Koda Integrative Therapy Group

Therapeutic Massage and Health Partners for Recovery and Performance

Filtering by Tag: #neuromusculartherapy

Knee Pain, Science and Your Clients

Clients in pain have expectations that their therapist will be able to make the discomfort go away. Over the past years my clients have been talking about the different kinds of overuse injuries that can occur at the knee. With this blog post, I want to give you a better visual of how they are all related to each other, and why knee pain is different -depending on where it is. Let’s break our knee down into three different zones:

1) central and front; 2) outside-lateral edge; 3) inside-medial edge

Think of each zone one as the beginning of problems in the knee - each is related to the different functions of the muscles found most in this area. Zone 1 - includes the front of the knee, and becomes painful when it gets overworked and breaks down (or tightens up) when the other muscles attached into the patellofemoral joint (knee) do not strongly support the movements and actions of the back of the leg. Injuries that occur here are because of mobility restrictions and muscle imbalances in the knee itself.

By comparison, zones two and three are the continuations of problems in the knee from the hip. Instead of the front of the knee breaking down, the body finds a way to compensate around those restrictions and imbalances, either because the hip or the foot is out of balance. This occurs by rotating the the thigh in as shown by the orange arrows - think of compensations and patterns of imbalance - which move the force away from the knee and hip joints. When that rotation is present, new areas become vulnerable to breaking down. When they do, not only do you have to fix the rotation, you also have to go back and fix those underlying problems.

When sports medicine evaluated participants for anthropometric variables, motor performance, general joint laxity, lower leg alignment characteristics, muscle length and strength, static and dynamic patellofemoral characteristics, and psychological parameters in a 2-year follow-up study, 24 of the 282 students developed patellofemoral pain. Statistical analyses identified significant differences between those subjects who developed patellofemoral pain and those who did not: based on quadriceps and gastrocnemius muscle flexibility e,plosive strength -or lack, thumb-forearm mobility, reflex response time of the vastus medialis obliquus and vastus lateralis muscles, and the psychological parameter of seeking social support. Only a shortened quadriceps muscle (1), an altered vastus medialis obliquus muscle (2) reflex response time, a decreased explosive strength capacity (3) and a hypermobile patella (4) had a significant impact on the the incidence of patellofemoral pain.

Let’s take a closer look - Zone 1

(green/front of the leg + knee cap itself)

As you can see in the picture above, zone 1 is the middle strip. It gets top billing for a few reasons. The first is that problems here typically involve less compensation.

Injuries in this area (muscles involved - Rectus Femoris, Vastus Intermedius, ?)

  • Quad muscle strain

  • Quad tendonitis (inflammation in tendon above the knee cap)

  • Patellar tendonitis (inflammation in tendon below the knee cap)

Likely cause:

  • Loss of knee extension (your ability to full straighten your knee out) - this is a musculoskeletal issue!

    • This can be due to tight calf muscles (especially the gastroc), hamstrings/adductors, and glutes.

    • These restrictions can lead to mobility losses in the joints as well (ankle, knee and hip)

  • Strength imbalance between the front and back of the leg resulting in the front of the leg getting overloaded.

  • A combination of both.

Treatment goals:

  • Restore mobility to the joints and muscles. Either through muscle release and stretching.

  • Balance strength out so that the front of the knee is not getting overloaded.

Zone 2 (blue, outside of the leg/knee)

This area of the knee is the outside of the leg and knee where the lateral quads and IT Band are located. These muscles involved are the lateral quads - Vastus Lateralis, TFL. Injuries in this area mean that you are compensating by rotating the upper leg in. This can create friction/inflammation between the IT Band and the lateral quad or down along the outside of the knee cap where the band attaches.

Injuries in this area:

  • IT Band Friction Syndrome (either at lower attachment outside of the knee cap or up higher in thigh between the band and lateral quad muscle beneath it)

Likely cause:

  • Whenever there is compensation, you need to think of the causes in layers that need to be addressed one by one.

    • The first restriction is the rotation. The inner thigh muscles (pes anserine, inner hamstrings/adductors) get stuck in a short position while the IT Band and outer hip get stuck in a stretched out/long position.

    • The second restrictions to consider are what that rotation is trying to make up for. Most likely, this means that the knee has lost its ability to fully extend. Sound familiar? These are the same restrictions we talked about above in the front of the knee.

Treatment goals:

  • Get rid of the rotation so that the leg is straight.

  • Restore mobility to the knee itself.

  • Balance out strength so that the whole leg is working.

Zone 3 (purple, inside of the knee)

This area of the knee is along the inside of the knee where the pes anserine is located - it includes the Adductors, and balances the other muscles of the thigh during movement. Injuries in this area mean that you are compensating by rotating the upper leg in. This can create friction/inflammation between the the muscles stuck in that short/tight position along the inner knee.

Injuries in this area:

  • Patellofemoral Syndrome (PFS)

  • Pes Anserine Bursitis/Tendinopathy

Likely cause:

  • Whenever there is compensation, you need to think of the causes in layers that need to be addressed one by one.

    • The first restriction is the rotation. The inner thigh muscles (pes anserine, inner hamstrings/adductors) get stuck in a short position while the IT Band and outer hip get stuck in a stretched out/long position.

    • The second restrictions to consider are what that rotation is trying to make up for. Most likely, this means that the knee has lost its ability to fully extend. Sound familiar? These are the same restrictions we talked about above in the front of the knee.

Treatment goals:

  • Get rid of the rotation so that the leg is straight.

  • Restore mobility to the knee itself.

  • Balance out strength so that the whole leg is working.


nerve_lower leg.jpg

Modern Day Ice Therapy_To Use Cryo, or Not?

The original author of RICE - Dr. Gabe Mirkin coined the term-- for Rest, Ice, Compression and Elevation. His best-selling book The Sportsmedicine Book (Little Brown and Co) in 1978. He started the practice of icing anything that hurts, feels tight, or seems "injured,” and it has gained widespread acceptance among practitioners of all types - sports medicine, PTs, athletic trainers, coaches, personal trainers and more. For a clinical bodyworker when I see clients with fairly severe pain complaints, I advise virtually every one of them has been told to ice. I convince them to go one step further, when they begin working with me.

Unfortunately, the practice of icing was based upon questionable science -- which has since been debunked. Dr. Mirkin retracted the protocol that made him famous in an article that he wrote in June, 2013, Ice Delays Recovery from Injuries. In that article, he cites the Cleveland Clinic showing that ice delays healing by reducing the body's production of IGF-1, or insulin-like growth factor - a compound that is present in the fluid that surrounds inflamed tissues. Dr. Mirkin later expanded upon that article with another post in March, 2014, Why Ice Delays Recovery.

Healing is delayed by cortisone-type drugs, nonsteroidal anti inflammatory drugs such as ibuprofen, applying cold packs or ice, and anything else that blocks the immune response to injury - Dr. Gabe Mirkin, originator of the RICE protocol.

When athletes of all ages are subjected to icing at every turn, the routine immersion of young players in ice baths following strenuous workouts. Studies have shown that immediately after cooling, there was a decrease in strength, speed, power and agility-based running. Icing is not good for athletes. It delays recovery from hard workouts, because the body needs inflammation to heal and recover.

Icing after workout has become trendy among baseball pitchers, whose arms and shoulders are subject to huge mechanical stress - beginning with Sandy Kofax. Some very prominent opposing views are emerging as the coaching catches up with the science, like  Why Icing the Pitching Arm is Harmful, has been i followe-up with Coach Mills of pitching.com through interviews Gary Reinl, author of the book ICED! The Illusionary Treatment Option. Reinl advocates active recovery, in which no ice is used, but the joint is intentionally mobilized after pitching to keep fluid moving and metabolic exchange happening. His research, ice actually increases swelling and causes further damage. Additionally, Josh Stone is an athletic trainer who caused a firestorm in the sports medicine community by strongly espousing the deletion of icing as a protocol for athletes recovering from physical stress or injury, using tissue loading and exercise instead. His article, Ice - The Overused Modality provides a compelling and informed case for rehabilitation via movement.

...active recovery is how you regenerate tissue... Stillness is the enemy. Ice is stillness to the extreme. You stop the process and worse, you’ve caused additional damage. -- Gary Reinl, author of ICED! The Illusionary Treatment Option

It's Probably Not an Injury -- Icing Will Slow Down Recovery

Icing is attractive in that it provides a dramatic, immediate, illusory and temporary benefit. Along with a numbing and distracting ‘reduction’ in pain. I had a client recently who complained of severe low back pain, and when he arrived moved haltingly and was barely able to walk. When I started working on his hips, and high hamstrings his skin felt like it had been in a freezer for hours. Ice and NSAIDs were his only tools for reducing his pain. When I discovered trigger points in his gluteus medius and maximus muscles among others, I was able to apply heat and stretching and helped him jump start the recovery process again. The extreme icing he was doing, while it temporarily reduced his sensation, was making his condition much worse by further embedding trigger points in muscles that referred to his low back.

The use of ice for injuries is a belief long held, but it is dying slow controversial death in the physical therapy and sports medicine communities. Despite the conclusive science that has emerged. With Dr. Mirkin, or the originator of the Icing missing, this debate which makes the argument against ice even more compelling. The trigger point literature has provided ample evidence that the great majority of pain complaints have no basis in injury, but rather are due to myofascial trigger points.

Trigger points originate at a cellular level due to chronic or acute muscle fiber overload. Inflammatory chemicals, and acetylcholine reduction near the motor endplate, creates a zone of dysfunctional muscles, which causes local hypoxia, edema and blocked capillary function. This causes ‘increasingly’ nociceptive signals to be sent along the neurological feedback pathways to the central nervous system - which prohibits the muscles from releasing . These signals are misinterpreted as pain referral via a mechanism that is still being researched, but is thought to be due to up irregular neural activity.

The use of ice on tissues that already have trigger points and compromised capillary function causes further stagnation and vasoconstriction - the last thing those tissues need. The introduction of vasodialiation or heat, and stretching, will help decongest the area and reduce the pain.

A typical example, when someone experiences pain in the front of their shoulder, it is highly likely that it will be diagnosed as an injury of some kind - a supraspinatus or labral tear, or at least an inflammatory state such as bursitis. However, as in all pain, most shoulder pain is due to taut fibers and trigger points in muscles that have adapted to stress and posture. There are 13 different muscles directly refer pain to the anterior shoulder, and when I see patients with serious shoulder pain often in my practice, and in Active Release Techniques treatment, the failed resolution with their issues is due to an actual imbalance between the muscle used - not something needing surgical repair.

So there are two problems here: the general assumption that the pain is due to injury, when in fact most of the time it is not. The pain messaging is a ‘warning’ of under-performing or hypersensitize tissue. By using ice to treat the "injury" in a method now shown to impede healing. The pain most likely originates in trigger points, the ice treatment is far more damaging - cold is the last thing trigger point needs. Ice puts already taut, stagnant muscle areas in the deep freeze, further stagnating the local metabolism. Trigger points need metabolic exchange in order to be cleared - a restoration of capillary function and movement in the area, not stasis, which is the inevitable result of ice treatment.

Heat, on the other hand, causes vasodilation, enhances local metabolism and is efficiently distributed by the body due to enhanced capillary action. Ice vasodilates capillaries, and according to Travell & Simons, penetrates quickly to deep tissues as layer upon layer of tissues go into stagnation. According to Gary Reinl, the icing craze took off after a news story about a surgeon who performed the first procedure to reattach a boy's severed limb - using ice to preserve the tissues of the arm prior to the surgery. Somehow that got inappropriately applied to damaged or stressed tissues. Ice is great for shutting tissues down and preventing decay, not so much encouraging healing and recovery. Cooling muscles deeply is a major perpetuator of trigger points, and ultimately pain.

Travell & Simons cite muscle cooling as one of the most insidious perpetrators of trigger points ((Simons D, Travell JG, Simons LS. Myofascial pain and dysfunction. The trigger point manual discussed how waking up with a stiff neck due to cold air on their neck at night causing trapezius and levator scapulae trigger points knows the potentially damaging effects of cold on muscle. Icing an athlete's muscles after or during a workout or icing a sore shoulder shuts down the capillaries and increases the likelihood that microscopic stagnation fostering trigger points and pain will develop. When a cold distraction spray is used in trigger point therapy (for the purpose of neurological distraction, not cooling), it is very important to apply heat to the area immediately after to reverse the negative effects of muscle cooling.

Latent TrPs in a fatigued muscle, especially in the calf or neck and shoulders, may be activated by direct cooling of the overlying skin, as by a cold draft from air conditioning or an open car window. -- Travell & Simons, The Trigger Point Manual

The Clinical Bodywork Perspective - Movement is Health

I was trained in Traditional Integrative Massage, and my work later evolved into what I teach and practice today, Clinical Integrative Bodywork. The concept of treating pain with cold is completely foreign to the asian medicine techniques used in China, Thailand and Korea. Pain, in both Traditional Chinese Medicine and Traditional Thai Medicine lack of circulation is equated with stagnation. The body in health should be in a constant process of physical and energetic movement, or flow. Herbs, bodywork, acupuncture and heat may all be employed to facilitate the flow. Cold stagnates and impedes flow. This correlates in an interesting way with the principles of trigger point therapy.

Modern Trigger Point therapy was developed by western doctors independent with an asian influence from acupuncture. Trigger points are a phenomenon of stagnation “or continuous firing of the neural messaging from the Peripheral Nervous System, at the cellular level. When trigger points develop, the sarcomeres at the center of the fiber bundle contract and stay stuck, making the fiber feel hard, taut and static. The only way to eliminate the referred pain caused by the trigger point is to disrupt the contracture and point there the muscles have been ‘stuck together.’ Some manner and allow the sarcomeres to move normally again - like heat, massage or stretching is consistent with reversing the process.

My approach to working with pain is to try and understand the body's logic and unwind the symptoms from the point of Highest Pain through the first and second layers . For example, over a period of time during when trigger points are producing a steady flow of referred pain in the area of a joint (common because of attachments) and inundating the central nervous system, the body goes into a self-protective splinting action. This splinting creates the taut fibers in additional muscles adhesions to immobilize the joint. In a sense my goal is to help the body understand that nothing is injured and things need to move again. Clinical trigger point therapists and pain management specialists are facilitators who provide the body with a conscious experience of movement without pain.

Heat, compression and movement are some of our best tools as clinical bodyworkers dealing with pain. The Flax Hotpack is a wonderful tool that combines moist heat with light compression and the topical application of organic icy-hot including CBD - Essential Oils - such as Menthol, Turmeric, various varieties of Ginger, Eucalyptus, Lemongrass and others. The herbs are applied through a carrier oil, which provides an excellent form factor as a tool for facilitating muscle release in bodywork.

In CBD treatments, using joint articular and compression of muscle tissues become techniques are being shortened and lengthened while forcing useful compounds into the body. The moist heat and herbal oils are highly effective in relieving stagnation and stimulating flow in the tissues. Neurological distraction also plays an important part. The heat, pleasant smells and rolling pressure all serve to disrupt the pain response triggered by stretching taut fibers, making it easier for the fibers to let go and the trigger point encapsulations dissolve.

I would encourage you not to blindly follow the advice of the people who yet heard about icing. Unfortunately, it would seem that many health practitioners would rather unquestioningly keep doing what they've always done rather than do the research and go against the grain. If you have an injury or have worked your muscles very hard, your body's inflammatory response isn't a mistake, it's the first step toward healing and should not be suppressed. If you have pain, chances are that it's not an injury unless you have other indications that would indicate so. You can make the pain go away if you understand what muscles could be causing it and encourage their movement and metabolic vitality -- and you won't need drugs, surgery or ice.


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.



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).


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).