Manual Therapy in the Training Room

Manual therapy in the Training Room

More than joint mobilization 6 modalities for your bag of “tricks” Š Positional Release Therapy, (PRT) Š Myofascial Release, (MFR) Š Craniosacral Therapy, (CST) Š Tui Na, (Chinese Massage) Š Shiatsu, (Japanese massage) Š Acupressure PRT

Š Place the involved tissues in a position of comfort, (POC). Š This reduces irritability of the tender point, (TP). Š Ideal position is determined by the patients perception of reduced tenderness & the clinicians perception of reduced tone in the TP. Effects of PRT

Š Normalization of muscle hyper tonicity Š Normalization of fascial tension Š Reduction of joint hypomobility Š Increased circulation & reduced swelling Š Decreased pain Š Increased strength Contraindications for PRT

Š Open wounds Š Sutures Š Healing fx’s Š Hematoma Š Hypersensitivity of the skin Š Systemic or localized infection Š Malignancy Contraindications

Š Aneurysm Š Acute rheumatoid arthritis Conditions that respond to PRT Š Patients with a distinct physical mechanism of injury, e.g. Sports injuries, motor vehicle accidents 4 Phases of Tx

Š Phase 1: acute phase--PRT can be used immediately after injury, due to the gentleness of the tx. Š Phase 2: treating structural dysfunction in the acute and chronic pt. Š Phase 3: restoration of functional movement Š Phase 4: normalization of life activities General Principles of tx

Š Anterior TP’s usually tx’d in flexion Š Posterior TP’s usually tx’d in extension Š TP’s near the midline tx’d with more flexion if anterior and more extension if posterior Š TP’s lateral to midline tx with sidebending and rotation Achieving the optimal position of comfort Š Ultimate goal of PRT Š Comfort zone, (CZ), is specific and different for each tx position CZ has been reached when:

1) Reduction in tenderness noted 2) Palpable softness of tissues in area of TP. Perseverance is key when trying to eliminate a TP TP & Position

Š Remember to maintain contact with TP while moving Patient into treatment position. Š By maintaining contact-it is meant to be a gentle pressure on the TP, not increased pressure TP, Position and Pressure

Š As CZ is approached increase pressure over TP periodically to monitor progress Š When CZ is reached contact with TP is maintained, but non additional pressure is applied POC

Š When in POC, patient should not have pain Š If there is pain--then not in POC Š Discomfort arising after POC is achieved is part of normal release process Š This discomfort should subside after 1-3 minutes POC

Š POC is maintained for 90 seconds Š Once a TP has been fully released the body must be returned to neutral position SLOWLY. PRT

Š Positional Release Therapy: assessment & treatment of Musculoskeletal Dysfunction--Kerry J. D’Ambrogio & George B. Roth. Myofascial Release

Š “Fascia is a tough connective tissue that spreads throughout the body in a 3 dimensional web from head to foot functionally without interruption.” Š Restrictions of the fascia can create pain or malfunction throughout the body. MFR

Š “By requiring the therapist to respond to the subtle changes that occur in tissue tension during myofascial stretching, the therapist is able to work with the patient and not on the patient.” MFR

Š “An athlete with fascial restrictions will not efficiently absorb the shocks of continued activity.” Š “ connective tissue is composed of collagen, elastin and the polysaccharide gel complex, or ground substance. These form a 3 dimensional, interdependent system of strength, support , elasticity and cushion.” MFR

“ MFR along with therapeutic exercise and movement therapy improve the vertical alignment and lengthen the body,providing more space for the proper functioning of osseous structures, nerves, blood vessels and organs.” Fascia

Š Is a slightly mobile connective tissue which is derived embryologically from mesoderm Š Composed of an elasto-collagenous complex Š The elastic component is stretchable & is the core of the complex Fascia

Š The elasto-collagenous complex creates a 3 dimensional web, which runs from the top of the head to the tip of the toes. Š Fascia surrounds every organ muscle, bone and nerve as well as blood vessels. Elastocollagenous complex

Relaxed Complex

Elastic fibers Collagen fibers Elastocollagenous Complex

Stretched complex

Collagen fibers Elastic fibers Soft Tissue Mobilization

Š J-stroking Š Vertical stroking Š Strumming Š Bear Claw J Stroking & Vertical Stroking

Š Stroke in direction of the restriction ( with J stroke only) Š Use counter pressure with one hand Strumming

Š Downward pressure is applied with the fingertips and then a strumming motion is applied to the muscle tissue Š Strumming if performed correctly is NOT a COMFORTABLE technique Bear Claw

Š Is a form of strumming--used to clear the gluteal and hip regions. Cross Hand Releases

Š Slowly stretch the tissue until you encounter a barrier Š Maintain the stretch for 90-120 seconds or until you feel a release. Š Do not try and force your way thru the barrier. Š Follow thru the barrier until all is quiet Arm Pull

Š This technique can be utilized with patients who have upper extremity dysfunction. Š It can also be used to aid patients with cervical, thoracic and lumbar dysfunction Anterior Thoracic Release

Š 2nd person maintains longitudinal traction thru the U.E.’s and follows the release 3 dimensionally. Š Patient is in supine position. Interscapular Release

Š Patient is in the prone lying position Š Assistants maintain longitudinal traction thru the U.E.’s Leg Pull

Š Leg pull can be utilized with patients with lower quadrant dysfunction, including lumbar and thoracic dysfunction Lateral Thoracolumbar Release Š 3 person technique- Pt. is sidelying-1 person and the top leg, 1 person on the top arm and 1 person on the chest. Anterior thoracic Release

Š One assistant maintains traction thru both U.E.’s. Š One person on the anterior chest Interscapular Release

Š 3 person release- Pt. is in prone position--1 person on arm abducted to 90 degrees--1 person on scapula and 1 person on the opposite arm Cervical Release

Š Patient in supine position with the head off of the table Š Drop head into slight extension and apply gentle traction Š Continue with head traction and apply caudad pressure to the chest Š Maintain traction and apply caudad pressure top each shoulder. MFR

Š Myofascial Release the search for excellence: John Barnes Š The Myofascial Release Manual: Carol Manheim & Diane Lavett Craniosacral Therapy

Š Based on the belief that the cranial bones move in relation to each other throughout life. Š William Sutherland, an osteopath, became fascinated with the design of the cranial bones. Basic Concepts of CST

Š Craniosacral system is a semi-closed hydraulic system Š Boundaries formed by the meningeal membranes, ie the dura mater. Š CSF intake via the choroid plexus Š CSF returns to the venous system via the arachnoid villae. “Listening Stations”

Š Heels Š Dorsum's of the feet Š Anterior thighs Š ASIS Š Ribs Š Shoulders Š Cranial vault-3 holds Techniques for headache & Concussion Š Occipital release Š Frontal release Š Sphenoid release Š TMJ release Release for Posterior of Temporalis Š Sit at head of table Š Arrange tips of fingers 2-4 over the tip of the ear,(ask pt. to clench teeth briefly and if I right place you will feel mov’t) Š Apply medial pressure with cephalad traction Temporalis cont’d

Š Apply moderate amount of medial pressure and without sliding pull fingertips superiorly Š Maintain medial pressure and traction until you feel release Masseter Release

Š Sit at head of table Š Place thumbs over the masseter fibers and apply medial pressure until you get a release. CST

Š CranioSacral Therapy: John E. Upledger & Jon D. Vredevoogd Š CranioSacral Therapy ll: Beyond the Dura: John E. Upledger Tui Na: Chinese Massage

Š Chinese massage and theory are inseparable. Š Yin-yang theory: at the core of traditional Chinese medicine. Š Yin and Yang are interdependent Š The balance between Yin and Yang is not a fixed state Techniques to use in the Training Room Š Gun Fa--Rolling Š Yi Zhi chan Tui Fa- one finger meditation Š Rou Fa --kneading Š Mo Fa -- round rubbing Š Na Fa -- grasping Š Cuo Fa-- rub rolling Techniques cont’d

Š Ca Fa --scrubbing with palm or edge of hand Š An Fa -- pressing with thumb or heel of palm Š Ya Fa --suppressing with the elbow Š Tui Fa --pushing with thumb, heel of hand or both palms Techniques cont’d

Š Ma Fa --wiping Š Ji Fa -- chopping using the edge of the hand, back of the hand or tips of the fingers Š Zhenb Fa --vibrating with 1 finger, 2 fingers or the palm Š Dou Fa -- shaking Techniques cont’d

Š Yao Fa --rotating Š Ban Shen Fa --pulling/stretching Š An Rou Fa -- revolving Š Pia Fa --knocking using cupped palm or fist Š Che Fa -- squeezing/tweaking Š Nian Fa -- holding /twisting Applying techniques

Š Sciatica Š Strained lumbar muscles Š Tennis elbow Tui Na

Š Chinese Massage Manual: The Healing Art of Tui Na: Sarah Pritchard Shiatsu

Š “Practitioner uses pressure with his/her thumbs, fingers, palm, elbow, knees and feet to induce deep relaxation and a feeling of well being.” Š First practitioners of Shiatsu in Japan were blind, because it was thought that their sense of touch was more heightened. Styles of Shiatsu

Š Namikoshi--first of the “Shiatsu” styles. A very western approach, which does not rely on the meridian system Š Tsubo therapy--concentrates on the therapeutic effect of tsubo’s, (pressure points) Š Zen Shiatsu--utilizes meridian functions and Oriental theory. Yin & Yang

Š Yin & yang consume and support one another Š Yin & Yang transform into each other Š All diseases are due to imbalance of Yin & yang. Š All diseases can be defined as either Yin or Yang 5 Element Theory

Š Wood: controls earth and is controlled by Metal Š Fire: controls metal and is controlled by Water Š Earth: controls water and is controlled by Wood Š Metal: controls Wood and is controlled by Fire Š Water: controls Fire and is controlled by Earth 5 Element Theory

Š Metal: Lung Meridian,(Yin), Large Intestine, (Yang). Lung meridian is responsible for intake of air,(Ki). Š Large Intestine meridian is responsible for Elimination 5 Element Theory

Š Earth: Stomach,(yang) & Spleen/Pancreas,(Yin) meridians. Stomach meridian is responsible for Intake of nourishment. Š Spleen/pancreas is responsible for Digestion and Transformation. 5 Element Theory

Š Fire: Heart, Yin & Small Intestine, Yang. Š Heart meridian is responsible for being the emotional and spiritual center. Š Small Intestine meridian is responsible for Assimilation 5 Element Theory

Š Water: Bladder,(Yang) & Kidneys, (Yin) Š Bladder meridian is responsible for purification. Š Kidney meridian is responsible for Impetus. 5 Element Theory

Š Fire: heart Govenor, (Yin) & Triple Heater, ( Yang) Š Heart Govenor is repsonsible for Circulation Š Triple heater is responsible for protection 5 Element Theory

Š Wood: Gall Bladder, (Yang) & Liver, (Yin) Š Gall Bladder is responsible for Decision making and Distribution Š Liver is responsible for Control and planning, detoxification Characteristics of Shiatsu

Š Dx & therapy are combined Š Uses only the hands and fingers-no mechanical devices or medicines Š No side effects Š No age limits Š Shiatsu is a health barometer Š Tx’s the whole body Aim of Shiatsu

Š Applies manual and digital pressure to the skin with the goal of preventing and curing dysfunction by stimulating the body’s natural powers of healing. Yin

Š Water Below Š Moon Inside Š Dark Slow Š Heavy Matter Š Descending Rest Š Damp Contraction Š Cold Yang

Š Fire Above Š Sun Outside Š Bright Fast Š Light Energy Š Ascending Activity Š Dry Expansion Š Hot Kyo & Jitsu Š Kyo: too little energy Š Jitsu: to much energy Kyo

Š Kyo: feels unresponsive: it may feel soft, like Jello, a sinking feeling, nothing there to hold you out Š Too little Ki Š To tonify Kyo,(put more energy into it), you use a long slow holding pressure at medium to light depth Jitsu

Š Jitsu: feels hard or unresponsive-- bounding or bouncy--not letting you in, holding out, stuck or stagnant. Š Too much Ki Š To sedate Jitsu use fast, strong and deep techniques Diagnosis: East & West

Š Oriental Western Š Abstract Concrete/specific Š Subjective Objective Š Artistic Technical/scientific Š Right brain Left brain Š Oriental med: Western med: science Philosophy & art Diagnosis: East & West

Š Oriental concerned Western more with spiritual develop. materialistic & how well one concerned;phys Understands symptoms emphasized Diagnosis: East & West

Š Oriental dx very Western very precise imprecise;very concerned with what’s general wrong Š Holistic;concerned Symptomatic; focused With whole person on specific organs, not Not with specific whole person complaint Diagnosis: East & West

Š Based on human Based on to human machines & lab Communication tests touching Diagnosis: East & West

Š Medicine is general, Medicine is precise Lifestyle oriented drug & surgery oriented Š Patient heals Dr. & medicine heal Himself;healer only patient Guides Š Healer more passive Dr. more paternal, aggrerssive Diagnosis: East & West

Š Healer & Pt. Dr. gives med’s, Pt. Involved in not seen as giving relationship in anything-Dr. is giver which both receive, and Pt. is receiver. Healer grateful to Pt.-giver is receiver And receiver is giver Pressure

Š Pressure should be deep, but not uncomfortable to the patient. Š Listen to the patients feedback--they are ALWAYS RIGHT. Š Too much pressure and your patient will tighten up Š Too little pressure and tx will be ineffective. Low back pain

Š One thumb works BL25,(located between the 4th & 5th lumbar vert.), while the other finds trigger points along the top of the illiac crest. Low back pain

Š One hand on the sacrum for support, while the the thumb of the other hand works the piriformis m. working a line from the sacrum to the top of the femur. Š The piriformis originates along the edge of the SI jt. Low back pain

Š Feel around for trigger points in the lumbar area, while applying elbow pressure to GB30 in the gluts. Low back pain

Š Points along the Bladder meridian in the posterior calf and thigh can be used to help alleviate low back pain. Shiatsu

Š The Complete book of Shiatsu Therapy: Toru Namikoshi Š Zen Shiatsu: Shizuto Masunaga with Wataru Ohashi Š Tao Shiatsu: Ryokyu Endo Š Shiatsu: Elaine Liechti Š Reading the body: Ohashi Acupressure

Š Predates acupuncture Š Theoretical background rests on 2000- 4000 year old tradition of Chinese medicine. Acupressure

Š Can use customized menu’s for tx. Š Use of certain acupressure points in combination at the same time, I.e. Left hand on one point and the Right hand on another at the same time. Athletes and Acupressure

Š Muscular relaxation point: GB 34 Š In the depression in front of and below the prox. head of the fibula Š Helps relieve muscle soreness anywhere in the body Š Particularly useful after practice or contest Athletes and Acupressure

Š ST 36: particularly useful before a practice or contest. Š Wit leg straight, 3 body inches down from inferior pole of patella and 1 finger width out from the midline of tibia,(in Ant tib muscle) Š Apply firm pressure angling the pressure toward the tibia-for more stim-press and let up several times Athletes and Acupressure

Š To calm nerves: H7 Š Located below the little finger in the wrist crease, (press under the tendon of the FCU muscle Š K1: on the plantar surface of the foot - on he flexor digitorum brevis muscle, (between 2nd and 3rd toes) Š Revival point--renewed energy Athletes and Acupressure

Š To relieve muscle cramps:LV3 Š In the notch of the metatarsals between the the first and 2nd toes, (interosseous dorsalis muscle) Special Headache Release

Š LH on GB 20 (at base of occiput, between external occipital ridge & mastoid process) Š RH on GB 39 (3 cun above the lateral malleolus, back border of fibula) Š RH on GB 34 (in front & slightly below proximal head of fibula) Š Address both L. & R. sides Muscle Relaxation Release

Š Treat both sides: sit R. Š LH: base of sternum Š RH GB 34(ant. & just distal to prox. head of fibula) left side Š RH LV 3(1.5-2 cun above web between first & 2nd toes; L. side Š ST 36(3 cun below patella in depression between tib and fib; L. side Muscle Relaxation cont’d

Š RH on GB 34 right side Š RH on LV 3 right side Š RH on St 36 right side Aupressurre

Š A Complete guide to Acupressure: Iona Marsaa Teeguarden Š Basic Acupressure: Aminah Raheem