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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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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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