A CASE STUDY

SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

Weekly I receive inquiries from massage therapists and potential clients asking for help with the pain they are experiencing from surgical scar tissue and adhesions. So, this column will present a case study of one of my clients detailing the treatment process with explanations of why it was successful. I hope this will answer some of your questions and give you some helpful suggestions for treating surgical adhesions and scar tissue. The name has been changed to protect confidentiality.

Sarah, a 63-year-old disabled office worker, was referred to me by her daughter. Sara’s problems started 20 years ago when she donated a kidney for her daughter. The surgical incision was half way around her body. Six months after the removal of the kidney Sara had an additional surgery for the removal of surgical adhesions that had resulted from the initial surgery. These adhesions had produced significant pain and prevented her from returning to work. The second surgery was followed by a third surgery four months later, again for surgical adhesions. Sara still had not been able to return to work and her pain had worsened.

By the time she was referred to me she had undergone a total of seven surgeries for adhesions and was still unable to work. This disability had lasted approximately 20 years and by the time she came to me her overall vitality and health reflected the 20 years of medication and pain, and she appeared older than her 63 years.

Upon evaluation she was severely bent over on her right side in an acute collapse of the core distortion pattern and could not rotate her upper body to the right. She was not able to fully straighten up due to the restrictions deep in her abdomen from the surgical adhesions. When I palpated the surgical adhesions and scar tissue, I found them to be fibrous, thick and hypersensitive from the surface tissues in the rectus abdominus, obliques, and latissimus dorsi all the way through the soft muscle of the intestines, and into the psoas and quadratus lumborum of the deep intrinsic stabilizing muscles. In addition, she had significant pain in the lower lumbar region of the spine, hip, neck and shoulders as a result of the structural collapse. She was also depressed due to the fact that she had not been able to work or take part in activities that she enjoyed.

Sara was a challenge. It was obvious that surgery was not the answer for removing scar tissue – in fact, all the surgeries compounded the amount of adhesion and scar tissue which resulted in the degeneration of her structure. Pain medication had only created additional problems, and obviously had not allowed her to resume a normal life. What was amazing was that she still had hope and ambition and dreams for her future.

To effectively treat Sara it was necessary to determine long term, intermediate and specific session goals. The long term goal was simple – a return to normal life activities pain free. The intermediate goals would be the steps to accomplish the long term goal. These included a reduction of pain, a balancing of the structure, lengthening and normalizing the scar tissue and surgical adhesions, and an increased range of motion. Each of these would be accomplished through a series of treatment sessions with Sara. To accomplish the intermediate goals, there needed to be specific goals for each session. I discussed this with Sara, and let her know that I would be applying different techniques in the process of accomplishing the ultimate goal of total rehabilitation. I also explained that, since she had been in this condition for so long, it was going to take some time, but that we would measure her progress by the small successes along the way which would accomplish the intermediate goals leading to the long term goal – her rehabilitation.

The goals for the initial treatment sessions for Sara were to lessen the sensation in and around the surgical adhesions and scar tissue, to release the build up of fluid and toxins associated with the pain and inflammation, clear the trigger points and soften the surface layers of the scar tissue which would prepare the areas for the deeper treatments as therapy progressed.

These initial sessions also supported the intermediate goal of balancing the structure. The strokes were applied in specific sequences and directions that would facilitate the release of the structural distortion to initiate the structural balancing. These initial strokes were lighter milking strokes which were applied very slowly to allow more change in the tissue with less threat and less sensation for a client who is in severe pain.

After three sessions my palpation of the scar tissue was less painful for Sara, and the surface of the tissue was less fibrous and rigid. I was now able to feel the deeper fibrous edges of the surgical adhesions that went through and around the soft tissue muscle of the intestines, and into and around the deep stabilizer muscles of the spine – the psoas and quadratus lumborum. The trigger points in the surface tissue of the rectus abdominus, the obliques and latissimus dorsi were cleared, and the fluid, toxins and ischemia that had built up in these tissues were greatly reduced. Thus, Sara was now ready for deeper work into the surgical adhesions and fibrous tissue.

In the next phase of treatment one of the goals was to unwind the myofascial holding patterns that had been pulling her structure further into structural collapse. To further enhance the effectiveness of this stage of the work, it was necessary to work beyond the actual surgical adhesions and release the myofascial holding pattern that supported the structural collapse of her spine and the full structure. This included balancing the pelvis to address the pain that was associated with her hip and low back. Thus, the session goals for this phase included unwinding the myofascial holding pattern of the structural collapse, not only in the adhesions of the scar tissue, but also in the restrictions throughout the rest of her structure. This would also help reduce the pain in her hip and lower back due to the structural collapse. We were also going to start releasing some of the hardened fibrous adhesions and their compression on nerve tissue which was one of the significant causes of her pain. Another goal in this phase was to increase her range of motion as the fascia and scar tissue restrictions were released and mobilized.

This was a very important phase of Sara’s treatment, and it was necessary to accomplish those goals for her to continue on her journey to rehabilitation. They were accomplished over seven treatment sessions. Each session achieved more unwinding of the myofascial holding pattern, a softening of the surgical adhesions in the smooth muscle organs allowing deeper work, and releasing the myofascial holding pattern of the low back that was found in other muscles associated with the pelvis. All of this also increased her range of motion.

After the seven sessions Sara was standing straighter with a significant reduction of the structural collapse. She was more mobile and was able to participate more freely in her daily life activities. Her energy was better, and her spirits were high because she was finally feeling and seeing the improvement, was able be more active, was having more fun, and feeling more satisfaction in her accomplishments. The pain was reduced both from the release of the direct pressure of the surgical adhesions on nerves, and from the release of the structural collapse which had caused the low back pain. She was also experiencing less pain in her neck and shoulders due to the fact that she was no longer bent over, and her neck and shoulders were now more supported by a straighter spine.

Sara was now ready for the release of the deep surgical adhesions that surrounded the psoas and quadratus lumborum. These deep adhesions were responsible for maintaining the remaining collapse of the structure, and were still compressing some of the nerves close to the lumbar spine creating some radiating pain. In addition, there were deep fibers of adhesions in the other muscles of the pelvis that had supported the structural collapse that had not released with directed myofascial unwinding. All of these deeper tightened fibers needed to be release with deeper more individualized and specific strokes to release the core of the structural collapse. If we view these adhesions like an onion, we were now ready to work on the core after having taken off the surface and intermediate levels.

The goals here were going to be specific release of the fibrous tension of the surgical adhesions, release of the shortened fibers and adhesions in the psoas and quadratus lumborum to release nerve entrapment and allow structural balance, release other fibers in pelvis that supported the structural collapse, and increase range of motion back to normal function. After seven more sessions that incorporated the deep individual fiber release to sufficiently lengthen and balance Sara’s structure, take the pressure off the nerve entrapments, and return range of motion to normal ranges, we were able to accomplish the long term goal of pain free living. It was only by setting goals, using them as observable and obtainable measurements which allowed us to track improvements along the way, that we were able to achieve successful resolution of Sara’s acute condition.

The Three-step Approach of first releasing ischemia, fluids and toxins, then applying directed myofascial unwinding strokes, and finally releasing individual fibers allowed me to work with Sara staying within her pain thresholds even during the most acute phase of her rehabilitation. Using this three-step approach, I was able to finally release the deepest of the surgical adhesions, and ultimately, release her structure in to balance. Sara has gone back to work, and is finally happily participating in activities that had given her such enjoyment before the kidney donation.

RELEASING ADHESIONS AND SCAR TISSUE

SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

Therapists have been asking questions about treating scar tissue from surgeries or injuries. Therefore, I would like to share some information and a few techniques I use to successfully release the restrictions and pain associated with adhesions and scar tissue.

One area that has presented itself is working with scar tissue after back surgery. Oftentimes, the areas where scar tissue and adhesions have formed are considerably more painful than they were before surgery. Nerves can be entrapped within or between the adhesions and scar tissue causing painful inflammation, and the affected areas are prone to strain injuries due to lack of flexibility.

When working with scar tissue surrounding back surgery sites, my first concern is the normalization of the structural imbalance involving the spine. Normally, I can successfully work to improve the spinal balance by working muscle groups and fascia that are not close to the site of the surgery fairly soon after surgery before the area is fully healed. Pelvic balancing provides a balance base for the spine, promotes a lessening of the curvature of the lumbar spine, and thus reduces the tension in the soft tissue that is supporting the spine. Spinal surgeries have cut through this soft tissue. When there is significant tension and strain within this soft tissue during the healing process, there tends to be a substantial formation of adhesion and scar tissue at the surgical site. Thus, normalizing the spinal curvatures by balancing the pelvis as soon as possible after surgery, working away from the surgical site while it is healing, you can very effectively minimize the degree of scar tissue and adhesion and reduce the rehabilitation time.

If the surgical site has already healed, you will usually find a significant build up of adhesion and scar around the site. Again, if I want to successfully release that scar tissue, I will be much more effective if I first balance the pelvis which balances the spine and takes the pressure off the soft tissue around the surgical site. Even when the surgeries are years old, this is my first step in successfully treating the chronic pain surrounding the surgical site associated with scar tissue and adhesions.

Whether it is a recent surgery that has healed or an old surgery from years in the past, once the pelvis has been balanced and the spinal curvature has been decreased reducing the strain and tension on the adhesions and scar tissue at the site of surgery, I am now ready to address the scar tissue and adhesion around the surgical site. If the surgery heals while the spine is in a severe curvature, the adhesions running from the scar tissue will extend out a considerable distance form the actual site of the surgery. This is due to the strain that transfers into the surrounding tissues and the body’s natural instinct to bind as many tissues together as possible to support the weakened area of the surgery. When this is in the low back, these adhesions may extend from the sacrum into the lower to mid thoracic vertebrae. They also may be internal to the spine involving the psoas, iliacus, and quadratus lumborum. When they are this extensive, they almost always entrap nerves creating pain in and of themselves. Thus, if these muscles and areas are involved, the pelvic balancing protocol will need to include working these deep muscles.

It is also important to note that as scar tissue forms, it fans out like a web binding and adhering to all layers of fascia to stabilize the weakened areas. These need to be released. I have found the most successful approach after pelvic balancing is to work the peripheral bound tissues first, and then work towards the core of the scar tissue. It is best not to overwork this scar tissue. Sometimes it may take a few sessions of releasing several layers at a time in each session until you are able to easily work into the core.

Those of you who have been following SET TALK probably already have guessed that the approach for working into the body and into the scar tissue and adhesions is going to be the one that I have explained and mentioned extensively in the past – THE THREE STEP APPROACH. In this approach the first strokes will be to release the fluids and toxins and relax the surrounding tissues to reduce the pressure on the scar tissue and adhesion and release some of the sensation from the area. The second step will be directed myofascial unwinding strokes that will involve slow, constant, steady pressure that only move as the tissue releases. Due to the multi-directional aspect of scar tissue and adhesions, these strokes should be applied in any direction that adhesions are able to be felt. Sometimes the stroke directions may cover as many directions as the lines found in an asterisk. Make sure you stroke both across and along each tightened fiber to accomplish the release. If the fiber is a long one, there should be several strokes across it at various places allowing the strokes to overlap, followed by several strokes along either side and right on top of the adhesion. Often times I will use two hands with the hands working in opposite directions in what I call counter strokes that create the maximum degree of stretch between the two hands. I find it most effective to first do the directed myofascial unwinding strokes on the scar tissue across and then along the fibers.

After the tissues have spread and no longer pull either into the scar site or bind and hold the area immobile, I now will apply very specific individual fiber strokes – the third step of the THREE STEP APPROACH. These are applied with fingers or thumbs. As in the directed myofascial unwinding strokes, these strokes are very slow and only move with the release of tissue. I will usually work along the fibers since the directed myofascial unwinding strokes have already spread the fibers apart. Sometimes, when I find an area that is very thickened, I will find it necessary to work across the fibers also using individual fiber strokes. It is absolutely necessary to be patient with these strokes because too much specific pressure on scar tissue or adhesions can cause tearing in the soft tissues which results in the reformation of scar tissue in the healing process afterwards. Therefore, I find it best to do less, rather than more, in the first couple of sessions. Then, as the tissues soften and normalize from the preceding sessions, I can apply more fiber strokes in subsequent treatment sessions. This avoids the possibility of actually aggravating the condition during the early sessions. It’s like peeling an onion – we take several layers off in each session until there are no layers blocking the core.

Sometimes even with the best techniques there will be a reformation of adhesion in the fascia after we have released it. When this happens we will need to come back to this area weekly to release this tissue before it becomes hardened and more extensive. What you will find is that after several treatments on a weekly basis, there will be less and less reformation of adhesion. Usually, a point will be crossed where the body will quit forming adhesions in the area. Scheduling treatments a week apart allows the treated tissues to heal and normalize. Working too frequently may only aggravate the symptoms and could adversely affect the healing process.

There are many occasions with back surgery where the scar tissue is right next to the bony process of the vertebrae, and the scar tissue and adhesions cause significant entrapment of major nerves coming from between the vertebrae. Again, the three-step approach used along with pelvic balancing is very effective. The final individual fiber strokes will release the adhesions closest to the osseous matter of the lumbar vertebrae and thus, release the nerve entrapment.

I hope this discussion has been valuable for you. Before you work extensively on these surgical sites, it is my wish that you will take some advanced training with some hands on supervision so you will be efficient and gentle in treating your clients. If you would like more information on how to treat this subject, I have just recently completed a book RELIEF FROM BACK PAIN that discusses and instructs extensively on these topics. This book is available through the SET website or by contacting us directly. I also cover these techniques in my workshops which are listed on the website. My previous articles that also include discussion on the three-step process are available in back issues of the Massage Message, or you can go to our web site and download them for yourself.

HEADACHE RELIEF

SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

If you are a practicing massage therapist, it’s almost certain that you have clients who are suffering from full blown headaches, or who come in for stress relief or some other symptoms leading to headache patterns or chronic headaches. Most clients who come in with a headache already established want immediate relief. Our clients have been educated by the media and the drug industry that headache pain should not exist in their lives. The truth is that headaches are often the result of the clients’ lives, especially when stressed.

When a client walks into the office for a session, often there have been several stressful occurrences just in the process of getting to the office. We take for granted when we get into a car that everything is going to be okay, and that we will arrive at our destination safely in a reasonable amount of time. This fantasy does not always live up to reality. We have our lives threatened daily in vehicle travel, and can be caught in traffic or rerouted making it next to impossible to maintain on-time schedules. Driving to a massage is no different, and a type “A” personality, who is normally highly stressed, will absolutely be even more stressed after traveling through traffic in a car.

There are several different kinds of headaches – some easy to treat, and some quite difficult. The ones that are easily treated generally are due to stress and tension, and are usually successfully treated with a relaxation massage. Other types of headaches resulting from structural imbalances, or injuries, car accidents, and trauma, are more difficult to treat.

Stress seems to be a trigger for the onset of just about any type of headache. It is important for the massage therapist to be able to recognize and effectively release the areas of soft tissue and muscle contractions involved with the headache. The back of the neck and tops of shoulders are normally tight and are typical areas of complaint in almost any headache situation. However, if you only work the back of the neck and shoulders, you will in essence be facilitating the structural imbalance which is often the culprit. Since the head and neck are usually already protruding forward in 90% of the people with headaches, the cervical vertebrae is not effectively supporting the head, which forces the muscles in the back of the neck to contract tightly to hold up a 13 lb head. So, if we are to successfully address the headache triggers on the tops of the shoulders and the back of the neck, we need to initially apply massage techniques that will move the head, neck, and shoulders back into structural alignment before working extensively on the contracted muscles on the top of the shoulders and back of the neck. When the head, neck, and shoulders are released back into an improved structural alignment, the musculature in the back of the neck and tops of shoulders will have already relaxed because it is no longer compensating for the forward head posture. The work on the soft tissue of the back of the neck and tops of shoulders can then be deeper and more effective with less sensation for the client. Clients like this.

When the headaches are the more severe type such as clusters and migraines, the structural improvement resulting from working the front of the chest and the neck first, followed by treating the back of the neck and tops of shoulders has a two-fold effect. Not only will the triggers found in the spasmed muscles of the levator scapula, splenius capitus, supraspinatus, trapezius and rhomboids dissipate, but the structural improvement increases the flow of cerebral spinal fluid and circulation of blood to the cranium and brain, often with long-term positive effects on the relief of the client’s migraine or cluster headache syndromes.

As I have mentioned, we want to relieve the stress, but also a promote significant structural shifting that will take the stress off the back of the neck and shoulders. The most effective way I have found for releasing the soft tissue is the 3-step approach that has been described in previous articles (Massage Magazine, November/December 2001, or you can read a copy of that article on the website.) The following is the sequence of application that I have found to be most effective in accomplishing the structural changes. First, have the client lie supine and work the pectoralis major and minor, then the subclavius directly under the clavicle, followed by working the SCM and all three scalene muscles. This allows the cervical vertebrae to shift back into alignment. I also find that rotating the head as you work the individual strokes on the scalenes, starting at the front and working progressively toward the back, will restore full range of motion in the rotation of the head, and allow a more direct release from the stroke on the tightened musculature. Caution: Massage therapists must always be aware of the contraindications for treating these areas.

After releasing this musculature on the front of the shoulders and neck, I will then have the client lie one side. While tractioning the shoulder, release the top of the shoulder and supraspinatus working from the coracoid process to the superior angle of the scapula. It is important not to put a shearing pressure on the cervical vertebrae in this position. Then work the posterior fibers of the neck – splenius capitus, levator scapula, and trapezius – working from the base of the cranium into the tops of the shoulders. I use fingertips or thumbs, and again I’m very careful not to put a shearing pressure on the cervical vertebrae – the pressure is directed toward the feet. After working the large fibers of these muscles, I now work the small tightened fibers directly under the ridge of the occiput. This will often further release C1, atlas/axis, and occiput. It is not uncommon for the clients to identify this area as causing their headaches. I will then repeat the shoulder and posterior neck on the opposite side.

After releasing the musculature of the neck and shoulders, I will then work the soft tissue that encapsulates the entire cranium, being careful not to pinch any of the cranial nerves between the thin soft tissues and the bones of the cranium. It is important to release the tissue around the sutures which I find are often sore. Another important area I pay special attention to is the temporalis over the temporal bones and the nerve pathways that are imbedded there. Oftentimes, having the clients open and close their mouths while working this area increases the effectiveness, and allows me to use less pressure. I usually finish with lengthening strokes down the whole back to further reduce pressure that may be pulling on the back of the neck and shoulders.

I have also found cranial/structural or craniosacral work to be incredibly effective in reducing the headache symptoms as well as supporting the client’s structural improvement and overall well-being. It has been my observation that, in the majority of headaches, the occiput is usually jammed. The techniques of both cranial/structural and craniosacral will mobilize the occiput. This is important for two reasons: 1) the tightened soft tissue at the base of the occiput will often greatly restrict the motion of the relationship between the occiput and the atlas/axis (C1, C2), which most certainly contributes to chronic and long-term headache patterns; and 2) it increases the mobilization of the dura down the spine to the sacrum, producing a sense of well-being and an increase in the flow of cerebral spinal fluid.

The combination of the cranial/structural or craniosacral with the soft tissue work along the base of the occiput will facilitate the mobilization of the occiput and normalize its relationship to C1 and C2. Many clients who have severe neck and back problems will be so locked up in this area that it may take more than one treatment to restore this mobilization. However, I have found that without mobilizing this area, a major contributor to many types of headaches will not be addressed. The degree of mobilization is directly proportional to the reduction of symptoms.

There are other cranial relationships that I have also found to be present with headache syndromes. They are generally related to the immobilization of cranial sutures or specific cranial bones. Some of the symptoms relate directly to the palatine, the occipital/mastoid suture, and C1. Once the mobilization of these sutures is restored, the headache symptoms usually disappear.

Massage therapists who have had cranial/structural or craniosacral training will have the techniques for mobilizing the cranium. If you haven’t had that training, I suggest you release all the restrictions in the soft tissue that covers the entire cranium like a skull cap. The resulting increase in mobility of all the cranial sutures will have a very positive effect and will help to reduce the headache symptoms.

For those of you who have learned my Quick Release Technique, I strongly recommend that you apply this prior to doing any soft tissue work. The Quick Release Technique addresses the head/neck/shoulders, the stress, the trapped energy, the structural imbalance, and the cranial jamming found in most headache situations. The quicker the symptoms of the headache can be relieved, the more confidence a massage client will have in the massage therapist, and the more successful the therapist will be. The Quick Release Technique will dissipate the majority of stress headaches within 10-15 minutes. (The Quick Release Technique can be found in book Relief from Head, Neck, and Shoulder Pain available through the website.)

I hope I have given you some additional ideas on how to successfully treat headaches. There is a great deal of written information on the causes and types of headaches in medical literature, but very little on effective treatment. Therefore, this article focuses on treatment protocols that I have found to be effective in treating most types of headaches. There is no shortage of headache clients.

I hope the information in this article will increase your awareness of effective treatment for supporting your clients. Keep up the good massage therapy.

Arthritis

SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

If I had a dime for every client who told me they saw a physician because of joint pain, and, with only a cursory exam, were told by the physician that they had arthritis, I would not have to work today! Furthermore, they were given the explanation that they were getting older and that almost everybody has arthritis.

Osteoarthritis is present in a large percentage of the population over 40. As a massage therapist you will see numerous clients with pain symptoms from osteoarthritis. It is important that you know and understand the causes of osteoarthritis, referred to simply as arthritis, and how to effectively treat the affected areas for pain relief.

The clinical definition of osteoarthritis according to Taber’s Cyclopedic Medical Dictionary is: “a chronic disease involving the joints, especially those bearing weight. Characterized by destruction of articular cartilage, overgrowth of bone with lipping and spur formation, and impaired function.” Now, I find that the effected joints of just about any client I have ever seen with osteoarthritis are stressed due to one or more of the following conditions: structural misalignment, tension in the soft tissue associated with the joints and muscles for movement, damage due to old injuries or surgeries, or strain patterns in soft tissue that weaken the strength of the joint. Each of these conditions involves irritation of the tissues and an imbalance within the joint capsule that leads to a degeneration of the joint itself, and ultimately arthritis.

Once we understand the conditions that weaken joints, we can then consider how to apply massage techniques that will strengthen the weakened arthritic joints, and prevent non-arthritic joints from developing arthritis.

Structural imbalances cause uneven stresses on the joints both internally (between cartilage and ligaments) and externally (within the supporting tissues around the joints). Therefore, the ability of massage therapists to rebalance the soft tissue responsible for the weight bearing and movement of a joint becomes very important in the rehabilitation of the joint, whether it is to prevent arthritis or to stop further degeneration associated with arthritis that is already present. Many times when the joint is realigned structurally, the pain and degeneration found with osteoarthritis disappears.

Tension in the soft tissue, whether it is in the connective tissue or the muscle tissue that effects joint movement, often causes binding and undue pressure within the joint itself. It also limits the overall range of motion of the joint allowing degeneration to occur and a build up of calcium deposits. Either one of these directly feeds already existing arthritic degeneration or, over a period of time, leads to arthritic degeneration within the joint. Releasing the restrictions in the soft tissue that bind the joint or limit its range of motion allows a healthy joint to remain healthy, and stops the arthritic degeneration allowing an arthritic joint to return to full range of motion and become healthy once again.

In the process of life many people injure their joints or have damaging surgeries, and will later develop arthritis due to the damage within the joint. Often these injuries and surgeries leave the joints imbalanced and bound with tightened tissue that includes scar tissue and splinting. If the injured joint had been treated to release the scar tissue in the soft tissue and to restore balance and range of motion, the long-term effects of the injury would have been minimized. Unfortunately, many of our clients have not had the benefit of treatment in the initial stages of rehabilitation from their injuries and surgeries. Once arthritis has developed within the injured joint, the joint will degenerate rapidly due to the aforementioned untreated conditions. To eliminate the further development of arthritis, and to successfully rehabilitate the joint, proper soft tissue releases must be applied which will reduce scar tissue and splinting and restore full range of motion within the proper balance.

When the body is out of alignment, strain patterns result in the muscles and soft tissue. These strain patterns reduce the strength of the muscle function by at least 50%, and oftentimes 75%. When these strain patterns exist around joints, the muscles have to tighten, bind, and compensate for the resulting weakness of the joints. The result is a build up of fibrous connective tissue that directly restricts range of motion and the strength of the joint. This often results in injury to the joint capsule itself, or to an ongoing irritation that can lead to arthritis. Since these strain patterns are in the soft tissue, proper therapeutic releases by a massage therapist can prevent arthritis, or rehabilitate an arthritic joint.

When a client comes to my office with concerns about arthritis in their joints, these concerns are usually accompanied by pain in the joint, inflammation, and swelling. Therefore, it is necessary for initial soft tissue treatment to reduce the swelling and inflammation as these are a direct cause of pain as well as restriction and tension in the joint. Therefore, using strokes that will release the fluids and toxins with the venous flow is an important first step. (Please refer to previous articles on three-step approach).

After the inflammation and pain has been reduced, it is now time to address the tension, adhesions, and restrictions found in the myofascial holding patterns that can both bind and cause misalignment to the affected joint. All of the musculature and soft tissue that has any affect on the movement of the joint needs to be treated with strokes that will release the myofascial holding pattern, the adhesions, and restrictions so the joint can return to balance and full range of motion. Special attention needs to be paid to the speed of these strokes to allow the myofascial holding pattern to unwind and release the restrictions. Therefore, the deeper you go the slower you go! This approach will also allow you to work deeper in an area where the client is already experiencing pain. Clients will communicate their relief as these holding patterns and restrictions release.

When the myofascial holding patterns have been released, very specific individual fiber strokes can be applied to soften the resistant fibrous adhesions and scar tissue. Again, the deeper you go the slower you go! This allows the joint to return a healthier state, usually with pain greatly diminished or gone.

The wonderful secondary gain with these releases is that they tend to structurally realign the joints since soft tissue controls the alignment, range of motion and movement patterns much more so than the cartilage and the effects of the arthritis inside the joint. It helps if the massage therapist has a good understanding of the proper alignment and movement of the joints. However, even without this knowledge, they will be able to reduce the painful symptoms of arthritis and facilitate realignment if they release the soft tissue in the three-step manner mentioned above. This is due to the fact that the tightest tissues maintain the structural distortion, and their release allows realignment.

I have used these techniques over the years with great success treating clients who come in with osteoarthritis. Many times I have not been sure that a proper diagnosis has been made, and have been concerned that only a cursory examination was done in the physician’s office. Still, the majority of my clients improve, and many become pain free with full range of motion and return of strength to joints that were diagnosed as being arthritic. One thing I can be sure of is that they are happy to have received effective treatment and to be rid of their pain. They also refer their friends and loved ones, which is a sign of their confidence in this therapy. Obviously, there are extremely acute cases of arthritis that involve severe joint degeneration. However, even the clients who could not become totally pain free continue to come periodically because proper treatment does minimize the amount of pain and slows down further arthritic degeneration to their joints.

Acid Reflux

SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

ACID REFLUX and HIATAL HERNIA

It’s getting to the point that everybody knows what the “little purple pill” is – Nexium for acid reflux. Why? The answer is quite simple – the majority of Americans over the age of 40 have, or are experiencing, the symptoms of acid reflux and are very uncomfortable with it. Additionally, the advertising is alluding to long-term damage from the erosion of the esophagus due to acid reflux. Clients’ fears are expanding, as is their awareness. This is partially due just to good old advertising and marketing. We as massage therapists could actually thank these people for increasing this awareness of acid reflux and hiatal hernias. However, it is unfortunate that many massage therapists do not know that there are effective soft tissue treatments that can eliminate the symptoms without drugs, or any other invasive medical procedure, and, thus, have not developed the skills to treat these conditions.

To develop the skills to treat hiatal hernia and acid reflux we must first understand what the conditions are that trigger these symptoms. Medical diagnosis include: “Protrusion of the stomach upward … through the esophageal hiatus of the diaphragm” (Taber’s Cyclopedic Medical Dictionary), the esophageal hiatus is “the opening in the diaphragm for the passage of the esophagus and the vagus nerves” (Dorland’s Illustrated Medical Dictionary), “sliding hiatus hernia…the gastroesophageal junction and a portion of the stomach are above the diaphragm” (The Merck Manual, 16th edition). Another form of hiatal hernia is a tearing in the diaphragm that allows a portion of the stomach to protrude through the tear. There can also be damage to the esophageal hiatus where the esophagus empties into the stomach. When the esophageal hiatus is damaged the sphincter valve at the top of the stomach cannot function properly, and the contents from the stomach can then backflow up the esophagus (acid reflux), especially when a client is prone or supine or has a full actively digesting stomach. Acid reflux can occur even when there is no significant damage to the esophageal hiatus. This can be due to overactive digestion taking place in the stomach (as can result from spicy food or overeating), or the presence of excess stomach acid. How can massage therapy effectively treat these conditions? Well, let’s look at where the stomach is located and what muscles have a major effect on both the esophageal hiatus and the stomach itself.

The esophageal hiatus is located in the center of the diaphragm. The diaphragmatic muscle attaches on the sternum, the lower ribs, and extends all the way around to the back including the thoracic vertebrae. This leaves it extremely reactive to any structural distortion. If the skeletal system misaligns, that misalignment is reflected in contractions and distortions throughout the diaphragm. The diaphragm itself is a muscle that responds to the somatic nervous system. When people are stressed, they tend to contract the muscle fibers of the diaphragm, which often exaggerates any existing structural distortions. The sympathetic nervous system (which dominates during stress) will continue to affect the diaphragm long after the initial stressor has been reduced. If this takes place over weeks or months, the resulting contractions will become fixed in the diaphragm via the fascia, and exaggerate any already existing distortions. Stress and structural distortions aren’t the only conditions that affect the diaphragm. If we add extra weight to the structure, we have yet another distortion factor for the diaphragm. If the esophageal hiatus is constantly stressed by these distortions and imbalances of tension, it reacts like an “0” ring with unequal pressure on all its sides, and cannot seal effectively.

A tear in the diaphragm that allows the stomach to push through creating a hiatal hernia is equally stressed by structural distortions and the somatic nervous system as described above. If this tear is subjected to all these stresses, it often worsens allowing more of the stomach to protrude through the diaphragm. Often a tear in the diaphragm will occur when a person lifts weight when structural distortions or stresses in the body are also distorting the diaphragm. It is very possible that the tearing would not have happened had there been no structural distortion or stress.

To resolve hiatal hernia problems massage therapists need to be able to address both the structural distortions and the stresses that involve the diaphragm. The diaphragm has surface attachments across the sternum and ribs that attach to the sternum, but the majority of the body of this muscle is deep in the abdomen and below some organs. To treat this area effectively, I recommend using the 3-step approach starting with the surface tissue and moving progressively deeper with successive strokes (see SET TALK article on Deep Tissue, Nov-Dec. 2001, or review the article on the website under Publications). It is important to remember to follow the principle of “the deeper you go, the slower you go!” You can work around and through the organs, but you must work slowly and gently, softening the points of your fingers to avoid creating a sharp specific edge that could actually damage the organs. In other words, as you work deeper in the abdomen, apply just enough pressure to sink in slowly, and only move deeper as the client relaxes and stops resisting. Once in deeply, only move the stroke as the tissue releases. The deeper the stroke the shorter the length of the stroke. Do not “plow” through the tissues!

The intent of these abdominal strokes is to release the rib cage so it can expand upward while reducing the distortion and stress on the diaphragm. The structural distortions of the diaphragm tend to pull down on the ribs. When body reading your client before the session, you will notice that the ribs on one side are pulled down and tighter than on the other. The floating rib on this side will be closer to the crest of the ilium than on the other side. To work for structural balance, you want to release this side first so you will not be moving the body further into distortion. There are other structural considerations such as pelvic balancing, lumbar curvatures, and scoliosis. However, if the diaphragm is released from the side where the floating rib and the ilium are closer together, the other structural distortions will be reduced as well. Then, releasing the other side will tend to bring the ribs further into balance, and thus release the distortions of the diaphragm.

In releasing the diaphragm you are releasing the stresses that have accumulated from both the sympathetic and parasympathetic nervous systems. In addition, when releasing the left side of the diaphragm, you will be releasing the pathway of the vagus nerve, which is usually very tightened and restricted. Releasing this often results in a calming of the stomach and reduction in the hyperacidity found with acid reflux, nervous stomach and ulcers.

Working with your hands to release the stresses on the diaphragm will treat hiatal hernias and acid reflux very effectively. However, the treatment will not be complete until we have been able to smooth the majority of the sheet-like muscle of the diaphragm. The fingers will have worked through small areas and released ridged adhesions, but there will be larger parts of the sheathing part of the muscles that will still be somewhat tightened and imbalanced. This is where a softer, rounder surface than the fingertips can smooth and integrate the diaphragm allowing even more effective release of the esophageal hiatus allowing the sphincter valve of the stomach to close and function properly, or take the pressure off a diaphragmatic tear. I find holding a small hard rubber ball or tennis ball gently against the diaphragm under the ribs and very gently rolling it along the wall of the diaphragm to be very effective in balancing the diaphragm. Caution – this needs to be far enough below the ribs so as not to pull down on the ribs or in any way compromise the xyphoid process. Also, the floating ribs need to be avoided at all costs, so you want to begin medial to the floating ribs. The ball, like the hand in deep strokes, should be applied with the principle of “the deeper you go the slower you go!” The ball would not be effective if you had not first released the very tight ridging in the diaphragm with your previous strokes. You will be amazed at how much tension release you can feel in the soft tissue while firmly but gently using the ball to smooth and balance the diaphragm.

Clients generally report immediate improvement of acid reflux or hiatal hernia symptoms after just one session. This improvement may be reported as less pain and discomfort, less intense or fewer occurrences, or a general calming of the area. I usually work one session per week until the client is symptom free for the week, then schedule for 10 days until symptom free, 2 weeks until symptom free, and space out accordingly after that.

This work is very specific. We are not curing the condition or practicing medicine, but rather reducing the stress and distortion found in the diaphragm and its adjoining soft tissue that allows for a higher function within the esophageal hiatus and less pressure on the diaphragm itself. A majority of my clients who have hiatal hernia or acid reflux symptoms will see the end of these problems with this treatment.

Cranial Techniques

SET TALK
By Don McCann,MA, LMT, LMHC
MA3267 MH705 MM3717

INTEGRATING CRANIAL TECHNIQUES AND MASSAGE

A perfect marriage: Two distinct techniques that restore homeostasis can only enhance each other when integrated into one treatment. The massage therapist who can apply effective massage techniques along with effective cranial techniques has a combination of the most effective tools that a massage therapist can have.

In the ‘80’s and ‘90’s Craniosacral Therapy became a huge presence in the field of massage thanks to the Upledger Foundation, and they continue to train countless numbers of massage therapists each year in Craniosacral techniques. As with any quality therapy, variations on these techniques have emerged. Thus, there are many licensed massage therapists who are practicing Craniosacral, Craniostructural, Cranial/Structural and Osteopathic cranial techniques. In teaching my Cranial/Structural soft tissue release seminars, I encounter many questions from licensed massage therapists, who practice a cranial technique, about how and when to integrate these techniques with massage or other bodywork therapies.

Cranial techniques can impact the body in phenomenal ways. One is the re-establishment of homeostasis. Osteopathic doctors applied cranial techniques back in the early 1900’s during the flu epidemic that ravaged the U.S. around the time of WWI. It has been documented that these cranial techniques were among the most successful treatments for this flu because they facilitated the healing process by returning patients’ bodies to homeostasis. This is just one early example of how cranial techniques have impacted medicine in our world. There are too many other instances to elaborate on in this column, but suffice it to say that there have been many broad applications of cranial techniques with huge success over the years.

The return to homeostasis can look very different from client to client, condition to condition, and technique to technique from infancy to old age. One goal of massage therapy is to support a return to homeostasis for our clients. Massage therapists are able to apply very effective massage techniques to relieve stress, pain, structural imbalance, trauma pain, emotional stress, physical restrictions, or performance restrictions. Using cranial techniques in conjunction with massage techniques will further enhance the process of restoring homeostasis and healing.

What is the basis of cranial techniques? – the mobilization and balancing of the cranial rhythm, which actually becomes a soft tissue energetic technique. The cranial bones serve mainly as handles to release the restrictions in the reciprocal tension membrane and dura, similar to the humerus bone when we move an arm through its ranges of motion to restore motion to a shoulder. The goal is to release the soft tissue restrictions that limit the range of motion, not to move a bone into place. Cranial technique is restoring motion, not positioning, or adjusting, the bones. The restriction of the motion of the cranial bones is held within the soft connective tissue. Restoration of the cranial motion is greatly dependent upon mobilization of the soft tissue, and very similar to the myofascial work that takes place within the field of massage.

Within the field of massage we have many kinds of soft tissue technique. All of it has some degree of mobilization, release of tension, and release of restrictions found in soft tissue. All the soft tissue techniques produce increased range of motion of the joints within existing myofascial holding patterns or structure of the body.

So, with common goals and hands-on manipulation of soft tissue, it is obvious that the application of both cranial techniques and massage techniques is optimum for the massage client’s well being.

Integration of cranial technique and massage:

Stress relief and relaxation: When clients are uptight and in need of stress relief, I have found that the mobilization of the cranium will lead to a quick release of tension and stress. Consequently, when I have a stressed client on the table, my first therapy application is a cranial technique that produces a significant degree of relaxation and normalization of body functions. This allows the client to be more receptive to further soft tissue manipulation via relaxation massage techniques.

Clients can also be very stressed due to structural imbalances that cause pain and discomfort and tightened muscles restricted into holding patterns. I begin their sessions with the application of a Cranial/Structural technique that will initiate structural balance, increase structural alignment, and relax the soft tissue of the structural holding pattern, all resulting in some significant myofascial unwinding. Additional soft tissue massage at this point will further release: 1) toxins and waste products, ischemia, and inflammation; 2) structural myofascial holding pattern; 3) adhesions, lesions and scar tissue, all producing long lasting stress relief and structural balance.

Pain relief: When a client has significant pain coming into a massage room, they are looking for quick and substantial relief. Pain is a symptom, whether from stress (see above), trauma, structural imbalance, inflammation, or emotions. Pain from trauma has several manifestations. One is the actual pain from the trauma. When a body is in pain, the entire body reacts with tension, structural distortion, and limited motion. This includes the cranium. It only makes sense to use a cranial technique that will remobilize the cranial motion to help remobilize the entire body and specifically the area of trauma. Oftentimes, this immediately reduces the intensity of the pain. If the injury caused a structural imbalance, the healing process and reduction of the symptoms often cannot be complete without rebalancing the structure with both cranial techniques and massage techniques. Again, integrating soft tissue treatments to reduce swelling and inflammation, to further balance the structure, and to release forming scar tissue and adhesions is an optimal treatment for trauma.

Sometimes the pain is actually caused by cranial compression, as is often found with headaches. The remobilizing of the cranial motion releases this compression, the soft tissue of the dura, and the fascia of the neck and shoulders relieving the headache. Additional soft tissue treatment of the musculature of the neck and shoulders makes this a complete treatment.

Pain caused by structural imbalance can be extensive if the imbalance causes disc problems or nerve entrapments. Structural imbalance problems can also be related to hip, knee, foot, and ankle and nerve entrapments of the arm. Initiating a structural change using Cranial/Structural technique at the beginning of the session, and then integrating myofascial unwinding and directed myofascial release techniques to further balance the structure, is a very quick and direct way to reduce the pressure of the nerve entrapment/impingement, joint imbalance or unequal pressure on the disc or vertebral areas.

Many emotional blockages manifest as physical pain. The mobilization of the cranium, either with Craniosacral or Cranial/Structural, can release structures or chronically tightened tissues that block emotional release. Follow this with effective soft tissue releases to the tightened soft tissue, and trapped emotional energy readily releases allowing homeostasis and the end of pain.

At this point, it is necessary to differentiate between Craniosacral and Cranio/Structural. The easiest distinction is Craniosacral seeks to mobilize the cranium within the restrictions of the soft tissue of the cranium and the dura for homeostasis. Cranial/Structural seeks to release the restrictions of the soft tissue of the cranium and dura, thus releasing the cranial distortion, which repeats itself throughout the body, for structural balancing of the full body. These are the gross and simplified distinctions between the two cranial techniques, and there is much overlapping between the two techniques that I will not go into here.

Hip Degeneration and Replacements

SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

PREVENTION OF AND WORKING WITH HIP REPLACEMENTS

If you are a massage therapist doing therapeutic work, you are going to run into clients who are in pain from hip problems, hip replacements being the most severe. Unfortunately, after having surgery for hip replacements, many clients, especially the elderly, never fully recover proper alignment, full range of motion, or pain-free function. What is even more unfortunate is that the criteria for hip replacements involves waiting until the client experiences constant severe pain for a period of time before the surgeons will perform the surgery. The tragedy here is that these clients are offered little if any intervention other than drugs for their pain, even after chronic or acute arthritic or degenerative changes are noted in the hip joint. This is very unfortunate especially when deep tissue therapy, properly applied, can relieve and rehabilitate much of the problem. I have had clients who were told they were within a year of a hip replacement due to the pain and degeneration who have become pain-free go for years without having this drastic surgery.

Let’s look at a major cause of pain that is associated with a degenerative hip, and how therapeutic massage can intervene.

A very basic condition that is usually present is a pelvic imbalance, the anterior / posterior rotation of the iliums, that results in the contraction of some of the musculature of the hip, which often involves compression of the nerves. This may occur in the gluteals (maximus, medius, minimus), the piriformis, or rotators. Other muscles that directly affect the rotation of the iliums and cause a tightening of the gluteals in compensation are the quadriceps, adductors, hamstrings, quadratus lumborum, TFL, iliacus, and psoas. These muscles are all involved in a pelvic distortion, either in compensation for or in support of the distortion. I have found that when the pelvic imbalance is released, the tension in these muscles is reduced, and there is a marked improvement in any hip condition a client may present.

To facilitate the release of the pelvic imbalance, the deeper tissues of the pelvis and hip need to be treated. Often these muscles and other soft tissue are inflamed and painful. To effectively treat them, I find it necessary to use a 3-step approach working first to release fluids toxins and surface tensions, second to unwind the myofascial holding patterns, and then to release deep fibers and adhesions last. (see the SET TALK article on Deep Tissue in Massage Message, Nov – Dec 2001, or on the website under Publications). This approach will essentially release many of the causes of hip pain. This sequence not only directly affects the musculature and structure of this area, but reduces the amount of sensation that the client will experience while the contracted tissue is being treated.

It is important to release the tissues responsible for the anteriorly rotated ilium in a hip problem before releasing the compensating spasming muscles that counter that rotation. I find the best results are produced when following this sequence: quadriceps, adductors, hamstrings, gluteals, quadratus lumborum, rotators, TFL, and abdominals. If the pain and problem is in the hip joint of the posteriorly rotated ilium, it is still necessary to release the anteriorly rotated ilium first before the posteriorly rotated ilium. Otherwise, when the client becomes weight bearing, the pelvis will immediately begin slipping into compensation from the anteriorly rotated ilium, and little will be gained for long-term recovery.

Don’t hesitate to work with the hip if it is arthritic or the cartilage is degenerated. I have had many clients come to me with severe pain from arthritis and hip degeneration who are presently walking around pain-free and fully functional. The soft tissue changes from the balanced pelvis took the stress off the hip. So, my important message to you is, by all means do intervention therapy before surgery is ever considered. Unfortunately, many clients will not believe you can make a significant change because a medical doctor has diagnosed a medical problem, and they feel a medical treatment, surgery or cortisone, is the only way to treat the pain. However, people want to feel better. Usually, that is enough of a reason for them to allow you to work with deep tissue therapy on this type of problem.

Treating clients with hip replacements

Many times clients who have had the hip replacement surgery will still be in considerable pain. Once again, proper soft tissue therapy can release that pain and facilitate their rehabilitation. Limiting factors from the surgery are pelvic imbalance, misalignment of leg and hip, leg length difference from an inappropriate length of surgical apparatus, scar tissue and adhesion, and improper gait while walking.

Oftentimes the pelvic imbalance that existed before surgery that was responsible for the degeneration of the hip will not have been addressed, and will now be a stress factor on the surgically repaired hip. It is therefore necessary to bring the hips into structural alignment by balancing the anterior / posterior hip distortion. When this is accomplished, the structure supports the hip and the pressure is equal on the hip joints. Many times this is the key component for the client’s recovery. This process is similar to the pelvic balancing that we would have applied before surgery as previously described in this article. The complications are often increased scar tissue and adhesions from surgery, uneven leg length due to surgical apparatus, and misalignment of the leg/knee/ankle being non-supportive. However, again using the 3-step approach, we will be able to work deeply to soften the scar tissue and adhesions. This will take pressure off compressed nerves, allow more normal circulation, increase the range of motion, and facilitate pelvic balance. When pelvic balance is achieved through these techniques, you will also note an improved alignment of the entire leg and an improved gait. There will also be a relaxing of the compensating muscles that have been working hard to make up for the imbalance – chronically contracting and compressing on nerves.

However, after a hip replacement there are some special considerations that you need to be aware of when treating these clients. The first is when the client is on the side, one knee should be on top of the other – the top leg should not cross the sagittal plane of the body. If undue pressure were put on the leg in that position, it is theoretically possible to unseat or detach the apparatus. Another important consideration is that on either side of the head of the trochanter there is usually considerable scar tissue that will need to be addressed. This scar tissue often causes a shortening of the gluteals and IT band and, in essence, the lower leg will no longer be directly beneath the upper leg. If the client spends years walking this way, the next replacement could be a knee replacement. It’s often possible to prevent this by lengthening and softening the scar tissue around the head of the trochanter.

Unfortunately, there will be a limitation as to the length of time any soft tissue treatment can effectively help the client if the apparatus is causing an imbalance due to leg length discrepancy. In my practice I have seen some very substantial differences in leg lengths after the surgical apparatus was inserted. However, what has become evident is that pelvic balancing is still effective for pain relief, but the client cannot remain balanced long term. Consequently, clients with this condition will need the support of continued sessions for years to keep the spasm and scar tissue from causing constant pain and eventual degeneration of the lower leg or back. With this continued support, I have a number of clients living very satisfactory lives relatively pain free.

Another serious complication with hip replacements is increased pressure on the discs of the lumbar spine in the low back, especially when the pelvis hasn’t been balanced or there is a change in leg length. Again, treating to achieve pelvic balance is the number one consideration. When the pelvis is balanced, the sacrum becomes more level, which in turn reduces the curvature of the spine. Consequently, good structural deep tissue therapy is very effective in supporting the lumbar spine and low back for your clients.

Neuralgia is another complication. The incision from the surgery often compromises nerves and sets up a chronic pain syndrome due to the nerve damage. Again, pelvic balancing using the 3-step approach will take the pressure off the replaced hip and help normalize and soften fibrous adhesions and scar tissue that irritate and prevent the nerves from returning to homeostasis. After the scar tissue has softened, a substantial amount of the neuralgia symptoms disappear. The client will feel better and be in less pain.

The goals of rehabilitation include increased strength, range of motion, and functional gait. The better the alignment, the stronger the musculature that was affected by the surgery. In addition, when the fibrous, hardened scar tissue is normalized and softened, it is able to function more like “normal” tissue in its ability to be mobile and support the joint structure. The treatment of the soft tissue of the hip and pelvis will also release splinting, and facilitate increased range of motion quickly, so that physical therapy to strengthen the muscles will be more effective allowing the client to function better while walking, dancing, etc. Also, the muscle tissue will strengthen more easily since the scar tissue and adhesions will have been released allowing greater flexibility of these tissues.

When to start treating after surgery

Common sense goes a long way here. First of all, you need an MD’s release before you work in or near any surgical site. It would not be a practice builder to work over partially healed tissue and irritate or separate the tissues that are trying to heal. Generally speaking, it is better to have the tissues heal with the pelvis in a reasonably good state of balance. Thus, I recommend doing some pelvic balancing with the client before surgery.

After surgery, and the MD’s release of the patient saying the surgery was successful and healed, (usually 3-4 weeks), I will treat the muscles of the hip and pelvis that do not pull on the surgical scar tissue that is forming, but will still provide support to the hip and pelvis by maintaining the structural balance. After the incision is no longer bright red, and appears firmly reknit (usually 5-6 weeks), I find it is okay to start working gently with the developing scar tissue being careful not to pull any tissue away from the knitting incision site. Usually after 8-10 weeks it is okay to work at the incision site to soften and normalize the tissues that are knitting in the scar. Note: don’t do this if the scar does not look healthy, or is bright red. It is also not okay if there is a major indentation along the scar line that could indicate some tissues did not reattach or mend well. In this case, it will take longer for full healing to take place before you are able to work the tissue. It is better to err on the edge of caution than to contribute to a complication. Also, everyone heals at different rates. So, be careful!!

Many of the hip replacements that you will see with the elderly may be years old, and have several almost permanent distortions in the leg, hip and back. You will still have positive results by balancing the pelvis. There may be degeneration in other joints that are now becoming problems and can only be maintained, not improved. Good deep tissue therapy is still better than drugs for the client’s well being. If you feel you aren’t qualified to work deeply in these areas, please take additional training, or refer your client to someone who already has the training and experience.

I hope this has opened your eyes to the very real possibility of successfully treating hip problems using deep tissue massage therapy techniques. Keep up the good massage therapy.