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Treatment Tools

By Debbie Roberts, LMT

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Movement: A Valuable Technique

Oftentimes we are tasked with returning a client back to full function after they have become immobilized. This can be done by using the mechanoreceptors of the joint, however you should also consider the value of movement as a technique, and how gaining the knowledge that a personal trainer has can benefit you and your clients.

As therapists and business owners we are always looking for new and different skills that we can add to our practice tool box. What if you were to think about personal training knowledge as a technique rather than a different profession? Studying how the human body moves should be your first goal in rehabilitation, as studying movement has the same end goal— to relieve the client of pain and get them on the road to recovery. Getting them out of pain can be the easier part of massage therapy because we almost always make someone feel better in the first moments of treatment. However, helping a client return to either their regular sports activity or just the activities of daily living is different than just getting them out of pain.

Treatment for Immobilization

For example, what happens after someone has been immobilized for a period of time? When fascia is immobilized or injured microfibers form in between the adjacent layers of connective tissue and bind them together so the insult can heal. The tissue becomes plastic-like and loses its elastic properties; plus the immobilized body part has now lost valuable proprioception of the joint. The definition of proprioception, according to McGraw-Hill Concise Dictionary of Modern Medicine 2002 by the McGraw-Hill Companies, Inc., is the subconscious sensation of body and limb movement position, obtained from non-visual sensory input recevied from muscle spindles and joint capsules. The main goal of any rehabilitation specialist is to have the client regain mobility of the joint; flexibility of the tissues; lost proprioception; strength and to return to function, as well as integration of the central nervous system function. Gaining more insight through the practice and study of movement is one tool or technique that begins to give you those "aha moments".

Movement: A Valuable Technique - Copyright – Stock Photo / Register Mark "Motion is Life," said Hippocrates, Greek physician, 460-377 B.C. This simple statement helps to emphasize the point that we as holistic healers must have a system of evaluating, treating and most importantly returning the client back to function. A system is defined as a set of interacting or interdependent component parts forming a complex/intricate whole. Understanding movement through the eyes of a rehabilitation specialist gives you a complete system that has checks and balances, so that what we treat will not adapt back to the dysfunction in the coming months.

As a teaching professional, I often get students who have been in the profession for many years and over that time have taken numerous technique classes, however they still lack the valuable knowledge of how a human being's central nervous system works, with regard to movement. The first massage therapy book I read, Structure and Function did not teach me more than how the pieces and parts worked individually. The book didn't teach how, or even the importance of understanding the integration of those parts working together. It was through my personal training courses that I began to understand how a body would need to function after I finished a massage therapy treatment. Fundamentally we start off in this profession learning what range of motion a joint should have, but not how to rehabilitate it once it has been immobilized. I know this might sound like a job for a physical therapist and not a massage therapist, but we end up with these clients because they have so many other issues caused by the immobilization.

Recent Cases & Examples

I have had four cases recently of the ankle and foot being immobilized in a boot. The first one had to leave the boot on extra time because her fracture was not healing properly, so naturally when the boot came off she had complete loss of function and could hardly move the ankle joint at all and she was starting to experience pain up the chain to her quad and hip. The second after physical therapy still lacked balance and sadly was now suffering with opposite hip and groin pain. The third person had foot surgery and had to have pins after a calcium clean-up, and the foot was left in a very awkward everted position within the boot. So hers was compounded by an overly tight transverse arch and the usual loss of ankle joint motions of inversion, eversion, plantar flexion, and dorsiflexion. In addition, because of the walker her shoulders were now killing her. The fourth person (due to toe surgery) now faced the same issues as the client in the previous example, plus loss of dorsiflexion of the big toe, which is necessary for push off in gait.

All four of the ladies were left with having some back issues, even one with a stress fracture in her hip, pelvis, and pubis. She had radiation therapy approximately 30 years ago and the diagnosis of osteopenia which her doctor felt left her vulnerable for this kind of stress on the pelvis. As you can see, each person had an ankle boot, but none of them could be treated the same.

If Hippocrates can make a statement that long ago, which still lives on today, what do you think he would ask of us as healers today? I feel like he would ask you to gather around under the tree of life and watch and observe how the people are moving around the tree. He might say, "Students observe the tree and how it stands against the wind, but if we cut it in half it will lose its strength as a whole". Now think with me, when a human being is treated as a part and not a whole how long will your treatment results last?

How do we get the human being to stand like a tree again? Unfortunately, there isn't an ABC recipe because the factors are never quite the same. You must consider the physical condition of the person before the injury; the degree of injury or surgery; length of time of the immobilization; amount of disruption there has been to their central nervous system and the degree of proprioception before the incident occurred. But there is a system of checks and balances that you can go through to find out if you are achieving the desired result, or not.

First

Clearance from a medical professional to be a part of the client's rehabilitation process.

Second

Regain elasticity to the tissue. Hands, heat, cupping, etc.

Third

Regain range of motion. Use isometrics with an appropriate percentage of contraction depending on the person's condition followed by the client moving into their new range. This is assuming that they have been cleared for full weight bearing. Put the client in a safe environment and have them close their eyes for 10 seconds, then open for 10 seconds, rotating this up to at least one minute.  This will take the righting reflex out of the equation and make them rely on their joint mechanoreceptors. This movement will progress to standing on a moderate unstable surface such as an airex blue foam pad performing the same round of 10 seconds. Progress this movement pattern from a bilateral stance to a unilateral stance.  Your progression will then go back to solid ground and stand with eyes open on one leg working up to 30 seconds to one minute. In some clients you will want to progress this to eyes closed.

Use your checks and balances system— did your previous treatment strategy hold, or change the individual in the right direction? If not, go back to the beginning and look for other ways, in addition to what you have already found to work. Progression of movement is always easy. It is having the understanding on how to digress from the progressions or look for alternatives that makes a good rehabilitation specialist.

Fourth

Now movement begins through the foot and ankle joint opposing gravity. Toe and ankle raises, walking lifting the knees higher, step up to balance, and there are so many more.

Again, I cannot emphasis enough that the client is not being helped if they are coming back repeatedly with the same chief complaint. Keep in mind that initial relief from pain does not resolve the issue as a whole. Understanding movement can certainly make you a better rehabilitation massage therapist, it can also make you an excellent referral source to someone who has studied this line of thinking and can help the client regain their health and vitality for good. Immobilization is a long road for the client. You can follow the steps outlined above and start to think of movement without compensation as the goal. We are not machines to be broken down into moveable parts, our brain recognizes sequences of movement.

In the book, Blink, Gladwell defines expertise as advanced pattern recognition, and explains that expertise and experience are not the same. Experience may only demonstrate high levels of technical skill, whereas expertise is defined by advanced problem-solving and innovation. 

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