Body Mechanics Orthopedic Massage

Body Mechanics Orthopedic Massage
Manual experts for your body. Life is too short for limits.

Friday, January 31, 2014

Rom: Where we begin to compare the subjective to the objective

If you are looking to be a little more thorough in your technique for massage assessment but don’t really know where to start, simple range of motion is a great place. During your interview process with a client you should have covered such topics as: Where does it hurt? What is the quality of the pain? When did it start? How did it start? Does it radiate? What is the pain on a scale of 1-10? Is there any compensatory issues? Aggravators?  Relievers? This is your subjective information.  Some of us cover a little more, some of us cover a little less, but this is how your client ‘feels’ about his or her pain/condition.

It is very important information, but keep in mind the body is not cut and dry.  Injury is not always where the pain is, nor does structural abnormality add up to pain either. It is only by combining the different tools that we have, that we can begin to scrape the surface and make educated guesses about what is really going on in the body.

Range of motion is a huge assessment tool that is really undervalued. For the most part, when we think of range of motion, we think of boring dry numeric assessment of how many degrees of motion is normal or abnormal, and while that information is important, for most therapists, it matters little if the arm has 3 degrees less rotation, or 8 degrees.  Once we know something is limited, whether normal or over-mobile, it is in comparing that information with the rest of the data we have learned that ROM really becomes a valuable tool.

You will want to divide your range of motion up into two categories. Normal ROM for an average person, and normal ROM for ‘that’ person.  In your first assessment you will compare their ROM with what you know to be normal for others. Recording this information will give you a baseline by which to measure your client.  As time progresses and you learn how their body works, you will begin to measure them by what is ‘normal’ for them.  It is important to understand the distinction between these two things, because for your client, normal may not be normal at all. . Lack of moment or over-mobility may also be completely normal for a client and not add up to any relevant pain. In the case of injuries, however, it often can be.
Once you have made both a verbal assessment and a physical one you will start to overlay the two sets of information and compare what you have learned.  Comparing what the client ‘feels’ to what we observe is where the real value is. The more areas of assessment we have to compare, such as ROM, palpation, verbal assessment, passive ROM, and special test etc…the more likely we are to gain an accurate picture of what is going on in a particular body.

I will give you a brief example of how it works:
A client comes in complaining of low back pain. It is chronic and constant, and he has been receiving 30 minutes of massage on his low back for 3 weeks, once a week with no change. He has been to his doctor and been cleared to see you. He is a runner, in good physical health and has no history of back injury.  He is now afraid he has a disk problem, and has stopped activity for fear of seriously hurting himself, which has aggravated the pain.  Because he has come to your clinic, you do a full assessment, including ROM of the surrounding area (low back and legs) Even though he complains that he has low back pain, he has no limited movement in any direction of his lumbar spine. If anything, he is over -mobile. Now you think to yourself, “that does not seem right, someone with low back pain should be tight and trigger pointy”. So you perform the ROM for his legs and while you find most things pretty normal, you realize that he has almost no mobility in his IT bands and gluts.

By comparing the two sets of data we can start to build a picture of the probable cause for the client. If you had just had the one set of verbal information to go on, you would have massaged his lower back like everyone else. If you had just done the ROM with no verbal information, you would likely assume that perhaps the limited mobility is normal for that client, but since we know he stopped running recently, and we know exercise warms the tissue, we can draw the conclusion that the symptoms were aggravated by withdrawing from activity.  Because you draw from the compared data, you treat both the lower back and the legs with massage, stretching and fascia work, which eases the symptoms for your client.  As you learn more tools you can add them in, such as tests for disc problems as a rule out, but remember, this is an educated guess, not a diagnosis. 

Sometimes things are not so clear but the more you practice the more you will realize how complex the body is and the rules you were taught often do not apply at all, as biology is not rule based, but biology based. There are, however, patterns in many of the things you will encounter. Getting familiar with ROM and using it as an assessment tool is just one step forward in giving you a tiny peek under the hood.  Good luck building your tool box!
For more information on Orthopedic Massage please see  Orthopedic Massage NYC
by Beret Kirkeby

Sunday, January 12, 2014

Why we start treatment by getting to the other side. Orthopedic Protocol

I have been teaching a lot recently and it has gotten me thinking about what I want to say in my blogs. Recently, I have become incredibly aware of how lucky I was with my initial training and the early part of my career. I have been blessed enough to go to a 2800+ hour Orthopedic program and then travel the world learning more,  I have almost always worked with medical company's or for insurance claims, seeing clients that had issues that there was no guide book for. I was also lucky enough to do this early enough in my career that I did not know how little I knew, and it gave me free range to experiment with what worked for me, not just with what I had been taught as a base.

For the rest of my blogs I am going to change the focus from the general public, to speaking to other therapists. Teaching here in NYC has shown me that the information I was given freely, is not given to others freely and I want to share what I have. Some of the information will seem obvious to some, but here in the states therapists can either have very little training or quite a lot of training. By no means do I reserve the right to tell people what to think.  However, I can present a structure based on my training and experience on how to think like an orthopedic massage therapist. .

    Starting on the other side........

When you have finished all of your assessments and are ready to treat your client, how do you decide where to start? If a client has back pain do you jump right to the pain point? If they came in for a pulled hamstring do you start with the back because that is where you always start?

 Starting on the other side is a basic orthopedic principle. For some of you this will be a basic principle tried and true, but for some you will never have heard of it.  All this means is that after you assess your client, whatever the probable problem is, you are meant to begin treatment on the opposite side of the body. For example, if the client comes in with a problem in their right leg, the treatment starts with the left leg. It begins an important practice in orthopedic treatment, as using your treatment as an assessment protocol. Starting on the opposite side allows you to do three things.

1. Use your massage to asses what the 'normal' tissue and ROM is, thereby using it to compare to the dysfunctional side, making more objective decisions about your treatment.
2. Decide on a depth of reasonable pressure on the patient's healthy tissue.
3. Get the client used to your touch so that you can work in more sensitive areas that they might guard and get them into a relaxed state with the muscle pump 'on'.

This all seems straight forward when you first think of it, but can get a little confusing if you think on it too much. Obviously if its a limb problem, such as the left arm, you would begin on the right, etc. But issues with the body are not always cut and dry. Take these for example, if the complaint is in the low back, what is the opposite side?

Well, is its low back  right side SI joint, then the opposite side is the left side SI joint. However if its is low back L5-S1 center, and both QL's seem equally tight, then the opposite side is likely glutes. Issues on the main part of the trunk of the body might often use 'up/down'  as the 'opposite side' and that is totally fine. The idea is to start giving yourself a structure to understand the tissue and to gather information as you are treating.

More complexity can be added if you are working with time constraints. You will not always be doing a full body massage. If someone comes in for a 30 minute treatment, and the complaint is a pulled calf muscle, you might only be working one leg, so you might start at hamstring, once again using 'up/down' as opposites, rather than left right. While hamstrings and gastrox are not technically opposite muscles, it still gives you a place to start.

The most valuable information for learning and assessment perhaps comes from using this principle on a micro scale. When you are working for insurance companies, PT's, or chiros, you are often only given 15 min or so to treat. It's really not enough time to reap the benefits of massage, you are just working the prescribed area. In this scenario, I would recommend working 'antagonist/agonist' starting of course with the opposite muscle of complaint. Not only as a beginner does this give you an excellent opportunity to review valuable information about which muscles counteract which movements, but what is fascinating here is you will start to see patterns in pain emerge. You will find that much of the time when you begin with the area that is opposite of the complaint, that the muscle in question will be tight, splinted and in fact the cause of the problem. So when you treat it first, and then move onto the original area of complaint there is no complaint left to treat, other than compensatory issues. And this should get you thinking about pain in general,why it occurs, where it occurs, and how you can rethink you assessments to make them more objective.

Regardless if you are treating whole body, or micro areas, treating on the opposite side is a valuable tool for organization, assessment and gives your client a better treatment on the whole. Even in a relaxation session, small things like this, a can improve a client experience without them ever knowing it was done. Once you start to apply structures in thinking to your treatments, your ability to find patterns within them will quickly develop.

*QL-Quadratus Lumborum
*SI-Sacroilliac Joint
*PT- Physical Therapist

For more information on Orthopedic Massage, or Beret Kirkeby check out Massage NYC
By Beret Kirkeby