness Turning Exercise Upside Down

Sol Petersen There is a change of view in personal training methods for elite athletes based around new research concerning the fascia and connective tissues that are an intimate and integral part of what we usually consider to be the ‘muscles’. The new fascial research is emphasizing posture, awareness, elasticity, diet and gives us some insight into explaining why barefoot Olympic runners had less shin splints than runners in conventional protective shoes. What if ‘Everything you know about muscles is wrong’? This is the provocative title of an article that can be seen on www.menshealth.com. The Men’s Health article is based on a workshop for athletes by Tom Myers, author of Anatomy Trains. Says James Ready, the trainer for the Arizona Diamondbacks baseball team, who has begun employing Myers's fascial approach. "These days, our big emphasis with weights is about posture, not big plates," Ready says. He has also reassessed the way he diagnoses injuries. "I've had to step back and take a deeper look at everything I learned in school. We were taught to find the point of pain and treat it. But take hamstring injuries; the hamstring is usually just the smoke. You have to look elsewhere for the fire." Exercise often is very ‘muscle oriented’ yet most musculo-skeletal injuries are related to the connective tissues and fascia. Each muscle fiber, bundle and group of bundles is encased in a tube of fascia, as well as each nerve, bone and organ. In fact the fascia and connective tissues are the global connecting matrix for the whole body. If we watch children jumping, bouncing, skipping we are observing the elastic recoil of the connective tissue much more than the work of the ‘muscles’. In the new fascial approach there is a great emphasis on develop-

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ing elasticity. The use of elastic recoil was the secret of how Bruce Lee’s one inch punch could send a man flying. Dr. Robert Schleip is at the forefront of applying fascial research in the clinical and fitness areas. Here are his 10 steps to building a better fascial body.

Ten Steps to Building Better Fascial Fitness ONE ~ Emphasize the engagement of long myofascial chains rather than of single joints/muscles. This means less stretching and exercising of individual muscle groups and more attention to bodywide functional myofascial chains. TWO ~ Direct stretch loading, with many directional variations, with a preference for careful loading around the end range of available motion. This means less repetition of exactly the same vectorial loading directions and stretch loading with both multiple variations of loading as well as relaxed muscle participation. THREE ~ Use the elastic rebound energy and emphasize the energy storage of fascia, the ‘cat-like catapult

Fascial Fitness This quality of body listening, of body-mindfulness is also a key dynamic in developing the appropriate fitness in your whole body and being tissue rehydration and viscoelastic recovery. Runners training for a marathon will have fewer injuries if they run at different speeds and include brief walking periods rather than running for 30 minutes or more at the same speed. SEVEN ~ Appreciate your unique constitutional difference yet challenge your fascial body to create a stronger resilience. Fascial properties are partly genetic. A ‘Viking’ body type is good for stability and an arctic climate while an ‘Indian temple dancer’ body type tens to be more flexible in a tropical climate. So instead of the Yoga and stretching classes being filled with hypermobile women, these women may need to play with weights and dynamic stability loading. On the other hand, the Obelix-type men in the weight-lifting room will probably need to include some leg swings, stretches and kicks.

Energizing Anterior Myofascial Chains with Qi Gong.

action’ rather than muscular effort. This means the way of the ninja, less rope-like abrupt direction changes and more direction changes with elastic deceleration and acceleration. Equal emphasis on the preparatory ‘counter movement’ as on the main functional movement. FOUR ~ Recognize the importance of the Preparatory Counter Movement. The body’s preparation to achieve any powerful action usually begins with a dynamic prestretch. The pre-movement, the set-up, is crucial for the archer, the fast bowler, the golfer, for anyone involved in athletics or fitness. To go forward we go back first. FIVE ~ Body-Mindfulness is the key for an accurate use of the body’s dynamics. The ‘No pain no gain’ attitude can push us beyond true limits to injury. In a Fascial Fitness approach, the cultivation of a sensuous body perception with a high level of kinesthetic acuity is required - such as in the correct practice of Pilates, Yoga and Tai Chi. SIX ~ Re-hydrate your tissues during training. We do this with an inclusion of appropriate resting times for

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EIGHT ~ Train with care and be cautious when you experiment with rebound energy. Inclusion of fascial rebound and long myofascial chains often triggers an exhilarating sense of playfulness, of fun and adventure orientation. However, if untamed, this also leads to more frequent injuries than standard muscle training with monotonous repetitions. Start with lower loads than usual. Increase the load the following week only if a sense of elegance can be maintained (particularly during the elastic rebound phase). So reduce exercising with an abrupt /jerky movement quality and work with loads that allow smooth and elegant direction changes. NINE ~ Gentle perseverance and patience is the key in fascial training. Be patient; take the long view with gentle perseverance. Because of collagen’s slow renewal cycle (the half life of collagen is approximately 1 year), after 2 months of training the fascia, we may have very little to show, but then we may have a high return after 6 months or a year. This has real implications after injuries where we will not be looking for instant results but will anticipate training the fascia and connective tissue with a long term progress orientation - over 6 to 24 months, much like the slow progress in training for yoga or martial arts. It has been shown that boot camplike short intense training programmes often propagate compartment syndromes & fascial inflammation. TEN ~ Let’s get the fuel right for fitness and enduring energy. We don’t put the wrong fuel in our car so let’s take care to cleanse the body system and give ourselves the right fuel. This means a well-hydrated body that is not too acidic or too alkaline. It is important to respect

Fascial Fitness Developing New Methods From Ancient Wisdom In conclusion, we are now finally beginning to appreciate the complex role of the connective tissues and the neuro-myofascial body stocking in our approaches to exercise and fitness. The ancient Qi Gong and Tai Chi practices are well known for emphasizing elastic recoil and whole body integrated strength in their approaches to health and wellness. Watch animals â&#x20AC;&#x201C; they are great teachers. These 10 steps to Fascial Fitness should act as an important reminder in our self-care and empower our physical body to its resilient best. Now, back to barefoot runners; it appears that these runners strike the ground more gently with more of the forefoot than runners in conventional running shoes. This obviously reduces the stress transmitted to the fascial and skeletal framework. Try going for an extended run barefoot on soft grass and compare your whole body experience with doing the same in training shoes. This quality of body listening, of bodymindfulness is also a key dynamic in developing the appropriate fitness in your whole body and being.

Fascial Fitness Resources

our physiology. The bodyâ&#x20AC;&#x2122;s acid/alkaline balance, hormonal influences, chronic inflammation, poor hydration, weak lymph or blood flow all have a strong affect on the fascia and connective tissues and this affects our fitness. Scurvy caused massive connective tissue damage to sailors who had long periods without fresh fruit. This vitamin C deficiency in the fascia was cured by bringing citrus fruit on board, It has been suggested that the hunter/ gatherer active life style and lighter nutrition support our fascia and muscles better than a sedentary life style cultivating stress hormones and chronic inflammation on a heavy red meat diet with saturated fats and refined sugar products.

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You can find out more about fascia and the innovative research and Fascial Fitness programmes developed by Dr. Schleip on www.somatics.de, www.fasciafitness.de or www.anatomytrains.com Fascial Fitness course is coming to New Zealand and Australia in January 2013 with Divo Muller and Dr. Robert Schleip. Sol Petersen is a Structural Integration and Fascial Fitness trainer with over 30 years experience. As a Body Psychotherapist, Adaptive Physical Education teacher and Tai Ji teacher, he specializes in applying Hakomi Mindfulnessbased Psychotherapy to Manual, Movement and Aquatic Therapy. Co-founder of Mana Retreat Centre in New Zealand, his passion is the development of a truly integrative approach to the education and healing of body, mind and spirit.

Based on the Latest Research in Fascia, A new approach to train your fascial web. Conventional training has been emphasizing on muscles, cardiovascular fitness and coordination. However, most of the sports injuries occur in the connective tissues. Fascial Fitness will show you how to train the connective tissues, to prevent and repair damage, and to build elasticity and resilience into the body. This workshop is the only training program for the development of supple, flexible and strong connective tissue! Learn the latest findings in Fascia Research and put it into practice. Fascial Fitness complements conventional sports training with recommendations for specific loading exercises, dynamic stretching as well as 'bouncing' movements that utilise and strengthen the elastic recoil inherent in collagenous tissues.

Introductory Course Auckland, NZ: January 4 and 5 2013 with Dr. Robert Schleip & Divo Muller To register email solpetersen@xtra.co.nz with contact details. www.theradiantbody.com Sydney: January 15 and 16 2013 with Divo Muller and tele-conference with Dr. Robert Schleip Accredited for full AMT CEU Points! Venue: The Coronation (Subud) Hall, 95 Lennox St, Newtown. Register at www.terrarosa.com.au

Advanced Certification Course Auckland, NZ: January 4 and 5 2013 with Dr. Robert Schleip & Divo Muller To register email solpetersen@xtra.co.nz with contact details. www.theradiantbody.com

If the 'fascial' body is well trained â&#x20AC;&#x201C; optimally elastic and resilient â&#x20AC;&#x201C; it can be relied on to perform effectively, to allow peak performance, to foster the coordination of supple, elegant movement and to offer a higher potential for injury prevention.

About the Instructors Divo Muller is one of the first internationally authorized Continuum teachers in Europe since 1992. She is a Somatic Experience practitioner, author of a book, numerous articles and DVDs, which teaches a specially designed movement approach for women, based on Continuum. Divo teaches regularly all over Europe as well as in Brazil and in New Zealand. She offers a unique movement program in her Studio Bodybliss in Munich. She is one of the original developer of Fascial Fitness program. Robert Schleip PhD is an International Rolfing Instructor and Fascial Anatomy Teacher. Robert has been an enthusiastic certified Rolfer since 1978. He holds on M.A. degree in psychology and is a Certified Feldenkrais Teacher since 1988. He earned his Ph.D. with honours in 2006 at the age of 52, and shortly thereafter established the Fascia Research Project at Ulm University and has a lab of his own. He was co-initiator and organizer of the first Fascia Research Congress at the Harvard Medical School in Boston, USA in 2007.

Research on

Cupping Romy Lauche History Cupping therapy is probably one of the earliest medical techniques used by mankind. First evidence of its use dates back to 3300 BC. Nowadays cupping is mainly used in Asia and in Arab societies; its use in Europe is very limited. But practitioners and researchers show growing interest in this technique, as recently published studies suggest. This article presents some of the current research that has been conducted in Europe. Clinical trials Several trials have been conducted in Germany in the past couple of years. There was one study (L端dtke et al., 2006) that investigated the effect of traditional cupping on nocturnal burning pain (German: Brachialgia paraesthetica nocturna). This disease is characterized by feelings of pain, formication, paraesthesia and numbness of the hands. The symptoms mainly occur at night and can be released by massaging and bathing in warm water. Nocturnal burning pain is often assumed to be a pre-stage of the carpal tunnel syndrome. In this study patients were randomly assigned to traditional cupping or a wait list control group. The patients in the cupping group received one cupping at the trapezius only, while both groups also received standard care in form of analgesics, physical therapy and psychological interventions. The post-intervention observation period was 1 week, the main complaints pain, formication and paraesthesia were assessed using a 100mm visual analogue scale each (0-no complaint, 100-worst imaginable complaint). After 7 days, the patients in the cupping group reported significantly less complaints compared to the control group, formication and paraesthesia were the complaints with the largest im-

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provements. In another trial from our department (Dept. of Complementary and Integrative Medicine in Essen, Germany) Michalsen et al. (2009) applied traditional cupping in a trial on the treatment of carpal tunnel syndrome, an entrapment syndrome of the median nerve, which is characterised by numbness, tingling, burning, and pain in at least 2 of the 3 digits supplied by the median nerve (i.e., thumb, index finger, or middle finger). Patients received traditional cupping or a local application of heat and 7 days after the treatment, outcomes were assessed. Analysis not only showed significant improvements in the carpal tunnel syndrome score, but also in neck pain, functional disability and physical quality of life. In 2008 we started several trials on cupping for chronic nonspecific neck pain. This form of neck pain is the most common and it reflects mainly poor microcirculation, increased muscle tension and postural problems rather than inflammatory, traumatic or degenerative causes. We investigated the efficacy of dry cupping*

Cupping Different types of Cupping

 Dry Cupping uses double-walled glass cups inverted over an open flame to heat the air inside, after which each glass is placed on an afflicted area. As the air inside the cups cools, vacuums are created, drawing up the skin within each cup. The treatment lasted about 10-15 minutes and after removing of the cup, a cupping mark may be visible. This cupping mark is extravasated blood, i.e. blood drawn from the capillaries into the sub-skin; it will disappear within several days. Traditionally, flame was used to draw air out of the cup, but modern implement now used a mechanical device or a rubber ball to draw air out of the cup to create a vacuum.

 In Traditional Cupping, the skin is superficially incised before applying the cups, which sucks blood out through the incisions. After some minutes, the bleeding will stop. Traditional cupping is mainly used in conditions that show signs of overabundance, e.g. in inflammation, swelling etc.

 In Cupping Massage, the area to be treated is first covered with massage oil. The cup is placed on the skin and a rubber ball at the end of the glass is used to press the air out of the cup, so that negative pressure attaches it to the skin. The glass is held at the base and gently moved over the area to be treated, usually over muscles. The skin reddens and petechial may appear which will fade away after several days.

 Pulsating Cupping can be applied using a mechanical device such as the Pneumatron® 200S (Pneumed GmbH, IdarOberstein, Germany), which generates pulsating suction to glass or silicone cups. Reduction of pressure and atmospheric pressure itself are alternated by a defined frequency leading to an oscillation of skin and subdermal tissues. Cups can be applied stationary or can be moved (with the help of massage oil!) like in cupping massage, the treatment lasts about 10- 15 minutes.

(Lauche et al., 2011), pulsating cupping (Cramer et al., 2011), traditional cupping (Lauche et al., 2012a) and cupping massage (Schumann et al., 2012). The studies were all randomized and they all applied a comparable wait list control group design. Except for traditional cupping, all therapies were utilized 5 times with 2 treatments each week. In the trial of traditional cupping, a single treatment was utilized. Before and 4 days after treatment the outcome measures pain, functional disability and quality of life were assessed. Fifty patients were included in each trial. They had been screened by the study physician to make sure that the right cupping method was chosen for each patient. For example, in traditional cupping, the patient had to show signs of overabundance or so called plethora. This refers to symptoms such as a voluminous gelosis of the subskin, which indicates local blood congestion, swelling and connective tissue adhesions in the neck region. On the other hand patients with blank myogelosis, i.e. hyperirritable muscle areas associated with small palpable nodules in taut bands of muscle fibers together with decreased microcirculation, were included in the studies of dry or pulsating cupping.

i.e. the amount of reduction was meaningful. Despite some minor adverse events, the cupping treatment proved to be a safe therapy.

Trial on traditional cupping and its influence on the body image In the study of traditional cupping we also investigated the body image before and after therapy (Lauche et al., 2012b). In this context, body image was defined as the perception of the contours of the body. In order to gather data on the body image we used drawings and qualitative interviews. Body image drawings were adapted from the work by Lorimer Moseley (2008) who had investigated body image in back pain patients and found distortions in those patients. We used a line drawing of the posterior lower and upper back, but with only parts of the body drawn in. The area from the shoulders to the neck was left blank and patients were asked to fill in the contours as they felt them. A previous imagination exercise was used to facilitate the drawing.

After cupping, patients in the treatment groups reported less pain, less impairment and increased aspects of quality of life. The pain reductions were not only statistically significant but they were clinically relevant,

After the second drawing at the end of the study patients also participated in an interview about the drawings and their body image and perceived changes after cupping. This way it was made sure that patients gave

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Cupping was the moment when some of the patients realized how focused they were on the pain. Altogether this study indicated that pain and body image distortions were also present in patients with chronic neck pain and that cupping might actually reduce pain and influence the body image.

Figure 1: Body image drawing before (left side) and after cupping therapy (right side). The patient reported “My body has shrunk”, which showed in the drawing.

their own pictures meaning instead of a speculative interpretation by a third party. All patients in the RCT delivered the drawings and six of the patients were included in the qualitative interview study. Figure 1 displays some drawings from one patient before and after cupping therapy. This drawing actually was the inspiration for the following interviews, because the patient reported, that not only had the pain vanished completely, but also had her body shrunk after cupping. The second drawing actually represented improvement in the eyes of the patient, although it did not look like it.

However there is always the discussion about cupping being just placebo and we most certainly do need more placebo controlled clinical trials to be able to distinguish between specific effects and placebo. Lee et al. (2010) have already developed a sham cupping device, which uses a small hole in the glass, so that the vacuum can diminish after attaching the cup to the skin. The cup itself is held by adhesives. We currently are using this paradigm in a clinical study on fibromyalgia with mainly cupping naïve patients and results may provide information if patients believed they got the real treatment. In patients who are very familiar with cupping the use of a placebo might be more challenging.

Summary Cupping, despite its age (and controversy), seems to be a very effective treatment for a variety of diseases. It might also have the potential to prove effective for body image distortions related to chronic pain conditions. As always, more research – clinical and basic research – will be necessary in order to fully understand its mechanisms and clinical value.

Other drawings before therapy showed distortions of the neck area, some contours were missing, others were very prominent. In most drawings we found images that did not fit the normal body physique with elevated shoulders or shoulders with areal edge. In the end we failed to identify certain patterns within the drawings.

References

The interviews revealed several topics relevant for the body image. It became clear that the neck, being tense, a burden or heavy like an anvil, and the pain hindered patients to sense non-painful parts of the body. All the attention was drawn to the pain in the neck and the neck felt wrong in terms of its contours. After cupping the tension was relieved and patients felt as if their neck was smaller, their shoulders had rounder edges and the burden was lifted. Some drawings represented that change as figuratively as the drawing in figure 1.

Lauche R, Cramer H, Choi K, Rampp T, Saha Fj, Dobos Gj, Musial F. The influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain - a randomised controlled pilot study. BMC Complementary and Alternative Medicine, 2011, 11:63.

Interestingly not only did cupping affect the body image, but also did the drawing and the interview. Patients were “forced” to draw their attention to their body, the painful area and also the “blind spots”. That

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Cramer H, Lauche R, Hohmann C, Choi K, Rampp T, Musial F, Langhorst J, Dobos Gj. Randomized controlled trial of pulsating cupping (pneumatic pulsation therapy) for chronic neck pain. Forschende Komplementärmedizin, 2011; 18 (6):327-34.

Lauche R, Cramer H, Haller H, Langhorst J, Musial F, Dobos Gj, Berger B. “My Back Has Shrunk” – The influence of traditional cupping on body image in patients with chronic neck pain. Forsch Komplementmed, 2012b, 19(2): 68-74. Lauche R, Cramer H, Hohmann C, Choi K, Rampp T, Saha Fj, Musial F, Langhorst J, Dobos Gj. The effect of traditional

Cupping cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: A randomised controlled pilot study. Evidence-Based Complementary and Alternative Medicine 2012a, Vol. 2012, Article Id 429718, 10 Pages. Lee MS, Kim JI, Kong JC, Lee DH, Shin BC. Developing and validating a sham cupping device. Acupunct Med. 2010;28:200-204. Lüdtke R, Albrecht U, Stange R, Uehleke B: Brachialgia Paraesthetica Nocturna can be relieved by "Wet Cupping" – Results of a randomised pilot study. Complement Ther Med 2006;14:247–253. Michalsen A, Bock S, Ludtke R, Rampp T, Baecker M, Bachmann J, Langhorst J, Musial F, Dobos Gj: Effects of traditional cupping therapy in patients with carpal tunnel syndrome: A randomized controlled trial. J Pain 2009;10:601– 608. Moseley Gl: I Can’'t Find It! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain 2008;140:239–243.

Romy Lauche studied psychology with a focus on neurophysiology and research methods at the University of Jena, Germany. Her PhD thesis studied the influence of cupping therapy on chronic neck pain. Romy is now working as a researcher at the Department for Complementary and Integrative Medicine in Essen, Germany. Her main interests are complementary and integrative medicine in general (traditional medicine, manipulative therapies) and mind/body techniques in particular (mindfulness, meditation, qigong, yoga) for the treatment of chronic conditions. During her PhD study, Romy has also become certified mindfulness instructor and acquired knowledge in fMRI research. She recently published a study evaluating the effectiveness of another traditional East Asian Gua Sha treatment on neck and low back Pain.

Schumann S, Lauche R, Irmisch G, Hohmann C, Rolke R, Saha F, Cramer H, Choi Ke, Langhorst J, Rampp T, Dobos G, Musial F. The effects of 5 sessions of cupping massage on chronic non-specific neck pain: A randomized controlled pilot study. BMC Complementary and Alternative Medicine, 2012, 12 (Supplement 1), 80.

World Record in Massage Thailand recently broke the Guiness World Record in mass massage. 641 masseurs in Thailand, who massaged 641 people simultaneously for 12 minutes on August 30, 2012., smashed the previous Guinness World Record of 263 people being massaged in Daylesford, Victoria, in March 2010. The event took place in the Thailand Medical Hub Expo 2012 , at the Impact Mueangthong Arena in Bangkok. The event was organized by the Ministry of Public Health to promote the Southeast Asian nation's massage and spa industry.

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Massage tools Contributions by:  Rick Goggins, coauthor of ‘Save Your Hands’

and massage educator, US.  Richard Gold, author of ‘Thai Massage’, and

massage instructor, US.  Robert Granter, massage therapist and in-

structor, Australia.  Joe Muscolino, the Art and Science of Kinesiol-

ogy, USA.  Greg Polins, inventor of Thumbsavers, US.  Thomas Zudrell, inventor of Spynamics, and

instructor of the Dorn Method, Germany. An Irish bodyworker once said that Aussie therapists are very fond of tools. Not sure how true it is, but certainly some therapists like to use tools in massage and bodywork. Tools can help and enhance the therapeutic effects of a treatment, and tools can also help therapists preventing them from fatigue and injury. The highest risk for a massage therapist is mainly wrist, fingers, and thumbs injuries. A survey conducted by Terra Rosa a few of years ago indicated that 60% of the surveyed massage therapists in Australia have a prevalent to wrist and thumb injuries. According to Greg Polins, the inventor of Thumbsavers, thumb is the most commonly (mis-)used body parts in massage. While Deep Tissue Massage and trigger points therapy can attract new clients and help a business grow, overuse of the thumb joint can have a catastrophic outcome. “If you are performing six to eight deep tissue sessions a day, five to six days a week, your hands are going to hurt. It's simple physics. You can lower or raise your table, but at that eighth hour of deep-tissue work on your sixth day, your hands just hurt. When pain begins to interfere with work, a therapist might incorporate hand stretching, exercises, and yoga into his/her daily routine hoping to prevent further injury and increase strength. If

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this is not working, at the next step the therapist will decrease a stressful modality and start doing craniosacral therapy or energy work. Should these strategies fail to resolve pain issues, rather than looking for a new, less painful job, a therapist might want to consider using one or more tools.” Thomas Zudrell, the inventor of Spynamics, says “Tools in massage and bodywork can make work easier for the therapist, often faster and sometime even more effective. The use of tools can leave a professional impression on the client as they encounter this all the time in conventional medicine”. According to Richard Gold “Tools can help preserve the practitioner’s body by lessening stress and strain, it provides an additional ‘set of hands’.” Therapists usually resort to tools that enabled them to apply pressure without pain. Massage tools come in different shape and form. Broadly speaking, there are hand tools, tools that can be used to help to decompress certain part of the joint or muscles, tools that apply heat or cold, vacuum cupping, and tools that send out vibration, radiation. And here are just some of them. Hand Tools A variety of hand tools have been developed to help massage therapists, which include tools for trigger point work, muscle stripping, cross-fibre friction, or similar techniques that require deep, sustained or repetitive pressure. Greg Polins, invented Thumbsavers from his daily experience as a massage therapist. In his eighth year of professional therapeutic massage, heI began to experience crippling pain in my thumbs and wrists from the extensive deep tissue massage. “My thumbs were so fatigued from a full day of massage that I was forced to ‘ice’ them every night. At one point the pain was so intense that it was difficult to hold a pen and write!! My thumbs looked like big toes. Fellow therapists were

Massage tools either finding other modalities or abandoning their careers. Others would say ‘use your elbows more’...ever use your elbow for TMJ? I needed a solution and fast I had too much time and energy invested in my training.” After considerable experimentation and countless prototypes, Greg developed an affordable massage tool that assists therapists by providing support Thumbsavers and reducing the stress on your hands and wrists from deeper tissue massages, while protecting your most valuable commodity... your hands! Because Thumbsavers is “worn” over the thumb, it provides a greater sense of dexterity for the user. Since it is smooth in texture, semi flexible and latex-free, it feels natural for both the therapist and the receiving client. Its design helps the therapist to use ‘proper hand mechanics’ when performing massage, thus reducing the chance for fatigue, pain and injury. Greg added that “I felt such an immediate result from using it that I decided to bring it into production (sounds simple but isn't) and share it with fellow therapists. All I needed was money to get started, so I sold everything that I owned except essential clothes and my massage table. I was starting from zero once again but I believed in my invention and my hands felt good again. Since Thumbsavers massage tools were first introduced to the professional massage therapy industry in 2004 the response has been overwhelming. Awarded a Patent (7252645) its popularity has spread around the world in both professional massage therapy practices and massage therapy schools and institutions. Greg said that he is deeply gratified knowing that Thumbsavers massage tools has helped so many therapists to continue with the careers that they have invested so much time, education selflessness.

A massage stick can help in pressing the appropriate reflex point in foot reflexology.

therapists, using a brace that supports the IP and MCP joints can make the difference between being able to successfully practice of not. I have not seen it, but it would be the best of both worlds if someone would come out with a thumb brace that supports the IP and MCP joints, but is open at the tip/pad of the thumb so that the therapist can still palpate and feel the response of the client's tissues as the pressure is being exerted.” There are also various tools that can be used for trigger point therapy including some ‘knobber’, and various forms of sticks. Tools with narrow tips (such as massage stick) can be used to get into tight spaces where fingers are too large (e.g. a massage stick can be used in reflexology). A variety of hand tools is used in the TCM technique of Gua Sha, where a smooth edge tool is stroked with pressure repeatedly over lubricated skin. The tools can range from a ceramic Chinese soup spoon, a coin, a metal cap with a rounded edge, honed animal bones, or a jade. This technique is also used in Indonesia, known as ‘kerokan’ (meaning scraping), a form of Javanese folk therapy.

Author and teacher, Joe Muscolino, said that “I am not normally a lover of tools for performing massage because any contact other than the skin of our hand (or forearm/elbow) will not deliver the sensitivity needed for palpation assessment that is so important toward being an excellent therapist. However, there are times when tools can be very helpful; especially thumb braces for therapists who have hyperextendable interphalangeal (IP) joints (and perhaps unstable metacarpophalangeal joints, MCP) in their thumbs. For these

A modern implementation of this technique is called the Graston technique where a collection of six stainless steel tools of particular shape and size are used, dependent on the area of the body and the outcome required. These techniques assist in soft-tissue mobilization, to break down excessively immobile scar tissue and connective tissue restrictions. Graston technique uses a collection of six stainless steel tools of particular shape and size. It is used to mechanically mobilize scar tissue, increasing its pliability and loosening it from surrounding healthy tissue. Graston technique was designed as an instrument assisted transverse friction massage popularised by James Cyriax, which was based on the theory of creating a traumatic hyperaemia and the prevention of adhesion formation.

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Massage tools Real Ease

Spynamics S.O.S.

Still point inducer

Decompression and traction tools There are also tools that help muscles and joints in particular region to relax, or provide traction: such as sacral decompression, and subocciptal decompression Spynamics Sacro Aligner was invented by Thomas Zudrell, with the intention to empower his clients with self help and self therapy to allow their body to do the necessary healing and adjustment reactions after therapy sessions. If these self therapy exercises are done with enough self discipline, clients often recover fast and have long lasting results. However this simple motivation has been a big challenge as clients often came back with various reasons explaining why they did not do their ‘homework’. So Thomas decided that he needed something that worked, safe to use, easy to understand, affordable and does not require too much time. This was the birth of the Spynamics Sacro Aligner. It started with an idea and developed into a great self help tool that even achieved a Gold medal recognition in the world’s oldest fair for inventions iENA (International Trade Fair) in Nuremberg in 2008. The patented design follows the natural shape of the human sacrum and lumbar vertebrae and when used properly can help to regain improved lumbopelvic alignment, muscle relaxation and improved nerve function. It encourages and improves sacroiliac joint alignment by bringing the sacral base back into the ilia to decrease the strain on the sacroiliac ligaments. Using own body weight while laying on the Spynamics Sacro Aligner together with simple dynamic movements, the structural system is guided into better alignment due to the natural mechanism of a myoneuro-structural rebalancing. A still-point inducer is a tool that helps to relax by resting your head on it. It induces ‘Still Point’ (a term given to the gradual stopping of the craniosacral rhythm, and is an indication that the body is making therapeutic changes). There is a commercial device available from the Upledger institute, or you can make it yourself from

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A cryocup® is an excellent way to apply cold therapy. Photo used with permission from Lippincott Williams & Wilkins. Promotional and/or commercial use of this picture in either print, digital or mobile device format is prohibited without permission from Lippincott Williams & Wilkins.

handballs. Take two soft handballs the size of tennis balls and a sock (tennis balls can be used, but it is quite hard and needs lots of padding). Place the two balls in the sock touching each other and tie the end of the sock. To use, lie on your back on a hard surface, place the balls at the base of your skull (in line with the bottom of your ears, as viewed from the side). Allow the weight of your head to rest on the balls, and relax for 10 minutes. Heat or Cold therapy According to Joe Muscolino, the use of heat therapy can be extremely beneficial to manual therapy. Joe believes that heat used in conjunction with soft tissue manipulation and stretching, as well as joint mobilization, allows for extremely effective clinical orthopedic work. Heat promotes general softening of myofascial tissues as well as relaxation of musculature, allowing the other therapies to that much more effective. Joe added that given how easy it is to buy a hydroccolator (liquid heating) device and place a hydrocollator pack on one area of the client's body while working another, employing heat therapy should be a staple of all therapists who do orthopaedic/ remedial massage. Cold therapy or cryotherapy usually involves the use of ice or ice packs. Ice is an anti-inflammatory that decreases swelling because it causes vasoconstriction of local arteries; and it is an analgesic that decreases pain because it can numb pain receptors in the region of application. We see cryotherapy is commonly used in a variety of sports: athletes with bags of ice on various parts of their body after competition, or a more extreme version is jumping into an ice bath. By lessening the sensitivity, the client will likely allow deeper pres-

Massage tools

Kinesio Tape is made popular in recent London Olympics by athletics.

Vacuum cupping.

sure to be used. Ice can also be used after deep tissue work to decrease swelling that might already have been present, or to prevent swelling from occurring that might result from the deep pressure. Cryotherapy can be applied using a commercial Cryocup, or using a home-made paper or Styrofoam cup. Fill a paper/foam cup with water but leave some room for water expansion and place it in a freezer. To use, peel off part of the paper to expose the ice, hold the cup and place and gently massage the ice on the required area.

Vacuum cupping

Taping There are mainly 3 types of tape: athletic tape, strapping tape, and Kinesio Tape. Athletic tape is mainly used for acute injury treatment or injury prevention during sport activities. It is inelastic, therefore restricts some movement. It is applied before a sport activity and removed afterward. Strapping tape restricts some movement, and can help correct poor posture and limits painful movement. Strap tape has only an elasticity of 30%, and is useful for creating ‘bracing’ support to a specific part of the body. Meanwhile Kinesio (or elastic therapeutic) tape or K tape has an elasticity up to 140% of its original length. It allows full movement and aids lymphatic flow. The tape is applied with the affected muscle in a stretched position, from the origin of the muscle to the insertion point. There are some theoretical benefits, include correcting the alignment of weak muscles as well as facilitating joint motion as a result of the tape's recoiling proterties. The tape also lift sthe skin, increasing the space below it, and increasing blood flow and circulation of lymphatic fluids. This increase in the interstitial space is said to lead to less pressure on the body's nociceptors, which detect pain, and to stimulate mechanoreceptors, to improve overall joint proprioception. Kinesio tape became very popular after being used by many athletes in the 2008 Beijing Summer Olympics and also in the recent London Olympics.

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In modern vacuum cupping, a vacuum pump is used to induce a vacuum inside a cylinder sealed to the skin. The vacuum “draws” the soft tissue perpendicular to the skin thus providing a tensile force to the soft tissue system, which can be left in one site for a prolonged period or moved along the tissue. Or it can be thought as a tool for petrissage. Robert Granter believes that this modality is an essential tool for the Remedial Therapist as the benefits are clear for both client and therapist. Effective soft tissue mobilisation can be achieved & stress can be taken off the practitioner’s fingers by its implementation. ‘The effects on the myofascial system and the nervous system are brilliant and the technique can significantly help to resolve many conditions” Rob continues “We often see indiscriminate and excessive use of Cupping and we therefore encourage all practitioners wanting to learn Cupping to seek training with practitioners who have successfully integrated Cupping into their practices over many years” Rob believes there is no need or justification for the excessive bruising often seen with this technique. So how can you maximize the effectiveness of the treatment and limit adverse tissue reaction? Rob suggests 5 Vital Signs to adhere to: 1. Watch and monitor the colour of the tissue being treated and do not allow the tissue to become a red/ purple colour keep it to a pink colour. As soon as the colour changes to a red/purple remove the cup. 2. Don’t leave the cups on for more than 2 minutes initially. 3.Be aware of your patients skin type: Fair skin will bruise more easily than “olive” skin 4.Monitor the degree of Vacuum inside the cup by

Massage tools watching the degree of Skin raise within the vacuum cup to ensure it is not excessive. 5. As a guide only draw the skin approximately ¾ of the way up to the 1st treatment line on the cup 6.Only apply the cup to sites where clear palpable broad myofascial dysfunction exists. If specific precision is required Cups are not your 1st choice Rob conducts Myofascial Cupping Courses, details of which can be found on his website softtissuetherapyonline.com Here are some of the FAQ on using tools. How can a tool help? Using a tool can help a therapist to apply deep, consistent pressure with less strain on the hands and wrists. Tools also help by reducing the need to apply pressure through the fingertips, which can increase pressure in the carpal tunnel, potentially compressing the median nerve. “Pressure on the fingertips can also reduce blood flow to the nerves there, which could reduce sensitivity of touch. Tools are also a good substitute for using the thumbs. If you apply 4 kg (or 8 pounds) of force through the tip of your thumb, you can create up to 45 kg (100 pounds) of force at the Carpometacarpal joint. Do this often enough and you can damage the cartilage there.” Says Rick Goggins, co author of Save Your Hands. When should we use tools? Are there times tools should not be used? Tools may be used in a conservative context as a preparatory treatment or if direct hands-on work becomes stressful. Tools should only be used once a thorough assessment has been conducted including careful palpation to determine the exact target tissue. Tools that have the capability to significantly impact on body structures may not be used before hand work. Tools also should not be used when there are any contraindications for massage in general. Tools should also not be used around sites of potential endangerment, such as the anterior triangle at the neck and the femoral triangle. Richard Gold warns that some clients might have trauma related to tools or devices. Client’s who bruise easily or are on medication that ‘thin’ the blood should be treated with additional caution.

well, does not place pressure on the carpal tunnel at the base of the palm, allows a relaxed grip using the whole hand, and can be used with the wrist straight to minimize tension on tendons and reduce pressure in the carpal tunnel” Says Rick. The end of the tool also needs to feel good to the client, preferably in a way that is indistinguishable from the therapists fingers. Thomas Zudrell suggests that a good tool is made from quality materials, easy to use, durable and reliable. The application of a tool should be based on natural laws of anatomy, physiology and physics to assist or copy actual body mechanics. Vibrating tools should have a possibility to adjust the frequency of the vibrations, and Natural Materials should be the first choice Should I tell my client when I’m using a tool. “Yes, I think informed consent is important when using tools in massage. It may be best to let the client know at the beginning of the session that you will likely use a tool and make sure they're comfortable with that. It may not be necessary to announce that you're going to use a tool just before you apply it to a client. They may not even be able to tell the difference.” Says Rick. What are the common mistakes in using tools for massage? Rick says a common mistake that can have serious consequences is using too much pressure. Because tools can require less practitioner effort, it can be easy to overdo the pressure when getting used to a tool. It helps to practice on someone and get a sense of the right amount of effort to produce the same pressure that you would with your hands. Client communication is also critical when using a tool on a particular client for the first time. Other mistakes come when choosing tools that are either too large or too small for the practitioner's hand, or holding a tool with a grip that creates more strain on the hand and wrist than it relieves. Richard Gold warns losing touch with our client’s by limiting direct touching contact and any hyperextension needs to be avoided. According to Joe Muscolino: “As a rule, braces and tools provide stability and often facilitate the therapist being able to generate greater pressure into the client than otherwise would have been possible. But these treatment tools should not obviate the importance of employing the best body mechanics possible; e.g., stacking joints and generating the force for the stroke from the core.”

What is a good tool? “Simply put, a good tool fits the practitioner's hand

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Joint Mobilization of the Thoracic Region Joe Muscolino There are many effective treatment approaches that are available within the scope of practice for massage therapists. Each one of these, when practiced individually, can be very helpful when working on clients with musculoskeletal conditions. Certainly, Western based Swedish strokes are beneficial in that they help to loosen muscle tone, break up patterns of adhesions, and increase local circulation, along with other benefits. Another effective approach is to use moist heat. As a central nervous system depressant, heat also helps to relax muscle tone, increase local circulation, and can also help to loosen fascia. Stretching is another treatment approach that can be extremely effective. Stretching also helps to break up adhesions and change baseline muscle tone to become more relaxed. There is an old saying: “If all you have is a hammer, everything looks like a nail.” Therapists who know and practice only one technique tend to force every client into being treated with that technique. Although a specific approach might be effective for some clients, it will not necessarily work on others. If the analogy is made that each treatment technique in our practice is a tool, then as we learn more techniques, we add tools to our tool chest and are able treat and help more clients. This enables us to become more effective therapists. The art of being a skillful clinical therapist is then learning when to apply each technique, as well as how to combine them. Although there is no one cookbook combination of treatment techniques that always works, when a client presents with taut soft tissues, the mix of massage and heat, followed by stretching is usually an effective and powerful approach. Besides helping in their own right, the massage and heat help to warm up and prepare the client’s soft tissues so that the stretching is that much more effective. Indeed, I strongly recommend this combination of techniques. However, across the spine and rib cage, broad stretching strokes, even when applied after massage and heat, are often ineffective at loosening taut soft tissues located at a specific ‘segmental’ joint level of the spine. A

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segmental taut spot often exhibits decreased motion, in other words becomes hypomobile, because of a combination of increased fascial adhesions and increased muscle tone of the small intrinsic muscles of that joint (such as rotatores, interspinales, and intertransversarii). The reason that broad stretches are largely ineffective at loosening a taut segmental hypomobile level is that adjacent segmental levels compensate by increasing their range of motion to become hypermobile. In so doing, they allow us to maintain full range of motion at that region of the spine. However, the downside is that when that region is stretched, by increasing their motion, these hypermobile joints allow the hypomobile joint to avoid being stretched. Therefore, as long as these hypermobile joints exist, the hypomobile joint will persist, and its tissues will remain taut. The challenge therefore becomes how to increase and restore the normal range of motion of the specific segmental hypomobile joint. This is where joint mobilization becomes so valuable. Joint mobilization is essentially a very specific form of stretching. Whereas a typical stretch of the spine is spread across many spinal joint levels, joint mobilization is a technique that allows the therapist to specifically target individual segmental joint levels. In effect, if a joint level is hypomobile, it cannot hide behind the motion of an adjacent hypermobility. Joint mobilization applied to that level will require it to stretch. In the December 2011 issue of this e-mag, I already addressed joint mobilization of the cervical spine (neck). Let’s now look at how to perform joint mobilization of the thoracic region (the upper and middle back). To apply joint mobilization to the thoracic region, the client’s trunk must first be brought into a position that causes tension and stretches the joints of the thorax. Once this is achieved, a specific joint mobilization force is then applied to the target segmental level.

Joint Mobilization

Figure 1: Initial position for joint mobilization of the thoracic region. The therapist’s left hand is supporting the client and bringing her upper and middle back into flexion and left rotation to create tension in the client’s thoracic region.

Figure 1 demonstrates this initial position for thoracic mobilization; the client’s upper back is flexed forward and rotated toward the side where the therapist is standing (the client’s neck is relaxed). It is extremely important that the flexion and rotation occur at the client’s thoracic region. If the client is flexed and rotated at the lumbar spine as seen in Figure 2, then the thoracic joint mobilization will be ineffective, more difficult for therapist to perform, and possibly injurious to the client’s low back. To efficiently support and move the client, the therapist’s hand in front must securely but comfortably grip the client’s shoulder to support her body weight. Figures 3a and b show two manners in which this can be done. Now that the client has been brought to the initial position of stretch and tension, it is time to apply the joint mobilization force. This can be done to the rib cage to mobilize the costospinal joints as shown in Figure 4a, or directly to the spine to mobilize the vertebral facet joints as shown in Figure 4b. In each case, the therapist uses the thenar eminence of the heel of the hand to contact and press on the client. The pressure is applied forward and laterally, but also into the client, requiring the rib or vertebra being contacted to mobilize and move a slight bit more. This mobilization force needs to be gentle but firm, and should be applied slowly and

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Figure 2: Incorrect initial position for joint mobilization of the thoracic region. The therapist is bending and rotating the client from the lumbar region.

This mobilization force needs to be gentle but firm, and should be applied slowly and evenly; the therapist should never apply this pressure in a fast thrusting manner. evenly; the therapist should never apply this pressure in a fast thrusting manner. The hand of the therapist that is holding onto the client’s shoulder in front can also be used to aid in the mobilization by gently pulling on the client’s shoulder and trunk and thereby adding to the flexion and rotation force as the treating hand applies the mobilization force to the client’s back. This mobilization stretch is applied for only a second or less and is usually repeated two to four times. The therapist can then move the treating hand to the next level of the rib cage or spine to be mobilized. After mobilizing all twelve levels of the thoracic region, the other side can be mobilized.

Joint Mobilization

Figure 3: Two methods of supporting the client’s upper body are shown. In A, the therapist arm is in front of the client’s crossed arms. In B, the therapist places his arm under the client’s crossed arms.

Figure 4: Two contacts of the thenar eminence of the treatment hand are shown. In A, the therapist applies the joint mobilization force to the angle of a right rib. In B, the therapist applies the joint mobilization force directly to the left side of the base of the vertebral spinous process.

Similar to more broadly applied stretches, joint mobilization is more effective when applied to tissue that has first been warmed up. For this reason, it is best carried out toward the end of the session after the massage and heat have already been done. Thoracic joint mobilization can take time to master and perform proficiently and smoothly. However, if you have a client whose upper and middle back have been resistant to your treatment, perhaps the addition of thoracic joint mobilization to your treatment approach will prove to be the key to helping this client.

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This Article is reprinted with permission from AMTA Massage Therapy Journal, Summer 2011 www.amtamassage.org/mtj Figures copyright by Yanik Chauvin.

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.

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Book Early as Places are Limited

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

“Core” Matters Josephine Key Massage therapists are increasingly being asked to solve their client’s frank pain problems. Exercise instructors – be they in the yoga, Pilates or the personal training industries have to deal more with clients who have various pain issues. Why do so many people have ‘injuries’- particularly those who are diligently working at being active and fit? If the exercise is ‘right’ surely we should expect to feel good? In the technology age we move a lot less - and with a more limited repertoire. Obesity is becoming an increasing problem. We certainly need to be more active. However, how we are active, and the kind of exercise we do is important in ensuring our musculoskeletal fitness and somatic wellbeing - or otherwise. The research evidence is increasingly clear that people with low back and pelvic pain disorders have altered control of movement. It’s not about strength but rather how they control quite basic movements. In particular they have difficulty recruiting their ‘deep’ myofascial system. They must compensate for this by over using the more superficial large muscles. This is a problem for the spine and pelvis which rely heavily on effective ‘deep system’ activity for proper antigravity postural support and healthy movement control. Now days, lazy ‘deep system’ control is more common than not - and why so many have ‘poor posture’ and breathing pattern disorders. Poor ‘deep system’ control results in feeling tense, increasingly stiff and tight – and having pain. This imbalanced myofascial activity underlies many ‘injuries’ and chronic pain complaints - tendinopathies; plantar fasciitis; back, groin, hip or knee

Terra Rosa e-magazine, No. 11 (December 2012)

Fig 1. The fabled, sought after 'six pak': overdevelopment of the superficial abdominals and pectorals constrict and stiffen the torso and compromise healthy breathing patterns and spinal movement control

pain etc. The site of pain is not necessarily the source of pain and compromised axial control is invariably the criminal. Core matters These days one hears a lot about ‘the core’. It has become a real selling point promulgated as the panacea for just about everything from helping back pain, enhancing performance, to improving your shape. ‘Core’ isn’t what most people think it is. Unfortunately it’s been dumbed down to mean ‘working your abs’ and ‘pull in your stomach’. This creates lots of problems. ‘The core’ is part of the deep myofascial system. The concept of ‘core stability’ probably emanated from from some Australian research into postural control in both healthy and chronic low back pain populations. They

“Core” Matters

Fig 2. This is not achieving proper 'core control' but is merely a superficial 'abs' workout. Overdeveloped abdominals are as much of a problem for the spine as underactive abdominals .

studied the feed-forward anticipatory role played by the intra-abdominal pressure (IAP) mechanism, an important aspect of the antigravity postural control and spinal stabilisation system. They looked at the role of transversus abdominis as a marker of function in a synergy of muscles responsible for generating intraabdominal pressure (IAP). However, it is important to appreciate that they also looked at function in the rest of the synergy - the diaphragm, the pelvic floor and the deep fibers of lumbar multifidus and the combined role these muscles play in generating appropriate levels of IAP. ‘Core control’ thus involves their simultaneous activity: it’s a ‘stabilisation synergy’. In healthy populations all elements in the ‘stabilisation synergy’ co-activate prior to the actual movement occurring. Yet, in people with low back and pelvic girdle pain the pre-activation response of all these muscles was variably delayed and/or diminished during movement. Spino-pelvic control suffers. However, it is apparent that these research findings and their implications have been ignored and/or misinterpreted such that the transversus abdominis muscle has been singled out as ‘the core muscle’. What about the important role of the diaphragm and the rest of the ‘stabilisation synergy’? Further, this differential function between the deep transversus and the more superficial abdominals is generally overlooked. Instead of specific activation of and building control and endurance in the deep ‘stabilising synergy’, much of the ‘core training’ offered simply becomes ‘strengthening the abs’ as a group principally in supine into repeated cycles of spinal flexion: ‘tail tucking’, crunches, curls, sit-ups, ‘teasers’ and so on. Research has demonstrated that excessive spinal flexion has adverse consequences on spinal health and wellbeing.

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Figs 3, 4, 5.These exercises do not necessarily activate 'the core', hyper-flex the spine and place the pelvis in provocative positions for the sacroiliac joint - and so place the subject at great risk of developing a diverse array of seemingly unrelated 'injuries'- pain in the neck and particularly the back; sacroiliac; hip knee and foot as well as tight leg muscles and various 'tendon' problems.

Choosing the ‘right’ exercise Movement re-education is an art dependent upon a good understanding of healthy spinal control mechanisms and being able to recognise the distinct common patterns of compensated control which drive the development of many pain syndromes. Therapeutic movement re-education needs to be highly specific in order to appropriately address ‘what’s wrong’ – its serious work requiring focus and feedback. Retraining ‘core control’ involves building basic patterns of control from the inside out Clients attending exercise providers are often asked

“Core” Matters

Fig 6. This exercise is extremely difficult to do well - unless you are an elite dancer. Even then, sacroiliac and 'hip' problems are likely and common .

‘what is their goal’? This can vary from ‘the look good in bed’ seekers - wanting to lose weight; ‘get rid of my tummy’; ‘get toned and fit’ to those wanting real help for their pain. They aren’t necessarily at opposite ends of the spectrum. Many clients while not complaining of pain are certainly at risk in developing it. In terms of exercise, what clients think they want and what they actually need are often quite different. The challenge for the teacher is to be able to match the needs and abilities of their client and deliver safe and effective exercise. This is impossible to do with large classes which invariably become little more than a ‘Simon Says’ play group for adults Let’s consider the Pilates industry for a moment. Undoubtedly ‘Pilates’ got its launch through the dance community. Dancers are elite athletes who nonetheless get injuries. The Pilates Method has provided useful tools to help dancers refine their control. Many teachers are ex dancers with advanced neuromuscular fitness and well able to cope with ‘advanced’ Pilates moves - but not so for most of their clients. It is apparent that whether it is in the Pilates, yoga or the fitness industry there is a trend in ‘upping the challenge’ probably to gain market advantage in a crowded field – large floor classes that strive to be ‘upbeat’ and ‘fun’ with more and more ‘new tricks’ to keep their audience interested. Yet many of the participants are missing control of quite fundamental links in the movement chain. To keep up with the pace and level of demand, those with wobbly function will use whatever they can, further imprinting compensated patterns of control. There is no opportunity for relearning quality control or cor-

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Fig 7. A safer way to work for proper 'core control'. Even so, many of your clients will have great difficulty achieving this and need support in carefully building the necessary elements of control towards being able to properly master this exercise .

recting adverse movement behaviour. Pain here we come. Just observe how many are constantly using the foam roller in an attempt to iron out their various pain and tightness issues! So don’t assume that because your clients are exercising that they are necessarily doing what’s ‘right’ and good for them. It could be the reason why they keep coming back with the same old problem – or developing new ones.

Josephine Key is the author of the book ‘Back Pain: A Movement Problem’. She graduated in physiotherapy in NSW and gained a Postgraduate Diploma in Manipulative Physiotherapy from Sydney University. Josephine founded the Edgecliff Physiotherapy Sports & Spinal Centre in 1985. Throughout her career she has lectured at postgraduate level and done extensive teaching, mentoring and writing in the field of musculoskeletal physiotherapy. She has a particular interest in the improved understanding, recognition and remediation of movement dysfunction associated with most musculoskeletal pain disorders, in particular those relating to the spine. control of posture and related movements found in her patients. Visit her website http://keyapproach.com.au/ Read 6 Questions to Josephine on page 40.

We have the best collection of Massage Therapy Books and DVDs www.terrarosa.com.au

Research Highlights Massage Right After Muscle Injury May Boost Healing Massage is known to help heal muscle injury, but the degree of recovery may depend on certain factors, such as the timing of the treatment, according to the results of a study in rabbits. A research from The Ohio State University Wexner Medical Center confirms for the first time the measurable effects of massage-like pressure on the recovery of muscle fibre damage. Knowing that massage therapy can ease muscle pain and weakness associated with exercise, the researchers studied 24 white rabbits to determine the massage pressure, duration and timing needed to improve healing following a muscle injury. In conducting the animal study, the researchers used a mechanical device that mimics movements associated with exercise and a second device that mimics a massaging motion. They compared different frequency, pressure and duration tests to determine their effect on muscle. "We have translated what we thought was going on in humans, largely based on self-reporting, into the laboratory and designed the instrumentation to apply controllable and measurable forces," Dr. Thomas Best, codirector of OSU Sports Medicine, said in a university news release. "We found if damaged muscle is massaged right away - for 15 minutes -- there is a 20 to 40 percent chance of recovery. Initial injury in the animal model was extended if massage did not take place within 24 hours," While the findings hold promise, experts note that research involving animals frequently fails to lead to benefits for humans. The study authors said their findings provide potential guidelines for future clinical trials.

Massage Therapy for Patients after Cardiac Surgery

sessed. The study was recently published in the Journal of Thoracic Cardiovascular Surgery. Elective cardiac surgery patients were randomized to receive massage or rest time at 2 points in time after surgery. Visual analog scales were used to measure pain, anxiety, relaxation, muscular tension, and satisfaction. Heart rate, respiratory rate, and blood pressure were measured before and after treatment. Focus groups and feedback were used to collect qualitative data about clinical significance and feasibility. A total of 152 patients (99% response rate) participated. The results showed that massage therapy produced a significantly greater reduction in pain , anxiety, and muscular tension. It also increases in relaxation and satisfaction compared to the rest time. However no significant differences were seen for heart rate, respiratory rate, and blood pressure. Pain was significantly reduced after massage on day 3 or 4 and day 5 or 6. Meanwhile the control group experienced no significant change at either time. Anxiety and muscular tension were also significantly reduced in the massage group at both points. Relaxation was significantly improved on day 3 or 4 for both groups (massage, and rest time), but only massage was effective on day 5 or 6. In addition, nurses and physiotherapists observed patient improvements and helped facilitate delivery of the treatment by the massage therapists on the ward. The authors concluded that massage therapy significantly reduced the pain, anxiety, and muscular tension and improves relaxation and satisfaction after cardiac surgery.

Massage Therapy for Osteoarthritis of the Knee Pain

Researchers from Cardiothoracic Surgical Research Unit, Department of Surgery, Monash University Alfred Hospital in Melbourne conducted a research to determine whether massage significantly reduces anxiety, pain, and muscular tension and enhances relaxation compared with an equivalent period of rest time after cardiac surgery. The feasibility of delivering the treatment, effects on heart rate, blood pressure, and respiratory rate, and patient satisfaction were also as-

A recent study found that a 60-minute â&#x20AC;&#x153;doseâ&#x20AC;? of Swedish massage therapy delivered once a week for pain due to osteoarthritis of the knee was both optimal and practical, establishing a standard for use in future research. This trial, funded by NCCAM and published in the journal PLoS One, builds on an earlier pilot study of massage for knee osteoarthritis pain, which had promising results but provided no data to determine whether the dose was optimal. The researchers defined an optimal, practical dose as producing the greatest ratio of desired

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Research Highlights effect compared to costs in time, labour, and convenience. Researchers randomly assigned 125 participants with osteoarthritis of the knee to receive one of four 8-week doses of Swedish massage (30 or 60 minutes weekly or twice weekly) or usual care. The usual care group continued with their current treatment and did not receive massage therapy. The researchers assessed participantsâ&#x20AC;&#x2122; pain, function, joint flexibility, and other measures at the start of the study and then at 8, 16, and 24 weeks thereafter.

Massage was applied to four acupoints for three minutes each. The massage acupoint sequence was from left Jian -wai-yu, right Jian-wai-yu, left Zuo-fei-yu, and finally right Zuo-fei-yu. An EEG system of 32 channels was used. Twenty-four volunteers, mainly college students, were enrolled. EEG rhythm powers of each massage sessions were derived.

The statistical analysis revealed that there were also significant interactions between the massage stage and the massage type on delta, theta, and beta rhythms , and there were significant differences at different stages for the mechanical massage group The mechanical massage At 8 weeks, participants in the 60-minute massage group had more significant differences than the handsgroups (i.e., both once- and twice-per-week) had signifi- on group for stage coherence of around coherence on cant improvements in pain, function, and global realpha rhythm. sponse compared with participants in the usual care group. Pain intensity had the greatest reduction in the The study was published in Evid Based Complement 60-minute, once-per-week group and was significantly Alternat Med. reduced compared to both the usual care and 30-minute groups. There was no significant difference in outcomes between the 60-minute groups, which led to the conclu- Massage therapy Improved on Heart Rate Varision that the optimal dose of massage was, on average, ability in Preterm Infants 60-minutes once per week. Compared to usual care, all the massage groups had similar reductions in stiffness, Researchers from School of Nursing, University of Louisville, USA studied the effect of massage on autonomic though range-of-motion was not significantly affected by usual care or massage. At 24 weeks, the clinical bene- nervous system (ANS) function as measured by heart fits had reduced for all groups (i.e., usual care and mas- rate variability (HRV) in preterm infants. sage groups) and were not significantly different beMedically stable, 29- to 32-week preterm infants (17 tween the groups, though they were still improved commassage, 20 control) were enrolled in a masked, ranpared to the start of the study. domized longitudinal study. Licensed massage theraThe researchers noted that there is promising potential pists provided the massage or control condition twice a day for 4 weeks. Weekly HRV, a measure of ANS develfor the use of massage therapy for osteoarthritis of the knee and that future, larger trials should use this dose as opment and function, was analyzed using statistical analysis. a standard. Further, they suggest that more definitive research is needed on massage for osteoarthritis of the The results showed that HRV improved in massaged knee, in terms of efficacy, how it may work in the body, infants but not in the control infants. Massaged males and its cost-effectiveness for patients. had a greater improvement in HRV than females. HRV in massaged infants was on a trajectory comparable to term-born infants by study completion. Body massage performance investigation by The authors concluded that massage improved HRV in brain activity analysis a homogeneous sample of hospitalized, medically stable, Massage has been widely applied to improve health and preterm male infants and may improve infant response reduce stress. However, the performance difference be- to exogenous stressors. The authors speculated that tween hands-on treatment and treatment by mechanical massage improves ANS function in these infants. devices has been little mentioned. Therefore, the team from Asia University in Taiwan investigated a subjectâ&#x20AC;&#x2122;s The study was published in Journal of Perinatology EEG performance under massage treatment applied by hand and treatment applied by mechanical devices.

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Research Highlights Massage Improves Growth Quality by Decreasing Body Fat Deposition in Male Preterm Infants. Researcher from Department of Pediatrics, University of Utah, conducted experiments to assess the effect of massage on weight gain and body fat deposition in preterm infants. The research was recently published in Journal of Pediatrics

cia, and to emphasize the potential role of injury, inflammation, and/or neural sensitization of the posterior layer of the human lumbar fascia in non-specific low back pain. I

They found that in addition to a tensional load bearing function of tendons and ligaments, muscles transmit a significant portion of their force via their epimysia to laterally positioned tissues, such as to synergistic or antagonistic muscles. Fascial tissues are commonly used Preterm infants (29-32 weeks) were randomized to the as elastic springs [catapult action] during oscillatory massage group (12 girls, 10 boys) or the control group movements, such as walking, hopping, or running, in (12 girls, 10 boys). Treatment was masked with massage which the supporting skeletal muscles contract rather or control care administered twice-daily by licensed isometrically. They are prone to viscoelastic deformamassage therapists (6 day per week for 4 weeks). Body tions such as creep, hysteresis, and relaxation. Such weight, length, Ponderal Index (PI), body circumfertemporary deformations alter fascial stiffness and may ences, and skinfold thickness (triceps, mid-thigh, and take several hours for recovery. There is a gradual transubscapular [SSF]) were measured. Circulating insulin- sition zone between reversible viscoelastic deformation like growth factor I, leptin, and adiponectin levels were and complete tissue tearing. Micro tearing of colladetermined by enzyme-linked immunosorbent assay. genous fibers and their interconnections have been Daily dietary intake was collected. documented in this zone. The results showed that energy and protein intake as well as increase in weight, length, and body circumferences were similar. Male infants in the massage group had smaller PI, triceps skinfold thickness, mid-thigh skinfold thickness, and SSF and increases over time compared with control male infants. Female infants in the massage group had larger SSF increases than control female infants. Circulating adiponectin increased over time in control group male infants.

They also found that fascia is densely innervated by myelinated nerve endings which are assumed to serve a proprioceptive function. These are Pacini [and paciniform] corpuscles, Golgi tendon organs, and Ruffini endings. In addition they are innervated by free endings, containing substance P, suggestive of a nociceptive function. New findings suggest that noicipetive activity of epimysial fasciae play a major role in delayed onset muscle soreness subsequent to repetitive concentric exThe authors concluded that twice-daily massage did not ercise. promote greater weight gain in preterm infants. MasThey concluded that fascial tissues serve important load sage did, however, limit body fat deposition in male pre- bearing functions. The innervation of fascia indicates a term infants. Massage decreased circulating adiponectin sensory role as an organ for propriocepton, and also a over time in male infants with higher adiponectin conpotential nociceptive function. Micro tearing and/or centrations associated with increased body fat. These inflammation of fascia can be a direct source of muscufindings suggest that massage may improve body fat loskeletal pain. Fascia may be an indirect source of back deposition and, in turn, growth quality of preterm inpain. fants in a sex-specific manner.

Biomechanical properties of fascial tissues and their role as pain generators Robert Schleip and colleagues from the Fascia Research Project, at Ulm University, wrote a review last year on the load bearing functions of fascial tissues and their proneness to micro tearing during physiological or excessive loading, to review histological evidence for a proprioceptive as well as nociceptive innervation of fas-

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6 Questions to Greg Polins 1. When and how did you decide to become a bodyworker? I have been a power- lifter / bodybuilder since I was 16 so there has been a lot of time spent in the gym. I was always watching people work out with poor form and eventually injure themselves. I became fascinated with kinesiology, the science of human movement. I began formulating solutions to their injuries in my mind and all that I needed to do was get my hands busy. That was in 1995. 2. What do you find most exciting about bodywork therapy? People will always find new ways to injure themselves so it is a constantly evolving profession. I can’t count how many times I have looked at an injury and asked the patient “you did what ?” After a thorough exam has been performed you can almost recreate the mechanism that caused the injury. So the “investigative” nature of bodywork always is exciting. 3. What is your most favourite bodywork book? Cyriax on Orthopaedic Medicine “ Absolutely a must read. Learn when and when not to do bodywork. In many cases you will actually “harm” the patient. This book opened my eyes to orthopaedic “testing” to determine the exact injury and not just guess. Many therapists see themselves as miracle workers. All they have to do is get in there and dig around. And typically the client will say it hurts more now than before you did the bodywork. That’s because you actually “caused more harm than good. It’s not so simple as “digging in and doing deep work.” You must investigate before you begin. If you see or feel any inflammation stay away from it. Ice therapy is a treatment too. I always keep several paper cups full of water in the freezer. Simply peel away the paper as you perform “ice mas-

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sage” on the affected region.

4. What is the most challenging part of your work? When I first entered the world of body working a highly valued instructor told me “ if you want to really succeed and stand above the other therapists then learn everything that you can about the shoulder .” So I did and my business boomed !!! People will always do “something stupid” and injure themselves. I opened a practice directly across the street for the areas largest gym, printed t shirts with my business name on the front and one the back it read “ shoulder pain ? I gave away well over a hundred. It worked, they became walking billboards and my business boomed. I later added “knee pain” and that worked too. Become a professional on the shoulder and the knee. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? Always take a detailed patient/customer intake. Know their current and previous injuries. Don’t just “dive in.” Do a thorough exam, including ROM (range of motion) and response to pain. Long before your hands touch the patient your “mind needs to do the bodywork.” If the area is inflamed STAY AWAY ...all you will do is make it worse. 6. How do you see the future of bodywork and massage therapy? Massage therapy and the medical world will continue to fuse which will produce a very effective profession. Medical massage will continue to expand.

6 Questions to Josephine Key 1. When and how did you decide to become a bodyworker?

3. What is your most favourite bodywork book?

I have been a practising physiotherapist for over forty years. I went to Sydney University straight out of school. I was interested in how the body works and ‘wanted to help people’.

There have been so many influences over the years that I cannot list them all. Leon Chaitow has been a prolific writer offering a great many practical insights for bodyworkers. I am very interested and excited about the recent developments in fascia research and as time allows I am currently dipping into the Stecco’s books on fascial manipulation.

Upon graduation I worked in large teaching hospitals for the first 10 years or so - a good way to consolidate theoretical learning with practical experience with many mentors to hand. However, the hospital environment is very ‘disease’ focused and my interest gradually shifted away from dealing with chronic and acute on chronic health problems and ‘saving lives’ to neurological rehabilitation – initially with adults and then to paediatrics. Part of my caseload involved working with adolescents with idiopathic scoliosis and here my interest in effective ‘conservative’ solutions neuromusculo-skeletal problems really began to develop. To gain more experience I went to work in a genera musculoskeletal private practice and subsequently did a postgraduate degree in manipulative physiotherapy. I commenced my own musculoskeletal practice in 1985 and since then I have continued my quest to better understand the functional relationship between altered movement and pain syndromes – and how best to treat them. I work as both a manual and movement/exercise therapist. 2. What do you find most exciting about bodywork therapy? The fact that one can facilitate often quite dramatic changes in a relatively short time frame! However, this is not necessarily straight forward, but dependent upon the therapist’s ability to read the body and ‘feel’ what the tissues are asking for. My academic manual training was somewhat prescriptive - applying ‘techniques’ to various ‘conditions’-often with little justification as to choice of technique. Some got better, some didn’t. This prompted a self-directed journey of exploration. Bodywork can be highly creative - a combination of understanding healthy neuromusculo-skeletal function and how it changes; manual skills development and clinical reasoning informed by science. Effective manual therapy is a continual process of ‘intuitive sensing’ - gauging the response to the intervention and adapting it as indicated. I still find it very rewarding to work with the body’s ability to heal itself and help someone achieve better musculoskeletal health. It is a privilege to work so intimately with tissues and touch. It is a process of lifelong learning - one is never good enough!

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4. What is the most challenging part of your work? Realising that I cannot be all things to all people – and the ability to say ‘no’. While bodywork can be very rewarding, it is also personally demanding. Therapists can ‘burn out’. A ‘work -life balance’ is important. I also find the dual approach of bodywork and movement therapy is both more effective for my clients and also enables a better ‘work-work balance’ for me. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? To be an effective bodyworker it is important that you can discern the reasons why your client is symptomatic - akin to the sleuth Sherlock Holmes; we need to understand what is the criminal and what is the victim. When this is apparent, your treatment approach becomes more self-evident. This involves looking at how your client functions. To date there has not been a lot of research in this area, however this is rapidly changing. You need to be informed about research developments, be discriminate about the findings and their applicability to your clinical practice. To this end, subscribing to good peer reviewed journals such as the ‘Journal of Bodywork and Movement Therapies’ and ‘Manual Therapy’ are useful. Attending well respected international conferences allows insights into the current debate as well as the latest advances in research 6. How do you see the future of massage therapy? Very healthy! Our modern lifestyle is very compromising to our neuro-musculoskeletal health. That coupled with poor advice and training protocols in the fitness and exercise industries means that there is an ever increasing queue of people lining up for your services – especially if you are good! Engage in the challenge and discover the magic of ‘getting it right’. Otherwise you may find yourself in laborious ‘panel beating’ with little real reward.