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Firstpublished2003 Reprinted2003,2004,2005,2006(twice),2007(twice) ISBN13:9780723432265 ISBN10:0723432260 BritishLibraryCataloguingin PublicationData Acataloguerecordforthisbookisavailablefrom theBritishLibrary LibraryofCongressCataloguingin PublicationData Acataloguerecordforthisbookisavailablefrom theLibraryof Congress Note Medicalknowledgeisconstantlychanging.Standardsafetyprecautions mustbefollowed,butasnewresearchandclinicalexperiencebroaden ourknowledge,changesintreatmentanddrugtherapymaybecome necessaryrappropriate.Readersareadvisedtocheckthemostcurrent productinformationprovidedbythemanufacturerofeachdrugtobe administeredtoverifytherecommendeddose, themethodandduration ofadministration,andcontraindications.Itistheresponsibilityofthe practitioner,relyingonexperienceandknowledgeofthepatient,to determinedosagesandthebesttreatmentforeachindividualpatient. NeitherthePublishernortheeditorsassumeanyliabilityforany injury and/ordamagetopersonsorpropertyarisingfrom this publication. The Publisher _ yoursourceforbooks, journalsandmultimedia inthehealthsciences www.elsevierhealth.com Working together to grow libraries in developing countries I I www.elsevier.com www.bookaid.org www.sabre.org The publishers policyistouse papermanufactured fromsustainableforests PrintedinChina I To Elise Yoursupport for this project has been essential and my work would not be what it is without you. Foreword Competencies are the particular, defined attrib- sage is an appropriate and beneficial form of utes and skills that all providers of health care therapy. require. They differ from profession to profes- The modern emphasis on evidence-based, sion, and alter over time as professions evolve patient-centred, safe, effective and cost-effective and develop, and as the demands of the con- health care provision offers skilled bodyworkers sumer, the public, insurance companies and an opportunity to demonstrate the value of low- Government agencies change. tech medicine, embodied in the scientific appli- In an ideal world the competencies of the mas- cation of massage therapy. sage therapist should include an ability to evalu- The original use of the term ‘orthopedic’ relat- ate the multiple structural and functional ed to the correction of childhood deformities and problems of the musculoskeletal system, and to disabilities, however the word has now achieved base subsequent therapeutic choices on the evi- a common currency to mean, ‘pertaining to the dence gained by diligent assessment. speciality concerned with preservation, restora- Similarly, the competencies of other ‘body- tion, and development of form and function of workers’, whether from the disciplines of the musculoskeletal system, extremities, spine, osteopathy, chiropractic, physical therapy or and associated structures, by medical, surgical, manual medicine, should ideally include basic and physical methods’ (On-line Medical (and hopefully advanced) massage and soft- Dictionary 2002). Understandably Lowe offers a tissue manipulation skills. slight expansion of this definition (p3), which Unfortunately, in the real world, these ideals emphasizes the variety of tissues amenable to are not universally met; either by massage thera- ‘orthopedic’ massage therapy attention. pists or the wider corpus of ‘bodyworkers’. This The sense in which the word orthopedic is book by Whitney Lowe aims to bridge these used in the title of this book therefore aligns mas- gaps. It attempts to encourage massage thera- sage therapy squarely with the scientific tradi- pists to use orthopedic science to better apply the tion. This objective is clearly highly desirable, multiple skills of massage therapy in particular, and also appropriate for those therapists whose and soft-tissue manipulation in general. For as objectives are in accord with the definition of Lowe correctly points out, entry-level training orthopedic approaches to treatment. There are, for the massage profession is anything but uni- however, many massage therapists who function form, and with notable exceptions (in Canada in a different mode. Their aim is less directed at and some US schools in particular) massage treating dysfunction than at attempting to relax, training provides inadequate schooling in han- calm and provide a safe and secure period for the dling (literally and figuratively) the wide range patient, using what can be termed ‘wellness mas- of musculoskeletal dysfunctions to which mas- sage’, during which self-regulating homeostatic viii FOREWORD mechanisms and systems can better operate. often does not use massage. A review of the Interestingly, it is with this massage approach, excellent representations of massage therapy in which provides non-specific interventions, that action, in the later chapters of this book, will much research seems to be involved (Field 2000), hopefully cause this to change. although Lowe offers a number of citations that And so Lowe is arguing for a use of massage support the value of specific massage inteven- that involves diligent assessment and planning, tions. It is to be hoped that all massage thera- and application of the multiple tools of the pro- pists, the specific and the non-specific, will find fession (together with a number of techniques in this book ideas and methods that can allow safely borrowed from osteopathy, such as posi- them to practice more safely and effectively. tional release and muscle energy methods) in a The chapter sequencing of the book takes the coherent and appropriate manner. He has reader through a foundational introduction to shown in his own work and teaching that this is the general principles involved in orthopedic a clinically effective, cost-effective, and safe massage, before moving on to regional applica- way of dealing with much musculoskeletal tions of the methods discussed. Lowe offers dysfunction. excellent insights for bodyworkers from other It is to be hoped that the careful planning that disciplines, as to what massage therapy has to has gone into this book will encourage those offer in a wide range of musculoskeletal prob- massage therapists currently operating with lems. Learning to employ massage alongside less than full dedication to the possibilities currently used methods (osteopathy, chiropractic their profession has to offer, to study more, for example) is capable of opening new vistas for train further, and think along the ‘orthopedic’ those who have never learned its value. This lines that Lowe encourages. The book is also for book provides an ideal first step toward that pos- educators who have the opportunity to influ- sibility. ence the professional direction of the next gen- The key features of orthopedic massage, wher- eration of massage therapists. It is to be hoped ever they are applied, involve a structured that other health care professionals, using assessment approach, choosing manual treat- (apparently) less time-consuming manual treat- ment methods that are appropriate to the needs ment methods, will consider the value of turn- of the tissues involved, the ability to vary thera- ing (or returning) to soft-tissue care, using the peutic input to meet changing needs (or lack of best that massage has to offer alongside, and progress), and a protocol for rehabilitation in sometimes instead of, more invasive forms of which soft-tissue dysfunction is normalized, treatment. flexibility is restored, movement patterns are corrected, and strength and conditioning are London, 2003 Leon Chaitow ND DO encouraged. Senior Lecturer, University of Westminster To be sure, these objectives would not be very different in other disciplines (physical therapy, chiropractic rehabilitation, osteopathy and man- REFERENCES ual medicine for example), but what would be Field T 2000 Touch Therapy Churchill Livingstone different would be many of the methods used – Edinburgh the massage therapist does not manipulate joints On-line Medical Dictionary 2002 (although many do mobilize them) and the chi- www.cancerweb.ncl.ac.uk/omd/ ropractor/osteopath/physical therapist all too Preface Massage as a health care treatment has been a als who have developed specialized knowledge part of medical practice in many cultures for and skills in the treatment of orthopedic disor- hundreds – if not thousands – of years. However, ders have not had the exposure to the highly spe- with the rise of the pharmaceutical industry and cialized skills of massage therapy technique and the development of numerous technological application. treatments, it virtually disappeared from As a clinician, I have seen many individuals Western medical practice in the early twentieth benefit from the effective application of massage century. Now we are in the middle of a resur- as a therapeutic intervention for orthopedic gence – a time in which we see a renewed inter- problems. But I have also seen instances where est in the use of manual therapies for treatment improper application of massage treatment can of soft tissue injuries and the use of massage as a be detrimental. therapeutic treatment. As an educator, I have noticed places where Since Western society is notoriously plagued there are gaps in the knowledge and training of by stress-induced illnesses, massage has evolved many practitioners who are using massage. into a popular remedy for helping many people Many of these individuals have good intentions, reduce this stress and enhance wellness in their but don’t understand all of the factors which life. In addition, however, attention is now being must be considered in formulating an effective focused on ways in which massage may be used plan of care that includes massage. to address specific pathological problems. Clinical experience has indicated that massage Soft tissue injuries that impair function of the can be a very helpful treatment for many soft tis- locomotor structures in the body are primarily sue pain and injury conditions. However, in addressed within the field of orthopedics. While order for it to be most effective, it needs to be there are numerous treatment methods for these firmly rooted in clinical science, and applied with soft tissue problems, it is only recently that mas- careful reasoning and skillful manual techniques. sage has come to be viewed as a beneficial treat- While this text does not purport to be a com- ment for specific complaints in more than a very prehensive reference on the field of orthopedics, general way. I have included certain fundamental principles Unfortunately, many of the individuals who with which a practitioner of orthopedic massage have had the opportunity to learn proper appli- should be familiar. These principles are present- cation of massage techniques, especially massage ed in the first several chapters. This text should therapists, have not had the background educa- also not be considered a comprehensive refer- tion in the field of orthopedics that leads to a ence on basic massage techniques for those who comprehensive understanding of orthopedic dis- have not had prior training in massage. orders. At the same time, many of the individu- However, I felt it important to include informa- x PREFACE tion on basic applications of massage in order for that we never lose sight of the fact that we must the reader to understand many of the treatment work with each person as a unique individual. suggestions that are presented. Chapters 4 and 5 It is my hope that this text will serve as a are designed to give a good background under- bridge to complement the skills and abilities of standing of the use of massage as a therapeutic all those who may choose to incorporate massage intervention. as an intervention for orthopedic disorders. I The chapters that focus on a specific region of have written this book with that in mind, intend- the body address commonly occurring soft tissue ing that it should appeal not only to massage pain and injury conditions. I feel that it is impor- therapists, but physical (physio-) therapists, chi- tant for the practitioner of orthopedic massage to ropractors, athletic trainers, nurses, physicians understand the treatments traditionally used for and any other interested professionals. each problem. Therefore, I have included a I would be delighted if this book were to description of how each condition is commonly become a starting point for a much larger inquiry treated, prior to a discussion of the ways in into the use of massage for orthopedic problems. which massage may or may not be appropriate We are badly in need of research to validate the as a treatment for that particular pathology. clinical experiences that form the basis for the While knowledge of pathological conditions is theories presented in this book. valuable, that knowledge alone is not enough to Finally, I hope this book will promote a fuller ensure that an individual will be an effective understanding of both pain and injury condi- practitioner of orthopedic massage. Personal tions, and the subsequent benefits of massage as interaction skills are important for any health a therapeutic intervention. Such an understand- care provider, but especially for any practitioner ing might then bring together health care of massage, because the nature of the treatment providers from these diverse professions – all of brings the practitioner and patient into a very whom share a mutual interest in the healing close relationship with one another. Therefore, power of touch. while exploring the detailed facets of kinesiolo- gy, anatomy, mechanics and pathology that go Bend, Oregon 2003 Whitney Lowe along with the field of orthopedics, it is essential Acknowledgments This book has been a work in progress for many shaped by the feedback from the initial reviewers years. It would not have been possible without of the manuscript, Leon Chaitow, Nancy Dail, the experiences I have had through teaching and Judith DeLany and Bob King, and their input clinical practice throughout that entire time. For was important in charting the course for the that reason I am greatly indebted to the thou- eventual direction of the book. sands of people who have contributed in that I have had an outstanding support staff manner without realizing they were an essential throughout this process as well. In particular I part of this project. would like to thank Deanna Roth and Lorina Several people and organizations were instru- Davis for their help at OMERI while I was occu- mental in the early stages of supporting my inter- pied with this and numerous other projects. I est in bringing together the field of orthopedics would also like to thank Mary Law, Katrina and massage. In particular I would like to thank Mather, Ailsa Laing, and the entire staff at the faculty, staff and students at the Atlanta Elsevier Science for the outstanding work they School of Massage as well as the clinical staff I have done from nurturing the initial ideas to the worked with at the Emory Clinic Sports final product. In addition thanks are in order to Medicine Center in Atlanta, GAand at Timberhill all the individuals who participated in the pro- Physical Therapy in Corvallis, OR. I would also duction of the photographs for the book includ- like to offer special thanks to Benny Vaughn, who ing Michael Giebelhaus, Anna-Lena Hilts, has been a wonderful teacher, colleague and Bonnie Raile, David Williams, Nelida Wilson and friend all along the way. the Central Oregon Community College A great deal of the material in this book has Massage Therapy Program. come out of my work in teaching massage. I have Finally I would like to thank you, the readers had the great fortune to share teaching responsi- of this book, because you will be the ones that bilities with some highly talented individuals fully bring it to life. Those of you who are practi- and their input and feedback has made this book tioners are the ones out there ‘in the trenches’. far better. In particular I would like to thank Lane You will have a unique opportunity to test the Blondheim, Rick Garbowski, Brian Glotzbach concepts put forth in this text and identify new and Alexandra Hamer. As a writer, I would also ways that this material can grow and expand in like to acknowledge the valuable editorial assis- order to reduce the pain and discomfort in peo- tance I have received from Elise Wolf and ple’s lives. Alexandra Hamer. They have both pushed and prodded me in directions that have significantly Bend, Oregon, 2003 Whitney Lowe improved my writing ability. This book was also SECTION 1 General principles 1 Orthopedic massage and musculoskeletal For any discussion of orthopedic massage to disorders be complete, it is essential to address some fundamental concepts. Section one 2 Understanding soft tissue injuries addresses the basic principles necessary for the practitioner to have a proper context in 3 Thermal modalities as treatment aids which to understand the use of massage in treating orthopedic problems. The field of 4 Introduction to specific massage orthopedics is expansive, since it is the techniques branch of medical science that deals with the movement systems of the body. To accurately 5 Physiological effects address pathological problems in locomotor structures, the practitioner must understand how they work in a healthy system as well as when they are injured. A comprehensive discussion of how each of the primary locomotor tissues works in the healthy body is beyond the scope of this text. However, the most common pathological problems with the major locomotor tissues are discussed. Understanding these processes will be essential for the practitioner to identify the nature of most soft tissue problems, and to determine the appropriateness and application of massage treatment. This first section also discusses the fundamental principles of massage as a therapeutic intervention. While this text is not meant as an instructional manual in basic massage therapy applications, it is important to include general guidelines about the methods of massage for those who have not had much exposure to it. There are numerous books, videos and educational programs that cover the basics of massage in more detail. The reader is strongly encouraged to get adequate training in basic massage skills before attempting the advanced treatment methods suggested in this text. 1 Orthopedic massage and musculoskeletal disorders Musculoskeletal pain and injury conditions are an increasingly common reason for individuals to seek medical care worldwide. In fact, these problems are the second most common reason for seeing a family practice physician, infectious diseases being the first (Craton & Matheson 1993, Kelsey 1982). Many of these problems fall under the category of Cumulative Trauma Disorders (CTDs). CTDs may account for as much as 56% of all occupational injuries in the United States (Melhorn 1998). While work related injuries are particularly common, people also seek help for conditions resulting from a wide variety of other activities. Sports, gardening, extended periods of sitting, lack of exercise or too much exercise, or an assortment of accidents may motivate them to seek treatment. Healthcare practitioners who work with these conditions approach them from within the perspective of orthopedics. Orthopedics is the ‘branch of medical science that deals with prevention or correction of disor- ders involving locomotor structures of the body especially the skeleton, joints, muscles, fascia, and other supporting structures such as liga- ments and cartilage’ (Thomas 1987). With this definition, it is clear that many different tissues may be involved in orthopedic disorders. The group of conditions or problems that would fall under the category of minor musculoskeletal dis- orders (those not requiring surgery) is huge. However, the emphasis in medical school educa- tion is dramatically skewed toward those prob- lems that warrant surgical attention (Craton & Matheson 1993). 3 4 ORTHOPEDIC MASSAGE: THEORY AND TECHNIQUE The result is a knowledge gap for a large num- respectively, regardless of the practitioner’s ber of physicians when it comes to treating minor profession. musculoskeletal disorders. This problem has There has been a dramatic increase in the use recently been discussed in several studies inves- of massage therapy as a therapeutic approach to tigating the curricula of medical schools in mus- the treatment of pain and injuries in recent years. culoskeletal medicine (Callahan 1999, Clawson Efforts are being made to validate case reports et al 2001, Jones 2001). It was also discussed in from practitioners and proponents who argue for the early 1980s by James Cyriax, the well-known massage’s ability to treat a vast array of medical British orthopedist, who stated, ‘At present the problems, not just provide general stress reduc- number of doctors and physiotherapists trained tion (Blackman et al 1998, Gam et al 1998). in this discipline [skilled evaluation and treat- However, massage is not benign, it can produce ment of the moving soft tissues] remain so small adverse effects. The more educated one is in the that the methods of orthopedic medicine are understanding of massage, the more likely it is available to only a tiny fraction of all patients that one will be able to determine its appropri- who need them’ (Cyriax 1982). ateness as a treatment for a particular injury or A great deal of medical school training will pain condition. focus on treatments using drugs and surgery, the Appropriate entry-level training in treating primary treatment tools of most physicians. musculoskeletal disorders is lacking in massage Unfortunately, many minor musculoskeletal dis- education. This is true for other practitioners orders do not respond well to those treatments. who utilize massage as well. Massage therapists Recommendations have been made that physi- use continuing education programs and work- cians make up for gaps in knowledge of treating shops to improve their skills and knowledge in musculoskeletal disorders primarily through this area. Unfortunately, the quality of training continuing medical education (Glazier et al programs varies greatly. There is a plethora of 1996). quick fix treatment courses that work to under- Consequently, other professions have attempt- mine the overall quality of massage education. ed to fill the gap and make treatment available to Massage therapists are generally ill-prepared to the large number of people in pain and discom- be able to distinguish between a treatment fort. These problems may be treated by physio- approach based in science and those that are not. therapists (physical therapists in the US), This text is designed to aid practitioners and occupational therapists, chiropractors, massage training programs in building knowledge, skills, therapists, athletic trainers, nurses, or any num- and abilities to use massage therapy for its great- ber of movement system specialists. est benefit in relieving the pain and suffering of An increasing number of people are turning musculoskeletal disorders. As the use of massage to massage as a beneficial treatment for mus- for treating orthopedic disorders expands, there culoskeletal pain and injuries. For example, in will be a greater emphasis on evidence-based the United States it is estimated that con- practice and clinical treatment methods that sumers visit massage therapists over 114 mil- are grounded in research. During this growth lion times per year (Eisenberg et al 1998). There process it will be important to maintain a bal- are many others who may be receiving mas- ance between the investigative, science-oriented sage as a treatment, though provided by a approach to treatment and the holistic alternative practitioner other than a massage therapist. In health environment in which massage therapy this text we will refer to massage therapy as a has flourished in the last 30 years. These per- practice that may be performed by profession- spectives represent two sides of the same coin, als in a number of different fields. References and the most effective treatments will occur to practitioner andclient will be used to desig- when they are seen as parts of an integrated, nate the individual performing the treatment comprehensive treatment process. This book is and the individual receiving the treatment, intended as a step in that direction.