Terra Rosa eMagazine Issue 3

Bodywork e-News 1

Contents

02 Myofascial Techniques for the Superficial Neck Fascia —Til Luchau

07 Imagery to lengthen the neck

08 The Relationship Between Stress and Neck & Shoulder Pain —Anita Boser

11 An Integrated Approach to Rehabilitation of Leg Injuries. Part II —Art Riggs

19 Deadbeat Diagnosis —Erik Dalton

24 Thai Massage —Richard Gold

28 Peripersonal Space & Bodywork

32 A New Theory on Reflexology

34 De Quervain’s Syndrome

36 A New Contraindication of Massage —Kristin Osborn

37 Complex Regional Pain Syndrome —Whitney Lowe

39 Research Highlights

41 Six Questions to Til Luchau

42 Six Questions to Anita Boser

Terra Rosa Bodywork e-News

Issue 3, June 2009 www.terrarosa.com.au

Welcome to our third issue of Terra Rosa Bodywork e-

magazine, our free e-zine dedicated to bodyworkers. It is an exciting full-on 40 pages of information.

Economic crisis is looming and has influenced our indus-try as well. News from an association in Australia indicate the decrease in membership renewal. This crisis will pre-sent great challenges, however this is a time to renew and shape our work. Massage has survived many crises, and will continue to be in demand. So be positive.

We got a range of great articles from respected authors. Til Luchau on the myofascial techniques for the neck, Anita Boser on neck & shoulder pain. Art Riggs continues his article on the leg. Erik Dalton discusses the latest research and treatment on iliotibial friction syndrome. Richard Gold gives an intro to Thai Massage. We turn to the area of peripersonal space and the latest theory on foot reflexology. A new contraindication of massage by Kristin Osborn and Complex Regional Pain Syndrome by Whitney Lowe. Don’t forget to read Six Questions to Til and Anita.

We hope to keep you informed and entertained. If you have something you wish to contribute, drop us an email: terrarosa@ gmail.com. We believe that therapists like you have lots of experiences to share. Thanks for all of your support and enjoy reading.

Disclaimer: The publisher of this e-News disclaim any responsibility and liability for loss or damage that may result from

articles in this publication.

Terra Rosa www.terrarosa.com.au

The Source for Massage Information

Bodywork e-News 2

Myofascial Techniques for the Superficial Neck Fascia

by Til Luchau

Intro

In this and subsequent articles, I’ll describe specific techniques that work with some of the most common client issues. I’ll draw on the work taught in Advanced-Trainings.com’s popular “Advanced Myofascial Tech-niques” workshop series, which for the last 25 years, has been attended by over 2000 practitio-ners in over a dozen countries. Although I’m at the Advanced-Trainings.com faculty are Certi-fied Advanced Rolfers, and I teach at the Rolf Institute®, rather than writing about struc-tural integration per se, my em-phasis in these articles will be on specific and practical techniques that would be useful to any hands-on practitioner. We’ll start by looking at the superfi-cial layers of the neck and pre-paring the neck and shoulders for deep work.

This article is originally pub-lished in the Massage and Bodywork magazine, USA.

Visit http://www.youtube.com/user/AdvancedTrainings for a video clip from the 2009 DVD “Advanced Myofascial Tech-niques for the Neck, Jaw, and Head” from Advanced-Trainings.com.

The Importance of the Su-perficial Layers

What are the most common complaints you see in your prac-tice? Chances are, neck pain and discomfort are high on the list. Although cervical issues can have many causes, you’ll often see better results if you begin by addressing restrictions in the superficial layers of the neck and shoulders. Whether caused by deep articular fixations, posture and misalignment, habits, stress, injury, or other reasons, neck issues respond quicker and stay away longer when the outer wrappings are released first. As with other parts of the body, many seemingly deeper neck is-

sues resolve when the external layers have been freed. In this article, I’ll describe how to work with these superficial but impor-tant layers in order to prepare the neck for working with its deeper structures.

The neck’s superficial tissue lay-ers have a great deal of influence on its alignment, mobility and health. These “outer wrappings” encircle the neck and shoulders like an over-large turtleneck sweater, or a surgical collar (Figure 1)

Anatomically, these layers in-clude the superficial and deep cervical fascias, as well as the muscles within those fascial lay-ers, such as the Trapezius, Ster-nocleidomastoid, and the

Figure 1: The superficial fascia of the neck, in green, surrounds the deeper structures like a sleeve or cowl . (Illustration courtesy and copyright Primal Pictures Ltd.)

http://www.youtube.com/user/AdvancedTrainings




Bodywork e-News 3

Platysma (Figure 2). Together, these cowl-like outer layers ex-tend from their upper attach-ments on the occipital ridge and lower face, to their lower connec-tions with the outer layers of the shoulders, chest, and upper back. Like a sleeve, they encircle the deeper musculoskeletal and vis-ceral structures of the neck’s core.

The superficial layers of the neck have a surprising thickness and resilience. When, because of in-jury, postural strain, or other reasons, they have lost pliability or are adhered to other layers and structures, the outside layers have the ability to restrict move-ment range, disrupt alignment, and bind the structures they sur-round. Imagine trying to move in a wetsuit that is a size too small—the outer layers of the neck can bind, distort, and con-strain movement in the same way.

Seeing Superficial Restric-tions

Try this: watch a friend turn his or her head from side to side. Watch what happens with the superficial lay-ers of the neck, shoulders, chest, and back. Are there areas of the torso’s fascia that move along with the head and neck? Or, do you see lines of tension and pull appearing in the skin and outer layers? Of-ten, these signs of fascial restric-tion will be most visible at the extremes or end-range of the movement. Look from both the front and the back; compare left and right sides for any differ-ences. Then, look again as he or she gently looks up and down (being careful, of course, to avoid any posterior cervical compres-sion when looking up). Your friend might feel different kinds of restrictions when moving, in-cluding pulls in the deeper mus-culature, or catches involving neck articulations or the upper

ribs. For now, we’re going to leave these aside and fo-cus on the outer layers first.

Sometimes superficial fas-cial tension will be visible as linear patterns “tug” in the skin (Figure 3). In other cases, a whole sheet of fas-cia will move or creep along with the rotating or nod-ding head. Linear “tug” pat-terns are more commonly seen in the thinner layers of the anterior neck and chest, while the “creep” of whole fascial sheets is seen more often when looking at the thicker posterior layers of the back. If it is difficult to see restrictions in the su-

perficial layers, you can use your hands to feel for tugs and pulls in the outer layers while your client rotates his or her head. Whether watching or feeling, note any areas that don’t have smooth, even lengthening of the dermis and superficial fascias when the head moves.

We are constructed like onions: layered, from superficial to deep. When testing for fascial tension with movement, don’t confuse movements of deeper structures for movement in the superficial fascia. For example, you’ll some-times see the ribcage turning along with the head, or a shoul-der roll forward, etc. Some of this movement is normal; if you see exaggerated or asymmetrical movement of the ribcage or shoulder, this might be because of deeper restrictions. Make a note to check for and address these patterns later, but remem-ber that since these deeper movements might be caused by restrictions in the outer layers, releasing the superficial layers is the logical first step. Unless you’re working with a scalpel and are cutting right through, you need to gently peel away the outer layers to get to the core.

Myofascial techniques for the neckMyofascial techniques for the neckMyofascial techniques for the neck

Figure 2: The superficial layers of the neck, in cross section. (Illustration courtesy estate of John Lodge.)

Figure 3 Fascial strain visible as "tugging" of the outer layers with movement.

Bodywork e-News 4

Releasing Superficial Re-strictions

Once you’ve seen or felt where your client/friend’s outer layers are tugging or creeping along with head and neck movement, you can go to work. A word about sequencing your superfi-cial work on the upper torso: in most cases, you’ll begin by re-leasing the posterior restrictions of the upper back, and end by working the anterior restrictions. This is the order we’re using in this article. Why this back-to-front progression? Since most of us tend to have our heads for-ward of the coronal midline, and be narrower across the front of our chest than across our upper back, the anterior fascial layers of the chest and shoulders tend to be shorter than the posterior layers of the shoulders and back. Ending by lengthening the shorter anterior restrictions bal-ances the earlier work on the posterior side, and leaves the client with a greater sense of an-terior width, length, and free-dom, and so helps with overall alignment. A possible exception to this ordering: if your client has a very flat upper thoracic curve, you may want to reverse the sequence, and end with work on the back to encourage more spinal flexion.

1. Over the Edge Technique

Ask your client to lie face down on your table, arms at the sides, with his or her head and neck just over the top edge of the table. The edge of the table should fall an inch or two below the top of the sternum. Your client may need to adjust upwards or down-wards a bit so that the edge is comfortable. You won’t want to leave your client like this too long, but you’ll usually have at least two or three minutes to

work before his or her head starts to feel too full.

Once your cli-ent is comfort-able, ask him or her to turn the head from side-to-side as you again watch or feel the outer tissue layers, in order to re-check your findings. Look again at the up-and-down movements too, again using care to avoid any neck compression with extension. Often, this prone position will make the superficial restrictions even more obvious.

The tool we’ll use to release these restrictions is the flat of our fore-arm; specifically, the first few inches of the ulna just distal to the elbow (Figure 5). Use this tool to gently anchor the inferior margins of the places you saw or felt superficial restrictions. We don’t use oil or cream, as we’ll be using friction more than pres-sure to contact the layer we want to release. Also, we won’t be slid-ing much—our client will pro-vide the movement needed for release.

Once you have the outer layers gently anchored with your fore-arm, ask your client to slowly turn his or her head away from the side you’re working. Feel for a direction of your pressure that gently lengthens the superficial layers being pulled by the head

movement. Imagine that you’re helping your client lengthen and free herself inside the wetsuit-like outer layers of superficial fascia.

Alternatively, you can ask your client to lift and lower the head (extend and flex the spine) as you lengthen the layers of the back inferiorly. You’ll find that most release will happen on the eccentric phase of the motion, that is, while your client is lower-ing his or her head.

Remember, your client will get uncomfortable you leave them in this position for more than a few minutes. Although relatively safe, head-down positions are proba-bly contraindicated for clients with uncontrolled high blood pressure, a history or risk of stokes, vertigo, or acute sinus issues.

2.Anterior Neck/Shoulder Differentiation Technique

After releasing the posterior re-strictions of the back and shoul-

Figure 4: The "Over-the-Edge" technique for releasing the superficial layers of the upper back and shoulders. Although relatively safe, head-down positions are usually contraindicated for clients with un-controlled high blood pressure, a history or risk of stokes, vertigo, or acute sinus issues.


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ders’ superficial layers, you’ll want to broaden and continue this release by addressing any surface restrictions in the upper chest and anterior shoulders.

To release these anterior restric-tions, we’ll use either our palms or fingertips to anchor the super-ficial fascia of the shoulders, chest, and anterior neck (Figure 6). Then we’ll use our client’s movement to release the restric-tions we saw or felt earlier. The palm is especially useful where you saw fascial layer “creep” with head movement. When using your palm, don’t be tempted yet to rub, slide, or massage the deeper layers of pectoralis, etc. Instead, use the broad surface of the palm to catch and gently an-chor the outer layers of the chest while your client moves his or her head.

In contrast to the broad tool of the palm, your fingertips will al-low you to work specific areas, and so are useful where you saw the local “tugs” in the outer lay-ers when your client was moving. When using the fingertips, the fingers are slightly curved rather than straight, and are sensitively “hooking in” to the outer layer you saw or felt moving with the

head. Push with your fingertips, as if straighten-ing out your curled fingers, to encourage superficial re-lease away from the direction of movement.

Whether you’re using palm or fingertips, don’t slide along the surface, and don’t dig down to the ribs or intercostals--

you want to feel a tug in the outer layers, the layers of dermis and superficial fascia that lie be-tween the actual surface of the skin, and the muscles or bones beneath.

Movement: as in the “Over the Edge” technique, ask you client to slowly turn his or her head away from the side you’re an-choring. Find a direction for your pressure that gently re-leases the superficial layers be-

ing pulled by the head move-ment. Imagine that you’re help-ing your client lengthen and free him or herself inside the wetsuit-like outer layers of superficial fascia.

A further option is to have your client tighten his Platysma mus-cle, which lies within the superfi-cial fascias that we’re working. Try it yourself as you’re reading this—turn your head, and then grimace or snarl until you feel a tug from your lower lip into the pectoral fascia of your chest. By anchoring the lower end of this tug in the chest, you can snarl and relax repeatedly to release any constriction in the anterior fascia. Having your client tighten and relax the Platysma in this way while you anchor its inferior attachments can help your client focus the release into the tightest areas.

Finishing

Once you’ve released the outer layers of the neck and torso from the back, and front, look again as your friend turns his or her head

Figure 5: An open palm or the tips of curled fingers may be used for the Anterior Neck/Shoulder Differentiation tech-nique.

Figure 6: Active contraction of the Platysma, as in grimacing, can aid in releas-ing the superficial fascia of the anterior thorax.


Bodywork e-News 6

from side to side. If you’ve been both patient and thorough, you’ll see fewer pulls and tugs in the outer layers, and more than likely, smoother and greater range of motion. Clients report that their movement feels easier, freer, or that their head is lighter and more upright.

Now that you’ve released the outer layers, the next step could be deeper work with the neck, ribcage, or spine, either in the same session as these techniques, or the next one. The deeper work will now be easier, more effective, and longer lasting. Or, instead of working deeper right away, first you might want to continue the theme of superficial release by adapting the techniques we’ve just done here to other, compli-mentary regions of the body, such as the lumbars, limbs, or hips. I’ll write about more about these possibilities in other arti-cles. In the meantime, keep in-vestigating what happens when you take time to release the outer layers of the body.

Tips for Effective Work

Keep everyone comfortable. You and your client should both be comfortable and able to relax. The pressure, position, or move-ments you use should never be uncomfortable for either of you.

Stay superficial. Even though the tools shown here—forearm, soft fist, palm, finger tips—can be used for deep work, stay in the outer layers of the body at first. You’ll be surprised at how much easier the deeper work will go, and how much longer its effects will last.

Use your client’s movement. In-stead of pushing tissue around, use your client’s slow, conscious movement to release and re-educate habitual movement pat-terns.

Touch the person, not just the tissue. Remember that your are asking for change from a living, breathing being; not from inani-mate compounds like “tissue” or “myofascia.”

Balance and integrate. Most cli-ents will feel more balanced if

you end with work in the front to counterbalance the back length of the first technique. Be sure to incorporate your local work into an entire-body perspective, rather than just focusing on parts.

Visit http://www.youtube.com/user/AdvancedTrainings for a video clip.

Bio

Til Luchau is the director and a lead instructor at Advanced-Trainings.com Inc., which offers continuing education seminars and support services for practi-tioners and schools throughout the USA and abroad. The origi-nator of Skillful Touch Bodywork (the Rolf Institute®'s own train-ing and practice modality), he is a Certified Advanced Rolfer® and a Rolf Institute® faculty member. He welcomes your comments or questions at [email protected]. See also 6 Questions to Til at page ..

© 2008, Til Luchau, Advanced-Trainings.com


Advanced Myofascial Techniques

Advanced-trainings.com

DVDs and Manuals available from www.terrarosa.com.au

Advanced Myofascial Workshops with Til Luchau & Co. in Australia in 2010 For more info: [email protected]





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Bodywork e-News 7

Imagery for the Neck Move your C7 towards your jugu-lar notch!

For people with forward head posture, a difficult task for the therapist and the client is to train the client to correct for the wrong posture, move the head back to the neutral position. We usually ask the client to maintain a neutral spine, the head should be stacked over the cervical spine with the shoulders re-laxed.

The usual exercise we can give is the “chin tuck”. Or we can ask them for a guided imagery of “head lengthening” : Sit tall, imagine that a string is length-ening your neck and pulling your head up towards the ceiling. In Alexander technique, we are instructed to “Allow the head to go forward and up from the spine.”

Imagery is quite powerful and acts as a stimulus for developing kinesthetic awareness and producing bodily change. Another simple imagery exer-cise that I recently learnt is to ask your client to “bring your C7 towards the

jugular notch of the sternum” (the large notch in the superior margin of the sternum). This is a simple imagery ex-

ercise that is quite powerful in bringing the head back to neutral position. Try it.

Anyone for a Stone massage?

Picture courtesy of Primal Pictures

Bodywork e-News 8

Stress and neck and shoulder tension are interrelated for most people. This article will explain why and show how massage therapists can not only relieve discomfort, but also help our cli-ents be better prepared to handle tumultuous times with resilience.

In an optimally functioning body,

action initiates from the core and translates through the limbs. Functional use of the arms starts from a stable pelvis then trans-fers through the spine to the scapula, then the arm, hand and fingers. Motions as simple as typing on a keyboard and steer-ing a car follow this pattern.

This level of performance can be interrupted by restrictions in the rib cage and thoracic spine re-sulting in dysfunctional move-ment patterns. When connec-tion to the core is inhibited, the muscles in the arms and neck (especially the trapezius, levator scapula and rhomboids) are overtaxed and develop adhesions

The Relationship Between Stress and

Neck & Shoulder Pain by Anita Boser, LMP, CHP

Layers of neck muscles from superficial to deep (from Primal Pictures)

Trapezius Splenius Capitis

Semispinalis Capitis

Semispinalis Cervicis

Multifidus Rotatores

Bodywork e-News 9

and trigger points. Anxiety is one culprit as it often obstructs breathing and movement of the thoracic spine.

Stress creates contraction. The breath becomes shallow with a tendency to hold the inhale. Breathe in this manner and no-tice what happens. The pelvic floor stiffens. The diaphragm holds tension. The intercostals and thoracic spine erectors and paraspinals stop moving. The natural flow of breathing through the torso becomes fro-zen, and the muscles eventually fix into this rigid pattern.

Now move your arms with this level of tension in the spine. No-tice the instant pressure placed on the rotator cuff and neck.

Deep breathing can restart the flow, but until the muscles are released the breath will not reach its comfortable maximum. That’s where the massage thera-pist can help. Release of the myofascia that covers the ribcage is a natural place to start, work-ing from superficial (pectoralis

major, trapezius) to deep (the intercostals). As the tissues glide, breath naturally becomes easier and fuller.

Since most ribs have three at-tachments to the thoracic verte-brae (See Figure above), improv-ing costal motility will start to cultivate freedom in the spine. However, the thoracic spine usu-ally does not regain its motion without specific attention.

The complexity of muscles that control the spine— the erector spinae overlying the paraspi-nals—allows for nearly unlimited movement. Work first through the layers of erectors,

(iliocostalis, longissimus and spinalis) freeing the fibers for individual articulation. To ac-cess the deeper muscles (semispinalis, multifidi and rota-tores) ask your client to undulate as you work on the interweave of muscles in the laminar groove.

When the thoracic spine has re-gained a level of mobility teach your client to reconnect with fluid movement. Undulations will reduce rigidity and tame tension. A fluid spine and ample breath are foundational compo-nents to shoulder life’s responsi-bilities and take the edge off stressful situations.

Anita Boser, LMP, CHP is the author of Relieve Stiffness and Feel Young Again with Undula-tion and the audio version, Un-dulation Exercises. She can be contacted at [email protected] or www.undulationexercise.com.

Feel better fast with Anita Boser’s exercises Whether you're 16, 36 or 65, an athlete or a couch potato, coordinated or a klutz, Relieve Stiffness and Feel Young Again shows you how just 10 minutes a day can make a difference in how you feel. Boser gives you easy-to-follow guidelines and photographs for 52 simple exercises that will allow you to move better and more comfortably. Try a different exercise every week and by the end of a year, you're sure to feel better. Wherever you ache, undulation will provide relief-naturally, without medication, without equipment, without expense. And you'll have fun, too!

Available from: www.terrarosa.com.au

Neck & Shoulder PainNeck & Shoulder PainNeck & Shoulder Pain

http://www.undulationexercise.com

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Bodywork e-News 10

Lomi Lomi Massage Workshop Down Under

With

Carrie Rowell

Join Carrie Rowell for a 4-day Workshop, Hawaiian Lomi Lomi Massage, covering an introduction to the principles, and a full body massage routine, complete with joint mobilization and passive stretching.

• Sydney Workshop, Date: September 24-27, 2009. Location: North Curl Curl at a beach house a few minutes walk from the beach (we can do our hula and Auhea exercises on the sand)

• Byron Bay, September 14-17 2009 • New Plymouth, New Zealand ,October 9-11 2009 Approved by AAMT for 20 CPE points.

For over 20 years, Carrie has studied various forms of sacred dance and movement. She applies the beneficial techniques learned from these arts into her bodywork therapy. Carrie practices and teaches bodywork in the US and traveled all over the world teaching Lomi Lomi massage, sacred dance and healing and empowerment workshops for women.

For centuries the ancient art of Hawaiian Lomi Lomi massage has been used as a powerful tool for maintaining a healthy way of life. The strokes are long and flowing, using forearms and elbows, and giving the feeling of many hands on the body at once. All seminars incorporate movement and breath exercises, specific Hawaiian Massage techniques and exercises for self care.

Practitioners work on each other and switch partners to learn how to apply the techniques to differ-ent body types. Individual attention is given by the instructor so that the students learn how utilize their body mechanics in the most efficient way for them. Each day you will learn new exercises and massage techniques designed to harness the power of the elements earth, air, water and fire.

To register your interest and get more details email: [email protected]

mailto:[email protected]

mailto:[email protected]

Bodywork e-News 11

Treatment #5 Returning Normal Extension

Because of the impossibility of normal gait without full knee extension, I feel that this is the major goal for proper rehabilita-tion after injury or surgery. Of course tight fascia and muscles, particularly the hamstrings, will prevent full extension, but the therapist should also be skilled in working with the deeper re-strictions in the joint itself by using mobilization techniques (shown later) to work with the knee joint. Let’s begin with some of the major muscles that contract after trauma and pre-vent the knee from straightening.

Working with Popliteus and Plantaris

One area of caution: You may feel a fairly strong pulse from the popliteal artery, but don’t let this

deter you; just use the usual pre-cautionary techniques to distin-guish the muscle tissue from the artery and be precise in your work.

Since these are relatively weak flexors of the knee compared to the hamstrings, popliteus and plantaris are often neglected in conventional therapy. Their role in preventing full knee extension is less one of strong muscular resistance than of being “agitators” delegating re-sponsibility to stronger mus-cles that do the dirty work of preventing knee extension. The body always reacts to pain as a strong dictate of movement, and both these muscles can be sensitive or painful when stretched if they shorten after injury. At the first sign of pain in popliteus and plantaris, they send inhibi-

tory reflexes to the quadriceps inhibiting them from contracting to straighten the knee. They also recruit their allies (agonists?), the hamstrings, to strongly con-tract and prevent the knee from straightening. Reducing irrita-tion to and lengthening these small muscles is a first step in proper functioning of the larger muscle groups.

Photo # 10-- Popliteus and Plan-taris

AN INTEGRATED APPROACH TO REHABILITATION OF

LEG INJURIES

Part II with Art Riggs

After introducing the importance of a holistic view of knee rehabilitation in order to restore proper gait, the previous article ended with our fingers deep in the IT band. The techniques that were demonstrated began with more superficial work that is appropriate soon after injury or surgery, and progressed to tools for re-turning flexion mobility. We now turn our attention to treatment strategies to improve full extension to the knee and to a more detailed explanation of the complexities of gait, including techniques to deal with the compensatory reactions in the feet and hips that occur after injury.

Note: This article will use the more common usage of the term “leg” to refer to the entire lower extremity as opposed to strict medical terminology where “leg” specifically refers to the portion of the lower extremity between the knee and ankle.

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Although most of the examples in this article will recommend working with muscles in a stretched position to effect a re-lease, working in a very sensitive area like the posterior knee is best done with enough flexion to allow easy entry through superfi-cial layers and have popliteus and plantaris relaxed so they are not irritable. As they relax and lengthen with your work, then slowly extend the knee by using a smaller bolster to retrain their stretch receptors to feel safe with more extension. Once these muscles relax, the primary flex-ors and extensors of the knee can begin to work properly without neurological interference from popliteus and plantaris.

Usually popliteus and plantaris are shortened as a protective mechanism rather than from ad-hesions. Therefore, strokes in a distal direction are most effec-tive to train them to relax and lengthen. Use very soft fingers to sink through superficial tissue to find the tight muscles and very slowly stroke distally, with an intention of simply relaxing and stretching an irritable muscle. The texture and depth of pop-liteus and plantaris is very simi-lar to what it feels like to work on the scalenes in the anterior neck, so use the same principles. While working on these muscles, it is also a perfect time to begin stretching the more superficial fascia in the posterior knee.

Working with the Ham-strings

These are the most important muscles to relax and stretch to allow extension. The hamstrings will have learned to contract anytime the knee approaches the painful angle of straightening. You must not only release any fibrous restrictions, but must also train these muscles (and to a much lesser extent, the gas-trocnemius which also crosses the joint and is a minor flexor) to relax into a lengthened position. In the prone position refrain from using a bolster under the ankle so the leg can straighten.

Hamstring work is almost always beneficial for injured knees, but remember that if the knee is still inflamed and extension is pain-ful in the joint, then it is a natu-ral reflex for these muscles to be short and tight. If the joint is painful in movement or struc-tural barriers such as adhesions are present, then the hamstrings will naturally contract to protect the knee. Extensive work with the hamstrings will always be helpful, but permanent length-ening will only take place after the joint heals. This will some-times take several weeks or even months, so follow-up visits over an extended period of time are helpful to incrementally lengthen the muscles. Joint mo-bilization will be very helpful in freeing the joint so the ham-strings will not contract for pro-tection.

Photos #11 & 12 --Facilitated Lengthening Strokes for the Hamstrings

Although this may be the most important muscular work you do to return normal function to the knee, luckily, it is relatively sim-ple work without fancy tricks. Notice that if you have your cli-ent slide down so that both feet are hanging off the table; com-paring the injured knee with the healthy knee is an easy measure-ment to determine normal ex-tension. In this case, the right knee doesn’t allow full extension, so the right heel is about an inch higher than the left. Use your fingers, knuckles or forearms to slowly stroke distally while visu-alizing grabbing and stretching the hamstrings. You should con-tinue your intention of lengthen-ing below the knee to the gas-trocnemius and soleus. Note the dorsiflexion of the ankle to pro-vide stretch.

Treatment for the Legs Treatment for the Legs Treatment for the Legs

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Photo #13 --Anchor and Stretch Techniques for the Hamstrings

Not all your work with the ham-strings will be to educate them to lengthen. There may be signifi-cant thickening and adhesions in different depths of the muscles or surrounding fascia that need detailed release. Anchor and stretch strokes using precise pressure at fibrosed areas are effective. Visualize that you are placing all of your intention on a knot in a rubber band. Anchor with proximal oblique pressure at adhesions when the knee is flexed and then slowly lower the ankle to extend the knee and fo-cus the stretch at your anchor.

Cautionary note: If your client is recovering from anterior cruciate repair, the surgeon may prefer that the knee does not reach full extension. It is advisable to check with the doctor for guide-lines about the limits of exten-sion to work for. This caution should also apply to the use of joint mobilization techniques shown in the next section.

Treatment #5--Joint Mobili-zation Techniques for the Knee

The largest paradigm shift in my bodywork occurred after I had been practicing for almost 10 years when I took a spinal me-chanics class and began working with joints, not only in the spine, but virtually anywhere on the body. I hope that new therapists won’t wait as long as I did.

With the knee, we are primarily working to improve extension, flexion, and a bit of rotation be-tween the femur and the tibia. Anatomists agree that the knee joint is the most complicated in the body, but some relatively simple joint mobilization tech-niques can be practiced safely and effectively even if you are new to this concept. Although it is tempting to look at the joint as a simple hinge, in reality, when moving from extension to flexion and back, the tibia must slide anterior and posterior and rotate relative to the femur. After knee injury or surgery, tightening muscles that surround the knee can contract and compress the joint from all sides impeding the articulation of the bones. If nor-mal movement between the tibia and femur is not returned within a reasonable period of time, then adhesions form deep in the joint and can permanently restrict joint mobility. Since most thera-pists are apprised of ways to stretch the knee into flexion, we will concentrate on extension and rotation.

Anterior and Posterior Shear of the Tibia and Fe-mur

Straightening the knee to full extension requires that there is freedom for the tibia to glide back and forth on the femur (shear) rather than just straight-ening like a simple hinge. Soon after injury, adhesions begin to form, and even the slightest limi-tation can impact gait. Most therapists are trained to work on the knee supported by a bolster, but this practice prevents ex-tending the joint into its struc-tural barriers to release them. Early in the recovery process, you may work in supine position with the leg just resting extended on the table as you gain your cli-ent’s confidence, but as you be-gin making progress, place a bol-ster under the ankle or calf so the knee is suspended in space (“bridging”) as demonstrated in the photo.

Photos # 14 & 15--Anterior/Posterior Sheer


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Remember to place your inten-tion deep in the joint, and that unlike simply stretching the knee into extension as you would if the client is prone, you are ap-plying posterior pressure directly down towards the table and visu-alizing sliding the tibia and fe-mur in opposite directions. Mo-bilization can be applied in two ways. First, you can use rela-tively quick pulsations of pres-sure with about two pounds of force, repeating the pulsations for a minute or more. It is crucial to move the joint all the way un-til end range resistance is felt. This is helpful in over-riding conscious soft tissue holding patterns and begins to free up the joint as the bones slide back and forth. Secondly, you can ap-ply a steady pressure downwards with a bit more pressure, but be-ing careful that your client is not too uncomfortable. Sustain the pressure for a minute or two, waiting for a feeling of softening in the joint and a sense that the bones are sliding past each other.

In the first photo I am putting pressure on the femur so that it is sliding posterior relative to the tibia. Conversely, by placing your hands below the knee on the tibia, you are now sliding the tibia posterior relative to the femur. As you become adept at these procedures you can expand your effectiveness by experimenting to either compress or traction the joint as you apply anterior/posterior shearing pressure. The key to the success with this and most joint

mobilization techniques is to ap-ply enough force to mobilize the joint, but not so much force that your client has pain or is fighting against you.

Mobilizing Rotation of the Tibia and the Femur

When the knee moves, the tibia actually rotates upon the femur, rotating externally as the knee extends and internally as the knee flexes. If rotation is im-paired, then flexion and exten-sion are impaired. The rotation is subtle, but important to work with.

Cautionary note: Rotational joint mobilizations should not be per-formed if there is any question of a torn meniscus or ligaments after injury, but are very helpful after surgical repair of such inju-ries.

Photos # 16 & 17 —Supine Rota-tional Mobilization.

Reverse the process as you pull the leg back into full extension by rotating the tibia externally through the range of motion. Of course it can even be more help-ful to perform this technique while also stretching tight fascia or muscles, but your primary intention is to be rotating the tibia around the femur.

As you flex the knee by helping your client bring her knee to her chest, place steady pressure to rotate the tibia internally. When you reach the end range of com-fortable flexion, stay in this posi-tion and continue to exert gentle internal rotational force while waiting for softening of resis-tance

Photos # 18 & 19 —Seated Rota-tional Mobilization

This technique works well if your client has large or heavy legs or you feel unstable on the table. It


Bodywork e-News 15

has the added advantage of sta-bilizing the femur during move-ment and of the natural gravity of the lower leg placing traction the joint while you work. As you have your client flex her knee, rotate the tibia medially and then reverse the rotational direc-tion to external as the knee is extended. Remember that the most release will happen at the end range of movement so hold a sustained pressure at this range of motion for up to a minute.

UNDERSTANDING MOVE-MENT PATTERNS

The treatment suggestions that we have covered so far should provide considerable benefit for your clients who have knee prob-lems and anyone looking for bet-ter movement and freedom of the entire leg. As mentioned ear-lier, a great many people have sustained injuries that persist in compensatory patterns of move-ment that have been ingrained for decades. A holistic treatment plan that deals with the compli-cated relationship between the feet, ankles, knees, and hips will be a great boon to your practice and will provide better move-ment for all your clients, not just with injuries.

Now, let’s revisit the chart in Box 1, more detail to discuss the ba-sic kinesiology of walking gait at toe off and heel strike with more attention to the feet, ankle, and hips.

Toe off: This is the important stage of walking that propels the body forward. With limited knee extension, the stride is shortened, approximating the “mincing”

steps of very elderly people (I find that working for better knee extension is greatly appreciated by my older clients). If the foot is not far enough behind the body,

Box 1: In varying degrees, limited knee extension will have the following results in gait, including a short stride. If you can return normal extension to the knee (the primary restriction), then most of the secondary compensations in the foot and hip will improve with minimal intervention. Muscles that are inhibited will need to be strengthened, and any good sports medicine book will have suggestions. These images confine themselves to the pelvis and below, but notice how pelvic tilt is also affected and will have effects up the spine and beyond. If you consider how a tight psoas on the affected side will present side-bending and rotational strain on the lower back, it becomes clear how the effects of injury radiate globally.


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it loses its power to propel the body forward and energy is ex-pended in lifting the body up in-stead of forward. The foot ceases to flex at the toe joints (transverse arch) and become immobile causing the plantar fascia to shorten. The ankle re-mains in a neutral position rather than plantarflexing to push off, so tibialis anterior be-comes short and gastrocnemius and soleus become weakened.

As previously covered, since the knee won’t extend, the ham-strings, upper gastrocnemius, plantaris, and popliteus become shortened and will all need lengthening work, but don’t for-get to work with the superficial fascia, especially behind the knee to stretch this tissue. Perform joint mobilization to return nor-mal flexion, extension and rota-tion of the joint itself.

Many therapists neglect the hip in rehabilitation of the leg. If the leg cannot extend freely to the rear, then rectus femoris and psoas will become short because they don’t need to release to al-low the hip to extend for a long stride. They also will become fibrous from overwork, since the leg is not propelled by the foot and ankle to swing forward, rec-tus femoris and psoas will have to use more energy to lift the leg to overcome inertia. Instead of swinging freely forward, the knee will be lifted at a more ver-tical angle by the pull of these muscles.

Heel Strike: If the knee cannot

straighten, then the leg is unable to swing forward in front of the body with ease. Instead of land-ing on the rear of the heel with the ankle slightly dorsiflexed, the foot lands flat at a more vertical angle, preventing the normal rolling motion from heel to toe that dissipates shock. Gastrocne-mius and soleus remain short and will need lengthening so the foot can dorsiflex. The ankle will need to be mobilized in both plantar and dorsiflexion be begin working like a smooth hinge.

In addition to being short in the distal portion to prevent knee extension, the hamstrings will also remain tight near the ischial tuberosity as they prevent a full leg swing forward. It is easy to see how working with the ham-strings is the key to rehabilita-tion.

All of these complex feedback loops occur from the simple re-striction to knee extension. Re-member the chicken/egg rela-tionship with the joint and the muscles. The lack of proper joint movement will cause the mus-cles to shorten, but these short-ened muscles will solidify im-proper joint movement if the walking pattern becomes in-grained. Be sure to become skilled in joint mobilization tech-niques on the joint itself to help restore proper mechanics. The best news is that these tech-niques work equally well for re-storing proper movement pat-terns after injury to the feet, an-kles, and hips.

Although one can understand these kinesiological principles at a cerebral level, by far the best way to understand what is hap-pening in your client’s body is to feel the sensations in your own deep experience by mimicking the limping pattern. What joints aren’t moving? What muscles are contracting improperly? If you simply concentrate to pre-vent your knee from straighten-ing, you will experience the pro-found compensations from the toes up through the hips as you walk. In classes, I actually have students tape their knees to pre-vent full knee extension, and also have them experiment with placing a pebble in the forefoot or heel of their shoes. This is an excellent way to feel both the joint and muscular adaptations to pain or discomfort, and will enable a strategy for treatment.

Treatment #6 Balancing Secondary Compensations

Now we can move to some tech-niques to return proper function to secondary areas that respond to knee dysfunction. Work to satellite areas is extremely im-portant because of their ten-dency to reinforce limping pat-terns, but until proper function is returned to the primary site of injury, the secondary compensa-tory patterns will persist. It is perfectly appropriate to work on secondary compensations throughout your treatments be-cause they often cause discom-fort as they adapt. However, your primary goal should be to


Bodywork e-News 17

return the primary injury site to health as soon as possible, and then focus on the feet and hips.

Freeing the Toes, Trans-verse Arch, and Plantar Fas-cia

With a limping gait, the feet be-come stiff and inflexible as they land similar to wearing a very stiff-soled shoe that prevents the toes from flexing and providing power on toe off.

Photo # 20 Restoring Toe Exten-sion

Working in the end range of mo-tion is the key to this technique. With soft fingers, bend the toes as far as possible into an upward dorsiflexed extension. With knuckles or fingers patiently work the area of the metatarsal heads, with both cross-fiber strokes and in the direction of lengthening of tissue. This is also and excellent way work on the plantar fascia for the length of the foot.

The biomechanics of stretching the foot into dorsiflexion in ei-ther the prone or supine position

Photo #21 Softening the Plantar Fascia and Freeing Dorsiflexion.

can be difficult when the leg is straight. This technique offers the advantage of using your body weight, being able to exert strong pressure to dorsiflex the ankle, and the use of the broad and comfortable tool of your forearm. This technique is also useful to treat plantar fasciitis.

Improving Ankle Movement

Photo #22 ---Freeing the Ankle Retinaculum

The front of the ankle is sur-rounded by a fibrous retinacu-lum that can stiffen the ankle joint like an Ace Bandage, limit-ing both plantarflexion and dor-siflexion and causing torsion on

the ankle. Use your knuckles or the ulnar surface of your forearm to soften and free this tissue. Anchor in one direction and then mobilize the ankle in any oppos-ing direction to improve freedom. This is an excellent technique after ankle sprains or on virtu-ally anyone who wishes easier ankle movement.

Improving Hip Mobility

Photo #23 Freeing the Proximal Hamstring for Easier Leg Swing

By flexing the leg with the knee relatively straight, you can place the hamstrings on a nice stretch while releasing any areas with anchor and stretch strokes against the stretch. Don’t strain yourself by holding the leg with your arm if your client is large. You can be inventive and use your shoulder and body to apply stretch to the leg or even have your client apply the stretch by using a strap over the bottom of her foot.


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Photo #24 Releasing the Rectus Femoris

The rectus femoris and front of the pelvis will become short and tight if your client has been walking with a limp that pre-vents the leg from freely swing-ing back into extension. Work-ing in the neutral supine position will soften tissue but not stretch enough to open the area. This position allows you to work eas-ily using your own body weight as you stretch the leg into exten-sion. Support your client’s head and neck, and possibly low back with pillows, and have your cli-ent pull her opposite leg to her chest to keep the pelvis in a neu-tral position.

Apply pressure with you other hand to extend the hip and work in the direction of stretch work-ing with your fingers for superfi-cial tissue and with you forearm for deep muscular work on the quadriceps.

This technique is also useful for working with the psoas in a stretch, but do not over-extend the hip. If the hip is too ex-tended, it becomes difficult to sink through the superficial tis-sue in the anterior pelvis to con-tact the psoas.

Conclusion

I hope that this article have given you insight into the inter-esting interrelationship of the joints of the legs as well as some specific tools to successfully treat problems, not only to the knees, but to the other joints of the lower extremity. All joints of the leg are inextricably linked to-gether in a complex feedback loop that must be treated in a holistic manner for the best re-sults. Remember that each client

will present his or her own unique adaptive mechanisms to injury and that the solutions to solving limping problems rarely are simple or lie in only one area. These considerations are what make our work so interesting and rewarding.

Remember that a holistic treat-ment not only includes a broad view of distant joints and com-pensations, but should consider the whole person you are work-ing with, including the causative factors of their injury (especially with overuse injuries), their ap-proach to self-help though home programs of stretching and strengthening, and their emo-tional feelings. Fear, anger, de-pression, and self-judgment are often associated with injuries. We always treat more than mus-cle, tendon, and bone. The best therapists’ skills are more of an art than a craft as they provide a hopeful healing environment for their clients with their humanity and contact with the person be-hind the injury.


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Bodywork e-News 19

The iliotibial band (ITB) syn-drome is typically regarded as an overuse injury common in run-ners and cyclists. Lately, this controversial condition has gained greater attention due re-cent articles that include my “IT-band Friction Fallacy”1; Mark Charrette’s “Lateral Knee Pain and Orthotic Support”2, and Whitney Lowe’s “New Perspec-tives on ITB Friction Syn-drome”.3

Although many researchers and clinicians are convinced that the pathoanatomy of iliotibial band friction syndrome (ITBF) is well known and well understood, the jury is still out on the exact cause(s) of this lateral knee pain con-dition. Blindly following conven-tional wisdom may often point good clinicians to the wrong therapeutic path. The following example demonstrates how ‘chasing the pain’ can lead physi-cians to a linear treatment proto-col that results in months of un-warranted pain and unnecessary medical interventions.

Case Study

Recently, a 44 year old orthope-dist, for our purposes will be re-

ferred to as Dr. Smith, was re-ferred to me complaining of eight months of debilitating, self-diagnosed, IT-band friction pain. During his history intake, he admitted suffering sporadic foot, hip and low back soreness but dismissed these issues as “unrelated”. A self-described “weekend-warrior”, Dr. Smith’s knee pain flared with excessive running or cycling. Both he and his staff (a physical therapist and physiatrist) had carefully scruti-nized the painful knee and ar-rived at a unanimous diagnosis of ITBF based on results from Ober’s Test (determines the tightness of the ITB), Renne's test (specifies the area of pain during weight bearing) and No-ble's test (identifies the area of pain when the leg flexed at a cer-tain angle). To further strengthen their diagnosis, MRI studies showed a thickened iliotibial band over the lateral femoral epicondyle. The summa-tion: diagnosis confirmed….IT-band friction syndrome. Case closed.

Dr. Smith related that his group’s initial treatment goals focused on relieving the

(supposed) inflammation via ice treatments and anti-inflammatory medications fol-lowed by a series of physical therapy sessions. Sadly, the ‘series’ of physical therapy slowly evolved into months of heart-breaking disappointment. Typi-cal treatment modalities (stretching, ultrasound, electri-cal stim, cross-fiber frictioning and trigger point work) brought little relief. Discouraged with the lack of progress, Dr. Smith and his physiatrist partner began a more aggressive approach with corticosteroid and proliferation injections (Fig 1). Although many of their ITBF patients re-sponded favorably to this treat-ment protocol, Dr. Smith did not. Desperate to get back to his bik-ing and running regime, Smith decided to undergo a surgical

Deadbeat Diagnosis by Erik Dalton

Bodywork e-News 20

release of the IT-band at the pos-terior 2 cm where it passes over the lateral epicondyle….but still no relief. So how did eight months of aggressive treatment lead to abysmal failure?

Conventional Wisdom

ITBF is generally thought to be a multi-factorial, non-traumatic, overuse condition in which the distal aspect of the iliotibial band rubs over the lateral femoral epi-condyle during repetitive knee flexion and extension move-ments (Fig 2). This ultimately leads to irritation of the iliotibial band, bursa and lateral synovial recess. In this popular theoreti-cal model, the deep posterior ITB fibers are more vulnerable to back-and-forth rubbing on the knee’s epicondyle. Several stud-ies 4,5,6 have described a dynamic “impingement zone” at approxi-mately 30° of knee flexion where the ITB is most vulnerable to mi-crofiber tearing and associated inflammation.

Therapists who abide by this ‘conventional wisdom’ often seek out the sore spots around the

condyle and cross-fiber friction the affected tissue in an effort to break down weak-linked adhe-sions, enhance fibroblastic activ-ity and encourage tissue remod-eling.7 Follow-up treatments of-ten include elbow ‘fascia-mashing’ and manual ITB stretching routines. All of these approaches can be effective if IT-band fibers truly are damaged.

Science vs. Conventional Wisdom

In a compelling paper published in the Journal of Science and Medicine in Sport (2007), a prestigious research team led by John Fairclough and seven co-authors8 challenged the idea that excessive friction between the IT band and the lateral femoral epi-condyle creates microscopic tears and 'inflames' the tract or a bursa. These researchers found that several basic anatomical ITB principles had been overlooked:

(1) the IT band is not a dis-crete structure but a thick-ened part of the fascia lata which envelops the thigh,

(2) it is connected to the linea aspera by an intermuscular septum and to the supra-condylar region of the fe-mur (including the epi-condyle) by coarse, fibrous bands which are not patho-logical adhesions and,

(3) a bursa is rarely present but can be mistaken for the lateral recess of the knee.

According to their findings, it appears the ITB is actually pre-vented from rolling over the epi-condyle…partly because of its femoral anchorage…and partly because its fibers are bound tightly to the tough enveloping fascia lata.

Although Fairclough and his team were able to induce slight medial-lateral movement across the condyle, they proposed that ITB pain was primarily caused by increased compression of a highly vascularized and inner-vated layer of fat and loose con-nective tissue separating the ITB from the epicondyle (Fig 3). Dr. John Fairclough concludes that “ITB syndrome is related to im-paired function of hip and leg musculature and its resolution can only be achieved through proper restoration of lower quadrant muscle balance.”

Deadbeat DiagnosisDeadbeat DiagnosisDeadbeat Diagnosis

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Myoskeletal Treatment Plan

One of the first things that caught my attention while ob-serving Dr. Smith’s gait was the presence of a cavus right foot (high rigid arch) presenting on the same side as his IT-band pain (Fig. 4). With his lower leg stuck in external rotation, it ap-peared the stiff supinated foot was preventing the tibia from internally rotating during heel strike. This seemed rather un-usual since friction or compres-sion of the IT-band is generally thought to result from foot hy-perpronation coupled with ex-

cessive internal tibial rota-tion.9

Although gait observations, anatomical landmark assess-ments and functional testing revealed myoskeletal imbal-ances through the hips and lumbar spine, I initially de-cided to address the cavus foot problem. My experience has shown that a cavus foot stresses all myoskeletal struc-tures (foot to lumbar spine) leading to disorders such as peroneus tendinosis, stress fractures, trochanteric bursitis, plantar fasciitis, tibiofibular fixa-tions, and hip/back pain…. but not IT-band friction syndrome

Some cavus feet (particularly those with claw toes) do not re-spond well to manual therapy. Fortunately, Dr. Smith’s foot did regain flexibility as the muscles of the lateral fascial compart-ment were separated. Once myo-fascial flexibility improved, rear and forefoot joint mobilization routines helped restore glide to the rigid tarsal bones (navicular, cuboid and cuneiforms) and the talocalcaneal joint. (Fig. 5). Al-

though this myofascial/joint mob pro-tocol softened the stiff arch, it quickly became apparent that most of the rigidity was coming from Dr. Smith’s severely fix-

ated tibiofibular (ankle) joint. (Fig. 6)

I find this oft-neglected tib/fib joint to be the “key lesion” in many lower extremity disorders. Optimum ‘Stirrup Spring Sys-tem’ functioning (see my Don’t Get Married articles, Massage Today) demands that both ends of the tibia and fibula (proximal and distal), maintain smooth cephalad and caudal movements (Fig. 7). If working properly, the tib/fib articulations should per-form as magnificent shock ab-sorbers with their actions en-hanced by tibialis anterior and


Bodywork e-News 22

peroneus longus and kept in sync by a resilient but tough in-terosseous membrane.

The “figure 8” plantar and dorsi flexion technique was used to loosen the fibrotic ankle ligaments and articu-lar cartilages providing better anterior/posterior and superior/inferior glide but the fibular shaft still seemed stuck. Moving up to the proximal fibular head, I tested for A/P glide there. Finally--the ‘main event’ so responsible for months of mysterious lateral knee pain was exposed. With the knee flexed, my fingers and thumb were unable to budge the fibula in an anterior direction. Further-more, any slight pressure repli-cated the intense pain previously identified as the source of his problem. (Fig. 8)

Summary

Runners like Dr. Smith share a high risk for hamstring injuries with the most commonly torn of the group the biceps femoris. When asked about past ham-string problems, Smith related

that he had suffered a chronic pull a year before the knee began to flare. Therefore, with each step, the injury-shortened biceps femoris tugged on the fibular head causing chronic repetitive microtrauma at the tib/fib ar-ticulation. In time, the fibula be-came posteriorly fixated on the tibia causing joint play loss and lateral knee pain. By applying a simple contract/relax technique (Fig 9) over several sessions, we were able to establish normal

movement to the fixated tib/fib articulation thereby resolving his painful condition.

As with many “conventional” protocols, stepping outside the box provided that important dis-tinction to Dr. Smith’s recovery--relying more on accurate identi-fication and restoration of the functional biomechanical deficits in the entire kinetic chain rather than focusing on a specific in-jured tissue. Incorporating myo-fascial and skeletal mobilizations to Dr. Smith’s foot, ankle, proxi-mal fibular head, hip and pelvis were key factors allowing his re-turn to normal running and bik-

ing activities. Rather that chas-ing the pain, our intent, as al-ways, focused on ‘finding and fixing’ all compensatory kinks along the kinetic chain.

References:

1 www.erikdalton.com/NewslettersOnline/March_09_Newsletter.htm

2 www.dynamicchiropractic.ca/mpacms/dc_ca/article.php?id=53550

3 http://massagetoday.com/mpacms/mt/article.php?id=13991

4 J. Fairclough, K. Hayashi, H. Toumi, et al. Is iliotibial band syndrome really a friction syndrome? Journal of Science and Medicine in Sport, Volume 10, Issue 2, Pgs. 74-76

5 Orchard JW, Fricker PA, Abud AT, et al. Biomechanics of iliotibial band fric-tion syndrome in runners. American Journal of Sports Med, 1996; 24:375-9.

6 Hamill J, Miller R, Noehren B, Davis I. A prospective study of iliotibial band strain in runners. Clinical Biomechanics, 2008; 23:1018-25.

7 Clement DB, Taunton JE, Smart GW, et al. A survey of overuse running inju-ries. Physical Sports Medicine, 1981; 9:47-58.

8 Schwellnus M, Mackintosh L & Mee J. Deep transverse frictions in the treat-ment of iliotibial band friction syn-drome in athletes: a clinical trial. Physiotherapy 1992; 78(8): 564-569.

9 Ellis R, Hing W & Reid D Iliotibial band friction syndrome – a systematic review, Manual Therapy, 2007; 12: 200-208


http://www.erikdalton.com/NewslettersOnline/March_09_Newsletter.htm









http://www.dynamicchiropractic.ca/mpacms/dc_ca/article.php?id=53550




http://massagetoday.com/mpacms/mt/article.php?id=13991




Bodywork e-News 23

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Bodywork e-News 24

How It Started

In Thailand, what is known in the Western world as Thai mas-sage is known as Nuad Bo’Rarn. Nuad is a Thai word that trans-lates as, “to touch with the inten-tion of imparting healing.” Bo’Rarn is a word derived from ancient Sanskrit; it translates as, “something which is ancient and revered.” The same word, Bo’Rarn, is applied to the re-vered sutras (texts) of Buddhism. Also, in Thailand, Thai massage is recognized as a core compo-nent of an entire system of tradi-tional medicine. There are four aspects of traditional Thai medi-cine:

1) Herbal medicine;

2) Nutrition and food cures;

3) Spiritual practices, including mantras, prayer, incantations and mindfulness meditation;

4) Nuad Bo’Rarn (Thai massage).

Historically, Thai massage was not specifically what Westerners consider massage. It was thought of as and utilized as the hands-on practice of traditional medi-cine. Thai massage techniques were applied to the treatment of the varied ailments that afflict humanity, including mental and

emotional illness.

The historical founder of Thai medicine is known as Jivaka Kumar Bhaccha (the father doc-tor). He is identified by scholars as a close personal associate of the historical Buddha, and was the head physician of the origi-nal Sangha, the community of followers that gathered around the Buddha. This would place him as living in India approxi-mately 2,500 years ago.

Buddhist monks and followers brought their traditional medi-cine with them as they made their way from India to what is now modern Thailand, in ap-proximately the second century B.C. For centuries, the tradi-tional medical knowledge was transmitted orally from teacher

to student. Over the centuries, a distinct tradition evolved that was primarily influenced by the Ayurvedic traditions from India, but also began to incorporate theories and practices from an-cient China. In addition, healing practices of the indigenous tribal peoples of the area also became part of the local medical prac-tices. By the time Theravada Buddhism was declared the offi-cial religion of the kingdom in approximately 1292 A.D., the traditional medicine was well established in the Buddhist monasteries, known as Wat. Tra-ditionally, the Buddhist monks—and to a lesser extent Buddhist nuns—administered the healing

Thai Massage by Richard Gold

Jivaka Kumar Bhaccha

Bodywork e-News 25

work to the people in their vil-lages.

Besides the specific hands-on techniques, herbs and foods were utilized in healing; Buddhist phi-losophy pervades the practice of medicine in Thailand. Healing work is understood to be the practical application of metta, or loving kindness. Metta is under-stood to be a core component of daily life for each individual seek-ing awareness and fulfillment on the path taught by the Buddha. Teachers describe metta as the “foundation of the world,” essen-tial for the peace and happiness of oneself and others.

In Thai Theravada Buddhism, significant emphasis is placed on the practical application of spiri-tual philosophy: that higher ide-als be brought into everyday life and decisions. Accordingly, the practice of Thai massage demon-strates the practical application of the four divine states of mind: 1) metta, 2) compassion, 3) vicari-ous joy and 4) mental equanimity (brought to fruition through meditative practice).

How Is It Different?

Today, Thai massage is being practiced in clinics and spas all over the world and has experi-enced remarkable growth and acceptance. In fact, there has even been a dramatic growth of schools for traditional Thai massage in Thailand. It com-bines elements of yoga, medita-tion, acupressure and assisted stretching to provide a unique and wonderful bodywork experi-ence.

However, Thai massage does dif-fer in several ways from Western massage. Key distinctions in-clude:

• Thai massage is practiced with the client fully clothed in loose-fitting clothing.

• No oils or lubricants are utilized in Thai massage.

• Thai massage is practiced very slowly.

• Thai massage is a core compo-nent of an entire traditional medical practice (traditional Thai medicine).

• The practice emphasizes press-ing, compression and stretching techniques. The rubbing tech-niques of Western massage (effleurage and petrissage) are absent.

• Thai massage practitioners util-ize their feet, knees, elbows and forearms, in addition to their hands and fingers extensively during therapy.

• Sessions take place on a cotton pad or mat that is placed on the floor or on a low platform.

• Thai massage therapists are en-couraged to work in a concen-trated and meditative state of mind, unencumbered by thought or fantasy. They are supposed to “transmit” this quality of mind through their touch to the client.

• Although it is the physical body of the client that is being ad-dressed, the primary focus and intention of the therapy is to bring balance and harmony to the “energetic” body and mind of the recipient.

Primacy Of Abdominal Work

Like Indian Ayurvedic and Tradi-tional Chinese medicine, tradi-

Thai MassageThai MassageThai Massage

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tional Thai medicine is based on an energetic paradigm of the hu-man body and mind. In the Thai medical model, bio-energy (Qi) travels through the body on what are designated as Sen lines, which are somewhat similar to the me-ridians of acupuncture/Chinese medicine theory. Ten primary Sen are identified in Thai medicine, which, essentially, originate deep in the abdominal cavity in the vi-cinity of the navel and connect the center of the body to the sen-sory and excretory orifices and the extremities. Because of this energetic understanding, the practical, therapeutic application

of Thai massage focuses on the abdomen. The practitio-ner will work with the client to establish an awareness of breathing deeply into the ab-domen. Once the client is breathing deeply, the thera-pist will proceed with a spe-cific series of deep palm com-pressions, followed by deep thumb presses. All these pro-cedures are designed to in-vigorate the functioning of the organs and to eliminate ener-getic blockages and stagnation of blood and lymph. The im-proved functioning of the ab-dominal region has positive implications for the overall health and vitality of the client.

Going Forward

Thai massage offers the prac-ticing massage therapist a wonderful new approach to bodywork and therapeutic touch. In addition, more and more massage and bodywork es-tablishments are receiving re-quests from clientele to provide this unique style of therapeutic touch. There are great opportuni-ties to practice Thai massage in spas, clinical settings and resorts around the globe. The learning, practicing and receiving of Thai massage can be a profound, won-derful and joyful life experience.

About the author

Richard M. Gold, Ph.D., L.Ac., ABT, has been practicing Asian healing arts and acupuncture since 1978. He is the author and

instructor of the new DVD Mas-tering Thai Massage produced by Real Bodywork. He is the author of Best Selling Thai Massage book, 2nd edition, published in 2008.

He is a founder and current board member of the Pacific College of Oriental Medicine. Additionally, Gold is the president and chair-man of the board of the Interna-tional Professional School of Bodywork (IPSB). He teaches at both institutions. Gold is based in San Diego, and can be reached at: [email protected].

Thai MassageThai MassageThai Massage

Bodywork e-News 27

Learn the ancient art of Thai Massage with master instructor, Richard Gold. This beautifully filmed DVD features over 3 hours of instruction and over 170 detailed techniques.

Each technique is clearly demonstrated showing proper alignment, positioning and proper body mechanics so that pressure can be applied effectively and effortlessly.

This DVD includes traditional Thai stretches, work on the Sen energy lines plus abdominal massage.

Mastering Thai Massage is one of the most comprehensive programs available!


DVD Best Selling



Bodywork e-News 28

In the book “The Mind Has a Body of Its Own”1, authors Sarah and Matthew Blakeslee de-scribed marvelously how the brain maps the body. The brain contains maps of every point in our body, as well as the space around the body. An important theme of the book is that body maps in the brain can account for a range of experiences and perception. These recent find-ings offer scientific explanations for many phenomena, including phantom limbs, syndromes in which stroke patients neglect one side of the body, etc. More importantly for us, the authors suggest the possibility for neuro-biological explanation of many alternative therapies, including aura, Reiki, and energy therapy.

Our brains and bodies use the maps to translate incoming sen-sory signals into meaningful in-formation. To act efficiently, our brains need to locate objects in the space around our bodies, and need to hold a constantly up-dated report on the body's shape and posture. This requires an integrated neural representation of the body (the body schema) and of the space around the body (peripersonal space). Periper-sonal space refers to the space immediately surrounding our bodies, which can be reached by

our limbs. By integrating mul-tisensory (visual-auditory-tactile) cues around the body, the peripersonal space system provides information about the position of objects in the sur-rounding environment with re-spect to the body. Research has found that brain cells become active as objects approach the space around the body. Periper-sonal space can be seen and ex-perienced in the way that we are

able to use tools or instruments. When we are playing tennis, the racquets seems to be part of our hand. When Andre Rieu plays his violin, he became one with the instrument.

The space around us is real and can be sensed. Tai Chi and Qi Gong practitioners train their body with their relationship to their peripersonal space, with the goal of uniting the mind, body and intention. We can ob-serve that when two people jug-gle or dance together, they plan and execute their actions to-gether, sharing their periper-sonal space mapped by each other’s brain2.

Scientists never believe the ideas that our bodies are surrounded by the energy fields giving rise to aura, and have never been able to detect this kind of energy. However some people could really experience auras. The Blakeslees hypothesized that people who can visualize aura is a natural construct of the parie-tal lobe. People seeing aura is believed to be a natural product

Peripersonal Space & Energy

When New Age gurus invoke the mysteries of quantum physics to explain the mysterious energy fields and human consciousness, they are essentially explaining one mystery with another mystery.

Sandra & Matthew Blakeslee

Bodywork e-News 29

of cross-wired brain. Auras can be due to a flexible body map and a blending of peripersonal space and colour and any other sense. The fact that our body and perip-ersonal space are very flexible provides a new scientific under-standing of this phenomena.

Recent research also suggested that our peripersonal space can be extended into a space where an imagined posture would take us3. There are clear advantages of rep-resenting the ‘‘space’’ of an imag-ined posture. For example, before performing an action, an individ-ual may imagine it to learn about

its feasibility (‘‘Can I reach that box on the top shelf?’’). In many movement therapies employing imagery such as Ideokinesis and Alexander technique, guided im-agery actually exploited our brain to think of a better posture.

Peripersonal space can be har-nessed to treat and cure human illness, which is the basis of many alternative therapies. This idea has been accepted in many cul-tures around the world. The flexi-bility of our body maps and perip-ersonal space maybe the key to understanding how various “touch” therapies work.

The Blakeslees wrote1:

"In traditions of healing touch -- shamanic healing, energy healing, universal life energy, Reiki, and scores of other healing practices around the world -- practitioners use a combination of visual im-agery, motor imagery, and ges-tures to merge their own periper-sonal space sense with that of their patients. It might involve laying on hands, manipulating the vitalistic energy fields be-lieved to suffuse and surround the body, or passing magnets or crys-tals over special body points called chakras. The experience,

Peripersonal SpacePeripersonal SpacePeripersonal Space

Penfield's homunculus Sir Wilder Penfield, a Canadian neurosurgeon, in the late 1930s mapped out the areas of the brain involved in sensation and motor activity by stimulating them elec-trically. In cartoon like drawings Penfield showed the surfaces of the brain and a proportional representation of the external parts of the body. His early sketches have been referred to as Penfield's or motor Homunculus (= little man). Figure "A" is a section through the sensory

cortex (Parietal Lobe) and "B" is a section through the motor cortex (Frontal Lobe).

An interesting aspect of this map is that the propor-tional areas assigned to various body parts on the brain are not to their size, but rather to the sensitivity and complexity of the movements that they can perform. Hence, the areas for the hand and face are especially large compared with those for the rest of the body.

Bodywork e-News 30

both for the healers and their patients is quite real: both can often literally feel the shifting of the energetic currents or fields they believe are there.” "The scientific method has never been able to confirm that qi flows or other mystical vital energies are real and present in the mind and body. Yet the ex-periences of these things are so palpable for so many people that it would be a cop-out to dismiss them out of hand as 'nothing more than' wishful thinking. Perhaps science, hav-ing banished these energies from the account of reality, can nonetheless explain the sensory awareness that people have of them. The brain's touch, move-ment, and peripersonal space maps go far in explaining many key elements of these beliefs and experiences."

In various touch modalities, such as Reiki, Therapeutic Touch, Po-larity or Craniosacral therapy, we can feel and experience the “energy” from a therapist, the warm sensation, and sometimes can tell where the therapist’s hand (even when the therapists didn’t touch any parts of our skin). This energy can induce powerful sensations in the body, and the sensations we feel are a combina-tion of the flexibility of our body map to reach out to the therapists. It is also due to what we believe is happening. Healing works be-cause the body and mind is flexi-ble and creative. The power of placebos, expectation and belief is

a potent form of medicine. Skep-tics tend to think that this is all imaginary. However, since our body maps actually extend out into the space around us, we probably really can sense the per-son really close to us doing ener-getic touch.1,2

Peripersonal space is physically mapped in the brain’s parietal and frontal lobes. The motor in-tentions are within that space. Studies using functional MRI (fMRI) imaging technique showed that parietal and frontal areas are involved in the repre-sentation of peripersonal space4. (fMRI is an imaging scan that shows the blood flows response

related to neural activity in the brain).

Using various bodywork mo-dalities, we can actually direct and manipulate this periper-sonal space, because the ex-perience is represented also in the brain. Sarah and Matthew Blakeslee hypothesized that using fMRI imaging on the frontal lobes, we might be able to see the effect of Reiki or therapeutic touch.

A study by Jeanne Achterberg has investigated the effect of healing in 20055. She and her colleagues recruited 11 healers, each was asked to select a per-son they had worked with pre-viously with distant intention-ality, and with whom they felt an empathic, compassionate bond. Each recipient was placed in a fMRI scanner and was isolated from the healer.

The healers sent forms of distant intentionality related to their own healing practices (including Reiki) at two-minute random in-tervals that could not be antici-pated by the recipient. Significant differences between the experi-mental (send) and control (no send) conditions were found. There are areas of the brain that were activated during the send periods. This study suggests that remote, compassionate, healing intentions can exert measurable effects on the recipient, and that an empathic connection between the healer and the recipient is a vital part of the process.5

While this study does not suggest


Bodywork e-News 31

the effect on peripersonal space, it opens up for neurobiological explanation for many of the alter-native therapies.

There are two implications of these findings for body-workers: first, that there is a possibility of scientific explana-tion of the mechanism of touch therapies and other energetic work from a neurological point of view. The second is that when we are working on a body, we are also working on and affecting their peripersonal space and mind.

The author here does not pretend to fully understand about the brain and neurology, there’s probably an oversimplification of the matter. However the point is that we should not get stuck in presudoscience explanation of many of the energetic therapy but we should try to advance the sci-ence figuring out the real mecha-nism.

Many mainstream scientists are also interested in trying to find out the mechanisms of alternative therapies. Paul Tofts, a professor in medical imaging, in the book “Quantitative MRI of the Brain” stated: “The Placebo effect is phe-nomenon considered very power-ful in medicine, and yet the mechanism of action (for alterna-tive treatments) is not fully un-derstood. With quantitative MRI we may be in a position to objec-tively record responses to such treatments.”

Neurologist V.S. Ramachandran in his book “Phantoms in the Brain” wrote: The message preached by New Age gurus con-tains important insights into the human organism – ones that de-serve scientific scrutiny…. We should not reject an idea as out-landish simply because you can’t think of a mechanism that ex-plains it…. Finally we should not have blind faith in the “wisdom of the east” but there are sure to be many nuggets of insight in these ancient practices. Unless we con-duct proper “western-style” ex-periments, we’ll never know which ones work and which one doesn’t.

More importantly the implication of peripersonal space for body-worker is summarised by Keith Eric Grant6:

“There are features and reactions of the body that are not explicitly physical, but stem from the im-mense pattern-matching and mapping processes of our brain. In some cases, what we perceive might be both a mapping of the peripersonal space and a map-ping from one sensory mode to another…. The bottom line is that, as humans, we are neurologically wired to respond to and be part of the sensory world immediately surrounding us. As massage prac-titioners, this opens the door to helping our fellow humans cope with transitions and traumas, and for sharing their joys. Our emo-tions map into our body, but just as surely, our bodily experiences

map into our emotions.”

References

1 S. Blakeslee, M. Blaskeslee. The Mind Has a Body of Its Own. 2007. Random House.

2 G. Campbell, Brain Science Podcast, Episode #21 Discussion of the book, The Body Has a Mind of Its Own, by Sandra Blakeslee and Matthew Blakeslee. Aired September 22, 2007.

3C.C. Davoli, R.A. Abrams. Reaching Out With the Imagination. Psychological Sci-ence, 20 (2009), 293-295.

4Makin, T.R., Holmes, N.P., & Zohary, E. Is that near my hand? Multisensory rep-resentation of peripersonal space in hu-man intraparietal sulcus. Journal of Neu-roscience, 27 (2007), 731–740.

5J. Achterberg, K. Cooke, T. Richards, L. Standish, L. Kozak and J. Lake. Evidence for correlations between distant inten-tionality and brain function in recipients: a functional magnetic resonance imaging analysis, J Altern Complement Med 11 (2005), pp. 965–971.

6K.E. Grant. Mapping Body into Motion. Massage Today June, 2008, Vol. 08, Is-sue 06.


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A new Japanese study into reflexol-ogy has made a significant break-through in establishing a scientific link between reflexology areas in the foot and parts of the human brain.

The research, which used functional Magnetic Resonance Imaging (fMRI) to measure the brain activity of people undergoing reflexology, is the first study of its kind and offers tantalising proof that differences in the brain can be made by stimulat-ing specific areas of the feet.

Although reflexology is believed to be more than 4,000 years old, little is known about how the alternative therapy actually works, as Tracey Smith, Research and Development

Manager at the Association of Re-flexologists, explains.

Although this practice has shown positive effects on the human body in some clinical studies, how reflex-ology works is not yet fully under-stood. “One of the major criticisms levelled at reflexology as a therapy is that there has been no proof of any route of connection between the foot and any other representative organ in the body, which is the un-derlying idea of reflexology,” she said.

The fMRI study, which took place at the University of Tohoku, recruited 25 subjects (22 men and 3 women aged 18–41 years). The study inves-tigated three reflex areas relating to the eye, shoulder and small intes-tine. Brain activity was measured during three sensory stimulation reflex areas, corresponding to the eye, shoulder, and small intestines. The experimenter stimulated each reflex area using a wooden stick with the right hand.

A statistical analysis showed that reflexological stimulation of the foot reflex areas corresponding to the eye, shoulder, and small intestine activated not only the somatosen-sory areas corresponding to the foot, but also the somatosensory areas corresponding to the eye, shoulder, and small intestine or neighboring body parts. These areas of the brain correspond with Penfield’s Homun-culus.

The authors concluded that the acti-

vated area during the stimulation of each reflex area was consistent with the somatotopic representation of the corresponding or neighboring body parts in the somatosensory area. Previous fMRI studies of acu-puncture revealed the somatotopical mapping of acupoints on the fore-arm, hand, leg and foot, and part of the visual processing areas, which were activated when an acupoint related to visual function was stimu-lated. The results indicated that re-flexology had some effects that were not simply sensory stimulation. This new results support that claim and indicate that a neuroimaging ap-proach may be a useful procedure for examining the underlying effects of this alternative medical practice.

“Although this particular report is not enough evidence in itself, it does raise interesting questions about our understanding of the human body and shows the potential for alternative therapies to have greater influence on conventional treatment in the future,” Tracey adds.

T. Nakamaru, N. Miura, A. Fuku-shima. and R. Kawashima. Soma-totopical relationships between cor-tical activity and reflex areas in re-flexology: A functional magnetic resonance imaging study. Neurosci-ence Letters 448 (2008), 6-9.

Rankin-Box, D., 2009. MRI re-search sheds new light on reflexol-ogy. Complementary Therapies in Clinical Practice 15, 119

A New Theory on Reflexology

Reflex areas for the eye (No. 8), shoul-der (No. 10) & small intestine (No. 25)

Bodywork e-News 33

Nerve Mobilization

Review by Tyraus Farrely, AMT In Good Hands (March 2007 & December 2008) • Excellent quality • Excellent value for money • Invaluable learning resource • Awesome Animated Graphics • Best nerve treatment DVD I have ever seen Overall Rating ***** A must see, highly recommended!

The Best Yoga Collection

Bodywork e-News 34

De Quervain’s syndrome or De Quervain's tenosynovitis, or De Quervain's stenosing tenosynovi-tis is an inflammation of the sheath or tunnel that surrounds two tendons that control move-ment of the thumb.

It is mainly caused by repetitive movements of the wrist and thumb, which can cause irrita-tion and pressure on an ana-tomical tunnel known as the first dorsal compartment. Inside the first dorsal compartment run the two tendons of abductor pollicis longus and extensor pollicis bre-vis. De Quervain’s syndrome is characterized by inflammation of these tendons or their synovial sheath (tenosynovitis).

The swelling causes increased restriction of the tendons through the first dorsal tunnel and sets up a chronic cycle of swelling and restriction.

The condition is more common in women than in men (a study indicates 5 times more in women). However, some younger women develop symp-toms during pregnancy and in the period after birth. It is also referred to as mother's wrist due to the conditions experienced by mothers caused by repeated ul-nar deviation while holding their newborn babies. It was also

called washerwoman's sprain as it can be caused by wringing mo-tions, such as wringing out a washrag (probably not that com-mon anymore).

Recently, it is also related to overuse of thumb from repeated text messaging, referred to as Blackberry Thumb. Although some relate it more with carpal tunnel syndrome.

Pain, tenderness and swelling are the major complaint with De Quervain’s syndrome. Some-

times numbness near the base of the thumb. Movements of the wrist and use of the tendons of the thumb exacerbate the pain.

A simple test for de Quervain syndrome is called the Fin-klestein Test. Hold the thumb in the palm, and then ulnar devi-ated If this causes intense pain over the radial styloid, which disappears if the thumb is re-leased, De Quervain's tenosyno-vitis is likely. Another variation

De Quervain’s Syndrome

Grasps the thumb in the palm of the hand and ulnar deviates the thumb and hand. Test positive if it pro-duces sharp pain along the groove of the radial styloid.

Hold the thumb in the palm & ulnar deviate.

Picture courtesy of Primal Pictures

Bodywork e-News 35

is while the thumb is grasped in the palm, extend the thumb with the other fingers resisting. Sharp pain along the tendon in-dicates likely syndrome.

It is very important to rest from the repetitive motions that cause the inflammation. Frequent rest breaks should accompany any tasks that require repetitive use of the wrist and hand.

The use of a wrist splint or brace may help to reduce the occur-rence of the condition, especially when used at the first sign of a problem. The wrists is immobi-lized with a splint or brace for part of the day to limit move-ment while the area is healing.

If the area is inflamed, massage is contraindicated. Massage loos-

ening the muscles around the thenar eminence will help.

Cold applications may help re-duce inflammatory.

Transverse friction of the tendon will help mobilize adhesions be-tween the tendon and its sheath.

The client’s writs is brought to ulnar deviation to put the ten-dons into stretch and friction is applied while they are stretched (Lowe, 2003).

Several Hyatt Regency Spas in US are now offering Blackberry Thumb Massage for their guests. A hotel news release describes a session; “First, hands are warmed up with soothing rocks and an aroma hot towel. Next, kneading and compressions loosen muscles and warm oil is applied with firm strokes. The therapist then kneads and stretches deltoids, biceps, triceps, flexors and extensors, and uses an acupressure massage tech-nique on hands and arms. The 30-minute treatment culminates with an aroma hot towel cleanse on each hand.”

Feels good, but not sure if it will help much with De Quervain syndrome.

References

Cutler, N. How You Can Help Treat de Quervain’s Tendonitis. http://www.integrative-healthcare.org/mt/archives/2006/11/how_you_can_hel.html

Lowe, W., 2003. Orthopedic Massage. Elsevier Health.

Custom-made splint to immobilize wrist movement.

De Quervain’s SyndromeDe Quervain’s SyndromeDe Quervain’s Syndrome

Cartoon courtesy of Montaz http://www.momtaz.nl/

http://www.integrative-healthcare.org/mt/archives/2006/11/how_you_can_hel.html
















http://www.momtaz.nl/

Bodywork e-News 36

It has been bought to my attention re-cently a new contraindication in Mas-sage which Therapist should be aware of and is currently not being addressed in the Colleges.

I practice both Lymphology and Reme-dial Massage. I have had several pa-tients in my clinic, referred from other Clinics that have performed Remedial Massage on these patients, all within a short period of time from one another, complaining of pain in their legs. This is not so unusual from our daily pa-tient’s complaints except for one thing. The pain turned out to be Superficial Blood Clots.

These clots are quite quick to disappear but left untreated will travel into the Deeper Venous System and brings along a different more life threatening problem.

All of these patients have some form of either Lymphoedema Or Lipoedema in their legs.

These patients cannot have any form of Remedial, Deep Tissue, Trigger Point or Vigorous Massage on their Oedema-tous limbs because it has and will con-tinue to cause Superficial Blood Clots.

How do we know if the Limb/s is oedematous or not?

There are some simple tests which you should know.

1. Do your history.

You cannot rely on the patient telling you they have a problem because they may not know they have Lymphoedema or Lipoedema.

Ask if the patient has had any form of

Cancer, now or in the past. Most pa-tients develop their Lymphoedema Secondary due to Cancer node removal and radiation therapy,

Mostly 3 – 8 years after the event. If they have had their surgery or radiation recently and there are no signs of oe-dema that doesn’t mean they haven’t got the start of it.

92% of patients that have had node removal or radiation will get Lymphoe-dema. There are 8,000 new cases every year reported in Victoria alone.

Lipoedema is a genetic disorder of Women. The basic signs of this disease are the top half of the torso is a size 8 and the bottom half a size 14 or thick ankles.

2. First Signs of Oedema.

Puffiness, Stiffness, Discomfort, Heavi-ness, Tightness, Heat, Pain, (bursting, shooting, joint), Numbness, Difficulties in putting on Jewellery, Shoes or doing up Pants, An increase in weight for no apparent reason, Increase in skin tem-perature, Fibrosis and easy Bruising. This can be found in both Arms and Legs. The patient may get 1 or all of these symptoms.

3. Other conditions associated with Lymphoedema.

High Blood Pressure, Heart Conditions, Arterial and Venous conditions (Thrombosis and Varicose Veins), Dia-betes, Thyroid condition, Inflammation – infections, Auto-Immune Disease, Hormonal Conditions and Pregnancy.

If you are in doubt whether or not this person suffers from Lymphoedema or Lipoedema, let the client know that you have a suspicion and leave that limb or limbs out of your session. Effleurage is fine going from distal to proximal, gen-tly and rhythmically. The patient should be told they may have some swelling in their limb, so they can be sent to a Professional Lymphologist for correct diagnosis.

Because Only 3% of Doctors know how to correctly diagnose Lymphoedema and even less know about Lipoedema a properly trained Lymphoedema Spe-cialist is the best option to refer to. Much of my work to do this year is to try and rectify this situation.

If you have any questions please email me on [email protected]

Written by Kristin Osborn Dip. R.M., Dip. M.Sc., T.A.A.

Lymphologist, Clinician, Writer, Mem-ber AMT, ALA and LAV

Resources used: Theory and Practice of Lymph Drainage Therapy 2nd Edi-tion 2004

A New Contraindication of Massage

By Kristin Osborn

mailto:%[email protected]

Bodywork e-News 37

Pain resulting from nerve en-trapment syndromes is a com-mon reason for clients to seek the care of a massage practitio-ner. However, there are numer-ous neurological disorders that at first glance might appear to be a nerve entrapment problem, but are an entirely different patho-logical condition. Complex re-gional pain syndrome (CRPS) falls into that category.

A brief review of fundamental neuroanatomy is helpful to prop-erly understand what occurs in CRPS. The autonomic nervous system has efferent fibers that control activity in various smooth muscles, glands, and cardiac muscle. Within the auto-nomic system there are two divi-sions, the sympathetic and para-sympathetic. The primary func-tion of the sympathetic branch is to stimulate activity, while sig-nals from the parasympathetic branch serve to inhibit activity. Of these two, the sympathetic branch is more involved in CRPS.

The sympathetic nervous system has a vital role in protective re-flexes as the body responds to stress. It is in high gear during the “fight or flight” response. However, excess sympathetic system activity can generate and maintain pain states in different

regions of the body. It is this ex-cess sympathetic activity that causes the symptoms of CRPS. While there is still not a com-plete understanding of how ex-cess sympathetic branch activity causes these pain conditions, it appears that there is some spill-over of noxious input from the sympathetic efferents into vari-ous nociceptors, especially in the extremities.

The term complex regional pain syndrome has only recently been added to the medical lexicon. It includes two separate conditions that have similar symptoms but are different in cause. The two conditions were formerly called reflex sympathetic dystrophy (now called CRPS 1) and causal-gia (now called CRPS 2).5 The primary difference between them is how they occur. In CRPS 1 (reflex sympathetic dystrophy)

Box 1: Symptoms of CPRS • Some initiating event, often traumatic, but may be trivial- sur-

geries, fractures, dislocations, • Pain that is disproportionate to the inciting even • Allodynia (painful response to a stimulus that is usually not

painful) • Hyperalgesia (exaggerated sensory response to a stimulus that

would ordinarily produce only mild discomfort • Allodynia and hyperalgesia in that extends beyond the distri-

bution of a single peripheral nerve • Evidence of autonomic dysfunction (edema, alteration in blood

flow, sudomotor dysfunction such as excess sweating in the region)

• Pain is usually described as a burning, searing, or shooting • Vascular abnormalities (more common in CRPS 1)—often start

vasodilation and skin warming in the early phase and progress to vasoconstriction in later stages

• Excess edema in the affected extremity • Motor impairment including weakness, inability to initiate

movement, tremor, muscle spasm, or dystonia • Changes in growth patterns of hair and nails on the affected

limb • Trophic changes in the skin

Complex Regional Pain Syndrome

By Whitney Lowe

Bodywork e-News 38

symptoms commonly occur as a result of some traumatic incident, but there is no evidence of spe-cific nerve damage. In CRPS 2 (causalgia) there is also some event that initiated excess sympa-thetic activity, but this condition also involves identifiable damage to the nerve. Most of the symp-toms of CRPS 1 & 2 are similar and are included in Box 1.

Distinguishing CPRS from other neurological disorders is aided by detailed evaluation of several clinical features in addition to those listed in Box 1. The condi-tion can affect either the upper or lower extremity, but is more com-mon in the upper extremity and the pain is usually aggravated with moving the affected limb. Various myofascial dysfunctions may also accompany the extrem-ity pain.1 Women are affected more often than men with an ap-proximate 3:1 ratio.2 Some degree of depression or psychological dysfunction is common with CRPS. However, it is unclear if this psychological dysfunction is a causative factor or a result of the condition because depression and similar psychological manifesta-tions are common in severe and chronic pain conditions.4

Treatment for CRPS varies widely but physical therapy is a primary component of most treatment protocols. The goal of most physi-cal therapy treatments is to de-sensitize the area and restore nor-mal function of the affected ex-tremity. Massage may play a fun-damental role in this process. Be-

cause myofascial dysfunction is often a part of the array of symp-toms, addressing the myofascial component may interrupt the cy-cle of pain and dysfunction. Rashiq found that in many cases if the myofascial pain condition was properly addressed the whole syndrome may resolve.3 Massage is also likely to be helpful because it is effective at decreasing overall sympathetic system activity.

If you have a client that demon-strates signs and symptoms that indicate the possibility of CRPS, it is important to have them prop-erly evaluated by a physician. There are a number of other treatment strategies such as nerve blocks and medications that are effective in addressing the prob-lem and it may be important to start these treatments as early in the rehabilitation process as pos-sible.

CRPS can be a debilitating condi-tion. Because it occurs more often in the upper extremity it may be easy to dismiss many of the symptoms as arising from a pe-ripheral compression neuropathy such as carpal tunnel syndrome. However, awareness of the vari-ety of symptoms associated with CRPS allows the practitioner to look at a bigger picture and catch this condition early on, if present, so it can be most effectively treated.

Notes

This article is originally published in massage Today.

1. Allen, G., B. S. Galer, and L. Schwartz. Epidemiology of com-plex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 80:539-544, 1999.

2. Ghai, B. and G. P. Dureja. Complex regional pain syndrome: a review. J Postgrad Med. 50:300-307, 2004.

3. Rashiq, S. and B. S. Galer. Proximal myofascial dysfunction in complex regional pain syn-drome: a retrospective prevalence study. Clin J Pain. 15:151-153, 1999.

4. Walker, S. M. and M. J. Cous-ins. Complex regional pain syn-dromes: including "reflex sympa-thetic dystrophy" and "causalgia". Anaesth Intensive Care. 25:113-125, 1997.

5. Wasner, G., M. M. Backonja, and R. Baron. Traumatic neural-gias: complex regional pain syn-dromes (reflex sympathetic dys-trophy and causalgia): clinical characteristics, pathophysiologi-cal mechanisms and therapy. Neurol Clin. 16:851-868, 1998.

CRPSCRPSCRPS

Bodywork e-News 39

Neural coding for massage stroke

Researchers have found that some nerves in the skin send 'feel good' signals to the brain when activated by gentle, slow massage stroke. But they only work when the skin is stroked at just the right speed, 1-10 cm per second with an optimal rate around 4 centimetres per second. Rub too fast or too slow, and the nerves are not stimulated.

Researchers demonstrated the effect of C-fibres on volunteers using a 'robotic tactile stimula-tor' – a mechanical arm fitted with soft brush. Sensually ca-ressed by the robot, the volun-teers produced C-fibre signals that could be recorded.

Professor Francis McGlone said: "If you get a piece of grit in your eye, have a toothache, or bite your tongue, it hurts so much because there are more C fibres there. The research we have been doing is building evidence for another role of C fibres in the skin that are not pain receptors, but are pleasure receptors."

He said the findings appear to explain "the pleasant… aspects of touch we are all familiar with, such as when grooming or being cuddled".

The nerves are found in skin cov-ered by hair but are absent in the palms of the hands. "We believe this could be Mother Nature's way of ensuring that mixed mes-sages are not sent to the brain when it is in use as a functional tool," said Professor McGlone.

Massage can relieve pain

For those who experience linger-ing pain following exercise, a re-laxing deep massage can help relieve musculoskeletal pain as-sociated with exercise-induced pain, according to research re-ported in The Journal of Pain.

Researchers at the University of Iowa performed a double-blinded, randomized controlled trial to study the effects of mas-sage on pressure-pain thresholds and perceived pain using delayed muscle soreness following exer-cise as the pain measurement. Trial participants were divided into three groups: no-treatment (control), superficial touch and deep tissue massage. Pain was assessed before treatment, after exercise and before and after treatment.

The authors found that subjects given deep-tissue massage were able to increase their pain thresholds and decrease stretch pain compared with the no-treatment group. When combin-ing the deep-tissue massage and light-touch groups, they found that stretch-pain reductions re-mained significantly better than in the control group although the light-touch treatment was not significantly better than no treat-ment.

The authors concluded that their study demonstrates that soft-tissue massage can reduce hy-peralgesia and pain using a de-layed onset muscle soreness model. The findings support use of massage to reduce stretch-pain perception and hyperalgesia.

Unique multifidus design contributes to spine stabil-ity

The novel design of a deep mus-cle along the spinal column called the multifidus muscle may in fact be key to spinal support and a healthy back, according to researchers at the University of California, San Diego School of Medicine. Their findings about the potentially important “scaffolding” role of this poorly understood muscle has been published on line in advance of the January issue of the Journal of Bone and Joint Surgery.

“The multifidus muscle was for-merly thought to be relatively unimportant based on its fairly small size,” said Richard L. Lie-ber, Ph.D. “Our research shows that it’s actually the strongest muscle in the back because of its unique design. It’s like a long, skinny pencil packed with mil-lions of tiny fibers.”

The researchers discovered that the multifidus has a unique packing design consisting of short fibers arranged within rods,

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Picture courtesy of Real Bodywork

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and that these fibers are stiffer than any other in the body. Using laser diffraction methods that they developed to measure mus-cle internal properties during back surgery, they demonstrated that the multifidus’ unique design serves a critical function as a sta-bilizer of the lumbar spine. These findings could have implications for surgery, according to Steven R. Garfin, M.D.

“It is important to identify what each individual muscle does, and this is just a start, showing that the multifidus contributes signifi-cantly to spinal stabilization,” said Garfin. “The more we know about what muscles do, the better we can devise therapeutic inter-ventions such as physical therapy to target specific muscles.”

Garfin explained that many mus-cles get weaker as they are ex-tended. But the researchers dis-covered that, unlike all other muscles, the multifidus actually becomes stronger as it lengthens, when the spine flexes. “The length of the sarcomere—the structure within the muscle cell where fila-ments overlap to produce the movements required for muscle contraction—is shorter in the multifidus than in any other mus-cle cell,” explained study’s first author Samuel R. Ward, P.T., Ph.D. “But as it gets longer, for instance as a person leans for-ward, the multifidus actually strengthens.”

Motor Control Exercises Re-duce Persistent Lower Back Pain

Motor control exercises, when performed in conjunction with other forms of manual therapy, can significantly reduce pain and disability in patients with persis-tent low back pain, according to a

new systematic review published in the January issue of Physical Therapy (PTJ). In addition to feeling less pain, patients per-forming these types of exercises are able to be more physically ac-tive and experience positive ef-fects over a longer period of time than those who receive other treatments, according to re-searchers.

Motor control exercise, also known as specific stabilization or Core exercise, is a new form of exercise for back pain that has gained the attention of research-ers and health practitioners over the past decade. The exercise fo-cuses on regaining control of the trunk muscles, also known as the transversus abdominis and multi-fidus, which support and control the spine. Previous studies of pa-tients with low back pain have shown they are unable to properly control these muscles. Through motor control exercise, patients are taught how to isolate and “switch on” these muscles and then incorporate these move-ments into their normal activities.

“Although the exercises seemed promising, until now we did not have clear evidence on whether or not they were more effective,” ac-cording to researcher Luciana G Macedo, PT, MSc, a PhD student at The George Institute for Inter-national Health, Sydney Univer-sity, Australia.

Massage Therapy & Life Ex-pectancy

A statistical analysis performed by Medical Massage Care indi-cates that therapeutic massage tends to increase life expectancy. Using the data from 50 states in the US, the author found a posi-tive correlation between the num-

ber of massage therapists per 1,000 residents of a state and the life expectancy for that state. As the number of massage therapists per resident increases, the life expectancy tends to increase. A model suggested that with an in-crease in one therapist per 1000 residents, the life expectancy in-creases 1.7 years.

Hawaii is the state with the great-est number of massage therapists per resident and is the state with the greatest life expectancy as well. Utah and Colorado also place in the top ten in both cate-gories. The states with the lowest concentrations of massage thera-pists tend to have the lowest life expectancies. Louisiana, Ken-tucky, Georgia, Mississippi, and Alabama all place in the bottom ten for both number of massage therapists and life expectancy.

Certainly encouraging, although drawing a long bow, the author suggests that the higher number of massage therapists meaning more people are getting into mas-sage, and it improves life quality, thus life expectancy!

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6 Questions to Til Luchau6 Questions to Til Luchau6 Questions to Til Luchau

1. When and how did you decide to become a body-worker?

My bodywork interest originally came out of my psychological training. In the early 1980’s I was studying Gestalt and other experimental psychotherapies at the Esalen Institute in Big Sur, CA. Gestalt emphasizes the role of the body in psychologi-cal growth, and our teacher encouraged us to study a body modality in order to be better therapists. There were great opportunities for studying the work of early bodywork pio-neers at Esalen then—several of Ida Rolf’s, Moshe Feldenkrais, Milton Trager, and Randolph Stone’s original students and teachers were in residence there. I enjoyed the body work it-self, and got good feedback, so I continued studying and it became a focus of mine. Soon I was teaching at Esalen, then later at the Rolf Institute, where I’d gone to train in 1985. (I also worked for a long time as a body-centered psychothera-pist--that part of my work still informs my work as a body-worker and teacher, and has evolved over the years onto my coaching practice and organizational development work.) 2. What do you find most exciting about bodywork therapy?

The one thing? think it is the experience of actually receiving great bodywork. Earlier this year, we had a 9-day retreat in Mexico for a dozen of our (Advanced-Trainings.com’s) faculty and assistants. We traded a lot of work and ideas, and I real-ized there that we all had one thing in common—a love for the amazing altered state of heightened somatic awareness that comes with skilled bodywork. Bodyworkers classically neglect receiving bodywork themselves. There are exceptions to this of course, and I think those that make sure to stay connected to the actual experience of receiving good work, do much better work, and enjoy it more. Helping people, learning and re-searching, sharing and teaching, and working together with talented colleagues in a training situation are the things that keep me loving this work.

3. What is your favourite bodywork book?

The Encyclopedia Anatomica from Taschen has great photos of gorgeous, anatomically precise wax models that were made for Florentine medical students in the 18th century. Ka-pandji’s Physiology of the Joints series is an unparalleled source of inspiration and technical insight into how joints function. 4. What is the most challenging part of your work?

I find this question particularly challenging! Why can’t I think

of a “most challenging part?” It isn't’ for any shortage of diffi-culties...maybe its just because the good and the “bad” are so intrinsically wrapped together in this work, and that those that make it their path take all that together, that I can’t tease out a challenge that isn’t also a gift. 5. What advise you can give to fresh massage thera-pists who wish to make a career out of it?

I always enjoy it when I get to work with a new therapist who is enthusiastic about the work itself, and who sees this path as one of multi-dimensional development. As a way to make a living, there are a lot of easier and more lucrative ways to go; as a path with “heart,” this is hard to beat. 6. How do you see the future of massage therapy?

I don’t know about Australia, but in the USA, the changes in the profession are extreme—the number of practitioners being trained exploded, but now is declining some; the quality of education varies widely; there is a general shift towards the polarized dichotomy of being either treatment-oriented, or relaxation/spa –oriented; there is increasing commoditization of massage and massage education, as businesses consolidate into larger entities, and look to efficiency and volume. The recent economic worries haven’t caused the sky to fall for most established practitioners here, although it has varied region to region, and I do know plenty of stories of folks whose practices have slowed way down. I think there will always be a place for highly-skilled practitio-ners to be appreciated for their work. Although “Massage Therapy” as a career and profession is undergoing all sorts of changes, us humans have been using skillful touch for longer than we’ve been humans. There is at least 100,000 years of history of bodywork. It isn’t going anywhere.

Til Luchau is the director and a lead instructor at Advanced-Trainings.com Inc., which offers continuing educa-tion seminars and support services for practitioners and schools throughout the USA and abroad. The originator of Skillful Touch Bodywork (the Rolf Institute®'s own training and practice modality), he is a Certified Advanced Rolfer® and a Rolf Institute® faculty member.

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6 Questions to Anita Boser6 Questions to Anita Boser6 Questions to Anita Boser

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

I was receiving a Hellerwork session, the 7th of the Hel-lerwork Series, and on the table decided that I would like my life more if I were helping people feel better rather than helping them save money on insurance. It was an odd thought, alternative health care had never occurred to me before, but I considered it from every angle and decided to make the leap.

2. What do you find most exciting about body-work therapy?

That's easy. When my clients get off the table with the experience of less pain, more hope, or new aware-ness. The transformation feeds my spirit.

3. What is your most favourite bodywork book?

Oh my, that's not easy. Just one? My latest favorite book is Michael Stanborough's Direct Myofascial Re-lease Techniques. I purchased it last October and have-n't made it all the way through yet. There's a lot of in-formation! My all time favorite is probably The Endless Web. I love to read it and get lost in the infinite beauty and connectedness of the body.

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

Detaching myself from the expectation of specific re-sults from my work.

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

You can do it!! Remember to ask for help, from other practitioners, from mentors, from your friends, from your clients. You don't have to do it all by yourself.

6. How do you see the future of massage ther-apy?

Better understood as a diverse therapy with different applications for different intentions. More accepted and widely used. And, continually evolving as we reach new understanding.

Anita Boser, LMP, CHP gradu-ated from the Institute of Struc-tural Medicine and practices Hellerwork Structural Integra-tion in Issaquah, WA, USA.

She is the author of Relieve Stiff-ness and Feel Young Again with Undulation and the audio ver-sion, Undulation Exercises. She created a way to make this fun-damental movement pattern ac-

cessible to people who don't feel like they move well. Her practice as a Hellerwork Structural Integrator in-cludes teaching her clients how to use small movements to melt stuck spots, especially in the back. She accumu-lated a variety of exercises that transform bodies from stiff and uncomfortable to graceful and at ease.

She can be contacted at [email protected] or www.undulationexercise.com.

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Terra Rosa eMagazine Issue 3