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Massage Today
October, 2013, Vol. 13, Issue 10

The Theory of Orthopedic Massage, Part 2

By Ben Benjamin, PhD

In my previous article published in the August 2013 issue, I introduced the topic of orthopedic massage and explained five core theoretical principles of this modality.

This article continues by discussing orthopedic massage assessment and treatment techniques.

Assessment

The assessment process involves taking a detailed history and then performing a series of physical assessment tests. Each question in the history and each assessment test is designed to give you specific information about the client's condition — such as the possible causes of their injury, the severity of the injury, the specific structure(s) that are injured, any other relevant medical conditions and so forth. The duration of the assessment will vary depending on the area of the body you're testing. For example, for the back, there are 26 tests plus a set of palpations, while for the shoulder there are 12 tests. To yield accurate information, each test must be performed with precision and skill.

Orthopedic assessment tests fall into three major categories:

  • A resisted test is an isometric activity that stresses a specific muscle-tendon unit. The client tries to move in a particular direction while you resist that motion with equal and opposite force, so that the person is working the muscle but there is no movement through space. In this way, you isolate the structure that you're testing. Pain felt on a resisted test tells you that some part of the muscle or tendon is injured. (If there is pronounced weakness in a test on one side of the body this may indicate injury to a nerve.)
  • A passive test is performed by the therapist with no assistance from the client. The client stays relaxed, like a rag doll, so they're not placing any stress on their muscles or tendons. Pain on this type of test generally indicates an injury to a ligament, joint or bursa.
  • An active test is performed solely by the client. It allows you to see what types of movements they can and can't make. These tests don't give you definitive information on the injury because the person is using their muscles, tendons, ligaments, joints and bursas all at once. However, they do give you an indication of sensitive areas you need to treat with particular care. For example, if the person can't lift their arm above their head at all, this suggests a serious injury to the glenohumeral joint, subacromial bursa or another structure in the shoulder.

orthopedic - Copyright – Stock Photo / Register Mark When an assessment test provides information about a particular type of injury, we refer to it as being an indicator for that injury. There are three different types of indicators:

  • A major indicator is the most important assessment test for a particular structure. Only if this test is positive (i.e., only if the test causes pain) is that injury present. As one example, resisted lateral rotation of the shoulder is a major indicator of an injury to the infraspinatus muscle-tendon unit. For some injuries, there are multiple major indicators.
  • An auxiliary indicator gives you additional reliable information about an injury you've already identified. For example, once you've identified an infraspinatus injury, pain on passive elevation tells you that the injury is likely located in the tendon at the tenoperiosteal junction, rather than in the muscle.
  • A minor indicator is a test that is positive only some of the time when a particular injury is present, so you cannot rely upon it to give you accurate information. In the case of an infraspinatus injury, passive medial rotation is a minor indicator because sometimes it's painful, but most of the time it's not.

Treatment

Following the assessment, the next challenge is determining the appropriate treatment for the client. The goal is to restore full functioning by eliminating any adhesive scar tissue or fascial restrictions, rebuilding strength and either restoring or increasing flexibility. In an orthopedic massage practice, you might use a combination of friction therapy, massage therapy, anatomy trains or some other form of myofascial work, muscle energy techniques, positional release, active release techniques, trigger point therapy, active isolated stretching and strengthening and various other modalities. The technique that I've found to be most effective at removing adhesive scar tissue in the majority of injuries is friction therapy, so I'll briefly describe that method here.

Friction Therapy

Cross-fiber friction therapy, also known as transverse friction massage, is a very precise form of medical massage developed by Dr. James Cyriax, commonly known as the “father of orthopedic medicine.” It is remarkably effective in treating most muscle, tendon and ligament injuries. Of course, if the injury site is inaccessible to the therapist's fingers, this treatment cannot be applied and another must be chosen.

As I explained in my previous article, when microscopic tears occur in muscles, tendons and ligaments, scar tissue develops to mend the damaged structures. It often forms in a jumbled matrix, so the resulting scar has much less integrity and uniformity of structure than the original tissue it replaces.

Cross-fiber friction massage works by breaking down scar tissue that is preventing proper healing. It also separates ligament-to-bone adhesions and promotes the formation of properly aligned and mobile tissue. In chronic tendon injuries where collagen tissues have degenerated, friction therapy promotes collagen formation. This type of treatment also increases the blood supply to areas that normally have very little circulation. It accomplishes this through a mild, controlled trauma to the injury site.

Of the three main components of orthopedic massage — theory, assessment and treatment — the cornerstone of this approach is the assessment. Unless you know exactly what is causing a client's pain, it's very difficult to relieve that pain. It's also difficult to know why what you do works or doesn't work. I find it very satisfying that after taking a detailed history and doing a physical assessment, I have a really good idea of whether or not what I do can help the person. In cases where my skills will not be helpful, I can provide an immediate referral to a more appropriate professional, without wasting the clients' time and money. In cases where I do offer treatment, I do so with the confidence that I can make a lasting difference.


Click here for more information about Ben Benjamin, PhD.

 

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