Active Isolated Stretching for the Head, Neck and Shoulders

I’ve had several clients with neck pain and ‘stiffness.’ Some have been unable to move their head, neck and shoulders – which throughout the day could be inconvenient. The Active Isolated Stretching (AIS) method of muscle lengthening and fascial release allows me to use a type of Athletic Stretching Technique to provide dynamic and effective self-care and facilitated stretching of major muscle groups for my clients in pain. I have expanded into this area of Kinesiotherapy to provide better results for my clients, and more importantly AIS provides functional muscle balance and physiological restoration of superficial and deep fascial planes Range of Motion.

As I recently learned, over the past few decades many experts have advocated that stretching should last up to 60 seconds. Physical Therapists have published studies comparing, 15-60 seconds of static stretching on improving muscle length. For years, this prolonged static stretching technique was the gold standard. However, prolonged static stretching decreases the blood flow within the tissue creating localized ischemia and lactic acid buildup. This can cause potential irritation or injury of local muscular, tendinous, lymphatic, as well as neural tissues. These are similar to the effects and consequences of trauma and overuse syndromes.

The AIS Technique – Performs Functional Muscle Release for Deep, Superficial Fascial Lines throughout the body.

Using an Active Isolated Stretch program, either active or assisted, performs a series of stretches in the functional muscle group – each repetition should last no longer than two seconds per repetition. This movement, and assisted movement, allows the target muscles to optimally lengthen without triggering the protective stretch reflex and subsequent reciprocal antagonistic muscle contraction of the joint or movement. The isolated muscle achieves a state of relaxation, and with subsequent repetitions these stretches provide maximum benefit, more lengthening and can be accomplished without opposing tension or resulting trauma.

Myofascial Release to Achieve Optimal Flexibility

Aaron Mattes' myofascial release technique, which also incorporates Active Isolated Stretching and Strengthening uses active movement and reciprocal inhibition to achieve optimal flexibility. Using a 2.0 second stretch he has been proven there is key to avoiding reflexive contraction of the antagonistic muscle and regain length throughout the functional muscle group. The sequence of repetitions allows increased circulation, warmth to the muscle and lengthening to the End-of-the-Range-of-Motion, without activating muscle group contraction, restoration of full range of motion and flexibility can be successfully achieved.

Many rehabilitation clinics use AIS after surgery with excellent outcomes. But, using AIS for re-conditioning to bring movement to limbs and digits damaged by stroke, nervous system disorders and surgical procedures. Hypermobility patients benefit from strengthening areas that are strained from compensation patterns. Some of the most impressive results are using AIS as ‘pre-habilitation’ or preparation for upcoming events. Using AIS to prepare for surgery, many patients have realized substantial benefits:

-         Reducing recovery time after surgery by 50% of predicted time frame

-         Preventative ‘flexibility’ facilitates alleviation of pain symptoms,

-         Improve conditions in the musculoskeletal condition, that surgery may not be necessary.

Since flexibility is not a general body situation, but it is specific to each joint in the body- there can be work or exercise to undo the movements or effort that produces repeated overuse of the same muscles each day - that leads to a restriction in the Range of Motion and reduced flexibility. Eventually this reduced flexibility may exhibit pain patterns in many ways, because the muscles have to work harder still to produce normal results.

 

I.    Standardized Stretch and Strengthen Format - Shoulder

List of muscles and stretches

a.      SCM – head and neck stretch

b.      Scalenes – head and neck stretch

c.      Rotator Cuff: Supraspinatus, Infraspinatus, Subscapularis and Teres Minor– shoulder and upper strengthening

d.      Trapezius, all fibers

e.      Latissimus Dorsi

f.       Pectoralis Major/Minor

g.       Biceps Brachii

  1.  Frozen Shoulder/Adhesive Capsulitis Treatment with Summary Treatment – with Active Isolated Stretching

There is usually consistent irritation in the subacromial region, which will increase the tension in the scapular thoracic region. Extrinsic causes such as an acromial spur, tendon calcification, a curved or hooked acromion, or acromioclavicular osteophytes may be present. Most frequently impingement involves the musculotendinous portion of the supraspinatus, the infraspinatus, the subscapularis, or the long head of the biceps.

Benefits of AIS on Condition: The program should include the entire shoulder AIS stretching program and emphasizing shoulder sideward elevation, having the palm of the hand facing backward. The strength program should include the rotator cuff muscles, shoulder stabilization exercises, and posterior shoulder adduction using a band or pulley and pulling downward toward the buttock, having the body face away from the mechanism of overload.

2. Medial Epicondylitis (Golfer’s Elbow) Summary Treatment with Active Isolated Stretching

Summary of Condition: Medial epicondylitis is also called “little league” elbow.  Medial epicondylitis illustrates a snapping motion of the elbow in pronation or a motion such as throwing breaking balls in baseball causing stress on the medial side of the elbow. This may result in Inflamation and Edema that make movement of the olecranon difficult, extremely painful. This results in an injuring of the radioulnar pronator cuff muscle inserting on the inner condylar ridge of the humerus.

Benefits of AIS on Condition: After the elbow is healed and free movement is permitted by the physician, restore the range of motion with gentle AIS stretching. If the injury is mild, begin stretching of the elbows, radioulnar, wrists and hands. Strengthen the elbow flexors and extensors, radioulnar pronators and supinators with small weights. Progression to stretching bands or surgical tubing is permitted when the subject is pain free. Incorporate the use of a rubber band and a soft ball for the hands and fingers. Ice massage and stretch the muscles frequently. An ace wrap for gentle support is helpful.

Wrist Flexion

The wrists are a complex joint full of bone, ligaments, connective tissue, muscles and nerves. Muscles stretched are over the wrist and into forearm - either extensor or flexor muscles. The Arm Lines are, posturally speaking, a bit different from the other myofascial meridians. The Deep Front Arm Line is a stabilizing line; in poses like the yoga plank, it manages side to side movement of the upper body. In the open movement of the arm, the DFAL controls the angle of the hand, generally through the thumb, as well as the thumb's grip. So they are active at all times - both agonist and antagonist muscles - depending on the movement. Stretching these vital muscles is imperative.

You begin the stretch by extending the elbow, slowly flexing the wrist downward by contracting the wrist flexor muscles. Apply a gentle stretch across the posterior (dorsal) hand with the opposite hand. (Excerpt from Active Isolated Stretching: The Mattes Method. Pg. 33)It also has multiple ranges of movement—flexion and extension (moving the palm backward or forward relative to the forearm), adduction and abduction (moving the hand from side to side). Compare this to the movement of, for example, the knee joint, which only has flexion and extension. It also marks the area of transition between the forearm and the hand—so the health of the wrist can directly impact your grip strength and dexterity in the hand.

Another thing to consider is that if we lack motion at the wrist, we’ll try to make the motion up at the shoulder and elbow. Conversely, if we lack shoulder mobility, we’ll try to make it up at the elbow and wrists. It is therefore just as important to focus on scapular and shoulder mobility as it is on the wrist, as the two are interconnected and focusing on one may not alleviate the problem for the other. As an example, in the catch phase of a clean, we need to have adequate wrist extension, forearm pronation and external rotation of the shoulder to allow us to receive the bar on the front of the shoulders and fingertips dorsal) hand with the opposite hand. (Excerpt from Active Isolated Stretching: The Mattes Method. Pg. 33)

 Upper back and chest stretch-Mattes Method

Upper back and chest stretch-Mattes Method

 Pectoralis, Trapezius and Lat Stretch - Mattes Method (AIS)

Pectoralis, Trapezius and Lat Stretch - Mattes Method (AIS)

Hamstring vs. Gluteus Minimus (Hidden Relationship)

It has been demonstrated that although stretching daily has been measured by Bandy, Irion & Biggler in the Journal of Physical Therapy, Vol 77, 10/1997, the outcomes they defined established that a 30 second duration once a day was an effective amount of time (better than 15 sec, the same as 60 sec) to sustain an increased Range of Motion (ROM) when executing Hamstring Stretches. There was no additional benefit or increase for longer times or more frequency per day.

One of the key areas for athlete complaints are the areas below:

1)     Hamstring Pain (tightness, sprain or strain feeling)

2)     Patelofemoral Pain (knee pain and lack of movement)

Since there are multiple muscles that contribute to both these issues, we can assume that a couple key muscles are the ones impacting both the range of motion of the Hamstring and the Hip Joint (these muscles attach at multiple joints) and the knee or Patelofemoral joint. Because there is an overlap of the symptoms showing up in both cases. Quadriceps, Hamstrings, and Adductors and Abductors, we will look at these pain patterns together. There are also ‘non-related’ muscles that stabilize each of these areas separately: Quadratus Femoris, Piriformis (Hamstring) and Gastrocnemius/Soleus and Tibialis Anterior (Patelofemoral) that are impacting the performance of these joints.

Interpreting Leg and Knee Pain Symptoms

Many of trigger points that cause hamstring, knee and hip pain can be identified from a client’s presenting symptoms, medical history, and postural presentation. Listed below are some examples of these clues and some information about how each might relate to trigger point activity.

Hamstrings are a great example of how trigger points can create a confusing referral pattern that leaves you chasing the wrong muscle.

When people grab their hamstring and talk about how painful it is. They are often quite careful about not stretching their ham too aggressively. They may spasm easily when the knee if flexed, as they try to touch the heel to their hip (quad stretch), or they have a problem getting up after long periods of sitting. I’ve seen a lot of this problem over the years, especially from runners. This seizing hamstring can really shut down their activity and confuse them. Their hamstring goes into painful spasm even though they continue to stretch it as directed. This can be debilitating and discouraging.

The problem is that the seizing hamstring is a referral pattern of another muscle, the gluteus minimus. The gluteus minimus is located on the side of the hip. The goal is to help you to see that seizing hamstring pain is really the referral of the gluteus minimus and not the lateral hamstring itself. By eliciting the pattern for the hamstring first, an easy way to elicit trigger point referral is to stretch the muscle. Lay on your back, straighten your knee and stretch your hamstring by pulling your leg back toward your chest while keeping the knee straight. If you want to focus the stretching on the lateral hamstring, turn the toe out. That’s right! You feel it behind the knee.

     

Comparing the referral pattern for the lateral hamstring, and notice how it extends down the side of the leg but is mostly felt in the back of the knee. You can also press into your hamstring near those green spots in the pic and you’ll feel it in the back of knee too, but this is harder to do to yourself.

Now, elicit the pattern from the gluteus minimus. Look at the picture above to see where you should place the ball. Take a tennis (or lacrosse) ball and lay it on the floor. Now, lay on the tennis ball so that it presses into this spot. You may need to squirm around on it a bit to find the specific spot.  Most people guess too far back and need to turn onto their side a bit more with the ball farther forward. There are several trigger points in this area that produce different pain patterns into the hip and down the leg.  Referral means the ‘feeling of pain’ somewhere distant to the site of injury or muscle work being done in manual therapy (where the therapist touches).

A study by Dr. Lars Bendtsen (2000) following on the work of Janet Travell confirmed the role of central sensitization in chronic pain. Certain muscles were tender even when the subject was not experiencing a muscle pain at the time. Bendtsen theorized that long-term inputs from trigger points eventually lead to central sensitization in specific areas of the spinal cord and lumbar/sacral plexus including the nerves around the sciatic nerve and the lower spine (L5-S1). This causes additional changes in the affected muscles, a self-perpetuating cycle that converts periodic headaches into chronic pain. Because of this, even if the original initiating factor causing episodic pain s is eliminated, the trigger point-central sensitization cycle can continue and worsen on its own. This means that whatever causes the lower pain threshold in some people may also cause them to have chronic or recurring pain.

Trigger point pain is a failure at the motor-end plate (see picture above), where the nerve touches the muscle and share both in-bound and outbound messages to move/contract and move/relax. Remember that there is a two part motion in any muscle movement creating the motion and returning to neutral. The failure of the muscle to return to neutral means that it is still active. Active muscles that don’t rest, and continue to be in the heightened state for years become over-used (think repetitive stress).

Trigger points in the hips, anterior and lateral hip flexor and leg muscles will increase tension around the nerves as they leave the spinal cord of the lumbar/sacral plexus, go through the sacrum under the bottom of the pelvis (ischial tuberosity) and then down the leg. With a reduction in the functional space of the nerve, the tingling, neuropathy (lack of feeling) and pain will occur.

Weakness in this area can be a direct result of trigger points in multiple areas, like the Gluteal muscles, hip flexors are the high hamstrings which are one of the multiple areas of pain and weakness that impact the area around the Nerve plexus. Anytime there is consistent chronic pain investigate the nerve plexus or septum between the muscles.

What are some causes of “overactive” Hamstrings or Quads? If you have weakened abdominal muscles along with weakened lower-back stabilizing muscles (QL or Psoas) to assist in your movement or to compensate for the weakness, to allow you to do what you need to do, your other muscle will attempt to ‘work harder’ to balance weakness.

Trigger points of the Nerve plexus that result in reduced ROM and active or latent pain. You can identify the source through either Active or Passive muscle testing, and orthopedic special tests to help target treatments. These results should be treated through a series of Soft Tissue treatments like Active Release, Trigger Point therapy or Clinical Deep Tissue. Tigger point release or ‘local twitch’ response on the affected muscles will allow normal range of motion and return to active training cycle within 24-48 hours. Monitoring and ‘management’ of muscle tension should prohibit return of trigger point pain and weakness even during peak training.

Referral pattern of the Gluteus Minimus directly impacts the Hamstring

To find this pattern that you should look around the green spot for the location of trigger point pain. The sensation of a seizing hamstring can be felt strongly when it is elicited. Again, pay attention to the subtle parts of the pattern, and it becomes obvious that the pain and referral from the Gluteus Minimus is creating a secondary point (or causing another Trigger Point) in the Hamstring. Notice the tension in the calf and the tension in the lower hip, and the why is the function of the muscle. The tension will run all the way down into the knee and foot along the back side - because of the back anatomy train of the leg.

The gluteus minimus is one of the secondary muscles that can produce hip extension. This muscle is located deep and somewhat anterior to (in front of) the gluteus medius. The gluteus minimus and gluteus medius are separated by deep branches of the superior gluteal neurovascular bundle, a group of nerves and blood vessels.

The gluteus minimus emerges from the external surface of the ilium, part of the large pelvic bone, between the base and the front of the gluteal lines, bony ridges on the ilium that are used to mark the attachments of different gluteal muscles. It inserts into the greater trochanter of the femur, which is a bony prominence located at the top of the thigh bone, near the hip joint.

Along with the gluteus medius and tensor fasciae latae, the gluteus minimus serves as the primary internal rotator of the hip joint. The gluteus minimus helps with abduction (movement away from the midline of the body) and medial (inward) rotation of the thigh at the hip. Together with the gluteus medius, it acts to stabilize the hip and pelvis when the opposite leg is raised from the ground. Meanwhile, the complimentary action of abdominal muscle (rectus abdominis) is illustrated while lifting the right lower limb. (A) With normal activation of the abdominal muscles, the pelvis is stabilized and prevented from anterior tilting by the downward pull of the hip flexor muscles. (B) With reduced activation of the abdominal muscles, contraction of the hip flexor muscles is shown producing a marked anterior tilt of the pelvis (increasing the lumbar lordosis – and increasing the extension of the hamstrings). The reduced activation in the abdominal muscle is indicated by the lighter red color. Reproduced with permission from Neumann DA, Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2nd ed, Elsevier, 2010

The hip extensor muscles, as a group, produce the greatest torque across the hip than any other muscle group (FIGURE 3). The extensor torque is often used to rapidly accelerate the body upward and forward from a position of hip flexion, such as when pushing off into a sprint, arising from a deep squat, or climbing a very steep hill. The position of flexion naturally augments the torque potential of the hip extensor muscles. Furthermore, with the hip markedly flexed, many of the adductor muscles produce an extension torque, thereby assisting the primary hip extensors.

With an anterior tilt, because it affecting the stabilization and balance of the pelvis, a movement that changes the muscles in this cross, impacts the support of the hips and increases the stress on the opposing muscles that maintain the balance in the torso and lower legs. When the abdominals and gluteal muscles are weak the tension appears in hip flexors and lower back.

As a stabilizing function, the skeletal muscles work to support the body against gravity, therefore the muscles are active when you are NOT in motion as well. So you are using them when you are working out (1), when you are driving/sitting (2) and while you are sleeping (different intensities), but constantly active. So this pull against the ‘lower back’ which affect the attachments for the Gluteus Minimus, Medius and Maximus as well as the Tensor Fasciae Latae (TFL), the Piriformis and Iliopsoas.

By Releasing the muscles that are exerting to much tension (stretch and roll) and developing strength in the muscles that are weaker (not necessarily weak), this. will return the balance of use between the four groups

Releasing Hamstring Trigger Points...and the Gluteus Minimus Role

Study of myofascial performance has demonstrated that although stretching daily has been effective and when measured by Bandy, Irion & Biggler in the Journal of Physical Therapy, Vol 77, 10/1997, the outcomes supported that that a 30 second duration (per muscle) once a day was the minimum effective amount of time (better than 15 sec, the same as 60 sec) to sustain an increased Range of Motion (ROM) when executing Hamstring Stretches. There was no additional benefit or increase for longer times or more frequency per day.

 The areas that we are discussing in the session:

1)     Hamstring Pain

2)     Patelofemoral (knee) Pain

Since there are multiple muscles that impact both the range of motion of the Hamstring and the knee - or Patelofemoral Joint (since these muscles attach at multiple joints) we sould look at common influence of the pain. There is an overlap of the symptoms showing up in both cases. Quadriceps, Hamstrings, and Adductors and Abductors. There are also ‘non-related’ muscles that stabilize each of these areas separately: Quadratus Femoris, Piriformis (Hamstring) and Gastrocnemius/Soleus and Tibialis Anterior (Patelofemoral).

Interpreting Leg and Knee Pain Symptoms

Many trigger points that cause hamstring, knee and hip pain can be identified individually from a client’s presenting symptoms, medical history, and postural presentation. The patterns for each muscle are distinctive, and can be demonstrated simply by access to the general source points listed in Travel and Simon’s work on Myofascial Pain (1993). Listed below are some examples of these clues and some information about how each might relate a client’s pain symptoms to trigger point activity.

Hamstrings, specifically the biceps femoris, are a great example of how trigger points can create a confusing referral pattern that leaves you chasing the wrong muscle.

When people grab their hamstring and talk about how painful it is. They are often quite careful about not stretching their hamstring muscle too aggressively. I have watched clients after a massage (including ART protocols) get up, lift their leg gingerly to stretch their legs - and have this overwhelming tension that prohibits movement. Is is mental…probably more than half. They may also spasm easily when the knee if flexed, as they try to touch the heel to their hip (quad stretch), or they have a problem getting up after long periods of sitting. I’ve seen a lot of this problem over the years, especially from runners of long AND short distances, hurdlers and lacrosse and soccer players suffer from long days of tense hamstrings and reduced flexibility.  This seizing hamstring can really shut down their activity and confuse them. Their hamstring goes into painful spasm even though they continue to stretch it as directed. This can be debilitating, injury producing and discouraging.

The only other problem is that the seizing hamstring is a referral pattern of another muscle, the gluteus minimus. The gluteus minimus is located on the side of the hip deep to three layers of muscles. The goal in this discussion is to help you to see that seizing hamstring pain is really part or secondary to the referral of the gluteus minimus and not the lateral hamstring itself. By eliciting the pattern for the hamstring first, an easy way to elicit trigger point referral is to stretch the muscle. Lay on your back, straighten your knee and stretch your hamstring by pulling your leg back toward your chest while keeping the knee straight. If you want to focus the stretching on the lateral hamstring, turn the toe out. That’s right! You feel it behind the knee.

Here is the referral pattern for the lateral hamstring. Notice how it extends down the side of the leg but is mostly felt in the back of the knee. You can also press into your hamstring near those green spots in the pic and you’ll feel it in the back of knee too, but this is harder to do to yourself.

Now, elicit the pattern from the gluteus minimus. Look at the picture above to see where you should place the ball. Take a tennis (or lacrosse) ball and lay it on the floor. Now, lay on the tennis ball so that it presses into this spot. You may need to squirm around on it a bit to find the specific spot.  Most people guess too far back and need to turn onto their side a bit more with the ball farther forward. There are several trigger points in this area that produce different pain patterns into the hip and down the leg. Referral means the ‘feeling of pain’ somewhere distant to the site of injury or muscle work being done in manual therapy (where the therapist touches).

A study by Dr. Lars Bendtsen (2000) following on the work of Travell and Symons confirmed the role of central hyper-sensitization of the myofascial endplate in chronic pain. Certain muscles were tender even when the subject was not experiencing a muscle pain at the time. This tenderness and pain is the ‘energy crisis,’ and continuous loop of the triggerpoint.

Bendtsen theorized that long-term inputs from trigger points eventually lead to central sensitization in specific areas of the spinal cord and lumbar/sacral plexus including the nerves around the sciatic nerve and the lower spine (L5-S1). This causes additional changes in the affected muscles, a self-perpetuating cycle that converts periodic headaches into chronic pain. Because of this, even if the original initiating factor causing episodic pain is eliminated, the trigger point-central sensitization cycle can continue and worsen on its own. This means that whatever causes the lower pain threshold in some people may also cause them to have chronic or recurring pain.

Trigger point pain is a failure at the motor-end plate (see picture above), where the nerve touches the muscle and share both in-bound and outbound messages to move/contract and move/relax. Remember that there is a two part motion in any muscle movement creating the motion and returning to neutral. The failure of the muscle to return to neutral means that it is still active. Active muscles that don’t rest, and continue to be in the heightened state for years become over-used (think repetitive stress) and tired. It takes more effort to do normal movements, and heaviness and deep pain are common.

Trigger points in the hips, anterior and lateral hip flexor and leg muscles will increase tension around the nerves as they leave the spinal cord of the lumbar/sacral plexus, go through the sacrum under the bottom of the pelvis (ischial tuberosity) and then down the leg. With a reduction in the functional space of the nerve, the tingling, neuropathy (lack of feeling) and pain will occur.

Weakness in this area can be a direct result of trigger points in multiple areas, like the Gluteal muscles, hip flexors are the high hamstrings which are one of the multiple areas of pain and weakness that impact the area around the lower Nerve plexus. Anytime there is consistent chronic pain and resistant muscle tension investigate the nerve plexus or septum between the muscles in order to understand the source and the impact of the chain of muscles in that area.

What are some other causes of “overactive” Hamstrings or Quads? If you have weakened abdominal muscles along with weakened lower-back stabilizing muscles (QL or Psoas) to assist in your movement or to compensate for the weakness, to allow you to do what you need to do, your other muscle will attempt to ‘work harder’ to balance weakness.

Trigger points of the Nerve plexus that result in reduced ROM and active or latent pain. You can identify the source through either Active or Passive muscle testing, and orthopedic special tests to help target treatments. These results should be treated through a series of Soft Tissue treatments like Active Release, Trigger Point therapy or Clinical Deep Tissue. Trigger point release or ‘local twitch’ response on the affected muscles will allow normal range of motion and return to active training cycle within 24-48 hours. Monitoring and ‘management’ of muscle tension should prohibit return of trigger point pain and weakness even during peak training.

Referral pattern of the Gluteus Minimus

To find this pattern that you should place the green spot where the trigger point is located. The sensation of a seizing hamstring can be felt strongly when it is elicited. Again, pay attention to the subtle parts of the pattern. Notice the tension in the calf and the tension in the lower hip, and the why is the function of the muscle.

The gluteus minimus is one of the secondary muscles that produces hip extension. This muscle is located deep and somewhat anterior to (in front of) the gluteus medius. The gluteus minimus and gluteus medius are separated by deep branches of the superior gluteal neurovascular bundle, a group of nerves and blood vessels.

The gluteus minimus emerges from the external surface of the ilium, part of the large pelvic bone, between the base and the front of the gluteal lines, bony ridges on the ilium that are used to mark the attachments of different gluteal muscles. It inserts into the greater trochanter of the femur, which is a bony prominence located at the top of the thigh bone, near the hip joint.

Along with the gluteus medius and tensor fasciae latae, the gluteus minimus serves as the primary internal rotator of the hip joint. The gluteus minimus helps with abduction (movement away from the midline of the body) and medial (inward) rotation of the thigh at the hip. Together with the gluteus medius, it acts to stabilize the hip and pelvis when the opposite leg is raised from the ground. Meanwhile, the complimentary action of abdominal muscle (rectus abdominis) is illustrated while lifting the right lower limb. (A) With normal activation of the abdominal muscles, the pelvis is stabilized and prevented from anterior tilting by the downward pull of the hip flexor muscles. (B) With reduced activation of the abdominal muscles, contraction of the hip flexor muscles is shown producing a marked anterior tilt of the pelvis (increasing the lumbar lordosis – and increasing the extension of the hamstrings). The reduced activation in the abdominal muscle is indicated by the lighter red color. Reproduced with permission from Neumann DA, Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2nd ed, Elsevier, 2010

The hip extensor muscles, as a group, produce the greatest torque across the hip than any other muscle group (FIGURE 3). The extensor torque is often used to rapidly accelerate the body upward and forward from a position of hip flexion, such as when pushing off into a sprint, arising from a deep squat, or climbing a very steep hill. The position of flexion naturally augments the torque potential of the hip extensor muscles. Furthermore, with the hip markedly flexed, many of the adductor muscles produce an extension torque, thereby assisting the primary hip extensors.

With an anterior tilt, because it affecting the stabilization and balance of the pelvis, a movement that changes the muscles in this cross, impacts the support of the hips and increases the stress on the opposing muscles that maintain the balance in the torso and lower legs. When the abdominals and gluteal muscles are weak the tension appears in hip flexors and lower back.

As a stabilizing function, the skeletal muscles work to support the body against gravity, therefore the muscles are active when you are NOT in motion as well. So you are using them when you are working out (1), when you are driving/sitting (2) and while you are sleeping (different intensities), but constantly active. So this pull against the ‘lower back’ which affect the attachments for the Gluteus Minimus, Medius and Maximus as well as the Tensor Fasciae Latae (TFL), the Piriformis and Iliopsoas.

By Releasing the muscles that are exerting to much tension (stretch and roll) and developing strength in the muscles that are weaker (not necessarily weak), this. will return the balance of use between the four groups

I. Anterior Tilt/Tight Abductors (Stretches for Appropriate muscles sequence):

Lengthen (stretch)

1)     Hamstrings: Semitendinosis, Biceps Femoris, Semimembranosis

        a.      Knee Pain**

        b.     Hip Pain

2)     Quadriceps: Vastas Lateralis, Vastus Intermedius

        a.      IT Band Pain

        b.     Hip Pain  

        c.      Knee Pain

3)     Adductors: Adductor Magnus/Longus, Sartorious, Gracilis

II. Reduce tension/adhesions (compression on foam roller/trigger point ball)

4)     Adductors: Adductor Magnus/Longus, Sartorious, Gracilis    

5)     Abductors: Gluteus Maximus, Gluteus Minimus, Gluteus Medius

6)     Hip Flexors: Piriformis, TFL, Quadratus Femoris (high hamstring), Pectineus (adductor)

Strengthen:

1)     Abdominals: Rectus abdominus, Obliques, interus/externus, Quadratus Lumborum, Iliopsoas

 Series of stretches to target back and thighs

Series of stretches to target back and thighs

Muscle Movements and the Stretch, Pt 1

The Physiology of a Muscle Stretch

The biomechanics of a musculoskeletal stretch is under conscious control. When we straighten our knees (think getting from from a chair), the brain signals the quadriceps to contract and the knee ‘joint’ straightens out from a 90 degree bend into a 180 degree plane. We will look at the complex movement of this joint in three posts - one for the physiology discussion and impact of stretching (pt 1); One for the opposition forces like reciprocal inhibition and supporting movements of other muscles (pt 2); and the actual response of the structure of the knee through the involvement of the tendons, ligaments and other soft tissue - which have separate receptors that 'regulate' the action though Golgi Tendon organs (pt 3). Since the movement of the quads, activevates the movement of stretch, or lengthening the hamstrings, then we can add the ‘support’ movement of the adductors of the thigh and the abductors of the hip flexors and gluteal muscles. So there is a lot going on, just to help you stand. You may not be ‘aware’ of all this movement, which is how the action ‘triggers’ a chain of physiologic responses that take place without conscious awareness of the brain. But the muscles are aware, because of the receptors in the muscles and the joint.

In order to maintain your posture (even bad posture - so stop slouching) your muscles are constantly monitoring their shape. A change in shape of a muscle (the stimulus) causes the muscle to readjust its shape (the response) and maintain your posture. The receptors within the joint and the muscles work together to detect movement and changes in muscle tension and length. These receptors signal the central nervous system (CNS) to respond by regulating the contracting state of the muscles. This in turn affects the range of motion of a joint or muscle group. 

This is the way that conscious biomechanic actions influence the unconscious physiological response - so we don’t move ‘too far,’ or remain stable in our positions that we hold throughout the activity. Moving the body initiates a sequence of biomechanic and physiologic events that involves the Spinal Cord (CNS) individual muscles (PNS) and structures like joints, which makes a lot more sense when you compare these actions to a “system” of pulley-lever and internal controls (rough metaphor - I know)!

The spinal cord initiates movement through a 'reflex arc,' in order to regulate the tension and length of skeletal muscle movement. This 'reflex' affects operates between the CNS and the muscle belly anywhere in the body - so let's just stick with the example of the knee. A motor neuron carries the message from the central nervous system to the effector in the quadriceps (since they are the prime movers in the movement of the knee). In a 'knee-jerk' reflex arc the sensory neuron directly connects to the motor neuron in the spinal cord. This is called a simple reflex arc. from the spindle (receptor) to where it connects with the motor neuron in the spinal cord. The regulation and monitoring of the movement occurs automatically, in response to the neural messaging - to create the biomechanical actions (and therefore the movement). When a muscle contracts or stretches, receptors within the structure alert the CNS to this movement event. The CNS signals the muscles to respond appropriately, either by relaxing or contracting the appropriate muscles. Different muscles respond by creating, supporting or allowing the movement - so there are many muscles reacting to create a single chain.

All of this takes place without our being aware of it, an it's within milliseconds or the thought leaving the brain. The arc of nerves between the muscles and spinal cord allows this messaging and feedback to produce balance and fine-tune movement. There is a complex array or receptors and corresponding reflex arcs connecting the musculoskeletal system to the CNS.  To provide a brief example, I am only discussing the three major reflexes:  the muscle spindle, reciprocal inhibition and Golgi tendon organs as they will give the control response for the end of the muscle movement.

There are three types of stretching that we generally discuss: Ballistic stretching - uses jumping movements to activate the target muscles (more propulsive - fast twitch focus); Passive stretching - uses the body weight, gravity, and synergist/agonist muscle group relationship to create a stretch. The person is having the muscle acted upon, so that no muscles are "active" in the process of creating the stretch; Facilitated stretching - also known as PNF or proprioceptive neuromuscular facilitation - it involves briefly contracting the target muscle for a stretch, and then taking a longer stretch to take additional stretch through the 'slack' created by the response to the CNS.

Muscles that are shortened will benefit from the extra effort of lengthening them, so that they remember the correct and full Range of Motion regardless of their level of use. So Stretching is designed to lengthen muscles shorted under constant use, or warm muscles that have been static for long period of time. PNF or proprioceptive changes are necessary, to make muscles more efficient in between workouts, or when the nervous system isn't responding in the way that you expect - to support your movements.

Principles of Efficient Stretching   - Active Isolated Stretching
 

Principle #1: Prolonged or forceful stretching is counterproductive. After about 2 seconds, a muscle contracts defensively in response to a stretch that is forceful enough to injure it. (This action is known as the myotatic or stretch reflex.) .  
 
Principle #2: Active movement facilitates stretching. Sherrington’s Law of reciprocal inhibition in muscular contraction states that when a muscle on one side of a joint is contracted, the muscle on the opposite side of the joint is sent a neurological signal to relax or release.  
 
Principle #3: Muscles are more efficiently stretched when they are at rest or relaxed Momentary rest between stretches is as important as the stretch itself. It reduces fatigue and enhances blood flow to resupply oxygen and nutrition and eliminate waste products.  
 
Principle #4: Regular breathing increases oxygenation Increased oxygenation of the blood helps deliver nutrition to the muscles and improves waste removal. When oxygen is lacking anaerobic metabolism occurs, converting glucose to lactic acid, which promotes fatigue. I
 
 
Principle #5: Flexibility is specific Flexibility is most efficiently maximized by identifying and then isolating which part of which muscle is inflexible. AIS stretches are designed to stretch the distal and proximal ends of a muscle separately. In addition, they use 10-15 and 45º rotations in both directions to maximize the stretching of all the different muscle fibers. 
 
Principle #6: Specific movement establishes specific neuromuscular pathways Repetition of specific movements creates new neuromuscular patterns, essentially rewiring the neuromuscular system. The development of new neurons — through appropriate stretching improves the functioning of existing neurons.  
 
Principle #7: A gentle assist facilitates increased flexibility  Another factor that stimulates neurogenesis is actively going beyond a person’s normal capacity. Gentle assists challenge the tissue, facilitating neurological development and enabling a gradual increase in flexibility. People who have degenerative neuromuscular conditions such as multiple sclerosis or polio are generally not encouraged to move beyond their comfort level — which means there’s no opportunity for them to restore lost functioning.
 
Principle #8: A muscle’s ability to withstand a stretch and tensile force is important for injury prevention. To injure a normal muscle, the muscle must either be stretched beyond its capacity or subjected to a load that is too great for it to bear. A strong muscle can absorb greater amounts of force and a fully flexible muscle can lengthen and absorb force before failure or injury occurs. 

Principle #9: Flexibility and strength are interdependent.  Flexibility without strength and strength without flexibility are both inefficient and increase the vulnerability to injury and dysfunction. Typically people are weakest at the end of their range of motion. AIS develops strength within the optimal range of motion.  
 
Principle #10: Muscle extensibility increases with body temperature. (from DeLee research 2003) The basic, ground substance of connective tissue is hyaluronic acid — a highly viscous substance that binds and lubricates the collagen, elastin, and muscle fibers. It has the consistency of Vaseline at room temperature when the muscles are “cold,” and as the temperature of the muscle increases it becomes more malleable and fluid. This is why are warming up is important in order to maximize flexibility. 
 
Principle #11: To prevent injury, minimal force should be used during stretching. Laboratory studies show that most muscle injuries occur when more than 70% of maximal sustainable force is used. The same research showed that 50% or less of maximal force should be used to prevent injury. 
 
Principle #12: Placing tension throughout ligaments and tendons increases their strength The way to strengthen tendons and ligaments is to put tension through them. Brief, repeated stretches put a tensile force through these structures and increase their strength. (In contrast, prolonged stretching can lead to injury; tendons and ligaments are not elastic, and therefore when you stretch them, you damage their integrity and structure.) 
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Delayed Onset Muscle Soreness...and Massage in Recovery

What is DOMS?

We’ve all experienced that agonizing muscle ache, where there is pain of trying to get out of your car, wobble up the stairs, or move normally after a hard day at work or workouts. This soreness is called delayed onset muscle soreness (DOMS). If you’ve been exercising long enough, you’ve probably felt it. If you've been sitting all day after exercising - you definitely felt it. Some athletes relish this pain as an indicator of success, but is that really the accurate?

I frequently see DOMS occur after a daunting day of activity - with little mental or physical break from one activity. Think six hours in dance class for professional ballerinas, think ANY Iron-man Triathlon. Think of going to the gym before class or work, or bootcamp - and not getting home until 12 hours later. That's a long day... It can also occur in experienced athletes after taking a few weeks off from workouts as part of a recovery.  

A number of treatment strategies have been introduced to help alleviate the severity of DOMS and to restore the maximal function of the muscles as rapidly as possible. Here what aids in the recovery process:

  1. Nonsteroidal anti-inflammatory drugs have demonstrated positive effects based on the dosage. They may also be influenced by the time of use.
  2. Massage has also shown varying results that may be attributed to the time of massage application and the type of massage technique used.

Here is what hasn't worked:

  1. Cryotherapy, stretching, homeopathy, ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms.

Exercise is the most effective means of alleviating pain during DOMS, however the effect if 'active recovery' use as an analgesic is also temporary. Athletes who must train on a daily basis should be encouraged to reduce the intensity and duration of exercise for 1–2 days following intense DOMS-inducing exercise. Alternatively, exercises targeting less affected body parts (think alternate sequence of workouts - upper body, lower body or legs, arms and back or chest,  should be encouraged in order to allow the most affected muscle groups to recover. Eccentric exercises (lengthening under tension and/or weight) or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of, or during, the season in order to reduce the level of physical impairment and/or training disruption. This introduction to activity (10-15% increase) should also be applied when restarting an exercise program. There are still many unanswered questions relating to DOMS, and many potential recovery.

DOMS is Not Fiber Damage

Studies show (1) that DOMs is not restricted to any particular muscle group, but some people tend to experience it more in certain muscles. Technically speaking, DOMS is (primarily) caused by a type 1 muscle strain – some degree of fiber damage, but nothing too serious – predominantly as a result of unaccustomed exercise (either different levels or activities) or long periods of forced inactivity. As you may have experienced, it can range from slight muscle discomfort to severe pain that limits range of motion. Generally, muscle soreness becomes noticeable ~8 hours post-workout and peaks 48-72 hours later, although the exact time course can vary.

There is little doubt that DOMS is correlated with exercise-induced muscle damage to some degree; however, measurement of muscle damage at a microscopic level are poorly correlated with reports of soreness. Basically, if you’re really sore, it doesn’t mean you completely “shredded” the muscles you are feeling soreness in. This is supported by MRI images showing little damage to some muscles post-exercise. Not only do the time cycle, or course of changes that markers of muscle damage indicate, differ from one another, but they also don’t match the time course of muscle soreness (Newham, 1988). It is possible for severe DOMS to develop with little or no indication of muscle damage, and for severe damage to occur without DOMS.

Certain types of exercise can cause significant muscle damage. The image below is taken after an extensive eccentric exercise protocol. As you can see, the muscle fiber just looks messed up. The majority of studies examining exercise-induced muscle injury and DOMS use untrained subjects undertaking large amounts of unfamiliar eccentric exercise. This model is unlikely to closely reflect the circumstances of most people who workout. However, it does give us some insight into what happens in the muscle. (See Image No. 1 below - Image of muscle from an electron microscope after eccentric exercise. Notice the disruption in the muscle pattern).

Another DOMS-inducing stimulus that occurs during exercise is metabolic stress (this does not refer to the buildup of lactic acid, because lactic acid and collagen buildup do not cause DOMS.)  Thinking that lactic acid causes muscle soreness is as inaccurate and dogmatic idea, as the idea that massage gets rid of body toxins.  Viewing by-products of exercise as toxins is outdated and flat-out wrong, after high-intensity exercise, rest alone will return blood lactate to baseline levels well within the normal time period (think 24 hours) between training sessions. However, there is some evidence that hydrogen ions and reactive oxygen species – both of which increase in concentration during exercise – may contribute to DOMS (2). Metabolic stress during exercise can cause changes on a structural level at the cell membrane (sarcolemma). The damage allows fluids and other factors to enter the cell, which promotes inflammation (3).

Cell swelling occurs during exercise-induced muscle damage when fluid and plasma proteins can exceed the capacity of the drainage. The result is edema in the muscle, with significant swelling lasting ~48 hours post-exercise.

Does DOMS mean more muscle growth?

Some studies show the presence of DOMS after long-distance running, which indicates it doesn’t just occur during resistance training. This should be an anecdotal sign that DOMS isn’t a good gauge of muscle growth, because running causes minimal hypertrophy - and there may indeed be DOMS after long distance endurance races.

People who are new to working out often have the most pronounced DOMS. They also happen to grow the most, so you can see how the two may be intertwined. This is due to the new stimulus that exercise provides. Again, they get sore because they aren’t accustomed to exercising – not because they are growing like monsters. Interestingly, there is no difference in DOMS between sexes even for beginners.

There is some evidence to show DOMS may negatively affect workouts by altering motor patterns in subsequent workouts. This could cause reduced activation of the desired muscle. Hence, DOMS could actually hinder your next workout. In addition, severe DOMS can decrease force capacity by up to 50% (6). This causes functional deficits that may impair training at a certain level, which could hinder muscle growth in the long term.

Exercising while having DOMS does not seem to make muscle damage worse (7), but it may interfere with the recovery process. In extreme cases, exercise-induced muscle damage can cause rhabdomyolysis, a serious condition that can lead to renal failure. So be careful when throwing a newbie into an advanced program – especially if they’ve never exercised. You could do some serious damage.

”The “No pain, No gain” theory is wrong – at least for muscle growth.” 

How do I feel DOMS?

Nociceptor

So if you aren’t destroying your muscles or burning them up with lactic acid, then why do they hurt? I recently discussed this concept with a member of my lab.

Nociceptors are free nerve endings that respond to damaging stimuli by sending pain signals to the brain. In muscle tissue, these receptors can sense chemical stimuli such as inflammation or disturbances in microcirculation to blood vessels. These receptors are not inside the muscle because muscle cell death is not painful. In comparison, tearing a muscle can be extremely painful. The pain is due to the release of muscle substrates into the space where nociceptors are located. This also helps us appreciate that DOMS probably doesn’t occur due to something inside the muscle (i.e., in the contractile apparatus) (7).

How can I reduce DOMS?

One of the best ways to decrease the risk of DOMS is to slowly progress into a new exercise program. If you’ve ever had an advanced program, you’ll notice the first week or two may have reduced volume. The “prep” phase of programs has two purposes: 1) allowing the muscle time to acclimate to a new movement, and 2) leaving room for more adaptation.  

We all know we should warm-up properly. This is probably one of the only times you’ll hear it doesn’t help. While it may prepare you for exercise (I highly suggest it), neither warming up nor stretching before exercise has been shown to reduce or prevent DOMS.

Something a lot of people use to relieve DOMS is foam rolling. However, it has only been shown to improve DOMS in some studies. During foam rolling, you use your own body mass on a foam roller to exert pressure on an area of soft tissue. The motion places direct pressure on an area, which stretches it. It is considered self-induced massage because the pressure somewhat resembles the pressure exerted on muscles by a massage therapist. Again, there are only a few studies that have measured the effects of foam rolling on performance. These studies found foam rolling can enhance recovery after DOMS and alleviate muscle tenderness. Self-massage through foam rolling could benefit people wanting to recover in an affordable, easy, and time-efficient way.  

Another intervention commonly used is massage. Some researchers have shown decreases in pain associated with DOMS after a massage (8). However, massage has no effect on muscle metabolites such as glycogen or lactate. One study found massage decreased the production of the inflammatory cytokines by mitigating cellular stress resulting from muscle injury (8). Many people believe massage can provide increased blood flow to specific areas, reduced muscle tension, and mood enhancement. Massage produces direct pressure, which may increase ROM and stiffness. These benefits are expected to help athletes by enhancing performance and reducing injury risk.  The effects of timing of massage (pre- or post-exercise) on performance, injury recovery, or injury prevention are not clear because the mechanisms of each massage technique have not been widely studied.

Supplements to reduce DOMS

Caffeine has long been known to increase alertness and endurance, shown by the the average person’s morning grumpiness before drinking the black gold. Interestingly, a recent study by Hurley et al., reported caffeine has the ability to reduce DOMS. They mesured perceived soreness in males consuming caffeine one hour before a workout. They found a lower level of soreness in the biceps on day 2 and 3 compared to a placebo after subjects completed a bicep curl protocol.  Using a dosage of 5mg/kg bodyweight they found a beneficial effect of caffeine on soreness. For comparison, a 185lb (~84kg) male would take about 420mg of caffeine preworkout. That is a ton of caffeine! An 8oz Red Bull contains roughly 85mg. Does your preworkout supplement have that much caffeine? Probably not. If you’re wondering when caffeine peaks in the blood, it’s about one-hour post ingestion. Caffeine is an adenosine antagonist and affects the activity of central nervous system (CNS) by blocking adenosine receptors, thus resulting in decreased levels of soreness. This suggests that short-term caffeine ingestion before a strenuous workout may decrease overall soreness levels.  However, the subjects who took caffeine were able to perform more reps than the control group, which could be a confounder.

Taurine is found in muscle and has multiple biological functions. Remember that Red Bull I mentioned earlier? Well, it has about 1,000mg of taurine. For reference: Up to 3,000mg a day of supplemental taurine is considered safe. One double-blind study (10) of males completed over 21 days measured the effects of 50mg of taurine (20x less than the content in a Red Bull) after 7 days of eccentric exercise.  The researchers found a reduction in DOMS and oxidative stress markers after exercise; however, there was no effect on inflammatory markers. Could this be a way to battle the other side? If inflammation is one component to DOMS and oxidative stress is another component, we need a study to combine the two. That probably won’t happen soon, but it would be fun to see if they were synergistic.

Omega-3 fatty acid is found in fish and is becoming increasingly used tofortify foods. You can also find EPA/DHA in those lovely pills that make you burp fish all day. Several studies reported positive effect of omega-3 fatty acids on DOMS, presumably due to the decrease in pro-inflammatory factors such as IL-6 and TNF-alpha. There are a ton of studies to show taking an omega-3 supplement is good for you in many ways, and this seems to hold true for DOMS. If you’re interested in the results, the main table from Jouris et al 2013is below.

Manual Therapy to reduce DOMS

y, on the other hand, Cryotherapy probably doesn’t reduce DOMS.  This goes directly against the current trend of athletes jumping in a tube surrounded by liquid nitrogen to help recovery. Whole body cryotherapy exposes athletes to cold, dry air below -100C for between two and four minutes in a specialized chamber. A recent Cochrane Review by Costello et al., found that there was insufficient evidence to determine whether cryotherapy can reduce muscle DOMS or improve recovery.  

No guidelines currently exist for its clinical effectiveness or for safe usage. Cryotherapy is thought to work by reducing  temperature in the skin, muscle, and core. The theory is muscle soreness is relieved by reducing muscle metabolism, skin microcirculation, nerve conductivity and receptor sensitivity. In addition, it could have a placebo effect by reducing the subjective feeling of DOMS post-exercise. Using a meta-analysis based on four eligible studies, it seems cryotherapy does not reduce DOMS or improve recovery. Furthermore, insufficient evidence exists on whether this therapy could actually be harmful.  We do know, however, that cold water emersion post-exercise can decrease rate of muscle growth. For the time being, cryotherapy and cold water emersion are probably two things you should avoid – you probably won’t recover any faster, and you may not build as much muscle.

2) Neuromuscular Massage, is a consistent deep tissue treatment which aims to release muscle adhesion at the source - the neuromuscular endplate. It can be painful, it can be time consuming - and if you use it during training, you may have to plan it for the off days where you have nothing else going on. It actually changes the proprioception or spacial orientation of the muscles. Athletes report 'having more space, more flexibility and greater capacity.' Since a lot of this is in the mind, if you've been training within specific parameters for a big race, you know how your body functions - once you make these changes you have to dial it into your mind as well. Hurdler's are a very specific example - if you know exactly how much hip flexion it takes to get over a hurdle, and after an NMT appointment you have "way more stride," it's going to through you off.

3) Active Release Techniques, is another deep tissue technique which aims to release muscle adhesion, realign muscle fibers and can be uncomfortable. But it is a much quicker and less of a change to the proprioception wherever it is used. Made famous by chiropractors, this technique actually takes muscles through a stretch (both active and passive), where the body is guided back to length, strength and done with full knowledge of the brain (hence the active). The client is shown, talked through and is participating in the treatment - so that by the end of the time, they know how much change has taken place. Although there can be significant changes, the awareness around the movements doesn't progress from total relaxation to 'realignment' within 24 hours. The reset is immediate - and there is minimal change to the parasympathetic nervous system, and there is no catch-up time to the brain.

Conclusion

Soreness can provide some insight, but don’t use it as a marker for a good workout. High levels of soreness indicate the athlese has exceeded the capacity for the muscle to undergo repair. Indeed, soreness can impede the ability to train properly, and it may decrease motivation.

The consensus among researchers is that there is no single component that causes DOMS. Instead, there are a number of complex events that may explain this phenomenon. It is the main cause of reduced exercise performance including decreased muscle strength and range of motion for both athletes and non-athletes. A combination of all the post-workout recovery tools, is probably a good idea to see what works for you as an individual.

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Simple Explanation of Pain

This is a great, easy to follow video about chronic pain. It helps you understand what current research has been saying about chronic pain - thats its not a joint or muscle problem, rather a 're-wiring' of the brain perception of itself. In other words, the brain has become more sensitive than before.

During the past twenty years, research on chronic pain has significantly increased, with considerable advances in understanding its etiology, assessment, and treatment. These discoveries have important healthcare implications, when pain is one of the leading causes for why people seek out medical care. Pain is an even bigger influence for movement and manual therapies. Whether or not pain relief is your immediate goal, the fact remains that the majority of people who walk into your office experience some degree of pain and/or tension that they want help with.  This is why we must understand what pain is, and more importantly, what pain is not, when communicating with our clients.

For manual and movement therapists, knowledge of the anatomy and movement of the body becomes fundamental as well. This is a simple review of the most recent understanding of pain, providing a summary of some of the latest pain science research, and how both are relevant and applicable to you and your clients. It proposes explanations for phenomena where, with your treatment, your client’s pain may decrease, remain the same, or perhaps gets worse. Ultimately, understanding these phenomena will empowering to both you and your clients success in managing the pain in their lives.

Within roughly the last twenty years, neuroscience and pain science have discredited the belief that pain reflects the state of physical tissues (i.e. pain = tissue damage), a purely biomechanical explanation for pain (Gifford 1998, Lederman 2010). This is the major falsification reversed, in how we once believed and understood pain to manifest in the body. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Simply put, pain is the brain’s perception of tissue damage (Butler and Moseley 2003). Perception is the key focal point, because pain is about how a person consciously and non-consciously creates meaning of his/her physical reality. This perception of tissue damage (i.e. pain) is modulated by a number of cognitive, emotional, and sensory inputs (Gifford 1998; Carlino et al. 2014).

When someone in pain walks into your office, they want answers to the following:

1.  What’s wrong with me?

2.  How long is this going to last?

3.  Is there anything I (the client) can do about it?

4.  Is there anything you (the practitioner) can do about it?

(Verbeek et al. 2004; Gifford 2014)

These questions are prompted by the underlying assumption that pain is the indicator for something “wrong” in the physical body. A number of hypotheses will be made (joint misalignment, degeneration, compression), so that a treatment regime can be identified designed to “fix” these physical morbidities. When experiencing pain health practitioners sensibly, but mistakenly, place all of our attention in the physical domain. Today, we see that this is a false conclusion that pain predictably represents tissue damage.

“Pain is an opinion on the organism’s state of health rather than a mere reflexive response to injury. The brain gathers evidence from many sources before triggering pain.”

-V.S. Ramachandran

One of the brain’s chief priorities is to keep the body safe and protected. Pain warns us of danger and compels us to take action to relieve and/or avoid that danger. This stimulus is known as ‘flight-or fight.’ Thus, the experience of pain is based on a prediction of danger that we are physically in, not how much we are actually going to experience. Even if there are no problems in the tissues, nerves, or immune system, you can still hurt if your brain concludes that you are in danger (Butler & Moseley 2003).

Historically, a class of sensory receptors called nociceptors were once, incorrectly, referred to as pain receptors. Nociceptors are receptors that require higher thresholds of stimuli to trigger an action potential, which in turn sends larger, more amplified signals to the central nervous system (CNS). These larger signals serve to get a person’s attention by acting as warning signals. The brain, though, can ignore input from the body, large or small, if the brain is either distracted enough or does not value the incoming messages. Because pain is context-dependent, the drama around pain, injury – whether real or perceived – will take priority in the brain’s attention. A notable example of this is seen with soldiers in the heat of battle who are shot but don’t feel pain until much later, once they are out of the dangerous environment.

The recovery from tissue damage includes the resolution of healing (particularly inflammation) and attenuation of nociception excitation. The process is not complete if the final stage of attenuation is not completed – and the system returns to homeostasis. The point is, that a time frame exists, and this is the expected cycle within which all tissues complete their healing phases. Pain serves an important role during healing to ensure the process is preserved, and to prevent further tissue damage in order to facilitate a full recovery (Lederman 2015; Figure 1).

 If pain persist past the healing window, it is considered chronic. It is important to reiterate, though, that an individual can experience acute pain even without tissue damage present. We can refer to this more accurately as a "pain event."

The neuromatrix theory of pain proposes that pain is an imprint, or “pain neurosignature,” of nerve impulse patterns. These patterns are generated by the body-self neuromatrix (Melzack 2001) and influence the structures, soft-tissue and functional activities. There are many inputs to the brain that can create or later trigger a pain neurosignature, including movements, thoughts, emotions, touch, memories, fears, smells, and visual stimuli, to name a few. Interestingly, the neuromatrix requires no actual sensory input for a person to experience pain, only the activation of a pain neurosignature or pattern that 'triggers' a response in the body; phantom limb pain is an example of this.

The most important takeaway from the neuromatrix theory of pain is recognizing that pain is an output of the brain rather than being dependent on or a response to sensory input like damaged tissue (Melzack 2001; Gatchel et al. 2007).

CONCLUSIONS

Our experience of pain is a top-down process—always. In fact, there is no such thing as myofascial pain, bone pain, organ pain, or even the existence of nerve pain. There’s just pain. This means damaged and pinched nerves do not have to hurt. Even in the presence of actual tissue damage—given pain is an output of the brain—it is our brain that concludes whether our tissues are in danger.

Pain is primarily a psychological experience (Craig and Hadjistavropoulos 2004). This is not to say that pain is all in your head, as in your discomfort is imaginary, but it is a construct of the brain projected onto the body. Modern pain science does NOT imply people imagine their pain.

Pain is real. Pain is always real. Pain literally changes our PNS and CNS physically and chemically. This is the dark side of neuroplasticity. Pain can be an output from our brain, that changes the input from the PNS and CNS. The resulting messages can then change the brain’s perception – a complicated ‘loop,’ with no end.

Myths about Massage that are 'Wrong.'

Massage Therapy has many wonderful and therapeutic benefits but the advice or cautions that wind up being shared are often inaccurate. What we hear can be a little misleading, so, I thought I'd take on the role of 'Masage ' today and discuss what's real and what's not.

Let me know if you have your own favorite Massage Therapy Myth, or illusions that have been shattered in the course of manual therapy. I love the good stuff.

Myth #1 - The sign of a really good massage is that you feel quite sore the day after

Everyone is different and some people are more sensitive than others but just because you don't feel sore the next day doesn't mean you had a bad massage.  Furthermore, there should be different things expected from different types of massage. Why? Because the techniques and the results or goals of the session are DIFFERENT. The sign of a good massage is that you feel better than you did before - it may take a while to feel the full benefits but you should experience some of the following:

  • Relaxation 
  • Renewed energy 
  • Increased mobility or flexibility of the area of the body 'worked' on
  • Difference in tension levels - do you 'feel better.'
  • Less pain 
  • Better sleep
  • Alertness 
  • Reduction in headaches

Myth #2 - You shouldn't have a massage if you're pregnant

Massage Therapy does not induce an early labor and is perfectly safe for both mother and baby during normal pregnancies. Most physicians (and yes, you need to let your doctor know before you go!) will support massage after the first trimester and right up until the due-date. High risk pregnancies are handled a little differently, but not much - if everything is communicated up front.  It can be extremely beneficial for the Mom-to-be and offer a way to relax and unwind during a physically and mentally tiring time.

Normal aches and pains from pregnancy, can be dealt with and if the therapist is trained, there is no danger to the mother or the baby. More complicated situations can also be handled - but that requires an advanced understanding and training around pregnancy and the impact on the female body.

Post-natal massage can be equally beneficial, and for those are are interested in 'naps' during the day it is ideal (generally six weeks after birth - with a doctor's note again)! Ask your Massage Therapist about Pre-natal massage and other forms of appropriate therapy to help both before and after your baby is born.  

Myth #3 - Massage will get rid of cellulite 

If Massage Therapists could really banish cellulite we'd never see a dimpled thigh ever again. And when I have clients that come in wanting to reduce water retention and ' discussing,' if I know how to help them get a 'thigh-gap,' to look more shapely...I stop listening, and you will never get an answer from me. This is NOT my area of expertise, or interest.

However, cellulite is persistent subcutaneous fat and it's appearance. It is found mainly in women, or they seem to care more, and the 'texture' is determined by hormonal factors, genetics, diet and lifestyle.  Eating a healthy, low fat diet rich in fruits, vegetables and fiber and taking regular exercise is the best option to prevent and reduce the appearance of cellulite.  Massage is an excellent addition to your healthy lifestyle and wellness routine, and good circulation is good for the SKIN, HEART and whatever else ails you.

Myth #4 - Toxins can be flushed out of the body via Massage

This is an interesting Myth, which while popular and interesting, is completely false. The body processes excess waste (by-products of food, drink, airborne pollutants etc.) in a variety of ways i.e. sweat, urine, faeces, or if you're ill by vomiting.  Your liver, kidneys and skin do a remarkable job of getting rid of these 'toxins' on a daily basis and keeping the skin, muscles and fascia of the body (including joints) free and balanced.  Massage does, however, increase blood supply to various parts of the body and can regenerate a lack-lustre circulation. This helps move things around and replaces 'things dislodged by massage' - collagen from adhesions, lactic acid from workouts, and lymph from injury sites. 

This may be what is actually being referred to when someone is talking about toxins - the by products and 'waste' not needed by the body. These things are actually replaced by the nutrients that the body needs - which circulation also brings in. So, it's a one-for-one exchange. Drinking water is a pleasant thing to do after a massage (we like ours with a slice of lime or cucumber) and is a great reminder to drink more fluids that aren't laced with sugar, colorings or other additives. Eating a healthy, again, focusing on a low fat diet rich in fruits, vegetables and fiber and taking regular exercise is the best option to prevent and reduce the toxins and inflammation (caused by diet imbalance).  Massage is an excellent addition to your healthy lifestyle and wellness routine, and good circulation is good for the SKIN, HEART and whatever else ails you.

Myth #5 - You shouldn't get a massage if you have cancer

Many Massage Therapists and cancer patients have often fallen foul of this myth.  Until recently, it was assumed that the action of massage could actively spread cancer cells throughout the body.  However, it DOES NOT. Therapist who receive training, and the general public should now realize that cancer cells are caused by the body's immune system malfunctioning, they cannot be spread or increased through manual contact. Cells that turn cancerous will do so regardless of massage therapy stimulus, and there is no way the contact between therapist and the client will cause cancer cells to move through the body then the same could be said of any form of exercise.

On the other hand, Massage Therapists need to be 'trained and knowledgeable' about the impact of Massage Techniques appropriate for work on tissues going through Chemotherapy, Radiation and other types of drugs associated with Oncology. This is an advanced technique that needs to have specific ways of working the patients in an appropriate manner - much like lymphatics and other types of techniques that actively work on areas that are injured.

Myth #6 - You shouldn't get a massage during 'workout' cycles

Many Massage Therapists and athletes have often run into issues with clients who have athletic trainers that tell their athletes - 'don't get a massage you'll be too relaxed or flexible.'  Until recently, it was assumed that the action of massage could impact the muscle fiber pliability, and lead to injury during heavy and continuous workout cycles. However,  most techniques DO NOT have a negative impact on the 'proprioception' of the brain, the biomechanics of sports movement and how the athlete performs. There will be a positive impact, and the return of full range of motion and movement capability may be different, but managed regularly as part of the work out cycle - the Athlete and the "Athlete's brain" will get used to the new normal without incident. They will also REMAIN INJURY FREE.

In fact if therapists have received 'sports' training, and understand the muscle recovery and cycle of activity there should be no functional impact,  on the athlete. This should encourage athletes and trainers alike to focus a small amount of their strategy on 'recovery,' instead of letting it happen without purpose or intent. Regardless of massage therapy stimulus, and techniques, recovery in the form of relaxation of muscles and reduction of stimulus or stress on the body on a regular basis will increase performance and prevent injury.  Relaxation and the 'optimization' of the body should be the goal of any form of massage.

What Massage Therapy Myths have you heard recently?  What misconceptions about Massage would you like to dispel?  Share them with us here in the comments section (below), our Facebook page, twitter account or Instagram account.

Beyond The Myth: Soft Tissue Release and Recovery

Beyond The Trigger Point Hype

This is a trigger point, but there is more to it than the medical definition: a hyper-irritable spot in fascia surrounding musculoskeletal tissue - muscle belly, attachments or the fascia itself

They can be identified by palpation, pain patterns or loss of strength and range of motion.

Because there is an impact to the soft tissue or is linked to musculoskeletal pain, They can be reset and released for pain reduction, increased range of motion and prevention of injury. The release feels like a small twitch in the muscle, but no contraction. unlike spasms, they do not involve the whole muscle.

They are NOT caused by trauma, inflammation, degeneration or infection – but they can develop as the body protects itself from these things.

There is a nervous system involvement – but they cannot be explained through a neurological examination.

Soft Tissue and Pain Treatments

How Understanding Pain Can Benefit Therapy

"Soft Tissue Release is only part of the equation, but if you don’t achieve it – full recovery may not be possible!"

Pain is usually the natural consequence of tissue injury resulting is one of the biggest reasons why manual therapy and therapeutic intervention can be critical to a successful recover. In general, as the healing process commences, the pain and tenderness associated with the injury will resolve. Unfortunately, some individuals experience pain without an obvious injury or suffer protracted pain that persists for months or years after the initial insult. This pain condition is usually neuropathic in nature and accounts for large numbers of patients presenting to pain clinics with chronic, non–malignant pain.

What they do not consider, in the attempts to control, improve or ‘get rid of it,’ Pain is the nervous system functioning properly to sound an alarm regarding tissue injury or potential injury which may be related to ongoing structural or imbalance in the body. The idea that neuropathic pain from the peripheral (PNS) or central nervous system (CNS) malfunctioning can become the single greatest gift in resolving the cause of the pain.

Acute pain and chronic pain differ in their etiology, pathophysiology, diagnosis and treatment. Acute pain is self–limiting and serves a protective biological function by acting as a warning of on–going tissue damage.

Chronic pain, on the other hand, serves no protective biological function. Rather than being the symptom of a disease process, chronic pain is itself a disease process. Nociceptive pain is mediated by receptors (messages are transferred to PNS) and fibers which are in skin, bone, connective tissue, muscle and viscera. It affects the sensitivity of any of these structures.

       Nociceptive pain can be somatic or visceral in nature. Somatic pain tends to be well localized, constant pain that is described as sharp, aching, throbbing, or gnawing. Visceral pain, on the other hand, tends to be vague in distribution, paroxysmal in nature and is usually described as deep, aching, squeezing and colicky in nature. It affects the ability of the muscle to ‘act,’ and in turn affect the physiology of the musculoskeletal structure (i.e. Knots, adhesions, contractures). This failure of the receptors in the body becomes the primary location for trigger points.

Neuropathic pain, in contrast to nociceptive pain, is described as "burning", "electric", "tingling", and "shooting" in nature. It can be continuous or paroxysmal. Whereas nociceptive pain is caused by the stimulation of peripheral receptors due to introduction of biochemical compounds produced by the body, neuropathic pain is produced by damage to, or pathological changes in the peripheral or central nervous systems.

Pathophysiology

The mechanisms involved in neuropathic pain are complex and involve both pathologic impact to peripheral and central nervous system phenomenon. The underlying dysfunction may involve deafferentation within the peripheral nervous system (e.g. neuropathy), deafferentation within the central nervous system (e.g. post–thalamic stroke) or an imbalance between the two (e.g. phantom limb pain).

Peripheral Mechanisms:

Following a peripheral nerve injury (e.g. crush, stretch, or axotomy) sensitization occurs which is characterized by spontaneous activity of the neuron, a lowered threshold for activation and increased response to a given stimulus – PAIN arrives. Following nerve injury nerve fiber can develop new receptors and sensitivity (slowly 1mm/month), which may help to explain the mechanism of sympathetically maintained pain and then subsequent decrease without treatment.

Following a peripheral nerve injury, anatomical and neuro–chemical changes can occur within the central nervous system (CNS) that can persist long after the injury has healed. The "CNS plasticity" may play an important role in the evolution of chronic, neuropathic pain. As is the case in the periphery, sensitization of neurons can occur following peripheral tissue damage and this is characterized by an increased spontaneous activity, a decreased threshold and an increased responsivity to afferent input, and cell death – MORE PAIN arrives.

So now you’re wondering what you can do – if anything – to reduce sensitivity, manage pain or reduce chronic conditions and live normally. Early recognition and aggressive management of neuropathic pain is critical to successful outcome. Often multiple treatment modalities are needed and should be provided by an interdisciplinary management team. Numerous treatment modalities available include systemic medication, physical modalities (e.g. physical rehabilitation), psychological modalities (e.g. behavior modification, relaxation training), and various surgical techniques (as a last resort). It should be noted that caution is warranted regarding the use of invasive techniques. Such approaches may produce deafferentation and exacerbate the underlying neuropathic mechanisms.

Manual Therapy Impact

Why therapeutic treatment of muscles works  

Neuromuscular Therapy (NMT) is an approach to soft tissue release and manual therapy that involves quasi-static pressure that is applied to soft tissue to stimulate skeletal striated issues (i.e. Adhesions, Trigger Points).

You cannot strengthen a muscle that has a trigger point, because the muscle is already physiologically contracted.  attempts to strengthen a muscle with trigger points will only cause the trigger point to worsen.

*Devin Starlaynt, MD author of Fibromyalgia and chronic myofascial Pain: A Survivor’s guide

  Through applied knowledge of Anatomy and Physiology, Kinesiology, Trigger Point physiology and trigger point development – i.e. Ergonomic or biopsychosocial influences, neuromuscular therapy treatments are designed to address postural distortion (i.e. Rolfing focuses on poor posture), Functional Muscle dysfunction (Corrective exercise re-trains biomechanical challenges), movement and psychological impairments to movement (i.e. Somatic retraining and PNF – Proprioceptive Neuromuscular Facilitation stretch). Both Nerve Compression syndrome or congestion and ischemia deal with the musculoskeletal impact on other areas of the body: nerves, veins and arteries. Remember, when normal distribution and circulation is impaired all systems become impacted.

Because Myotherapy incorporates trigger point therapy, manipulation of soft tissue through massage, dry needling, and joint mobilization it has become an allied health discipline throughout the world. Therapists with this expertise will also use stretching, nutritional support, exercise, posture, heat and cold therapy as well as ultrasound and TENS (Transcutaneous Electrical Nerve Stimulation) to achieve the return to normal balanced activity they seek. Pain reduction is an off-shoot of the successful procedures.

Why is Soft Tissue Ignored?

Muscles as a system in the body, is not ‘owned or claimed’ by any Medical Specialty. Soft tissue treatments are taught in medical school – because they are generally NOT life-threatening. Muscles tissue is the largest organ in the body. Tissue complexity is well documented, and there are multitudes of ‘dysfunction,’ beyond Trigger Points and Myofascial Pain Syndrome where the “primary target of these activities creates the wear and tear of daily activities.” These show up as Repetitive Stress Injuries (RSI) and Cumulative Trauma Disorders (CDT), but nevertheless it is the bones, joints, bursae and nerves on which the medical community focuses.

Where Physical Therapists and Chiropractors are involved with joint dysfunction, biomechanics, and exercise therapy, they often emphasize these things at the expense of soft-tissue or muscles. They simply over-simplify muscle pain as a “sensory disorder,” which can easily affect people with apparently perfect bodies, posture and fitness levels. There is a lot of wasted time ‘treating’ patients, through various methods when a little pressure on key muscles or lengthening of the muscle itself will provide relief. Muscles release in and of itself cannot be expected to occur in a single session – although occasionally it may feel like that.

Massage Therapists in generally know surprisingly little about myofascial pain syndrome, because the training varies for every practitioner. When they become pre-occupied with symmetry and structure, then the ability to give relief may be hard to find. Outside of Neuromuscular therapists, common skilled treatment of Trigger Points and Myofascial Pain is very rare, but look for these individuals who have spent time and effort to begin to understand treatment and management of pain and you’re going in the right direction.

Myofascial Pain vs. Fibromyalgia

   As a last point on the complexity of muscle pain, there is a common mistake in comparing Myofascial Pain and Fibromyalgia. Although unexplained FM might be a more clearly neurological disease, while MPS may be more of a problem of muscle tissue. They have related sets of unexplained symptoms, and they may be two sides of the same coin, with overlapping parts on an undefined spectrum of sensory malfunction, or different stages of the same process.

  Do NOT confuse “tender points” of fibromyalgia with ‘trigger points’ in muscles – they are not even close. Whatever the similarities of these two causes or labels, therapeutic approaches for MPS seem to be helpful for some FM patients as well. Although pure FM cases seem to be mostly immune to manual therapy.

Muscles, Trigger Points and Referred Pain

In addition to minor aches and pains, muscle pain is often the cause of unusual symptoms in strange locations. For example, people diagnosed with Carpal Tunnel syndrome are experiencing pain caused by congestion of the nerves in the Armpit or Neck (brachial plexus).

Sciatica: often described as shooting pain in the buttocks and legs, this is caused by muscular tension of the piriformis or other gluteal muscles – which in turn irritates the sciatic nerve. Many other ‘trigger point problems’ are mistaken for some “kind of nerve problem.”

Chronic Jaw Pain (TMJ), Toothaches, earaches, Sinus Headaches, Ringing in the Ears (tinnitus), Dizziness and Allergies: these may ALL be symptoms of trigger points in the muscles around the jaw, face, head and neck. There are several large nerves (i.e. Trigeminal Nerve in the cheek near the TMJ, Occipital Nerves at the base of the skull) which when impacted created these types of issues due to muscle tension and dysfunction caused by trigger points.

Migraines or Headaches in general: Since there are over 300 types of headaches, let us just say that some muscle, somewhere in the neck can contribute to headaches given enough tension. There are obvious headaches that affect the Sternocleidomastoid (SCM) around the eyes, ears and back of the head. Then there are less obvious muscles like the Occipitals that just simply block or congest the blood flow to the brain enough to cause tension. There is no way to predict the pattern of a headache from one trigger point, because they may cause secondary sights with the muscles that they touch. Isolating and treating the group of muscles involved in any trigger point situation may take several attempts – it all depends on the client.

Trigger points have many strange “features,” and behaviors. Some people deal with trigger point pain better (i.e. Less resistant to) than others. It helps to have a competent therapist, who understands the discomfort around the treatments – most people who have had trigger point treatment will NOT over do the impact to the nervous system (or overstress the clients comfort level). Some discomfort should be expected. Because of their medical obscurity and confusion with many other problems, the trigger point discussion or diagnosis is often the last thing to be considered. Despite their clinical importance and many distinctive characteristics, muscle pain is NEVER the first problem people look at.

A diagnosis of Trigger Points or Myofascial Pain means that the primary source of your symptoms is from trigger points. Often trigger points are present secondary to other sources of pain: like arthritis or bulging discs. Trigger points may cause the painful symptoms attributed to these conditions. Here is a list of diagnoses which may be Trigger Point origins:

-        Back Pain (lower, middle and upper)

-        Neck pain/stiffness

-        Rotator Cuff/shoulder pain

-        Jaw Pain (TMJD)

-        Tennis/Golfer’s Elbow

-        Carpal Tunnel Syndrome

-        Thoracic Outlet Syndrome

-        Frozen Shoulder/Adhesive Capsulitis

-        Repetitive Strain/Stress Injuries

-        Pelvic Pain

-        Hip Pain

-        Sciatic Pain

-        Knee Pain

-        Ankle Pain/weakness

-        Plantar Fasciitis

-        Achille Tendonitis

-        Bursitis

-        Arthritis

-        Disc Pain (bulge/rupture/herniation) or Radiculopathy

-        Tendinitis/Tendinopathy

“Many researchers agree that acute trauma or repetitive micro-trauma may lead to the development of a trigger point. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbance and joint problems may all predispose to the development of micro-traumas.”  *David J. Alvarez, D.O. and Pamela G. Rockwell, D.O for American Family Physician

How Trigger Points are Formed

     Far from damage to muscle and connective tissue, trigger points can arise from every day use. Although it takes about 7-10 years to constantly place enough stress for them to form, it can happen because of:

1)     Repetitive overuse at home or work in activities like work at the computer, cell phone or gardening. These are using the same body parts hundreds of times daily without rest.

2)     Sustained loading or stress like heavy lifting, wearing body armor, sustained tension when extending muscles (like reaching to pull things down or moving patients in bed).

3)     Habitually poor posture or a sedentary lifestyle, that deconditions the body – or pushes people to overstrain their tired muscles after a week at work. Poorly designed furniture may also contribute.

4)     Muscle clenching and tension do to mental/emotional stress.

5)     Direct injuries from a blow, strain, break, twist or tear – car accidents and falls are critical situations to deal with immediately after they occur.

6)     Inactivity for long periods in exceptional positions, or prolonged rest (i.e. Couch surfing) may also compromise the way the muscles respond.

The only way to deal with trigger points is with a skilled practitioner. There are no commonly available lab tests or imaging studies that can confirm the diagnosis. Myofascial pain can be regionalized or general. Trigger points can be Active (causing pain to touch) or Latent (impacting movement and pre-disposing to injury) and are only noticeable when someone touches them. Treating Trigger Points individually can be simple – get a massage or manual therapy that identified and releases them. You just must get them all primary, secondary, and active – and then leave the latent ones for the next time.

Treating myofascial pain syndrome or the source of the trigger points and pain may be more complicated. Since trigger points are a contraction mechanism of the locked muscles, getting the release is only the first step. Once trigger points are released the muscles need to be moved throughout the full range of motion.

Soreness and ‘post-workout’ fatigue may be common after a trigger point session. However, with 24-48 hrs. rest the muscle will return to a normal one, if work-load balance remains abnormally high

trigger-point_action potential.jpg

Massage Treatments and Chronic Pain and Disease

     When someone asks me why I became a massage therapist, I just say - "I wanted to be passionate about my career." Then it became, "I want to help people manage pain. " Then I honestly wanted to share my joy and the usefulness I've found in manual therapy within anyone who would listen - at one point we were 'chastised to get a bullhorn and shout it from the street corners,' so this is my version of doing just that.

    Integrative Health and Medicine current offers a comprehensive prevention-based approach to effectively treat chronic disease and enhance health. This should include the use of soft tissue therapy and treatments to leverage CAM health care appointments. All appointments from health practitioners such as naturopathic doctors, chiropractors, physical therapists, acupuncturists, nurse practitioners, nurses, midwives, and nutritionists and orthopedic surgeons can benefit from pre- and post- healthcare appointments from a CMT/NMT. To fully embraces a multi-disciplinary team of licensed health care providers working at the highest level of their scope of practice, massage and neuromuscular therapy provide extensive preventative at pre-tax savings, as well as effective knowledge of soft tissue details .

These health care practitioners have been lumped into the term complementary and alternative medicine (CAM) providers, and if we use the term Integrative Health and Medicine professionals with distinct licensed professional certifications, CAM can be used in the traditional and there is no need to “discover” a new model of care.  Patients who work with Integrative Health and Medicine practitioners are already achieving basic wellness goals 1) are healthier, 2) have lower health care costs, and 3) report extremely high levels of patient satisfaction. Through a collaborative approach to health care, integrative health care solutions contribute improved health care every day.

How does the interrelated way in which the contributions of licensed Massage Therapy professionals can help reduce health care costs and fit into the existing Health Care system?

Without disruption, Massage therapy can be used prior to ALL appointments to soften, warm and prepare tissues in areas like the spine, or head and neck to leverage existing services  and make them more than previously identified.  Like corporate Wellness programs, Massage Therapy aims to help get people healthier to prevent big-ticket chronic diseases, like the seven preventable chronic diseases: cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions and mental illness. The cost of these chronic and life threatening heath issues, costs the U.S. economy $1.3 trillion annually, including the cost of lost productivity, treatment in the form of insurance reimbursement and medication. Combining the diversion of caregivers with the costs of absenteeism and ‘reduced workload’, the total impact of chronic disease already exceeds $1 trillion a year, including more than $100 billion in California alone.

While healthy lifestyle change requires investment from more than just the health care arena, health-oriented providers play a critical role. CAM users were 64% more likely to report that their health had improved over the last year.  Not only are prevention and health promotion fundamental cornerstones of CAM, integrative health and medicine practitioners including Massage Therapists can consistently provide additional resources and avenues into conventional providers. Because CAM creates better outcomes, contrary to the common critique that there is a lack of evidence, thousands of studies, including randomized controlled trials published in top medical journals which highlight research demonstrating the ways naturopathic medicine prevents cardiovascular disease and metabolic syndrome at a cost less than prescribing a pill!                                                                      

European countries, in which general practitioners are co-trained in integrative approaches, have incorporated CAM into national health care systems based on studies showing better outcomes and lower costs. Keeping costs low by keeping care simple and adhering to a common-sense therapeutic order, allows individuals to make a choice on healthy alternatives that have a longer lasting impact. With back pain alone, the cost to the health care system is 60% less with CAM treatments and largely due to expensive, often ineffective diagnostics and surgical procedures.

Massage therapists are experts in administering less invasive, low-cost treatments that support the body while it heals itself, and that serve as effective substitutes for riskier modalities such as prescription narcotics. An approach to treatment that begins with low-force, non-addictive, low-cost care options that feel good just makes sense. Reduce costs up front through complementary, alternative, and integrative therapies. Many people have the impression that the use of CAM creates substantial add-on costs for health care systems and individual payers. The myth that patients are draining their bank accounts on out-of-pocket costs associated with CAM looks like actual costs – $33 billion – which is pocket change compared to the $268 billion spent out-of-pocket on conventional care in the same year.  

In Washington state, where CAM health care providers of every discipline have been a mandated part of the health care system for nearly 20 years, data show that patients who see CAM providers have lower prescription drug costs, hospitalization costs, and total costs, despite starting out in poorer health and incurring the “additional” cost of the CAM provider’s services. Because CAM providers – including Massage Therapists offer therapies that are less expensive than those provided by other health care professionals, they not only reduce costs, but also may increase access through “first contact points of entry,” reaching people who are unwilling or unable to access the conventional health care system.

So, when you look at what we do, and why being a massage therapist is 'life changing,' not only for ourselves, fellow therapists and our clients...It can be for everyone in the health care system.

 

 

Posture and Impact on Pain

Your spine is strong and stable when you practice healthy posture. But when you slouch or stoop, your muscles and ligaments strain to keep you balanced — which can lead to back pain, headaches and other problems. In addition to physical pain, there is a physiologically efficient posture, and everyone knows that, right?  Okay, maybe you did not.

If most people understand what their posture does to there mind (as well as their body) then most people would also understand the value of Massage (all types no favorites). Here is how to use massage to prevent and maintain balance throughout the body in muscles, structural system and nervous system.

Natural Spine Curve

A healthy back has three natural curves:

  • An inward or forward curve at the neck (cervical curve)
  • An outward or backward curve at the upper back (thoracic curve)
  • An inward curve at the lower back (lumbar curve)

Good posture helps maintain these natural curves, while poor posture does the opposite — which can stress or pull muscles and cause pain.

Physiological Efficient Posture

Loss of an upright Physiological Efficient Posture makes the relationship between posture, psychology and pain more transparent.  'Bad' or inefficient posture can adversely affect all the systems of the body. I take for granted that I was used as bad example in class a lot (thank you to everyone who noticed), but I even I was unaware of ALL my postural faults: shoulder, hips, foot.

Think of the impact to cardiovascular, digestive, endocrine, energetic, excretory, fascial, immune, integumentary, lymphatic, muscular, nervous, respiratory, reproductive, skeletal and urinary systems when there is a constriction or reduced space within the structural system. This generally happens when you slouch over a desk, stay sedentary for 8-10 hours at work (my developer friends will appreciate this) and/or playing video games AFTER you get home from sitting in front of a desk all day your body does have the opportunity to 'move.'

Muscles were designed to move, by simply changing these habits and limiting sitting, walking regularly throughout the day and minimizing 'technology use' for 1-2 hours - then anyone can reduce the risk and long term negative affects of inefficient posture.

When you do have to work at a desk, "sitting up with good, tall posture and your shoulders dropped is a good habit to get into," says Rebecca Seguin, PhD, an exercise physiologist and nutritionist in Seattle.

This can take some getting used to; exercise disciplines that focus on body awareness, such as Pilates and yoga, can help you to stay sitting straight, Seguin says. Make sure your workstation is set up to promote proper posture.

Client’s mood and physical process in ALL the system above have all been shown to improve when an upright Physiological Efficient Posture is restored. Furthermore, bad posture and/or bad mood can be cyclical- they can improve and decline without effort or mindfullness. More importantly loss of the Physiological Efficient Posture moves people away from Homœostasis and further into Allostasis. These affects can be reversed through strengthening, massage/structural integration or psychological ‘restoration’ of movement. 

The Primary Alignment is the relationship between the body's Center of Gravity (Core) and its Counterweight. To understand more about the importance of a Physiological Efficient Posture and the Primary Alignment follow discussion on the philosophy of Somatics and Feldenkreis manual therapy (both related to the mind-body connection). 

Massage and Posture

In order to find out how Postural Alignment can be influenced by Massage Therapy practices, use assessments that focus on Orthopedic Testing and Bio mechanical assessments (HOPRS), Core Integration (Structural Integration -Rolfing) and Postural Alignment in corrective exercise to provide safe and gentle changes. These processes can help people with:

Many of these ailments ar a direct (and negative result) of posture that is not efficient and positive for the human body Alkylosing Spondylitis, Anxiety, Arthritis, Asthma, Back Pain, Balance Problems, Breathing Impairment, Depression, Digestive Problems, Fatigue, Foot Problems, Frozen Shoulders, Headaches, Insomnia, Jaw Problems, Joint Pain, Knee Problems, Kyphosis, Learning and Behavioral Difficulties, Lordosis, Low Energy, Menstrual Problems, Migraines, Multiple Sclerosis, Neck Pain, Pins and Needles, Poor Posture, Problems during and after Pregnancy, Recurrent Infections, Repetitive Strain Injuries, Scoliosis, Sciatica, Sinus Problems, Sports Injuries, Stress Management, Tension, Visual Disturbances, Wellness Care, Whiplash Injuries and more.

Postural Alignment does not treat or cure any disease or symptom. It is primarily concerned with creating a healthy, balanced state on all levels by helping people back towards homœostasis. Pilates and yoga are great ways to build up the strength of your "core"—the muscles of your abdomen and pelvic area. These muscles form the foundation of good posture, and a strong core can have many other benefits, from improving your athletic performance to preventing urinary incontinence. In addition to helping to increase body awareness and core strength, yoga is an excellent way to build and maintain flexibility and strengthen muscles throughout your body. Check in daily with your body's needs and listen to it's requirements.

How to Identify which Massage Techniques are Best for You

I've had many people come in an specifically asking for a modality based on what they read on the website, and yes Trigger Point therapy, or Myofascial Release or Clinical Deep Tissue can help relieve pain.  Client expect these sessions to make them uncomfortable, because If it's a good pain, it's okay right?  Other professionals like Athletic trainers I work with think Active Release Techniques are the best, because, "won't the stretch and movement will be more effective for athletes who need to release the adhesion or contracture," and they can continue training, right?  Of better yet, if Physical Therapy can't address the issues, then it's more serious than a Massage Therapist can resolve - and the next step is surgery?  Finally, my most favorite question was 'will this machine (refers to electrical stimulation)' help my body with cellular renewal, and relieve my pain?

 As I stand there looking at you, I'll be doing a mental assessment. My first impression is that you are here - to see a massage therapist, because you either have no idea where  to start, or at the end of your rope, because no one else has been able to address your concerns.  My review of the situation is 'an assessment or an educated evaluation of a client’s condition and physical basis for his/her symptoms in order to determine a course of treatment” (Clinical Massage Therapy: Rattray and Ludwig). Here's what you'll here me ask:

Do you have a history of pain/injury?

  • If I'm observing structural imbalance, physical differences between right/left side and movement challenges  - is their pain?
  • If there is a postural difference, can you tell me about that 'x?'
  • If you have any reduced ranges of motion/movements that make it more difficult for you to do 'something?'
  • If you have any diagnosis or input from other medical professionals (Chiropractors, Physical Therapists, etc conduct orthopedic or special tests) in order to identify or diagnose you issues?

Why all the questions? Because clinical assessment for massage therapists is usually divided into five areas, which you can remember by the acronym ‘HOPRS’. I am also incredibly interested in why my clients come in asking for specific treatments, and if they self-diagnose through Google or Web MD - call me nosy:)

H – Health history questions (usually known as your case history or medical intake)
O – Observations (i.e.: of posture)
P – Palpation (of soft tissues including muscles and fascia)
R – Range of motion testing (of movements at joints)
S – Special Orthopaedic Tests (specific tests that help us to identify problems more precisely)

There are many misconceptions and misunderstanding of how Massage Therapy can help clients. My job is to make the best use of the time that you pay for...unfortunately there is no 'set recipe, process, protocol' or magic technique. What is missing from questions about best modality, most effective techniques - is the goal for the session, or what they are trying to accomplish. Unless the client communicates what they want to change versus the 'fix' or the 'magic technique,' the story is incomplete. I would never tell my clients they are wrong. They are just misinformed.

Massage can help in all of these situations...you need to be clear about the issues and goals before you select the technique. And to my instructors, I was listening when you said, ' less (pressure) is more (of a benefit)!'

I look at my Massage Techniques much the same way that we saw 'bodymaps' presented in the movie Dr. Strange. They are all slices of the same canvas - the human body. None of the philosophies is exclusively right (or incomplete) when compared to the others: Energy meridians from Traditional Chinese Medicine and Thai Massage can be compared to the energetic understanding from Trigger Point Therapy and Cranial Sacral flows in the body (think Laws of Thermodynamics)...it's all about the energy. It exists, it has to flow, it tends toward equilibrium - and when it doesn't there is a problem. Then there is the whole description of Biopsychosocial Model - people are influenced by their environment. However you want to look at the universe, closed systems of organisms tend to be the exception, not the rule. Once you step into a massage room, there is a partnership that should exist - and effectively address whatever the goal of the session is.

So what does that have to do with massage? Think of energy transfer (or for those who are allergic to the term energy, how about friction and/or heat) between the hands of the massage therapist and their client's body. Think of the messages and signals that the therapists fingers pick up during palpation, because it's all part of what makes ANY massage effective....it is specific to what you body needs, and how I interpret (or anyone else) what will help address the adhesion, trigger point, contracture or block in the flow of 'chi.' Orthopedic assessment helps therapists understand what the body is telling us, and gives us a framework - reducing all the information down to the right path.

If you ask which massage modality is best for me? I'm going to ask, "What do you want to accomplish in the next 30-90 minutes of your life?"

Why Active Release Techniques is Different (from massage)

Most of my friends thought that adding Active Release Techniques to our services was crazy. For one it was developed by Chiropractors...who are not typically as comfortable with soft tissue dysfunction as massage therapists. Fortunately for my clients, they have benefited from my lack of attention to 'background noise.'

When looking at Active Release Techniques (ART) treatment I was immediately drawn to the philosophy - and the ability to sufficiently define and 'diagnose' soft tissue dysfunction. Active Release is a hands-on, touch based and case management process that allows a practitioner to treat soft tissue injuries and provide preventative care. The soft tissue that I deal with primarily refers to muscles, tendons and/or ligaments, fascia and nerves. The specific injuries that it can be addressed through these treatments include repetitive strains, adhesions, tissue hypoxia and/or Delayed Onset Muscle Soreness (DOMS), and finally joint dysfunctions.

ART was initially developed like other forms of Myofascial Release - in fact that was one of the original names. However, the technique has evolved and been redefined due to it's inclusion of peripheral nerve entrapment, and a lot of 'resistant muscular issues' can be treated more effectively when including nerves in the manual treatments.

Although ART gained attention as part of the Ironman Triathalon treatment process for Hawaii athletes (1995) it is now a fundamental treatment process for the preparation for all Ironman events throughout the world, as well as other professional and collegiate sports competitions. Stanford University is one of the current organizations that uses it for all Athletes during season.

Additional applications for ART in work-place injuries started even earlier (1990). Today ART is approved by OSHA (Occupational Safety and Health Agency) as an efficient treatment for preventative care for repetitive motion injuries, and cumulative trauma disorder (CTD) throughout the United States.

Active Release appointments are different at four specific levels:

1) tissue position without tension, passive patient

2) tissue position with tension, passive patient

3) tissue lengthened after contact, passive patient

4) tissue lengthened after contact, passive patient.

Like most massage it is most effective with correct anatomy and kinesiology of the muscles treated. Appointments tend to be shorter (20 min on average), as there are only 3-5 passes required to affect change on the muscle. Over a week there can be as many as 3 appointments, which is strictly based on the tolerance of the patient. Benefits can be seen immediately.

Finally, the use and application of ART as part of training and recovery cycles is remarkable. Better posture and support along with movement retraining and corrective exercise instruction can bring great dividends. Learning to relax musculature after and between repetitions is key to reducing the total insult (breakdown) of issues. Correct movement and postural alignment is fundamental to reducing the re-occurrence of lesions and soft tissue adhesion.

So...now you know the secret, it integrates massage, corrective exercise techniques (PT) and postural alignment in all treatments without creating the core change to the proprioception of the body (ie. body awareness - where Awareness of the body and its relationship with the surrounding environment is mediated by sensation) created by deep tissue massage.

 

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Seeking Wellness - Progress not Perfection

As we get older life isn’t like the movies. It’s not a party every night or always hanging out with friends or family. The reality is, if nights aren’t spent working, then there is something to read, facebook posts to respond to or website updates that need to happen. If I'm not working on my business, then I'm probably watching Netflix, pretending like I don’t have those two work deadlines next week. Once I accept that I DO have those two deadlines and rush to cram, my sleep and sanity suffer. It’s a draining, all-too-familiar cycle for most people!

It is hard to perform at your best if you are not taking care of your mind and body. Wellness matters, and I’m not just talking about eating right and exercising throughout the week (although those are extremely important). Wellness is much broader than that, and wellness matters because everything we do, every thought, and every emotion we feel relates to our well-being. These feelings in turn, directly affect our actions. It’s a dynamic process of change and growth. Therefore, it is important to make sure you are striving for wellness in all aspects of life. This is referred to as a Biopsychosocial (BPS) model of how human being interact with their environment.

Developed by Osteology in the mid- Nineteenth century. It attributes disease outcome to the intricate, variable interaction of biological factors (genetic, biochemical, etc), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.).[1] The Biopsychosocial (BPS) model counters the biomedical model, which attributes disease to roughly only biological factors, such as viruses, genes, or somatic abnormalities.

 

There are eight dimensions of wellness interrelated with each other and equally vital in your pursuit of health and wellness. The eight dimensions are:

Since I just defined what is considered a Biopsychosocial Environment, wellness should be your balance of these factors and top priority when looking at health concerns. I know that it is way easier said than done! Fortunately, there are a number of resources to help manage the stresses you may face, and for support there are health care professionals that are available to help with minor or major issues. You just have to ask.

Here is a list of five resources and events to look out for, particularly highlighting ways to enhance your social, emotional, physical and environmental wellness without a lot of cost.

Wellness Carnivals happens every fall, and they are full of organizations and dedicated to actively promoting health and wellness on campus and providing opportunities for students to get involved. There are free raffle prizes, food, and games throughout the event. Come hang out with others and learn about the numerous resources and opportunities that help you seek wellness. Sounds like a great way to take a break from stress, right?

 

Mind Spa & Massage

Did you know that there are places that offer 'inexpensive massage' and mental relaxation at an affordable rate. Yes, LOW COST I have like $5 in my bank account, so this is personally a huge deal for me. It is important to pay attention to self-care, relaxation, stress reduction and the development of inner resources, so you can learn and grow from all experiences. Therefore, give yourself time to go to a Mind Spa to relax , or have a massage at a 'school' that is training massage therapists. Each will come with some soothing music, or massaging recliners or biofeedback programs. If it sounds too good to be true, go check out all they have to offer and see for yourself. After all, you are technically investing in a better you.

Community Sports

Physical activity is a key component to a healthy lifestyle. Regular physical activity can increase your energy levels, improve your cognitive abilities, and help you sleep better. What better way to get your daily dose of exercise than to get out on the field or court with your friends or neighbors? Get away from the idea that you can only work out by going to the gym; there are a number of ways to move your body! Think of what you enjoyed doing as a kid and try to incorporate that into your day. Make it fun! Get some roller blades, take dance lessons, or kick around the soccer ball, just get out there and get your heart pumping!

 

Botanical Gardens

Did you know that you can adopt a plot and have your own small garden in the middle of the city?  How cool is that? It’s your own little patch of earth, where you can grow your own fruits and veggies. You can also visit edible urban gardens that allow you to pick fresh fruit and veggies if your a member? Not only is gardening and being in nature a great stress reliever, but it’s also a great way to motivate healthy eating and create a sense of community. Learn more about how to adopt a plot and where edible gardens are located throughout the city.

These are just a few examples of the unique wellness enhancing opportunities.

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Foam Roller

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Physiotherapy vs. Neuromuscular Massage

Physiotherapy is a health profession concerned with helping to restore physical well-being to people who are suffering from an injury, pain or disability. Using knowledge from our extensive scientific and clinical background (Masters or Doctorate of Physical Therapy), and they are Chartered Physiotherapists or managed by a professional association. They can assess, diagnose and treat conditions and illnesses that affect people of all ages and social groups.

Chartered Physiotherapists, or Physical Therapists, use manual therapy including manipulation, mobilization and myofascial release as well as complementary modalities including electrotherapy and Medical Acupuncture & Dry Needling. In recent years pain management education and counselling techniques have also become integral in most treatment programs. The Chartered Physiotherapist also utilizes prescriptive exercise as a rehabilitative tool to help patients achieve their full potential. While traditionally, Physiotherapy and/or Physical Therapy was regarded as rehabilitative and mainly hospital-based, the profession has expanded greatly into other health care areas. 

Neuromuscular therapy (NMT) is a specialized form of manual therapy that integrates specific massage techniques, flexibility stretching and home care practices to eliminate the causes of neuromuscular pain. NMT theory explains how injury, trauma and other factors can destabilize nerve transmission, making the body vulnerable to pain and dysfunction.

Through neuromuscular therapy training, students learn to manipulate muscles, tendons and connective tissue to restore balance to the central nervous system.

Neuromuscular therapy examines five elements that cause pain: ischemia (lack of blood flow), trigger points (more about trigger point therapy), nerve compression, postural distortion and biomechanical (movement) dysfunction. During an initial session, neuromuscular therapists interview patients about their health history, current physical condition, lifestyle, and stress levels and devise a treatment plan that addresses their pain syndromes.

Using fingers, knuckles or elbows, neuromuscular therapists apply concentrated pressure on areas of pain until they reach a trigger point, usually a spot that’s extra tender or numb. At this point, they’ll begin a stronger, more localized massage to relax the muscle. Relaxing muscles in this way releases lactic acid, increasing blood and oxygen flow, which, in turn, enhances the function of joints, muscles and movement.

Although both are forms of manual therapy, and they deal with the soft tissue of the body - Neuromuscular therapists can be more preventative - since they may see clients with varying degrees of discomfort. The appointments can also be used in conjunction with many other types of treatment including chiropractic visits, acupuncture, physical therapy and orthopedic rehabilitation (post surgery).

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Stress Management using a Stillpoint

The Stillpoint and Relaxation techniques

Specific effort to counter and manage stress daily can help us reach a place of absolute calm where the mind is truly quiet. Further discussion and evaluation in use of stillpoint to reset or downregulate muscle relaxation and massage is important. What is actually known about ‘the stillpoint’ and how to achieve it?

Stress relief practices such as meditation, tai chi, and yoga counter the harmful effects of stress. Another method, the stillpoint technique, can help us reach a place of absolute calm where thoughts are stilled and the mind is truly quiet, which is supported by deep and measured breathing to oxygenate and

Robert Harris is a stress expert and one of Canada’s leading craniosacral therapists. He explains, “By finding your stillpoint, you can sink into calmness naturally and quickly, enabling you to identify and sustain the ultimate Shavasana (diaphragmatic breathe).” This is the ability to completely detach yourself from all thoughts.

What is a stillpoint

The term stillpoint has its roots in osteopathy and craniosacral therapy (CST). The latter is a gentle, non-invasive, hands-on therapy. CST theory and practice is based on the concept of the continuous subtle movements of the cranial bones, which are understood to be in constant motion in response to rhythmical cerebrospinal fluid fluctuations within the spinal cord and brain environment. The goal and challenge is to change, reduce or 'still' these movements to positively affect the parasympathetic nervous system - and thereby change pain symptoms in the body.

The gentle stillpoint technique is used to help shift the central nervous system from its usual state of alertness to one of calmness (similar to sleep, where the mind shuts off and lets muscle recovery begin). The natural rhythm that is always occurring within the craniosacral system eases into a therapeutic standstill. Recipients report the experience as a feeling of deep peace pervading the body. This sense of peace and tranquility indicate that the fight-or-flight responses of the sympathetic nervous system have stepped down.

Harris describes the stillpoint experience as “relaxation so deep that one not only feels their mind going quiet and staying quiet, but eventually there is the feeling of becoming liquid. In this liquidness we access the potential for great surrender and release of chronic tensions.”

How to find your stillpoint

A stillpoint can be achieved with relative ease by contacting two very particular spots at the back of the head – beneath the Occipital ridge. Even the slightest pressure in this area can create slack or release within the connective tissues of the brain. When this happens, there is a neurological recognition and response. The tensile nature of these tissues eases off, and the nervous system goes into temporary suspension.

These two spots lie opposite the pupils of the eyes along a horizontal plane at the back of the cranium. Along this plane there is an internal divide between the upper and lower brain, marked by an inwardly folded membrane called the tentorium cerebelli.

Trained craniosacral therapists use a gentle hands-on method to help patients achieve the kind of release described above, and the goal is to identify and affect the rhythms of the human body (ie. Identified through touch). However, through years of working with clients, it can be shown conclusively shown that it can be empowering for people to be able to access stillness for themselves, easily and quickly, whenever they need to.

With this in mind, many therapists recommend two Tennis Balls taped or wrapped in a sock (tied at one end), and these these soft rubber balls are designed to be adjustable, allowing individuals to lie on them comfortably in a position that gently cradles their head at the exact spots where the relaxation response becomes activated.

 

Enhance yoga practice

If yoga or meditation is your chosen approach to relaxation, and you are having difficulty finding and maintaining a relaxation response, discovering your stillpoint may help.

During stillness, the mind is settled and less distracted; it has better focus and heightened sensory awareness. By using pressure on the occiptal area at the back of the skull, your position may accompany a relaxation of muscle tone and a release of soft tissue restrictions.

As a result, your yoga practice can become more directed. You can execute postures with greater ease and flexibility, and you can experience a deeper, longer, and more rewarding Shavasana.

Yoga instructor Leslie Howard describes what a stillpoint experience is like for her. “Going into stillness at the end of my yoga practice is like lying back into the ocean … the oceanlike wave lulls me back to source, to a place where I am just hanging, suspending,” she says. “I return with less anxiety, more clarity and calmness.”

She also observes that inducing a stillpoint during her yoga practice has enabled her to “listen and accept those around her with greater ease and understanding.” This is a crucial element for stress reduction, on or off the yoga mat.

It has been shown that spending time, even just a few minutes a day, in a state of stillness can have a profound effect on stress. Every time our stress cycle is interrupted it takes a little longer to re-establish itself, and the body gets better at restoring a healthy balance between the sympathetic and parasympathetic nervous systems.

We can’t eliminate stress completely from our lives, but fortunately, we can find some relief. Connecting with your stillpoint will help you reach the ultimate relaxation, when and wherever you need it.

To find a massage practitioner, you can search for a craniosacral therapist who practise the stillpoint technique at: NCBMTB and AMTA  and ABMP websites:

1)      http://www.ncbtmb.org/tools/find-a-certified-massage-therapist

2)      https://www.amtamassage.org/findamassage/index.html

3)      https://www.abmp.com/public

 

Promising research on Stillpoint in Medical Treatment

I.                     Dementia: A small study examined the effects of the stillpoint technique on nine older patients with dementia. Treatment was given daily for six weeks. Even post-treatment the patients had reduced physical aggression and verbal agitation. They were more cooperative with caregivers and had more meaningful interactions with family and caregiving staff.

II.                   Sleep: In another small study researchers investigated the effects that cranial manipulation, specifically the CV4 technique, had on muscle sympathetic nerve activity. In the first study of its kind researchers showed that this technique was able to alter sleep latency (the time it takes to go from full wakefulness to sleep) in healthy subjects.

While this study provides insight into the possible physiological effects of cranial manipulation, it doesn’t explain how these changes occur.

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Sleep and Muscle Relaxation

Beyond a sleeping position, research suggests that not just the sleep position, but sleep itself, can play a role in reducing musculoskeletal pain, including neck and shoulder pain. In one study, researchers compared musculoskeletal pain in 4,140 healthy men and women with and without sleeping problems. Sleeping problems included difficulty falling asleep, trouble staying asleep, low amount of sleep during the night, and waking early in the mornings without feeling 'rested,' and non-restorative sleep.

People who reported moderate to severe problems in at least three of these four categories were significantly more likely to develop chronic musculoskeletal pain after one year than those who reported little or no problem with sleep. One possible explanation is that sleep disturbances disrupt the muscle relaxation and healing that normally occur during sleep. Additionally, it is well established that pain can disrupt sleep, contributing to a vicious cycle of pain disrupting sleep, and sleep problems contributing to pain.

With many things, like neck pain, an ounce of prevention may be worth a pound of cure. It's true that some causes of neck pain, such as aging impact on the body, wear and tear on the neck and spine, stress are not under your control, finding the sleep position to support sound sleep is. On the other hand, there are many things you can do to minimize the risk of improper (read discomfort producing) positioning of the head, neck, shoulders and spine. One place to start is to look at how you sleep and what effect this may have on neck and shoulder pain.

What is the best sleeping position for neck pain?

Two sleeping positions are easiest on the neck: on your side or on your back. Of these two, sleeping on your back, puts less stress on the neck muscles, because you may not toss and turn as much throughout an average of 5-6 hours of sleep. If this is what you choose, find a ‘rounded’ pillow to support the natural curve of your neck…not too high (flexion and extension as it pushes the chin forward) with a flatter pillow ‘plane’ to cushion your head above. Any material will do, as long as this can be achieved by tucking a small neck roll into the pillowcase of a flatter, softer pillow, or by using a special pillow that has a built-in neck support with an indentation for the head to rest on (think bamboo or all natural fiber).

Additional tips for side- and back-sleepers:

If you try using a feather pillow, it will easily conform to the shape of the neck, but the feather pillows will collapse over time, and will need to be replaced every year or so. Thicker ones may push the neck up to far, and thinner ones may need to be ‘rolled’ which will not provide anything but a bolster to the neck (without support for the head).

Another option is a traditional ‘shaped pillow’ made of "memory foam,” which will conform to the contour of your head and neck. Some cervical pillows are also made with memory foam. Manufacturers of memory-foam pillows claim they help foster proper spinal alignment. You must find one that isn’t too high or stiff, so that it doesn’t keep the neck flexed overnight and can result in morning pain and stiffness.

If you sleep on your side, keep your spine straight by using a pillow that is higher under your neck than your head. Be sure to keep your neck inline with your upper back when lying down - and ensure that this is the primary position attempting to achieve (ie. not sleeping upright in bed).

When you are riding in a plane, train, or car, or even just reclining to watch TV, a horseshoe-shaped pillow can support your neck and prevent your head from dropping to one side if you doze. If the pillow is too large behind the neck, however, it will force your head forward. Resting with your 'head propped' up, should not be counted in your prone, sleeping position, as this is translates into incomplete sleep for the parasympathetic nervous system. The entire idea of rest to to remove as much of the influence of gravity on muscles as possible.

Side sleeping or on your stomach is tough on your spine, because the back is arched and your neck is turned to the side. Preferred sleeping positions are often set early in life and can be tough to change, not to mention that we don't often wake up in the same position in which we fell asleep. Still, it's worth trying to start the night sleeping on your back or side in a well-supported, healthy position.

 

 

Moist Heat and Muscle Soreness

Heat is commonly used following exercise to prevent delayed onset muscle soreness (DOMS). Most heat used in a clinical setting for DOMS are only applied for 5 to 20 minutes. This minimal heat exposure causes little, if any, change in deep tissue temperature. For this reason, long duration dry heat packs or organic hot/cold 'heat' packs used at home to slowly and safely warm tissue and reduce potential heat damage while reducing pain associated from DOMS.

Clinically, it has been shown that moist heat penetrates deep tissue faster than dry heat. Therefore, in home use heat packs along with moist heat may be more effective than dry heat to provide pain relief and reduce tissue damage following exercise DOMS. However, heat packs moistened with heat will only last for 2 hours compared to the 8 hours duration of chemical dry heat packs.

Heat has been used therapeutically for thousands of years. It offers immediate pain relief and can increase circulation to speed the healing process after injury. For this reason, it is popular for use on many types of pain including joint and muscle pain as well as soft tissue damage.

The effect of heat on pain is mediated by heat sensitive calcium channels. These channels respond to heat by increasing intracellular calcium. This generates muscle action potentials that increases stimulation of sensory nerves and causes the feeling of heat in the brain. These channels have in common their sensitivity to other substances such as vanilla and menthol. These multiple binding sites allow a few factors to activate these channels. Once activated, they can also inhibit the activity of pain receptors, and are located in the peripheral small nerve endings . For peripheral pain, for example, heat can directly inhibit pain. However, when pain is originating from deep tissue, heat stimulates peripheral pain receptors which can alter what has been termed gating in the spinal cord and reduce deep pain.

Another effect of heat is its ability to increase circulation. These receptors along with noiciceptors, increase blood flow in response to heat. The initial response to heat is mediated through sensory nerves that release substances to increase circulation. After a minute or so, nitric oxide is produced in vascular endothelial cells and is responsible for the sustained response of the circulation to heat. This increase in circulation is considered essential in tissue protection from heat and repair of damaged tissue.

Heat is used in different modalities in the treatment of back pain and muscle soreness. Dry heat can be applied through either heat packs or techniques that warm tissue such as diathermy and ultrasound  Heat packs can be dry or moist. In Sports Massage Hydrocolator heat packs are usually at 165 deg F and are separated from the skin by 6 - 8 layers of towels and used only in clinical settings. Hydrotherapy (warm) uses water at 105 deg F and involves immersing a limb in the water. Hydrotherapy can include contrast baths or simply warm water immersion. A major problem with this type of heating is that it is usually used for short periods of time, for example, 5 - 20 minutes. There is also a combination of cryotherapy-heat therapy (10 min ice/10 min heat) which increases circulation and speeds muscle relaxation, generally used in minimizing pain and inflammation.

Moist heat, in most studies, appears to be advantageous in pain relief to many short duration dry heat modalities such as electric heat pads. But these heat modalities are used for short periods of time, for example, 20 minutes maximum. Many studies have shown that short duration of heat application results in poor heat transfer to deep tissues. Therefore, in deep injuries, heat application for short duration causes pain relief through the gate control theory of pain in the central nervous system and not through the peripheral nervous system. Long term application of heat, such as in chemical heat wraps, solves this issue by applying heat for hours to warm deep tissue gradually. But dry chemical heat wraps heat deep tissue much slower that pain relief is delayed by at least 30 minutes.

While moist heat penetrates deep tissues better than dry heat for warming. This is supported by research examining heat transfer from various types of heat modalities from skin to subcutaneous tissues. Moist heat modalities transfer heat much faster than do dry heat modalities and research shows that they cause much faster heat penetration than dry heat. Even air with high humidity transfers heat faster than dry air. But it is not just the type of heat but the duration as well that affects heat transfer into deep tissues.

For example, contrast baths use warm and cold water immersion that alternates within minutes in warm and cold baths. While this changes skin temperature, there is no evidence that it penetrates into deep tissues. Whirlpool heat penetrates quickly, but is used for only a short duration as are hydrocolator heat packs which provide moist heat but are left on for less than 20 minutes due to their high temperature. Someone with thick subcutaneous fat will therefore only see a small difference in deep tissue temperatures with these modalities.

To penetrate deep into tissue, lower temperature and long duration heat packs are often used. Long duration heat products (for example, chemical dry heat) offer the advantage of being safer and can be left on for hours to warm deep tissue and provide increased circulation and pain relief.  But the increase in tissue temperature is slow as is the onset of pain relief. Chemical moist heat lasts for a shorter duration than dry chemical heat packs, lasting between 30 minutes and two hours. For more information refer to Moist or Dry Heat for Delayed Onset Muscle Soreness, Journal of Clinical Medicine Research - J.Petrofsky, 2013

 

 

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Shoulder Hotpack

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What is Neuromuscular Therapy or NMT

When people ask my ‘what type’ of modalities I specialize in – I usually say I’m a neuromuscular therapist. I prefer to use that title rather than massage therapist, because most people will respond with, ‘Oh, you’re a masseuse.’ Um, no! Because I do a lot more than relaxation massage and helping people de-stress (although I do that too). I am more of a pain management specialist.


What is neuromuscular therapy – it is the most effective type of massage therapy for muscle pain, and it is also called trigger point or myotherapy. The American Academy of Pain Management recognizes this form of massage therapy as an effective treatment for pain caused by soft tissue injury (such as a muscle strain), joint pain throughout the body, muscle tension, spasms and injury and/or surgical recovery or addressing trigger points.

Neuromuscular therapy consists of alternating levels of concentrated pressure on the areas of pain, tightness or muscle spasms. The massage therapy pressure is usually applied with the fingers, knuckles, or elbow at a consistent rate (ischemic pressure) on the spots chosen – until the muscle releases. The pressure may continue from 30 secs to several minutes.

Because Neuromuscular therapy is a specialized form of deep tissue massage digital pressure and friction are used to release areas of strain in the muscle for superficially and deep (think joint pain you can’t get rid of), and these areas of strain are called tender or trigger points and are the cause of muscular pain symptoms.

Trigger points are areas of hypersensitivity in a muscle caused by a continual firing of the signals to the muscle that do not allow it to relax between movement (either contraction or stretch).  These are small areas with the muscle in which there is a contracture of muscular tissue (think of a tiny grain of rice under a sheet).  Blood circulation and nutrients are lacking in that part of the muscle and therefore the muscle spindle is unable to relax.  Trigger points cause pain, fatigue and weakness in the muscle.  Trigger points also create a phenomenon called referral pain.

Referral pain caused by trigger points can exist in areas far from the trigger point – the best example of this Carpal Tunnel – because the source of the issue is generally in the neck, yet clients come in with pain in their wrist. Additional people suffer from sensations of pain, tingling, or numbness.  Examples of referral pain include: sciatica like symptoms (lower leg), lower back pain (from hips and thighs) and headaches (neck).

Neuromuscular therapy is used to treat many different soft tissue problems.  The following list is a small example of issues that may be helped by neuromuscular therapy:
Lower back pain, upper back pain, carpal tunnel like symptoms, sciatica like symptoms, hip pain, headaches, plantar fasciitis, calf cramps, tendonitis, knee pain, iliotibial band friction syndrome, jaw pain, tempomandibular joint pain (TMJ disorders).