Massage Therapy and Joint Play

I took a really good course last weekend that covered Joint Play. This is a really important part of everything from injury prevention to rehabilitation. A joint is the place where two bones meet and one of the bones moves around the other in it’s intended range of motion. A great example is the shoulder joint. The main shoulder joint is where the top of the arm bone attaches to the outside of the shoulder blade. As the arm moves around the socket at the outer part of the shoulder blade, there needs to be small motion that occurs inside the shoulder joint. That is the joint play.  If the end of the arm bone is the ball and the edge of the shoulder blade is the socket, good joint play range of motion ensures that the ball stays within the socket space no matter where the arms moves to. If that small motion isn’t there, the arm movement will stop and reach the end of it’s range prematurely and can mimic Frozen Shoulder. It’s like a hinge in a door that doesn’t move well, so the door doesn’t close. It feels like it catches or pinches causing local shoulder pain that can begin to travel causing neck, rib pain and headaches. A lot of my success with treating the shoulder is just returning that small essential motion in the joint. These small motions can occur in the jaw (TMJ), the spine, shoulders, elbows, wrists, hip, Sacroiliac joint, knees, feet to name a few. Each of these joints have their own movements and often any limitations can be restored. The treatment for restoring joint mobility is a little different from standardized massage therapy as the treatment is very regionalized but I feel like it is such a crucial part of getting to the cause of dysfunction/discomfort. There is always treatment to the surrounding muscle tissue, especially the symptomatic one in addition to the joint play treatment. I remember one teacher saying that if you have a painful/tired muscle, look to see what joint they move. For example, if you have a sore biceps muscle on your arm, I look at the shoulder and elbow movement. If someone has a sore front leg muscle, I look at the hip and the knee joint. It’s not well known that the ribs are also very mobile during torso and arm movement and breathing, and in our society, the ribs are commonly stiff and can benefit from mobilization. Very often, I have found that treating just the tight muscle may feel good for a shorter period of time, but can return if there is an involvement in the surrounding joints.

Having said all that, there is opportunity for pain to refer away from where the joint is not functioning properly. Neck joints in the spine can cause pain down the arms or produce headaches. Low back spine joints can refer pain into the hip or down the leg and mimic Sciatica. A stiff joint in the foot can produce pain that goes up the leg. There is a thought out there that you find the pain but look for the cause elsewhere.

Having joint play in my treatment tool box has vastly reduced pain and dysfunction with patients, increasing functionality and improving daily activities. It is a gentle treatment and follows with the Osteopathic process, which often reveals very good results. Be gentle and the body will let you do more. As always, the patient’s success is partly what we do in the treatments, but just as much, it is important for the patient to be involved so they can continue to improve at home with stretches, exercises and movement/posture changes. It continues with the philosphy that we were designed to move a certain way and very often dysfunction can occur when we don’t.

Trigger Point Therapy

Trigger Point Therapy is a tool in my treatment toolbox that I use often with helping to relieve pain symptoms that the client is experiencing. They can vary from localized pain of taut bands of muscles that can occur throughout the body from feet to the top of the head. They can also exist with symptoms like jaw pain, neck pain, headaches, pain down the arm or leg or into the hips. They occur where there is a taut band in a portion of a muscle. There is debate as to the actual physiology behind trigger points but the symptoms or undeniable. These taut bands (trigger points) in hypothesis occur when the muscle tightens/ shortens due to fatigue or being put into a shortened position for an extended period of time, trauma, dysfunction of a nearby joint that it is involved in movement or stabilization of including anything from foot, knee, hip, spine, shoulder, elbow or hand. Often it will produce a vague, dull achiness, which can help to differentiate is from a nerve related pain. When there is pain down the arm or leg, it can often be misdiagnosed as a nerve related pain but special assessment can be done to determine if it is nerve or trigger point related. The tricky thing is that the trigger point can refer pain to another area, making it seem that there is a dysfunction in that distal area. For example, the outside of the thigh muscles can refer deep achiness right into the knee. The rotator cuff muscle trigger points can refer down the arm to the hand. Neck muscles can produce head aches in different areas of the head by different neck muscles.

Each person experiences a reduction of symptoms in different ways so there is no one way to relieve a trigger point. In addition to releasing the trigger point, it is important to determine why that muscle, or portion of the muscle is tightening and help educate the client to avoid a reoccurrence in the future. Writing this entry reminds me of trigger points that can occur in the upper back and neck that can produce head aches. We are in a society that is spending a lot of time in a slight forward slouched upper back and head forward position and the end result is that the muscle in the back of the upper back and neck just get tired. Our heads are heavy and produce a greater force the more forward they are. Good upper body and head position is important as it dramatically reduces the exertion put on the upper back and neck muscles. It is part of the posture and movement pattern re-education that I teach in treatment so that a client can be empowered to make posture/ movement changes when the symptoms of trigger points occur (in addition to others). It’s about treating the symptoms, finding the cause and helping the client to make movement/ postural changes to avoid reoccurrence in the future.

Here is an interesting tidbit

I remember in my 30’s I had a reoccurring issue with my low back. There were acute back spasms, pain going down the leg, numbness and tingling on the shin. I was often in getting treatment and trying to figure out what was happening. I remember getting an x-ray done of my low back through a walk in clinic. I got the results and was told that I have some arthritis in my back. Honestly, it felt like it was the beginning of the end. Arthritis. They talk about how pain is a signal elicited by the brain if it feels like you are under a threat. This can be cause by tissue damage, visual, audio, tactile and many other stimuli. There is a good possibility that if I am told that I have arthritis in my back, and that is responsible for my pain then the pain can become chronic. I have learned to become careful in practice with the language that I use when talking about what I find or what they have found out about their pain/dysfunction. I found something interesting (below) that talks about how things like arthritis/ bulging discs/ torn rotator cuff and meniscus/ osteophytes may not be responsible for the pain being experienced. These different studies/ scans, in the study that I am attaching, were done on asymptomatic people. The result of the attached study is that there are all these people in the pool that have no symtpoms, yet here they are with torn this and that and bulging discs and arthritis ect. Maybe the Orthopedic world is looking too hard for something to be wrong or something to blame for the pain if they find something on a scan. Arthritis, for example, is a totally natural occurrence. Everyone gets it. Maybe in extreme cases of advanced arthritis or rheumatoid arthritis can perhaps cause some pain/stiffness, but for the most part it can be a perfect benign presentation. Maybe the symptoms are just from the way we are moving or sitting. Something that we can remedy easily and quickly. The picture below shows the studies, the number of participants and the results from the scans. There are lots of special tests to rule out and scan results like meniscus or rotator cuff, disc issues but we shouldn’t depend just on the scans to make determinations as to the source of the pain. It’s good to ask questions like “I see that I have a bit of a rotator cuff tear, but how can we know for sure that is what the issue is?”. When we see someone about an injury or pain we are feeling, we need to be part of the conversation.

To stretch or not to stretch

With Massage Therapy, part of our focus is on the muscular system and maintaining good function allowing the client to reduce their pain and stiffness. In addition to releasing the muscle tightness/stiffness, it is also important to be able to determine why the muscles are tightening up. Often I find that a client may come in and say that they have been stretching and stretching but to no avail. This may be due to the tightness occurring when the muscles are activated to try to stabilize a part of the body that is too mobile. If you take, for example, the low back, the range of motion is limited by a few factors including the surrounding connective tissue. The connective tissue that surrounds the spine will stop you from bending too far backwards, forwards, side to side or rotation. Connective tissue is comprised of collagen fibres for strength and elastin fibers for flexibility. A certain part of the population, including me, have a little more elastin fibers to collagen fibers so we can bend a little more than everyone else. With a little less stability from the surrounding connective tissue, the muscles are recruited to work harder to stabilize our low back. If we use our backs too much, the muscles begin to fatigue and the brain says “stop what you are doing” and uses pain to get us out of the perceived threat. So the muscles are functioning overtime because of lack of stability. When our low backs begin to tighten and we begin to experience pain, we are inclined to stretch those muscles. If the muscles are short and tight, they will not want to lengthen as they are doing a job of trying to stabilize so they will respond to our stretching by tightening more. Our stretch becomes a tug-of-war and will ultimately end up not being successful. During the assessment portion of a treatment, I like to look at the joints and move them passively (without the client’s involvement) to determine if the motion in the joint is not enough or too much. If there is too much motion, the direction to go in is not to stretch the muscle but to help to stabilize the low back joints in the spine to reduce the need for the muscles to tighten so much. This is a much different approach from standard Massage Therapy where there is more focus on “releasing the muscles”. Make the body more stable and reduce the need for muscles to work so hard. Going back to my previous entry about movement patterns and pain/dysfunction it is also important that we learn to move around the joints that are strong and stable. The low back is a perfect example as really it is a very unstable structure. The spine is essentially a bone on top of a gelatinous disc on top of a bone on top of a gelatinous disc all the way to the top of the spine. We are not really designed to move mainly through the spine and especially not exerting a force. Keep the spine as still as possible and move through the two hip joints, for example. As someone that is hypermobile through my joints, this has been an essential component to maintaining a healthy, pain free back and I’m always happy to share with others what I found has worked for me.

The other component is that with most movement through the body, there are the muscles that move the joints and those muscles that help to stabilize the joints through that movement. It is essential that we maintain strength and function of the stabilizers to match the strength of the muscles that are primarily moving a joint (or group of joints). Someone once said, not having this support is like having a tree where the brances are  stronger than the trunk. If the proper stabilizing muscles are not recruited, other muscles are activated that are much less efficient as stabilizing also producing and short, tight, fatiguing group of muscles and consequently pain and dysfunction.

So muscles that have tightened may not need to be stretched. Of course we work on those muscles during the treatment to reduce the reactivity and pain but we also help the client to support and improve the way they move in preventing pain the future. The courses that I have taken in Mat Pilates Teacher Training provide a really good base of support to create a strong, mobile, well supported body.

The long stretch…

There are generally two schools of thought with stretching in terms of how long you hold the stretch. There is the 30 second stretch and the 3 minute stretch. I come from the place of the longer stretch in increase range of motion and the 30 second stretch in terms of maintaining the increased stretch. I think the important thing to think about with a stretch is that it is not just the mechanical stretch of the muscle but also the aspect of allowing the nervous system to adjust to the increased length of the muscle. Someone once described a 3 minute stretch in 3 parts.

1)The first minute of the stretch, there is a bit of resistance or protective shortening of the muscle as you are taking the muscle a little further than where it is used to going so you wait for that first minute for the nervous system to feel comfortable with the lengthening of the muscle.

2)The second minute, the protective tightening of the muscle reduces allowing the muscle to begin to lengthen.

3)The third minute is the time that the muscle is left in the lengthened position to allow the nervous system to experience not just the muscle in the lengthened position but also the joint going into that position. An example is the hip joint and a hamstring stretch. The stretch is not just intended for the hamstring but also for all the deeper tissue surrounding the hip joint.

When people ask me if I prefer foam rolling vs stretching, I think that both have their place but for allowing a muscle to lengthen and increase the joint movement in that direction, I always advise the stretch.

I always like to think of a stretch as slow cooking. A more gentle stretch for a longer period of time. All we want with muscle/skeletal system is for the body to be able to move in the manner to which it is designed.

 

Mat Pilates Training

I’m very excited to announce that I will be taking a Mat Pilates Teacher Training course in April. The skills that I learn in the course with be very helpful for teaching good core strength and proper movement pattern to my clients. I find myself being drawn more and more into the benefits of good movement patterns as often I find that pain and dysfunction occur when we move in patterns which our bodies do not function well in. As I mentioned in my previous post, evolution has designed us to move in a certain way. Some areas are much more stable than others. One teacher said that it is a simple decision when we choose how to move. It is like coming to a crevasse and you have two bridges. One is a strong cement bridge and the other is an old unstable wood bridge. Which would we choose to cross. My job is to reveal those options to you so you can be empowered to make the right choice.

Be Strong + Move well = Less pain.

Developing a treatment philosophy

With any condition that a patient comes in to see me with, I feel like it is always important to have a philosophy to refer to when helping a patient to feel better. It might be neck, shoulder, back or hip pain. It might be headaches, numbness and/or tingling, loss of range of motion of a body part or perhaps an issue with balance or function. There are many ways to help with re-establishing good movement or posture patterns and/or functional retraining when there is an activity that the patient wants to return to. Very often, in my experience, it is when we deviate from good movement or postural patterns that symptoms may arise. Our bodies need to learn again where it should be, whether it is posture or the way that we move. My greatest success with helping the body to move better in a pain free manner is to look at how the body is supposed to move. There are lots of hints and clues with our physical evolution.

Take the shoulder for example. Good movement of the shoulder involves movement of the surrounding ribs, shoulder blade, collar bone, the vertebrae of the upper back with control and stability of the surrounding muscles and ligaments. Everything has a job as the shoulder joint is properly stabilized no matter what direction it moves. One teacher of mine talked about the importance of just allowing the body to do what it was designed to do. It is my job to look at how each part is working during a movement, to make sure that everything works properly. A small dysfunction in one area can cause pain in another area. As owners of the body in pain, we are drawn mainly to where it hurts, making it difficult to assess where the dysfunction is originating. In my own experience, I experienced significant discomfort in one area, to which the treatments I received was focused mostly in the symptomatic area, and it wasn’t until we discovered that the function of another area needed to be improved. Once the function of that area improved, then it significantly helped with the symptoms that I was experiencing. There was a thought put out that sometimes you need to put the symptoms aside for a brief moment and just see how the whole region is working.

With all of the above in mind, I have adopted the philosophy of looking at how the whole system is working. Often the easiest part of treating is the short term effect of removing the symptoms with soft tissue release and mobilizing a joint to allow better movement but I like to move past that to teach the patient to improve their posture or to learn to move in the manner in which we were designed to move so that if we find that there is a return of the symptoms, then the patient knows how to remedy the situation. A classic example is working in front of the computer and falling into a slouched position and feeling upper back and neck pain. During a treatment, I will show the patient the optimal position to hold the body where it is strongest and least like to experience pain or dysfunction.

Learning about ourselves and how we are meant to move and hold ourselves is the secret to reduced pain, mobility, flexibility, strength and endurance.