BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND …...Sebastian Kneipp Mid 19th century - - Began using hydrotherapy to treat his own tuberculosis (then called consumption). Following

8/23/2012 © Blue Sky School of Professional Massage and Therapeutic Bodywork 1

CST201-III – Class Notes – Semester 2

BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND

THERAPEUTIC BODYWORK

CLINICAL SOFT TISSUE TECHNIQUES

Hydrotherapy CST 201-III Session 1 & 2

LEARNING OBJECTIVES:

By the end of this session, the student will be expected to:

1. Define hydrotherapy and its terminology.

2. Recognize the history of hydrotherapy and its influence on massage

3. Describe and list the three physical states of water and the temperatures at which they change form.

4. Explain the benefits of water.

5. List the physiological effects of water.

6. For thermotherapy and cryotherapy:

a. Define

b. Describe methods of utilization

c. List physiological effects of

d. List effects of

e. List indications and contraindications

7. Cite examples of comparative effects of cold and heat and hydrotherapeutic applications.

8. Integrate concepts into practice

HYDROTHERAPY AND SPA APPLICATIONS

Textbook: MTPP

Batmanghelidj, F., (1997). Your Body’s Many Cries For Water. Falls Church, VA: Global Health

Solutions, Inc.



HYDROTHERAPY & WATER

A. Hydrotherapy:

The use of water in any of its three forms (solid, liquid, or vapor) internally or externally for a

therapeutic effect.

Hydro means water.

As a prefix it is defined as fluid or liquid.

Hydrotherapy techniques include things that may not be liquid, but rather a hot or cold thermal

treatment.

B. Water has three forms:

Solid – called ice at 32 degrees Fahrenheit.

Liquid – called water.

Vapor – called steam at 212 degrees Fahrenheit.

History

Water is the foundation of life on earth

Human bodies are 70 – 80% water - - approximately the same percentage as the amount of

water on planet, Earth. Chemical makeup is similar to oceans.

All cultures use water for healing and spiritual practices

May have originated from observing animals

Hippocrates –

USED BATHS AND HOT FOMENTATIONS TO HEAL PATIENTS

Dark Ages

Bathing was considered a sin (because nudity was) and fell out of use; disease became

rampant

Vincent Preissnitz 19

th century peasant who popularized the use of cold water for healing after seeing farm

animals healed that way. He suffered a severe injury to his chest at 17 and healed himself

after doctors gave no hope. Word spread of his self-cure.

Sebastian Kneipp

Mid 19th

century - - Began using hydrotherapy to treat his own tuberculosis (then called

consumption). Following his cure he began treating others and eventually wrote Meine

Wasserkur, published in 1886. This text is highly regarded and Kneipp therapies are still

used in many countries today.



Ignaz Phillip Semmelweiss

Mid 19th

century Hungarian doctor - - Made the correlation between the cause childbed fever

and lack of hygiene. Began advocating hand-washing as part of medical practice which is

still in use today.

John Harvey Kellogg

Introduced spas to America when he established the Battle Creek Sanitarium in Michigan.

As a healthy dietary alternative, he developed and is most famous for his corn flakes,

however his book, Rational Hydrotherapy, published in 1901 is the definitive text on water

therapy to this day.

Sister Elizabeth Kenny

Australia – Used hydrotherapy as an essential part of treatment for polio. It was the most

effective treatment taught and used worldwide.

Benefits of water:

The reason water is such an effective healing agent is that it stimulates a specific action, which

in turn creates a reaction.

For example, ice acts on an injury by numbing it. But, the skin reacts to the cold by reducing

fluid movement which controls bleeding.

Analgesic: Hot fomentations increase natural anodynes in the body, which decrease nerve

sensation thereby relieving pain.

Anesthetic: Prolonged use of cold water in the way of a compress or ice pack produces a

numbing effect.

Antiedemic: Cold water or ice packs can reduce localized swelling at an injury site.

Antispasmodic: Water applied at appropriate temperatures is unrivaled in relaxing muscle

spasm.

Antipyretic: Water at temperatures below 98 Fahrenheit quickly, safely and effectively

decreases fever.

Antiseptic: Boiling water can be used to sterilize against harmful bacteria.

Astringent: Cold water is well known to arrest hemorrhaging.

Burn Treatment: Cold water or ice is quite effective in decreasing burn pain and retarding or

stopping the formation of blister.

Diaphoretic: Water can be used to produce sweating.

Diuretic: The more water consumed, the more urine is produced.

Emetic: Forcing down several glasses of warm water will often cause vomiting.

Expectorant: Hot fomentations or inhaled steam loosens congestion in the lungs and bronchials

to be coughed up easily.



Immunologic Enhancement: Cold water tonifies muscles, which in turn increases the

circulation of lymphocytes into the blood and promotes the production of white blood cells that

fight off disease.

Laxative: Abundant use of cold water ingested into the body promotes peristalsis of the bowels

and loosens stools, thereby relieving constipation without any unwanted side effects of

purgatives.

Purifier: Water helps eliminate poisonous toxins and harmful elements in the blood via urine,

feces, sweat and the lungs.

Sedative: Warm water acts quickly as a sedative as it soothes and relaxes both nerves and

muscles with none of the harmful side effects of drugs.

Stimulant: Warm baths for brief periods (less than 5 minutes) stimulate the circulation and

increase the pulse rate from 70 to approximately 150 beats per minute. Short cold baths are also

stimulating.

Tonic: Cold water is known to tonify muscles by causing them to contract. Repeated hot and

cold applications of water can increase muscle tone also.

HYDROTHERAPY APPLICATIONS:

Hydrotherapy has been expanded to include thermal applications which are not pure water such

as:

o Paraffin baths.

o Thermophores (moist electric heating pads).

o Hydrocollator packs (gel-filled heating pads).

o Freezable gel packs.

o Hot and cold stone massage.

Traditional therapies include:

o Baths

o Shampoos

o Sponging

o Sprays

o Tonic friction

o Whirlpool, Jacuzzi, hot tubs

o Saunas



Internal Hydrotherapy

o Lavages

Enemas, colonics, douches and wound irrigations

o Consumption

Every function in body requires water. It is a transport for all elements.

Water acts as cushion for organs and spine (disc)

The physiological process of stress on our bodies causes dehydration - - stress =

dehydration = stress.

Requirements for intake

Intake recommendation – Body weight – ½ = # of ounces

6 ½ cups per day just for basic function

1 cc of water to process every 1 calorie consumed

Body has to process the water out of juices and other beverages before

utilizing the water content – requiring more intake. Some liquids are

dehydrating (coffee, cola, alcohol)

Eliminations – perspiration, respiration, excretion

Signs of inadequate water intake:

Fatigue, muscle soreness, joint pain

Kidney stones, urinary tract infections

Dry lips, cold sores

Constipation, nausea, vomiting, heartburn

Wrinkles, dry skin or poor skin tone

Swollen feet, legs, hands, face – water retention

Dizziness and changes in blood pressure

Disorientation, apathy, depression, aggression

Damage to nervous system, kidney, liver

Morning sickness – similar to hangover which is caused by

dehydration from the alcohol

Increase in asthma symptoms

Headache



Why Does Hydrotherapy Work?

The human body’s primary function is to maintain homeostasis (balance between opposing

pressures) in a changing environment and this is the key reason hydrotherapy gets its therapeutic

results.

When water is applied at temperatures above or below that of the body, the nervous system

perceives the changes in temperature forcing alterations in the flow of blood and lymph.

The greater the temperature difference, the more pronounced the effects.

The effects of an application vary depending on the temperature and length of time it is applied.

Hydrotherapy can be applied to the whole body or locally.

C. Physiological Effects

The major factors contributing to how water affects the body:

Temperature

Moisture

Mineral Content

Mechanical Stimuli

Reflexive or Consensual Effect

Hydrostatic Effect

Temperature:

Both hot and cold applications reduce pain and discomfort through the gate theory.

Water temperatures below 32 degrees F or above 124 degrees F can cause tissue damage.

Use caution when placing a hand or foot into water of unknown temperature.

A thermometer is the best method for checking water temperature.

Rule: As warm as necessary and as cold as possible



Moisture:

Definition: The amount of humidity in the air.

The more moisture in the air the heavier it feels.

Heavier air is often more difficult to breath.

A steam bath at 100 % humidity helps moisten the mucous membranes.

A sauna humidity of 6% to 20% is easier to breath but very drying and can irritate the skin

and mucous membranes.

Mineral Content/Chemical:

The use of additives can increase the effects of water.

Chemical effect is also produced by internal hydrotherapy.

The properties found in mineral water help enhance the hydrotherapy treatment.

Minerals found in water:

o Saline = purgative effects.

o Iron oxide = rust colored water.

o Sulfur = cleansing effect.

Minerals that draw out toxins:

o Sea Salts (sodium chloride).

o Epsom Salt (magnesium sulfate).

o Baking Soda (sodium bicarbonate).

Detoxification Bath Recipe:

o 1 cup salt.

o 1 cup baking soda.

o Tub of warm water.

o Soak 20 minutes.

o Rinse off.



Mechanical Stimuli:

Using forcible water, stimulating the skin during the treatment intensifies the body’s response.

1 gallon of water = 8.33 pounds.

Water hitting the body promotes relaxation and health.

Pressurized water can intensify the therapeutic results.

Examples are:

o whirlpool

o hydro-tub

o pressurized hose as in a shower or spray

Reflexive or Consensual Effect:

Application to a certain area of skin effects a distant area

Can occur in blood circulation, organs or glands

Hydrostatic Effect:

Shifting of fluid from one part of the body to another

General dilation of blood vessels occurs when a large area of body is exposed to heat

Hydrotherapy can either draw blood and lymph from or push towards a distant area of the body

Hydrostatic pressure:

Force water exerts on a submerged body is equal from all directions effecting venous,

lymph and urine output. Pressure depends on density and depth. At 15 cm (6”) below

water, pressure is equal to the venous system. Below this 300 ml of blood is shunted

back to the heart from the extremities. Therefore caution should be used when treating

anyone with a cardiovascular problem or late stages of pregnancy. It can be used to

increase circulation using a footbath, whirlpool or underwater massage.



D. Thermotherapy

Definition: The external application of heat for a therapeutic purpose.

Heat application causes the skin to become hyperemic (increased amount of blood vessels) as a

result of vasodilation (dilation of blood vessels). This creates a perception of warmth causing

perspiration (sweating) and is produced in an attempt to cool the body.

Effects of heat:

o Vasodilation

o Increases local blood flow.

o Increases oxygen absorption.

o Increases metabolism.

o Reduces pain.

o Relieves stiffness and soreness.

o Increases relaxation.

o Increases range of motion.

o Increases white blood cell count by producing an artificial fever.

o Reduces muscle spasms.

o Increases extensibility of collagen (scar tissue and tendons).

o Draws blood away from a congested area

o Heat to one extremity produces vasodilation in both

o Increases respiration, increasing elimination of carbon dioxide

o Increases perspiration

o Relaxes fascia

Indications for heat:

o Pain

o Congestion – encourages expectoration

o Muscle tension

o Muscle spasm

o Muscle soreness

o Insomnia



o Nervous states – soothes nerves

o Prepares for massage

o Cold clients

o Joint pain

Contraindications to heat treatments:

o Clients with an aversion to heat

o Acute injury

o Autoimmune conditions (multiple sclerosis, hyperthyroidism)

o Recent burns, including sunburns

o Cardiac impairment (heart condition – danger of heart attack, heart valve problems)

o Cerebrovascular accident (CVA) or stroke

o Edema

o Fever

o Hypertension (high blood pressure) or hypotension (low blood pressure)

o Inflammation

o Malignancy (resistant to treatment) or chronic illness

o Significant obesity

o Phlebitis (inflammation of the vein)

o Pregnancy

o Rosacea (A chronic form of acne usually involving the middle third of the face,

persistent redness and swelling)

o Sensory impairment (infants, elderly, people with diabetes, clients with mental

conditions, clients with multiple sclerosis)

o Skin infections or rashes

o Directly over a tumor or cyst

o Clients who are weak or debilitated

o Asthma

o Claustrophobia

o Kidney disease

o Bony areas due to lack of protection



E. CRYOTHERAPY

Definition: External, therapeutic application of cold.

It is the safest, simplest and most effective method for reducing pain and swelling in injuries.

Physiological effects of cold ( 4 stages):

1. A sensation of cold is felt by the client. During this stage vasoconstriction results in the

skin appearing blanched and pale.

2. Tingling or itching is then felt by the client. A sudden deep-tissue vasodilation occurs to

restore the body to homeostasis.

3. Aching or burning is then felt by the client. Vasoconstriction resumes and the cycle

continues.

4. Numbness or analgesia (painful stimuli are so moderate that, though still perceived, they

are no longer painful).

Remove the cold application immediately after numbness to prevent tissue damage from

excess cold.

Hunting response is the alternating vasoconstriction and vasodilation in one or more

applications of ice. It is during this alternating vasoconstriction and vasodilation that creates an

increased deep local circulation, one of the most important effects of cryotherapy.

Effects of Cold Application

First stage – short use – retro stasis (the pushing of blood or lymph from the affected area):

o Vasoconstriction

o Increases muscle tone

o Increases heat production

o Increases respiration

o Increases heart rate

o Increases blood pressure

o Increases digestive function

o Decreases sweating

o Reduces acute inflammation

o Reduces swelling

o Reduces pain



Second Stage – prolonged use – derivation (drawing blood or lymph from one area by increasing

the amount of blood or lymph to another part):

o Increases red blood cells

o Increases skin temperature

o Decreases respiration

o Decreases heart rate

o Decreases core temperature

o Increases muscle tone

o Increases metabolism

o Increases gastric motility

o Decreases circulation (stops bleeding)

Indications for cold treatments:

o Acute strains or sprains

o Chronic muscle spasm which becomes acute (more painful)

o Bursitis

o Following athletic activity, resulting in chronic pain from old injury

o Applied to axilla and groin to reduce excessive fever

Contraindications of Cold

o Arthritis

o Aversion to cold

o Cerebrovascular accident (CVA) or stroke survivor

o Open wounds

o Hypertension (cold may raise blood pressure)

o Raynaud’s syndrome

o Rheumatoid arthritis

o Sensory impairments (infants, elderly, people with diabetes, clients with mental

conditions, clients with multiple sclerosis)

o Skin infection or rashes

o Chilled person



o Asthma (cold could trigger an asthma attack)

o Any vascular / circulatory problems where there is difficulty with dilation and

constriction of the vessels (e.g. severe arteriosclerosis, diabetes)

o Bony areas due to lack of protection

F. Alternating Hot and Cold

Short alternating heat and cold has a stimulating effect on reflexed tissues and organs.

Contrast bath is one of the most potent procedures in hydrotherapy.

Alternating causes vasodilation then vasoconstriction causing a pump-like action and therefore

an increase in blood flow.

G. Safety, Temperatures and Manner of Treatment:

Safety

Prevent burns to clients and self

o Be attentive

o Never leave room during a hydrotherapy session

o Communicate with client

o Place hot towels carefully – test small area first before placing fully on chest, face or

back. If too hot, give one quick shake and test again

o Check for redness of skin when using heat treatment

o Apply cold immediately to any burn

When using electrical appliances

o Check cords for cracks or exposed wire

o Never put appliance where cord could be tripped over

Bare floors

o Keep floors dry

o Remove oil from feet before allowing client to stand

Remind clients to drink water

o Some hydrotherapy treatments can dehydrate client



Temperature Ranges and Effects on the Body:

See MTPP beginning on page 245

Body Temperatures

Body Part Degrees Information

Oral (mouth) 98.6 Fahrenheit (37 Celsius) Establish before treatment.

Forehead / Cheek 93.4 – 93.9 Fahrenheit

Axillary 97.6 Fahrenheit One degree below oral temperature.

Rectal 99.6 Fahrenheit One degree above oral temperature.

Skin 93 Fahrenheit

Brain 104 Fahrenheit (40 Celsius)

Liver 106.5 Fahrenheit

Calf Muscles 92.5 Fahrenheit

Thigh Muscles 93.6 Fahrenheit



Manner of Treatment

Environment o Warm

o Quiet

o Well organized

o Peaceful

o Soft lighting

Therapist

o Calm and attentive

o Well organized

o Quiet

o Nurturing

o Knowledgeable about treatment

o Mentally present and centered

o Should explain treatment fully to client before beginning procedure

o Encourage client to bring dry set of clothes (undergarments) along

Materials

o Clean

o Prepared ahead of time

o Ready to be used

o In good working order

o Hot should be hot

o Cold should be cold

Clean Up

o Disinfect table with spray disinfectant

o Disinfect footbath with disinfectant

o Remove towels, sheets, etc to laundry

o Prepare room for next treatment

Client

o Should be kept warm and comfortable

o Body temperature should be at least 98F before any cold treatment is applied

o Be prepared for the procedure by understanding the treatment and its effects

Following treatment

o Client should rest for at least 15 minutes after full body treatments

o Client should drink 8-16 ounces of room temperature water after treatment

o Client should not catch a chill after treatment.

o Do not let clients leave wearing wet clothing or having wet hair

o Encourage clients to bundle up during cold weather

Generally speaking a person should rest following a full body hydrotherapy treatment. The

resting time should be at least as long as the treatment time.



H) Wisconsin State Law

CHAPTER 460

MASSAGE THERAPY AND BODYWORK

460.01 Definitions. In this chapter:

(1g) “Adjunctive therapy” means any of the following:

(a) The use of a device that simulates or enhances a manual action.

(b) The application of water, lubricants, or other nonprescription topical agents to the skin.

(c) The application of heat or cold to the skin in the absence of an electromagnetic device.

(1r) “Affiliated credentialing board” means the massage therapy and bodywork therapy affiliated

credentialing board.

(2m) “License holder” means a person granted a license under this chapter.

(3) “Manual action” includes holding, positioning, rocking, kneading, compressing, decompressing,

gliding, or percussing the soft tissue of the human body or applying a passive range of motion to the

human body without joint mobilization or manipulation.

(4) “Massage therapy” or “bodywork therapy” means the science and healing art that uses manual

actions and adjunctive therapies to palpate and manipulate the soft tissue of the human body in order to

improve circulation, reduce tension, relieve soft tissue pain, or increase flexibility. “Massage therapy”

or “bodywork therapy” includes determining whether manual actions and adjunctive therapies are

appropriate or contraindicated, or whether a referral to another health care practitioner is appropriate.

“Massage therapy” or “bodywork therapy” does not include making a medical, physical therapy, or

chiropractic diagnosis.






Hydrotherapy

CST 201-III



1. For each of the hydrotherapy treatments:

a. Define / describe.

b. List the equipment needed.

c. Explain the procedure.

d. List indications and contraindication.

2. Explain the manner of treatments for hydrotherapy and list what you should attend to for the five

different factors.

3. Integrate hydrotherapy treatments with massage therapy sessions and treatments learned throughout

the program.

HYDROTHERAPEUTIC APPLICATIONS:

Hot Foot Bath

Definition: A warm to hot bath for the feet. (Often used before foot reflexology or as part of other

hydrotherapy treatments.)

Water temperature:

o 100-110 degrees Fahrenheit.

Equipment:

o Chair.

o Blanket or towels.

o Foot tub.

o Cold compress (cold wet washcloth).



Procedure:

o Client sits in the chair.

o Fill foot bath with water of desired temperature.

o Test water with hand and then slowly have client place feet into the water as tolerated.

A blanket can be placed over the client’s legs and the foot bath.

o Soak feet in the bath for 10 to 30 minutes.

o Add hot water as needed.

o Use a cold compress to the back of the client’s neck and/or forehead so the client will not

get congested or have their head overheat.

Indications:

o Warms the muscle tissue prior to massage (especially for reflexology).

o Headaches due to sinus congestion.

o Nosebleeds.

o Lung congestion.

o Warms the body.

o Helps prevent or relieves the body of cold symptoms.

Contraindications:

o Loss of sensation in the feet and ankles.

o Diabetes, peripheral vascular disease – arteriosclerosis.

Ice Massage

Description: o Ice massage is the application of ice with deep circular friction over a small area.

Equipment:

o Ice chunk.

o Cloth.

Procedure:

o Apply the ice to the area to be treated while moving the ice in circular motions.

o Continuous movement / massage for 5 to 15 minutes.

Numbness should be experienced by the client noting you are done.



o The client will experience in order:

cold

slight burning

deeper ache

numbness

o Pat dry with a soft cloth.

Indications:

o Acute pain.

o Active trigger points (with referred pain).

o Muscle spasms.

o Decreases muscle tone.

o Inflammation and swelling.

Contraindications:

o Adverse reaction to cold.

o Skin sensitivity.

Paraffin Bath

Description:

o The application of paraffin layers that deliver penetrating heat into painful joints and

body parts.

Equipment:

o Heating unit.

o Paraffin.

o Oil (not mineral oil).

Procedure:

o Melt paraffin.

o Wash hands and forearms.

o Hands and forearms should be free of any open wounds.

o Dip the relaxed hand into the melted paraffin.

o Remove the hand from the paraffin.



o Allow to cool a few seconds.

o Repeat 3 to 4 times.

o Wrap in a plastic wrap or in a plastic bag and then a towel.

o Place hot pack on towel or use Fomentek Bag.

o Leave on 20 to 30 minutes.

Indications:

o Arthritic or stiff joints.

o Bursitis.

o Fibrositis.

o Gout.

o Prepares for massage.

Hot Compress

Description:

o It is a cloth dipped in warm to hot water, wrung out, folded and placed on the skin

promoting relaxation to the client.

o The compress will cool fast. Change the compress often to avoid chilling the client and

to achieve the full benefit of relaxation.

Procedure:

o Dip a washcloth or hand towel in hot water; squeeze out any excess water.

o Layer the cloth by folding it in half or to the desired size.

o Apply to the desired area of the client’s body.

o Leave the compress on until it starts to cool.

o Remove or replace with a fresh compress as needed.

Indications:

o Warms the muscle tissue prior to massage (especially therapeutic facial).

o Warms the body if the client is cold.



Cold Compress

Description:

o A cool compress is a cloth dipped in cool to cold water, wrung out, folded and placed on

the skin.

Procedure:

o Dip a washcloth in cool to icy water; squeeze out any excess water.

o Layer the cloth by folding it in half or to the desired size.

o Apply to the desired area of the client’s body.

o Leave the compress on until it starts to warm.

o Remove or replace with a fresh compress as needed.

Indications:

o Pushes blood away from an area.

o Cools the body.

o Slows bleeding.

o Reduces inflammation.

Ice Pack

Description:

o A solid mass that retains cold for about 20 minutes.

Procedure:

o Lay a thin layer of cloth, such as a pillow case or t-shirt, on the skin.

o If the cloth is too thick, the cold will not transfer into the affected area.

o Place the ice pack on top of the towel.

o Leave the pack in place for a maximum of 20 minutes or shorter depending on if the area

becomes numb.

Indications:

o Reduces inflammation.

o Reduces muscle soreness after a deep massage.

Fomentek

Description:

o “World’s largest hot water bottle & ice pack.”



Procedures:

o Cold Use:

Fill the bag with chilled water.

Burp the bag.

Apply directly to the body.

o Cryotherapy:

Fill the bag with 20% alcohol and 80% water.

The alcohol in the solution acts as antifreeze so the pack stays pliable and

conforms to the body.

Burp the bag.

Store in the freezer.

A dry towel is placed next to the skin and the ice pack is placed on the towel.

o Warm Use:

Fill the bag directly from the sink with hot water (ideally 110 degrees to 113

degrees water).

Burp the bag.

The Fomentek bag will stay therapeutically warm for up to 2 hours.

Indications:

o Use as indicated as you would for any other hot or cold treatment. However, for

convenience you may want to avoid the “wetness” involved with the hydrotherapy

treatment.

o Supporting the client in body positioning (use like a bolster).

o Warm / Hot:

Warming the tissue before you do massage.

Warming the client.

Back pain.

Muscle aches & pain.

Joint stiffness.

Arthritis pain.

Menstrual cramps.

Muscle spasms.



o Cold:

Removes inflammation.

Muscle sprains and strains.

Sore joints.

Bursitis.

Tendonitis.

Sunburn.

Controls fever.

MANNER OF TREATMENT AND RULES OF HYDROTHERAPY

The most important aspect of hydrotherapy treatments is the manner in which they are applied.

The environment, the materials used and the therapist needs to be prepared to carry out a smooth

and calm procedure. All treatments should be done in a caring and nurturing manner with the

utmost thought given to the overall well-being of the client.

During your treatments, you should attend to:

o Environment

Warm.

Quiet.

Well organized.

Peaceful.

Soft lighting.

o Therapist

Calm and attentive.

Well organized.

Quiet.

Knowledgeable about treatment.

Mentally present and centered.



o Materials

Clean.

Prepared ahead of time.

Ready to be used.

In good working order.

Hot should be hot.

Cold should be cold.

o Clean Up

Disinfect table with spray disinfectant.

Disinfect foot bath with disinfectant.

Remove used towels, sheets, etc. to laundry.

Prepare room for next treatment.

Wash thermometer with soap and water.

o Client

Should be kept warm and comfortable.

Temperature should be at least 98 degrees Fahrenheit before any cold treatment is

applied.

Be prepared for the procedure; understand the treatment and its effects.

Be sure to explain the treatment procedure to the client before starting and that

they not only understand but are comfortable.






Therapeutic Facial CST 201-III Session 3



1. Describe and demonstrate how to check for appropriate temperature when applying hot compresses

to the face.

2. List the benefits of applying hot towels in a therapeutic facial massage.

3. Demonstrate proper positioning of the client.

4. Demonstrate proper body mechanics when performing these techniques.

5. Demonstrate effective communication skills with client before, during and after the massage.

6. Perform a therapeutic facial massage.

Muscles and Massage Techniques for the Face.

Supplies Needed: Bottom Sheet

Blankets for warmth

Bolster

Pillow for therapist

Oil and cream

4-5 washcloths

2-3 hand towels

Contact case & glasses

Large bowl and/or Crock-pot



FACIAL MASSAGE SEQUENCE – QUICK REFERENCE

Preparation of Client: Clothing, Comfort, Breathing, and Tongue Position

Centering and Clearing

Steaming the Face

Palm Face

Skin Roll

Apply Oil

Forehead Strokes:

Full Face Three Circle Stroke

Full Palm Wipe to Temples (3x)

Temple And Eye Polarity Points – R & L is one stroke (3x)

Interweaving thumbs

V-strokes, horizontal and vertical for forehead wrinkles

Kneading brows

Alternating full hand press and wipe (3x)

Eyes: 1) Attunement and Relaxation

Tapotement

Upper eye contact points

Lower eye contact points

Inner eyebrow contact points

Sinus contact points

2) Eye Opener Upper Lid

3) Lower Lid Stretch

4) Palming Eyes

Nose: 1) Bridge of Nose

2) Tip of Nose

Mouth: 1) Delicate Strokes and Circles to Soften Upper and Lower Lips

2) Stretch to Smile, holding mouth corner points

Chin: 1) Jaw Bone Squeeze

2) Jaw Bone Stroke and Circles

3) Small Circles on Masseter Muscles

4) Small Circles on TMJ

Cheeks and Ears:

1) Starting at bridge of nose, gradually making larger circles onto cheeks

2) Cheek to Ear Stroke

3) Ears

Neck: 1) Thyroid Stimulation

2) Uplift Strokes for neck, Trapezius

Connecting Face and Head

Energizer

Honey/Nutmeg Mask for Myofascial Release

Final Steam

Dry Face Finish



FACIAL MASSAGE INSTRUCTIONS

MAJOR NERVE CENTERS OR ACUPRESSURE POINTS

Widows’ Peak (WP) Point – Balances Thymus, hypothalamus, and solar plexus.

Pituitary Contact – Middle of forehead, 3rd

eye. As with all contacts, pressure is very light, yet very firm.

Often the firmness comes from the energy. This contact awakens the body to change, activates the ability to

see clearly.

Temples – Hollow in temples where sphenoid and temporal bone join – tip of sphenoid is palpable here.

Circle up and forward. Reverses binding between temporal and sphenoid bones.

Mouth Corner Points – On either side of mouth, touching some redness of lip, hold delicately.

Nose Points – Either side of nostril (sinuses, integrates face, lets eye energy move up instead of down.)

PREPARATION

Preparing the Client

Sufficiently disrobe so that neck and shoulders are bare and accessible. Suggest longer slower inhalations

and exhalations of breath. Suggest that the client let the tip of the tongue curl up and place it behind their

upper front teeth. This prevents clenching of the jaw and is also an energy balancing position often used in

meditation.

Centering and Clearing

Create a space of unconditional love with no strings attached. Prepare to be totally nurturing to your client.

Steaming the Face

Herbs such as tansy, yarrow or chamomile may be added to the water used for steaming the face.

These herbs dissolve emotional crystallization in the muscles. Chamomile or lavender can be used

for relaxing muscle tissue.

Use 4 washcloths, 2 at a time – one across top of face to nostrils, the other across neck, jaw &

mouth, keeping nostrils open so client can breathe easily. Steam the face and gently press warm

cloth into face, maintaining contact as much as possible before preparing new cloth. Slide new

cloth onto face as cooled one comes off. Repeat several times to prepare the muscles for massage.

Palm Face

This helps to relax the face and prepare the face to be worked on

Client should be breathing diaphragmatically with slow deep breaths.

See the face with innocence, as in a baby’s face, and as you massage the face, see the worries and

fears held there as something sticky on the baby’s face and massage them away, restoring the face to

its natural state of innocence.

Skin Rolling

This is done to stimulate the blood flow in the facial muscles. It will also loosen tighter areas of the face.

Roll the forehead, cheeks and neck.

Oil Application

Use lighter weight oils on the face – good choices would be olive, sesame, sunflower, almond,

avocado, flaxseed or grape seed. Ghee and saffron can be used to bring all energies together.

Peanut, safflower, and corn oils are all too heavy as are massage creams.

Apply oil to face, neck and shoulders.

Create and maintain atmosphere where client can trust – relax – let go and heal.

Your attention with almost all strokes on the face is a movement to expand, open, widen, and uplift.



TECHNIQUES

Full Face Three Circle Stroke

Place your thumbs at the widows’ peak (WP), anchoring your fingers at the temples. Move your

fingers to the center of the brows, hold for 30 sec – 1 min, then back to the temples, lift.

Thumbs at WP, fingers move from temple, trace brow, hold, move to nose points, hold 30 sec – 1

min then back to temple.

Thumbs at WP, fingers move from temple, hold to Nose Points, hold, to mouth points, hold 30 sec –

1 min, then back to temple.

Forehead Strokes

Full Palm Wipe to Temples (3x)

Position hands with the thumbs at WP pointing down the center of the forehead, palms and fingers at

side of head. Slide thumb down center of forehead, spread thumbs to side of eye, lift at temple.

Temple and Eye Polarity Points – R & L is one stroke, repeat 3x

Thumbs at WP, fingers at temple, index finger goes lightly above brow to hold opposite brow,

returns with greater firmness to home temple position, circle at temple when you get to edge then lift

off.

Interweaving Thumbs Work with full pad of thumb, weave half moon circles slowly over forehead using tip of each thumb,

not on the temple, just the forehead.

V-Strokes, Horizontal and Vertical for Forehead Wrinkles Put index and middle finger of one hand parallel to wrinkle, hold, and then open fingers, not

stretching skin, but opening it somewhat. Take pad of other index finger and do slow deliberate

rotations until skin is soft under your finger.

Kneading Brows (3x) With the index finger below brow and thumb above brow, grip the tissue firmly. Move across brow,

move index finger to thumb, thumb to index, on to end of brow.

Alternating Full Hand Press and Wipe (3x)

Palm of right hand over center of forehead, palm of left hand over back of right hand: breathe

energy down your arms, allowing the energy to create pressure on forehead. When the

energy under your right hand peaks, lift left hand just enough so you can move the right hand

across brow (wiping it), moving the right hand so the fingers point toward the chin. Lift your

little finger of right hand to keep it free of the brow hair as you mover across the brow.

Hold left hand on forehead in position, using right hand to give temple are a full four-finger

massage. Touch various side pints, up side of head, behind ear, hair, etc. Move arms in wide

angle wing shape as you come off head, then flick energy.

After 2 alternating press and wipe strokes, move the grounding hand to the side of the head

and hold the head as you turn it sideways for more thorough work at the occiput and circular

friction on the scalp

After 3rd

alternating press and wipe strokes, fingers go to occiput and thumbs are in front of

each ear, stretch up back of the head with fingers. Pull energy up.

WHEN FINISHED WITH FOREHEAD STROKES, DO A FULL FACE UNIFYING

STROKE BEFORE YOU PREPARE TO GO ON TO THE EYES.



Eyes

Attunement and Relaxation a. Tapotement on closed eyes

b. Hold eye contacts points above eye with fingers, thumb at WP

c. Hold eye contact points below eye with fingers, thumb at WP

d. Lift at inner corner of eyebrow for relief of sinus pressure.

e. Using first 2 fingers of each hand, apply pressure above and below the eye following the

orbits of the eye (helpful also for sinus pressure).

f. Palm eyes to relax with fingers toward chin.

NOTE: Points around eyes are, for the purposes of this facial massage, touched firmly but with

only the weight of your hand for pressure; breathe energy for additional pressure.

Gently use a Q-tip or little finger under brow bone affecting muscles just under the brow. This must

be done very carefully and within clients tolerance level.

Palm eyes to heal

Nose

Bridge of nose - -using your thumbs alternately, stroke down the bridge of the nose from the top to

the tip.

Tip of nose – squeeze the tip of the nose gently between your thumbs and index fingers.

Mouth

Delicate strokes and circles to soften upper and lower lips using pads of thumbs to soften and to

smooth upper lip and then lower lip.

Stretch to smile with little finger behind ears, pads of thumbs at mouth corner points, lift mouth into

a smile.

Chin

Jawbone Squeeze – holding the rim of the jawbone at the chin, then draw your hands slowly apart,

squeezing right along the jawbone as far as the earlobe.

Jawbone Stroke and Circles

a. Begin with pads of thumb under lip, move thumbs down to chin, across jaw, moving to under

earlobe (3x)

b. Again begin with pads of thumb under lip, move thumbs down to chin; use thumb to make

small circles along jawbone, moving from chin to under ear (3x)

Cheeks and Ears

Masseter Muscles - -locate the chewing muscles on each side of the face. Then circle slowly over

them with the flats of your fingers.

TMJ – have your client open their mouth fully to locate the TMJ. Circle slowly over the TMJ with

the flats of your fingers. With fingers on bridge of nose make small circles onto cheek, gradually making larger circles to include

the sides of the face. Wipe along upper and lower check one areas with full smoothing, uplifting strokes.

Deep friction is OK, but continue the stroke to carry the energy to the side of the face.

Cheek to Ear Stroke – put the heels of your hands on either side of the nose, with your fingers

pointing toward the ears. Now slowly part your hands, gliding them firmly over the cheeks toward

the ears.

Ears – grasp the ears between your fingers and the heels of your hands and very gently stretch them

away from the head. Then squeeze all around them with your fingers and thumbs.



Neck

Thyroid Stimulation – delicately vibrate up the front of neck on either side of the windpipe. Use

fingers of one or both hands, however you have most control at this delicate place.

Uplift Strokes for Neck and Trapezius – Turn head sideways, hold it with full hand grounding

around the ear while you fan out the other side. Stroke up trapezius to scalp line, then use your own

neck techniques, thinking and visualizing “UP”. Do shoulders, back of neck, etc as you feel the

need to.

Shoulder stretch – Standing at the head - -place your left hand on the right shoulder and the right

hand on the left shoulder. Gently apply pressure downward to stretch the shoulders.

Honey/Nutmeg Myofascial Release

Mix one tablespoon honey to one teaspoon ground nutmeg and apply to face and neck. Notice that

as honey dries, your fingers will stick to the skin allowing it to be lifted. Experiment with moving

fingers while remaining in contact with the skin and also with lifting fingers away from the skin to

see which is more pleasant. Use honey to help vibrate area in front of neck beside windpipe.

Honey can be left on face as long as 20 minutes and will be removed during final steam.

Final Steam

Use four washcloths and fresh warm peppermint water (energizing). Let first 2 cloths stand on face

a bit to soften honey, then gather honey up with one cloth as you slide another warm cloth into place.

Several exchanges of warm cloths may be necessary to remove all honey. Use great care and

consciousness in this process. When most honey is gone, use a fresh cloth in each hand to remove

final visible traces, then touch with your fingers to see if further washing is necessary.

Dry

Dry face with soft towel as if you were polishing the face very gently.

Use clean, dry, hand towel to perform a dry shampoo on hair (will help to dry any damp hair and

remove any remaining traces of honey.

Re-check face for honey by using a full unifying stroke over entire face.

Energizer

Touch 2 fingers of right hand on solar plexus, then touch thymus (approximately nipple line or 1 ½

inches higher), then clavicle hollow, below lip, above lip, third eye, WP, then top of head.

Advise client as to how to get up from table and have water ready for them when they get up.

Any of these techniques can be incorporated into a regular massage and the order may be changed at

therapist discretion to individualize each massage.

References:

Based on cross fiber work from Marge Kapsos

Arrangement of some of the material – Connie McGrath

Strokes and information used with permission from: Facial Rejuvenation, Linda Burnham, 1986.

Acupressure for Pain Control, Dr. Albert G. Forgione, 1982

Points referenced:

Acupressure Face-Lift, Lindsay Wagner

Acupuncture Without Needles, J. V. Cerney

Diet and Nutrition, Rudolph M. Ballentine






Reflexology CST 201-III Session 4



1. Define Reflexology.

2. List the benefits of Reflexology.

3. Explain who Dr William Fitzgerald and his role in reflexology

4. Describe Zone Therapy.

5. Explain who Eunice Ingham is and her role in Reflexology.

6. Perform a reflexology treatment.

7. Incorporate all or parts into a full body relaxation massage.

8. Demonstrate proper body mechanics when performing these techniques.

9. Demonstrate effective communication skills with client before, during and after the massage.

Reflexology

Textbook: MTPP

Better Health with Foot Reflexology: The Original Ingham Method, by Dwight C. Byers.

Definition of Reflexology: Also called zone therapy. Reflexology is a science that deals with the principles

that there are reflex areas in the foot, hands, ears, and throughout the whole body which correspond to all

the glands, organs, and other parts of the body.



Benefits of Reflexology: Increase circulation

Increase lymph flow

Increase energy

Balance the endocrine system

Relieves stress and tension

Promote the unblocking of nerve impulses

Incorporates well into a full body relaxation massage

Zone Therapy:

Description: The body is divided into 10 vertical zones, five on each hand extending from the head to the

fingertips and toes, front to back.

Dr. William Fitzgerald is credited with the discovery of Zone Therapy. In 1917, he published a book called

“Zone Therapy” or “Relieving Pain at Home”. In this book he revealed how to relieve pain through

manipulation of the hand and fingers with various devices. Dr. Fitzgerald’s research was mainly limited to

the hands and fingers. Dr. Fitzgerald’s theory was that the body could be divided into ten vertical zones,

five on each hand extending from the head to the fingertips and toes, front and back.

Eunice Ingham is given credited as having founded Reflexology. She was a physiotherapist who worked

with the concepts of zone therapy to discover how the body reflexes itself within itself. She mapped the feet

for these reflex point’s-Reflexology. She began her work in the early 1930’s. One of her experiments was

to find a tender spot and then tape wads of cotton over these spots and have the person walk home upon

them. This over stimulated the area therefore causing “reflex” reaction in the body. Ms Ingham realized

that in doing a therapeutic treatment it was best for the therapist to use their thumb or fingers. By using the

thumb and fingers it allowed the therapist to pinpoint the problem areas and be more exact in the therapeutic

treatment.

Ingham wrote two books “Stories the Feet can tell through Reflexology (1938) and a sequel “Stories the

Feet have told through Reflexology”.

In 1973, the International Institute of Reflexology was founded to carry on Eunice Ingham’s work.



Treatment:

Hot Foot Bath

Definition: A warm to hot bath for the feet. It is often used before a foot reflexology treatment or as part of

other hydrotherapy treatments.

Water temperature: 100-110 degrees F

Feet and ankles covered

Equipment: Chair, blanket or towels; foot tub and cold compress (cold wet washcloth)

Procedure: ▪ Client sits in the chair

Fill foot bath with water of desired temperature.

Test water with hand and then slowly have client place feet into the water as

tolerated.

A blanket can be placed over the client’s legs and the foot bath.

Soak feet in the bath for 10 to 30 minutes.

Add hot water as needed.

Use a cold compress to the back of the client’s neck and/or forehead so the client will

not get congested or have their head over-heat.



REFLEXOLOGY

Starting with the client’s left foot.

Apply lubrication

Shimmy up the foot

Tap the top and bottom of the foot

Shimmy up the sides of each toe

Shimmy up the front and back of each toe

Box each toe and shimmy up

Pinch in between each toe on the web (Works the lymph)

Scoop in between each toe

Roll your knuckle over the top of each toe (Works the sinuses)

Press next to the nail on the lateral side of the big toe

(Blood supply to the brain)

Slide down to the inside of the big toe and press in at the base

(Works the tonsils)

Press in the center of the meaty part of the big toe with your knuckle and turn clockwise 3 times

(Stimulates Pituitary Gland)

Walk your thumb up the outside of the big toe (Works the cervical area)

Pinch the tip of each toe on the nail bed (Works sinuses)

Walk up the outside of the little toe

Press into the base of each toe (5 & 4 Stimulates ears, 3 & 2 stimulates eyes,

1 Stimulates the throat)

The big toe is one and the pinky is five

Push the toes back and place knuckles of one hand into the ball of the foot ¼” down from the base

of the toes (Works the jaw)

Place thumb between big toe and the next toe and glide down and around the ball of big toe

(Stimulates Thyroid)

With a flat pad of the thumb press directly below the ball of the toe (Stimulates the stomach on the

left foot and the liver on the right foot)



Find the upside down V at the base of the ball of the foot, press into it

(Stimulates Solar Plexus)

Drop down ¼” and press (Stimulates adrenal glands)

Drop down ¼” and press (Stimulates Kidney)

Slide down the inside of the arch to just above the heel

(Works the Ureter)

Do not work up and down. Work only down.

Press in at the heel at the lower edge of the arch (Works Bladder)

Glide up the medial side of the foot from the heel to the big toe, use a thumb over thumb or hand

over hand scooping motion

(Works spine)

Cover the left foot

Repeat these steps on the right foot.

Colon Massage

Starting on the left foot

On the outside of the left foot, just above the ridge of the heel

Work the last 1/3rd

of the descending colon 3x

Push down toward the heel and make a turn for the sigmoid colon and rectum

Move up to the second 1/3rd

of the descending colon, pushing downward toward the last 1/3rd

of the

descending colon, work it 3x.

Cleansing stroke

Move up and work the last 1/3rd

of the descending colon three times

Cleansing stroke

Starting just below the ball of the foot on the lateral/outside side of the left foot, work the first

1/3rd

of the transverse colon (move from left to right from your angle) Make the movements in a

horizontal motion

Cleansing stroke



Starting on the medial side of the right foot just below the ball of the foot, then to the medial side of

the left foot, working left to right, work the second 1/3rd

of the transverse colon 3x

Cleansing stroke

Starting on the lateral/outside or the right foot at the base of the ball of the foot, moving left to

right, work the last 1/3rd

of the transverse colon 3x

Cleansing stroke

Starting at the lateral/outside of the right foot just below the ball of the big toe, work the first 1/3rd

of the ascending colon 3x in an upward motion

Cleansing stroke

Work the second 1/3rd

of the ascending colon in an upward motion 3x

Cleansing stroke

Work the last 1/3rd

of the ascending colon 3x

Cleansing stroke

Press your knuckle into the inside of the arch just in and above the ridge of the right heel; turn

clockwise 3x, to stimulate the ileocecal valve

Cleansing stroke

Work the entire small intestine using your knuckles, rub up and down and in clockwise circles to

stimulate the small intestine

Cleansing stroke 3x

Cover the right foot

Finishing the foot

Go back to the left foot

Work the ridge of the heel (Works the sciatic nerve)

Work the lateral side of the heel (Works the ilium)

Press into the center of the heel (stimulates bone formation)

Work the entire heel



Side of the foot

Work the hollow just below the medial side of the ankle bone

(Stimulates the Uterus and Prostate)

Contraindicated if a client is pregnant

Work the hollow just below the lateral side of the ankle

(Stimulates the Ovaries and Testes)

Contraindicated if a client is pregnant

Place your thumbs on top of the foot next to each other midway between the ankle bones; move

down and around the ankle bone and then back up to the starting position (Stimulates Lymph)

Work between each metatarsal (Stimulates breast, chest and lungs)

Work on top of each metatarsal

Work the lateral edge of the foot

(Works the upper and lower arm and elbow)

Wring out the foot working from heel to toes

Angel wings

Tap the foot

Shimmy up the foot

Drag off static energy and throw behind you

Pull toes with permission, cover toes with towel or sheet as not to slip off the toes and hurt the

client, hold the toe and lean back

Repeat finishing strokes on the right foot

Energize














Craniology

CST 201-III Session 5



1. Observe and demonstrate a craniology session

2. Articulate the benefits of craniology.

3. Integrate the techniques used into a therapy session.

CRANIOLOGY PRACTICE:

Proper Positioning

o One partner should be seated with their feet flat on the floor.

If their feet do not reach, then a pillow or books should be placed under their feet.

o The therapist should be standing behind the client.

Routine

1. Start with the suture lines, moving very slowly. Do each line twice.

a. Coronal suture:

i. 1-1.5 inches from hairline. Make half-moon across the suture with the middle fingers,

about finger-width apart.

ii. Move the scalp, not the hair.

b. Parietal (squamous) suture:

i. About 3 fingers over the ears.

c. Lambdoid suture:

i. Supporting forehead with fingers, and working the suture with thumbs.

d. Sagittal suture:

i. Moving both middle fingers simultaneously.

e. Circle of Wills (flat area at top back of head):

i. Working half-moons in a clockwise direction with the thumbs.



2. Lateral Lift:

a. Support head in hands above ears.

b. Lift with the ulnar side of hands as the person inhales, release on the exhale. Do three times

in each position.

c. Move up to the second position and repeat previous moves.

d. Move up to the third position and repeat previous moves.

3. Diagonal Lift:

a. Place right hand on the right side of the occipital area, left hand on left side of forehead.

b. Lift on the inhalation and release on the exhalation. Do three times in this position.

c. Move hands up a little and repeat previous moves.

d. Move up and lift in the third position.

e. Repeat lift on other side.

4. Loosen up shoulders with the heel of the hand in the Trapezius.

5. Work thumbs back and forth across spine, moving up from the third thoracic vertebrae to the

occiput. Work along the base of the occiput, stabilizing the head if needed.

6. Check for vertebral artery syndrome. Then grasping client’s head gently in your hands, move slow

and smooth through a figure-8's. (1) forward, (2) left (ear to the shoulder), (3) back, (4) center, (5)

forward, (6) right, (7) back, (8) center. Do this 3 x.

7. Resists: With an isometric move, have the client push three times increasing the range of movement

each time in each of the positions below (a-d)

a. Forward, while you resist with equal pressure on forehead backwards.

b. Left, while you resist with equal pressure to the right with your left hand.

c. Right, while you resist with equal pressure to the left with your right hand.

d. Back, while you resist with equal pressure forward on back of head.

8. Jaw: Standing behind the client work with thumbs on jaw-line fingers underneath, from chin to TMJ

joint. Do circular motions around the TMJ area. Let your fingers do the walking on the cheek

muscles

9. Eyes: place index and middle fingers of the left hand at top of right-eye orbit on the bony ridge.

The index and middle fingers of the right hand just under the orbit on the bony ridge. Alternate

pressing gently several times. Reverse to do the other eye and sinus.



10. Nose: Using firm pressure

a. Place index fingers on each side of the upper nose by the upper eye ridge and press

superiorly and hold for a moment.

b. Press inferiorly and slightly posteriorly with the middle finger at the base of the nostrils on

the mandible. Do not close airway off.

c. Do the above two moves using diagonal fingers at the same time (i.e. right index finger with

left middle finger, then switch).

d. Using the same finger combination alternate pressing into the nose on the bony ridge.

e. Place index and middle fingers of both hands on both sides of the nose and press superiorly

and inferiorly simultaneously. (a & b combined)

f. Grasp bridge of the nose and move anteriorly.

11. Ears: massage ears between thumb and index finger from the ear lobes to the top of the ear, then

follow the curve of the ear, massage the whole ear. Place a negative polarity (charged) finger (2,4)

in one ear and a positive finger (3,5) in the other ear and hold until a pulse, vibration or heat is felt.

Then switch fingers and repeat to balance the charges.

12. Touch corresponding points along the motor sequence line, just forward of the top of the ears,

follow superiorly in a straight line to the Sagittal suture. Moving your fingers up by about one inch

each time. Use two fingers that are next to each other, hold until a pulse, vibration or heat is felt and

balanced.

13. Touch points along the sensory sequence line, just behind the top of the ears follow superiorly in a

straight line to the Sagittal suture. Repeat moves as in #12 above.

14. Occiput Lift - place thumb and finger of left hand at the reflex point for the vagus nerve at the base

of the head (two outside points of the occiput). Support left elbow on your hip, place right hand on

forehead, and lift firmly on inhalation and release on exhalation, repeat two more times. Do only in

this one position.

15. Rotate knuckles of the forefingers on Upper Trapezius. Then use your elbows, massage the

shoulders and arms.

16. Place fingers on forehead from the bridge of the nose to the hairline on each side of the mid-line.

Press with firm pressure. Move laterally and press, keep repeating until you reach the side of the

forehead. Then move the forehead anteriorly.

17. Balance stapes, incus, and malleus of the ear by firmly grasping the earlobe and taking up the slack

by gently pulling inferiorly. Once the earlobe is stretch in this position then give a firm but gentle

quick tug. The other hand is placed on top the head to stabilize. Repeat on other side. Make sure no

earrings.










The Power of Precision Series: The Essential Principles

Assessment and Treatment Strategies for Soft Tissue Pain and Injury.

By Ben Benjamin, PhD

Video Lecture




1. List area of the body that refers pain.

2. List areas that do not refer pain.

3. Identify and define the types of scar tissue.

4. Identify what causes pain.

5. Define referred pain.

6. List the rules of referred pain.

7. List reasons of lax ligaments.

8. List assessment tools used to help determine appropriate treatment.

9. List principles of resisted tests.

These principles are important to understand when working with clients who are in pain.

66% of all doctor visits are due to soft tissue injuries and pain.

What is an Injury?

o Damage or disruption to tissue.

o Lesion, swelling, or tear.

o Irritation or tissue.



Scar Tissue:

o It is the scar tissue that causes pain to come and go.

o Types:

Good scar tissue: The fibers are lined end to end. In the direction of the original

tissue it is replacing.

Poorly formed scar tissue or Adhesive scar tissue: The fibers are lined in the

wrong direction from the original tissue it is repairing. This random tissue

formation results in the fibers to stick together and re-injury occurs as the tissue

stretches and contracts.

Destructive scar tissue or Adhesive scar tissue:

1. Internal: Fibers stick together within a ligament, tendon or muscle.

2. External: Fibers stick to other structures other than the original tissue.

Referred Pain:

o Definition: Pain felt at a place other than its source.

o Rules of referred pain:

Pain refers distally out from the midline of the body.

It does not cross the midline of the body.

Pain is referred within the dermatomes.

The distance the pain travels shows the severity of the injury.

o Areas that refer pain:

Neck

Thorax

Low Back

Hip joint

Shoulder

Areas that attach to the trunk.

o Areas that do not refer pain:

Knees

Ankles

Feet

Hands



Elbows

Wrist

Hands

Areas distal to the body.

Ligaments:

o Healthy ligaments: The ligament is the correct length and the joint is held firm and

stable.

o Lax ligaments: The ligament is longer than it should be and the joint is not firm and tight

in place.

Reasons for lax ligaments.

1. Congenital-born with this condition.

2. Severe accident-usually on only one side.

3. Chronic injury-an injury that happens over and over.

Examples:

Low back: SI joint

Knee: Lateral collateral ligament (whole knee is unstable)

Knee: Medial collateral ligament

Tension:

o Tension comes before the injury. It leads to postural dysfunction and a less flexible

body.

o The postural dysfunction causes strain on ligaments.

o Is not the cause of pain, but it is the result of injury and then becomes part of the cycle of

pain.

o Tension leads to an inflexible body which allows the body to be more vulnerable when

and if an injury does occur.

o The client that is more flexible and in good health will have a shorter the healing time if

an injury does occur.



Muscle Spasm:

o A muscle spasm is a secondary result of an injury.

o It is a protective mechanism for the body. It helps keep the body in a set position so no

tears occur. As therapists we do not want to relieve this spasm as it is helping the client.

o It is the chronic tension that is a problem. The body has forgotten to stop the protective

mechanism and it is this muscle spasm that we want to remove or work out for the client.

Arthritis:

o Definition: Inflammation within the joint.

o There are many types.

Osteoarthritis: Increased bone growth which can block movement of a joint, but

frequently does not cause pain.

Traumatic Arthritis: Protective arthritis

Increases in the fluid of the joint (inflammation) result in the joint having

limited mobility. This protects the joint/area from additional injury.

Types of Pain:

o Clear Pain: Pain that is easy to identify its source. No referred pain.

o Confusing Pain: Is referred pain.

o Vague Pain: Between clear and confusing pain.

The involved area of the body can be identified; however it cannot be touched

because it is too deep. Creating a vague and diffuse pain.

X-rays do not show pictures of soft tissue injury or damage.

MRI shows serious injuries like disc problems or slight fractures.

Assessment: a systematic way of gathering information on the client and their condition

allowing the therapist to develop and treatment protocol. Also allows the therapist to determine

if they are qualified to treat the condition.

Diagnosis: assigning a name to a condition.



Assessment Tests:

o Resisted Tests: Tests muscles and tendons for injury.

Uses the muscle without movement in space.

Equal and opposite movement.

Pain on resisted motion.

Weakness can also be measured.

Principles of resisted tests:

1. Be gentle.

2. Increase force stepwise.

3. Client should be in a stable position.

4. Test is a stretched position.

5. If client overpowers the therapist, position yourself to have a

mechanical advantage.

6. Equal and opposite force.

o Passive Tests: Tests passive structures (joints, bursa and ligaments).

Tests areas that do not initiate movement.

Client does not help.

Removes the muscles and tendons from the picture.

Jerk test needs additional training and we will not be exploring this

technique.

o Active Tests: No clear information can be gained from this test.

The client moves their own body with not assistance.

Seriousness of the injury and cautions.

Shows how careful you need to be when working with the client.






Postural Analysis & Pelvic Stabilization

CST 201-III Session 7 & 8



1. Perform a posture analysis on client in both the standing and supine positions.

2. Compare structural vs. functional distortions.

3. Explain the benefits of performing a posture analysis on a client as part of a therapeutic treatment

plan.

4. Discuss the “Righting Reflex”.

5. Demonstrate the ability to chart observations.

6. Integrate posture analysis as a tool to assess what muscles to treat.

7. Demonstrate range of motion of the hip.

8. Describe the indications and contraindications when using therapeutic techniques for the hip and

upper legs.

EXPERIMENTS TO TEST THE EFFECTS OF INCORRECT POSTURE

Stand up, round your shoulders forward and slouch. Notice tension at the base of the skull, the forward

head, the restricted breath and the decreased volume in the abdominal area.

Now stand up and arch your low back. Notice the tension in the low back, especially around the sacroiliac

joints. Also note what happens to the knees (hyper-extension)



POSTURE DISTORTIONS

Structural: Malformed bones which cause a misalignment of the skeletal structure.

Functional: Chronically tight (hypertonic) muscles that pull a bone out of proper alignment.

There are 4 general types of functional distortions seen in the body – tilts, flexions, extensions and

projections. The body has two main reasons for functional distortions. The first is the fact that nothing is

done to restore the body to its correct posture after injury or repetitive motion. The second is the

“Righting Reflex”. The Righting Reflex is the body’s innate need to keep the eyes level with the

horizon and forward. The body will reflexively do whatever is necessary to achieve this.

Postural Analysis

Textbook: MTPP

Handout – Postural Analysis Worksheet

1. Charting

2. Client Standing: See attached sheet

3. Client Supine: Swing client’s legs. (This is to make sure the client is positioned correctly on the

table and to note any restrictions and limitations and pain with movement.)

4. Client Supine: Check the horizontal plane of the ankles by hooking up under the medial malleolus.

NOTE: The client is measured in this position, as the ankles are difficult to measure when the client

is standing. It is a great way to see of the client has a leg length discrepancy.

5. Client Supine: Check at the knees:

a. Push inferiorly on the head of the fibula.

b. Push inferiorly on the superior edge of the patella.

6. Client Supine: Measure the horizontal plane at the level of the ASIS.



Hip Range of Motion (ROM)

Acetabulum Rotation

Client Position: Supine

Contraindications: Do not perform these techniques on someone who has had a hip replacement.

Goal: To gently stretch the muscles and ligaments of the acetabulum-femoral joint.

Move the femur through a half arc or “u” shaped motion. Repeat this movement several times

paying attention to client’s comfort level.

Torquing


Indications:



Note: Be sure to keep the client’s knee at a 90 degree angle at all times to minimize the stress on the

client’s knee. Be sure to communicate with the client asking for feedback. The client should feel a

stretch in the hip and gluteal area during this technique.

1. The therapist will gently torque the client’s hip as they take the client’s leg through the same range

of motion as the acetabulum rotation.

2. To accomplish the torque at the head of the acetabulum –

a. First, start by pushing the knee away from you while you are gently pulling the ankle toward

you.

b. Second, as you are pulling the knee toward you, gently push the ankle away from you.

c. Perform steps one and two while taking the knee through the acetabulum rotation.

3. Repeat 2 – 5 times.

Helpful Hint: The knee should always lead the movement for this technique.



359 Rotation


Indications: To correct femoral head alignment



Note: There are four steps to the technique.

1. Place one hand lateral to client’s knee and place other hand on plantar portion of client’s foot.

Gently push the client’s bent knee into their chest or to client’s tolerance. Hold for 5 – 10 seconds.

(This is a muscle energy technique) Repeat 2 more times.

2. Utilizing the same hand position as Step 1, hold the bent knee into the client’s chest as you instruct

the client to straighten their leg against your resistance with 20 % of their strength. Repeat this 2

more times, taking up the slack each time.

3. Glide the client’s leg in an arc, start with the leg almost straight and bend the knee as you move the

leg laterally and superiorly toward the chest as you did in the acetabulum rotation. Continue moving

the leg medially and inferiorly until the leg is almost straight. (Henceforth called the 359 rotation)

Be sure to support the client’s knee so it does not become hyperextended. Return from the almost

straight leg position, moving medially and superiorly toward the chest, then laterally and then almost

straightening the leg. Repeat 2-3 times.

4. Bend the client’s knee into their chest. Lower the bent leg laterally and hold the knee down gently

on the medial surface with the superior hand. The other hand is holding on the bottom of the client’s

foot. The therapist hip is holding against the tibia area of the client’s lower leg. The therapist will

ask the client to slowly straighten their leg while the therapist is applying resistance (isotonic

movement). Gradually guide the laterally rotated leg until it is almost straight. The therapist should

rotate the hand that is on the knee to protect the client’s knee from hyperextending. Gently place the

leg back down on the table.



Isometric Contractions

Anterior Rotation (Tilt) Correction


Indications: Used to correct an anterior rotation/tilt of the pelvis

Contraindications: Do not perform these techniques on someone who has had a hip replacement, loose

ligaments/hypermobility or low back pain.

1. After supine posture analysis, lower the client’s short leg off the table with therapist on the same

side.

2. Therapist places superior hand on the opposite ASIS, this hand must hold firmly to insure that no

movement of the hip occurs.

3. Place the inferior hand on the thigh just proximal to the knee.

4. Ask the client to raise their upper leg toward the ceiling with about 20% of their strength with

therapist meeting it equally to allow no movement to occur.

5. Repeat 2 more times. However during each repetition the leg will be lowered farther toward the

floor. (Optional movement: the leg can also be moved laterally)

6. Repeat on the opposite leg.

NOTE: Alternative client position can be used for clients with low-back pain. Instead of having leg off

table, leg can remain on table with other knee bent.

Pubic Symphysis Correction

Client Position: Supine with knees bent; Heels placed 10 – 12” from the gluts with ankles together.

Indications: To correct the alignment of the pubic symphysis

Contraindications: Do not perform these techniques on someone who has had a hip replacement or loose

ligaments.

1. Outward Movements – The client moves their knees apart, while the therapist resists with equal

pressure on the lateral part of client’s knees.

1st position: Knees together

2nd

position: Knees 6” – 10” apart

3rd




2. Inward Movements – The client moves their knees together, while the therapist resists with equal

pressure on the medial portion of client’s knees.

1st position: Knees 12” – 16” apart

2nd


3rd

position: Knees almost together

NOTE: Be careful when working with male clients, as they may pinch themselves. They may need

to readjust before using this technique.

Sacroiliac Joint Mobility

Hip Hiker


Indications: Affects the quadratus lumborum as well as loosens the sacroiliac joint allowing it to glide

freely: Makes a great home exercise for clients. It will help the client have a better stride when walking, as

well as free up their tight backs.

Contraindications: SI joint hypermobility.

Note: The movements should be done effortlessly and there should be no pain.

1. Client is still supine, with both knees bent and feet flat on the table

2. Therapist hands are resting on the client’s ASIS while facing the client

3. Direct the client to move their right hip toward their right shoulder and at the same time have them

move their left hip toward their left foot.

4. Alternate the hips.

5. Once the client understands and can demonstrate the movement correctly, have them continue the

movement 10 – 20 times on their own.

Helpful Hint: You can help the movement by instructing the client to push their foot into the table or

project their bent knee toward the corner of the ceiling and wall of the room.



Pelvic Rock


Indications: SI joint hypomobility

Contraindications: Do not perform technique on a client that has osteoporosis or SI joint hypermobility or

osteoporosis.

1. Instruct the client what you will be doing.

2. Get permission to get on the table with your client

3. The client is supine with knees bent (allowing the hips to fall laterally), ankles together.

4. The therapist is kneeling at the foot end of the table. The therapist thighs/knees support the client’s

laterally rotated hips.

a. Place right hand on the ASIS – this hand will gently push posterior (toward the table) and

slightly superiorly.

b. The left hand reaches towards the PSIS pulling in an inferior and anterior motion.

c. Hands move in an opposite motion creating a rocking motion.

d. Alternate the right and left hand and repeat.

e. Feel for restrictions.

f. If restrictions are felt, the side that is restricted can be worked a few more times until it is

looser.



Medial Press – Ilium Compression

Modification of Erichsen’s Test – a test for hypermobility


Indications: SI joint hypomobility

Contraindications: Do not perform technique on a client that has osteoporosis or SI joint hypermobility.

1. Instruct the client what you will be doing

2. Get permission to get on the table

3. The client is supine with knees bent (allowing the hips to fall laterally), ankles together

4. Therapist’s hands are on the client’s ilium. Palms are cupping the ASIS with the fingers rotated

toward the ceiling.

5. Ask the client to put their hands on your elbows to assist with the compression. Let them know you

will instruct them as to when to push.

6. Gently compress the ilium together, now the therapist can ask the client to gently push.

Alternate Methods:

Client Position: Side-lying

Press down on upper ilium.

Client Positions: Supine

Place towel under client’s hips and pull ends of towel together over the ilium.


Therapist reaches across to opposite ilium and pulls towards self with therapist’s knee stabilizing

ilium on side closest to therapist. A towel should be used as padding between therapist’s knee

and client’s ilium.


Therapist can use elbow of one arm to stabilize ASIS on side closest to them while pulling the

opposite ASIS with fingertips.



Psoas

Client position: Supine

Indications: To correct anterior rotation/tilt or torque

Contraindications: Abdominal Aortic Aneurysm

1. Have client bend knees up

2. Locate ASIS and navel. Place fingers halfway between

3. Angle fingers towards the spine and gently circle down

4. Have client press leg into therapist arm closest to leg. Therapist should feel psoas pop into hand. Or

they may feel the psoas relax if it was already fully contracted.

5. Remember to gently come back out of position

Iliacus

Client position: Supine


1. Bend client’s knees up

2. Grasp around ilium

3. Rock client’s leg back and forth

4. Move hand further up

Long Leg/Short Leg

Client position: Prone


Contraindications: Hip replacement or herniated disc

1. Measure client – determine short leg due to a functional posture distortion.

2. Therapist stands on the opposite side of the table to the short leg.

3. Cradle the client’s leg at the knee

4. Place your other hand on the client’s sacrum

5. Lift the cradled (short) leg up and slightly across the body towards you.

6. Repeat 3x – each time stretching across the body a little more within the tolerance of the client.

7. Move to the other side of the table and repeat with the long leg.

8. Return to the first (short) leg and repeat this leg. Short leg is worked 2:1

Note: Work with the breath lifting leg on the exhale and returning it to the table on the inhale.



Frog

Client Position: Prone and moved all the way over to the same side of the table that therapist is working on

with leg easily moved off the table.

Indications: To gently stretch the muscles and ligaments of the acetabulum-femoral joint.


1. Have client hold on to the opposite edge of the table for security.

2. Lower the client’s leg off the table – knee bent.

3. Therapist cradles the knee/leg.

4. Therapist uses a passive circular motion when moving the hip thru its ROM 3 – 5x. Beginning with

small circles gradually increasing in size. Always staying within the comfort level of client.

Note: Direction of circle is Superior – Posterior – Inferior – Anterior

Motorcycle

Client Position: Prone and moved all the way over to the same side of the table that therapist is working on

with leg easily moved off the table.

Indications: Hypertonic quadratus lumborum and hamstrings


1. Have client hold on to the opposite edge of the table for security.

2. Lower the client’s leg off the table – knee bent.

3. With therapist facing the head of the client, place client’s foot above the therapist’s knee about mid-

thigh.

4. Therapist uses their other leg to sandwich the client’s foot.

5. The therapist’s arm closest to the table will lightly be placed along the sacrum and spine of the client

for stability.

6. The therapist’s other hand holds the knee.

7. Move the leg gently towards the client’s head feeling for resistance. When resistance is felt – stop -

- come back a little.

8. Have client do a 20 % isometric push trying to straighten their leg.

9. Repeat 3 – 5x each time moving closer to the client’s head until resistance is felt always staying

within the comfort level of the client.

Note: Therapist MUST keep their knee bent and locked as client pushes against the leg to prevent

hyperextension of the knee.



STANDING POSTURE ANALYSIS

Horizontal Landmarks – should be symmetrical

Anteriorly check for the following:

Arches

Medial malleoli

Fibular Head

Patella – Can be checked to determine if they are level, but is not an ideal landmark as it can be easily

moved around. Also check where they are “pointing”

Greater trochanter

ASIS

Iliac crest

AC joint

Ears

Eyes

Head tilt

Level of fingertips can also be observed

Posteriorly check for the following:

Calcaneus

Creases of the knee

Posterior superior iliac spine

Scapulas – check that superior angles are level; check that distance of medial borders to spinous processes

are equal

Occiput

Ears

Vertical Landmarks – should be perpendicular to ground

Midsagittal Plane

Nasal septum

Manubrium

Pubic symphysis

Coronal Plane

External auditory meatus

AC joint

Humeral head

Femoral head

Lateral epicondyle of femur

Lateral Malleolus

Check relationship of ASIS to PSIS

Normal anterior tilt: Men 0 – 5 degrees

Women 5 – 10 degrees








Gait Analysis

CST 201-III Session 7 & 8



1. Demonstrate the ability to perform a “working” gait analysis

2. Demonstrate the ability to use and document assessment tools learned throughout trimester.

3. Demonstrate the ability to prepare and implement a treatment plan.

4. Perform treatment as determined necessary with the use of assessment tools learned and using any

or all modalities learned throughout the year whether weekend seminar or classroom.

5. Demonstrate the ability to chart all observations using SOAP notes

Gait Analysis

Check the following:

A. Stride

1. Does one leg step out farther than the other?

2. Is it equal distance?

3. Do legs swing straight out in front or move side to side?

4. Is it smooth and free-flowing?

5. Is there a shuffle or limp?



B. Arm Swing

1. Does one arm swing out farther?

2. As one leg moves anteriorly the contralateral arm moves concurrently.

3. Does it look smooth and flowing or choppy?

4. Can you evenly see the space between thumb and first finger facing forward? Or is one arm

rotated?

C. Heel Strike

1. Heel hits ground first

2. Flat foot

3. Mid-stance

4. Toe off

5. Are feet rotated internally or externally?

6. Foot slapping

7. Sound - -does one foot sound louder as it hits?

D. Hip Movement

1. There should be some free –flowing movement

2. Too much movement

3. Pelvis remains level during mid-stance

E. Shoulders

1. Shoulders level

2. Free movement

F. Head Tilt

G. General Observations

1. Any appearance of pain with walking

2. Any splinting of a body part – doesn’t move freely






Clinical Application of Massage




1. List causes of injury.

2. List and explain stages of rehabilitation in sequential order.

3. Identify and define the types of tissue repair.

4. Describe how massage can influence remodeling.

5. Differentiate the influence of vascular vs avascular tissue in the recovery time of that tissue.

6. Name and describe factors that affect recovery time.

7. Define trigger points and describe how to identify them by their symptoms.

8. List and explain three important issues of aftercare.

9. Describe and demonstrate education issues that the therapist should use when deep tissue massage is

part of the treatment protocol.

Clinical Application of Massage Therapy:

Although massage therapists cannot diagnose, they can and must assess the client’s condition.

Assessment is vital in proper formulation of a treatment protocol for the client.

Causes of Injury:

o New activities to which your body is not accustomed.

o Weekend warrior activities.

o Maintaining a particular position for an extended period.

o Repeated movements of any kind.

o Trauma



Stages of Rehabilitation:

o Reduce muscle spasm.

o Assess and correct faulty body mechanics.

o Restore flexibility to muscles and joints.

o Rebuild muscle strength.

o Build endurance.

o Address diet, stress and emotional well being.

Understanding tissue damage:

o Tissue damage results from injury by:

1. Physical or mechanical means.

2. Chemical irritants.

3. Exposure to extreme temperatures.

o Injuries resulting from trauma may be acute or chronic

Acute: Refers to those conditions that last for a short time, usually a few days to a

few weeks.

Chronic: Refers to conditions that have a long duration - in some cases a lifetime.

o Tissue damage is often referred to as lesion.

A lesion is any noticeable or measurable deviation from the normal composition of

healthy tissue. Examples: mole, wart, break in the skin or a torn muscle.

o Repair of damaged tissue:

Resolution: Tissue healing involving tissue replacement. This occurs as long as

cellular membranes are intact and nuclear contents are present.

Regeneration: Tissue healing that occurs when damaged tissue is replaced with new

tissue of the same type. There must be enough undamaged tissue in the area to

reproduce itself.

Fibrosis: A process in which the original tissue type is replaced with a different kind

of tissue. Fibrosis occurs when the damage is so severe that there are not enough

healthy cells to reproduce the tissue required or when the damage tissue does not have

the ability to readily reproduce itself. The scar tissue formed by fibrosis is usually

stronger than the original tissue.

Remodeling (also called scar maturation phase): The process by which collagen

fibers in the scar tissue are formed randomly following fibrosis.

Note: The remodeling phase can be influenced by the therapeutic techniques performed by a

massage therapist.



o Factors that influence recovery time:

Age.

Wound condition.

Rehabilitation.

Health of the patient.

Nutrition.

Circulation:

Skin has the most abundant blood supply; therefore it heals the fastest, about 3

to 7 days.

Muscle:

Soreness: 24 to 72 hours.

Mild (minor) muscle tears: 3 to 7 days.

Moderate muscle strain: 1 to 6 months.

Mild contusions: few days.

Moderate contusions: 4 to 6 weeks.

Severe contusions: 2 to 6 months.

Bone:

Simple fractures: 3 to 5 weeks.

Fractures that cannot be cast: 4 to 10 weeks.

Tendons:

Mild strains (tear): 5 to 7 days.

Moderate strains: 7 to 10 days.

Severe strains: 3 to 6 weeks.

Ligaments are fairly avascular collagenous tissue.

Mild sprains: 2 months.

Moderate sprains: 6 months.

Complete ruptures need surgeries.

Nerves: Nerve regeneration is possible but it is extremely slow.

Cartilage is such an avascular tissue it cannot repair itself; therefore surgeries

are often needed.



o Common Techniques Used in Clinical Massage

Ischemic compression

Cross-fiber friction

Myofascial release

Flushing effleurage

Joint mobilization and stretching

o Sample of a clinical application protocol

Assessment phase-check out what is going on with the client

Preparatory phase-warm the tissue

Palpatory phase-explore the tissue for areas to target treatment

Treatment phase-treat these areas with a variety of techniques

Interval phase-giving the tissue a break

Retreatment phase-return to problem areas

Recovery phase-flush the tissue with a final effleurage to remove metabolic waste

and decrease residual soreness

Aftercare phase-instruct client in proper use of ice, water intake, and modify

activities of daily living

o Trigger point

Definition: Trigger points are hypersensitive areas found in muscles, tendons,

ligaments, skin, periosteum, and even organs.

Hypersensitive indicates that it takes little additional stimulation to cause discomfort.

Referred pain phenomena are the tendency of trigger points to produce sensations.

Sensations such as pain, tingling, numbness, itching, aching, heat, or cold. Referred

pain is distal from the trigger point. Occasionally, the pain is produced beneath the

trigger point itself, like a bull’s-eye.



Types:

Active trigger point: painful when no external physical stimulation takes

place. This area will reproduce the symptoms which the client has been

suffering with.

Latent trigger point: remain hidden until activated by some stressor such as

physical activity, emotional stress, or active status. A latent trigger point may

cause a muscle to weaken, shorten, or become stiff. It can restrict range of

motion (ROM) and therefore are common sources of movement limitations.

Symptoms of trigger points:

Local twitch response: it is a local reflexive impulse that causes the affected

muscles or an adjacent muscle to fire spontaneously.

Jump sign: is a spontaneous reaction of pain or discomfort that may cause a

client to wince, jump, or verbalize on application of pressure.

o Aftercare

Ice: Ice numbs the soreness while the pack is in place and minimizes the soreness felt

the next day.

Water: Drinking plenty of water helps flush out the toxins such as lactic acid and

reduce residual soreness.

Healthy muscle tissue is well hydrated.

Excessive muscular tonus and spasm may restrict the flow of blood and

lymph.

Education: it is necessary to educate the client receiving deep-tissue work about

expectations regarding their pain level during and after treatment.

1. Some increase soreness is quite common and may be expected.

2. This soreness could last a couple of hours to 1 to 2 days.

3. Aftercare can reduce the degree and length the soreness lasts.

4. If the client chooses not to use the aftercare skills taught be the therapist the

therapist cannot be held liable. This should be noted in the client’s chart.

5. Good communication is necessary during treatment. Therapists must use

caution not to over treat an area. Clients must communicate the level of pain

felt during the treatment. If either is ignored, the client can be extremely sore.

And adjustments for future visits.

6. Physical condition of the client will influence the modality and duration of the

treatment.



Please Read:

The following information is to help guide the student through the remainder of the school year and

into their professional careers as massage therapists. This information is to help the student realize

that there is very little that is completely black and white in massage and that we as therapists must

look at the whole person and that individuals circumstances. Much of the information is review;

however, we know that review is how to remember things. We want students to start to critically

think through what is the best for meeting the client’s needs. Critically thinking is a process and if

you work to develop it, it will become easier. Proceed with caution; however it is okay to take

calculated risk. Remember to get informed consent from your clients. It is okay to refer to your

handouts when performing new protocols. Trust yourself. Develop confidence. Become the best

therapist.



GUIDELINES/PROTOCOL FOR BLUE SKY STUDENTS

(Based on information from A MASSAGE THERAPIST'S GUIDE TO PATHOLOGY 2nd Edition

by Ruth Werner)

IMPORTANT NOTES:

We are treating individuals NOT conditions or diseases

Everyone needs touch. When you work on a client, work with confidence and nurturing intent.

Communication is EXTREMELY important therefore ask the client what they need and empower

them to ask especially during the session

If you are not familiar with medical condition or disease, ASK THE CLIENT about it...how it affects

them, if they have had massage since being diagnosed, what their limitations are physically, etc.

Clients don't always need "hands on" massage or deep tissue work. Remember to utilize all of the

skills you have learned including lymphatic, Polarity, Jin Shin Do, Reiki, etc.

The following information is guidelines...not gospel. Use your judgment and logical thinking to

understand why/why not perform a technique.

DIABETES (a metabolic disorder)

Massage therapy/bodywork is OK under the right circumstances: client has healthy, responsive

tissue with good blood supply.

Energy work is appropriate anytime but especially indicated where massage/bodywork is not

appropriate: advanced diabetes, kidney failure, pitting edema, lack of sensation due to diabetic

neuropathy.

Check with client to see that they have eaten within the last hour or so to prevent blood sugar from

getting too low with massage. Also, make sure they have something with them or that you have easy

access to candy, juice, etc. in case of low blood sugar.

HEART DISEASE (a circulatory disorder)

Massage therapy on HEART ATTACK survivors depends on how long it has been since the heart

attack and what the outcome was (ex. bypass surgery, exercise regularly, etc.)

Massage therapy for clients with CONGESTIVE HEART FAILURE is contraindicated though

energy work may be helpful with stress.



HYPERTENSION a.k.a. HIGH BLOOD PRESSURE (HBP) (a circulatory disorder)

Predisposing factors: obesity, smoking, high cholesterol, atherosclerosis and water retention

If a client has HBP but is not required to take medication, massage is probably OK as it may help to

lower blood pressure

If a client has HBP and is taking medication for it, make sure the HBP is under control with meds.

Also check if the client has had massage therapy since being diagnosed.

Deep abdominal work is ALWAYS contraindicated for HBP.

CANCER

Determine how long the client has had cancer, if it is "active" or in remission. If a client has been in

remission for 5 years or more, the client may be considered "cured" and it is therefore OK to perform

massage therapy.

When in doubt, get doctor's authorization (especially if the client has active cancer and/or has been

in remission for less than 5 years), use energy work or very light or lymphatic type massage

If massage is performed, do not work directly on tumor, undiagnosed swelling, thickening of tissue,

radiation burns or lymphedema. (NOTE: Blue Sky training in lymphatic massage DOES NOT

mean you are qualified to work on an area of lymphedema)

If client is feeling nauseous, do not use rocking, shaking or tapotement techniques.

CONTACTS

Inform the client that they might want to remove their contacts so they don't dry out or stick to their

eyes due to pressure from face cradle and/or keeping eyes closed and not blinking.

ALCOHOL

DO NOT work on anyone who has had alcohol within an hour of the massage therapy session as

massage will increase metabolization of the alcohol and impair the client. Also, since alcohol is a

depressant, the client may not have the sensation or pain response they would without alcohol.

VARICOSE VEINS (a circulatory disorder)

Twisted or "ropey" superficial veins found more often in women than men

If a client has one varicose vein and no other medical issues, it is OK to LIGHTLY work over the

varicose vein (use your judgment)

If a client has multiple varicose veins and/or other medical issues, this is a local contraindication:

DO NOT massage over or distal to varicose veins though it is OK to massage the feet if the client

has varicose veins (use your judgment)



FIBROMYALGIA

Clients are hypersensitive and easy to over treat. Clients may change the type of work they want

(ex. light or heavy pressure) from session to session as well as body part to body part (ex. the left

arm may be more sensitive than the right). Check with the client before and during each session to

determine if the pressure is appropriate.

Energy work may be appropriate if client is extremely hypersensitive.

Cold application is contraindicated.

MULTIPLE SCLEROSIS (a nervous system condition)

Client symptoms may be exacerbated by heat so take care to make sure the environment is not too

hot for the client.

DO NOT over stimulate the client as painful, uncontrolled muscle spasms may result.

If the client has sensation, massage may help reduce depression, spasticity and stress.

If the client DOES NOT have sensation, lymphatic or energy work is more appropriate.

OSTEOARTHRITIS a.k.a. DEGENERATIVE JOINT DISEASE

If client is in an acute inflammatory stage, massage is contraindicated; however energy work may be

appropriate.

If the client has chronic osteoarthritis, massage is indicated to relax muscles which will, in turn,

reduce pain.

RHEUMATOID ARTHRITIS

If client is in an acute inflammatory stage, massage is contraindicated; however energy work may be

appropriate.

If the client has chronic rheumatoid arthritis, massage is indicated to relax muscles, which will, in

turn, reduce pain. Massage may also help to balance the autonomic nervous system, which may

reduce the incidence of attack.



MEDICATIONS:

NOTE: Massage may affect how the body metabolizes medications. Be sure to check with the client

frequently during the massage session to make sure the client isn't experiencing any adverse effects. As

with any massage, be sure to direct the client to turn to one side before they get up and get up slowly in case

dizziness occurs.

Diuretics: If client is on a diuretic, DO NOT suggest to the client to "drink plenty of water" as the

client may be on a fluid restriction.

Anticoagulants: Client may bruise more easily therefore avoid using deep work, compression,

friction, tapotement and skin rolling.

Hormones: (including hormone replacement therapy, birth control). Estrogens may change blood-

clotting abilities.

Steroids: Used to treat inflammatory conditions therefore do not utilize techniques such as friction,

skin rolling or stretching methods that may create inflammation.

Anti-infectives: (including antibiotics, antivirals, antifungals, etc.) Those taking anti-infective

medications have a compromised immune system; therefore it is important to avoid overstressing the

system.

Central Nervous System Medications: (including antianxiety/sedatives, antipsychotics,

antidepressants, anticonvulsants, antiparkinsonism agents). Massage can increase or decrease the

effects of these medications depending on the techniques and intention.

Analgesics/Pain Relievers: (including codeine or other narcotics, aspirin, acetaminophen/Tylenol

and naproxen/Aleve) Pain perception is inhibited when taking analgesics. Reduce the

intensity/pressure of massage and avoid techniques that cause inflammation. NOTE: Aspirin thins

the blood therefore watch for bruising.

Anti-inflammatory: (including non-steroidal anti-inflammatory medications [NSAIDS] such as

aspirin, ibuprofen, naproxen/Aleve). Used to treat inflammatory conditions therefore do not utilize

techniques such as friction, skin rolling or stretching methods that may create inflammation.



PREGNANCY

PREGNANCY CONTRAINDICATIONS HIGH RISK PREGNANCIES = **Do not proceed without

written release of physician**

Diabetic Mother

Cardiac Disorders- heart disease

Chronic Hypertension

Previous Problem in Pregnancy - previous miscarriage

Mothers under 20 or over 35

Asthmatic Mother

Suspected RH Negative Mother or other genetic problems

Drug addictions or exposure to drugs

Previous multiple births

Proceed With Caution if no prenatal care (Physician's Release Advised)

CONTRAINDICATIONS FOR MASSAGE DURING PREGNANCY = When in doubt, be conservative and

consult the physician with any questions and/or obtain release to work on client.

Any woman with a "high risk" pregnancy unless specifically authorized by the treating physician

(see previous section for conditions considered "high risk")

Abdominal massage and hot packs totally contraindicated for 1st trimester and limited to

superficial effleurage for remainder ***be sure to get consent to work on abdomen***

ROM - do not do movements when nausea present; or when symphysis pubis separates (2nd

trimester). Use caution when utilizing ROM techniques. The hormone relaxin affects the

composition of collagen in the joint capsules, ligaments and fascia to allow greater elasticity,

which in turn, creates more yield in the abdomen.

Pressure point around ankles and Achilles tendon should be avoided; pressure point between

thumb and finger should be avoided

Rocking or rhythmic motions if client is experiencing morning sickness

Swedish strokes that affect circulation should not be used in the 3rd trimester if the client has a

heart condition

Tapotement, cross-fiber friction, deep tissue, acupressure and ischemic compression

contraindicated on the legs because of the increased danger of blood clots during pregnancy



OTHER CAUTIONS AND TIPS:

Client should urinate immediately before treatment and will sometimes need to get up during

treatment.

Avoid the used of essential oils as some induce uterine contraction/miscarriage. Exceptions after

the first four months are:

3-5 drops of Lemon oil can be added to a warm foot bath to ease the aching of varicosities

Lavender has a calming effect (use 1% dilution: mix 10 drops essential oil in 50 ml carrier

oil)

Neroli helps decrease gastrointestinal smooth muscle spasm (use 1% dilution: mix 10 drops

essential oil in 50 ml carrier oil)

Tangerine has an uplifting effect (use 1% dilution: mix 10 drops essential oil in 50 ml carrier

oil)

Assist client on and off the table where necessary

Carole Osbourne-Sheets, author of Pre- & Perinatal Massage Therapy, states that the best

prenatal table is one that inclines not one with the pregnancy cut-out option

For women experiencing heartburn, the client should complete any meals at least two hours

before massage to minimize symptoms.

Allow the client to change position often if necessary

** NOTE: For the comfort and safety of the pregnant woman, eliminate the prone positioning

after the first 13 weeks, regardless of your or the client’s perception or preferences in this

regard**

In this position the weighty uterus rests against the inferior vena cava and may create supine

hypotensive syndrome.

SIDELYING POSITIONING GUIDELINES

Best to lay on the left side to avoid compression on the vena cava which runs on the right side of

the body

Maximizes maternal cardiac function and fetal oxygenation

Avoids sinus congestion despite increased mucus production

Reduces uterine ligament strain

Decreases edema (lays flat)

Avoids increased intrauterine pressure or supine hypotension

Facilitates sharing/talking/communication (face not buried in the face cradle)



SUPPORT PLACEMENT IN SIDELYING POSITION:

Where needed for horizontal spine alignment

Under abdomen

Under upper leg (ex: if client is lying on left side, right leg is supported by pillow/bolster and

right leg is almost completely extended) OR between the knees

Under upper arm (ex. if client is lying on left side, right arm is supported by pillow/bolster)

ELDERLY/GERIATRIC CLIENTELE

Skin is thinner, circulation is not as efficient (especially to the extremities), bones are more fragile

and these clients may be taking multiple medications for various medical conditions. People who

are elderly are not sick because of these conditions because the aging process is normal. They are

often depressed and alone and crave sensory stimulation.

Depending on the situation, shorter and lighter massage is appropriate for this population.

DENTURES

Alert these clients that their dentures may fall out when they are face down therefore they may want

to remove them before beginning massage.

AROUSAL RESPONSE OF CLIENT

If the arousal is a simple neurological response, it can be ignored.

If the arousal is intentional/sexual and the client becomes inappropriate, end the session immediately

and contact your supervisor.

SKIN CONDITIONS:

NOTE: If the skin has been compromised in any way (broken skin, open skin, scabbed skin, etc.) the area

is at least considered a local contraindication.

Common warts: a virus; a local contraindication or gloves and tea tree oil can be used if the

therapist chooses to work on the feet.

Contact dermatitis: a non-contagious skin rash usually brought about by an irritation or allergic

reaction; it should be treated as a local contraindication.

Eczema: a non-contagious skin rash usually brought about by an irritation or allergic reaction; it

should be treated as a local contraindication.

Hives: non-contagious; it should be treated as a local contraindication.



Psoriasis: non-contagious; it should be treated as a local contraindication in the acute phase.

Athlete's Foot: a fungus; a local contraindication or gloves and tea tree oil can be used if the

therapist chooses to work on the feet.

Acne: Pimples are infections where the skin is compromised; it should be treated as a local

contraindication.

SURGERIES

If surgery is recent, make sure that the incisions are completely healed with no weeping areas.

Depending how recent the surgery and what type, you may need to get a doctor's authorization. The

area should at least be a local contraindication.

If the surgery is not so recent, depending on the type of surgery, massage would be beneficial to help

to break up scar tissue and keep the tissue mobile and flexible.






Spine and Thorax: NMT Seminar Review




1. Demonstrate a more specific treatment to the spine and thorax than with relaxation techniques

alone.

2. Demonstrate the ability to both recognize and treat trigger points.

3. Discuss an overall review of the PNMT Spine & Thorax seminar.

SUGGESTED READING:

1. Spine and Thorax, Doug Nelson’s PNMT Seminar Book.

BEFORE CLASS:

Review PNMT Spine and Thorax Manual

1. Understanding Back Pain: Review Structure and the Back and Low Back Pain Overview . Any

back pain that may seem to originate from unusual pathology felt by the therapist (bulges,

protrusions, abnormal curves, etc.) which has not been addressed by a healthcare professional

should be referred to a specialist (Chiropractor, Neurologist, etc.) since any deep manipulation of a

herniated disk, etc. could lead to complications and further pain issues for the client.

a. Review all tests/assessments

2. Fascia: Review the Notes About Fascia. Understanding fascia, what it is and how to work with it is

key to helping many pain conditions of the body.

a. Reviewing much of the pre-warming techniques taught earlier is ideal here. Go over the

common myofascial release (gentle stretching) and NMT (thumbs used mostly to engage and

release the fascia) techniques, as well as skin rolling.



b. Go over Spinal Myofascial Warm-up in class as a sample of how to warm up the back prior

to working specifically.

c. Responds best to moist heat

NOTE: Since the body is a holistic unit, to focus only on the site of pain may not be the most effective

method in helping our clients. For example, it’s not unusual for clients suffering low back pain to need

some work done on the psoas or abdomen (because of the attachment sites of the muscles in question

pulling on the hip and SI joint). Clients with severe pain along the medial border of the scapula may

need some deep work along the inferior boarder of the clavicle and AC joint (tight pecs can often pull

the AC joint forward and contribute to this painful condition). So as therapists, we need to think

globally, not locally when we address our client’s complaints. Again, become critical thinkers!

3. Upper Back: For this segment some review of pages will be helpful. Focus primarily on developing

the palpatory skills to feel the tissue along the medial and inferior boarders of the scapula, as well

as the often tight band of muscles between the spinous and transverse processes.

a. Treat area

b. Give the tissue a chance to rest!

c. If the trigger point isn’t released, move to another area then come back to the area at a later

time in the session.

4. Middle Back: Emphasis will be on the key concepts as addressed in the Upper Back above.

5. Lower Back:

NOTE: Learning how to adequately address the QL (Quadratus Lumborum) muscle is essential to

helping clients with low back pain. Nearly all clients that experience low back pain will have issues in

the QL. Pay special attention to the attachment sites along the iliac crest and transverse processes. Be

careful when working attachments along the 12th

rib.






Additional Conditions That Affect The Hip




1. Assess common complaints related to the hip.

2. Formulate a treatment plan to address client concerns.

3. Demonstrate techniques appropriate to client condition.

4. Demonstrate effective communication skills with client before, during, and after the massage.

5. Recognize when referral to another health care provider is appropriate.

6. Recognize that our goal is treating clients, rather than conditions.

SUGGESTED READING:

1. PATH

2. MTPP

3. Trail Guide to the Body



HIP CONDITIONS

For most of our clients presenting with hip disorders, no physician’s diagnosis will be available for our

reference.

In general, massage treatment goals for hip conditions include:

A. Muscle spasm reduction.

B. Increased circulation.

C. Decreased swelling.

D. Maintaining/improving ROM.

E. Adhesion removal.

F. Stress reduction.

G. Pain relief and supporting adjacent tissues.

Among our tools to assess a client and create our treatment plan are:

A. Pain Charts

B. Trigger Point Charts

C. Dermatomes

D. Myotomes

E. Muscle Testing

F. Special Tests

Pathologies common to hips include:

A. Osteoarthritis/DJD (Degenerative Joint Disease)

B. Bursitis

C. Sciatica

D. Piriformis Syndrome

E. Hip Replacement

F. Leg Length Issues

Osteoarthritis

Osteoarthritis is directly related to skeletal and postural difficulties.

Tendons and ligaments can be torn or stretched as a result of injury, exercise, or aging.

Fascial tissues tend to thicken and become rigid from overuse. When the body tries to compensate,

bone spurs may appear in joints and on bones.

While bodywork cannot cure arthritis it can alter postural difficulties enabling arthritic sufferers to free

themselves from the pain and limitations of the disease. Ida Rolf, in her book Rolfing: The Integration of

Human Structures states that “Many diagnoses of arthritis reflect nothing more than a shortened or

displaced muscle or ligament from a recent or not-so-recent traumatic episode.”



Sciatica

Most complaints of sciatica are actually Piriformis Syndrome in which the sciatic nerve is compressed by

the piriformis muscle creating identical symptoms.

In approximately 15 – 20% of the population, the sciatic nerve actually passes through the piriformis

muscle itself.

In both cases (Piriformis Syndrome and Sciatica), deep work directly over the sciatic nerve is

contraindicated.

NOTE: If a client presents with a diagnosis of true sciatica, we recommend consulting the

physician for guidance.

Bursitis

Bursitis can be caused by injury, repetitive stress of nearby muscles, infection, or systemic inflammatory

disease (including rheumatoid arthritis). Most clients with bursitis will not have an actual diagnosis from

their doctor. There are three named bursae in the hip. They are the Greater Trochanteric, the Ischial and

the Iliopsoas bursae. Bursae help reduce friction between muscle and bone by allowing for a gliding

surface.

Symptoms of an acute episode of bursitis include:

Tenderness

Painful and reduced ROM of the joint

Deep bursa are not palpable but the superficial bursa may be during an attack

Hip Replacements

Hip replacements are becoming more common in our aging population and present special concerns for

bodyworkers. Clients may need lower tables, stools, or assistance with getting on and off our tables.

Generally they can’t use the leg rests on massage chairs.

During a total hip replacement the gluteus maximus is divided along its fibers and the piriformis muscle is

the only muscle that is cut. This is significant information to bear in mind as scar tissue forms and could

cause piriformis syndrome. Massage on or around the surgical site depends much on the stage of healing.

Immediately post-operative sessions are generally limited to gentle effleurage and lymphatic drainage to

support edema reduction, indirect and contralateral massage is indicated to maintain adjacent tissue. Soft

tissue work around the incision site could help speed recovery. ROM and stretching are contraindicated

until cleared by the treating physician. Deep massage over the surgical area may be approached with caution

once the client has passed the sub-acute stage of healing.



Leg Length Discrepancy

Leg length discrepancy may be caused by:

Difference in bone lengths

Hip replacement

Pelvic rotation and/or muscular hypertonicity (this could be such things as headaches, repetitive

“whiplash” neck pain, postural deviations, hip pain, low back pain, and a multitude of other

conditions.)

If you suspect an actual difference in leg lengths, referral to an appropriate health care practitioner is

advised.

Review of Tests

FABER (Patrick’s) - -Client lying supine making #4 with leg checking internal and external

rotation. Severe restriction with inguinal pain during test may indicate hip pathology.

Gaenslen’s Sign - -Client lying supine with one leg off the side of the table other knee to chest.

Pain in the SI when unsupported leg is dropped off the table indicates pathology in the SI joint.

Medial Compressions (Erichsen’s) - - Can be done in supine or side-lying. Place hands on lateral

surface of ASIS and press medially. Pain indicates hypermobility. Comfort indicates hypomobility

and technique is then a treatment.

Lesegues Test - -Client lying supine raises single leg. Pain could indicate a true sciatic or disc

problem. Negative test assess the gluteus minimus for TrP. This indicates piriformis syndrome by

process of elimination.

Crossed Lesegues - -Client still in supine. Raise uninvolved leg. Pain in low back or down

involved leg (not the one being raised) may indicate a serious disc problem. Refer to MD.

Trendelenberg Test - - Client standing facing therapist. Ask them to lift up their leg - - raising knee

to the chest. If the hip drops inferiorly the opposite gluteus medius (weight-bearing leg) is weak.

OBER test - - Client in side-lying position. Cradle top leg with your hand having them completely

relax and lower the knee towards the table. If knee falls very little, it is being held by the ITB, TFL,

or the gluteus medius or minimus.

Modified Thomas - -Client supine at end of table. They hold the non-testing leg while you slowly

lower the testing leg while holding the ASIS on the same side. Testing leg should be to the table

before the ASIS is pulled inferior. Test again with a straight leg. If ROM improves greatly, the

problem is rectus femoris. If not it is the psoas.



PRACTICE – Treat the following muscles by working origin and insertion and/or compression

techniques

Gluteus Medius – A primary stabilizer of the hip

O. External surface of the ilium between iliac crest and posterior and anterior gluteal line.

I. Greater trochanter

A. Abduction

Test – Trendelenberg Test

Client presentation –

Pain just superior to the trochanter which worsens with weight bearing on that leg.

Client cannot sleep on that side or back due to hip pain

Pain when sitting “slouched” in a chair

Femur is medially rotated on that side.

Pain in the SI joint with a negative FABER.

Gluteus Minimus –

O. External surface of the ilium between anterior and inferior gluteal lines.

I. Anterior border of greater trochanter

A. Abduction, medial rotation and flexion of the hip

Client presentation:

Sciatic-like pain with a negative Lesegues.

Pain in buttocks when rising from chair or walking

Can be made worse by sitting on wallet in back pocket

Gluteus Maximus – consider for hikers (involved in uphill walking)

O. Coccyx, post. sacrum, post. iliac crest, sacrotuberous and sacroiliac ligaments

I. Gluteal Tuberosity and iliotibial tract

A. Extension, abduction, flexion and rotation


Pain in climbing stairs or hills

Pain with prolonged sitting

Any low back pain (due to myofascial connections)

Any knee pain (due to IT band connection)



Piriformis – sciatic-like pain or entrapment of sciatic nerve

O. Anterior surface of the sacrum

I. Greater trochanter

A. Lateral rotation of the hip

Test: By elimination of true sciatica using previous tests


Pain with prolonged sitting, standing or walking

Pain in SI joint area

Pain resulting from a sudden twisting motion

Medial rotation is restricted

Hip replacement

Tensor Fascia Latae – leg stabilizer during single leg weight-bearing

O. Iliac crest post to the ASIS

I. Iliotibial band/tract (ITB or ITT)

A. Flexion, abduction and medial rotation of the femur

Test: OBER


Positive OBER

Ant rotation of the pelvis

Restricted hip extension



Psoas – Traditionally thought of as low-back pain, can cause hip/groin pain. Involved in forward

swing of walking/running and last phase of traditional sit-ups.

O. Bodies and transverse processes of lumbar vertebrae

I. Lesser trochanter of femur

A. Flexion, lateral rotation and adduction of the hip

Test: Modified Thomas


Low back pain

Client stands with unaffected side doing the weight bearing

Pain when standing after prolonged sitting or getting up from bed

Pain when walking up stairs

Unexplained pelvic floor pain

Possible groin pain

Can mimic appendicitis

Iliacus – primary hip flexor

O. Iliac fossa

I. Lesser trochanter

A. Flexion, lateral rotation and adduction of the hip


Anterior rotation of the pelvis

Can’t cross one leg over the other

Restricted hip extension






Knee & Ankle




1. Demonstrate a more specific treatment to the lower extremity than with relaxation techniques alone.

2. Describe the difference between relaxation and therapeutic techniques.

3. Discuss the pathology and treatment for specific injuries to the knee, leg, thigh, ankle, and foot.

4. Recognize when it is appropriate to refer the client to another health care provider.

SUGGESTED READING:

MTPP

Hands on Manual: Therapeutic Treatment of the Lower Extremity.

A Massage Therapist’s Guide To Pathology.



GENERAL PROCEDURE FOR SITE SPECIFIC (NMT) WORK:

NOTE: Visualization of the muscles and attachments being worked often has a tremendous impact on

effectiveness of the work being performed as well as the therapeutic outcome. This is where all your efforts

during MSAK will pay off for both you and your client handsomely!

1. Listen to the client. Find out what their therapeutic goals for the session(s) are. Try listening with

your heart and eyes, as well as your ears. Talk with the client about how site specific work may

benefit them. Be aware that often the therapist’s greatest enemy is time limitations in a session. If a

client wants a full-body massage for relaxation plus specific work to help a frozen shoulder, there

may not be enough time to do both and maximize the benefits. Tell them it’s common to feel some

discomfort while working specifically (therapeutically) for best results. On a scale of 1 – 10, with 1

being “I can hardly feel you.” to 10 being “get off of me you maniacal fool!”, we want to work in the

4/10 range. Remember, it’s the client’s perception of 4/10, not the therapists.

2. Warm the area. Work superficial to deep… always. Myofascial Release, compressions, and gentle

effleurage techniques are excellent for general warming.

3. Assess the area. This is where we look and listen with our hands! Development of palpatory skills is

essential to be an effective therapist. Begin slowly and address the tissue clinically, working the

belly, origin, and insertions in turn. Often this alone, when done properly, can offer relief to the

client.

4. Gradually begin to work the area more specifically. Remember, we work superficial to deep,

general to specific, when addressing client’s needs therapeutically. Slowly engage the tissue.

Imagine your hands sinking and melting into the muscle as you work. Work the muscles and

attachments longitudinally and transversely (cross-fiber friction), breaking up any adhesions and scar

tissue.

NOTE: Check in with the client on a regular basis to ensure you’re not using too much pressure (beyond

our 4/10 range). Observe signs of resistance in the tissue or stiffening of other parts of the client’s body: this

is an indication you may be working too deeply or beyond the client’s pain tolerance. If we abuse our

clients, they’ll never come back! Working slower can help you work deeper and within the client’s pain

threshold. It may also be helpful to work an area deeply, move on to another part to let that area “rest”, than

move back to that area to check release of the trigger points, etc. Make sure you employ leverage and proper

body mechanics rather than muscular strength when working specifically. Use proper bone/wrist alignment

to protect your thumbs and wrists! Be aware, if using a tool like a T-bar, that you can’t palpate the tissue

plus the tendency to slip off the targeted area is greater, so address the area often with your hands to ensure

the desired results and minimal discomfort to the client.



5. Hold trigger points and ischemic areas 10 – 12 seconds before releasing. If referred pain doesn’t

lessen after holding a few seconds, you’re probably using too much pressure. Ease up a bit and

observe the results.

6. Gently stretch the area. Use deep draining strokes (moving towards the heart) to encourage blood to

nourish the tissue and drain the broken up deposits away. Energy techniques also are appropriate

here.

7. Sooth and smooth the tissue. Long and gliding effleurage is ideal here. Mentally “thanking” the

tissue for letting you work so deeply is a wonderful technique many therapists employ.

8. Educate the client during the post-session interview. Offering suggestions on helpful stretches (or

displaying a poster or brochure), benefits of drinking plenty of water (while offering a glass of

water… a MUST for all therapists to offer their clients water after each session), proper sleeping or

working positions, ice/heat therapies, etc. are all excellent examples of client education. It may be

helpful to inform the client that feeling some discomfort in the area worked for the next day or two is

very common (especially if they haven’t received bodywork in a while). Just drink plenty of water

and stretch the area gently during the first day or two.



INFLAMMATION:

It’s a good idea, prior to working specifically, to have an understanding of the body’s inflammation process

as a massage therapist.

ACUTE: Directly after injury. Typically can last up to 48 hours after injury occurrence. This may

also be due to repetitive stress injuries and/or overuse/strain of an ischemic area. Signs may include:

o Heat – site of injury is hot to the touch

o Edema – swelling of area begins and may increase

o Redness along injury site, sometimes bruising develops

o Pain is present

o Limited ROM (Range Of Motion), especially if injury involves a joint

Massage Therapy is contra-indicated for all acute phase injuries. Use of RICE is recommended.

o R – Rest

o I − Ice

o C − Compression (ACE bandage)

o E − Elevation

SUBACUTE: Typically occurs from 48 – 72 hours after injury. Signs are similar to the acute phase

but much less pronounced. ROM is still inhibited but noticeably increasing.

General massage and light draining strokes towards the heart to reduce edema is ideal. Bear in mind

the client’s pain tolerance. Gentle draining strokes around the injury site, but avoiding working directly on

the site may be best depending on the injury and client. The RICE method is still recommended during this

phase. Encouraging gentle ROM exercises may also be helpful to encourage synovial fluid development and

lymph flow to reduce swelling, as well as minimizing the development of scar tissue and neuralgia

(inhibited neural response).

CHRONIC: 72 hours beyond time of injury. Typically the site is no longer visibly swollen, but

there may be some loss of function and pain may occur after strenuous use.

General and direct massage is appropriate at this time. Deep cross-fiber friction to help break up adhesions

is also very effective, but only after thoroughly warming the area and within the client’s pain tolerance. It’s

especially important for the therapist to be positive and encouraging for the client. Help the client to

focus on the progress made, rather than any set-backs. Maintaining a positive mental attitude and

environment is one of the key ingredients in recovery, and essential for a professional in our field! Needless

to say, this also improves client bookings and retention, invaluable if you own your own business.



SPRAINS & STRAINS: Massage Therapists will often encounter conditions such as sprains and strains. Many times these conditions

can be mislabeled and confusing, especially for the clients. Here’s a brief description of each condition and

how to best utilize massage in healing:

STRAINS: Injuries to muscles, although some may consider injuries to tendons as well (injuries to

the tissue at the muscle-tendon and tendon-joint junctions are typically referred to as tendonitis,

although the symptoms are the same with the exception that tendonitis may have some heat and

swelling present at the injury site where none will be present in a strain). Common symptoms are

localized pain and stiffness. Treatment of both strains and tendonitis will be the same, however.

o TREATMENT:

1. Use RICE during the acute phase. Some gentle draining strokes to help reduce edema

would be appropriate here.

2. It’s during the sub-acute phase of healing that the massage therapist has the greatest

influence. Gentle kneading and stretching of the muscle can help to both ensure the ideal

alignment of collagen fibers and the flushing out of the irritating by-products trapped in

the tissue. This helps to speed up the healing process. At all times respect the injury and

work within the pain tolerance of the client.

3. Working the area thoroughly after the sub-acute phase will help to further strengthen the

area and minimize the likelihood of further re-injury. Here is also a good time to use deep

cross-fiber friction to reduce the amount of scar tissue build-up, which can weaken the

healing area making it prone to re-injury (especially important around joints where the

surrounding muscles act as structural support of the joint).

SPRAINS: Injuries to ligaments, the connective tissue that connects bone to bone. Redness,

swelling, heat, and limited joint mobility are common symptoms of a sprain. Sprains also typically

take quite a bit longer to heal since ligaments are significantly less vascular than tendons and

muscles, thus they get very little blood flow which limits the healing process. Often surgery is

needed to actually affect a repair for proper healing and joint support.

o TREATMENT:

1. Massage is contraindicated in the acute phase.

2. Gentle draining and kneading in the sub-acute phase as in a strain can be helpful (since

often the surrounding muscles and tendons are strained when a sprain occurs). Some

gentle ROM work can also help minimize stiffness due to limited joint use, although

most specific work can and should be done by the client’s physical therapist.

3. Occasional deep work after healing may also help to ensure healthy scar tissue formation

and as strong a joint as possible. Naturally, gentle stretching and general massage work is

indicated here as well.



BURSITIS:

Bursitis, another ailment massage therapist may encounter, is really inflammation of the bursae. Bursae are

fluid-filled sacks that help to buffer tendons as they cross joints so they can slide smoothly over the area. A

good example is the elbow and knee. Bursae help to minimize extra wear and tear around a joint.

Prepatellar bursitis may be referred to as “water on the knee” as may several other types of joint swellings at

the knee.

With excessive use like repetitive stress disorders, the bursae can get inflamed and excess synovial fluid can

collect in these sacks. Imagine a tennis ball amount of fluid fitting into a golf ball sized sack…. Ow! The

most common forms of treatment range anywhere from taking ibuprofen and using warm compresses to

surgically removing the bursae (which often grows back!).

TREATMENT:

1. Massage is locally contraindicated in the acute phase. In rare cases where the bursitis is

caused by a pathogen, massage is systemically contraindicated until the inflammation and

infection subsides.

2. In the subacute phase, massage can benefit the muscles surrounding the joint. This, in some

cases, may actually allow the bones to settle back down into correct realignment (via easing

the tension of the muscles pulling on the attachment sites surrounding the joint), relieving the

site irritating the bursae.

3. Be aware, as with any condition presenting pain to the client, that there most likely will be

compensation patterns in the body which means certain muscles will require treatment to

help bring the body back into normalcy.

4. Since the core problem is repetitive stress of the joint, any suggestions we can give to help

the client remove any aggravating factors that irritate the bursae will offer the only long-term

solutions. This means any suggestions to change their work stations ergonomically, or how

they use their bodies while performing their jobs, may help to relieve stressors on the

joint/bursae and thus relieve the problem.

KNEE REPLACEMENTS & SURGERIES:

Often times as a massage therapist you will encounter clients that have had (or will soon be having) knee

surgeries up to and including actual replacement of the entire joint. In cases such as this, deep fiber friction

around the patella is contraindicated. In cases where the patella is prone to slippage (patella tracking) or

dislocation, stabilizing the patella and working around it rather than displacing it and working under it (as

you would in a healthy joint) is indicated.

Knee replacement surgeries are now using a technique called arthrotomy in which a margin of the

quadriceps tendon and the medial retinaculum are divided. The muscles themselves are not actually cut. It

is not uncommon for swelling to persist for a few weeks following surgery, but clients should be referred



back to their physicians for any severe swelling accompanied by redness that begins several weeks

following surgery.

In the subacute phase of post-surgical healing, you may be able to work a bit more specifically (although

still limited) to help minimize scar tissue build-up. This is especially true for the large muscles (like the

quads) attaching to the joint. One should still obtain a medical release from the client’s doctor and leave

most of the deep work to the client’s physical therapist for both practical and professional liability issues.

Naturally, all exercises should be provided by the physical therapist or the attending orthopedic physician.

ACL/MCL/LCL:

These four ligaments (there are two ACL’s, a posterior and an anterior) are the primary support structures of

the knee (offering static support) and work in concert with the surrounding muscles (offering dynamic

support) to fully support the knee. Both the medial and lateral collateral ligaments (MCL and LCL) connect

the femur to the tibia and fibula and prevent excessive side-to-side movements. Any lateral blows or trauma

to the knee will tear these ligaments.

The posterior and anterior cruciate ligaments (PCL and ACL respectively) criss-cross behind the patella and

help to support the knee internally from any excessive front-to-back movements. They also serve to anchor

the femur to the tibia. Often times this is the ligament damaged in any knee injury since the MCL and LCL

tend to have more intrinsic flexibility in their design. The only way to properly fix any severe damage to this

is through surgery.

Due to the limited blood supply feeding these (or any ligaments), injuries to these structures take a relatively

long time to heal. Massage is very limited in effectiveness in this area except during the subacute phase of

healing, where it may help reduce the affects of scar tissue build-up and general joint stiffness (due to lack

of use and limited ROM), although indirectly so in cases of tears to the ACL and PCL. See treatment for

sprains for further information in this regard.

PATELLAR TENDONITIS & PATELLOFEMORAL SYNDROME (PFS):

Both of these conditions are very similar in the symptoms experienced by the client and, as such, are

difficult to assess as a massage therapist. The importance of proper diagnosis from a qualified physician is

critical since patellar tendonitis (injury external to the joint capsule) can be effectively treated with

massage, and patellofemoral syndrome (injury inside the joint capsule) cannot.

PATELLAR TENDONITIS:

1. This is an injury to the tendon that attaches the quadriceps to the patella or across it on the way to

the tibia. It is because the quadriceps are a large and strong muscle group that, unless they are

fatigued already, pain in the joint is not present. Additionally, the patella tendon is a particularly

thick structure so tears are hard to pin down. Thus, without proper image diagnosing, this can

easily be labeled PFS.



2. A good way to tell if this is patellar tendonitis is to determine if pain is present while flexing the

quads or extending the leg. Does it hurt while using the leg extension machine in the gym or

while walking up the stairs? Any activity that will use the quads and patella tendon is what

you’re looking for since PFS is actually deterioration of the cartilage inside the knee and will be

painful during weight-bearing situations like walking down the stairs.

3. Since this condition is in the connective tissue, massage to relieve muscular tension and increase

blood flow to the area will be very effective. Also, any suggestions via exercises and stretches to

correct any possible muscular imbalances surrounding the joint will be equally effective.

PATELLOFEMORAL SYNDROME (PFS):

1. This condition is gradual deterioration of the cartilage inside the knee capsule. This condition is

typically a precursor to osteoarthritis of the knee. As such, massage will be ineffective in

addressing this condition directly, but can be very helpful in treating compensation issues arising

from this pathology.

2. Since the source of pain is loss of the shock-absorbing material inside the knee joint, any activity

that increases the weight-bearing load on the structure is a good indicator of this condition.

Asking the client if pain is present while walking down the stairs as opposed to walking up the

stairs would be a clue.

ADDITIONAL NOTES:

Clients should be referred to their physician for any joint tenderness, persistent swelling or mechanical

symptoms, such as locking or catching. These can be symptoms of a meniscus tear which must be treated

with surgery.

Knee pain is a frequent pain referral pattern for a degenerative hip. Children actually complain mostly of

knee pain when the hip is actually the problem.



SHIN SPLINTS:

This is a generic term covering a wide range of lower leg issues ranging from mild muscles strains and tears

to hairline fractures of the tibia and/or fibula. For many practical purposes, this involves a strain of either the

tibialis anterior or posterior muscles.

NOTE: If there is any redness, heat, or edema present around the tibia, than this would be an indication of

something more severe than shin splints. Massage would be locally contraindicated in these conditions. In

fact, in these conditions, tell the client to see a doctor since a stress fracture may be present.

TREATMENT:

1. So long as the cause is not from a fracture or chronic or external compartment syndrome (where

rest and medical attention is needed), massage is indicated.

2. Work the anterior shin area deeply and thoroughly. This will help not only to relieve tension but

also to stretch the muscles more effectively than simple stretching alone. Focusing attention on

the tibialis anterior is the order of the day, since the tibialis posterior may be too deep and too

tender to displace the gastrocnemius and effectively treat.

3. Alternating between hot and cold (action/distraction) treatments may also be effective, especially

in the acute phase. Reducing activity and resting the muscles is always in order. It’s

imperative that this not become a chronic condition and develop into something far more serious.

COMPARTMENT SYNDROME:

This condition arises from a build-up of fluid in any of the three compartments of the lower leg. Fluid can

increase by as much as 20% in the lower leg due to exercise. This fluid build-up can increase pressure on

the nerves and blood vessels in the area but is often relieved through rest. If the area is not given adequate

time to rest (as is often the case in athletes) or the foot has inadequate support and cushioning through a

poor shoe choice, this condition can be chronic and severe.

If left untreated, tearing of the osteo membranes between the tibia and fibula will result, as well as further

build-up of fluid. This excessive pressure will severely restrict the blood vessels serving the area, as well as

impinging on the nerves. This creates a vicious cycle (called exertional compartment syndrome) which

will lead to tissue death if not treated medically (usually through surgery to cut through the tough fascia and

relieve the pressure). With the possibility of tissue death (leading to amputation of the lower leg if

ignored… but probably too painful to go that far), this condition should be treated as quickly as possible.

TREATMENT:

1. Being caught early, massage can help tremendously with this condition. Ensure the client rests

the area, using RICE where appropriate.

2. By following the above principles for general site specific work (superficial to deep, general to

specific) and isolating each muscle in turn, effective treatment can be obtained.



3. As always, work only within the client’s pain tolerance. Be aware that the tissue may be

inflamed and sore, so don’t just “jump in there”! As the inflammation reduces through normal

healing, you’ll be able to work progressively deeper, freeing up any deep-seeded trigger points

and scar tissue that may have built up during the healing process.

4. With some muscles being pretty deep here, the ability to properly visualize the muscles as well

as the palpatory skills to “melt” into the tissue is essential here.

LOWER LEG COMPARTMENTS:

1. Anterior Compartment:

o Tibialis Anterior

o Extensor Digitorum

o Extensor Hallucis Longus

2. Posterior Compartment: There are three levels here…

o Superficial:

Gastrocnemius

o Middle:

Soleus

Plantaris

o Deep:

Tibialis Posterior

Popliteus

Flexor Digitorum

Flexor Hallucis Longus

3. Lateral Compartment:

o Peroneus Tertius

o Peroneus Longus

o Peroneus Brevis



PLANTAR FASCIITIS:

This condition stems from injury to the plantar fascia of the foot. It’s common among clients that are either

regular joggers, overweight, or flat-footed. These conditions add stress to the feet, exacerbating any present

alignment issues and further stressing the delicate fascia of the foot. Wearing shoes with poor arch support

(a common factor among joggers and working women… those cursed high heels!) and being on one’s feet

for long periods of time are also factors in this condition.

TREATMENT:

1. The most important ingredients in treating this condition are rest and patience. It may take as

long as 3 months to address this condition, using several different approaches in concert with

massage. Some things that may be helpful with massage are:

o Proper arch supports in all shoes (including slippers at home).

o Self-massaging of the feet in the mornings (before getting out of bed) to gently pre-warm

and stretch the plantar fascia. Even gently rolling the foot over a tennis ball may help

ease any tightness in the plantar fascia. Often tightness sets in the fascia during periods of

inactivity (such as sleeping) and when stepped on and stretched by walking, the fascia is

torn. Scar tissue develops on these areas, further weakening them and being prone to

more tears in the future. A viscous cycle is born.

o Avoid going barefoot until such time as the fascia can stretch properly without tearing.

o Using NSAIDS (like aspirin, ibuprofen, naproxen, or acetaminophen) and/or topical anti-

inflammatories (CryoDerm, Bio-freeze, Mineral Ice, etc.) can be useful during treatment

(not a long-term solution).

o Heat and/or ice may also be helpful, with gentle stretching of the foot.

2. Working with longitudinal stripping along the base of the foot will help organize the collagen

alignment. This will help make the scar tissue that does develop in the fascia less prone to further

injury. Gently rocking the metatarsals and stretching the plantar fascia via dorsiflexion is also

very helpful.

3. Deep work to release any present ischemic areas and/or trigger points in the gastrocs and soleus

will help to relieve any tightness in the plantar fascia. Tight calf muscles tend to pull the plantar

fascia tightly over the calcaneus, further proning the tissue to tears.






HANDS ON MANUAL:

Lower Extremity


Review all lower extremity muscles

Myofascial Release and Skin Rolling to the Entire Leg: For each area being worked consider using any of the following strokes to maximize desired treatment:

Myofascial Release

Compression

Vibration

Deep Friction

Cross-fiber Friction

The following muscles may be treated using any technique students

have already developed.

Muscles of the Anterior Thigh (Quadriceps):

Rectus Femoris

Vastus Lateralis

Vastus Medialis

Vastus Intermedius

Muscles of the Lateral Thigh (IT band and TFL)

Work the area in a supine and side lying position.

Moist heat can be beneficial when working IT band



Patella:

Work patellar tendon

Warm tendon by using friction with knife edge of hand on lateral, medial, superior and

inferior borders of patella.

Displace patella to access underlying tendons and ligaments.

Posterior Muscles of the Lower Leg (Gastrocs & Soleus):

To work the Soleus effectively, displace the Gastrocnemius.

Work the Gastrocnemius. Carefully cross the joint to work attachments.

Gently stretch the muscles.

Muscles of the Medial Thigh (Gracilis and Adductors):

Work the Gracilis:

Infinity (side-ways figure eight)

Two Pressure Points

Compression to the Gracilis and the Adductors

Work the Adductors

Using the side-lying position while working on the lower leg may allow the client to feel more comfortable

and allow the therapist easier access to these medial muscles.

Muscles of the Posterior Thigh (Hamstrings):

Begin working more superficially and gradually work deeper on the following muscles:

Biceps Femoris

Semimembranosus

Semitendinosus

Muscles of the Foot:

Plantar Fascia – Moist heat may be beneficial






Cervical Nerve compression and TOS




1. Recognize the common causes and effects of these injuries.

2. Identify musculature that may be the cause of each condition/syndrome.

3. Assess common complaints that are related to the neck, shoulder and wrist.

4. Demonstrate techniques that are appropriate to client’s condition.

5. Demonstrate effective communication skill with clients before, during and after the massage session.


7. NESL and State of Wisconsin application information is located at the end of this session’s notes.

SUGGESTED READING:

Basic Clinical Massage Therapy, Clay & Pounds. Pages 90, 92, 96, 119, 120, 121, 128, 148.

Clinical Massage Approaches: TOS & CTS, C. Daher. Pages 1-19.

Myofascial Pain and Dysfunction: Upper Extremities, Travell & Simons. Pages 189, 213, 215, 311-

312, 355-358.

GENERAL REVIEW OUTLINE:

In the next two weeks we will be exploring three major conditions that share very similar symptoms. They

are: Lower Cervical Nerve Compression, Thoracic Outlet Syndrome & Carpal Tunnel Syndrome.

Each can cause pain in the (neck), shoulders, wrists, hands and fingers. America’s work force is suffering

from one, two or all three of these conditions. We will take a look at each one: cause, effect and what can be

done to promote healing and relief from the pain.

Federal Bureau of Labor Statistics reported that 280,000 injuries and illnesses in 1992 resulting in

days out of work involved cumulative trauma disorders to arms, wrists and shoulders, including

carpal tunnel syndrome. This is the fastest growing category of injury. (Workers Compensation

Insurance Bureau, Washington DC) Crawford Medical Review ranks carpal tunnel first on the list of

disability claims nationally. Estimates of business and government cost at $25 billion annually.

Detroit Free Press. Jan. 10, 1995



Lower Cervical Nerve Compression Cervical Nerve Compression: Nerve Root Compressions of C5, C6, C7, & C8 can cause musculocutaneous

pain, weakness and tingling to the muscles and skin of the neck, shoulder, forearm, wrist, hand and fingers. Left

untreated this condition/symptom would be called Peripheral Neuropathy.

Symptoms: Mild to severe nerve compression can result in neurological signs such as: pain, tingling, numbness,

the feeling that pins and needles are being applied to the muscle or tissue, and muscle weakness. In most cases,

peripheral neuropathy begins very slowly and subtly, we are focusing on this condition assuming that the cause

is do to mechanical pressure on the nerve roots.

Muscle & Bones that maybe involved in this condition are:

1. Posterior Muscles: Upper Trapezius – Splenius Capitis - Splenius Cervicis – Levator Scapulae –

Multifidus – Rotatores – Iliocostalis Cervicis (of Erector Spinae) – Interspinales – Serratus Posterior

Superior.

2. Anterior Muscles: Anterior, Middle & Posterior Scalenes – Longus Colli – SCM.

3. Bones: C4, C5, C6, C7, T1, T2, Clavicle and the 1st and 2nd Ribs.

Tests for Cervical Nerve Compression: Cervical compression will cause increased symptoms while

traction will improve symptoms.

FYI: Spinal nerves in combination or singly control all parts of the body. Both motor nerves (which send

commands to the muscles) and sensory nerves (which sense what is felt by the skin and transmit the

sensation/information to the central nervous system) are distributed throughout the upper limbs.

The nerves that control the shoulder, arm, hand& fingers extend from C5 to T1. This bundle of nerves is what is

known as the brachial plexus. The nerves that go to the upper limbs pass behind the clavicle and divide into

three bundles – the medial, lateral, and posterior nerve bundles.

Each nerve bundle is distributed to different parts of the upper extremity to perform motor and sensory activities.

The bundles again branch off and become the major nerves of the upper extremities called the ulnar, radial,

axillary, median (C6-T1) and musculocutaneous nerves.

Thoracic Outlet Syndrome (TOS) Thoracic Outlet Syndrome: is a compression/entrapment of a nerve bundle called the Brachial Plexus and

Blood vessels called the Subclavian artery & vein. This network of lower cervical and upper thoracic spinal

nerve trunks C5, C6, C7, C8 & T1, pass from the cervical and thoracic spine through a long narrow tunnel call

the Thoracic Outlet, then down into the arm, hand and digits.

1. Thoracic Outlet: is a triangular aperture bound anteriorly by the scalenus anterior muscle, posteriorly by

the scalenus medius muscle, and below by the first rib.

2. Entrapments: may occur because of pressure by the palpable bands of taut muscle fibers that are

associated with myofascial Trigger points (TPs), when the nerve passes through the muscle entrapment

(T.O.S.) of brachial plexus and subclavian artery and vein occurs between the anterior and middle

scalenes. This appears to be the most common site. This site of entrapment is called: Anterior Scalene

Syndrome or Scalenus Anticus Syndrome.



3. Costoclavicular Syndrome is one of the three major types of entrapment that are classified under the

heading of T.O.S... The brachial plexus of nerves and subclavian artery and vein are located deep to the

subclavius (between the clavicle and the 1st rib).

4. Pectoralis Minor Syndrome is another, as we have heard before the brachial plexus of nerves and

subclavian artery and vein are sandwiched, between the Pectoralis minor and the rib cage. This

vulnerable area too can become a common area of entrapment. When the pectoralis minor is tight or in

spasm with or without TPs, may cause compression on the vessels and nerves that are sandwiched

between it and the rib cage.

The neurological symptoms and signs of neurapraxia that result are easily misinterpreted if this mechanism of

entrapment is not recognized.

Neurapraxia: The mildest type of focal (relating to a localized area) nerve lesion that produces clinical deficits;

localized loss of conduction along a nerve without axon degeneration; caused by a focal lesion.

Causes: Thoracic Outlet Syndrome can be caused by repetitive motion that keeps clients hand/hands in front of

them or above their head. It can also result from trauma, including motor vehicle accidents (MVA), slips, falls,

whiplash or seat belt trauma. It could also be caused by trauma following surgery, persistent coughing or simply

from a being born with an extra rib. Watch for clients who have many clients with activities using their arms or

who have anteriorly rotated shoulders.

Symptoms: Severe or continued compression/entrapment may cause various neurological signs such as:

1. numbness

2. tingling

3. numb-like feelings (pins and needles)

4. muscle weakness

5. the client may feel a sharp, burning pain in the shoulder, arm and down to the hand/fingers

6. may affect the client’s reflexes and possibly cause weakness in the deltoids, biceps, supraspinatus and

infraspinatus.

7. swelling of arm or hand

8. Raynaud’s syndrome (hands turn blue)

9. pain in arm or hand

Additionally, the subclavian blood vessels may also become involved in the compression/entrapment syndrome

due to the close proximity to the tunnel and bordering structures. When this occurs, the client or you may note

such changes as temperature or skin color in the affected area of extremity.

The main areas that may be involved (TOS):

1. Blood vessels: a. Subclavian artery

b. Subclavian vein.

2. Bones: a. Clavicle

b. Sternum

c. Ribs

d. Humerus

e. Scapula.



3. Nerve divisions of the brachial plexus: a. Axillary

b. Median

c. Musculocutaneous

d. Radial

e. Ulnar

4. Muscles: a. Pectoralis Minor

b. Scalenes (Anterior and Middle)

c. Subclavius

If postural problems exist, other muscles may need to be addressed to correct posture causing thoracic outlet

syndrome.

Hands-On

Since we are dealing with conditions/syndromes that have very similar symptoms we will treat them together.

Many of the muscle & bones listed per conditions/syndrome overlap.

We need first to assess whether treatment is within our scope of practice.

When in doubt don’t.

Assuming it is within our scope of practice, note what side of the body is affected the most. If equal: treat

equally. If not: pay more attention to the affected side of spine.

Treat the following muscles working origin to insertion whenever possible. Communicate with your client

regarding pressure and respond appropriately.

Muscles:

a. Levator Scapula

b. Splenius Capitis & Cervicis

c. Serratus Anterior

d. Deltoids

e. SCM

f. Scalenes

g. Pectoralis Major

h. Pectoralis Minor

i. Trapezius

j. Subclavius

You may additionally choose to do a first rib release for this client.

Check all for TPs.

NOTE: Ask your client to tell you if there are any changes in their symptoms during treatment. Make mental

notes of all their feedback. After the session make out SOAP notes to refer to for next week’s sessions.






Carpal Tunnel Syndrome




1. Recognize the common causes and effects of these injuries.

2. Identify musculature that may be the cause of each condition/syndrome.

3. Assess common complaints that are related to the neck, shoulder and wrist.

4. Demonstrate techniques that are appropriate to client’s condition.

5. Demonstrate effective communication skill with clients before, during and after the massage session.


SUGGESTED READING:

Basic Clinical Massage Therapy, Clay & Pounds. Chapter 5.

Clinical Massage Approaches: TOS & CTS, C. Daher. Pages 1-19.

Myofascial Pain and Dysfunction: Upper Extremities, Travell & Simons. Pages 122-123, 524.



Carpal Tunnel Syndrome (CTS)

Carpal Tunnel Syndrome – Has reached near epidemic proportions in the general population as well as

America’s work force. It is the most common of nerve impingement syndromes and a frequent cause of

missed work.

A major factor that contributes to CTS is highly repetitive movements that cause continuous wrist flexion

and extension. Work involving high shock impact or trauma to the hand and wrist are also contributors.

CTS is: an entrapment, irritation or swelling around the median nerve. This is typically caused by:

1. the four tendons of the flexor digitorum superficialis

2. the four tendons of the flexor digitorum profundus

3. the tendon of the flexor pollicis longus

These tendons pass under the flexor retinaculum (a.k.a. transverse carpal ligament) on the anterior side and

the carpals to the posterior side. The ulnar nerve does not pass through it.

The median nerve innervates:

1. the thumb

2. index finger

3. middle finger

4. half of the ring finger.

There are many factors that could influence this nerve impingement. They range from structural anomalies

and disease, to fractures. The tendons could simply dry out as they pass through the tendon’s sheaths.

NOTE: A lack of sufficient synovial fluid in the flexor tendons (named above) can produce an

inflammation in the tendon sheaths. This inflammation often imitates carpal tunnel syndrome.

Pregnancy has also been associated with this condition, usually during the third trimester. Symptoms tend to

diminish after giving birth.

Research has shown that adding Vitamin B6 (pyridoxine) to a person’s diet may help promote the

production of natural cortisone. This, in turn, leads to higher serum serotonin levels. Serotonin is necessary

for the production of synovial fluid. Therefore it’s reasonable to conclude that adding more Vitamin B6 to

one’s diet may help avoid tenosynovites.

Additionally, the median nerve passes between the humeral head and the ulnar head of the pronator teres.

This situation makes it a possible site of entrapment. Though this entrapment occurs up near the elbow, this

condition often mimics many of the symptoms of CTS.



This entrapment/condition is called: Pronator Teres Syndrome.

Symptoms of CTS:

1. Burning pain

2. Numbness or tingling in the wrist, hand or fingers

3. Nightly numbing pain that awakens the sufferer

4. Weakness or hand dysfunction

5. If left untreated, may ultimately lead to total disability of hand/wrist.

6. Dropping things

Additional contributing factors:

1. Intense work environments

2. Working in cold environments

3. Low job satisfaction level

4. Frequent use of computer mouse (higher risk than keyboard users) and gamers

5. Repetitive vibration (jackhammer etc)

6. Age – it is very rare in children

7. Women – pregnancy, postpartum, menopause and breast feeding (possibly a hormonal reaction that

causes more fluid retention?)

8. Family history

9. Obesity

10. Smoking and alcoholism

11. Stress

12. Medical conditions:

Diabetes

Autoimmune diseases

Kidney disease

Structural abnormalities

Cancer

Hypothyroidism

13. Certain medications

Two helpful tests that can be administered during the assessment process are:

1. Phalen’s: A passive hyper-flexion of the wrist. This increases pressure on the median nerve at the

radio-ulna articulation. A numbing sensation after thirty seconds is a positive indication.

2. Tinel’s: Light percussion or flicking of the inside wrist area following the median nerve pathway.

Pain is a positive indication.

If the client has a positive response to either test and has any of the symptoms addressed above, you may

want to refer them to their health care practitioner.



Remember we do not diagnose, we assess. The main muscles involved with CTS:

1. Flexor Digitorum Superficialis (4 tendons)

2. Flexor Digitorum Profundus (4 tendons)

3. Flexor Pollicis Longus

Muscles associated with Median Nerve Compression:

1. Pronator Quadratus

2. Pronator Teres

3. Palmaris Longus

4. Flexor Carpi Radialis

Ligament:

Flexor retinaculum a.k.a. Transverse Carpal Ligament

Nerve:

Median

Treat all muscles of the forearm working origin to insertion whenever possible. Communicate with

your client regarding pressure and respond appropriately.

1. Begin with client in supine position. Remove all oil/lotion from your hands.

2. Apply MFR to arm & shoulder area, then to forearm and wrist area. Pay special attention to the

flexor retinaculum/transverse carpal ligament.

3. Skin roll the entire forearm and upper arm, if not too uncomfortable for the client. Skin roll over the

area of the pectoralis major and minor, too.

NOTE: Keep in communication with your client. Ask them for feedback on your pressure. Does any

technique cause pain, numbness, tingling or any other symptom? Especially note if symptoms are

duplicated.

4. Apply compression to both sides of the forearm & hand.

5. Apply traction to the hand & wrist. Gently rock the carpals & metacarpals. Spread the flexor

retinaculum again, then move down to the palm. Spread the palm by moving thumbs from the center

of the palm to the sides at different angles. Use a firm, deep pressure.

6. Supinate the forearm (palm up) and place the wrist slightly into extension, if possible. Using your

thumbs or fingertips, transversely stroke across the flexor tendons starting an inch or so above the

wrist. Work up towards the elbow. Start out with light pressure and repeat the process three times,

increasing the pressure each time.



7. With forearm still in supination, glide up to the epicondyles of the Humerus. Cover the width of the

forearm. Your goal is to glide to both the medial & lateral epicondyles. Pronate the forearm and

repeat on the anterior side.

8. Finish the treatment with a snake-bite technique (wrist to shoulder), then with a long, slow

effleurage from the palm to the axillary area. This helps to promote lymph drainage. Pronate the

forearm and place the palm down, repeat the effleurage moving from the back of the hand to

shoulder.

9. Apply an ice pack to wrist, if possible, while you treat the opposite side.

10. Move to the other side of the table. Repeat the steps.

11. Suggest to your client to ice any and all areas that may become inflamed due to the therapy session.

NOTE: Remember to inform your client that they may experience soreness or minor inflammation in the

areas worked on for a few days after the session. This is perfectly normal. Suggest that they drink plenty of

water and do some light, gentle stretching of the affected area.






Upper Extremity: Common Problems




1. Identify musculature that maybe the cause of each condition/syndrome.

2. Apply common assessment tools that are related to the shoulder, elbow and wrist.

3. Demonstrate specific treatments to common problems encountered in the upper extremities.

4. Understand indications and contraindications to such techniques.

5. Demonstrate the ability to properly question the client to devise the most appropriate treatment plan.

6. Ability to work with other healthcare providers in assisting the client to meet their rehabilitative

goals (i.e. working with the surgeon/physical therapist during post-op recovery).

SUGGESTED READING:

Mosby’s Pathology for Massage Therapist 2nd

edition, pp 145 – 153



Epicondylitis

Definition: infection or inflammation of an epicondyle, or of associated tendons and other soft tissues,

particularly the medial or lateral epicondyle of the humerus.

When an injury involves the entire tendon and may produce inflammation from overuse this is usually

referred to as a tendonitis. Whether it is epicondylitis or tendonitis the treatment is much the same. Be

respectful of the severity of pain and the client’s limitation to pressure.

Tendons are relatively avascular collagenous tissue and therefore:

mild strain (tear) of the tendon may require 5 to 7 days to heal,

moderate strain may require 7 to 10 days to heal.

can take longer to heal if client returns to same activity level.

client should take time for necessary home care programs set up by you or their other health care

providers.

Epicondylitis is an inflammatory injury; therefore ice is a very important part of the healing process, even if

the client does not see the swollen tissue. It is the role of the massage therapist to educate the client to the

benefits of ice and how to ice properly. This can start in your office, following massage treatment; ice

massage could be applied to the areas just worked. This is beneficial because the client learns firsthand the

benefits of ice and sees how easy it is to apply.

Good Techniques:

Myofascial release

Cross-fiber friction or deep transverse friction

Followed up by flushing effleurage to move the accumulated metabolic waste and reduce client

soreness.

The two different types of epicondylitis may be referred to by a physician as any of the

following:

medial or lateral epicondylitis, epicondylitis, tendonitis or their common names

of Tennis Elbow or Golfer’s Elbow.

You should learn them by all of their names.



Medial Epicondylitis

Known as Golfer’s Elbow or Little League Elbow

Defined: as inflammation of the medial epicondyle of the humerus due to overuse or cumulative trauma, as

in athletes.

Muscles to Treat:

Pronator Teres

Palmaris Longus

Flexor Carpi Radialis

Flexor Carpi Ulnaris

Biceps Brachii

Brachialis

Lateral Epicondylitis

Known as Tennis Elbow

Defined: tension stress injury to lateral epicondyle, often seen in those who play racquet sports.

Muscles to Treat:

WAD of Three:

Brachioradialis

Extensor Carpi Radialis Longus

Extensor Carpi Radialis Brevis

Supinator

Extensor Digitorum

Extensor Carpi Ulnaris

Brachialis



The Rotator Cuff

The rotator cuff of the shoulder is the upper half of the capsule of the shoulder joint reinforced by the

tendons of insertions of the SITS muscles. The SITS muscles are the supraspinatus, infraspinatus, teres

minor and subscapularis muscles. Overuse, impingement due to postural distortions and normal aging can

lead to painful tearing of the rotator cuff tendons. The tears may be partial or complete tears, which would

require surgery to repair the injury. The most common injury occurs to the supraspinatus. This is due to the

large demands that are made on it. It acts with the middle deltoid to abduct the arm, but it is its job as a

glenohumeral joint stabilizer that is the problem. Carrying heavy objects and working overhead are likely to

create injuries of the supraspinatus. In addition to the injuries of the supraspinatus, any repetitive motions

are likely to lead to injury of the rotator cuff muscles.

Tests:

Empty Can Test: Isolates strains in the supraspinatus

1. Internally rotate the humerus at 90° forward flexion and 30° horizontal adduction.

2. Thumb down position.

3. Client holds their arm there and therapist gently pushes down, if pain or weakness then

indication of strain of the supraspinatus muscle.

Drop Arm Test: Serious tear or injury of the supraspinatus, refer to a physician if the test is

positive.

1. Assist the client in raising their arm 140° of abduction.

2. Have the client slowly lower their arm.

3. If they cannot control this motion all through the range, they may have a serious tear or

injury.

Note: The supraspinatus must work as an eccentric contraction to lower the arm and it must lengthen

to do this motion.

Infraspinatus Strength Test: To assess the infraspinatus muscle for tendonitis, strain or

weakness.

1. Client seated or prone.

2. Abduct the humerus to 90° and flex the elbow to 90°.

3. Apply pressure to the client’s wrist in the direction of internal rotation, while the client

attempts to externally rotate the humerus.

4. Pain along the infraspinatus or weakness is a positive test.

Note: This test does not distinguish between infraspinatus or teres minor strength, since they both

externally rotate the humerus.



Subscapularis Strength Test: To assess the subscapularis muscle for tendonitis, strain or

weakness.

1. Client in a seated or supine position.

2. Humerus by the side of the body and elbow flexed to 90°.

3. Apply pressure to the client’s wrist in the direction of external rotation, while the client

attempts to internally rotate the humerus.

4. Pain is a positive test.

Good Techniques:

Myofascial release

Cross-fiber friction or deep transverse friction

Followed up by flushing effleurage to move the accumulated metabolic waste and reduce client

soreness.

Stretching the muscle passively that has just been treated.

Adhesive capsulitis: a condition in which there is limitation of motion in a joint due to inflammatory

thickening of the capsule, a common cause of stiffness in the shoulder. Also known as “frozen shoulder”.

Frozen Shoulder: is painful, significant restriction of active and passive range of motion at the shoulder,

most frequently in abduction and external rotation. In this condition the joint capsule becomes tightened

and inflexible. This diagnosis is very controversial in that it is often used as a descriptive term to describe

many different conditions. Some consider it to be the final stage of a progressive disease. It is idiopathic in

nature. And is often more of a clinical, not pathological diagnosis. But it is something we as massage

therapists can treat.

It often starts with active trigger points, especially in the subscapularis muscle, which leads to a restriction

in the abduction of the humerus and eventually spreads to trigger points in the pectoralis major and minor,

Latissimus dorsi, and triceps muscles. Trigger points in these muscles leads to restricted external rotation

which leads to trigger points in the anterior deltoid and teres major muscles. As this continues to spread the

whole shoulder system is likely to overload and eventually involve all of the rotator cuff muscles; leading to

restricted motion of the shoulder and a lot of pain.

It is not uncommon for the client to undergo manipulation under anesthesia in cases where there is no

documented progress. The results of this treatment vary greatly and there are complications, such as, pain,

tearing of the capsule, tearing of the long head of biceps and the subscapularis tendon; hematoma; shoulder

dislocation; and spiral fracture of the humerus.



Treatment:

Measure the range of motion pre and post treatment

Goal to gain and maintain range of motion

Heat compensating structures

Ice to affected shoulder

Diaphragmatic breathing to reduce pain

Reduce hypertonicity and trigger points

Treat postural distortions

Endangerment sites:

Be aware of where nerves pass. In addition to being a possible entrapment site, we should be careful of

these areas when stripping muscles or using deep tissue techniques.

Radial nerve passes between the humerus and the lateral head of the triceps

Median nerve passes between brachialis and biceps brachii

Ulnar nerve passes between the triceps and brachialis. The ulnar nerve can also be entrapped by

Latissimus dorsi

This list only includes entrapment by muscles of the upper arm and shoulder. Other entrapments are listed

elsewhere.

Additional notes

The gallbladder and liver can refer pain to the right shoulder (and neck) – specifically in the area of the

inferior angle of the scapula. If client does not respond to treatment, they should be referred out.

Since we are dealing with conditions/syndromes that have very similar symptoms we will treat them

together. Many of the muscle & bones list per conditions/syndrome over lap. We need first to assess

whether treatment is within our scope of practices. Refer as needed.






Neck and TMJ




1. Formulate a treatment plan to address client concerns.

2. Demonstrate techniques appropriate to client condition.

3. Demonstrate effective communication skills with client before, during, and after the massage.

4. Recognize when referral to another health care provider is appropriate.

5. Recognize that our goal is treating clients, rather than conditions.

SUGGESTED READING:

Mosby’s Pathology for Massage Therapist 2nd

Edition. Pages 126, 138 – 139, 152, 185 – 187.

Myofascial Pain and Dysfunction: Upper Extremities, Travell & Simons. Pages 166-167, 173-180,

202-217, 219-233, 236-247, 305-319, 321-328, 344-366.

WHIPLASH

Whiplash as defined by Stedman’s Medical Dictionary is an imprecise term for various injuries resulting

from sudden and violent hyperextension of the head on the trunk, followed by hyperflexion, as in a motor

vehicle collision. Whiplash can include fractures, subluxations, sprains, muscle strains, and cerebral

concussion.

It is also known as cervical acceleration-deceleration injury (CAD) and whiplash-associated disorders

(WAD). Whiplash-associated disorders are a term to describe the many clinical symptoms following a

whiplash.

Other terms commonly used: cervical sprain (ligament injury only), cervical strain (muscle injury only),

headache of cervical origin (cervicogenic headache), cervical herniated disc and sprained cervical facet

joints.



Cervicogenic Headaches often accompany whiplash. They are defined as pain perceived as arising in the

head, but whose actual source lies not in the head but in the cervical spine, specifically C1 – C3. This is

cervical pain that refers to the head.

Symptoms of whiplash may include headaches, dizziness, pain, stiffness, rigid muscles, muscle spasms,

dysphagia (difficulty swallowing), difficult time breathing (chest and shoulder breathing),

temporomandibular joint disorder/dysfunction (TMJ) and inflammation.

Initial Symptom onset may be delayed from 24 hours to several days and bigger symptoms may be delayed

up to a week following an accident. Therefore, always encourage your client’s to be checked out by a

doctor.

Since lawsuits may be involved in a whiplash injury, keep accurate records of assessment and treatment and

do not allow access of any individual to the records, unless proper written documentation.

Davis’ Law:

If muscle ends are brought closer together, then the pull of tonus is increased, thereby shortening the

muscle, which may even cause hypertrophy. If muscle ends are separated beyond normal, then tonus is

lessened or lost, thereby weakening the muscle.

In looking at Davis’ Law the body prefers balance to extremes. Chronic shortening (like when sleeping,

working at a computer) of a muscle can produce spasms. However, the opposite extreme can occur when

muscles have been overstretched in an accident, exceeding their normal limit (whiplash). The micro trauma

of tearing many muscle fibers often causes a loss of strength and increase in flaccidity of the muscle.

Muscles Involved:

Extension injury:

Sternocleidomastoid

Scalenes

Infra and Suprahyoids

Longus Colli

Platysma

Flexion injury:

Levator scapula

Suboccipitals

Rhomboids

Trapezius

Splenius Capitis/Cervicis

Semispinalis Capitis/Cervicis

Rotators

Multifidus



Rotation injury or side impact:

Sternocleidomastoid

Suboccipitals

Levator scapula

Splenius Capitis

Splenius Cervicis

Scalenes

Semispinalis Capitis

Trapezius

In addition other muscles may be injured due to their association to the neck or directly associated to the

extent of the accident.

Note: Wearing ones seat belt and properly set head rest help reduce the injuries resulting during an accident.

The health of one’s body and soft tissue will also reduce the degree of tissue damage during an accident.

Note: Neck pain on the right side can indicate referred pain from the liver and gallbladder. If pain does not

respond to treatment this client should be referred out.

Temporomandibular Joint Dysfunction

Stedman’s Medical Dictionary defines temporomandibular joint dysfunction as a chronic impairment of

function of the temporomandibular articulation.

Symptoms: can be unilateral or bilateral

Muscle tenderness

Jaw pain

Tooth ache

Headache

Earache

Clicking of the jaw

Limited range of motion or locking of the jaw

Radiating pain to the ear, face, neck or shoulder

Causes:

Inappropriate alignment of the joint

Hypertonic muscles

Laxity of the supporting ligaments and muscle

Degeneration of the joint



Risk factors:

Gum chewing

Nail biting

Mouth breathing

Chewing large chunks of hard foods

Habitual protrusion of jaw

Clenching of jaw

Grinding of the teeth (bruxism)

Tension of muscles of neck and back

Poor alignment of the upper and lower teeth

Forward hip alignment

Muscles to treat:

Temporalis

Masseter

Cranial fascia

Cervical muscles

SCM

Pterygoids

Headaches

Steadman’s Medical Dictionary defines a headache as pain in various parts of the head, not confined to the

area of distribution of any nerve.

Medical terms for headache:

Cephalodynia

Cephalalgia

Encephalagia

Types of headaches Tension

Cluster

Migraine

“Other”

Tension Headaches:

Most common type of headache.

Spasms in the cranium, suboccipital, cervical and shoulder muscles.

Resultant reduced blood flow increases the accumulation of waste products in the area,

resulting in increased pain.

Described by some client’s as a “tight band” around the skull.



Cluster Headaches:

The headache lasts from 10 minutes to a couple of hours.

Pain is confined to the eye, nose or one side of the face.

The face may appear to be swollen or flushed.

There is often a watery eye and runny nose associated with the pain.

The pain recurs 2-3 times a day for 5-6 weeks and then there may be months with no

headaches.

Migraine Headaches:

Usually confined to one side of the head.

Vasoconstriction of the cerebral arteries occurs during the first phase causing the auras.

The pain is preceded by flashing lights, dark spots, double vision and hallucinations.

These auras are due to the reduced blood flow to specific areas of the brain.

Phase two there is vasodilation, which leads to the intense pain.

Nausea, vomiting, hypersensitivity to light, sound and smell are typical symptoms.

These headaches can be triggered by certain kinds of foods.

“Other” Headaches

Eye strain

Mental fatigue

Sinus

Hypertension

Chemical poisoning

Infections

Tumor Growth

Blood sugar abnormalities

Trigeminal neuralgia

Asthma

Dehydration

Many other things.

Note: Client’s can experience a combination of headaches.

Treatment:

Depends on if the client has an active headache and personal choice.

Massage as tolerated.

Full body relaxation massage is beneficial.

Head and face massage as tolerated.

Hydrotherapy can be useful.

Gentle stretching.






HANDS ON MANUAL

Neck and TMJ



1. Demonstrate range of motion of the neck.

2. Assessment common complaints regarding the neck.

3. Discuss the pathology and treatment for specific injuries to the neck.

4. Recognize when a referral to another health care provider is appropriate.

5. Treat for injuries or complaints of the neck.

SUGGESTED READING:

Basic Clinical Massage Therapy: Integrating Anatomy and Treatment, James Clay and David Pounds



Neck

Postural Analysis 1. Client Standing: Measure the horizontal plane of the client’s acromioclavicular joint.

2. Client Standing: Measure the horizontal plane of the client’s temporal bone (finger in the client’s

ears).

3. Range of Motion:

Flexion (40º) Extension (75º)

Lateral Flexion (35 - 45º) Rotation (80 - 90º)

Assessment 1. Vertebral Artery Test

♥ Goal: To assess for circulation deficiency of the vertebral artery at the transverse foramen.

a. Place the client supine.

b. Passively fully extend the head and neck, then fully rotate the head to one side, hold for

about 15-30 seconds.

c. If the client experiences dizziness (vertigo), nausea, fainting, and/or eye movement

(nystagmus) it is a positive test.

d. Repeat on other side.

Note if the test is positive do not do treatments that include rotation of the head. Client may want to

follow up with their physician.

Nystagmus is a rhythmical oscillation of the eyeballs, either pendular or jerky.

2. Spurling Test

♥ Goal: Assess for compression of a cervical nerve root or for facet joint irritation in the lower

cervical spine.

a. Client is seated.

b. Therapist standing behind client.

c. Instruct the client to slowly extend, side-bend and rotate the head to the affected side.

d. Therapist carefully applies compression downward (inferiorly) on the client’s head.

e. Radiating pain or other neurological signs in the affected arm is a positive test. Pain

remaining local to the neck or shoulder indicates cervical facet joint irritation on the side

being tested.

Note: Do not perform this test if the vertebral artery test is positive.

3. Cervical Compression Test

♥ Goal: Use this test when a client cannot turn their head for the Spurling Test.

a. Client is seated.

b. Therapist standing behind the client.

c. The client’s head is in neutral position; gently apply compression downward (inferiorly) on

the client’s head.

d. Radiating pain or other neurological signs in the affected arm is a positive test. Pain

remaining local to the neck or shoulder indicates cervical facet joint irritation on the side

being tested.



4. Cervical Distraction Test

♥ Goal: To relieve pressure on the cervical nerve roots (particularly following Spurling or Cervical

Compression Test)

a. Place client in a seated or supine position.

b. Grasp the client’s head at the occiput and temporal area.

c. The client’s head should be in anatomically neutral position.

d. Apply gentle traction in a superior direction, maintaining the traction for at least 30 seconds.

e. A decrease or relief in client’s pain is a positive test. The reason for this is due to opening

the intervertebral foramina, reducing pressure on the facet joints or relieving muscle spasms.

For each area being worked consider using any of the following strokes to maximize desired

treatment.

Myofascial release Compression

Stretching Pin and Stretch

Vibration Muscle Energy Techniques

Deep Friction Cross fiber friction

Posterior Cervical Techniques 1. Suboccipital Muscle Release

Therapist’s position: Seated at the head of the table

Client’s Position: Supine

a. Therapist’s fingertips or each hand contact the bony attachments of the deep cervical

musculature at the Suboccipital region.

b. By flexing the distal interphalangeal joints, the therapist puts sustained deep pressure over

the muscular attachments to the occipital bone.

c. While maintaining the pressure, the therapist leans slightly backward as far as the patient’s

soft tissue allows.

d. The traction force and muscle stretch produced may be sustained for several seconds, then

released and rhythmically repeated.

2. Glide through the lamina groove

Muscles/Tissue affected: semispinalis capitis; splenius capitis; splenius cervicis; upper trapezius

Procedure: a. Cradle client’s head with left hand.

b. Place right hand, palm up, around the posterior neck with right thumb in the right lamina

groove just inferior to the occiput.

c. Glide inferiorly in the lamina groove to base of the neck.

d. Repeat 3 times.

e. Repeat steps a) – d) on the left side.



3. Posterior Cervical Muscular Release/Stretch

Therapist’s Position: Standing at the head of the table


a. Therapist crosses their forearms under the client’s neck so that the client’s head is fully

supported on the therapist’s forearms and the therapist hands are pressing down on the

client’s shoulders.

b. The therapist gently and slowly lifts their arm, while gently pushing down on the client’s

shoulder, gently stretching the client’s neck into flexion.

c. Hold this position for a few seconds. Slowly release, returning the client’s neck into neutral.

d. Repeat with a bit more flexion.

4. Compression of the Posterior Neck Muscles

a. Compress the muscles of the posterior neck as you move the neck through its range of

motion.

b. Repeat several times

5. Cross-fiber stroking of the posterior neck muscles

6. Stripping the posterior neck muscles

7. Trapezius

a. Myofascial Stretching

b. Deep Stripping

c. Pincer Compression

8. Splenius Capitis and Cervicis

a. The therapists hand cups the client’s neck with the thumb placed at the level of C7, anterior

to the upper trapezius and medial to the transverse processes in the lamina groove. Do not

apply pressure yet.

b. With the therapists other hand, raise the client’s head and slightly rotate the head in the

opposite direction from the side in which is being treated.

c. Now apply pressure in an anterior and medial direction. Apply longitudinal and transverse

friction.

d. Move one thumb’s width superior in the lamina groove and repeat. Continue until the areas

between T2 and C3 have been treated.

e. Apply only ischemic compression if hypersensitivity is encountered.



Anterior Neck Techniques Note: Indication for treatment: whiplash, military neck, or reverse cervical curve.

1. Supra and Infra Hyoid Release – See pp 254 & 255 of Trail Guide to locate

Suprahyoid – Stripping

Locate the hyoid bone with your thumb and index finger.

Place your thumb just superior to the hyoid bone medial to its horn (end)

Pressing gently into the tissue, glide the tip of your thumb slowly superiorly to the inner

surface of the mandible at the center.

Starting again superior to the hyoid bone, place your thumb slightly lateral to the previous

starting point.

Slide the thumb slowly superiorly to the inner surface of the mandible, parallel to the first

pass.

Infrahyoid – Stripping

With the side of one thumb or finger, gently press the thyroid cartilage laterally away from

you.

Place the thumb or fingertips of the other hand just superior to the manubrium next to the

trachea.

Pressing gently, glide the thumb or fingertips slowly up to the hyoid boine. Place the tip of

the thumb just over the clavicle slightly lateral to the sternal notch and repeat the above

procedure.

Repeat this procedure until you have covered a fan-shaped area extending to the clavicular

attachment of Sternocleidomastoid. (taken from Basic Clinical Massage Therapy: Integrating Anatomy and Treatment, Pages 86-87, by Clay & Pounds)

2. Longus Colli and Capitis

Therapist’s Position: Standing at the side of client, shoulder height, facing the client


a. Therapist’s right hand will be placed with the thumb on the trachea and hyoid bone, and the

finger tips resting on the left ramus of the client’s mandible.

b. Displace the trachea and the hyoid bone toward the left side.

c. Position both thumbs at the level of C1 with pressure directed as medial as possible apply

longitudinal friction.

d. Make sure to stay medial to the anterior tubercles.

e. Apply transverse friction from medial to lateral, if the client can tolerate.

f. Work inferiorly until the clavicle has been reached.

3. Sternocleidomastoid

Note: Indication for treatment: headaches, whiplash injures, temporomandibular joint problems,

and inner ear problems.

Therapist’s Position: Seated at the head of the table


Note: Be cautious to avoid pushing on the carotid artery, especially when stripping the muscle.

Note: If the client lifts their head the therapist can see the muscles position much easier.

a. Pin and stretch the SCM

b. Use pincer compression. (This move is much easier to do when the client has no oil on their

skin.



c. The therapist’s right finger using cross-fiber motions treats the attachments of the sternal and

clavicular heads

d. Skin Rolling and myofascial release

e. Apply a small amount of cream on the mastoid process. Scoop into the mastoid process,

working superiorly. Use caution to insure that you stay on the SCM and not the styloid

process.

Temporomandibular Joint Dysfunction

Assessment 1. Three-knuckle Test

♥ Goal: To check the range of depression of the mandible.

a. Instruct the client to open their mouth/jaw and insert as many of their flexed proximal

interphalangeal joints of the non-dominant hand between the upper and lower incisors (teeth)

as possible.

b. The functional width of the mandibular opening is two or three knuckles wide.

c. A positive test for temporomandibular joint hypomobility is indicated if the client can get

only one knuckle or no knuckles at all between the incisors (teeth).

2. Excursion

♥ Goal: To check side-to-side movement of the mandible.

a. Line up the space between the two front teeth on the top and bottom.

b. Have client move mandible to the left as far as possible and mark the range of movement

using the above as your guide.

c. Repeat on the right.

External Treatment for TMJ 1. Frontalis

Therapist’s Position: Seated at the head of the table.

Client’s Position: Supine.

a. Cross fiber the muscle, changing positions until the entire muscle has been covered.

2. Occipitalis



a. Work with the fibers, changing positions until the entire muscle has been treated.

b. Cross fiber the muscle, changing positions until the entire muscle has been treated.

3. Fascia of the head



a. Dry shampoo.

b. Hair pulling. Gently interweave the client’s hair between your fingers and make a fist, the

tighter the fist the greater the pull.

Note: The client should feel their skin pulling, not the hair being pulled. Stay within the client’s

tolerance.



4. Temporalis



a. Gentle compression.

b. Stripping, being careful not to pull the client’s hair. Continue to change position until the

entire muscle has been treated.

c. Work with the fibers.

d. Cross fiber the muscle, move positions until the entire muscle has been treated.

5. Masseter



a. Gentle compression.

b. Glide superiorly from the mandible to the zygomatic arch.

c. Glide inferiorly from the zygomatic arch to the mandible.

6. Pterygoid-External Treatment



a. Just anterior to the TMJ there is a space.

b. Compress superiorly, inferiorly, and anteriorly seeking tender spots.

c. Place one or two fingers just under the angle of the mandible.

d. Compress against the medial surface of the mandible.

Note: Steps one, two and three work well for clients that are experiencing headaches.






NESL Review


Cumulative review for your NESL Exam

Resources:

ASHTON AND CASSEL: Review for Therapeutic Massage and Bodywork Certification =

REVIEW

Classroom notes

Quizzes

Subjects to be covered:

This list is not exclusive, but rather a good representation of what could be on the exam.

Professionalism Ethics

Swedish Techniques Sanitation

History Business and Taxes

Draping Yoga

First Aid and CPR Body Mechanics

Tai Chi Stress Management

Traditional Chinese Medicine Perspectives on Holistic Health



Concepts/information to know:

Professionalism

o Communication

o Ethics and ethical behavior

o Fee structure

o Confidentiality

o Charting and record keeping

o Informed consent

o Scope of practice

o Standards of practice

o Boundaries

o Transference and counter-transference

SOAP notes

Benefits of pre and post assessment

o Quantified and qualified goals

o Assessment

o Goal setting

o Process of massage

Therapeutic touch

Centering and focus

Culture and its influence on massage

Goal of valid research

Biochemicals/neurotransmitters: How do they affect clients

Length of massage to achieve different results: attentiveness, relaxation, warming muscles, etc.

Parasympathetic and sympathetic

Entrainment

State-dependent memory

Stretch reflex

Neurological laws:

o Arndt-Schultz Law ○ Davis’ Law

o Hilton’s Law ○ Law of Facilitation

Mechanical vs. Reflexive methods

Chakras



Endangerment sites

Indication/contraindications

Direction of strokes

Body mechanics

Health

o Definition

o Predisposing conditions

o Massage influence

o Stress

Inflammatory response

o Four signs of inflammation

o Therapeutic inflammation

Scar Tissue

Nerve Plexus

o Sacral

o Brachial

o Cervical

o Lumbar

Nerve impingements

o Nerve entrapment

o Nerve compression

Medication

o Functions: Stimulates a body process, inhibits a body process, replaces a chemical in the

body

o Cautions

o General role of medication

Sanitation

o Types of pathogens

o Ways pathogens spread

o Hand washing

o Disinfection/sterilization

o Universal precautions



Modalities: Know general description and name of person given “credit” for development

o Myofascial release

o Acupressure

o Jin Shin Do

o Ayurveda

o Shiatsu

o Sports

o Polarity

o Reflexology

o Muscle energy

o Swedish Massage

o Trigger point therapy

o Touch for health

o Lymphatic Drainage

o Hydrotherapy

o Craniosacral Therapy

o Therapeutic Touch

o Applied Kinesiology

o Amma

o Rolfing

o Neuromuscular Therapy

Energy

o Qi

o Meridians

o Yin and Yang influences

o Blocked energy - -felt as pain and tightness

History (list is not necessarily all inclusive)

o Ling

o Ida Rolf

o Dr. Trager

o Dr. Stone

o Vodder

o Palmer

o Ingham



o Prudden

o Dr. Upledger

o Dr. Mezger

o Dr. Kellogg

o James Cyriax

o Mary McMillan

Techniques

o Deep transverse friction

o Compression

o Skin rolling

o Rocking

o Friction

o Vibration

o Petrissage

o Effleurage

o Tapotement

o Reciprocal inhibition

o Isometric stretching

o Isotonic stretching

Documents

BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND …...Sebastian Kneipp Mid 19th century - - Began using hydrotherapy to treat his own tuberculosis (then called consumption). Following