resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
SOAP Notes: It's Time for a Cleaning
I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.
Are They Finally Fixing Medicare Reimbursement?
Even with federal sequestration cuts taking effect in March, including a 2 percent reduction in Medicare reimbursement to health care providers, hope may be on the horizon in the form of a much-anticipated, perpetually suggested overhaul of Medicare's Sustainable Growth Rate formula, which serves as the basis for determining physician reimbursement.
What They Don't Say Could Hurt You
I have written previously regarding the difficulties of drawing information from patients who are poor historians, forgetful or just plain uncooperative. The thought to revisit the topic occurred recently during preparation for an upcoming seminar.
Peer Points: Stories of Practice Success
When patients go see Arizona-based acupuncturist Jing Liu, it is to get top care from an practitioner well versed in all aspects of Traditional Chinese Medicine.
Helping Patients Through Pregnancy Loss
There is a lot of focus in the acupuncture world on fertility and helping women get pregnant. It's exhilarating to hear the news that a patient is expecting a baby. The other side of that is pregnancy loss. That includes abortion, miscarriage or stillbirth.
We Get Letters & E-Mail
Patient Perception and the Farce of "Fast Relief"; A Fly in the Ointment; Persecuted for Choosing to Practice Chiropractic.
Chiropractic: The Right Choice for Relieving LBP
"Low back pain (LBP) is a common threat to medicine and a reasonable threat to all national health care systems. ... Reducing ineffective treatments is necessary to decrease the LBP associated costs."
The Spirits of the Points: The Gall Bladder Official
The Gall Bladder is known as The Official of Decision Making and Judgment. In any given day, this Official makes countless decisions – conscious and unconscious, which influence every aspect of our being.
Side Effects From Big Pharma: Wellbutrin – Dangerous for You and Your Baby
Are some of your pregnant patients taking Wellbutrin? If so, it could be a danger to them and their baby. This drug is extremely popular, but it has a serious history.
Have a Heart: Say No to Soda
It's not enough that soft drinks and other sugar-sweetened beverages have been linked to cavities and weight gain, among other negative health consequences.
What the Science Says About Magnesium Stearate
It's often been said that scientific studies can be used to support just about anything. But discoveries are never made one study at a time.
Energy is a hot commodity. Society pays dearly for it and for the expertise of those who know how to cultivate it.
News in Brief
Controversial Florida PIP Law Under Review; D'Youville Chiro. Students Learning Art of Co-Managing; And the Award Goes To...; F4CP Recognizes Major Contribution by ChiroTouch.
Economics of Complementary/Integrative Care
Although this column doesn't usually feature a book review, we're going outside of our usual public health format to discuss a new book written by Patricia Herman ND, PhD.
Medicine Presents: A Great Opportunity
The changing nature of health care presents both opportunities and challenges. While we tend to focus on our profession, we can sometimes forget the impact other health care professions can have on us.
Let's face it – patient evaluation takes time. Unless you are really into the diagnostic evaluation game, you probably have found the formal exam protocol tedious if not downright annoying.
A Building Block of Healthy Aging
Coenzyme Q10 has gained enormous attention in recent years, and with good reason —it's the Energizer Bunny of the cellular world.
Herbal Medicine: Go Mainstream
When it comes to practicing herbal medicine in a mainstream setting, there are a number of important points to understand when it comes to prescribing formulas. Some important questions to ask are - what method of prescribing and dispensing is most effective in this setting?
Happenings in Our Evolving Profession
Good things seem to be happening for our profession and recent developments show we are all on board. Talking about being on board, this September The Veterans Express-Purple Heart Tour is expected to make its way out of the station.
The Potter's Wheel: Reflections on Practicing in a Technology-Driven World
In my very early years of practice, an older patient named Cora would call me at home, usually late Sunday night after she had consumed an unknown quantity of beer.
Helping Infertility Patients with the Spirit Essence
As many of you know, when it comes to treating infertility, we are dealing with a patient population that is, generally speaking, in emotional turmoil. These patients often experience fear, anxiety, despair, hopelessness, grief and anger.
Going Shoeless: The Pros & Cons of Barefoot Running
With the subculture of barefoot runners and the products catering to them growing daily, just about every chiropractor has been asked at one point or another about their opinion regarding barefoot running.
Why You Should Get to Know the National Vaccine Information Center
Barbara Loe Fisher has been a diligent advocate for providing parents with the information necessary to make informed decisions regarding the usage of vaccinations for their children.
Research Abstracts From the Journal of Manipulative & Physiological Therapeutics
Effect of Pain Relief on Lumbar Muscle Function and Activation; Effects of Thrust Amplitude and Duration of HVLA Spinal Manipulation; Immediate Effects of Upper Thoracic Manipulation on Cardiovascular Response.
There Are No Secrets: Treating Complicated Conditions with TCM
Including standardized extra points, there are just over 400 acupuncture points on the body. You get 400 and I get 400 - same. Yet, time and time again treatment protocols are coveted as if they were some secret formula only intended for the right and privileged.
You are What You Eat Part II: Integrative Protocols
In the previous installment of this article I discussed important ideas concerning gastrointestinal health and foundational ideas from TCM, which can provide key insights into creating effective protocols for healing the gut.
Correcting Kid Logic in Health Care and Research Design
A recent broadcast on public radio described a fascinating phenomenon known as kid logic.
Remembering Joe Weider (1920-2013)
With the death of Joe Weider, the world's most famous body-building visionary, crusader, fitness magazine publisher and icon, on March 23, 2013, chiropractic has lost one of its greatest friends and supporters.
March, 2012, Vol. 12, Issue 03
Massage Therapy and Joint Mobilization
By Joseph E. Muscolino, DC
Massage therapy involves a number of treatment tools that can be employed for a variety of purposes. Massage can be done to decrease stress, improve local fluid circulation, create energetic balancing or simply provide touch.Perhaps the greatest advance for massage therapy, though, has been the acceptance of clinical orthopedic massage in the world of complementary/integrative health.
Clinical orthopedic massage is done with the intent toward healing a specific musculoskeletal condition. Toward this end, massage therapy education includes science education, the major focus of which is learning muscles. Indeed, massage therapists often know their muscles better than many physicians. In the absence of true muscle doctors in Western medicine, massage therapists have filled this void and become muscle therapists; and usually excellent ones at that.
Muscles and Fascia
If you ask most orthopedic massage therapists what their intent and goal is when working on a client, they will usually describe a muscle or group of muscles that they want to manipulate and loosen. Certainly, tight musculature is likely one of the most common, if not the most common, presenting complaint of clients. However, with the increased awareness of fascial tissues (both the understanding of fascial adhesions and the concept of fascial contraction, as well as the understanding of the fascial links between muscles of a myofascial meridian), some of the focus of massage therapy is being shifted away from the muscles themselves toward fascia. Although the pendulum should not swing too far away from musculature, it is important that a greater understanding and focus on fascia occurs so that we can have a more balanced approach to treating all soft tissues. By encompassing the fascial tissues into the treatment paradigm, massage therapists can broaden their domain to define themselves not only as muscle therapists but rather as myofascial therapists.
Defining the scope of massage therapy in this way is crucially important. It is not just inflexible muscles that can decrease mobility, limit a client's function, and cause discomfort and pain. All inflexible taut soft tissues can do this, whether they are muscles, tendons, broad fascial planes between and around musculature, ligaments or even joint capsules. In this context, the role of massage therapy can be understood to manipulate all soft tissues.
Joint Capsules and Joint Manipulation
Massage therapists can and should pay attention to the flexibility/tautness of all soft tissues, including joint capsules and other deeply seated intrinsic ligaments. These deeper fascial structures connect and provide stability to the bones of a joint. However, if joint capsules become taut, often due to the accumulation of fascial adhesions over time, the joint will lose its mobility. The province of loosening joint capsules is usually left to chiropractic and osteopathic joint manipulation. With the use of high velocity, short lever arm manipulation (a fast thrust that is implemented over a short range of motion), called an adjustment, chiropractors and osteopaths stretch joint capsules, thereby increasing the joint's range of motion, and therefore the client's mobility.
Muscles and Joints - Chicken and Egg
Given that a major goal of clinical orthopedic work is to increase the client's mobility, it is important that both tight musculature and taut joint capsules are treated. Indeed, tight muscles and taut joint capsules can be looked at as the proverbial chicken and egg. If tight muscles are loosened with massage, the remaining taut joint capsules will still decrease joint motion; and this decreased motion will eventually cause the muscles to tighten again. If, on the other hand, the client has a chiropractic adjustment to loosen the joint capsule, but the muscles are not loosened, these tight muscles will decrease the joint's range of motion, ultimately leading to the joint capsule becoming taut again. For this reason, it is critically important that muscles and joints are both addressed. This is why chiropractors and massage therapists so often work together. Marrying joint adjustments with massage soft tissue manipulation ideally complement each other, addressing both the chicken and the egg.
Chiropractic and Massage
When chiropractors and massage therapists practice together, the order in which their work is performed can matter. Many chiropractors choose to have the massage therapist work on the patient/client after the adjustment is done. However, this decision is often motivated more by ease of schedule and patient flow than by optimal treatment protocol. Given that an adjustment takes only a couple of minutes, but massage is performed for anywhere from 15 minutes to an hour, it is often easier for the chiropractor to adjust all of his/her patients and then leave them for the massage therapists to work on.
However, for most clients, it is more beneficial to have the massage done first. An adjustment can be performed more gently when the client's musculature and other fascial tissues have already been loosened. This is important because, if an adjustment is performed too forcefully, not only might it be uncomfortable for the patient, but also there is an increased chance that it will trigger a muscle spindle (stretch) reflex that could then result in increased muscle spasming. The more gentle the adjustment, the less likely spasming will occur and the more comfortable it will be. Further, if the muscles and other fascial tissues are loosened first, the joint will release more fully, resulting in a more successful adjustment. For this reason, it is usually preferable to have the adjustment follow the massage, not precede it. When partnering with a chiropractor, it is valuable to discuss these ideas and determine how to best work for the benefit of your patients/clients.
Massage Therapy Joint Mobilization
Massage therapists who do not partner with a chiropractor can still do valuable work to address taut joint capsules through joint mobilization. Joint mobilization is performed by bringing a joint slowly through a small and precise range of motion. Joint mobilization is similar to chiropractic manipulation in that it is performed through a short range of motion and focuses on loosening deeper intrinsic ligaments and joint capsules. However, the crucial difference between a chiropractic joint manipulation/adjustment and joint mobilization is that joint mobilization is performed slowly and never involves a fast thrust.
Joint Mobilization of the Neck
In Figure 1, we see that the therapist uses one hand to contact the lower vertebra (C6). Three contact options are shown: the thumb, finger pads, and the radial side of the index finger. In each case, the contact is made on the facet (articular process) of the vertebra, approximately halfway between the spinous process and the transverse process (Figure 2). The facets form a broad smooth surface that is a comfortable contact for the client (contacting the transverse processes would be extremely uncomfortable for the client). The therapist's other hand must hold and move the client's head. As a rule, this hand is placed on the other side of the head from the hand that is contacting the vertebra. It must be placed under the center of weight of the client's head so that the head is easily balanced in the hand. Care must be taken not to cup over the client's ear or press on their mandible. Now, securely pinning the vertebra below (C6), bring the client's head and upper cervical spine (C1-C5) around the pinned vertebra until the end of passive range of motion is reached and tension is felt at the C5-6 joint (Figure 3).
Now the actual joint mobilization can be performed in one of three ways:
The position of joint mobilization is held for less than one second and then released. This procedure is usually repeated a few times at that level and then performed at the other joint levels of the neck. After mobilizing into right lateral flexion, left lateral flexion is done, as well as other ranges of motion bilaterally. The result is that the entire neck is mobilized in all ranges of motion.
Effective and thorough clinical orthopedic work requires increasing flexibility of not only muscles and superficial/intermediate fascial tissues, but also the deeper intrinsic ligaments and capsules of joints. Massage strokes are ideal for remedying tightness in the superficial and intermediate tissues. Supplementing this, stretching can be invaluable in increasing flexibility of most soft tissues. However, to truly address tautness/adhesions in the deepest fascial structures of the joints, intrinsic ligaments and joint capsules, joints manipulation is necessary. Although joint mobilization technique can take time and practice to learn well, the benefit to your clients and to your practice makes the effort well worthwhile.
Joseph E. Muscolino, DC, has been a massage therapy educator for 24 years, teaching both core curriculum and continuing education classes. He currently teaches anatomy and physiology at Purchase College, SUNY. He is the owner of The Art and Science of Kinesiology in Stamford, Conn., and is the author of The Muscle and Bone Palpation Manual, with Trigger Points, Referral Zones, and Stretching; The Muscular System Manual, 3rd edition; and Kinesiology, The Skeletal System and Muscle Function, 2nd edition (Elsevier, 2009, 2010, 2010), as well as other publications. For more information or to contact Joseph, visit www.learnmuscles.com.
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