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Massage Today
April, 2011, Vol. 11, Issue 04

Trends and Modalities: Are You Still Practicing Old School Techniques?

By James Waslaski

As an educator, it's critical to keep abreast of current research and to constantly challenge your belief systems. You may have read the popular article "Don't Get Married" (MT February 2008) written by a close friend and colleague Erik Dalton.1 In that piece, he cautioned manual therapists about getting too attached to trends and techniques for fear that new research findings may prove them totally wrong.

Regardless of whether you are an educator, practicing therapist or both, keeping up-to-date with the latest information is essential to our profession; and in some cases, it will also keep old school techniques in the past where they belong.

I have spent six years writing a textbook (available this year) called Clinical Massage Therapy: A Structural Approach to Pain Management (Pearson Publishing). During that time, I've edited the information in that text hundreds of times based on the reviews of other manual therapists and the fact that many of my earlier thoughts on bodywork techniques have been proven, by recent clinical studies, to be flawed. Let me share some of the things I have taught in the past that, in light of new research, now seem embarrassingly inaccurate.

Multidirectional Scar Tissue - Copyright – Stock Photo / Register Mark Fig. 1 Multidirectional Scar Tissue. Image by BodyScientific International Old School Rule #1

Deep cross-fiber friction aligns scar tissue.

About 18 years ago, I wrote and taught that in the presence of a muscle-tendon strain, the appropriate therapy was to apply deep cross-fiber friction in one direction only for up to 6 minutes and then apply ice. The person I studied with made the claim that the act of deep cross-fiber friction had the ability to re-align the disorganized scar tissue. However, if you look at the disorganized fibers, several mistakes are apparent in this thought process.

  1. Since the disorganized collagen is cross-linking in many directions, friction should also be multidirectional to soften the thickened collagen matrix of the scar. (Fig 1)
  2. The act of friction is not what re-aligns the scar; it is the pain-free movement, and eccentric mechanical forces that reorganizes the collagen matrix. (Fig 2)
  3. Six minutes of deep friction is now thought, by certain industry leaders, to possibly be excessive and may create a secondary inflammatory process.2 In fact, Dr. Cyriax only suggested 20-30 seconds to soften the collagen matrix.3 That series can be repeated several times to address deeper multidirectional collagen layers.

Aligned Scar Tissue - Copyright – Stock Photo / Register Mark Fig. 2 Aligned Scar Tissue. Image by BodyScientific International Old School Rule #2

Clients presenting with chronic tendon pain due to overuse of the elbow, shoulder, knee, or Achilles tendon have tendonitis.

In 2000, Khan et al found no signs of inflammation in tissue biopsies from patients diagnosed with overuse syndromes such as tendonitis of the elbow, shoulder, patellar ligament and Achilles tendon - no lymphocytes, neutrophils or macrophages at a cellular level. Additionally, they observed no swelling, redness or inflammation on the surface level.4

Muscle Resistance Test - Copyright – Stock Photo / Register Mark Fig. 3 Muscle Resistance Test. Image by BodyScientific International In the absence of an inflammatory process, the more appropriate term to describe a muscle tendon strain is tendinosis. Khan and associates concluded that a majority of tendon pain could be resolved simply by reducing the load on the tendon or by restoring normal muscle resting length to opposing muscle groups. Once muscle balance is restored and the tendon is unloaded, the therapist must reevaluate the area via muscle resistance tests to isolate the strain. (Fig 3)

To more effectively soften and reorganize the cross-linked collagen matrix, I believe therapists need to gently apply multidirectional frictioning to the damaged area. (Fig. 4) Then, to eliminate the pain and restore pain-free movement from most overuse tendon injuries, techniques then include eccentric muscle contraction are helpful. (Fig. 5) Unfortunately, too many manual therapists are still applying aggressive and prolonged deep cross fiber frictioning to muscle-tendon strains and possibly turning tendinosis into tendonitis.

Multidirectional Friction - Copyright – Stock Photo / Register Mark Fig. 4 Multidirectional Friction. Image by BodyScientific International Old School Rule #3

Should we perform deep tissue or trigger point work to weak, inhibited muscles?

This particular old school teaching really concerns me. To make my point, I'd like to relate this to manual therapists doing trigger point or deep tissue work to weak, neurologically inhibited (overstretched) muscle groups, prior to treating the short tight muscle groups. For simplicity, let's first look at the short, contracted muscle groups doing the pulling and then we'll address the stretch-weakened antagonist muscles. In the majority of the people on the planet, the pectoralis major, pectoralis minor, and subscapularis are short and tight, causing the rhomboids, middle trapezius, and posterior rotator cuff muscles to become neurologically weak and inhibited due to eccentric loading.

Eccentric Muscle Contraction - Copyright – Stock Photo / Register Mark Fig. 5 Eccentric Muscle Contraction. Image by BodyScientific International When you start a client face up and lengthen the short, tight anterior muscle groups, you aid in relaxing the weak inhibited posterior shoulder stabilizers. Once the therapist manages to restore normal muscle resting lengths to the tight agonist muscle groups, it reciprocally turns down the noxious afferent stimuli and relieves many of the myofascial and neuromuscular pain patterns. However, the jury is still out on the trigger point part of this, but I have always gotten better results treating short, tight contracted muscle groups prior to treating weak, inhibited antagonists. (Figs 6-8)

Pectoralis Major Work - Copyright – Stock Photo / Register Mark Fig. 6 Pectoralis Major Work. Image by BodyScientific International In most of the population, I believe it's difficult to resolve trigger points (myofascial tender points) in the weak, inhibited rhomboids by starting a client face down and doing trigger point work. Since much of our pain comes from living in forward head flexed postures with medially rotated shoulders, starting a client face up often makes more sense. This assures that the majority of short flexor muscles groups are lengthened prior to working on weak, inhibited extensor muscle groups. This commonly seen distorted neuromyofascial postural pattern is illustrated in greater detail when you view Tom Myers' Anatomy Trains and in the upper and lower cross syndrome taught by Erik Dalton.

Pectoralis Minor Work - Copyright – Stock Photo / Register Mark
Fig. 7 Pectoralis Minor Work. Image by BodyScientific International

Medical Vs. Clinical Massage

Subscapularis Work - Copyright – Stock Photo / Register Mark Fig. 8 Subscapularis Work. Image by BodyScientific International In my own career, I started in the field of sports massage, and went on to learn more advanced work from some of the greatest pioneers and structural body workers in our industry. Orthopedic or clinical massage is now a total system rather than a single modality. That total system of assessments, special orthopedic testing, clinical reasoning, multidisciplinary and multimodality treatments, along with precise client self-care protocols will facilitate myoskeletal alignment and eliminate pain and injuries. It will also optimize athletic performance, aligning us with all other manual therapists for the best interest of each client. Having said that, the question arises: Is this sports massage, clinical massage, medical massage or are we simply talking about massage with intent to bring the body back into balance, facilitate healing, and eliminate pain?

I'll be writing an in-depth article on the subject of medical massage in an upcoming issue, but, for now, let's loosely define this commonly used name. I believe "medical massage" should be considered an umbrella term to include most forms of specific restorative and enhancement manual therapy techniques, particularly those directed at resolving a client's/patient's particular pain complaints. I chose to use the term "clinical massage" in the title of my book in order to honor and respect the many other modalities that have an amazing effect in changing medical outcomes i.e., cranial and visceral manipulation, myofascial release, lymphatic drainage, posturology, myoskeletal alignment, anatomy trains, structural integration, oriental bodywork and the list goes on. Even a good relaxing massage to reduce the stress that leads to many diseases and illnesses plays a critical role under the umbrella of medical massage.

The fact is, positive things begin to accelerate exponentially when therapists learn to blend multiple touch-therapy assessment and treatment modalities with functional retraining to better address our client's/patient's pain and injury conditions. Much more information will be shared in future articles about the scope and practice of medical and clinical massage and the positive attributes gleaned by combining various modalities in an evidence-based clinical practice.

Author Note: The material presented at the World Fascia Congresses is a good example of how quickly information about the "stuff we touch" changes. www.fasciacongress.org/2012

References

  1. Dalton E. "Don't Get Married". Massage Today, February 2008;8:2.
  2. Cyriax J. Textbook of Orthopedic Medicine 7th edition. New York: Harper & Row, 1965, Vol 2.
  3. Khan K, Cook J, Taunton J, Bonar F. "Overuse Tendinosis, Not Tendinitis, Part 1". The Phys and Sports Med, May 2000;28:5.
  4. Cook J, Khan K, Maffulli N, Purdam C. "Overuse Tendinosis, Not Tendinitis. Part 2". The Phs and Sports Med, June 2000;28:6.

Additional Resources

  • Travell J, Simmons D. Myofascial Pain and Dysfunction: The Trigger Point Manual 2nd ed. Lippincott, Williams & Wilkens, 1999.
  • Lowe W. Orthopedic Assessment in Massage Therapy, 2006.
  • Dalton E. Advanced Myoskeletal Alignment Techniques, 2005.

Click here for more information about James Waslaski.

 

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