Integrative Fascial Release » Research and Industry News

IFR Now Recognized in South Africa with Physiotherapists

stevegold — Sat, 29 Jan 2011 04:36:31 +0000

Club Physio.Net has now been able to register IFR Foundations & Intermediate course with the South African Society of Physiotherapists.

What this means is that physiotherapists in South Africa who attend IFR courses sponsored by Club Physio.Net, will receive their continuing professional development points for each day of attendance.

This is a very exciting development for IFR, as it is the beginning of opening up and establishing much more exposure for IFR and that concepts, practices and techniques not usually taught within the realm of physiotherapy are now being offered.

Contra Indications Article

stevegold — Mon, 29 Nov 2010 20:34:52 +0000

Ruminations on Contra Indications

The Manual Therapists Dilemma-Do We Cause Harm?

Introduction:

As I researched for this article I found without surprise, larger issues were at play. Once on the side of regulation for our industry, now I have concern as to the efficacy of this road. What began as a simple article on contraindications turns out to be a journey in understanding the nature of our work and the decisions we are face every day regarding our practice. Steven Goldstein BSHSc MST MusculoSkeletal Therapy, ACNM Australian College of Natural Medicine, Chair National Education Subcommittee, AAMT Australian Association Massage Therapists.

One of the most basic considerations for manual therapist is to understand how and when to proceed with caution or not to treat at all. Our ‘duty of care’ requires that we recognize when a condition or situation presents itself that would make it unsafe for the client to receive our touch. Furthermore our care requires us to ‘do no harm’. And if indeed we proceed with a treatment and did not heed or understand the indications contrary to massage, we open ourselves up to malpractice and personal liability.

Contraindications provide a basic framework for understanding when, and under what circumstances, a particular therapeutic intervention is appropriate for treating the patient/client with minimal risk of injury. Therefore, contraindications serve as a guideline to help us determine if we should institute certain precautions in treatment, withhold treatment altogether, or recommend alternative treatments that would be more appropriate (Batavia 2003).(1)

Therapists understand that by modifying their depth of pressure, selecting techniques that are appropriate to the tissue type and the situation create efficacy in our treatment. We know a thorough case history is necessary, and to implement a treatment plan we must consider the clients medical history to ascertain if treatment is appropriate. Fundamentally we are always asking when can we and when can we not provide treatment. With serious medical conditions, we realize that we are obligated to modify our treatment by the site or area we touch, the position we need to place the client in to achieve desired results or the time frame we can work as in the stages of inflammatory response. And of course we have to know when not to treat a serious medical condition.

Traditionally contraindications have been categorized as total, local or site specific and/or medical. We were taught to pay attention to systemic or skin conditions that exhibited infectious or contagious symptoms, local traumas and injuries that showed the effects of partial tear, avulsions, lesions, fractures, breaks or punctures of soft-tissue structures, to name a few. Most traumas we understand are commonsense wise, and depending on the conventional wisdom of the time, many conditions are considered totally contraindicated.

I, for example, taught in 1986 could never treat acute injuries, or that cancer and pregnancy, erring on the side of safety, were totally contraindicated. By today standards this is not the case.

Problems with the Laundry List Approach:

One thing that can be stated with some certainty regarding contraindications is: ‘a blanket approach with absolutes will work but then we probably wouldn’t treat any of the relative contraindicated conditions’. An excellent resource for understanding how sources differ regarding contraindications is M. Batavia’s article (2003) Contraindications for therapeutic massage: do sources agree?, published in the Journal of Bodywork and Movement Therapies, 8(1), 48-57,

Batavia goes on to say: “Contraindications cited in these sources were classified as relative contraindications, absolute contraindications, precautions, or contraindications and precautions. A relative contraindication is a situation where massage should not be done in certain circumstances, but could be done in other circumstances. It also refers to what type of massage is being performed. For example, one type of massage might be contraindicated for a particular condition, but another type of massage might not be. An absolute contraindication is one where massage should not be done under any circumstances. A precaution is a situation where massage can be performed, but with particular precautions related to the pathology.”(2)

What is interesting about this article is Batavia found when purveying all the various physical therapy, manual therapy and massage texts he found a majority of the sources failed to cite specific references to support the position of the described contraindications and another 76% failed to offer alternative treatment strategies for those conditions that were considered precautions or contraindications. And half the sources he consulted failed to identify that more than 90% of the conditions have a precaution or contraindication associated with them. (3)

So how are we to reconcile this immense discrepancy and how do we as massage educators help students and practitioners navigate this difficult terrain?

Batavia goes on to say:, “While contraindications are a valuable guideline, to often they are misused and misunderstood in our educational programs. Many, if not most, massage therapy training programs are lacking in subject matter directly related to evaluating pain and injury conditions. In that situation contraindications are commonly used as a basic “laundry list” of situations or conditions to avoid when using massage.

The detriment to this approach is that frequently it is not spelled out there is a difference between relative and absolute contraindications. Without that distinction most of these conditions get lumped into absolute contraindications in an effort to err on the side of safety and precaution. While this does help the practitioner keep from providing treatment in a situation where it is not appropriate, it also dramatically limits the effectiveness of clinical work.”(4)

Batavia cites an example that an absolute contraindication is treatment for an inflamed area, when in actually it is a relative contraindication. He believes more clinical research is needed to validate contraindications listed in various sources, and we need to educate the educators, “we need better educational preparation of the faculty and instructors that are teaching from these materials as well. To some degree an absence of listed contraindications can be balanced by adequate knowledge of anatomy and physiology coupled with developed clinical reasoning skills.”(5)

So what are considered Absolute Contra indications?

Absolute contraindications clearly are those when the application of technique compromises the safety of the client or the practitioner.

Fiona Rattray (2000) in Clinical Massage Therapy states: ‘….contraindications may be absolute; in other words, massage is an inappropriate method of treating a particular condition that affects the whole body or a part of the body.”(6)

Massage literature has an extensive laundry list of Absolutes, the problem as Batavia has stated is that some of the Absolutes can be relative. Some are myths, such as massage therapy will systemically metastasize all cancer, other make good sense, such as inappropriate deep friction applied to healing fractures or compromised soft-tissue.

Can Massage Spread Cancer?

No, it cannot. Massage of a solid tumor site should be avoided, but there is more to a person than a tumor site. An old myth warned that massage could, by raising general circulation, promote metastasis since tumor cells travel through blood and lymph channels. We now recognize that movement and exercise raise circulation much more than a brief massage can, and that routine increases in circulation occur many times daily in response to metabolic demands of our tissues. In fact, physical activity usually is encouraged in people with cancer; there is no reason to discourage massage or some form of skilled touch. Massage is practiced widely at the Dana-Farber Cancer Institute, Memorial Sloan-Kettering, and growing numbers of hospitals around the country. Metastasis is not a concern; instead, patients and researchers report countless benefits.
- Tracey Walton, Nationally Certified Massage Educator from Florida, USA (7)

Rattray looks at absolutes for general conditions and absolutes for local conditions.

Absolute Contraindications for General Conditions (8)
Acute conditions requiring first aid or medical attention, such as:
Anaphylaxis shock
Appendicitis
Cerebrovascular accident CVA Stroke
Diabetic coma or insulin shock
Myocardial infarction
Pneumothorax

Severe asthmatic attack
Acute seizure
Syncope (fainting)
Acute pneumonia
Advanced kidney, liver or advance respiratory failure
Diabetes with complications such as gangrene
Pregnancy with pre-eclampsia or eclampsia toxaemia
Hemophilia
Hemorrhage
Post CVA or heart attack where condition has not stabilized
Severe artherosclerosis
Severe undiagnosed headaches in those over 50 years of age
Severe unstable hypertension
Shock ( although there is controversy here)
Significant fever (38.5° C or 101.5° F)
Systemic, contagious or infectious condition
Clearly we would have little controversy with Rattray’s list. Or this is from the CATCM – Canadian Association of Therapists in Complementary Medicine regarding Absolute Contraindications.(9)

Haemophilia:
Haemophiliacs people, possess not or few blood platelet which allow the coagulation of the blood during wound. Since massage can, occasionally, cause of micro muscular wounds (during kneadings for example) it is counter-indicated to make a massage. Even the lymphatic drainage which is however a light massage, which favors the movement of the lymph, can provoke haemorrhages.

Phlebitis:
The phlebitis is an inflammation of a vein (usually at the level of the legs). Massage can dislodge a bloody clot lodged in the affected vein, which could then lodge itself elsewhere in the organism (lung, brains). In the event of phlebitis, no massage, even of the non affected zones must be made. If the therapist suspects a phlebitis, he should redirect its client to the hospital immediately.

Fever:
Fever indicates that organism fights an infection. It is important to let the body do his work. Massage can provoke an increase of the body temperature, what should not be advised because body temperature is already too high. Moreover, massage could favor the movement of the infection in another zone of the body.

Little objection would be made with these lists, and when looking at the listed conditions, I would probably not treat most of them. I also do not contest the rationale that working on a client with a fever can cause harm, but where is the evidence to that effect? When is it appropriate to treat a person with a low grade fever? Or is it?

Absolute Contraindications to Local Conditions (10)

Let us proceed to look at Rattray list of absolute for local conditions. Again, with most, no objections to her advisory, but there are grey areas. What about very gentle touch modalities such as Reiki, Therapeutic Touch or the technique I utilise, Two Pointing?

Massage therapy is not appropriate locally for the following conditions:

Acute flare-up of inflammatory arthritidis, such as rheumatoid arthritis, systemic lupus erythematosus or ankylosing spondylitis.
Acute neuritis, acute trigeminal neuralgia.
Aneurisms deemed life-threatening- abdominal aorta depending upon location.
Deep vein thrombosis, thrombophlebitis or arteritis.
Ectopic pregnancy
Esophageal varicosities
Frostbite
Local contagious condition
Local irritable skin condition
Malignancy if judged unstable
Open wounds, sores or decubitis ulcers
Pain syndromes such as causalgia or reflex sympathetic dystrophy.
Radiation therapy
Recent burn
Sepsis
Undiagnosed lump
Varicosities (up to 24 post-treatment with saline injection)

Let us select reflex sympathetic dystrophy for an example

Ruth Werner in A Massage Therapist Guide to Pathology, comments on reflex sympathetic dystrophy: (p242)

“Most RSDS patients have little or no tolerance for touch of any kind, at least where the pain syndrome began. Physical therapy is often recommended to keep affected joints moveable and functioning; massage may help to relieve some of the pain associated with this therapy. Massage within tolerance in other parts of the body may be welcome and supportive.”(11)

So are we to look at Fiona Rattray list and conclude we have an absolute contraindication for RSDS or we look to Ruth Werner’s version. This is the grey area massage therapists find when needing to determine a course of treatment for an individual with as serious a condition as RSDS. Physical therapy is recommended, but massage therapy is not? Remedial therapists in Australia are often trained extensively in Range of Motion assessment, testing and application, does this then imply that massage application is out, but those that practice massage and have skill in ROM can apply physical therapy principles? Relative or Absolute?

Contraindications: Debatable Arguments: “Massage Therapists Do Not Harm People”

Albert Schatz (2 February 1920 – 17 January 2005)

Toward the end of his life this dedicated scientist published a website dedicated to healing and the law pertaining to massage therapy. He had until his death in 2005, practiced his version of massage for over 20 years. As a 23-year-old graduate student in 1943, Dr. Schatz discovered the antibiotic Streptomycin which was the first effective means of treating tuberculosis. This disease, also known as consumption and The Great White Plague, has killed more than a billion people during the last two centuries.

Dr. Schatz initiated the research which led to the discovery of Nystatin, an antibiotic which controls fungus and yeast infections. He has also done research with other infectious diseases, cancer, multiple sclerosis, atherosclerosis, the proteolysis-chelation theory of dental caries, fluoridation, the role of chelation in the formation and fertility of soils, and the use of garbage and soil to teach science, spiritual healing, and subtle energy.(12)

Schatz in his guest editorial article in Massage Magazine March/April 1998, spoke of why would massage therapists be regulated as an industry when there has been no evidence that massage causes harm.

Massage Law Newsletter, Vol. 5 No.1 1998

Schatz states, “The term contraindications refers to conditions which predispose people to harm by massage. Contraindications in and of themselves do not invariably cause harm. They are conditions for which massage may be potentially harmful.

This means that people with contraindications may or may not be harmed by massage. Moreover, if only one individual with a contra-indication is harmed by massage, that in and of itself does not necessarily mean that the contraindication was directly responsible for the harm. To establish a direct cause-effect relationship requires a significant number of cases of harm.(13)

Schatz in 1998, was in a spirited debate with Elizabeth Leach, Executive Director Ontario Massage Therapists Association, Toronto, Canada.

The core of Leach’s argument was this; “That massage therapy performed by massage therapists is quite safe. Massage therapy performed by unregulated individuals is not.’ (14) Massage Magazine September/October 1998, (75):8

Schatz response to Leach was, “Your Letter did not address the main point of my Guest Editorial because you did not present any well-documented evidence that massage therapists – unregulated or regulated – have actually harmed people. Instead, you focused on potential harm.

My more detailed report (in the Massage Law Newsletter. 5(2):1-12, 1998) expands my Guest Editorial. This report includes some of my research on harm over a period of several years. The title of the report is: Research shows that massage does not cause harm. Where adequate research was done, no harm was found and no state regulation was enacted. There”””””””””””””””””””””””””””””””’’s no need for state regulation to protect the public from harm, or for any other reason.(15)

Are we overly concerned about contraindications? What has evidenced based research shown to substantiate the ‘laundry lists’? Is it more that we desire the government and public perception that we are a legitimate health care provider, and that we conform to standards and practices that are in line with our ethical principles? Clearly we should have concern about contraindications, just as we have with sites of caution. However all conditions need to some degree be researched by the practitioner. The amount of training, your time in practice, the experience you have working with specific conditions all need to be considered when regarding whether or not to treat a condition listed as contra-indicated.

Relative Contraindications: Modifications to Treatment?

With many systemic conditions such as asthma or multiple sclerosis, we may not massage during the acute or flare-up stage but can apply treatment between flares or stages.

Batavia terms ‘relative contraindications’ as those that Rattray would view as the situation where you modify your treatment plan. Rattray calls these ‘treatment modifications.’ (16) p147

Modifications to treatment are necessary, whether a client has a condition that is contraindicated or not, the manual therapist is always adjusting and modifying treatment based on the previous results and feedback from the client. Assessment and palpatory literacy also determine with case history, the appropriateness of treatment.

Would you not assess if you found systemic contra-indications? Is assessment also contra-indicated? Again it would depend on what the assessment entailed. Orthopaedic physical assessment may or may not be appropriate. With pregnancy we modify for fundamental reasons, hormonal changes that release relaxin to relax pelvic ligaments, positional changes to accommodate supine hypotension and fetus growth.

With cardiovascular concerns such as thrombus or emboli, we might dislodge a clot and/or facilitate a life threatening situation. Other modifications might be with hydrotherapy, where the application of heat to an already inflamed area will painfully congest the site further.

With Fibromyalgia, deep work is generally contraindicated due to pain amplification and sensitivity, yet deeper work can be applied as the pain sensitization changes.

Batavia makes a cogent statement: “Guidelines around contraindications should be consistent in the literature that supports a profession. Variation in these guidelines can lead to inconsistent treatment and a great deal of confusion in both academic and clinical settings. In addition it is important that there be adequate evidence to support the use of various contraindications as well. This is one area where the massage therapy profession is at a disadvantage because despite an increasing number of textbooks devoted to massage, there is still a lack of supporting evidence used for making many of these decisions about contraindications.”

As I consulted many of the standard texts in massage education, most were using a ‘laundry list’ format. The challenge as you review contraindications is to place the contraindication in context with the health history obtained from the client, decide on the severity of the condition and differential diagnosis, decide which modifications to treatment through the varying of technique, position, duration, depth, speed, autonomic nervous system response.

We are taught when in doubt, do not treat, this maxim is still appropriate. On the other hand, clear decision-making will aid you in stepping outside of fear to help make an informed decision regarding the treatment and welfare of your client.

References

1. Batavia, M. (2003). Contraindications for therapeutic massage: do sources agree? Journal of Bodywork and Movement Therapies, 8(1), 48-57.1
2. ibid Batavia
3. ibid Batavia
4. ibid Batavia
5. ibid Batavia
6. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
7. Cancer & Massage FAQ’s http://www.tracywalton.com/index.html
8. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
9. Jocelyn Vincent ACDMD, CATCM – Canadian Association of Therapists in Complementary Medicine, http://www.asscdm.com/index.htm
10. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
11. Ruth Werner, 2005 3rd Ed., A Massage Therapist Guide to Pathology, comments on reflex sympathetic dystrophy: (242)
12. http://en.wikipedia.org/wiki/Albert_Schatz
13. Albert Schatz, Guest Editorial, Massage Magazine March/April 1998, (72):7
14. Leach, E. Letters to the Editor, Massage Magazine September/October 1998, (75):8
15. Albert Schatz, An Open Letter to Elizabeth Leach, Massage Law Newsletter, Vol. 5 No.1 1998 http://www.healingandlaw.com/Massage_Law_Newsletter/massage_law_newsletter.html
16. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148

2011 IFR Workshops

IFR International Workshop Series

WSEIT College of Education and Therapy Physiotherapy University

IFR Foundations Workshop-

Poznan, Poland

March 11-13th, 2011

Venue: College of Education & Therapy Poznan,Poland

Contact: Agata Nieboj

phone +4861-8327776 ext. 128
mobile 663 190 420
e-mail: international@wseit.edu.pl

Grabowa St. 22, 61-473 Poznań Poland

www.wseit.edu.pl

Bodywork Professional Development of the UK Presents

IFR Foundations Workshop-

London, England

March 19-21st, 2011 Saturday to Monday

Venue: London, England: British College of Osteopathic Medicine

Contact Nicola Brooks T +44 (0)7526 925734

http://www.bodyworkcpd.co.uk/

info@bodyworkcpd.co.uk

http://www.bodyworkcpd.co.uk/workshops/ifrfoundations.htm

Bodywork Professional Development of the UK Presents

IFR Fibromyalgia Workshop-

Edinburgh, Scotland

March 26-27th, 2011

Venue: Scottish Massage Organization Conference Location TBA

Contact Nicola Brooks T +44 (0)7526 925734

http://www.bodyworkcpd.co.uk/

info@bodyworkcpd.co.uk

http://www.bodyworkcpd.co.uk/workshops/fibromyalgia.htm

Bodywork Professional Development of the UK Presents

IFR Intermediate Workshop-

London, England

April 2nd-4th, 2011 Saturday to Monday

Venue: London, England: British College of Osteopathic Medicine

Contact Nicola Brooks T +44 (0)7526 925734

http://www.bodyworkcpd.co.uk/

info@bodyworkcpd.co.uk

http://www.bodyworkcpd.co.uk/workshops/ifrintermediate.htm

ACPEM 2011 National Conference Presentation

Association of Chartered Physiotherpists Practicing Energy Medicine

IFR Introductory Workshop-

Radstock UK

Friday April 8th,2011

Venue: Ammerdown Conference Center- Radstock-Bath UK

Contact: Jo Smith-Oliver T +44 020 8985 0472

info@josmitholiver.com

IFR National Workshop Series

IFR Level One-

Sydney, NSW

September 24-25th, 2011

Venue: TBA

Cost $495

To register contact Steven Goldstein
Phone: 0402 068 658 Email: myofascia@optusnet.com.au

NEW! Fascial Articulation Workshop NEW!

stevegold — Fri, 07 May 2010 23:14:20 +0000

Fascial Articulations Concepts & Information

Fascial Articulations will be presented as a AAMT sponsored workshop for AAMT Sydney-Post National Conference Workshop Monday May 24th, Cairns- Sunday July 25th, Adelaide- Sunday August 8th & Hobart Sunday September 12th, 2010

A window of alternatives to the prevailing approach

This workshop has come about due to my attempt to present how I currently treat clients in my clinical practice. As any practitioner can attest, the development of their skill and skill set evolves over time. This process of learning takes the therapist along many avenues in their attempt to refine how to assess and deliver a consistent and quality outcome of manual therapy care.

The approach and style, the orientation of their understanding, and their passion for particular modalities, all create and embody the uniqueness and manner through which the artistic expression of the therapist shines forth. My manner and expression has changed over time, and now the hybrid of my understanding allows me to enjoy and find playfulness in pursuit of passion and intuitiveness for soft-tissue dysfunction through the delivery of a variety of applications.

These applications consist of direct and indirect myofascial release, with an emphasis on autonomic expression that manipulates the sensory receptors of soft-tissue. I also learned from my studies and practice, that targeting muscles alone as the source of soft-tissue dysfunction will yield less than satisfactory results. This led me on a journey of investigating the nature of myofascial and from that, I now recognize clinically, as researchers have scientifically, that the myofascia is a dynamic partner in the tonality of the musculature.

What’s more interesting to my clinical experience is that the other main soft-tissue constituents; tendon, ligament and joint capsule, are all main contributors to the dynamic interplay of fibrosis, adhesion, congestion and excess tonality surrounding the musculature.

I tend to treat from a differing perspective. Whereas, most therapists assess and treat muscles at the beginning of a treatment, I employ most of my muscle applications towards the end of a treatment. I’ll begin with assessment of the cardinal lines of myofascial tension (Myers 2000) and the high leverage points that anchor myofascial within the myofascial net (Schleip 2003).

The three main lines that correspond to main muscular and habitual patterns of motion that we all employ are: sagittal which mediates flexion/extension, coronal/frontal which mediates abduction/adduction and horizontal/transverse which mediates rotation. Myers named these lines as SBL Superficial Back Line, SFL Superficial Front Line and LL lateral Line. The assessment of three cardinal lines ensure you a more global relaxation in the fascial tension and restoration of increase mobility corresponds along these lines.

Once I have assessed myofascial tension, I assess joint ROM from a fascial perspective. You may ask how can one assess from a myofascial perspective for ROM? Essentially the distinct difference is not moving into the limit of anatomical integrity, instead the assessment of joint motion is confined to the level of first resistance. That is, where you feel the first tug, snag or glitch to the smoothness and quality of this motion. The reason is this will usually indicate the congestion of the connective tissue in the form of superficial fascia or fibrous connective tissue component as capsular or ligament restriction.

Remember myofascial surrounds each and every muscle group as a unit, muscle fibres and even muscle fascicles have a connective tissue wrapping. Therefore when you feel the first level of resistance you are keying into the first level of myofascial restriction that prohibits smooth joint motion.

I then move the joint through its muscular range but again feel the first level of restriction as it nears end feel. Again the rationale is autonomic and neurological. When a therapist moves a muscle into its end range, and if restriction is present, the client will feel the pull or strain. When they feel the strain, they cannot help but to unconsciously guard or the very least, respond by flinching.

The guard response is what I’m attempting to avoid. Again if I can avoid any reactive distress by my passive range of motion assessment, I avoid moving the client back into a sympathetic state. Micheal Shea (1995) is found of stating, and I quote; “all soft-tissue release is predicated on how the autonomic nervous system is discharging its impulses.”

The nervous system discharges, soft-tissue releases. You cannot accomplish soft-tissue change without a compliant nervous system. That said, of course, if you are strategically deciding to assess ROM and need to employ a special test, say for example an anterior drawer test of the knee joint, you would use excessive force provocatively, as it is necessary to assess if anterior cruciate ligaments are damaged. This is referred to as a provocative test. However, there is always a price to be paid from an autonomic or neurologic standpoint regarding excessive compressive force. The body will always respond whether the practitioner is aware or unaware of this. You have chosen to over ride the ANS, by re-producing pain to substantiate your assessment or diagnosis. Once pain is provoked, the ability for the soft-tissue to change is diminished. This is nervous system Cause and Effect. The sophistication of the central and autonomic nervous systems is a wonder to behold.

The other forgotten component in changing persistent and stubborn soft-tissue dysfunction is change to joint capsule and ligamentous structures. Although once considered inert and non-contractile structures, they are major contributors to the holding of tensional and tonal states of the muscles. The sooner you understand that all the soft-tissue is in dynamic interplay, the better it is for you regarding your clinical outcomes.

Once assessment is complete, I initiate technique with the ANS autonomic nervous system in mind, to ‘settle the system’ by use of the gentle ‘Two Point’, this facilitates the ANS to enter into a parasympathetic state, with the lowering of high sympathetic tone (Shea 1995). The Two Point is applied either to transverse planes or the major peripheral joints, i.e. knee, ankle, shoulder, elbow or wrist.

This then leads me to address the quality and quantity of range regarding any involved joint by utilizing indirect technique approaches that are osteopathic in nature. Among them is joint play, that is, combining accessory motion (anterior/posterior, lateral translation, distraction or rotational movements of approximated positions (close pack)), with crowding or approximation to the joint mechanoreceptors that facilitate a neurologic response of relaxation.

The other assessment component employed is the use of the assessment of ease or bind motion of the crowded joint by assessing the three planes of distortion within an ease or bind position. This in osteopathic parlance is called stacking. Stacking is the engagement of two or more planes of distortion simultaneously to re-organize and transform congested soft-tissue. It is a highly effective approach for changing proprioceptive mechanoreceptors in the joint capsule and surrounding ligamentous structures.

I address the musculature & joint restrictions by utilizing low load resistive (modified MET’s). This is directionally based rather than muscle specific. My intent is to target joint capsule, fibrous connective tissue responds well to low load resistives, thus joint capsule & ligaments respond to this type of technique. Upon conclusion of all the above, I then address musculature. Clearly there are very appropriate times to address and release muscular hypertonicity straight way. My point is that when muscles are not responding or releasing, then you need to change your strategy and orientation.

FASCIAL PLANES OF DISTORTION

When palpating to distinguish the direction of a myofascial distortion, it is recommended that the therapist palpate the surface of the skin to determine the plane(s) of restriction. This method was first noted in osteopathic literature and is commonly held throughout all manual therapy disciplines.

The osteopathic concepts of ‘ease’ and ‘bind’ are assessed in two ways: either the direction of the restriction or barrier is palpated or the direction of the motion barrier or restriction is assess by PROM passive range of motion as a motion restriction. Ease is always away from the barrier or the greatest degree of movement. Bind is the barrier or where movement has the greatest degree of restriction

HOW TO LOCATE SUPERFICIAL FASCIA

Palpate the skin with your palm or fingertips in a manner that forms to the shape of the skin over the area you are palpating. Do not tense your hand or forearm and your shoulders should be relaxed as you perform this assessment.

Next engage through the skin by increasing the depth of your pressure to the first layer of muscle, then back off. You should be between skin and muscle. This is the space where superficial fascia resides. Palpation is to the first level or layer of restriction.

The skin should be assessed for its mobility. Place your hands flat upon the surface of their skin and move the skin in all directions. Ideally, the skin should move equally in all directions, except around tendinous insertions into osseous structures. If it does not move well in a particular direction, this will indicate the underlying fascia is restricted.

If the skin does move in one particular plane of movement, say in a cephalic or sagittal direction, a myofascial technique can be applied in the direction of the restriction.

Skin adhesion is an indication of the ease or bind of the superficial fascia below it. You can easily assess fascial restriction by moving the skin over superficial fascial tissue. Assess the four cardinal directions by moving the skin proximal/distal medial/lateral or inferior/superior

DIRECT & INDIRECT TECHNIQUE: CONCEPTS OF EASE & BIND

The direction(s) the skin moves easily is called ‘ease’. The direction(s) that the skin resists moving is called ‘bind’. This is the method to assess planes of fascial distortion.

You engage bind by using a static compression of the skin into the superficial fascia and you will release the current assessed bind and create both a new ease and bind position. If the skin moves easily in the area you are assessing, then you are probably able to use techniques that are more muscular oriented. If however, the skin does not move easily, then in a general sense you are dealing with myofascial that needs to be released before you can achieve desired results from your muscular approaches.
This simple assessment can be utilized to assess superficial back and front line restrictions or lateral line restrictions. (Myers 2000) “Manual therapy comprises direct & indirect techniques. Direct techniques load or bind tissue and structure. The tissue is moved towards a barrier on one or more planes. The direction of displacement of the soft-tissue is in the least mobile, most restricted & most limited direction. Techniques are performed at or just before the barrier. The result is a change of the position of the barrier which will move closer to what would be the end of a more normal range of motion. For example, a direct approach might be employed to treat elbow flexion contracture with shortened and contracted biceps that limits elbow extension, a direct technique would be to move the elbow into extension. At the barrier, or just before the barrier at the interbarrier zone, a technique is performed with the result an increase in range of extension motion.

Indirect techniques unload or ease the tissue or structure. The tissue is moved away from the barrier on one or more planes. The direction of movement of the tissue is the most mobile, least restricted, least limited direction. The distortion is thereby exacerbated. The problem is exaggerated. For example, with limited extension, there is relatively too much flexion. The problem could be described as excessive flexion. The treatment would be towards flexion. The result is a ‘release’ phenomenon: the soft-tissues “let go” of tension in a tissue tension release.” (Giammatteo & Kain, Integrative Manual Therapy 2005 Vol.4, p70 North Atlantic Books)

MYOFASCIAL SLEEVE RESTRICTIONS

Myofascia behaves as a superficial wrapping as seen from Serge Paoletti’s anterior fascia of the low extremity.
Which brings me to assessment & palpation of fascial sleeves. Most practitioners are used to assessing rotation of the humerus or femur which determines movement at the shoulder or hip.
Another assessment that can be included is assessment of restriction of upper or lower extremity fascial sleeves. This is assessment is crucial to improving motion at the joint and for allowing the smoother movement of the muscle through its fascial sheath.

When addressing the scapular complex (GH joint, AC joint, SC joint & scapula-thoracic joints, humeral ulnar, radial ulnar, radial carpal), sleeve restrictions often will be the first restriction to release. Since myofascial loves to be encased through fascial ‘grasps’, this simple static compressive technique can clear fascial tissue quite quickly.

Assess which direction of rotational restriction is ease and which direction is bind.
Engage myofascial by using a grasp and apply the twist in the direction of ease to unload the tissue, or bind to load the tissue.
Usually the engagement of the superficial myofascial wrapping is enough to create a myofascial glide, usually within 10-30 seconds. However if this isn’t successful, then here are some points to consider:
From a palpation standpoint you are pressing too hard
You will need to engage a second plane of fascial distortion, which is to put a direction or vector on the myofascial by creating a ‘lateral shear’. Osteopaths call this ‘stacking’
You may ask the client to use slight movement as you engage the myofascial, usually in a rotational direction.
Micheal Stansborough and other direct myofascial release authors call this Active Movement Participation AMP.
You will find once you’ve cleared a rotational distortion or restriction you will increase ROM at the joint and the clarity of the restriction will become more focal.
Myofascial restrictions & distortions will obscure the ability to distinctly palpate the muscular structure beneath it.

Fibromyalgia:New Perspectives for the Manual Therapist

stevegold — Tue, 16 Feb 2010 22:23:02 +0000

Introduction

By Steven Goldstein BHSc MST, BA Education

Fibromyalgia classically presents as wide spread musculoskeletal pain and we know that the origin of this pain is multifaceted and systemic. Because of this, a more comprehensive understanding is required of you to be successful in your treatment options. In this article I’m going to introduce the concept of ‘Central Sensitization’, a fibromyalgia research blog, and the FIQ Fibromyalgia Impact Questionaire. All three of these components will give you a greater understanding of how to work with and treat your Fibromyalgia client.

There has been much written regarding Fibromyalgia and Massage Therapy, but a short review may be in order to the salient features of the syndrome.

Fibromyalgia FMS is a syndrome that is considered by many to be a chronic, culmative overload of the body’s coping and cushioning mechanisms (1. Gillick) in which on going residuals of macro-traumas (whiplash, system disorders, post traumatic stress syndrome, are perpetuated with numerous and cumulative micro-traumas (chronic sinusitis, repeated impact trauma, musculoskeletal dysfunction in the upper or lower extremities, positional sleep traumas) which sensitizes the central nervous system in such a manner as to amplify pain 24/7 and create pain from usually non-painful stimuli.

This is known as Hyperalgesia: the amplification of pain sensations and Allodynia: non-painful sensations such as touch, noise, vibration, lights or smells are painful.

Prevalence indicates usually affecting women over men by a 4/1 ratio, but Fibromyalgia can occur at any age. Although it usually manifests between the ages of 30 to 50. (Rattray p983)

There is an enormity of presenting symptoms with a wide range of variance as to fool the manual therapist, and probably the best source for the presenting symptoms would be to check out Dr. Devin Starlanyl’s website: http://homepages.sover.net/~devstar/. I’ll cover presenting symptoms in a subsequent article.

Central Sensitization

“Fibromyalgia (FM) pain is frequent in the general population but its pathogenesis is only poorly understood. Many recent studies have emphasized the role of central nervous system pain processing abnormalities in FM, including central sensitization and inadequate pain inhibition. However, increasing evidence points towards peripheral tissues as relevant contributors of painful impulse input that might either initiate or maintain central sensitization, or both.

It is well known that persistent or intense nociception can lead to neuroplastic changes in the spinal cord and brain, resulting in central sensitization and pain. This mechanism represents a hallmark of FM and many other chronic pain syndromes, including irritable bowel syndrome, temporomandibular disorder, migraine, and low back pain. Importantly, after central sensitization has been established only minimal nociceptive input is required for the maintenance of the chronic pain state. Additional factors, including pain related negative affect and poor sleep have been shown to significantly contribute to clinical FM pain. Better understanding of these mechanisms and their relationship to central sensitization and clinical pain will provide new approaches for the prevention and treatment of FM and other chronic pain syndromes.”

Central sensitisation is defined as ‘‘an augmentation of responsiveness of central pain-signalling neurons to input from low-threshold mechanoreceptors’’ (Meyer et al.,1995). “While peripheral sensitisation is a local phenomenon, central sensitisation means that central pain processing pathways localised in the spinal cord and the brain are sensitised.”

The science is fascinating, but the clinical implications through the application of this understanding is essential. An important and ongoing source of pain is required before the process of peripheral sensitisation can establish central sensitisation. Progression towards chronic widespread pain is associated with injuries to deep tissues which do not heal within several months (Vierck, 2006).

Consequently, appropriate and effective manual therapy in those with (sub)acute musculoskeletal disorders is important to prevent evolvement from an acute, localized musculoskeletal pain problem to complex clinical cases, characterised by chronic widespread pain and even symptoms outside the musculoskeletal system such as increased sensitivity to bright lights, auditory loudness, odours, and other sensory stimuli. Pain due to damage or inflammation of peripheral tissues is clearly capable of causing chronic widespread pain/FM (Clauw, 2007). 15-20% people with whiplash injuries develop chronic pain and disability (Spitzer et al., 1995; Radanov and Sturzenegger, 1996; Coˆ te´ et al., 2001). Regardless of whether FM is present in chronic whiplash, altered central pain processing and central sensitisation is evident (Curatolo et al., 2001; Sterling et al., 2002, 2003, 2006; Banic et al., 2004). Moreover, altered central pain processing rather than impaired motor control has been identified as one of the prime prognostic factors for developing chronic whiplash (Sterling et al., 2003, 2006).

Excerpted below from ‘From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: Application of pain neurophysiology in manual therapy practice .’

Science Direct Manual Therapy 14 (2009) 3e12

Myofascial Treatment

“Anecdotally, muscles and fascia often become hypertonic and develop trigger points in people with chronic widespread pain/FM. Soft-tissue mobilisation is required to free up restrictions and restores local blood flow. However, it is important not to increase pain during treatment. The vicinity of myofascial trigger points differs from normal muscle tissue by its lower pH levels (i.e. more acid), increased levels of substance P, calcitonin gene-related peptide, tumour necrosis factor-a and interleukine-1b, each of which has its role in increasing pain sensitivity (Shah et al., 2005). Sensitised muscle nociceptors are more easily activated and may respond to normally innocuous and weak stimuli such as light pressure and muscle movement (Shah et al., 2005). Therefore, starting the soft-tissue mobilisation superficially with well-tolerated strokes along the length of the muscle fibres (referred to as ‘stripping’ in Benjamin and Tappan, 2005) and progressing towards deeper strokes that go perpendicular to the soft-tissue fibres is recommended Aggressive ways of treating trigger points (e.g. by using ischaemic pressure) are usually not well tolerated and therefore not recommended.”

The research is clearly demonstrating a lighter approach is needed when applying soft-tissue therapies with the sufferer of fibromyalgia. We know from the studies of ‘facilitation’ with regard to active and latent trigger points, that once the dorsal horn of the spinal cord is switched on, it maintains its’ ‘facilitation’, with a low thresh hold barrage of stimulus.

An awareness is needed of the mechanisms that activate the autonomic nervous system, such as ‘flight and fight’; and the de-activation of ‘high sympathetic tone’ (Shea 1995), so that the therapist modulates the ANS from a lower sympathetic state into a parasympathetic state which is demonstrated by ‘rest and repose’. With this type of client, modification of duration of treatment, amount of force or pressure and specific tissues totarget, i.e., myofascial tissue, are all essential to a greater degree of success through the cessation of the barrage of nocioceptive stimulus.

The clinical approach I utilize, uses a skill set that employs lighter touch, autonomic nervous system modulation, the use of mind-body techniques such as neuro-linguistic programming (NLP), awareness and imagery technique, along with low load resistive for targeting intrinsic ligament and axial spinal muscle groups, forms of applied kinesiology, reflexology; all have efficacy in the treatment application of the sufferer of fibromyalgia.

Finally remember you have to have a strong referral network due to the systemic nature of the presentation, that means you need to refer to qualified therapists who practice CAM therapies, including naturopaths, CAM therapy friendly allopath physicians, mind body therapists, rheumatologists, and cognitive therapists that deal with emotional and psychological issues that are part of the overall clinical picture.

Fibromyalgia Impact Questionnaire

A very important tool for the manual therapist in their treatment of Fibromyalgia is the FIQ or Fibromyalgia Questionaire. This is the tool recognized for use in clinical trials around the world, and therefore is the major current tool to measure changeable outcomes for your client.

It was developed by Dr. Robert Bennett in the 1980’s in Portland Oregon in an attempt to capture the total spectrum of problems related to fibromyalgia and the responses to therapy. It was first published in 1991 and since that time has been extensively used as an index of therapeutic efficacy. Overall, it has been shown to have a credible construct validity, reliable test-retest characteristics and a good sensitivity in demonstrating therapeutic change. The original questionnaire was modified in 1997 and 2002, to reflect ongoing experience with the instrument and to clarify the scoring system. The latest version of the FIQ can be found at the web site of the Oregon Fibromyalgia Foundation (www.myalgia.com / F I Q / F I Q). The FIQ has now been translated into eight languages, and the translated versions have shown operating characteristics similar to the English version.

Based on an intake questionnaire used in the OHSU Rheumatology Clinic and informal discussions with fibromyalgia patients, the initial version of the FIQ was developed in 1986. In particular, the functional component of the questionnaire was purposely biased to the use of large muscle groups rather than fine hand movements.

Make sure you download the questionnaire and thoroughly read the research behind the study, as it will allow you the insight about how the questions were formed and why they were asked. In particular the scoring is designed to target physical functioning versus physical impairment. The categories are such as to ascertain how ADL activities of Daily Living are affected.

Every client should be filling out this questionnaire and then you actually have the ‘research tool’ in your hand to validate and contribute to studies and findings from a research perspective.

FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQ)

Name: _________________________________ Date: / /

Directions: For questions 1 through 11, please circle the number that best describes how you did overall for the past week. If you don””””””””””””””””””””””””””””””””t normally do something that is asked, cross the question out.

Always Most Occasionally Never

Were you able to :

1. Do shopping? …………………………………………… 0 1 2 3

2. Do laundry with a washer and dryer? …….. 0 1 2 3

3. Prepare meals? ………………………………….. 0 1 2 3

4. Wash dishes/cooking utensils by hand?….. 0 1 2 3

5. Vacuum a rug?……………………………………. 0 1 2 3

6. Make beds? ……………………………………….. 0 1 2 3

7. Walk several blocks? ………………………….. 0 1 2 3

8. Visit friends or relatives? ……………………… 0 1 2 3

9. Do yard work?…………………………………….. 0 1 2 3

10. Drive a car? ……………………………………….. 0 1 2 3

11. Climb stairs? ……………………………………… 0 1 2 3

12. Of the 7 days in the past week, how many days did you feel good?
0 1 2 3 4 5 6 7
13. How many days last week did you miss work, including housework, because of fibromyalgia?
0 1 2 3 4 5 6 7

FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQ) – page 2

Directions: For the remaining items, mark the point on the line that best indicates how you felt overall for the past week.

14. When you worked, how much did pain or other symptoms of your fibromyalgia interfere with your ability to do your work, including housework?