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Open information for massage therapists & bodyworkers No. 12, June 2013
Heart Support, Heart Opening Mary Bond Case Puzzler: Anterior/lateral Hip Whitney Lowe An Interview with Susan Chapelle A Journey into Fascia Wonderland Venolymphatic Drainage Therapy Guido Meert Emotional Release Art Riggs Borborygmous Walt Fritz Fascia and Reflexology Pseudoscience & Pseudoskpetic Research Highlights 6 Questions to Mary Bond 6 Questions to Guido Meert
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Welcome to our 12th issue of Terra Rosa Emagazine. We continue bring you latest news and articles on manual therapy and bodywork. We are proud to bring you a range of articles, starting with Mary Bond on a healthy posture. Whitney Lowe presents an orthopaedic assessment and massage treatment for the hip. Susan Chapelle talked about her research work in the role of massage in postoperative patents. Then take a journey into the world of fascia research. Guido Meert introduced Venolymphatic Drainage Therapy. Art Riggs addressed the sensitive issue of emotional release. Walt Fritz talked about borborygmous? Then we look at the possible relation between reflexology and fascia. Finally what is pseudoscience and pseudoskeptics? Dont miss 6 questions to Mary Bond and Guido Meert. Enjoy and Happy Reading. Sydney, June 2013
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result from articles in this publication.
Heart Opening
This posture may be touted as heart opening, but without the support of breath, its necessarily an unresponsive posture. How sustainable can any opening be without support? Many approaches to fitness and posture emphasize lifting the ribcageits not exclusively a yoga teaching. For most people, lifting the ribcage means lifting the front of it because they have not yet become aware of the back of the body. Im hoping that the information about how the lungs work can provide incentive for you to revise this posture in whatever workouts you may be doing. Arm Support for the Heart In this illustration you see the arm buds of a human fetus developing from the same embryological tissue as the heart. Amazing, right? From our very inceptions, our arms make gestures of our hearts intentions. For carrying out those intentions, our hearts require that our arms be well supported. And heres where your corocoid corner awareness comes in. When you have the supportive band of serratus and company across your mid-back and your corocoid corners are spacious, your humeral heads will roll back into the shoulder socket when you raise your arms. Thats a secure way for your arm to connect into your trunk, and with support from the spine, for your arms to securely and openly express your hearts intent. If, however, you lift your chest by retracting the shoulder blades that only appears to widen the corocoid area, masking tightness there. When the scapula retracts like that the humeral head is forced forward in the shoulder socket. In this position its much more difficult for arm movements to find support from the shoulder blade and secure connection to the spine. Body Fashion and the Heart Consider the star of the moment. Im not commenting on Beyoncs structural organization, though judging by her performance in the American Super Bowl extravaganza, its clear shes super fit and well coordinated. Im submitting this image as our cultures current expression of an ideal womans body. Note that while the heart area appears open, the corocoid area is withdrawn. This postural pattern is indicative of lack of arm support for the heart. While provocative, its not really a generous posture. Youll see it everywhere in western mediaBeyonc is not alone. Such shoulders seem to embody confusion about womens hearts and womens identities. Watch also The Secrets of Shoulder video at: http://youtu.be/ hJmXNay-n7s
Mary Bond has been a student of the human body since donned with her first dancing shoes at age six. After receiving an MA degree in Dance from UCLA, she studied with Ida Rolf, originator of a type of body therapy known as Structural Integration. Mary began teaching movement and bodywork courses in 1994 and currently the Chair of the Movement Faculty of The Rolf Institute of Structural Integration in Boulder, CO. Her book, The New Rules of Posture, presents new developments in movement education. It evolved out of her wish to share the legacy of Ida Rolf with the general public. While this legacy includes the understanding of posture and movement, it also has philosophical implications. The deeper message is that the way we inhabit our bodies affects the ways in which we perceive the world and behave toward one another. Her 2012 DVD, Heal Your Posture, further elucidates this message. See her website http://healyourposture.com/ Mary will travel and teach in Melbourne and Perth, July 12-14th & July 20-22nd. Eyes Within Your Spine: Using The New Rules of Posture as a template for posture and movement analysis, Mary shares a sensory approach to movement education that can be tailored to any somatic discipline. For more details visit: http:// www.bodyworkeducationaustralia.com.au
Unlike posture improvement programs that promise instant results, HEAL YOUR POSTURE: A 7-Week Workshop with Mary Bond, author of "The New Rules of Posture", helps you understand the interrelated habits that underlie poor posture. By spending a week with each of 7 lessons, viewers will learn to re -map long-standing habits of walking, standing, sitting, and breathing that contribute to unhealthy and unattractive posture, as well as to back, neck, jaw and shoulder pain. Lesson topics include pelvis and hip awareness, healthy breathing, core support, help for flat or rigid feet, shoulder support, jaw and eye tension, spine mobility, and fluid walking. Rather than training muscles into an ideal shape, Mary's approach helps you recreate your best body from within, though awareness. How we use our bodies in daily life-how we sit, stand, walk move, bend and carry out domestic, leisure and work-related tasks-has profound implications in terms of comfort, energy and avoidance of mechanical stress. Teaching is an art, and Mary Bond displays great skill, knowledge and art as she gracefully leads us through a process of learning new ways of functioning. This highly informative video is a wonderful resource."
Available at www.terrarosa.com.au
Mary Bond Eyes Within Your Spine workshop July 12-14th & July 20-22nd, 2013 Melbourne and Perth, Australia Using The New Rules of Posture as a template for posture and movement analysis, Mary shares a sensory approach to movement education that can be tailored to any somatic discipline. For more information, see
http://www.bodyworkeducationaustralia.com.au
Anatomy in Clay
Sydney
14 February 2014, Muscle Palpation as an assessment tool for Orthopedic Massage 15-16 February 2014, COMT: Neck 17-18 February 2014, COMT: Lower Back & Pelvis
Dr. Joe Muscolino is presenting this workshop for learning muscles by building them in clay, which is the ultimate kinaesthetic experience for deepening the knowledge of the skeletal muscles of pelvic tilt and shoulder girdle.
Sydney
Gold Coast
8 February 2014, Anatomy in Clay Muscles of the Pelvic Girdle/ Powerhouse 9 February 2014, Anatomy in Clay Muscles of the Shoulder Girdle
21-22 February 2014,COMT: Lower Back & Pelvis 23 February 2014 , Advanced Joint Mobilisation
"Joe Muscolino is a master of his profession! His broad knowledge on the human body and extensive experience made the workshops interesting and engaging. I would highly recommend his workshops to any body-worker. I, myself, can't wait for the next one!" Zuzana G, North Sydney.
Case Puzzler:
Posterior/lateral thigh pain
Whitney Lowe
Background I had an interesting client case recently that emphasizes the crucial importance of accurate and comprehensive assessment. The client (we will call him Mark) was reporting a sharp pain on the posterior/lateral aspect of the left thigh (Figure 1). Mark reported the pain as coming on gradually over the course of several months, but was exacerbated one day when he adducted the left thigh while sitting and heard a popping sensation. The pain seemed to get much worse after that and has been ongoing for close to a year. Marks job requires sitting and his pain is worse after long periods of sitting, but is relieved when he gets up and moves around. He had seen several other practitioners (physical therapist, massage therapist, and orthopedist). He had gotten partial relief from these other approaches, which had all focused on the iliotibial band with suspected adhesions as the root of the problem. Previous therapeutic approaches included deep friction massage, strain-counterstrain, and three rounds of cortisone injections into the lateral thigh and iliotibial band regions. None of these solutions worked for any length of time and Mark continued to have the same pain and problem. Case Analysis If the ITB had been the problem, prior treatment approaches focusing on the iliotibial band should have provided relief. Marks case demonstrates how important it is to conduct your own assessment even if a client comes in with other healthcare professionals assessments. Similarly, this case shows that it is valuable to reassess a pain complaint and not to continue down a treatment path when results are elusive. To explore other possibilities with Mark, a very detailed history was taken of exactly how the pain had come about and how it was perpetuating on a daily basis. Also he was asked to try to pinpoint exactly where he was feeling the most pain. Marks long periods of sitting appeared directly related to how the condition was being aggravated. He said it felt better almost immediately when he got up and walked around, but then gradually started hurting again after sitting. That notion stuck with me because that pain pattern is not typical of conditions when fibrous adhesions, such as might occur with ITB problems, are the root of the problem. Key factors in the physical examination pointed in a different direction than ITB issues. He didnt have pain when attempting to actively abduct the thigh against resistance, nor when his primary tender spot was palpated during resisted abduction. If the ITB was the major culprit, this test should have greatly exaggerated his pain. Next, the reported primary tender area was palpated as he attempted to actively extend the hip and flex the knee while in a prone position. This test caused a significant reproduction of the primary pain. Further testing, involving palpation during the same two movements but with increased resistance, reproduced the same pain with greater intensity. These test procedures strongly recruited the hamstring muscles. When these test results were combined with information from the history, it became clear that the biceps femoris was the primary tissue involved in his pain complaint. Further, exploratory palpation found hypertonicity and pain in a deep band within the biceps femoris; this finding provided further evidence that the problem was not in the ITB, but in the hamstrings. Anatomy of the Problem The hamstring muscle group is composed of three posterior thigh muscles: the semitendinosus and semimembranosus on the medial side, and the biceps
Figure 2: lengthening strokes of active engagement performed during eccentric knee extension
femoris on the lateral side. The biceps femoris has two heads. The long head of the biceps femoris originates on the ischial tuberosity and the short head originates along the linea aspera on the posterior side of the femur. Both heads of the biceps femoris share a common insertion on the lateral aspect of the fibular head. When contracting concentrically, the hamstrings produce knee flexion. The semitendinosus, semimembranosus, and long head of biceps femoris also contribute to hip extension. The short head of the biceps femoris is not involved in hip extension as it doesnt cross the hip joint. The hamstrings also act on knee rotation when the knee is in a flexed position. The semimembranosus and semitendinosus medially rotate the knee, while lateral rotation is produced by the biceps femoris. Marks long hours of sitting put the hamstrings in a chronically shortened position. In addition Mark is an avid hiker, so on weekends his hamstrings get a good workout. Both activities produce hypertonicity in the hamstrings generally. In Marks case, the biceps femoris became chronically hypertonic and there was a small localized spasm of a portion of the muscle, though not a trigger point. Treatment Protocol Mark was treated using soft-tissue treatments aimed at reducing general hypertonicity as well as specific, targeted treatment for the spasm. Active engagement techniques deep stripping with active eccentric knee flexion - in particular were used to encourage elongation of the muscle (Figure 2). These techniques enable easier access to the deeper muscles of the hamstrings and intensify the treatment (notably with less effort on the part of the therapist). Static compression was used
to directly address the spasm and trigger point. There were immediate and positive results from this therapy. Treatment requires counteracting the effects of the problem with activities such as stretching, self massage, and hot baths or applications to help the muscle begin to relax. Mark was also instructed to alter his activity patterns at work and on the weekend. While he cannot help but sit at his work, he can get up more frequently. During these breaks it would be best if he walks around, but also takes a few minutes to do some simple stretching of the hamstrings and back of the leg and hips. There are useful home massage tools for Mark to employ, such as rolling on top of a tennis ball or other type of roller under his thigh, or other self massage tools widely available now. Conclusions Many times things are not what they initially seem. The other manual soft-tissue technique approaches had limited success, but no lingering adverse effects. However, there could be detrimental long-term effects from continued cortisone injections. The key takeaway here is that doing additional assessment is highly valuable, especially if the condition is not blatantly obvious or unresponsive to initial treatment.
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Susan Chapelle
(keep cells moving, decrease inflammatory response See the paper Chapelle, Bove, JBMT) and keep things moving so they dont stick together. Gentle postsurgical mobilization is excellent for reduction of adhesions. Newly formed adhesions can be manually lysed. But not so successful with bigger, and older adhesions. Then the question is, what we can access and affect. Human studies on ischemia are being looked at, as well as other new information that is all good for our profession. Can you briefly explain the research behind the article Visceral Mobilization can Lyse and Prevent Peritoneal Adhesions in a Rat Model published in the Journal of Bodywork and Movement Therapies (JBMT). As most therapists who were taught visceral mobilization, I found much hypothesis and no didactic, scientific, evidence-based or informed information. I work with many patients and had a great story, but was hallucinate along with me. I had no idea if I could or could not affect adhesions. Or move organs, affect fascia, integrate with nerves. This project gave me some very clear guidelines as to what we can affect. As well, the questions raised and observations spawned our second study on post-operative ileus. (Which spawned another hypothesis on neural involvement in the formation of adhesions, in review with the NIH for funding). Science should always spawn more questions. Thank goodness. There are many studies looking the efficacy of massage for a particular condition. Meanwhile there is not much research that specifically looked into the mechanism of how massage works. I dislike case studies. They are perhaps interesting but nothing other than. It can spark good conversation with no data. I am an evidence driven person, and one that does not like the A-C method of research. This is where you say, because of this, therefore that. With no data or information to inform the leap. I see the value in examination of the effect of a treatment, but hopefully on 15 people, not just I worked on this person, and this happened. We must look to inform mechanism, not just this, therefore that. There are now many research studies coming out, not in massage therapy but other manual therapies. Essentially, manual therapy has the same mechanism of change, it doesnt matter what title you are called. As a (massage) profession we are debilitatingly undereducated. It doesnt spark a ton of confidence in giving money to our profession to work in labs. There are
Susan presented her work at the AAMT conference in Adelaide, May 2013.
treatments out there that work, but have anecdotal mechanisms. We need better collaboration on preexisting models of disease. Or a really rich person who likes massage therapy and can fund a therapist to work in a lab ;-). Do you think massage therapists should be more research orientated? Or should treatments be evidencebased? I think everyone should be better informed as to the evidence available. I speak as a politician and therapist. We should not be afraid to say that we dont know or understand an area, and absolutely should not make up mechanisms that have no anatomical or physiological truth in them. It is ok to rub and say, so happy you feel better without saying what you are affecting. Most of the time we guess, based on intuition, or poor information. Being wrong can affect the publics health care, and the view of our profession. Better to be informed. Evidence informed is the best we have right now. We do not need to be research oriented to do our work. We should use our natural curiosity on why a person is getting better with treatment to look into the basic anatomy of the structures involved. Then we need to look at what research has been done in the area. Then we can be better informed for our patients, other professionals, and ourselves. What are you working at the moment? Various projects: A software that has a research oriented search engine for record keeping. Every clinic is a wealth of
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data. How massage therapy affects neural regeneration (Funded by BCMTA). The continuation of the work on visceral adhesions (if we get NIH funding, in review) Building better education systems and regulatory bodies for massage therapy Collaborative health care and funding for preventative health care in politics. Canada (everywhere) needs better funding for research into prevention. We are all going broke paying for healthcare. What are your favourite manual therapy books? Thieme Atlas of Anatomy: Neck and Internal Organs (or any of Thieme anatomy books) and Wall and Melzacks Textbook of pain, 6th edition. Manual therapy books are a wealth of subjective conjecture. I derive my rubbing skills from my clinic, my knowledge of what I am doing from science, anatomy and physiology. We are all capable of the same skills and level. Its the deeper understanding of the mechanisms that we lack. References Geoffrey M. Bove, DC, PhD, Susan L. Chapelle, RMT. 2011. Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model. Journal of Bodywork & Movement Therapies. Available from: http:// www.squamishintegratedhealth.com/wp-content/ uploads/Bove_Chapelle_11_Adhesions.pdf Susan Chapelle has been a practicing therapist for over 18 years. Susan worked in the entertainment industry backstage for 15 years before deciding to become a massage therapist. This led her to treating people in the industry and opening a clinic that specialized in the quick assessment and treatment of performing artists. In 2012, Susan accepted the award from the Massage Therapists Association of BC RMT of the Year. Susan has been working with palliative care patients for over 10 years, and recently embarked on a research study to deepen the understanding of how massage therapy effects post surgical complications in breast cancer patients. Susan enjoys living in Squamish for the outdoors. She is an avid climber, skier and mountain biker. Susan is one of the presenters at the 2013 AAMT Conference in Adelaide.
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Robert gave three specific examples of what he as a clinician had been able to learn from the scientific world. (1) Fluid dynamics Water constitutes around 68% of the fascial tissuesvolume . Fascia regulates the flow of fluid in the extracellular matrix, and fluid flow can causes fascial remodelling. A study conducted by Schleip and coworkers at the University of Ulm (Figure 1) showed that, in an in vitro study using fascia from animal, that during the tissue loading (fascia stretch) water is extruded from the tissue and this tends to contribute to a temporary decrease in tissue stiffness (i.e. tissue softening) immediately after the stretch. The findings also found that that after the stretch, the stiffness of the tissue increases and it also regains a gradual rehydration. This phenomenon is due to the behaviour of the ground substance in the extracellular matrix which prevented from absorbing fluid by tension that fibroblast cells put on extracellular matrix fibres. When this tension is relaxed, the extracellular matrix can absorb fluid rapidly. The implication is that when Robert applied pressure through his elbow to the thoracolumbar fascia, he now paid more attention to the fluid dynamics, rather than only trying to melt the tissue or breaking up the fibrous tissues, or stimulating the mechanoreceptors. Now Robert works more gently and more slowly. We should
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Figure 1. Changes in the mean water content of a porcine lumbar fascia before and following a 15 minutes stretch with a 4% strain (After Schleip et al., 2012)
now thinking not only about stimulating the mechanoreceptors or golgi tendon organ, but be aware of how the fluid moves. Another research by Melody Swartz (from Lausanne, Switzerland) described how subtle change in fluid shear on cell culture has a profound change in the fibroblasts. Fibroblasts are most responsive to the detection of fluid shear - i.e. to the slow motions of the water around them - as sensed through their antenna-like cilia (soft tentacle). It is indicated that a large portion of the impact of collagen stretch is less due to the direct effect of transmission of that stretch to the cell membrane, but rather to the sensation of the fluid shear which is induced by the collagen fibre reorientation which is then sensed by the hair-like cilia. This idea can be illustrated as follow: imagine how much the hairy tip of a painter's brush would bend if you move it at a steady speed through a fluid medium. Or imagine moving a finger through yoghurt. Both the speed as well as the viscosity of the fluid medium will influence the amount of shear. The clinical implication is that if you move very slowly at a constant speed through a dense tissue area (e.g. with the therapist's knuckle or a foam roll), then the tiny cilia of the fibroblasts will be bent only very gently by the resulting fluid shear, and this seems to stimulate them to produce an enzyme (MMP-1) which starts to break down excessive collagen in the next few hours. (2) A tool for evaluating the stiffness of tissue Most palpation that we do is subjective, and therapists cannot remember how stiff is the tissue before and after treatment (or even a week after treatment). Therapists should have a more objective tool to measure the therapeutic response. Robert suggested Myoton Pro, a tool recently developed to measure the tissue stiffness. The quantitative digital measurement provided by this myometer proved to be reliable and useful for assessing biomechanical properties of myofascial tissues. This tool works by creating a constant pre-load of the soft tissue via a movable indentation probe, which is then rapidly released and the tissue response
CGRP
Figure 2. The distribution of CGRP and Substance P (SP)immunoreactive nerve fibers in the Thoracolumbar Fascia (redrawn from Tesarz et al., 2011). (a) Mean nerve fibre length of CGRP and SP. Almost all fibres were found in the outer layer of the fascia and the subcutaneous tissue. The middle layer was free of SP-positive fibres. (b) Distribution of CGRP and SP-containing receptive free nerve endings expressed as percent of the total number of CGRP- or SPcontaining fibres in each fascia layer. SP-containing free nerve endings were restricted to the outer layer of the thoracolumbar fascia and the subcutaneous connective tissue while CGRP-containing free nerve endings were also found in the inner layer of the thoracolumbar fascia.
(damping oscillation) of the tissue is measured. This kind of tool could provide a more objective measurement on the effectiveness of our treatment. (3) Innervations of the lumbar fascia Prof. Siegfried Mense, in his lab. in Heidelberg, Germany, showed that the thoracolumbar fascia is densely innervated. Another recent study also from Heidelberg led by Jonas Tesarz et al. (2011), and published in Neuroscience journal, quantified the amount of innervation of the thoracolumbar fascia (TLF). Using calcitonin gene-related peptide (CGRP) and substance P (SP)containing free nerve endings, they quantified the amount of nerve endings in the TLF of rat. They showed that the TLF is a densely innervated tissue with marked differences in the distribution of the nerve endings over the fascial layers (Figure 2). They distinguished three layers: (1) outer layer (transversely oriented collagen fibers adjacent to the subcutaneous tissue), (2) middle layer (massive collagen fiber bundles oriented obliquely to the animal's long axis), and (3) inner layer (loose connective tissue covering the paraspinal muscles). It is the subcutaneous tissue and the outer layer that showed a particularly dense innervation with sensory fibres. SP-positive free nerve endings-which are as-
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Figure 3. Proposed interaction between the autonomic nervous system and fascial tonicity. Sympathetic activation tends to activate TGF -1 expression (as well as probably other cytokines) in the body, which has a stimulatory effect on myofibroblast contraction, thereby leading to an increase of fascial stiffness. In addition, shifts in the autonomic nervous system state can induce changes in pH, which affects myofibroblast contraction as well. Skilful therapeutic stimulation of mechanoreceptors in fascia - particularly of Ruffini or free nerve endings - can induce changes in the autonomic nervous system. Redrawn from Schleip et al. (2012).
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sumed to be nociceptive-were exclusively found in these layers. Because of its dense sensory innervation, including nociceptive fibres, the TLF may play an important role in lower back pain. Most of the myofascial pain may come from the superficial layer. This suggests that it may be most effective to work more superficially, stimulating proprioceptive nerve endings and reaching to the nociceptor. For many years Robert taught his students to work deeper for more profound change, but now based on this new finding, he often works more superficially to be more effective.
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In addition, Robert also suggested three areas of consideration that scientists can learn from therapists: (1) The influence of sympathetic activation on and fascial tonicity Vladimir Janda, suggested a close relationship between the autonomic nervous system (ANS) and fascial tonicity, implying that sympathetic activation may lead to an increased cellular contraction within fascial tissues. However it was not until recent findings that suggests that sympathetic activation induces an increased TGF1 expression; and- since this cytokine is known as the most potent stimulator of myofibroblasts contractionthat this may also lead towards an increased fascial contractility. Figure 3 illustrates a possible two-way interaction between ANS activation and fascial tonicity. Besides the influence of the ANS on cellular contractility in fascia, this diagram also emphasizes the potential influence of
therapeutic fascial stimulation on ANS tuning. Stimulation of non-nociceptive mechanosensory free nerve endings can influence ANS tuning. In addition, stimulation of Ruffini corpuscles- which are reportedly particularly sensitive to slow shear application - tends to inhibit sympathetic activation. (2) The Rhythmic oscillations of fascial tissues When connective tissue cells were put together in a cell culture medium with a collagen grid, they tend to show periodic oscillations. In particular, it has been shown that they expressed rhythmic calcium oscillations which were accompanied by contractions of the cells. A study by Follonier et al. (2010) demonstrated that myofibroblasts tend to oscillate in such an environment in synchronicity, when they were in close contact with each other (Fig. 4). The observed oscillations had a mean period length of 100 second. It is an intriguing question whether this very slow rhythm observed in these cell cultures - with one cycle taking more than one and a half minutes- could be related to the socalled long tide oscillations in biodynamic craniosacral therapy. The so-called breath of life has a deep and slow rhythmic impulse expressed about once every 100 seconds. This needs to be tested in real-
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This book is the product of an important collaboration between clinicians of the manual therapies and scientists in several disciplines that grew out of the three recent International Fascia Research Congresses (Boston, Amsterdam, and Vancouver). The book editors, Thomas Findley MD PhD, Robert Schleip PhD, Peter Huijing PhD and Leon Chaitow DO, were major organizers of these congresses and used their extensive experience to select chapters and contributors for this book. This volume therefore brings together contributors from diverse backgrounds who share the desire to bridge the gap between theory and practice in our current knowledge of the fascia and goes beyond the 2007, 2009 and 2012 congresses to define the state-of-the-art, from both the clinical and scientific perspective. Prepared by over 100 specialists and researchers from throughout the world. Available at www.terrarosa.com.au
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Based on the Latest Research in Fascia, A new approach to train your fascial web.
Conventional training has been emphasizing on muscles, cardiovascular fitness and coordination. However, most of the sports injuries occur in the connective tissues. Fascial Fitness will show you how to train the connective tissues, to prevent and repair damage, and to build elasticity and resilience into the body. This workshop is the only training program for the development of supple, flexible and strong connective tissue! Learn the latest findings in Fascia Research and put it into practice. Fascial Fitness complements conventional sports training with recommendations for specific loading exercises, dynamic stretching as well as 'bouncing' movements that utilise and strengthen the elastic recoil inherent in collagenous tissues.
If the 'fascial' body is well trained optimally elastic and resilient it can be relied on to perform effectively, to allow peak performance, to foster the coordination of supple, elegant movement and to offer a higher potential for injury prevention.
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fluids and react to it by secreting chemokines and several cytoykines (8). The vessels are even able to regulate the frequency and amplitude of their pumping activities and in a manner of speaking to interact with their environment. It is a fascinating experience to learn to palpate, stimulate and channel those individual and subtle waves of swelling, straightening oneself and exorotation of the extremities and detumescing, slumping down and endorotation of the extremities through the tissues of the patient. I prefer to call those waves, inspiration- and expiration-waves of the breathing of the tissue rhythm. If we are able to manage it to reinforce those body waves, we can amplify the milking and nourishing effects of the ground substance, without exerting any aggressive force on the tissues. Therefore it is helpful to apply some pumping drainage-techniques first, which complement a lymphatic drainage. I am grateful, to be able to develop some venolymphatic drainagetechniques and a general treatment schedule (6): 1. Myofascial release 2. Treatment and stimulation of the organs responsible for excretion and detoxification 3. Lymphatic + venous + intraosseous pumping (perfusion of the tissue) 4. Treatment and stimulation of the diaphragms 5. Release of articular restrictions 6. Active exercises and general lifestyle/attitude changes For more information on venolymphatic drainage, may I invite you to read my book Venolymphatic Drainage Therapy (Churchill Livingstone, 2012), and my book Venolymphatic craniosacral osteopathy, which unfortunately is only available in German at the moment. Perhaps, we will meet each other between the lines References (1) Bellisent-Funel M.C.: Hydrophylic-hydrophobic interplay: from model systems to living systems. 2005 Comptes Rendus Geosciences, 337, 1, 173 179. (2) Fenn E.E., Wong D.B., Fayer M.D.: Water dynamics at neutral and ionic interfaces. 2009 Proc. Natl. Acad. Sci. U.S.A., 106, 36, 15243 15248.
drainage - to be aware of some contraindications: acute inflammation, heart failure, infectious diseases, thrombosis, embolisms, malignant diseases and other acute diseases (5)! Unlike the blood circulation, the lymphatic system has no cardiac pump to make the fluid circulate. However, the mechanisms responsible for keeping the interstitial fluid in motion include the intrinsic pumping movements of the lymphatics and vessels (vasomotion) as well as the intrinsic mobility of the tissue (3). Fibroblasts exert tensile forces on collagen fibers of the extracellular matrix (ECM) via integrins and thereby squeeze the ground substance. Afterwards they decrease their tension upon the collagen fibers and allow the ECM to take up fluids and swell up (10). Proinflammatory cytokines (prostaglandin E1, interleukin1, interleukin-6, TNF-) seem to trigger the relaxation of the fibroblast-collagen network and lower the interstitial fluid pressure. Substances that provoke the squeezing of the ECM and increase the interstitial fluid pressure are for example platelet-derived growth factor or 1-integrins (4). There are several body-rhythms (rhythm of the heart, respiration, peristalsis), which interfere with each other and ultimately produce a slow rhythm in the human body, unique for that person and that moment. Beside the pumping activity of the fibroblastcollagenous network, one of the most interesting rhythms that promote this body- or tissue-rhythm, is the active vasomotion of lymphatics and vessels (7). Thereby the endothelial cells seem to be able to feel out the flow or the absence of flow of the interstitial
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About the author Guido F. Meert (physiotherapist and osteopath) was born in Aalst, Belgium: in 1963. He is currently working in practice in Roding, Bavaria, Germany. Guido is the Founder, Technical Director and Lecturer of the German Osteopathic Skill Centre (Deutsches Fortbildungsinstitut fr Osteopathie) in Neutraubling (Germany), Waldenburg (Germany) and Plauen (Germany). He regularly gives lectures on theoretical and hands-on seminars in Germany and Switzerland. He has authored 3nbooks: "Das Becken aus osteopathischer Sicht" (The pelvis from an osteopathic view), "Das vense und lymphatische System aus osteopathischer Sicht". Translation in English: "Venolymphatic Drainage Therapy" and "Veno-lymphatische kraniosakrale Osteopathie (Venolymphatic craniosacral osteopathy).
Prepared in an easy-to-follow, practical format, Venolymphatic Drainage Therapy: an Osteopathic and Manual Therapy Approach explores the anatomy, physiology, embryology and biomechanics of the venolymphatic system and also presents a variety of effective treatment options which range from the treatment of functional disorders of the diaphragm, the intraosseous fluid system, the spleen, liver and gallbladder, kidneys and ureters to the management of problems connected with the abdominal mesenteries and abdominal organs. Richly illustrated with an abundance of artworks and photographs throughout, this volume will be ideal for osteopaths, chiropractors, physical therapists, physiotherapists and massage therapists worldwide. Available from www.terrarosa.com.au
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George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has been a leader in the massage therapy field over his 30-year career. He helped bring sports massage to the 2000 and 2004 Summer Olympic Games, and is a past president of the Massage Therapy Foundation. He is the General Manager of the 1996 British Olympic Preparation Camp Sports Massage Team and as Co-Director of the 2004 Athens Health Services Sports Massage Team he has supported the inclusion of massage therapy at the highest levels of international sports.
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George teaches throughout the world and has given keynote and motivational presentations to national and international organisations. His website is at www.coreinstitute.com
Emotional Release
Q&A with Art Riggs
Q
DEAR FRANK,
DEAR ART, Im taking an advanced continuing education class and the instructors are trying hard to elicit a strong emotional release when demonstrating on models. This upsets me. I feel this is unethical and potentially harmful, and it conicts with my previous training. What is your opinion? FRANK
means pursue that goal with accredited academic training and a long period of supervision. But how would we bodyworkers feel if psychologists began offering massages without proper training? The mind-body relationship is very real, though, and one of the wonderful gifts we can give our clients is the ability to feel and express their emotions within proper boundaries and in a safe environment. Spontaneous emotional reactions do happen during bodywork, and I will offer a few suggestions for dealing with them. However, there is a huge difference between allowing emotions to naturally occur and the manipulation of those emotions, either verbally or physically. In the early days of the Human Potential Movement1 , some therapists would perform painful work, exhausting clients until they would nally break down in tears or yell in anger, knowing that the therapist would be satised and lighten up. An important principle in our work is to never attempt to induce any emotional responsesadness, anger, contact with an inner child, or repressed memories. When potential clients ask me if I do emotional bodywork, I tell them that I am very comfortable with anything that comes up in a session, but I do not consider myself to be an evocative therapist that attempts to manipulate the session. Some clients will, of course, be looking for just such a relationship, and there will always be some well-meaning therapists who will serve these peoples needs. However, these practitioners are treading on thin ice. Often, the cathartic releases really arent therapeutic and can simply be unconscious reactions to play along with the therapists agenda, or a repeating drama without any
I can empathize with your feelingsor rather, I feel your pain. Some teachers in my CE classes over the years appeared to be trying to impress practitioners with the power of their work by demonstrating their ability to initiate emotional release. Some therapists in the class reserved their spots in queue for a meltdown virtually every day so they could have their 15 minutes of fame in the centre of the healing circle. My opinion is that expanding our skills is an important part of the profession, but it should be limited to our professional parameters. Youre correct: playing amateur psychologist is in conict with our scope of practice as bodyworkers. I know several clients who expressed their distaste for what they consider to be intrusive and leading questions by some therapists attempting to steer the session into psychological encounters. If one wants to be a psychologist, then by all
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Emotional Release
you feel that the reaction is escalating in an unhealthy manner, ask the client to sit up and offer water and a tissue. It is our job to maintain the safe shape of the session at all times. Avoid asking, What would you like to do? This may allow for some options that are not appropriate, such as the client asking you to leave the room or for close physical contact. Dont give the perception that you are uncomfortable or that the response is inappropriate. After an appropriate amount of time, check in on the client and offer specic options, such as working in a different area, sitting quietly, working with the breath to return to normal patterns, or winding down the session.
Frank, it is gratifying to see your ability to not look at everything that teachers say as written in stone. I hope you glean some useful techniques from the class, and Im condent you can maintain your professionalism.
Note real connections to deep emotions. Some clients practice a repeating cycle of several emotional release sessions until the routine seems repetitive, then move on to another therapist to start the cycle anew. Supercial reactions are usually not problematic and may well serve a purpose for some clients, but amateur attempts to initiate emotional catharsis can amplify serious consequences such as transference, projection, and other quagmires. There is also the danger of releasing deeply held emotional trauma that the massage therapist is unable to deal with. Guidelines A respected teacher and good friend, Lucy Rush, offers the following advice for dealing with clients who have an emotional reaction to your bodywork: Never try to create emotional release. Support a spontaneous release if it ariseswhether its sadness, anger, or physical reactions like changes in breathing or muscle movementsby simply observing and allowing it to happen. Do not attempt to intensify or prolong reactions by saying Let it all out, or engage in dialogue asking them to explain their feelings. Always have a glass of water or a box of tissues nearby. Some reactions may build on themselves. If Art Riggs is the author of Deep Tissue Massage: A Visual Guide to Techniques (North Atlantic Books, 2007), which has been translated into seven languages, and the seven-volume DVD series Deep Tissue Massage and Myofascial Release: A Video Guide to Techniques. Visit his website at ww.deeptissuemassagemanual.com. 1 The Human Potential Movement arose in the 1960s with the goal of cultivating what its advocates believed was the untapped potential for growth and change lying dormant in all people. Some examples include Werner Erhards EST training, Abraham Maslows theories of self-actualization, Transcendental Meditation, primal scream therapy, walking on hot coals, rebirthing, intense bodywork, and many other psychological and bodywork philosophies aimed at uniting the mind, body, and soul.
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Borborygmous
Walt Fritz, PT.
Borborygmus (plural borborygmi) (from Greek ) also known as stomach growling, or rumbling, is the rumbling sound produced by the movement of gas through the intestines of animals, including humans. (from Wikipedia) It is viewed as a common and natural occurrence that happens as fluids and gasses pass through the gastrointestinal tract. But I learned this word in a slightly different context. A number of years ago, as I lay on an acupuncture table, my stomach started to rumble. It happened 10-15 minutes into the session and I did what I think many of us do in a similar situation; I apologized for the untimely noises that my stomach was making. The acupuncturist, who was also a nurse, put me at ease. First she informed me that in Eastern Medicine, such sounds are considered a compliment. In Western Medicine, such sounds are known as borborygmus. I think many of us can relate to my experience, both as a practitioner, who hear the sound begin a short while after a session begins, as well as the client who experiences borborygmus. I loved this concept, as well as the word borborygmus. It is well established that during the fight or flight response there is an inhibition in stomach and upper digestive tract action. This is a function of the autonomic nervous system and is, in essence, a stress response. Essentially, all energy is sent to the parts of the body that are needed most for action (for fight or flight), such as the heart, lungs, and skeletal musculature. This action is triggered by the sympathetic nervous system. When the stress is gone, stomach motility, as well as other functions, resume (triggered by the parasympathetic nervous system). With humans, the fight or flight response may have played a stronger role earlier in our evolution. The need to respond/react to attack may have been daily occurrences. As we moved into more modern times the emergency responses that require
huge amounts of physical effort and our need for fullfledged fight or flight responses lessened, but the tendency for our bodies to act (or over react) continued. The stress response halts or slows down various processes such as sexual responses and digestive systems in order to focus on the stress situation, typically causes negative effects like, constipation, anorexia, erectile dysfunction, difficulty urinating, and difficulty maintaining sexual arousal. Prolonged exposure to stress responses can cause a chronic suppression of immune system function. I believe that many are walking around each day in a partial or full state of fight or flight. Clients arrive daily at my office after fighting traffic, fearing of being late for their appointment, bad news on the radio, etc. It is only after they have softened into the treatment table and the treatment begins that they come down from the perceived stress of the outside world. Good hands-on manual care can allow the feeling of threat and stress to diminish. It is then that their digestion restarts. It is then that the borborygmus kicks in. Enjoy the compliment! Copyright Walt Fritz, PT and Foundations in Myofascial Release Seminars 2009-2013
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Figure 2. View of the plantar aponeurosis (Photo by Carla Stecco, Used with permission).
where strain goes in the foot. If you are relieving strain above the reflex points (for example in the ankle and shin) you will relieve those points of strain in the sole of the foot. When a weight goes down and dies in some place, it becomes a reflex point." And "I think that many if not all reflex points in the foot are simply points where gravitational strain inserts and comes together. They are the end of the line we call balance" So next time we work on reflexology think of the connective tissue!
References Mike Benjamin. The fascia of the limbs and back a review. J Anat. 2009 January; 214(1): 118. doi: 10.1111/j.1469-7580.2008.01011.x http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2667913/ Julie Day. Whats New in Fascial Anatomy. Terra Rosa E-magazine No. 8, July 2011. http://www.scribd.com/ doc/60058449/Terra-Rosa-E-magazine-Issue-8-July2011 Joe Muscolino. Fascial Structure. Massage Therapy Journal, Spring 2012. http://www.learnmuscles.com/ MTJ_SP12_BodyMechanics%20copy.pdf Pavan PG, Stecco C, Darwish S, Natali AN, De Caro R. Investigation of the mechanical properties of the plantar aponeurosis. Surg Radiol Anat. 2011 Dec;33 (10):905-11. doi: 10.1007/s00276-011-0873-z. Ida Rolf. Rolfing and Physical Reality. Edited by Rosemary Feitis. Healing Arts Press, 1978, 1990.
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Research Highlights
Compiled by Jeff Tan
The Chemistry of Massage Therapy Do animals enjoy massage? Mice seem to, according to new research from the California Institute of Technology, where scientists picked out the neurons that fire when a mouse is stroked. There are hopes that identifying similar neurons in humans could help develop new pain or stress-relieving drugs. In a study published in Nature, researchers identified the nerves that respond to pleasant, massaging stroking in mice. The nerves, found under hairy skin, are called C-tactile fibres in humans, and they're why we enjoy cuddling and massages. Researchers found the corresponding nerves by injecting mouse embryos with a gene that caused the neurons to light up when active. They found that the Ctactile-like neurons were activated by stroking the mouse's hindfoot with a paintbrush, but not by pinching it with tweezers. Once they identified what was activating the sensation, scientists genetically modified other mice so their neurons would respond to a chemical stimulus that mimicked the feeling of stroking or grooming. To test whether the mice actually liked this feeling, they were put in two different chambers after being exposed to either the chemical massage or to simple saline. Before the test, most of the mice exhibited a preference for one chamber or the other, so the chemical massage was set up in the non-preferred chamber. After four days of conditioning, the mice increased the time they spent in the chamber that they associated with the massage - the chamber they initially didn't care for. This suggests that activating these neurons provided a positive or anxiety-relieving experience. Visceral massage reduces postoperative ileus in a rat model Abdominal surgery usually causes a temporary reduction of normal intestinal motility, called postoperative ileus. Postoperative ileus extends hospital stays, increases the costs of hospitalization, and may contribute to the formation of postoperative adhesions. Massage therapist from Canada Susan Chapelle together with scientist Dr. Geoffrey Bove designed experiments to determine if visceral massage affects postoperative ileus in a rat model. They used forty female Long Evans rats, they were assigned to 4 groups in a 2 (surgery) 2 (treatment) factorial design. Twenty rats were subjected to a small intestinal manipulation designed to emulate "running of the bowel." Transabdominal massage was performed upon 10 operated and 10 control rats in the first 12 h following surgery. Ileus was assayed after 24 h using fecal pellet discharge and gastrointestinal transit. Intraperitoneal inflammation was assayed using total intraperitoneal protein and inflammatory cell concentrations. The results showed that surgery consistently caused ileus. Compared to the operated group with no treatment, the operated with treatment group showed increased gastrointestinal transit and reduced time to first fecal pellet discharge. Similar group comparisons revealed that the treatment decreased total intraperitoneal protein and numbers of intraperitoneal inflammatory cells. The authors concluded that in this rat model, visceral massage reduced experimental postoperative ileus. The data suggest that the effect was through the attenuation of inflammation. A similar study could be designed and performed in a hospital setting to assess the potential role of visceral massage as part of the integrated care for postoperative ileus. The study was published in Journal of Bodywork and Movement Therapy in 2013. Impact of massage therapy on the levels of distress in brain tumour patients Massage Therapy for Decreasing Stress in Cancer Patients Research was published in British Medical Journal on Supportive and Palliative Care. The research indicates that massage therapy can have a positive influence on the quality of life of people suffering serious illnesses such as brain cancer. Patients with brain tumours report elevated levels of distress across the disease course. Massage therapy is a commonly used complementary therapy and is employed in cancer care to reduce psychological stress and to improve quality of life (QoL). A pilot study was conducted to obtain a preliminary assessment of the effect of massage therapy on patient-reported psychological outcomes and QoL. The study was a prospective, single-arm intervention. Participants were newly diagnosed primary brain tu-
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Research Highlights
mour patients who reported experiencing distress and who received a total of eight massages over a period of 4 weeks. Participants completed the National Comprehensive Cancer Network's Distress Thermometer (DT) six times over a 5-week period. The results showed that as a group, levels of distress dropped significantly between baseline and week 3, with a further significant reduction in distress between week 3 and week 4. At the end of week 4, the DT scores of all participants were below the threshold for being considered distressed. By the end of the intervention, participants reported significant improvements in one test domain focused on emotional well-being. Massage on Experimental Pain in Healthy Females A randomized controlled study conducted by researchers form University of Mississippi Medical Center, evaluated the effect of massage on affect, relaxation, and experimental pain induced by electrical stimulation. Published in Journal of Health Psychology, the authors hypothesised that there are 3 mechanisms of massage in reducing pain: through the gate control theory (pain signals can be modified by competing tactile stimuli, such as touch and pressure (counter-pressure) from massage), relaxation (cognitive relaxation induces physiological relaxation and a reduction in pain), and affect (Massage reduces negative affect and increases positive affect). Participants were 96 healthy women (mean age = 20 6 years) randomly assigned to a 15-minute notreatment control, guided imagery, massage or massage plus guided imagery condition. Guided imagery is a non-tactile cognitive relaxation intervention used to minimize response to acute and chronic pain, which has been shown to work relaxation process. The statistical analysis revealed no group differences in pain intensity, threshold, or tolerance. The two massage conditions generally reported decreased pain unpleasantness, lower unpleasant affect, maintenance of pleasant affect, and increased relaxation compared to the notreatment condition. The results do not support the hypothesis that massage works by interrupting ascending pain messages. However the most likely mechanisms are: Massage works via increased relaxation (Massage was found to be superior to guided imagery) and Massage works via affective pathway (Massage superior to guided imagery in Reduced unpleasant and Maintenance of pleasant). The results suggest that massage may alter immediate affective qualities in the context of pain. Static Stretch doesn't enhance Sports Performance Researchers recently have discovered that static stretching can lessen jumpers heights and sprinters speeds. In addition static stretching also does not reduce peoples chances of hurting themselves. Two recent studies provide reasons not to stretch. A study published in the April 2013 issue of The Journal of Strength and Conditioning Research by Dr. Jeffrey Gerlgley from Stephen F. Austin University, concluded that if you stretch before you lift weights, you may find yourself feeling weaker and wobblier than you expect during your workout. Another new study from Croatia, published in The Scandinavian Journal of Medicine and Science in Sports, provide a comprehensive reanalysis of data from previously conducted experiments. The two studies boost a growing scientific consensus that pre-exercise stretching is generally unnecessary and likely to be counterproductive. Researchers at the University of Zagreb began examined hundreds of earlier experiments in which volunteers stretched and then jumped, dunked, sprinted, lifted or otherwise had their muscular strength and power tested. For their purposes, the Croatian researchers wanted studies that used only static stretching as an exclusive warm-up. The scientists found 104 past studies that met their criteria. They amalgamated those studies results and using statistical calculations determined how much stretching impeded subsequent performance. The numbers, especially for competitive athletes, are sobering. According to their calculations, static stretching reduces strength in the stretched muscles by almost 5.5 percent, with the impact increasing in people who hold individual stretches for 90 seconds or more. While the effect is reduced somewhat when peoples stretches last less than 45 seconds, stretched muscles are, in general, substantially less strong. They also are less powerful, with power being a measure of the muscles ability to produce force during contractions, according to Goran Markovic, a professor of kinesiology at the University of Zagreb and the studys senior author. From the they determined that muscle power generally falls by about 2 percent after stretching. And as a result, they found that explosive muscular
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Research Highlights
performance also drops off significantly, by as much as 2.8 percent. A similar conclusion was reached by Dr. Jeffrey Gergley in another study, in which young, fit men performed standard squats with barbells after either first stretching or not. The volunteers could manage 8.3 percent less weight after the static stretching. But even more interesting, they also reported that they felt less stable and more unbalanced after the stretching than when they didnt stretch. Just why stretching hampers performance is not fully understood yet, although the authors of both of the new studies write that they suspect the problem is in part that stretching does exactly what we expect it to do. It loosens muscles and their accompanying tendons. But in the process, it makes them less able to store energy and spring into action, like lax elastic waistbands in old shorts, which Im certain have added significantly to the pokiness of some of my past race times by requiring me manually to hold up the garment. Static stretching alone is not recommended as an appropriate form of warm-up. A better choice is to warm-up dynamically, by moving the muscles that will be called upon in your workout. Jumping jacks and toy-soldierlike high leg kicks, for instance, prepare muscles for additional exercise better than stretching. From: Reasons Not to Stretch. http:// well.blogs.nytimes.com/2013/04/03/reasons-not-tostretch/ Exercise is as effective as massage for sore muscles Its a common belief that massage is the best for treating post-workout pain. However a new research published in the Journal of Strength and Conditioning Research has found that massage and exercise had the same benefits. Lars Andersen, the lead author of the study and a professor at the National Research Center for the Working Environment in Copenhagen, and his colleagues asked 20 women to do a shoulder exercise while hooked up to a resistance machine. The women shrugged their shoulders while the machine applied resistance, which engaged the trapezius muscle between the neck and shoulders. Two days later, the women came back to the lab with aching trapezius muscles. On average they rated their achiness as a five on a 10 point scale, up from 0.8 before they had done the shoulder work out. Then the women received a 10-minute massage on one shoulder and did a 10-minute exercise on the other shoulder. Some women got the massage first, while others did the exercise first. The exercise again involved shoulder shrugs; this time the women gripped an elastic tube held down by their foot to give some resistance. (Hygenic Corporation, which makes the tubing used in the study, supported the study.) Andersens group found that, compared to the shoulder that wasnt getting any attention, massage and exercise each helped diminish muscle soreness. The effect peaked 10 minutes after each treatment, with women reporting a reduction in their pain of 0.8 points after the warm up exercise and 0.7 points after the massage. Its a moderate change, said Andersen. He said he expects that athletes would notice a difference in having their soreness reduced by this amount. I think that for athletesby reducing soreness then theyre able to perform better, but we didnt measure this. But if you are sore your movements are very stiff and its difficult to perform, he said. Andersen said hed like to see future studies track whether warming up the muscles to relieve soreness does indeed impact how well athletes perform. The study suggests that maybe (massage or exercise) has some benefit for individuals prior to an activity, even though the benefit may be short-lasting, said Jason Brumitt, of the School of Physical Therapy at Pacific University, who was not involved in the research. Its not clear how massage or exercise would relieve soreness, but Brumitt said that its thought that they help to clear out metabolic byproducts associated with tissue damage. Andersen recommends that people try light exercise to ease their pain. The effect is moderate, and only offers temporary relief, but the benefit of using exercise, Andersen said, is that it doesnt require a trained therapist or travel time. If people go out and exercise and get sore they can find some relief in just warming up the muscles, he said.
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5. What advice can you give to fresh massage therapists who wish to make a career out of it? 2. What do you find most exciting about bodywork therapy? I am thrilled by my clients amazement when they stand up from the table with new awareness of support and mobility in their bodies. The fun part, for me, is helping them find their own way of describing (and therefore of taking responsibility for) the restored lift through their central line, for example, the settled sensations through their legs, or the articulation in their feet. You will never, ever be finished learning about the body, or about how best to be of service. Your education will come at you in waves and sometimes from unexpected sources. Be patient as you accumulate the layers of your own unique approach.
6. How do you see the future of massage therapy? The increasingly non-physical character of work and recreation generates physical dysfunctions related to sedentary lifestyle, while the ease and speed of electronic communication fosters detachment from our bodies. Furthering the disembodied state is the subconscious threat of traumatizing ecological and manmade disasters. Living in our bodies, feeling our feelingstaking time for thatbecomes less and less comfortable. The potency of touch summons our clients back into their bodies and into the felt sense of their experience. This is what we are doing when we touch stemming the tide of dehumanization.
3. What are your most favourite bodywork books? I go back again and again to Calais-Germains anatomy books. Also Schultz and Feitis, The Endless Web, and Jeffrey Maitland, Spinal Manipulation Made Simple. Sandra Blakeslees book, The Body Has a Mind of Its Own, explains the neuroscience behind body organization and movement. So much of the healing we hope to deliver must take place in the brain.
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