Terrarosa e-magazine #14 by Terra Rosa

Terra Rosa E-Magazine

Open information for massage therapists & bodyworkers

No. 14, July 2014

Terra Rosa e-magazine, No. 14 (July 2014)

Terra Rosa E-Magazine, No. 14, July 2014

Inside this Issue 3

The Great Debate about Stretching — Chris Frederick

Cervical Injuries & Treatment Strategies — George Kousaleos

Don’t Underestimate the Thorax — Jo Key

Fascia Distortion Model — Frank Römer

Fascial Fitness and Pilates— Kerrie Murphy

Fascia and Back Pain— Andreas Schilder

Functional Fascial Taping® and Research — Ron Alexander

Cover Feature: Donna Eddy

PNF Stretching

Barefoot vs. Shod Running

Working at the End of Range — Art Riggs

Throwing and Elastic Storage— James Earls

Research Highlights

6 Questions to Donna Eddy

Disclaimer: All material provided in this e-magazine should

6 Questions to Chris Frederick

be used as a guide only. This information should not be took or used as a substitute for professional or medical advice. 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. 14 (July 2014)

Published and made freely available by: Terra Rosa www.terrarosa.com.au www.massage-research.com

The Great Debate About Stretching By Chris Frederick, PT, KMI Introduction The great controversy about stretching, particularly in therapy and athletics, started about 15 years ago (Shrier, 1999). Previously, it was assumed that stretching improved overall functional and athletic performance, increased specific flexibility and reduced injuries. A majority of clinicians and therapists as well as trainers and coaches from all disciplines were convinced about the importance of stretching as a necessary part of their protocols for successful outcomes. An article titled The Stretching Debate featured invited commentary on research, that was largely negative, on the benefits of stretching (Chaitow, 2003). Many of these opinions, most of them by recognized manual therapists, were emotionally charged and reflected the conflicts between what therapists believed worked for them and what the researchers were saying was really happening in stretching. Since then, adamant pro and anti stretch camps have formed within professions practicing varietal therapies including fitness and sports coaches. This acrimonious climate has been taken advantage of in the media, adding more fuel to the fire (Reynolds, 2013). Consequently, the author of this article feels that it is extremely important to bring awareness to these facts and hopefully present a balanced, concise attempt to further explain and bring more light to the debate of stretching.

“...conflicts between what therapists believed worked for them and what the researchers were saying was really happening in stretching.” ness. Stretching before exercising does not seem to confer a practically useful reduction in the risk of injury, but the generality of this finding needs testing.” (Herbert & Gabriel, 2002).

Negative outcomes in research

Six years after that study, another similar systematic review seemed to confirm the conclusions of the former. Namely, “There is moderate to strong evidence that routine application of static stretching does not reduce overall injury rates”. But there was an additional finding in that study that cast doubt on the concluding statement being taken at its word as a reliable and valid guide for using stretching in preventative therapy and training: “There is preliminary evidence, however, that static stretching may reduce musculotendinous injuries” (Small, 2008).

Injuries

Strength, power and speed

In August 2002, an article appeared in The British Medical Journal that created a great deal of interest and controversy. The paper in question was a systematic review of research that evaluated the benefits (or lack of benefits) associated with stretching procedures in relation to protection from injury and post exercise soreness (Herbert & Gabriel). Conclusions taken directly from the study were “Stretching before or after exercising does not confer protection from muscle sore-

There are many studies that demonstrate overall decreased parameters for strength such that many trainers and coaches do not allow stretching before weight training and other strength focused activities (Babault, 2010; Sekir, 2010, Manoel, 2008).

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With regards to both power and speed, a study about the effects of stretching on sprinting is a good representation of what other studies have found. A repeated

Debate on Stretching

measures design was used, which consisted of the same group of 25 healthy, recreational runners completing a 40 yard sprint trial immediately following each of four different stretching conditions aimed at the iliopsoas muscle and lasting one minute each. In the no stretch condition, subjects improved significantly from pre- to post-sprint times. However there were no statistically significant differences in pre- and post-stretch sprint times among the static, ballistic and dynamic stretching conditions. The study concluded that sprint performance may show greatest improvement without stretching and through the use of a generalized warmup with walking as the activity. Obviously, these findings have clinically meaningful implications for runners who include iliopsoas muscle stretching as a component of their warm-up before running. For the record, similar negative results have been observed with various kinds of jumping (Behm, 2007). The studies discussed above are several examples of negative outcomes with some studies even suggesting in their conclusions that stretching not be performed as a therapeutic or training guideline. Taking a look at positive outcomes in stretch research may help to form a balanced opinion and approach using science to inform our practice.

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Positive outcomes in research In one study, authors found three positive results from stretching: “(i) there was steady-state force enhancement following stretch in voluntarily contracted muscles; (ii) some force enhancement persisted following relaxation of the muscle and (iii) force enhancement, for some stretch conditions, exceeded the maximum isometric force at optimal muscle length” (Lee & Herzog, 2002). This study counterpoints other studies concluding that stretching weakens force production in muscle and suggests further study to see how stretching may actually enhance muscle force production. A recent systematic review on multiple studies indicated the following positive outcomes from stretching:  Increased ROM.  ROM increases bilaterally from unilateral stretch.  Static and dynamic warm-ups are equally effective at increasing ROM prior to exercise.  Pre-contraction stretching (e.g. PNF) lowers excitability of muscle.  A pre-stretch contraction has been associated with greater acute gains in ROM compared to static stretching in many studies.

Debate on Stretching

“There are many examples of a number of ubiquitous problems that is seen in research on stretching.” other media and in professional journals that is prevalent.

   

In contrast to static stretching, dynamic stretching is not associated with strength or performance deficits. Dynamic stretching improved dynamometermeasured power as well as jumping and running performance. Static stretching performed before or after warmup does not decrease strength. Four repetitions of 15-second holds of static stretching did not affect vertical jump.

Getting perspective on studies about stretching There are many examples of a number of ubiquitous problems that is seen in research on stretching. One view is that one of the big problems in this and in many studies is that the word “stretching” is not adequately defined. Even after reviewing individual studies, the majority are only moderately specific about the type of stretching studied, e.g. most often “static” stretching. In the conclusions, it gets much worse as the general term “stretching” is used without qualifying it with a descriptor term, e.g. “static” (Thacker et al., 2004). The problem occurs when only the conclusions and not the details of studies like this are read (as is often the case), and the wrong impression is promoted. That is, all stretching is this or that when it should more accurately state, for example, “static stretching that utilizes the specific parameters used in this study is this or that”. This author believes this problem is one major source of misinformation about stretching in the news,

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It should be noted that much of the negative outcomes of studies on stretching over the past ten years has come from static stretch research (McHugh & Cosgrave, 2010). It should also be noted that the majority of stretch studies have attempted to isolate the stretch to one accessible muscle, most often the hamstrings (Slavko, 2013). “Static” and “the hamstrings” are obviously only two of a multitude of variables that can be studied and controlled in stretching research. Unfortunately, those are the two most common variables seen in research of stretching human tissue. Many other clinically relevant variables that can be applied in stretch therapy remain largely unstudied (Page, 2012). For example, the author has never seen a study that attempts to compare or differentiate any type of stretching applied to tonic versus phasic muscles. Therefore much of the negative press about stretching and the concomitant advice that has recently arisen from fitness and therapeutic sources appear to be limited at best and potentially harmful at worst. Much of this advice is seen as being derived from narrow, evidenced-based studies and not from systematic reviews comparing multiple methods or approaches to clinical assisted stretching much less self-stretching. What may be an even bigger problem with using outcomes of research studies to guide clinical practice is disturbing evidence that has recently come to light. As reported in a Wall Street Journal article, “most results, including those that appear in top-flight peer-reviewed journals, can’t be reproduced” (Naik, 2011). Bruce Alberts, editor of Science magazine was quoted in that same article: “It's a very serious and disturbing issue because it obviously misleads people who implicitly trust findings published in a respected peer-reviewed journal”. As a result, he had that journal devote a large chunk of one of its issues to the problem of scientific replication (Jasny, 2011). The point to be made here is that the results of scientific studies can be viewed with respected suspicion just as much as anecdotal report from a trusted colleague or mentor. One is not better or necessarily more accurate and certainly not more trustworthy than the other, if one is to believe the multiple sources that have recently exposed the fallibility of the scientific method.

Debate on Stretching

“Practical, reliable professional experience from one’s personal practice integrated with input from experienced colleagues or mentors, when needed, which is then informed by evidence in research is the best strategy for optimal client outcomes.” With this being the case, if a clinician wants to use evidenced-based protocols in stretching, it is advised to follow the recommendations of study outcomes only to the specific degree they were derived. That is, it should not be assumed by the therapist that the outcomes are also valid, using one example, for muscles and/or other tissues not studied in research. Unfortunately, incorrect and potentially harmful assumptions and generalizations (and therefore incorrect advice) about stretching still abound in all fields. Ian Schrier, MD, PhD a well-known researcher on stretching, concluded the following key points in his 2007 article Does Stretching Prevent Injuries?   

Stretching immediately before exercise is different from stretching at other times. Stretching immediately before exercise does not appear to prevent injury. Regular stretching that is not done immediately before exercise may prevent injury.

Obviously, the debate about stretching is far from over and the author enthusiastically encourages the reader to join in on this discussion. We agree with a 2012 clinical commentary that discussed current concepts of muscle stretching interventions and summarized the evidence related to stretching as used in both exercise and rehabilitation (Page). Noting both negative and positive outcomes from stretching as we just did, the article stated that several authors observed individual responses to stretching. For example, the effectiveness of type of stretching seems to be related to age and sex: men and older adults under 65 years responded better to contractrelax stretching, while women and older adults over 65 benefit more from static stretching. Another one: 60second holds of static stretches were associated with

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greater improvements in hamstring flexibility in older adults compared to shorter duration holds. Growing studies like this suggest that stretching programs may need to be individualized for best outcomes. It has been this author’s observation in practice that this is indeed the case and that standard protocols in stretching and flexibility training are mediocre at best and harmful at worst. Practical, reliable professional experience from one’s personal practice integrated with input from experienced colleagues or mentors, when needed, which is then informed by evidence in research is, in the author’s opinion, the best strategy for optimal client outcomes. It is important to note that while science is moving steadily forward in research of connective tissues and is producing findings that can be clinically very supportive of stretching used in different kinds of manual therapies, practical parameters for a broad range of clinical application sadly lag far behind. The many possibilities of multiple types of stretching combined with the application of multifarious parameters have yet to be studied. Some or even many of these may well yield positive outcomes. Practice-based evidence (along with credible backing from fascia research) has certainly produced many positive outcomes with stretching. We need both reliable and valid clinical anecdotes as well as good research for best outcomes with our clients. Note: This article is an extract from Chris & Ann Frederick’s latest book Fascial Stretch Therapy (Handspring Books, 2014). Fascial Stretch Therapy (FST) shows how assessment, treatment and training are used in a variety of common circumstances encountered in manual therapy and athletic training. The book describes and shows the therapist or trainer how to integrate FST in their current practice, business or workplace to enhance what they already do and provide. Available at: www.terrarosa.com.au References Babault, N, et al. (2010) Acute effects of 15 min static or contractrelax stretching modalities on plantar flexors neuromuscular properties. J Sci Med Sport 13(2). Pp. 247–252. Behm, D.G., Kibele, A. (2007) Effects of differing intensities of static stretching on jump performance. Eur J Appl Physiol 101(5). pp. 587– 94. Chaitow, Leon et al. (2003) The stretching debate. Journal of Bodywork and Movement Therapies 7(2). pp. 80–96. Herbert, R. Gabriel, M. (2002) Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. British Medical Journal 325. pp. 468–472. Jasny, B.R. (2011) Again, and Again, and Again … Science. Available at: http://www.sciencemag.org/content/334/6060/1225. [Accessed: 19 December 2013] Lee, H-D, Herzog, W. (2002) Force enhancement following muscle stretch of electrically stimulated and voluntarily activated human adductor pollicis. Journal of Physiology. 545.1. pp. 321–330. Manoel, M.E. et al. (2008) Acute effects of static, dynamic, and proprioceptive neuromuscular facilitation stretching on muscle power in women. J Strength Cond Res. 22(5). pp.1528–1534.

Debate on Stretching McHugh MP, Cosgrave C.H. (2010) To stretch or not to stretch: the role of stretching in injury prevention and performance. Scandinavian Journal of Medicine & Science in Sports. 20(2). pp. 169–181. Naik, G. (2011) Scientists' Elusive Goal: Reproducing Study Results. Wall Street Journal [Online]. Available at: http://online.wsj.com/ article/SB10001424052970203764804577059841672541590.html [Accessed: 19 December 2013]. Page, P. (2012) Current concepts in muscle stretching for exercise and rehabilitation. Int J Sports Phys Ther. 2012. 7(1), pp. 109–119. Reynolds, G. (2013) Do we need to stretch? [Online] N.Y. Times. Available at http://well.blogs.nytimes.com/2013/04/26/ask-well-dowe-need-tostretch/?comments#permid=36 [Accessed 4 November 2013]. Shrier, I. (1999) Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clin J Sport Med. 9(4). pp. 221–227. Schrier, I. (2007) Does Stretching Help Prevent Injuries? In: MacAuley, D., Best, T.M. Evidence-based Sports Medicine, 2nd ed., p. 36-53. Slavko, R., Wüst, D., Schwitter, T., Schmidtbleicher, D. Static Stretching of the Hamstring Muscle for Injury Prevention in Football Codes: a Systematic Review. Asian J Sports Med. March 2013: 4(1): 1 –9. Small, K. et al. (2008) A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury. Res Sports Med. 16(3). pp. 213–31. Sekir, U. et al. (2010) Acute effects of static and dynamic stretching on leg flexor and extensor isokinetic strength in elite women athletes. Scandinavian Journal of Medicine & Science in Sports. 20(2). pp. 268 –281.

Chris Frederick has been a physical therapist/ physiotherapist since 1989, focusing on manual therapy – particularly with integration of Fascial Stretch Therapy and Kinesis Myofascial Integration – along with personalized movement prescription to restore function. He has an extensive background in dance, both as a professional dancer of classical ballet, as well as being a practitioner in the specialty of dance physical therapy/physiotherapy. Chris is also well versed in the ancient movement and healing arts of tai chi and qigong. He is a coauthor with Thomas Myers of the chapter on stretching in the seminal book “Fascia: The tensional network of the human body”. Chris and his wife Ann Frederick are both certified by Thomas Myers in Kinesis Myofascial Integration and are the authors of the popular book “Stretch to Win”, and the new book “Fascial Release Therapy”. They are Directors of the Stretch to Win Institute at www.stretchtowin.com, where they offer certification training workshops in Fascial Stretch Therapy. Read 6 Questions to Chris on Page 50.

Thacker, S. B. et al. (2004) The Impact of Stretching on Sports Injury Risk: A Systematic Review of the Literature. Med. Sci. Sports Exerc. 36(3). pp. 371–378.

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Cervical Injuries & Treatment Strategies By George P. Kousaleos, LMT “Swan neck.” “Bull neck.” “No neck.” “Pencil neck.” “Rubber neck.” “They’re running neck and neck.” “She stuck her neck out.” “You’re a pain in the neck.” The neck is often used to demonstrate physical characteristics or the human condition. The neck is one of the most important and distinguishable regions of the human body. It has multiple responsibilities, including support for the head and face, and coordination of movement between the cranium and thorax. It houses the cervical portion of the spinal cord, seven delicate vertebras, major arteries and veins, lymphatic vessels, lymph nodes, a myriad of muscles, and connective tissue that wraps, envelopes, and interconnects all of the above. As massage therapists quickly learn, pain in the neck affects thousands of people each day. Indeed, neck and back pain are probably the two most common complaints by those who suffer soft-tissue injuries and seek massage therapy as a primary treatment. These pains are commonly caused by automobile accidents, athletic injuries, overuse, or postural distortions. This article will look at the anatomy of the neck, and treatment strategies that include relaxation techniques, clinical procedures, and exercise options for some of the most common client complaints. The Anatomy The deepest structure of the neck is comprised of seven cervical vertebrae. The atlas, or C1, is where the head attaches to the neck. It is different from the other six, in that it lacks a vertebral body. The atlas has 2 arches, anterior and posterior, that allows it to sit atop the axis, or C2. The axis allows for the atlas and head to rotate

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on its unique structure, known as the odontoid process. The odontoid process sits upright, allowing the foramen of the atlas to surround this tooth-like process. The other five vertebrae (C3-7) have a more traditional formation with vertebral bodies, transverse processes, and spinous processes. All of the cervical vertebrae support and protect the spinal cord within the vertebral foramen, an opening that is posterior to the vertebral bodies. Between each vertebra is an intervertebral disk, which consists of a dense outer annulus fibrosus, and a soft, jelly-like nucleus pulposus. Because the intervertebral disks act like shock absorbers, there are many injuries that affect the condition of the disk. Some compression injuries tear the annulus fibrosus, while more serious injuries force the jelly-like nucleus into the vertebral foramen. These injuries can endanger the spinal cord or individual spinal roots or spinal nerves.

Cervical Injuries & Treatment Strategies The muscles of the neck can be divided into three regions – posterior, lateral, and anterior. The deepest muscles in the posterior region include the erector spinae, which are comprised of lateral and medial components. The longissimus and splenius portions form the superficial and deep muscles respectively. The longissimus are responsible for erect posture and the splenii are responsible for rotation. There are also spinalis muscles which attach spinous processes of the upper thoracic and lower cervical vertebrae to the spinous processes of the upper cervical vertebrae. The semispinalis capitis is one of the strongest muscles of the neck, attaching from thoracic and cervical transverse processes to the occipital bone of the skull. Some of the important shorter muscles of the posterior neck include the rectus capitis posterior major and minor, which attach the atlas (minor) and the atlas (major) to the occipital bone. Other important muscles of the posterior neck include trapezius and levator scapulae, which are often considered as head and shoulder muscles, as they attach to the clavicle and scapula, respectively, from the occiput. The most important lateral muscles of the neck include the sternocleidomastoid (SCM) and the scalene group (anterior, medius, and posterior). These muscles either turn the head (SCM) or tilt the head to the side (scalenes). The scalenes are also muscles of quiet inspiration as they lift the first two pairs of ribs at the superior part of the thorax. Between the anterior and medial scalene is the scalene opening, which allows for passage of the brachial plexus and the subclavian artery. The anterior muscles of the neck are also called prevertebral muscles. Most anatomy books include the scalenes in this group, but for our treatment strategies we will view them as lateral muscles. The prevertebral muscles also include the longus capitis, longus colli, and the rectus capitis anterior. These muscles combine to bend the neck and head forward (bilaterally) or tilt the head and neck to the side (unilaterally). The final important soft tissues of the neck consist of three investing layers of cervical fascia and the epimysium of each muscle. These fascial tissues are dense and fibrous and surround the full outer layer of neck musculature, a deeper layer surrounding intrinsic musculature, and the deepest layer, which surrounds the vertebral column. The epimysium of each muscle will often be the site for adhesions and thickening following injury. These layers of fascia are richly innervated with sensory neurons and are often the primary site of strained or injured soft tissues.

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Muscles of the neck (image from Gray’s Anatomy).

Common Neck Injuries Neck sprain or strain is the most common cervical injury that massage therapists treat. These injuries are often caused by impact or contact with another person, object, or surface. Neck sprain or strain is most frequently associated to sports accidents, but can easily occur in falls or automobile accidents. Neck sprain usually refers to ligament damage and neck strain refers to muscle damage. The common symptoms of neck sprain/strain are: 

Pain in the neck that increases with movement



Muscle stiffness and decreased range of motion

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Delayed pain in neck (24 to 48 hours) following accident

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Headache associated to neck pain



Tingling or numbness in arms or hands

Massage therapy treatments can be safely administered once a physician has evaluated the injury and ruled out more serious damage to the vertebra and intervertebral disks. Whiplash occurs when there is forceful impact from behind, causing the neck and head to violently move forward and back in an abrupt motion. While many whiplash injuries are caused from rear-end automobile accidents, there are also lateral whiplash injuries that occur from violent side impact. The common symp-

Cervical Injuries & Treatment Strategies toms are:

The criteria are:



Neck pain and stiffness



Headaches



Pain in the shoulders or upper back

Treat the whole body – all soft tissue is connected through the multiple layers of fascia that surround and support the body.



Difficulty concentrating



Blurred vision or ringing in the ears

Spend considerable time warming the soft tissues of the neck before applying deeper pressure.



Irritability and fatigue



Balance the treatment of the neck by working with posterior, lateral, and anterior regions of the neck.



Address any corresponding issues in the paraspinal tissues of the thoracic and lumbar regions.



Test range of motion of the neck before and after treatment.



Teach safe stretches for the neck and back and encourage the client to practice alignment exercises that improves posture.



Massage therapy is most effective when delivered in a progressive series of sessions that gradually works deeper with less sensitivity.



Go slow, improving the parasympathetic reflexes of the autonomic nervous system.

Like neck sprain/strain, a physician should evaluate the whiplash injury. Based on the severity of the symptoms, MRI or CAT Scans may be useful in determining the severity of the injury. Once structural damage has been ruled out, any massage therapy treatment can be enhanced with the use of ice (for acute stage), or contrast (for chronic stage) therapies. Overuse and Postural Distortions Overuse injuries to the neck are often caused by daily activities that are repetitive in nature, or create undue strain for extended periods of time. These can include carrying heavy backpacks or purses, work-related repetitive motion with the arms and shoulders, or sitting at a desk in a strained position that holds the head and neck forward of the body. The common symptoms are: 

Neck pain and stiffness



Pain that radiates from neck to shoulder



Tenderness at the base of the skull



Chronic, dull pain throughout the neck and upper back



Tension headaches

Massage therapy treatments are even more beneficial if the client can change the repetitive pattern that may have caused the injury. Carrying a lighter backpack or purse in a more balanced position, or changing the workstation to allow for better body mechanics is necessary for an optimal outcome. While forward head position is common in the computer age, postural distortions of the neck may also be caused by distortions in the back, pelvis, or legs. Chronic tightness of the fascia and muscles of the upper neck is one of the primary causes of tension headaches. Treatment Strategies Every discipline of massage therapy can have a positive effect on diminishing neck pain. From Swedish to Shiatsu - from neuromuscular to myofascial - from sports massage to structural integration, a treatment plan that incorporates the following criteria should improve the soft tissue dysfunction found in common neck injuries.

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Treat the whole body The best session strategy is one that incorporates a thorough treatment of legs, pelvis, back, abdomen, chest, and arms, as well as the neck, head, and face. Some massage therapists prefer to start the session with treatment for the extremities and trunk before moving into the neck, shoulders, and skull. Others prefer to start with more general work on the neck, then move to other regions of the body, followed by deeper work for the neck, shoulders, and skull. If time is limited and a full-body treatment isn’t possible, at least work on the paraspinal, chest, and shoulder tissues that attach below the neck, and the cranial tissues that attach from the skull. Warm the tissues Tight, contracted, or shortened tissues do not allow for full circulatory response of blood, lymph, or interstitial fluid. Warming the tissues prior to specific work assists in the body’s ability to nourish and cleanse the affected area. This increases the solubility of the ground substance, or matrix, of the dense fibrous connective tissues, which starts the process of diminishing adhesions and reducing spasm.

Cervical Injuries & Treatment Strategies Balance the neck treatment No matter where the neck injury is, plan a balanced treatment to works will posterior, lateral, and anterior tissues. The older the injury is, the more likely that compensation has built from the opposite side. Work with the client in prone, supine, and side-lying positions to achieve maximum benefit on each area. Address paraspinal tissues Because the neck is a part of the spinal column, spend quality time during the session reducing hypertonicity that is common in the superficial and deep muscles of the back. If obvious kyphosis or lordosis is apparent utilize corresponding methods that improve the alignment and support of the chest and pelvis. Remember that the thoracolumbar aponeurosis is the densest tissue in the back and can restrict the release of tissues in the mid and lower back. Test range of motion Testing the range of motion of the neck prior to treatment will give the therapist and the client a starting point to measure the effectiveness of the treatment. Use forward flexion and hyperextension, lateral flexion to both sides, and rotation in either direction. Have the client attempt each movement with light to moderate effort, as neck pain can increase during movement. Test the same range of motion following the session, again with minimal pressure. Hopefully, the client will have increased their range of motion and will have decreased any painful sensation caused by movement. Teach stretches Along with the cervical range of movement used prior to the treatment, it is also beneficial to instruct the client to stretch the full spinal column through a series of flexibility exercises. Like the neck, the back and trunk should steadily become more pliable. The most common series of stretches include forward flexion (from standing or sitting), side bending (from standing or kneeling), moderate hyperextension (from prone position), and spinal twists (from standing or supine position). Important aspects to consider when teaching flexibility exercises includes teaching the client to use light to moderate effort, to use a full and even breathing cycle, and to use slow and thoughtful movements.

deeper layers of soft tissue. Many clients who are experiencing neck pain can initially handle only light pressure. Progressive sessions also allow the client to practice self-help exercises or other home treatments (ice or contrast) that will expedite recovery. Still other clients have either time or financial restraints that limit the amount of massage therapy that is affordable or practical. For all of these reasons, establishing a progressive series of 3 to 6 treatments will support the recovery from most common neck injuries. Go slow Many disciplines of massage therapy teach, â&#x20AC;&#x153;To go deeper, go slower.â&#x20AC;? Since most neck injuries include strain or spasm of both extrinsic and intrinsic layers of fascia and muscles, the need to manipulate multiple layers of tissue is apparent. Whether it is the first treatment session or the sixth of a progressive series, it is important to remember that by applying pressure too quickly sympathetic responses can easily be stimulated. Most people in pain experience higher levels of fear and anxiety. Controlling the application of pressure through slower stroke speed is critical to successful outcomes.

About the Author George P. Kousaleos, LMT, is the founder of the CORE Institute in Tallahassee, FL. He has practiced and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years. George has served as a member of the Florida Board of Massage Therapy and was Co-Director of the International Sports Massage Team for the 2004 Athens Olympics. He will teach CORE Myofascial Therapy for the first time in Sydney in September 2014.

Progressive series Whether treating neck injuries, or injuries to any part of the body, the best results often happen with a progressive series of sessions that engage increasingly

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CORE MYOFASCIAL THERAPY with George Kousaleos Sydney 26 Sept-5 Oct 2014 "George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success. His amazing CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the human body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapyâ&#x20AC;? - James Waslaski LMT; Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage

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An advanced, six-day workshop designed to give practicing massage therapists in-depth knowledge and hands-on experience in full-body myofascial treatment protocols. With this knowledge and skill, you will be able to improve your clientsâ&#x20AC;&#x2122; structural body alignment and increase their physical performance.

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George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has been a leader in the massage therapy field over his 30-year career. He helped bring sports massage to the 2000 and 2004 Summer Olympic Games, and is a past president of the Massage Therapy Foundation. His website is at www.coreinstitute.com

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Don’t Underestimate the Thorax By Josephine Key A paper by Tsang et al. (2013) offers great kinematic data on functional movement of the upper spine and confirms the clinical approach of many experienced therapists successful in the treatment of ‘neck pain’. The authors concluded that “the motion of the thoracic spine, in particular the upper thoracic spine, contributes to neck mobility, and that the upper thoracic spine should be included during clinical examination of neck dysfunction.” I never treat the neck without addressing the thoracic spine Why so? No part of the body functions in isolation. As the pelvis is to the lumbar spine, the upper thorax similarly acts as an adaptable platform of support for the head and neck. When our postural alignment changes, the natural movement kinematics of the whole spine and in particular those in the upper spine change. This further creates altered loading patterns (tension and compression) of the joints and soft tissues. In time, stiffness and pain will predictably ensue. This pretty much underlies all neck pain syndromes. Many of us adopt a habitual slumped posture sitting at work and during many leisure activities – most of which also invariably involve use of the arms down in front of the body. The shoulder girdle and head and neck ‘hang forward’ off the thorax. We start to lose the sense of and ability to come back up to ‘neutral’. And in time the cervico-thoracic spine and upper thorax becomes stiff. The cervical joints above become the ‘victim’ and can’t assume a neutral position or move properly. Many ‘exercises’ prescribed for neck pain simply bother it more. The secret is to address the ‘criminal’ – to get mobility into the upper thorax and through the cervico-thoracic junction. To this end ‘The Fundamental Shoulder Patterns’ are a good start. (See: www.keyapproach.com.au/blog ). It’s important to realise that it isn’t simply a ‘stiff thorax’ which biomechanically effects cervical function.

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Changed posture-movement of the thorax also directly affects the kinematic patterns and loading patterns of the shoulder girdle. Appropriately treat the thorax and you’ll also make better gains with your shoulder patients Secondly, thoracic joint dysfunction per se has a marked influence not only on the adjacent soft tissues but also upon autonomic function - the autonomic supply to the head and neck is T1-5 and that to the upper limb T2-10. The literature is increasingly showing sym-

Kinematic Chain Normal kinematics of the neck: The interplay between the cervical and thoracic spines By Sharon Tsang, Grace Szeto, Raymond Lee. Published in Manual Therapy 2013 Oct;18(5):431-7. The movement coordination between the cervical and thoracic spine was examined in 34 asymptomatic participants (24 female and 10 male). The authors used 3D motion sensors attached to the skin overlying the head, T1, T6, and T12 spinous processes to measure the angular displacement of the cervical, upper thoracic, and lower thoracic spine during active neck movements. The study found that both the cervical and thoracic spines contribute to active neck motion, the greatest contribution being from the cervical region in all movement directions. The inter-regional movement coordination between the cervical spine and upper thoracic spine in all three planes of movement was found to be high.

Comments by Til Luchau on the paper by Tasang et al. (2013)

pathetic involvement in many central and peripheral pain syndromes. Thirdly, the changed myo-mechanics and altered loading patterns also affect the fascial system which functionally connects the thorax to the head neck and upper limb. This tissue is richly innervated and forms a continuous whole body signalling system and structural web arranged in various layers. If you are not addressing the thorax you will achieve limited results in the treatment of not only head and neck pain, but also shoulder and upper limb pain syndromes â&#x20AC;&#x201C; not to mention low back and pelvic pain.

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It takes a lot of careful work to measure big-picture correlations by piecing together the small-picture details, and this study has endeavoured to do just that. Even though, as Einstein said, "Not everything that counts can be counted, and not everything that can be counted counts,â&#x20AC;? there is an odd kind of satisfaction when we get a quantified validation of something we knew already. Did you know that the spine moves when the neck does? Of course you did, but to see it laid out in nice charts done under carefully standardized experimental conditions reassures us that we really do know what we know. There are a few gems here, for instance, that the lumbars respond more to cervical side bending than to other neck movements. And it would be interesting to see if symptoms correlated to variations in the neck/spine movement coupling, rather than focus solely on asymptotic examples as this study did. Still, kudos to the authors for their diligent work.

Fascial Distortion Model By Frank Rรถmer The understanding of the body language Every day, countless patients try to show and describe their complaints to doctors and therapists. Most of the time their attempts fail as a result of miscommunication or misunderstanding. Doctors prefer an MRI diagnosis, osteopaths find the dysfunction in other parts of the body, PTs work most of their time at the right place but, unfortunately, too often with the wrong techniques. This misunderstanding now has an end in the Fascial Distorsion Model. Through the joining of body language and verbal description of the patients pain, FDM therapists are able to establish an appropriate diagnosis and therapy. The founder and developer of the FDM model was Stephen Typaldos, DO - an American emergency room physician. He noticed that his patients always used the same body language to show their problems and developed the Fascial Distorsion Model in which the clinical signs and the body language of the patients were combined to form a diagnosis and a appropriate therapy. The first distortion discovered by Dr. Typaldos was a triggerband in 1991. Six different distortions are now known and treated. Unfortunately, Stephen Typaldos died in 2006. The FDM is beginning to spread into the professional healthcare communities and trained practitioners can now help to improve and develop this discovery. Dr. Typaldos discovered 6 different disorders within the fascia of the musculoskeletal system. 1. 2. 3. 4. 5. 6.

Triggerband Continuum Distorsion Herniated Triggerpoint Cylinder Distorsion Folding Distorsion Tectonic Fixation

The patient may have one or all six disorders. One of these disorders, the so-called triggerband, is here exemplified. In a trauma, there may be a rotation or splitting of the fascial layer resulting in pain and restricted

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Figure 1. Treatment of a Continuum Distortion of the ellbow movement. Fascia in the body is always oriented to accurately transfer or transmit forces along appropriate planes. If a force is introduced into the system that cannot be physiologically contained, such as a transverse (across the grain) force, a splitting of the fascia may occur. Patients report a drawing, burning pain which they illustrate by moving their fingers along the path of their pain. In the clinic, we see a movement restriction due to the shortening of the trigger strip, a loss of strength and a reduction of stability and coordination. Treatment is done with the therapists thumb following the course of the lesion accurately and with deep pressure to re-establish the normal orientation of the fibres (twisting/untwisting). After closing the fascia it is as good as before the trauma. A third possibility for the emergence of a triggerband is the calcification of the fascia along a stress line. It is assumed that the load is suspended and the patient requires a more stable fascia. To ensure this, the body reinforces the connective tissue with calcium. With the same triggerband therapy as before, the stored calcium is released again from the fascia. Often a repeated treatment is necessary until the patient is pain-free.

FDM The six typical fascial dysfunctions Triggerbands When a triggerband is put under undue stress that leads to a rotation, splitting or calcification of the fascia the patient describes a searing pain and points with several fingers along a line. This distortion can be treated by applying heavy pressure to the affected structure to de-rotate, to close or to decalcify it. Continuum Distortions Ooften the result of a injury in the transitional area between the fascia tissue and the bone. The body loses its ability to respond correctly to external forces in the transitional area. Patients will point with one finger at the point(s) of pain. By applying heavy pressure to this point we encourage the transitional area to be able to accept reasonable external forces again. Folding Distortions Compression or traction forces together with a rotation can cause pain deep within a joint and produce folding distortions. This results in not just a restriction of movement but also a feeling of instability. This can be corrected by traction and compression manipulation. Herniated Triggerpoints Injuries where tissues that normally lay underneath the fascia have bulged through the fascia and have become stuck there. The patient describes a dull as well as a tense pain. By means of heavy pressure eon the HTP the tissue can be pressed into its original position. Cylinder Distortions Tangled coils of cylinder fascia. The ability of the fascia to uncoil and recoil is restricted and maybe even lost. The body language of the patient with a cylinder distortion is extremely varied. Mostly they will run a flat hand over the affected area. The injury is also treated is by using a flat hand and applying pressure to the area. Tectonic Fixations A physiological alteration where the fascial surface has lost its ability to glide naturally. This is painless. Patients often complain of a complete restriction of movement. The treatment of large joints that have indications of tectonic fixations is very strenuous for the therapist and patient.

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In the Fascial Distortion Model, the concept of Chronic Pain patient gets a whole new meaning. Previously, these patients were considered incurable. The FDM provides a different perspective on persistent chronic pain. In chronic pain, there is an incorrect bonding of the split triggerband via cross links, which leads to excessive restriction of the tissue and dysfunctional movement. These pathological cross-links connect structures together which do not belong together leading to even more pain and an even greater restriction of movement. Through a targeted treatment using triggerband technique, the adhesions are dissolved and the lesion is brought back to an acute state where the body can then heal correctly. This results initially in bruising and increased pain as the triggerband is returned to the acute state so the body can re-establish the normal linking necessary for correct physiological functioning. In the second and third treatments, the triggerband is treated with the same technique thus completing the correct realignment of the cross links of the fascial structure. After the treatment, the patient is asked to move and assess whether there is still some remaining pain on movement or whether they are now pain free. The outstanding results of the FDM technique, along with ongoing clinical research into fascial treatments, give therapists a strong foundation on which to build. Old theories, such as muscular contraction causing chronic decreased ranges of motion in the shoulder, are rapidly changing in light of the FDM techniques which can restore full pain free ranges of motion in two treatments. After learning and understanding the model, therapists will be able to immediately achieve greater clinical success based on the ability to correctly assess the patients problems utilizing the FDM's body language assessment and description techniques and then treating with the appropriate FDM therapy. The FDM is a revolution in the entire medical field. Let us work to rethink and improve existing models to identify new disorders and, above all, to find the right therapy for each patient. In the field of fascial research, we will gain in the next few years many new therapies that should not be ignored. An Example of FDM treatment for a supination trauma Previously it was thought that the best treatment for a supination trauma was immobilization, at least partially using a plaster cast for up to four to eight weeks. The assumption was/is that such traumas came from an injury to the ligaments that could be healed by keeping the limb immobilized. Surgery is mostly

FDM avoided. With FDM we have a different approach to the patientsâ&#x20AC;&#x2122; complaints on pain. The most common complaints after a supination trauma are stabbings pains in the lateral malleolus as well as lateral twinging pains in the lower leg running down to the foot. If the complaints disappear after a few weeks there is still often an unstable feeling in the ankle joint. Translated into FDM distortion this means that the patient has a folding distortion on the lateral malleolus continuum distortion, the lateral lower leg triggerbands, as well as in the ankle joint. When beginning the FDM treatment the aim is that the patient has a normal gait after being treated. To begin with the patient should indicate where the painful areas are. This is followed by a triggerband technique to correct the twisted fascia of the lower leg. After the second treatment the patient should be able to hop on the affected leg with feeling any pain. Often though, there is feeling of instability. This is rectified after the third round of treatment by means of a folding technique on the upper part of the ankle joint. If the patient has no further complaints

then the FDM treatment is finished and the patient can play sport again. When everything goes well, correcting a supination trauma should take three days. See examples of FDM treatment in a video: http:// youtu.be/aL2I2dcO7bI

Figure 2. Cylinder Distortion of the lower arm

Figure 3. Treatment of a refolding distortion of the shoulder

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Fascial Fitness with Robert Schleip and Divo Müller Sydney, January 2014 By Kerrie Murphy

“Come and explore the wide matrix of the fascial web and its relationship with Pilates and movement” The New Year began for me in a dusty community hall in Marrickville, NSW, alongside other body workers from many disciplines. We were there to be inspired and to learn from a leading researcher in fascia from the University of Ulm in Germany, Dr Robert Schleip, who led us on a journey of the latest discoveries of the body’s fascial web. His wife, Divo Müller, joined him and presented the practical application of these findings through movement. With industrial fans blowing on the back of our necks in the mid-summer heat, we began madly scribbling down notes about the discoveries Robert and his colleagues had to share, hungry for all the latest findings about the largest sensory organ of the body, fascia. In between Robert’s lectures on recent scientific findings, Divo would have us up on our feet demonstrating the science through motions and with great detail. This exploration took us out on the streets, jumping and skipping towards the playground where we reclaimed our youth, climbing and swinging in and around the equipment. Not quite with grace and vigour, but I am sure with practice this too could spring back! Back to the dusty floors in the hall, and to watch Divo move and ripple like a fish, and swing and bounce with ease, was a delight to see! Then it was our turn to explore. It was great fun and you could really sense the

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fascia moving and rippling under the skin. This was a new and novel experience for me and one to visualise and revisit in Pilates classes for breath, flow and ease. After 4 full days of work with Robert and Divo, I walked away with a greater appreciation of the function and purpose of the living sensory organ. This insight also highlighted how well Pilates trains the body harmoniously. With this new knowledge, I can only draw even more greatness out of the body of work Pilates has to offer and share it with my clients. I was so excited about the world of fascia; I want to share my experience and the highlights of the Fascial Fitness Workshop. Come inside and explore the wide matrix of the fascial web and its relationship with Pilates and movement.

Fascial Fitness & Pilates

Fascia - or ‘fascial net’, ‘fascial body suit’, ‘connective tissue’, is situated beneath the skin and runs in multi directions throughout the body. It comprises of several layers, the superficial layer which is just below the dermis, deep connective tissue membrane which surrounds muscles and bones, and the visceral fascia that suspends organ are within their cavities. It consists of fibrous collagen and soft living tissue, including ligaments, tendons and joint capsules. Healthy fascia is elastic and resilient. When it is properly conditioned, it helps improve movement performance and assists, to a large extent, with injury prevention. Our fascial body suit adapts to the changes of load that are placed on the body. It stretches and shifts in the

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direction that we move. Through movement of the fascia, it remodels the collagen network, which in turn moulds to the body and gives the body suit tone. The Pilates technique has always understood the important role well-trained fascia has when developing a well-balanced body. However, up until now, in the world of sports training, there has been a great emphasis placed on muscle strength, cardiovascular fitness and neuromuscular and coordination training. Modern insight into the field of fascia research has dramatically developed and is now able to apply specific training to the body and incorporate the principles presented more specifically to sports training.

Fascial Fitness & Pilates

Age, sex, body type, hormones, mental state and trauma to name a few, affect the condition and response of fascia. Therefore by understanding the qualities of fascia and how it responds to movement, strategies can be put in place to assess and program more specifically to each individual client.

few repetitions are necessary to achieve optimum results. 3. Fascial release - self treatment on rollers and barrels Stretching, or local compression, increases fluid which enters from surrounding tissues and from the local vascular network. This activity increases lubrication in the areas that are often difficult to reach.

Not only is this information great in targeting and addressing specific areas of the body and general population, but it is also wonderful for the Pilates industry Moving slowly in different directions is an effective way where scientific based evidence is now more attainable to rehydrate the tissues which are then given the chance and supports what we do so well for the health of fascia to soak up nourishing fluids. and it relationship to the whole mind body conditioning. The benefits include increases metabolism, increases The four principles of fascial fitness circulation, decreases fatigue and soreness, and minimises DOMS. 1. Rebound elasticity - the catapult mechanism Exercise has always been known to produce more youthful collagen, however it has now been proven that the type of exercise applied also influences the changes in elastic storage capacities.

4. Proprioceptive refinement - sensory

It has been shown that humans have the same kinetic storage capacity to that of kangaroos. The tendons and fascia are tensioned like elastic rubber bands. The release of this stored energy is what produces large jumps and leaps. This springiness and rhythmic movement is also created when walking and running.

When there is an increase of proprioception there is a decrease in myofascial pain. This has been proven with non-specific lower back pain. The thoracolumbar fascia is drenched in nerve endings and often the problem.

Slow passive stretching in varied angles and actively loaded dynamic stretching through to end range is required for easy shear ability. Not only is the direction and load specific, but it has been shown that increase of collagen fibres is dependent on exercise volume and that

Exercises that draw attention to detail bring awareness to neglected areas of the body. The quality of motions should include slow-motion, very quick micro movements, and large micro movements involving the whole body and while avoiding any jerky actions.

Fascia is the largest sensory organ in the body. It has a rich supply of sensory nerves, proprioceptive receptors, multimodal receptors and nociceptive nerves.

Stress and emotional tension cause changes in back pain, more so through the fascia than in the muscles. So 2. Fascial stretch - stretching the longest possible myo- if the proprioception of the lumbar spine is improved fascial chains through retraining the elastic lumbar, it helps the meDue to the varying density and multidirectional fibres of tabolism of the fascia, stimulates and assists in its healing while the pain receptors of this area are decreased. fascia, each type responds to different types of stretch.

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Fascial Fitness & Pilates Pilates application 1. Rebound Elasticity: Spring like movements that load fascial tissue over multidirectional pathways improve elasticity qualities. 

Foot work: double/single legs with angle variations.

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Jump board footwork and jumps. Encourage light soft landings, rebounding like a bouncing ball.

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Be creative with the upper body through light bounces. For example, springing off the wall with the hands.

2. Fascial Stretch: 3D stretches and rocking motions. Fascia loves to be pulled and stretched in all directions. Consider the long chains of Thomas Myer in order to explore long chains. Front line, back line, lateral line, and spiral line. 

Upstretch, elephant with rotation in torso and legs.

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Side splits with saw.

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Hanging back, swan, rocking.

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Side over of the high barrel/box.

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The twist.

Patience and consistent training of the fascia (up to twice a week) are necessary when it comes to collagen renewal. Unlike muscles, fascia changes more slowly. Schleip compared it to filling an aquarium, one small droplet of water at a time. Slowly the fascia grows, but the results are long lasting. Often however, muscles increase faster and the fascia is overloaded causing strain and tension, and loss of ability to stretch, bounce and move within the body. This highlights the importance of how much load and when to apply that load to the body being worked on, in order to achieve a positive outcome.

3. Fascial release: The fascial release helps dissolve fasMr. Pilates was well and truly on track in acknowledging cial adhesions and nourishes bunched up tissues. the importance of addressing the body as a whole, inThis in turn creates a more flexible body and a sense cluding the working of the fascial web. Ongoing research of feeling good. into the human body never ceases to amaze me in show Barrels and rollers are shaped to help get into those ing just how closely the mind and body work together. places that are hard to reach. With this gained knowledge we now have the ability to  Release - ITB, quads, hamstrings and movements work with a clearer intention and strategy for each perthrough forward bending, extension, lateral flexion son that we see in the Pilates studio for better health and spiralling motions of the spine. and wellbeing.  These actions are similar to squeezing out a sponge, releasing inflammation and waste products, only to The co-ordination of the mind and body is important “...not only to accomplish the maximum result with be replaced by healthy water. minimum expenditure of the mental and physical energy, but also to live as long as possible in normal 4. Proprioception: Increased body awareness has direct health and enjoy the benefits of a useful and happy impact and positive effect on muscular pain. life” (Joseph Pilates, Your Health, Presentation Dynam Breathing and centering exercises, with considered ics Inc. 1998, p.41). pace, direction, spatial orientation and the use of About the Author imagery, can bring proprioceptive attention.  

Balance work - standing lunge, step ups, wobble board, foot corrector and exercise ball variations.

Kerrie Murphy is the director and principal teacher at Infinity Pilates Studio in St Kilda East, Be mindful to use the eyes to lead the body into www.infinitypilates.com. Kerrie is an ex modern dancer space. This micro movement of the eyes improves and ballet teacher, Kerrie’s been practising and teaching spatial orientation and the neural pathways from the Pilates. Applying her extensive experience in the field, eye stimulate greater body awareness. she trains everyone from elite athletes to dancers to people in rehabilitation.

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Jean Pierre Barral’s New Articular Approach Available at www.terrarosa.com.au This series focuses on the new approach to the treatment of the joints that Jean-Pierre Barral and Alain Croibier have developed over the years. More than 40 years of clinical practice have led to this innovative, holistic approach on the: muscles, ligaments, capsule & labrum synovial fluid inside the capsule, arteries & veins, nerves, connections with the organs. 

The Knee—”A Neurological” Joint

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The Hip

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The Lower Leg & Foot

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The Cervical Spine

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The Thoracic Spine

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The Lumbar Spine & Pelvis

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The Elbow, Wrist & Hand

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The Shoulder

The two producers of this DVD, Peter Schwind and Christoph Sommer, have brought their experience gained during a long period of study with Barral and Croibier into this DVD: the purpose of this production is to make these unique, very precise and effective ways of working with the human being more easily accessable and open to a larger public. Peter Schwind and Christoph Sommer have been able to observe, over and over again within a 25-year long period, that therapists and medical doctors who practice various methods find the teachings of Barral a real complement and enrichment to their work.

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Fascia and Back Pain What does a chemical stimulation tell us about it?

By Andreas Schilder Back pain is a worldwide problem causing time lost from work, disability and economic cost. Over 75% of humans suffer from back pain at least once in their lifetime and the yearly prevalence of the working population is 8%, where the lower back represents the most mentioned region. Disorders of osseous structures, disc herniations or nerve root compressions that can be seen on imaging are traditionally assumed to be the only causes of low back pain (LBP). But recently, other sources of LBP, like muscles and fascia, are being more and more appreciated in basic as well as in clinical science. Moreover, immunohistochemical studies showed that thethoracolumbar fascia is innervated by nociceptive free nerve endings [1,4] and that the dorsal horn neurons receive input from the lumbar fascia [2]. From a clinical point of view, we asked the question: Is it possible to distinguish disorders of the fascia with pain of muscular origin by measuring different parameters, such as pain intensity, pain distribution, pressure pain threshold or pain quality?

commonly mentioned by LBP patients, it was remarkable that only the hypertonic saline injections into the fascia, but not those into muscles or subcutis, yielded substantial affective pain ratings, like “agonizing”, “cruel”, “exhausting”, “heavy”, “severe” and “torturing”.

We performed ultrasound-guided bolus injections of hypertonic saline into the posterior layer of the thoracolumbar fascia, the erector spinae muscle and the overlying subcutaneous tissue at lumbar level of twelve healthy volunteers [3].

References

However, hyperalgesia to blunt pressure, a frequent sensory sign in both localized acute and widespread chronic LBP, was only induced by injections into the muscle, not fascia or subcutis. A potential dysfunction of the thoracolumbar fascia thus might lead to a high pain intensity, large pain distribution patterns and substantially high affective pain qualities. Being theoretical, low back pain patients, suffering from spreading strong pain with high affective qualities might exhibit a structural change within the fascial tissue, while the muscle could be of minor interest. This could have positive impact on clinical characterization of patients and their treatment.

[1] Corey SM, Vizzard MA, Badger GJ, & Langevin HM (2011). Sensory innervation of the nonspecialized connective tissues in the low back of the rat. Cells, tissues, organs, 194 (6), 521-30 PMID: 21411968

We observed that the human thoracolumbar fascia was more sensitive to chemical stimulations by hypertonic saline than the underlying muscle and overlying subcutis, according to pain intensity. Control injections of identical volumes of isotonic saline induced only weak and short-lived pain sensation, indicating that distention induced by the bolus injections played a negligible role in pain induction in deep tissues.

[2] Hoheisel U, Taguchi T, Treede RD, & Mense S (2011). Nociceptive input from the rat thoracolumbar fascia to lumbar dorsal horn neurones. Eur J Pain, 15 (8), 810-5 PMID: 21330175

Regarding pain distribution, pain was confined to the ipsilateral side regardless of tissue type. These distribution patterns were measured by marking the painful areas on a scheme showing the back, the abdominal, and leg region, of a drawn standardized body. The painful area after fascia injection exceeded those after intramuscular or subcutaneous injection by far and was in the typical locations of “lumbago”. It was also similar to that seen in pseudoradicular LBP patients, and even consistent with pain distribution patterns given by patients with lumbar facet joint syndrome.

This article is originally published in BodyinMind.org Reproduced with permission.

Given that affective pain qualities are the ones most

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[3] Schilder A, Hoheisel U, Magerl W, Benrath J, Klein T, & Treede RD (2014). Sensory findings after stimulation of the thoracolumbar fascia with hypertonic saline suggest its contribution to low back pain. Pain, 155 (2), 222-31 PMID:24076047 [4] Tesarz J, Hoheisel U, Wiedenhöfer B, & Mense S (2011). Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience, 194, 302-8 PMID: 21839150

About Andreas Schilder Andreas Schilder is a doctoral student in the department of neurophysiology at the Medical Faculty Mannheim of the Heidelberg University (Germany). He obtained his Master degree in “animal physiology” in 2011 and studied “Bioscience” abroad at the Southern Illinois University Carbondale back in 2008. The current interest of Andreas is the contribution of deep soft tissues to back pain and its general characteristics.

Ron Alexander on ® Functional Fascial Taping and Research Can you explain how the research project on Functional Fascial Taping (FFT) came about? I have always been interested in being involved in a research project as have always been interested in how and why things work. Someone said to me years ago that you study to do clinical work and then you continue to learn through doing this work, however, it’s also important to further your understanding through post graduate courses, reading and discussing ideas with peers. Taking part in a research project is a process that allowed me to combine my practical experience and theoretical knowledge and to ask questions about FFT. Research provides the opportunity to test these ideas under controlled conditions. This scientifically adds validity to what you do, whilst increasing your own depth of understanding. Then you have the ability to implement the results into your clinical practice and share this knowledge. This process leads to further clinical observation and questions, and the cycle continues. This constant process of enquiry and testing is what I really enjoy about research. I had discussed the possibility of conducting a research project on FFT with Dr Jill Cook, Head of the Musculoskeletal Research Unit, at Deakin University. As a result of our discussions Dr Cook referred the following patient to me as a test case to determine if FFT could assist a long standing chronic non-specific low back pain patient. The following provides a brief clinical overview of this patient, for a more detailed explanation follow the link http://www.scribd.com/doc/232954803/RonAlexander-FFT-on-Low-Back-Pain. The patient had a history of back pain for 14 years. She had 2 laminectomies for disc decompression. These procedures were 18 months apart, both were unsuccessful and she contin-

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ued to have pain for the next 2 years. Three months prior to the commencement of the FFT treatment, a trunk flexion test showed trunk flexion to be 15°. The patient was given three treatments over a one week period and was able to achieve full flexion. The tape was worn for a further 5 weeks and she was weaned off the tape during this period. The patient made a full recovery, experiencing full range of movement and the total absence of pain. Her final progress was followed up at 3 years with no pain and full range. This successful case study indicated to Dr Cook that a RCT (randomized control trial) on FFT was warranted in order to determine if this result could be replicated with a larger sample size. It had taken me many years of trial and error to get to this point. Dr Cook sourced a Deakin University PhD Physiotherapy student, Shu-Mei Chen who was on scholarship from Kaohsiung Medical University Hospital, Taiwan to conduct the trial. I then submitted the case study for review by the Scientific Committee for the first Fascia Research Congress (FRC) at Harvard

FFT & Research

Figure 1. Taping the foot.

and it was accepted as a poster* presentation (Alexander, 2008a), available at: http:// www.scribd.com/doc/232954803/Ron-Alexander-FFT -on-Low-Back-Pain. Presenting this at the Congress was a great experience as it gives the presenters of posters the ability to talk about studies to delegates and other presenters. Case studies have a role to play in clinical practice and research. Case studies provide the reader with the ability to gain a broader understanding of clinical assessments, treatments and outcomes, and thereby create informed discussion amongst peers. Although the case studies are in themselves not strong evidence for the efficacy of a treatment they can form the basis of research topics and RCTs to test the validity of a treatment scientifically. You presented two posters at the first FRC in Boston. What was the topic of the second poster? The second poster* focused on the results of two real time ultra-sound (RTU) investigations that we conducted into the effect of tension/load from tape (Alexander, 2008b) http://www.scribd.com/ doc/232955487/Functional-Fascial-Taping-real-timeultrasound-investigation . The first RTU was filmed at the Australian Institute of Sport. The procedure involved applying the tape to the quadriceps. We observed the region before and after the application of tape with active knee flexion and extension (FE), to ascertain change. Interestingly we also filmed the application of the tape, without knee movement, in order to observe the presence of load being applied. The tape direction was longitudinal to the thigh and was ½ width of the standard 38mm wide, which makes it tighter. This comes about because force over area equals pressure and in this case the pressure is tension. So if we decrease the width of rigid tape, we increase the force and therefore more tension is possible. When the tape was applied the subcutaneous tissue including the superficial fascia moved in the direction of the tape.

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Figure 2. Taping the hip.

The deep fascia and the muscles below at 3cm deep, moved in the opposite direction. The effect was more than likely deeper, however, the RTU was not calibrated to view the thigh at any greater depth than 3cm. On this occasion we were in fact able to blame the equipment. The tissues and the Retinacula Cutis are held in a new position and muscle activation postapplication was completely different from preapplication. See the “RTU Box” for footage. Many therapists who have viewed the RTU are of the opinion that we are potentially viewing Myofascial Release inside the body, for the first time. The other RTU was conducted in Perth with a very skilled Musculoskeletal Physiotherapist Felicity Kermode who lectures on RTU in various countries. We investigated the Abdominal region using the apex of Transverse Abdominis (TrA) as a reference point to observe if movement was possible from tape. For a more detailed explanation See RTU Box. We applied tape to the Contra Lateral side of the body on the Thoracolumbar Fascia (TLF). The tape direction was from Lateral to Medial using the FFT gathering technique. We thought we may see an effect because the TLF is connected to the TrA. The result was really interesting because the TrA moved in the direction of the tape, however what we didn’t expect and what happened was that the whole abdominal cavity moved, the RTU measured 0.94cm displacement and was in the direction of the tape. The subject remained seated for a period of time and the tissues were held with sustained load in this new position. This observation may lead to new developments in Visceral Manipulation. Have there been any other RTU investigations conducted in relation to FFT? We have conducted many more RTU observations and each time the Subcutaneous Tissue (SCT) moves in the direction of the tape. So we can say with confidence

FFT & Research Real Time Ultra-Sound Investigation of the left Abdominal region. The procedure involved applying the tape to the quadriceps. Watch at http://youtu.be/Epqh_obihjs All 3 movie files are 5 second shots and repeated. The hip is right of screen in all shots. The tape width is ½ width of the The shot is 7.5cm deep, 1 cm markers are shown left of standard 38mm wide. The transducer is longitudinal muscle screen. We can observe the skin and the Subcutaneous Tissue layer. First muscle External Oblique followed by Interfibre direction, in a Mid Saggital line to the Quadriceps nal Oblique, Transverse Abdominis (TrA) and then the AbMuscle. The small dots on the left of screen are the RTU dominal cavity. measuring cm’s deep. 3cm’s deep is shown and a depth of

Real Time Ultrasound (RTU) of Taping Effect

approximately 2mm, we can observe the Subcutaneous tissue layer and the Superficial Fascia layer. Approximately 3mm the Deep Fascia. Greater than 4mm deep, the Muscles. One piece of tape applied, the standard tape application is 3 layers which are tighter each application.

The apex of the TrA is used as a reference point. A little black digital marker can be seen near the center of screen. This is a part of the RTU machine’s measuring tool. At the right of screen you can see +DIST 0.02cm displayed. It should be 0.00, so we need to subtract 0.02 of at the end. 1) Before Flexion and Extension, No Tape. Watch at http:// The digital maker is going to be moved manually, to follow any potential movement of the apex of the TrA. We applied youtu.be/qTjGItE7gb0 tape to the Contra Lateral side of the body. The tape were The first is shot is pre-tape observation under normal condi- applied to the Thoracolumbar Fascia from Lateral to Medial tions with active knee flexion and extension. Observe the using the FFT gathering technique, with 4 pieces of rigid amount of movement in the Superficial Fascia layer and the tape. The white areas shown in the body are the Connective muscle tissues relationship to each other. Tissues and the Fascia being highlighted. The TrA moves to the right of screen and then is measured. What we observe 2) Presence of tape being applied with tension (load). Watch is that the entire Abdominal region moves in the direction of at: http://youtu.be/59bSjlSjQKY the tape. The RTU displays 0.96cm however taking off the 0.02, it shows 0.94cm in the direction of the tape. There is The application of one piece tape with tension, without knee no skin or subcutaneous tissue movement which possibly is movement, in order to observe the presence of load being because a standoff is not used (standoff allows the skin to applied. The deep fascia and the muscles below are moving move) and more than likely the transducer is blocking the in the opposite direction at 3cm’s deep. tissue. 3) With tape on the body with active Flexion and Extension. http://youtu.be/fbP_7boT_EU

You may need to watch a couple of times to make out the RTU digital maker and Connective Tissue movement.

The tissues are held in new position, with load. The muscle activation post application is completely different from preapplication. We can observe virtually immobilisation of the Subcutaneous tissue layer and Superficial Fascia layer. Observe change taking place at the Deep Fascia, Retinacula Cutis and the muscle activity is different from the first RTU.

that the SCT and the Superficial Fascia Tissue Layer (SFTL) move in the direction of the tape and it has a controlling or stabilizing effect to those layers. We have observed the same movement of tissues in a distant region. For example we have applied tape to the proximal forearm, whilst observing with the transducer at the wrist and we observed the SCT and the SFTL move in the direction of the tape and the deep structures moved in the opposite direction and this change was on the opposite side of the body to where we were applying the tape. One possible explanation for this, if we think of the Biotensegrity principle where living tissue and cells are constructed by discontinuous compression columns supported and balanced by tension elements resulting in continuous tension (Fuller 1961,

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Ingber 1998, Levin 2002) then FFT may be offering a strong load by tightening components of the mechanical scaffolding of the body. It may alter the skin and/or remodel the internal architecture of the connective tissue (Ingber 2008, Langevin 2010). These tissues are heavily innervated with mechanoreceptors and potentially change the neural input by stimulating largediameter afferent fibres and then modulate nociceptor input. Another part of our study on FFT also included an RTU investigation on 23 asymptomatic subjects, this was filmed with Deluca J, Senior Musculoskeletal Sonographer at Latrobe University Medical Centre. We investigated motion analysis, from standing position, moving into truck flexion to 65°. The transducer was kept in

FFT Research This state allows patients to perform simple or complex activities depending on the presenting history. Sometimes just having the patient go about normal activity can be enough for them to achieve recovery. However this depends on the duration, nature and severity of symptoms and quite often additional rehabilitation advice is required. This allows the therapist to more accurately address the signs and symptoms of the musculoskeletal condition.

Figure 3. Taping the knee.

constant contact with the skin as the participant performed flexion. In all cases apart from one, the SCT and the SFTL moved independently from the deeper structures and then at some point in range they moved together. The case that did not follow this pattern had the complete opposite reaction in that the tissue layers worked together and then at a point in flexion they worked independently. In an attempt to find out why this occurred we questioned the subject and found out that she was doing regular Pilates, which may have given her better core recruitment and naturally wanting to bend from the hips, however, when asked to bend from the low back she demonstrated a similar pattern of the tissues sliding independently of each other first and then together. The concept of tissues sliding on one another has been around for some time for muscles, tendons and mechanical interfaces. This concept was later applied to the superficial tissues and other structures from the great work by Plastic Surgeon Dr Guimberteau JC and his famous DVD “Strolling under the skin”, which provides an exquisite demonstration of morphing fascial tissues in patients, un-going surgical procedures and returning back to the original configuration when the tissue is released. Why apply FFT when everything goes back to the way it was? By decreasing pain and assisting function, we return a patient to normal movement patterns. This is a key element in the treatment plan because FFT is holding the body in a pain free state for an extended period of time determined by us. Potentially the tape provides proprioceptive muscle activation and creates a decrease in fear avoidance behaviour, as patients are encouraged move into a previously painful position without pain.

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The tape is applied in the direction of optimal ease, which is variable and this is determined from the FFT Assessment procedure. However clinically for years I have observed that sometimes when you apply FFT, the tape direction that relieves pain can sometimes be in the direction or the opposite direction of movement that you are trying to increase. Tape is applied with almost maximum tension by the use of a gathering technique to take the skin and tissue slack up, in the direction you are trying to increase (See Figure 1). Wouldn’t this logically decrease range of motion? However in over 95% of cases what we see is that it actually increases range of motion (ROM). There are some specifics to this application in some regions and I know that this sounds counterintuitive, nevertheless we see this take place in most regions in the body and I find this extremely interesting. I have observed this result thousands of times, firstly with the dancers at the Australian Ballet, then later with athletes and patients. I have taught this technique to thousands of therapists who have observed the same outcome. I have thought for many years that superficial structures could be working independently of the structures below as well as potentially changing neural input. This thinking is supported by a cadaver dissection of the SCT and the SFTL conducted by Gil Hedley. This was the first time a dissection of this type had ever been conducted and recorded. Hedley removed the entire skin layer. He then sliced through the Reticular Cutis to remove the SCT and the SFTL from the Deep Fascia. Hedley also moved the layers on each other to demonstrate the amount of available movement. Put simply in practical terms, you can distract your skin and underlying tissue with strong sustained load, whilst moving your arm. As therapists we do this all the time when performing myofascial release with active motion. We conducted another experiment to determine how far the skin and underlying tissue can move in the low back. This was another part of Chen’s PhD. In this experiment we applied tape in a lateral direction 4cm above and 4cm laterally away from the posterior supe-

FFT & Research rior iliac spine (PSIS). We then used the PSIS as reference point and graphed the body over the hip. The result was that both the skin and underlying tissue had the ability to move up to 2.4cm. This test was undertaken on asyptomatic subjects, we have not as yet tested subjects with super hypermobile tissue, such as Ehlers-Danlos syndrome. The results would also vary in different areas such as over the tibia. When applying FFT the assessment procedure and tape application, one end of the tape is placed directly on the pain site, therefore load is going away from this point. Taping this way is unique to FFT. The tape is applied Figure 4. Taping the lower back. with a strong loading force. The start point could be called point A, the other end of the tape where a resulwill need to contact the relevant department of univertant reactive force would be created, called point B. sities to discuss your proposal. If they are interested, Both these ends pull the skin and underlying tissue tothe professor who will oversee the project, should have wards the centre of the tape, point C. In the centre a list of students who may be interested in undertaking there would be a balance between these two forces (See the research. Figures 2 & 3). According to the tensegrity principle, external force on the skin can transfer to the underlying The depth of understanding that comes from being intissue and cause multi-laminal sliding movement under volved with a rigorous scientific trial, is helped by readthe skin, and that could convert into an internal force ing scientific literature and undertaking clinical work. to evoke different levels and types of mechanoreceptor If your study supports what you are investigating and firing (Chen 2012#). The load from both ends pulling you have a great team then they should have the ability rd into the centre is consistent with Newton’s 3 law, to produce a good publication that will be published in where every action has an equal and opposite reaction. a respected journal with a wide readership. This in turn It’s nice when the physical laws of motion appear to supports our industry. support many years of clinical observation. This conHave you got any tips? cept potentially will lead to new insights into MechaRCTs do take a while. The processes involved are renotransduction and Mechanotherapies. search design, systematic review, ethics application, clinical trial, data collection, publication and thesis. Pain can come from numerous sources in the body and It’s good to remember that the research team will be the effect of applying rigid strapping tape on the body focused on the method and the processes involved in is multidimensional. The principle and application of the project. The subject or technique in the study, is FFT is different to other rigid taping techniques (RTT) that have been shown to be effective in decreasing pain. only one part of the project. The best research is done in collaboration and the ability to compromise is imMy observations of the effect of FFT on the body does portant, which can be challenging at times. Also the not take away from current theories regarding RTT. It amount of detail required in robust trials is incredible is looking at taping from a different perspective. resulting in a very lengthy process, patience is required and the ability to not lose sight of the bigger picture of How can I get involved with a research project? getting a study completed and published. It might also There are various levels of research, if you are looking come as a surprise that no one does research in today’s at robust RCTs, then it is a process that requires a cerworld without a publication in mind. tain level of academic expertise and a different skill set, whereby you will need to work cooperatively with relevant departments within universities. RCTs are normally conducted at PhD level, although there are exceptions to this. A clinician’s involvement can take on many forms and levels, and can lead to higher qualifications if that is part of your goal. In my case, I took on the role of co-investigator for three of the trials. You

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It may also be worth keeping in mind that the investigation may not be exactly the scope that you had intended. I have found that sometimes people try to either support something too hard or want to look at too many variables and this stops the study from ever getting off the ground. It may be better to do a more limited study and then do a follow up study at a later date.

FFT & Research Having a study published in an international scientific journal gives credibility which can make it easier the second time around for your team. My last tip is to believe in yourself, the technique and your team as these elements will see you through when the going gets tough. The knowledge that I have personally gained through the research process has been invaluable. Lastly, good luck and remember, nothing ventured nothing gained!

#Chen

SM. 2012. FFT Thesis. Neurophysiology of the Cutaneous Mechanoreceptors. Deakin University, Supervised by Jill Cook.

Alexander R. 2008a. Functional Fascial Taping for Lower back pain: A Case Report. Journal of Bodywork and Movement Therapies. Volume 12, July 2008, Pages 263-264. Alexander R. 2008b. Functional Fascial Taping Real Time Ultrasound Investigation. Journal of Bodywork and Movement Therapies. Volume 11, April 2008, Pages 390 – 391. Fuller B. 1961. Tensegrity. Portfolio Artnews Annu, 4, 112-127. Levin S. The tensegrity-truss as a model for spine mechanics: Biotensegrity Journal of Mechanics in Medicine and Biology. 2002 vol. 2, #3&4, 375-388. Ingber D. 1998. The architecture of life. Scientific America.

References *Posters. Fascia Research Congress Boston, MA, October 4-5, 2007. The Conference Center, Harvard Medical School. www.fasciacongress.org. Full colour version online download at www.fft.net.au

Ingber D. 2008. Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol. 97:163-179. Langevin HM, Storch KN, Snapp RR, et al. 2010. Tissue stretch induces nuclear remodeling in connective tissue fibroblasts. Histochem Cell Biol; 133: 405–415.

Chen SM, Alexander R, Lo SK, Cook J. 2012 Efficacy of Functional Fascial Taping on Pain and Function in Patients with NonSpecific Low Back Pain: A Randomised Double Blind Placebo Controlled Trial. Clinical Rehabilitation Vol 26, No. 10. 924-933.

Functional Fascial Taping with Ron Alexander “Evidence-Based Pain Relief” This workshop teaches a fast and simple way for clinicians to reduce pain, improve function, encourage normal movement patterns and rehabilitation of musculoskeletal pathologies in a pain-free environment. FFT has been shown to have a significant effect on Non-Specific Low Back Pain in a randomised double-blind PhD study. FFT is a non-invasive, immediate, functional and an objective way to decrease musculoskeletal pain. Presenter: Ron Alexander— STT [Musculoskeletal], FFT Founder and Teacher

Melbourne 11 October 2014

A great way to encourage treatments hold longer

One-Day Refresher for past participants

Brisbane 18-19 October 2014 Sydney 25-26 October 2014 Register Now at: www.terrarosa.com.au

Terra Rosa e-magazine, No. 14 (July 2014)

Cover Feature:

Donna Eddy And Posture Plus

Donna Eddy is an acupuncturist, massage therapist and movement specialist. She is also certified in Pilates, fitness instructing and workplace training. Donna developed the Posture Plus® program inspired from her clinical work, ongoing personal therapy, and her devotion to reduce aches and pains, and boost the wellbeing of her personal training clients. It appeared to her that many of her regular fitness training clients were potential future patients as they had many problems with pain, dysfunctional movement and activity necessitating a different approach. Donna wanted to give her clients a life choice, a system that enabled exercise and movement to become integral to everyday life. The Posture Plus® class program which is a blend of many movement and rehabilitation practices including but not limited to: Posture & Flexibility® (stretch therapy), Pilates floor method, Gymnastics, and Basic strength training The Posture Plus workshops and DVDs enable you to learn how to look after yourself. Donna has two tips to live pain free and enjoy movement: 1. Intention & Attention Being attentive in class (that is any class that you attend) or whilst following our DVDs. You are there to learn and play with your body.

ing on the last phone call you had or the calls you need to make) actually be connected to the moment, your body, the teacher, this position.... you will get more out of the session and more out of your body. 2. What can you do to challenge yourself more? We are all time poor. So how do you get the most out of what you are doing? Set the intention to do as much as you can, and then a little more with each and every movement you make. If you apply point one, you will know where you are and where you have come from, so you will know how much is the ideal amount to challenge yourself and extend your potential. In the Posture Plus program , Donna uses Chi balls to enhance the practice. Used as a prop to align postures to release tension and used as an isolation/ activation tool to perform exercises and drills to the best benefit. If you want a taste of Posture Plus, take advantage of the DVDs available from Terra Rosa website. If you want a Posture Plus workshop session for you or your team; clients; gym members contact donna@postureplus.com.au Read also 6 Questions to Donna on page 49.

 What are you doing in the exercise/ position?  Why are you doing it?  Do you need to practice this regularly or daily? Listen to the cues as they come. If you are present to the movement and present in each moment (not drifting off running checklists through your head or dwell-

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PNF Stretching What does research say about its mechanisms PNF or proprioceptive neuromuscular facilitation stretching, is a popular techniques used in conjunction with manual therapy. PNF can be regarded as a set of stretching techniques to enhance range of motion. PNF uses the body’s proprioceptive system to facilitate or inhibit muscle contraction. To increase the ROM of target muscles, PNF involves a shortening contraction of the target or opposing muscle. The techniques were credited to physiologist Charles Sherrington, who in the mid 1900s, defined the concept of neuromuscular facilitation and inhibition. Following on, Herman Kabat, a neurophysiologist, developed clinical PNF stretching techniques in the 1950s. There are various forms of PNF stretches, mainly Contract Relax or CR, Agonist Contract or AC and Contract Relax Agonist Contract or CRAC. In CR the target muscle(s) is placed into a position of stretch, then a static contraction of the target muscle. This is followed by a gentle stretching, where the muscle is moved into a greater position of stretch. In AC (which is the basis of Active Isolated Stretching) the target muscle is placed into a position of stretch to its end-range, then concentrically contracts the opposing (antagonist) muscle, followed by moving the joint to a new position in the range of motion. CRAC stretching is similar to CR except that following the contraction of the target muscle, a shortening contraction of the opposite muscle is used to place the target muscle into a new stretch position. PNF stretching has been well-proven to improve and provide a greater range of motion (ROM) as compared to static or other type of stretching (Sharman et al., 2006). Despite its success, controversies remain on the mechanism of actions. Neurological reflex muscle relaxation following isometric muscle contraction is the main basis of mechanism suggested for PNF stretches. However such mechanisms are not substantiated by research. Eyal Lederman in his book Therapeutic Stretching said that Post Isometric Relaxation is an erroneous premise. While Ian Shrier in Evidence Based Sports Medicine wrote that Reciprocal Inhibition is a myth that continues to be promoted in textbooks and the medical literature. Let’s look at the two common

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PNF stretching is well-known to improve ROM, however controversies remain on its mechanism of actions. mechanisms proposed for PNF stretching and examine what the antagonists said. Autogenic Inhibition The common explanation of the basis of CR stretching is autogenic inhibition or “reduction in excitability of a contracting or stretched muscle” due to the Golgi tendon organ (GTO) reflex. As part of the body’s selfregulatory mechanisms, GTOs protect muscle and tendon from overstretching. If the muscle belly contracts too forcefully, the GTO sends a signal to the nervous system that triggers the GTO reflex to inhibit the muscle from contracting. In other words, muscles relaxed after voluntary muscle contraction. It is also referred to as post isometric relaxation (PIR) (Hindle et al., 2012). Lederman in his book wrote: “Under normal circumstances, when a person is fully relaxed there is no motor tone in the muscles, i.e. there is no demonstrable activity on the EMG trace. Similarly, when a person is stretched passively the muscle is motorically silent. If muscle activity is observed, it is usually when the stretching reaches the end of ROM at the onset of discomfort and pain. This increase in motor activity is likely to be an evasive response to pain. It means that during the early phase of stretching, the muscle is relaxed and therefore further inhibition i snot possible – cannot relax a relaxed muscle, whereas, at the endranges, motor activity is likely to increase; an outcome which would defeat the purpose (muscle relaxation).”

PNF Stretching Studies showed that following contraction of a stretched muscle, inhibition of the stretch reflex response is transient and only lasts less than a second. Researchers questioned whether such short period of inhibition can result in a clinically meaningful muscle relaxation (Chalmers, 2004). In addition, the hypothesis is that muscle activity should be minimum, but studies using electromyography (EMG) have shown that muscle activity is actually increasing after PNF (not relaxed) (Wilkinson, 1992). Chalmers in his review wrote: “Studies examined suggested that decreases in the response amplitude of the Hoffmann and muscle stretch reflexes following a contraction of a stretched muscle are not due to the activation of Golgi tendon organs, as commonly purported, but instead may be due to presynaptic inhibition of the muscle spindle sensory signal.” Reciprocal Inhibition AC techniques were based upon the basis that stretching of the antagonist muscle creates reciprocal inhibition of the agonist muscle. As explained by Susan Salvo (2007) in Massage Therapy: Principles & Practices: “ When the central nervous system sends a message to the agonist muscle (muscle causing movement) to contract, the tension in the antagonist muscle (muscle opposing movement) is inhibited by impulses from motor neurons, and thus must simultaneously relax. This neural phenomenon is called reciprocal inhibition.” However, when the initial hypothesis was proposed, muscle activity was not measured. When EMG was recorded in the late 1970s, the reciprocal inhibition theory was mostly disproved. As described in the previous section, data from laboratory do not support the theory that contraction of a stretched muscle prior to further stretch, or contraction of opposing muscles during muscle stretch, produces relaxation of the stretched muscle. Muscles are electrically silent during normal stretches until near the end ROM. PNF stretch actually increases the electrical activity of the muscle during the stretch (during antagonist contraction, the muscle supposed to be relax), even though the range of motion is increased (Chalmers, 2004). While the effect of RI can be observed, it is brief and mostly happening under normal voluntary contractions. Studies also showed that PNF has a ‘cross-over’ effect, during a unilateral leg PNF stretching, the ROM in the unstretched leg also increases. The electrical activity in the unstretched leg was also active when the stretched leg was contracting against resistance. ROM gain following a CR stretch is the same whether the target stretching muscle is contracted, or an uninvolved muscle is contracted (Markos, 1979).

Research results do not support the theory that contraction of a stretched muscle prior to further stretch, produces relaxation of the stretched muscle. PNF stretch actually increases the electrical activity of the muscle during the stretch Summary Various mechanisms other than the spinal processing of proprioceptive information have been proposed. The contemporary view proposes that PNF stretching influences the point at which stretch is perceived or tolerated (Magnusson et al, 1996). The mechanisms underpinning the change in stretch perception or tolerance are not yet known, although pain modulation has been suggested. Other possible mechanisms include:  Distraction that increase stretch tolerance  Analgesia following sustained isometric contraction, thus increased stretch tolerance  Changes in viscolesticity of the muscles induced by PNF A recent study by Konrad et al. (2014) from Austria evaluated a six-week stretching program (including static, ballistic, or PNF stretching) on the various parameters of the gastrocnemius muscle and the achilles tendon. Several functional (Range of Motion, maximum voluntary contraction , etc.) and structural (fascicle length, tendon and muscle stiffness, etc.) parameters were evaluated. The results showed PNF increases ROM and decreases tendon stiffness. All stretching intervention increased ROM. However only in PNF stretching structural changes (decrease of tendon stiffness) were observed. However the decrease in tendon stiffness could not solely explain the change in ROM. Thus, Konrad and Tipp (2014) concluded that the increased ROM due to stretching could not be explained by the structural changes in the muscle-tendon unit, and was most likely due to increased stretch tolerance possibly due to adaptations of nociceptive nerve endings . Although there are still controversies behind the mechanisms underlying PNF, there is no doubt on its

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PNF Stretching efficacy. Sharman et al. (2006) recommended the following: “PNF techniques that are more effective utilise a shortening contraction of the opposing muscle to place the target muscle on stretch, followed by a static contraction of the target muscle. The inclusion of a shortening contraction of the opposing muscle appears to have the greatest impact on enhancing ROM. When including a static contraction of the target muscle, this needs to be held for approximately 3 seconds at no more than 20% of a maximum voluntary contraction. The greatest changes in ROM generally occur after the first repetition and in order to achieve more lasting changes in ROM, PNF stretching needs to be performed once or twice per week.” References Chalmers, G. "Strength training: Re‐examination of the possible role of golgi tendon organ and muscle spindle reflexes in proprioceptive neuromuscular facilitation muscle stretching." Sports Biomechanics 3.1 (2004): 159-183. Hindle, K., et al. "Proprioceptive neuromuscular facilitation (PNF): Its mechanisms and effects on range of motion and muscular function." Journal of human kinetics 31 (2012): 105-113. Konrad, A., M. Gad, and M. Tilp. "Effect of PNF stretching training on the properties of human muscle and tendon structures." Scandinavian journal of medicine & science in sports (2014). Konrad, A, and Markus T. "Increased range of motion after static stretching is not due to changes in muscle and tendon structures." Clinical Biomechanics (2014).

Increased ROM from PNF stretching was likely due to increased stretch tolerance possibly due to adaptations of nociceptive nerve endings . Magnusson, S. P., et al. "Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle." Archives of physical medicine and rehabilitation 77.4 (1996): 373-378. Markos, P. D. "Ipsilateral and contralateral effects of proprioceptive neuromuscular facilitation techniques on hip motion and electromyographic activity." Physical therapy 59.11 (1979): 1366-1373. Osternig, L.R., et al. "Muscle activation during proprioceptive neuromuscular facilitation (PNF) stretching techniques." American Journal of Physical Medicine & Rehabilitation 66.5 (1987): 298-307. Sharman, M., et al. "Proprioceptive neuromuscular facilitation stretching." Sports medicine 36.11 (2006): 929-939. Shrier I. “Does stretching help prevent injuries?” In: MacAuley D, Best T, editors. Evidence-based sports medicine. London: BMJ Publishing Group, 2007. Wilkinson, Andrew. "Stretching the truth. A review of the literature on muscle stretching." Australian Journal of Physiotherapy 38.4 (1992): 283-287.

Lederman, E. Therapeutic Stretching in Physical Therapy: Towards a Functional Approach. Elsevier Health Sciences, 2013.

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Barefoot vs. Shod Running A matter of preference? There has been a great interest in barefoot running. Several athletes running in barefoot were epitomized, Abebe Bikila from Ethiopia ran barefoot and won a marathon gold medal in the 1960 Summer Olympics. (In the 1964 Olympics he won again, but wearing shoes). British runner Bruce Tulloh won the gold medal in the 1962 European Games running barefoot in a 5,000 metre race. In 1985 Zola Budd broke world record in 5000 m run with barefoot. The Tarahumara people in Mexico are renowned for their long-distance running run barefoot. The book “Born to Run” by Cris McDougall published in 2009 sparked worldwide interest in barefoot running. It was claimed that based on theory of evolution, long-distance running ability was crucial for human survival. Human has been running for hundreds of thousands of years to chase prey or to outrun predators. This is followed by Daniel Liebermann, professor of human evolutionary biology at Harvard, who published an article “Foot strike patterns and collision forces in habitually barefoot versus shod runners” in the prestigious journal Nature. (see http:// www.barefootrunning.fas.harvard.edu/) Shoes companies also start to make “barefoot” or “minimalist” shoes and many claims have been made about the advantages of barefoot over shod running. Sales of minimalist shoes increased 300 percent in 2012, compared with a 19 percent increase in traditional running shoe sales in that same year. There’s an enormous publicity on barefoot running, and many claims made about its positive effects and superiority over running shoes. Benno Nigg and Henrik Enders from the Human Performance Laboratory at the University of Calgary investigated and published a critical review in the journal Footwear Science last year. They

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critically examined the claims based on available research evidence. Nigg also presented this work at the Connective Tissues in Sports Medicine Congress in 2013 at the University of Ulm in Germany. This article is based on Benno Nigg’s lecture and paper. Barefoot running land on forefoot (toe) while people running on shoes (shod) landed on the rear (heel). Lieberman et al. (2010) wrote: “habitually barefoot endurance runners often land on the fore-foot (fore-foot strike) before bringing down the heel, but they sometimes land with a flat foot (mid-foot strike) or, less often, on the heel (rear-foot strike). In contrast, habitually shod runners mostly rear-foot strike, facilitated by the elevated and cushioned heel of the modern running shoe.” An unpublished thesis by Herzog (1978) examined the landing strategy for barefoot running either on asphalt or grass based on 180 trials. Herzog found that running on asphalt, 23% landed on heel while 77% landed on forefoot. Meanwhile on grass, 54% landed on the heel, while 46% on forefoot. This implied ground condition heavily influenced landing pattern of the foot. In a recent study by Hatala et al. (2013) observed 23 subjects that are habitually barefoot in Northern

Barefoot Running ing created a shift of internal forces, the structure that are loaded are different, where the internal joint forces are similar. Barefoot running has less injuries

“Barefoot” minimalist shoes. Photo courtesy of Donna Eddy.

Kenya. Subjects ran at self-selected endurance running and sprinting speeds. The data showed that 72% landed on the heel, 24% on midfoot and 4% on forefoot. The results indicate that not all habitually barefoot people prefer running with a forefoot strike. The statement that barefoot running is associated with forefoot landing is thus not well supported by evidence. The studies suggest that landing strategy depends on many environmental and personal conditions, such as the surface condition, footwear, the subject, speed (e.g. sprinter don’t land on heel), training, etc. Forces on barefoot running is smaller than shod Liebermann et al. (2010) suggested that barefoot forefoot strikers generated lower impact forces compared with shod rearfoot strikers. This is based on studies of ground vertical force, which measures the (vertical) force back against the foot when the foot strikes on the ground during running. Nigg argued that higher impact forces are not associated with higher risk of injuries. In a review by Zadpoor and Nikooyan (2011) , the authors found no significant difference between the ground reaction force impact peaks for people developing a stress fracture compared to controls. Nigg also suggested that we should look at the internal forces for heel and toe landing. Based on his analysis, in toe-landing, the force is mostly on the achilles tendon, meanwhile for heel-landing mostly forces is on the tibialis anterior. The change between toe and heel land-

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This claim advocated by Robbins and Hanna (1987) based on anecdotal evidence from their work in Haiti that people that come to the clinic are the people who wear shoes. It was believed that toe landing create smaller impact forces. Likewise, Nigg argued that people that had shoes that can afford to go to the doctor. Robbins and Hanna (1987) proposed that running shoes with supportive structures and absorbent cushioning suppressed sensory feedback and therefore increased the likelihood of lower extremity injuries. Thus, they recommended barefoot running as a possible solution to running-related injuries. It is also reasoned that toe landing creates smaller impact forces of landing. However there is no experimental or even theoretical evidence on this claim. Nigg noted that running injuries have not changed over the years despite the massive development of the running-shoe industry. Bahlsen (1989) evaluated different landing impact forces on relative injury frequency and found no significant differences in injuries for low, medium, and high impact forces. However people with firm landing (high loading rates) significantly have fewer injuries. There is no experimental evidence that barefoot running has less injuries. A review by Murphy et al. (2014) concluded that “barefoot running is not a substantiated preventative running measure to reduce injury rates in runners”. Reports in 2010 seen a large increase in injuries caused by running barefoot or with minimalist shoes (Fitzgerald, 2010). A recent study from Griffith University Australia showed that transition to minimalist footwear appears to increase the likelihood of experiencing an injury, specifically increasing pain at the shin and calf (Murphy et al., 2013). The authors speculated that the runners who switched to full-minimalist shoes may have been forced to change their running form. Similarly a crowd-sourced data showed that the risk to suffer a running related injury was significantly increased during the period of changing from shod to minimalist running (Daumer et al., 2014). Prof. Lieberman said that “If you switch to minimal shoes or go barefoot you need to (a) do so gradually so your body can adapt, and (b) you need to learn proper running form.” Recently Vibram, the minimalist shoes company, agreed to pay

Barefoot Running $3.75 million in refunds to purchasers after a class action lawsuit accused the company of making claims without scientific backup that the Five Fingers shoes could decrease foot injuries and strengthen foot muscles. Barefoot running requires less energy This aspect can be looked at based on energy consumption on a global (respiration) and local (oxygenation of muscle tissues). Barefoot is believed to consume less oxygen as logically an increase in mass (due to shoes) should increase volume of oxygen (O2) demand. Frederick et al. (1984) gave a rule of thumb that 100g of additional mass will results in additional 1% of energy demand. However a recent study by Franz et al. (2012) did not find this relationship to be universal. Increase in shoe mass up to 300g, did not result in any change in O2 consumption. The additional mass added to the foot by the shoe does not seem to have a negative effect on the performance until at a ‘threshold mass’ of about 200 to 250 g. The reason is not fully understood yet, it could be a threshold of mass effects, or different shoe characteristics, etc. Franz et al. (2012) further studied the effect of mass on 3 types of runners (1) barefoot, (2) with shoes that weigh 150g, (3) barefoot with added 150g weight. The subjects were midfoot landing that run 25 km/week with 8 km/week on barefoot. The results show no difference between barefoot (1) and shoes (2). Furthermore there is a 3-4% less oxygen use for shoes (2) compared to barefoot (3). Possible factors include stride length or frequency, shoe damping effect from inserts, comfort or preference. The results of these studies are inconclusive and thus it is suggested that additional information may be found through the investigation of local energy aspects during running. There is also no significant difference between running barefoot or with running shoes in muscle activity. Nigg and his colleagues studied the soft tissue vibrations, caused by the landing of the foot on the ground which results in waves that travel up the body from the feet to the head. The vibrations of soft tissue compartments due to impact are usually damped. The magnitude of soft tissue vibration damping can serve as an indicator for the amount of work a muscle needs to expend for impact related vibration damping. A study by Enders et al. (2013) looked at participants who ran at 3.5 m/s on a treadmill in shoes and barefoot using a rearfoot and a forefoot strike for each footwear condition. The preferred strike patterns for the subjects were a rearfoot strike and a forefoot strike for shod and bare-

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foot running. The results showed that neither shod and barefoot nor rearfoot and forefoot strike resulted in a consistent change of the damping coefficient. Only preferred movement pattern showed significantly lower damping coefficients compared to the non-preferred strike pattern. It is suggested that a runner’s individual movement preference might be a much more important and influential aspect when considering soft tissue vibrations. Energy Storage in Running Alexander (1987) suggested that runners bounce along their tendons and ligaments. It was suggested that running shoes take away the natural musculature spring of the foot and lower legs. Running involves a “massspring mechanism” an exchange of potential and kinetic energy in the tendons and ligaments. Tendons and ligaments are elastic tissues that can store energy, where they are stretched and then release energy as they recoil. The main springs are the Achilles tendon and the longitudinal arch of the foot. Achilles tendon can store 35 Joule per step for running and, the arch of the foot can store 17 Joule. The mechanical energy per step is 100 Joule, and it was suggested that the arch and Achilles tendon can return 52% of the energy captured in each step, when we run. A study Perl et al. (2012) concluded that minimally shod runners are modestly but significantly more economical than traditionally shod runners regardless of

Barefoot Running strike type. The likely cause of this difference is more elastic energy storage and release in the lower extremity during minimal-shoe running.

Photo courtesy of Donna Eddy.

However there is still a great uncertainty on how much of the energy is returned. Nigg argued that if we were to use the Achilles tendon, we would hop like a kangaroo not run. He also argued that if we were to use 17% of the energy form the arch, then most sprinters will have a high-arch. Similarly athletes would not use orthothics that do not allow the foot to deform. . There is also a high variation of stiffness in the Achilles tendon, from a factor of 100 to 1000. Currently the theory and data on storage and return of energy in running is not well understood yet. Conclusions In conclusion, Nigg said that it's not the right question to ask or to compare ,which is better barefoot running or wearing running shoes. The most important factors in mitigating risk of foot injuries and raising running performance, are individual preference and comfort. The bottom line is if it doesn't feel good on your feet, don't run with it.

mond, B. G. (2013). Variation in foot strike patterns during running among habitually barefoot populations. PloS one, 8 (1), e52548.

References

Lieberman, D. E., et al. (2010). Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature, 463(7280), 531-535.

Alexander R. McN. (1987). The spring in your step. New Scientist 1588, 42-44, 30 April 1987. Bahlsen, A., (1989). The etiology of running injuries, a longitudinal, prospective study. PhD University of Calgary. Daumer, Martin, et al. (2014) Overload injuries in barefoot/ minimal footwear running: evidence from crowd sourcing. PeerJ PrePrints No. e250v1. Enders, H., von Tscharner, V., & Nigg, B. M. (2013). The effects of preferred and non-preferred running strike patterns on tissue vibration properties. Journal of Science and Medicine in Sport, 17(2), 218-222. Fitzgerald, M. (2010). The barefoot running injury epidemic. Competitor Franz, J. R., Wierzbinski, C. M., & Kram, R. (2012). Metabolic cost of running barefoot versus shod: is lighter better. Med Sci Sports Exerc, 44(8), 1519-25.

Herzog, W. (1978) Thesis Dissertation, ETH, Zurch.

Nigg, B., & Enders, H. (2013). Barefoot runningâ&#x20AC;&#x201C;some critical considerations. Footwear Science, 5(1), 1-7. Lorenz, Daniel S. Pontillo, Marisa. "Is There Evidence to Support a Forefoot Strike Pattern in Barefoot Runners? A Review." Sports Health. November/December 2012 vol. 4 no. 6 480-484 Murphy, K., Curry, E. J., & Matzkin, E. G. (2013). Barefoot running: does it prevent injuries?. Sports Medicine, 43(11), 1131-1138. Perl, D. P., Daoud, A. I., & Lieberman, D. E. (2012). Effects of footwear and strike type on running economy. Med Sci Sports Exerc, 44(7), 1335-43. Ryan, Michael, et al. "Examining injury risk and pain perception in runners using minimalist footwear." British journal of sports medicine (2013): bjsports2012.

Frederick, E.C., Daniels, J.T., Hayes, J.W.(1984) Current Topics in Sports Medicine, pp. 616-625

Robbins, S. E., & Hanna, A. M. (1987). Running-related injury prevention through barefoot adaptations. Medicine and Science in Sports and Exercise, 19(2), 148-156.

Gruber AH, Umberger BR, Braun B, Hamill J. "Economy and rate of carbohydrate oxidation during running with rearfoot and forefoot strike patterns." Journal of Applied Physiology. 2013 Jul;115(2):194-201.

Zadpoor, A.A. & Nikooyan, A.A. (2011). The relationship between lower-extremity stress fractures and the ground reaction force: A systematic review. Clinical Biomechanics, 26 (1), 23â&#x20AC;&#x201C;28.

Hatala, K. G., Dingwall, H. L., Wunderlich, R. E., & Rich-

Terra Rosa e-magazine, No. 14 (July 2014)

Working at the End Range of Motion Q&A with Art Riggs

DEAR ART, You sometimes mention “working at the end range of motion.” Why do you suggest that, and how do I work this way? —EXPANDING HORIZON

DEAR EXPANDING,

Restriction will vary from person to person; just have your client assume the position and ask what areas are hampering the posture. As you free up the most obvious one, you will often find that another link in the chain is crying out for some caring attention.

Photo Courtesy of Donna Eddy.

In a nutshell, short and tight fascia, ligaments, and muscles can prevent full range of motion of the bones. If we work on these tissues in a shortened or even neutral length, we can soften them, but we lose the chance to educate them to release and lengthen, thereby re-establishing movement and protective neural patterns that allow more mobility. I rarely see someone complaining of a problem in the neutral range of motion; instead I hear, “It hurts (or is limited) when I do this”—with “this” being some limitation near the end range of motion where soft-tissue restriction prevents more movement. For this reason, I frequently work with joints extended

comfortably very near the end range to challenge the restriction by asking for active movement as I work. Most of us work this way in varying degrees when we rotate or side-bend the neck. Working this way is particularly helpful (and popular) with athletes, yoga practitioners, or anyone with an active lifestyle who wants more mobility. There really isn’t anything fancy or difficult about it; I just ask people to get into positions where they complain of limitations and work in these positions at the precise area where they feel the “rubber band” tightening. Rather than demonstrating many different postures, let’s examine a couple of yoga postures to illustrate the versatility of these techniques; you can then generalize from these to suit your needs. Once you begin working in this way, the positions are limitless. My students often mention how it transforms their practices, making their work more interesting and fun, and gets them rave reviews from clients.

Terra Rosa e-magazine, No. 14 (July 2014)

Working at the End Range of Motion

Downward-Facing Dog 1. If tight calves or Achilles tendons are limiting factors, simply focus on those areas by either stretching a muscle or fascia away from an anchor, or by facilitating release by working in the direction of muscle lengthening. Notice if the restriction is superficial or deeper (Image 1). 2. Hamstrings, gastrocnemius, plantaris, popliteus, or tight superficial fascia can all restrict full extension of the knees. In addition to releasing short tissue, consider working with rotational patterns by rolling muscles or fascia to stretch in a straight line and improve tracking of the joint (Image 2).

2 3

3. Of course the proximal hamstrings are often restricted, but some restriction is almost always located at the transition between the pelvis and the low back. Have your client rock her pelvis back and forth, freeing external fascia near the sacrum, the lumbar fascia, and deeper muscles near the spine, including gently mobilizing the lumbars to facilitate extension (Image 3). 4. To free the shoulder girdle and arms, work to mobilize the scapulae to slide over the ribs, focus on the transition to the arms for abduction and rotation, and gently mobilize the thoracic kyphosis to improve its ability to extend (Image 4). The Lotus Pose

Either the full or half Lotus requires flexibility in many areas not demonstrated here (such as the ankle or rotation of the tibia on the femur), but letâ&#x20AC;&#x2122;s look at external rotation of the femur and freeing the low back and upper pelvis. 1. On a deep level, this is an excellent way to work with freeing the joint capsule by placing your intention on sinking through superficial tissue and rotating the actual femur in the acetabulum. Experiment with both compression or traction of the joint as you work the thigh through various ranges of motion. Move superficially, working with muscles and superficial fascia to freely rotate around the bone by grabbing large sections of the quads and iliotibial band. Remember to bring the tissue to its restrictions and then slowly wait for the tissue to melt (Image 5). 2. Pelvic mobility is very important. Work on the lumbar fascia, quadratus lumborum, and the upper attachments of the gluteals, asking your client to tilt her pelvis both anteriorly and posteriorly (Image 6). You can work on the table, seated, or on the floor. Working this way necessitates a rewarding communication with your clients and a few minor changes, such as explaining what you have in mind and why, and having them wear proper clothing to enable the different postures. Working on flexibility, not only of our clients, but with our definitions of bodywork, will keep your work fresh, fun, and effective. Art Riggs is the author of Deep Tissue Massage: A Visual Guide to Techniques (North Atlantic Books, 2007), which has been translated into seven languages, and the seven-volume DVD series Deep Tissue Massage and Myofascial Release: A Video Guide to Techniques. Visit his website at www.deeptissuemassagemanual.com.

Terra Rosa e-magazine, No. 14 (July 2014)

The Heskiers OneTool™ The All-in-one Bodywork Tool—The One Tool You Need

An ergonomically designed myofascial release tool that offers potentially effective and precise bodywork treatments for bodywork professionals. The Heskiers OneTool™ can be used in combination with your existing bodywork techniques . Practitioners can use the Heskiers OneTool to open the muscles in preparation for their respective treatments. The Heskiers OneTool™ can assist your hands by minimizing the pressure needed to give effective deep tissue treatments and may protect you from work related injuries to your hands, arms and shoulders.

Available at www.terrarosa.com.au

Terra Rosa e-magazine, No. 14 (July 2014)

Throwing and Elastic Storage By James Earls

Fig 1 . Baseball pitcher.

Recently, an article on biomechanics and evolution published in Nature (Roach et al., 2013) managed to attract much attention in the US based press. It did so by comparing the throwing abilities of Homo Sapiens to that of our primate cousins. Headlines screamed ‘Scientists Unlock Mystery in Evolution of Pitchers’ which is, of course, an area of huge interest to the average American sports fan but also, as a therapist, piqued mine. Within the Nature article, researchers compare many unique features that differentiate our shoulders from those of the apes, especially the lower torsion through the humerus that allows us a greater range of motion into external glenohumeral rotation. This increased

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range, according to the authors, allows more build up of elastic energy that can compensate for our weaker muscles. What they did not identify was which tissues are involved in this elastic mechanism. An interesting addition within the article noted Darwin’s idea of how bipedalism has ‘emancipated’ the arms, allowing us the freedom to manipulate and to throw. It is my contention, however, that whilst lumbar extension allows us bipedalism it also provides us the ability to couple and as well as uncouple the arms from the rest of the body. The longer waist that developed from Australopithecus (3.4 -1.9 million years ago) onwards also ‘decoupled’

Throwing & Elastic Storage These combine to increase the range of movement between the left hand and both feet that requires a lengthening of the tissues in between. The lines of tension used for this extreme throwing position are somewhat predictable if we consider the myofascial continuities mapped out by Myers (2013, Figs 2 and 3). The pitcher’s left ‘Superficial Front Line’ (Fig. 2) is lengthened and thereby, one has to presume, elastically loaded. Much of the anterior thigh tissue from his left lower limb will assist with deceleration in the cocking phase, capturing kinetic energy in the elastic tissues that can then be released to assist the acceleration of the pelvis during the throw. However, this dynamic will not be limited to individual segments through in-series tensioning the anterior thigh tissues may also assist the rectus abdominis and sternal fascia in their role of spinal control. Similarly, the adductors of the planted right lower limb assist with the control of the rectus abdominis and obliques with their connection into the pectoralis major via the so-called ‘Front Functional Line’ (Fig. 3).

Fig 2 . The Superficial Front Line according to Myers (2013).

the torso and the pelvis allowing greater range of movement between the lower and upper limbs. By going to greater ranges of rotation and extension the pitcher/ hunter/thrower can build up more elastic tension between each segment giving added acceleration to the distal hand. We can see this as a series of separate blocks and units (lower limb, pelvis, thorax, and upper limb) with the relevant elastic tissues between each) with the relevant elastic tissues between each however, this is only part of the truth within the body. Following the demonstration of strain distribution by Franklyn-Miller et al. (2009), we can also view the relationships through a myofascial lens that emphasizes the fascial connections from one segment to another. In looking at the extreme cocking position of the pitcher in figure 1 we see the left hip and spinal extension along with the pelvic, thoracic and shoulder girdle rotation.

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These in-series myofascial connections rely on appropriate ranges of motion through the whole system. If we are to recruit the potential energy created in the lengthening of the lower limb and trunk tissues to assist the recoil of the throwing arm we must be able to achieve complex positions similar to that shown in figure 1. Without the extension and abduction of the left hip, the flexion, abduction and lateral rotation of the right hip (all of which require the extension and rotation of the spine) we could not pre-tense and elastically load the thigh and trunk. Limitations in joints or tissues beyond the shoulder complex may therefore contribute to overworking the local soft-tissue of the shoulder complex. The rotator cuff and pectoralis major, for example, will work harder to decelerate the cocking and to accelerate the throw. Any decrease of in-series tensioning will require more work from those tissues due to the loss of elasticity and distal contributions. Through in-series tensioning the tissues of the lower body thereby assist the shoulder in its recoil (in parallel mechanisms will also be present but are beyond the scope of this article). By being able to see the line of force involved in long chain movement we can analyse the actions which should be present at each joint along the line and then investigate the reason for any restriction - motor control, soft tissue or joint limitations distal to a pathology could be responsible, or at least

Throwing & Elastic Storage References Earls, J., Born to Walk: Myofascial Efficiency and the Body in Movement. Chicester; Lotus Publishing; 2014 Franklyn-Miller, A., E Falvey, R.. Clark, A. Bryant, P. Brukner, P. Berker, C. Briggs, P. McCrory. 2009. “The Strain Patterns of the Deep Fascia of the Lower Limb.” Fascia Research II. Edinburgh, UK: Elsevier. Fukashiro, Senshi, Hay, Dean C. and Nagano, Akinori. Biomechanical Behavior of Muscle-Tendon Complex During Dynamic Human Movements. Journal of Applied Biomechanics: 22; 2006; 131-147 Fukunaga, Tetsuo, Kawakami, Yasuo, Kubo, Keitaro and Kanehisa, Hiroaki. Muscle and tendon interaction during human movements. Exercise Sport Science Review: 30; 3; 2002; 106–110 Gorman, J. Scientists Unlock Mystery in Evolution of Pitchers. The New York Times 26 June 2013, Available at: http:// www.nytimes.com/2013/06/27/science/evolution-on-themound-why-humans-throw-so-well.html? pagewanted=all&_r=0 Gracovetsky, S. The Spinal Engine. Montréal; Serge Gracovetsky, PhD; 2008 Myers, T. W., Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. Edinburgh; Churchill Livingstone Elsevier; 2013 Roach, N. T., Venkadesan, M., Rainbow, M. J., & Lieberman, D. E. Elastic energy storage in the shoulder and the evolution of high-speed throwing in Homo. Nature, 498(7455); 2013; 483-486.

Fig 3 . The Front Functional Line according to Myers (2013).

contributory to the problem Differential diagnosis and treatment programs can therefore be developed to address the issues distal to the affected site and that process can be aided with an understanding of the myofascial continuities. Finally, returning to Darwin’s comment on emancipation of the arms we can hopefully now see that lumbar extension provides us with both a freedom from weight bearing and access to manipulation. And, through the myofascial tethering, it also allows us a connection to the lower limbs, a greater range of movement that gives us the ability to harness more power though the system of our body. To utilize that power however, the pathways along the body must be clear – a truth not only for pitchers but for anyone using long chain complex movements.

Terra Rosa e-magazine, No. 14 (July 2014)

James Earls is a writer, lecturer and bodyworker specialising in Myofascial Release and Structural Integration. Increasing the understanding and practice of manual therapy has been a passion of James’ since he first started practicing bodywork over 20 years ago. Throughout his career James has travelled widely to learn from the best educators in his field, including Thomas Myers, developer of the Anatomy Trains concept. James and Tom founded Kinesis UK, which co-ordinates Anatomy Trains and Kinesis Myofascial Integration training throughout Europe, and together they authored ‘Fascial Release for Structural Balance,’ the definitive guide to the assessment and manipulation of fascial patterns.

JUST PUBLISHED Born to Walk presents the therapist with a powerful tool to assess and analyse movement. It breaks down walking into the 'essential events' that are required at each joint, then analyses how this series of events is integrated through the transfer of force along the Anatomy Train lines to create efficient human locomotion. Author James Earls combines the insights of evolutionary anatomy with the Anatomy Trains model and the latest research on the many roles of the fascial tissues to create an up-to-date and novel vision of how we walk.

Available at www.terrarosa.com.au In “Fascial Release for Structural Balance”, authors James Earls and Thomas Meyersboth respected bodywork professionalsargue that approaching the fascia requires “a different eye, a different touch, and tissue-specific techniques.” Designed for any bodywork practitioner using manual therapy, this book offers a detailed introduction to structural anatomy and fascial release therapy, including postural analysis, complete technique descriptions, and the art of proper assessment of a patient through bodyreading.

Terra Rosa e-magazine, No. 14 (July 2014)

Research Highlights Compiled By Jeff Tan New Ligament in the Human Knee Two knee surgeons at University Hospitals Leuven in Belgium have provided the first full anatomical description of a previously enigmatic ligament in the human knee. The study was published in the Journal of Anatomy. The ligament appears to play an important role in patients with anterior cruciate ligament (ACL) tears. Despite successful ACL repair surgery and rehabilitation, some patients with ACL-repaired knees continue to experience so-called 'pivot shift', or episodes where the knee 'gives way' during activity. For the last four years, orthopaedic surgeons Dr Steven Claes and Professor Dr Johan Bellemans have been conducting research into serious ACL injuries in an effort to find out why. Their starting point: an 1879 article by a French surgeon that postulated the existence of an additional ligament located on the anterior of the human knee. That postulation turned out to be correct: the Belgian doctors are the first to provide a full anatomical description of the ligament after a broad cadaver study using macroscopic dissection techniques. Their research shows that the ligament, called the anterolateral ligament (ALL), was noted to be present in all but one of the 41 cadaveric knees studied. Subsequent research shows that pivot shift, the giving way of the knee in patients with an ACL tear, is caused by an injury in the ALL ligament. The anatomical and functional relation between gluteus maximus and fascia lata Gluteus Maximus (GM) is usually described as the largest muscle of the human body having various functions. Some studies have identified GM as having the largest capacity for external rotation of the hip thanks to its insertion into the linea aspera of the femoral bone. Others consider fibres from the more cranial sites of origin primarily end in a thick laminar tendon that in-

Terra Rosa e-magazine, No. 14 (July 2014)

serts on the iliotibial tract. The activity of the cranial portion is ‘considerable’ increases during jogging and running. Other studies have identified a role in hip flexion due to the insertion of the GM in the iliotibial tract. Meanwhile another study said the most important insertion of GM is the iliotibial band. There is not full agreement regarding the distal insertions of the gluteus maximus muscle (GM), particularly the insertions into the iliotibial band and lateral intermuscular septum. A study led by Antonio Stecco from University of Padova, Italy studied 6 cadavers, 4 males and 2 females, mean age 69 yr, dissected to evaluate the insertions of the GM into the iliotibial band, fascia lata, lateral intermuscular septum and femur. They found that the distal insertions of the GM are more fascial then osseous. The iliotibial band is a reinforcement of the fascia lata and cannot be separated from it. Its inner side is in continuity with the lateral intermuscular septum, which divides the quadriceps from the hamstring. In all subjects the gluteus maximus presented a major insertion into the fascia lata, so large that the iliotibial tract could be considered a tendon of insertion of the gluteus maximus. The fascial insertion of the gluteus maximus muscle could explain the transmission of the forces from the thoracolumbar fascia to the knee. “Barefoot” Shoes May Cause Injury And Pain Advocates of “barefoot” running shoes promise a more natural experience, but runners in a new study reported higher rates of injury and pain with the less structured shoes. Published in the December 2013 British Journal of Sports Medicine, 99 adult runners in Vancouver, Canada, started a three-month training program in preparation for running a 10-kilometer race. They had never tried barefoot running or minimalist running before. A

Research Highlights third of the participants were given so-called partialminimalist running shoes, or a full-minimalist shoe with separated toes. The final third got a traditional structured running shoe, for comparison.

maximum back squat, 2) pretest measurements, 10 × 10 squat protocol, and post-test measurements, along with measurements at 24 hours, 48 hours and 72 hours.

Of the 23 injuries that happened during the training period, four were among the runners wearing traditional shoes, 12 among those wearing partialminimalist shoes and seven in the full-minimalist shoe group. Runners using the full-minimalist shoes also reported higher rates of shin and calf pain than the other participants.

Results showed that foam roiling (FR) substantially reduced muscle soreness at all time points while substantially improving ROM. FR negatively affected evoked contractile properties with the exception of half relaxation time and electromechanical delay (EMD), with FR substantially improving EMD. Voluntary contractile properties showed no substantial betweengroup differences for all measurements besides voluntary muscle activation and vertical jump, with FR substantially improving muscle activation at all time points and vertical jump at 48 hours post exercise.

“This study supports what I and others have been arguing for years,” Daniel Lieberman, author of widely cited studies comparing barefoot running to running with shoes. “If you switch to minimal shoes or go barefoot you need to (a) do so gradually so your body can adapt, and (b) you need to learn proper running form,” said Lieberman, who is chair of Human Evolutionary Biology at Harvard University in Cambridge, Massachusetts, and not involved in the new study. But, Lieberman said he would not go as far as calling minimalist shoes “worse” than conventional shoes, at least not based on this study. The runners did not transition gradually, the study did not examine their running form, and it only included the initial transition period to the new shoes, which many runners would adapt to over time, he said. “What matters most for injury is how you run, not what is on your feet, and this study only looked at the latter,” Lieberman said. In their report, Ryan and his colleagues speculate that the runners who switched to full-minimalist shoes may have been forced to change their running form, and that might account for the highest injury rate being seen in the group wearing partial-minimalist shoes. Foam rolling as a recovery tool after an intense bout of physical activity. A study from Canada published recently in Medicine Science in Sports and Exercise evaluated the effectiveness of foam rolling (FR) as a recovery tool after exercise-induced muscle damage. Twenty male subjects (≥3 yr of strength training experience) were randomly assigned into the control (n = 10) or FR (n = 10) group. All the subjects followed the same testing protocol. The subjects participated in five testing sessions: 1) orientation and one-repetition

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The most important findings of this study were that FR was beneficial in attenuating muscle soreness while improving vertical jump height, muscle activation, and passive and dynamic ROM in comparison with control. FR negatively affected several evoked contractile properties of the muscle, except for half relaxation time and EMD, indicating that FR benefits are primarily accrued through neural responses and connective tissue. Longer Massage Sessions Effective for Neck Pain A new research published in the March/April 2014 issue of the Annals of Family Medicine concluded that multiple 60-minute massage sessions are effective for neck dysfunction and pain among patients with chronic neck pain. Karen J. Sherman, PhD, MPH, from the Group Health Research Institute in Seattle, and colleagues examined the optimal dose of massage for individuals with chronic nonspecific neck pain. 228 individuals with chronic nonspecific neck pain were recruited and randomised to five groups receiving a four-week course of 30-minute visits two or three times weekly or 60minute visits once, twice, or three times weekly, or to a single waitlist control group. The researchers found that, regardless of the frequency of treatments, there was no significant benefit for 30minute treatments versus waitlist control in terms of clinically meaningful improvement in neck dysfunction or pain, after adjustment for baseline age, outcome measures, and imbalanced covariates. The likelihood of such improvement was significantly increased with 60minute treatments two or three times per week in terms of neck dysfunction (relative risks, 3.41 and 4.98,

Research Highlights respectively) and pain intensity (relative risks, 2.30 and 2.73, respectively).

cago. The study, reported online in advance of print in the Archives of Physical Medicine and Rehabilitation, also showed that massage improved vascular function in "After four weeks of treatment, we found multiple 60people who had not exercised, suggesting that massage minute massages per week more effective than fewer or has benefits for people regardless of their level of physishorter sessions for individuals with chronic neck pain," cal activity. the authors write. "Clinicians recommending massage and researchers studying this therapy should ensure "Our study validates the value of massage in exercise that patients receive a likely effective dose of treatand injury, which has been previously recognized but ment." based on minimal data," said Nina Cherie Franklin, UIC postdoctoral fellow in physical therapy and first author Massage Therapy for Fibromyalgia: A Systemof the study. "It also suggests the value of massage outatic Review side of the context of exercise." Although some studies evaluated the effectiveness of massage therapy for fibromyalgia (FM), the role of massage therapy in the management of FM remained unclear. A new systematic review published in PLOS One journal evaluated the evidence of massage therapy for patients with FM.

The researchers had set out to see if massage would improve systemic circulation and reduce muscle soreness after exercise. Healthy sedentary adults were asked to exercise their legs to soreness using a standard leg press machine. Half of the exercisers received leg massages, using conventional Swedish massage techniques, after Electronic databases (up to June 2013) were searched to the exercise. Participants rated their muscle soreness on a scale from 1 to 10. identify relevant studies. The main outcome measures were pain, anxiety, depression, and sleep disturbance. As expected, both exercise groups experienced soreness Two reviewers independently abstracted data and apimmediately after exercise. The exercise-and-massage praised risk of bias. The risk of bias of eligible studies group reported no continuing soreness 90 minutes after was assessed based on Cochrane tools. Standardised massage therapy. The exercise-only group reported lastmean difference (SMD) and 95% confidence intervals ing soreness 24 hours after exercise. (CI) were calculated by more conservative randomeffects model. And heterogeneity was assessed based on Exercise-induced muscle injury has been shown to rethe I2 statistic. duce blood flow. In this study, brachial artery flow mediated dilation (FMD) — a standard metric of general Nine randomized controlled trials involving 404 pavascular health, measured in the upper arm — was tients met the inclusion criteria. The meta-analyses taken by ultrasound at 90 minutes, 24, 48 and 72 hours showed that massage therapy with duration ≥5 weeks after exercise. significantly improved pain , anxiety , and depression in patients with FM, but not on sleep disturbance For the exercise-and massage-group, FMD indicated improved blood flow at all time points, with improveThe authors concluded that Massage therapy with dura- ment tapering off after 72 hours. As expected, the exertion ≥5 weeks had beneficial immediate effects on imcise-only group showed reduced blood flow after 90 proving pain, anxiety, and depression in patients with minutes and 24 and 48 hours, with a return to normal FM. Massage therapy should be one of the viable comlevels at 72 hours. plementary and alternative treatments for FM. However, given fewer eligible studies in subgroup meta"We believe that massage is really changing physiology analyses and no evidence on follow-up effects, largein a positive way," said Franklin. "This is not just blood scale randomized controlled trials with long follow-up flow speeds—this is actually a vascular response." Beare warrant to confirm the current findings. cause vascular function was changed at a distance from both the site of injury and the massage, the finding sugFull article available here gests a "systemic rather than just a local response," she said. Massage therapy improves circulation, eases muscle soreness Massage therapy improves general blood flow and alleviates muscle soreness after exercise, according to a study by researchers at the University of Illinois at Chi-

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"The big surprise was the massage-only control group, who showed virtually identical levels of improvement in circulation as the exercise and massage group," said Phillips. "The circulatory response was sustained for a

Research Highlights number of days, which suggests that massage may be protective," said Phillips.

Benefits of Clinical Massage Therapy for Chronic Lower Back Pain

Myofascial Roller Massage Reduces Delayed On- Clinical massage therapy has alleviated chronic lower set Muscle Soreness back pain (CLBP) in patients who participated in a recent University of Kentucky study of complementary A recently published study in The International Journal therapies. of Sports Physical Therapy demonstrated the effectiveness of an inexpensive, easy-to-use massage tool on re- Researchers in the University of Kentucky Department ducing hamstring muscle soreness after high intensity of Family and Community Medicine recently completed exercise. The study, conducted at the National Research a study pointing to real-world evidence that clinical Centre for the Working Environment in Copenhagen, massage therapy helps reduce symptoms in CLBP paDenmark, investigated the acute effect of massage with tients. The department partnered with 67 primary care the TheraBandâ&#x201E;˘ Roller Massager+ on delayed onset providers (PCPs) and 26 massage therapists in urban muscle soreness (DOMS). and rural Central Kentucky to study provider decisionmaking for complementary treatments and short-term This study involved 22 healthy untrained men perform- effects of clinical massage and progressive muscle reing high volume stiff-legged dead lifts to induce DOMS laxation therapies for CLBP patients. of both hamstrings. "In addition to sports performance, soreness, pain and stiffness of muscles and joints can Through the study, PCPs in five counties referred CLBP interfere with work and activities of daily living for mil- patients with point of service cards to community praclions of individuals," stated Lars L. Andersen, PhD, Pro- ticing, licensed massage therapists for clinical massage fessor with the National Research Centre for the Work- therapy or to a course of patient-administered progresing Environment. "Because of this, we elected to use sive muscle relaxation therapy. All study therapies were non-athletes in this study so that the results would be provided to patients free-of-charge. Of the 100 particimeaningful and transferable to a larger population pants in the study, 85 received clinical massage therapy, base." and 54 percent of those patients reported a clinically meaningful decrease of pain and overall disability. Approximately forty-eight hours after performing the DOMS-inducing exercise, the 22 participants were Dr. William Elder, UK Family and Community Mediasked to rate the level of their hamstring muscle sorecine, principal investigator for the study, said CLBP is a ness. Hamstring flexibility and hip flexion range of mo- common diagnosis, especially in people who have pertion (ROM) and pressure pain threshold (PPT) were formed physical labour as part of their job. The muscualso recorded. Each participant was subsequently ranloskeletal problem is perpetuated by the patient's emodomly assigned to either a roller massage treatment tional stress or anxiety. Because more members of the group or a control group. The TheraBand Roller Masaging population expect to maintain healthy functioning sager group received a roller massage for 10 minutes on into their later years, medical researchers are interested one hamstring with moderate pressure at one to two in measuring the effectiveness of alternatives to habitseconds per stroke. The other hamstring remained un- forming pain medications, such as narcotics. treated. The study served to forge relationships between the Study participants that received the roller massage University and community massage therapists. In additreatment had significantly less soreness and tenderness tion, the study indicates a need for future research incompared to the control group. There was no significant vestigating the extent to which complementary theradifference in flexibility between groups. pies could lessen or eliminate the patient's reliance on opioids for CLBP symptoms. While long-term studies "Our research team concluded that the massage admin- are needed to fully understand the benefits of clinical istered with a TheraBand Roller Massager+ had a sore- massage therapy, Elder said the initial study may give ness reducing effect to the affected hamstring," contin- physicians a higher level of confidence to refer patients ued Dr Andersen. "Interestingly, there was also a sigto massage therapists practicing in the community. nificant reduction in pain in the non-treated hamstring, suggesting a central nervous system or cross over effect See the YouTube video here of the Roller Massager+ on DOMS pain."

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6 Questions to Donna Eddy 1. When and how did you decide to become a bodyworker? I “fell” in to it! After a serious back injury (in 1995), I gave up gymnastics coaching and started my Diploma of Remedial Massage (incl . Sports & Swedish Massage) finishing in 1998. In that first year of study, I met Dr. Paul Connelly, a musculoskeletal and pain specialist, whom described my pain and I went on to study “Advanced Musculoskeletal Techniques” (osteopathic therapy) under him, which lead to Traditional Chinese Medicine study at University of Technology Sydney where I graduated in 2004.

have them do their movement practice DAILY and come seasonally for ‘tune-ups’ rather than let life get in the way and come when they are in agony again. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? For the newbie: Look after yourself. Get regular body work done yourself. Find a mentor whom you can take clients to and sit in on those sessions so you learn the tricks and subtitles of your mentors work. That’s what I did, I spent many hours sitting in on the sessions of clients as my teacher worked on them.

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

6. How do you see the future of massage and bodywork?

The most exciting is two fold, firstly watching someone hobble in in pain and the expression of relief and joy when they walk (sometimes skip) out the door!

Hmmm... I see great things as the generations coming through are more aware and have had manual and alternative therapies in the main stream their whole lives.

The second is when the patient “gets” their body. When they take the advice and do the work themselves and start being more mindful of what they are doing to themselves and what they can do for themselves. 3. What is your most favourite bodywork book? That is tough as I've got about ten that live on my ‘work bench’ in the clinic as constant reference. If there were a fire and I could only take one or two it would be: Travell & Simons “Myofascial Pain and Dysfunction. The Trigger Point Manual” (Vol 1 & II) and Deadman’s “A Manual of Acupuncture”. I couldn't leave without those.

Its been a case of Massage separating from the sex industry and all manual therapists being given respect and kudos for the great (often now ‘scientific/ evidence -based’) modalities that are out there. Massage and bodywork has come out of the shadows, there is a fair way to go before the utopian dreams of most manual therapists come true. But, I see progress. Speak to anyone and the majority have been if not already have a ‘therapist’ they go to.

4. What is the most challenging part of your work? Most challenging is patient compliance. Getting Westerners to take a proactive approach to their body. To

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6 Questions to Chris Frederick 1. When and how did you decide to become a bodyworker? I first experienced bodywork as a client in the late 1970s to early 1980s, when I was exploring different ways to improve flexibility and strength as a professional ballet dancer. I trained with who was considered some of the best of that era in New York City - Romana Kryzanowska for Pilates, Juliu Horvath for what is now known as The Gyrokinesis Method and R. Louis Schultz for Rolfing. These masters all had a positive influence on me deciding to become a physiotherapist after an injury ended my dance career. Since 1989, I've focused on getting experience and training in advanced manual therapy specialties of physiotherapy. Although I have taken a multitude of manual therapy courses, my first most impactful bodywork training was privately with Ann Frederick, creator of Fascial Stretch Therapy (FST), in 1998. The next was certification in Kinesis Myofascial Integration with Thomas Myers in 2004. 2. What do you find most exciting about bodywork therapy? The most exciting aspect of bodywork therapy for me is the never-ending integration of creativity, intuition and evidenced based science that grows daily over years to form a valid and reliable base for best client outcomes. After 25 years, it is extremely gratifying to be able to confidently, accurately and rapidly help people improve the quality of their lives.

that is easy to learn, fun to read and lasting in its impact of how to effectively visualize the connective tissue system of the body. 4. What is the most challenging part of your work? The most challenging part of being a bodyworker for me was to diligently search for the best ways to accurately assess the problems of a client in order to discover the most efficient and effective manual and movement therapy solutions to achieve the clientâ&#x20AC;&#x2122;s goals as quickly as possible. 5. What advise you can give to fresh massage therapists who wish to make a career out of it? The best advise I have to give to massage therapists new to the field is the following: Maintain the open attitude that learning never ends and that it is not necessary to have all the answers in order to find effective solutions to client problems. Practical, reliable professional experience from oneâ&#x20AC;&#x2122;s personal practice integrated with input from experienced colleagues or mentors, when needed, which is then informed by evidence in research is the best strategy for optimal client outcomes. 6. How do you see the future of massage therapy? In my opinion, the future of massage therapy and bodywork depends on developing better assessments for movement dysfunctions and offer not only manual therapy solutions but neuromotor re-education solutions in order to improve long term outcomes for clients.

3. What are your most favourite bodywork books? Rolfing: The Integration of Human Structures by Ida Rolf first caught my imagination being introduced to the amazing world of fascia. One of my many favorite books is Anatomy Trains by Thomas Myers because it lays the anatomical foundation for bodywork in a way

Terra Rosa e-magazine, No. 14 (July 2014)