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

It is running season, how about a little foot pain??

It's every runner's nightmare:  waking up one morning and feeling a stabbing pain on the bottom of the foot near the heel. Plantar fasciitis affects around 2 million Americans a year, and it's not just limited to runners. Anyone who is bearing extra weight on their feet, who has body-structure problems, is over-training, is pregnant, or has compounding injuries could be at risk. 

If you search the internet you will find loads of boots  and strange supportive gear that help you deal with plantar fasciitis after it appears. Doctors might prescribe pain killers, anti-inflammatories or cortisone injections to help you deal with the pain.  All these things are geared strictly to managing the problem. They are a mere band aid in for something that many people find literally debilitating.  

The plantar fascia is located on the bottom of the foot. It stretches from the heel to the ball of the foot, supporting the muscular arch above as well as interlocking bones. Technically, plantar fasciitis is billed as an inflammatory condition, however it's not that the body is randomly creating inflammation---rather, the inflammation is being created at the heel in order to try and repair the micro tearing that is occurring there, In truth, the problem is actually over-stress or tearing of the delicate foot fascia. and the inflammation is just a symptom. 

So here is the skinny. Understanding this problem for your body is key. The tissue on the bottom of the foot is very delicate when you compare it to the things it's being asked to do. The plantar fascia is not an isolated tissue, it is one small part of a long chain of tissue that runs from the top of the back of your body, down to the tip of your toes.  Picture this tissue as something like how, when you tie a rope around a box, it helps stabilize the box wrapping the whole way around If for some reason the rope were to get shorter, things would become uncomfortable for the box....there would be less and less space until finally the tension would be so great that most likely the rope would begin to fray at one of the corners (just like your heel) in order to create more length. That is exactly what is happening to your foot. The rope is tearing at its weakest point. When you have injuries that thicken the tissue and make it less contractile, or add extra stress to the "rope",  it is at risk for damage. 

By the same token, slackening the 'rope' can take pressure off the weaker tissues. Adding length to your

visual of the 'rope'

hamstrings and calves takes pressure off the bottom of the foot. Treating plantar fascia issues is a two-fold process. You must examine what caused the flair in the first place. Is it too much tension? A structural defect? Training?  Extra weight? Or is it another muscle pulling it tight?  The second step is to create less pressure on that plantar fascia by lengthening the tissue on the posterior chain, which will decrease the inflammatory reaction from the micro tearing. Professionals in sports medicine, physical therapy, massage and orthopedics can help you with the various parts of this painful problem to get you back on track, but I have also seen a good number of people help themselves once they truly understand the problem. A good foam roller and a trigger point ball are always a good investment for preventative care if you know you are prone to this malady. Once this is done and the cycle is broken, it is essential you give it time to heal...after all time heals all wounds.  If you are experiencing problems that are diagnosed or that do not resolve, it is very important to visit your primary care physician. 
For more info visit http://www.bodymechanicsnyc.com/
or see our sports massage program in NYC
By Beret Kirkeby

What is Orthopedic Massage?

What is orthopedic Massage exactly? Well, to be honest, that is a hard question. I have heard it described multiple ways, such as it is a combination of medical and sports massage, or a way of treating soft tissue injury which is its own style. 

Truthfully, the answer is an issue I also struggle with because my training is different from anyone trained in NY who is doing ortho work, and at first I did not realize that my training was any different because, in Ontario, where I went to school, everyone works the same way. I  was aware that I had gone to school nearly twice as long as the  New York program , but I never thought that what I  was being taught was entirely different that what was being taught here.

Lake Ontario- Toronto, Ontario

I suppose I should go back a bit and explain that in Ontario massage is covered by the National Health System.  Canadian massage therapists operate in a very different capacity than in New York. Massage is not seen as a luxury but as affordable basic health care for physical problems that do not require a prescription.  Canadian therapists might work in conjunction with a doctor or physical therapist, or entirely alone. The entire attitude towards the profession is different.

Here is what I learned about the difference:  In the first year of school in Canada we learn the basic concepts of Swedish massage, which is essentially the same as the training here in New York. It is the second year in Canada--where we only treat dysfunction,  go through an internships plus the continuing education-- is where things take a turn. The second year of massage in Canada is solely ortho. The therapists learn every single thing that could possibly go wrong physically (within reason, ie we are not studying super-rare subsets of infections and disease)  in each part of the body, including those things that we are NOT able or licensed to treat, and you are drilled on it...over and over. We are run through literally thousands of scenarios, good, bad and ugly, and graded on them. The drills are run like real live client interactions where we assess, interview, decide to treat or refer out to higher care, and then provide home care.  When the school thinks we have done enough ground work we are sent to practice on real assessments for real conditions. It is essentially our residency.  I was sent to a Parkinson's clinic, and an AIDs hospice for 3 month stints. By that time, organizing a treatment for someone with a physical problem is not really a challenge, however, reading about someone who is dealing with the possibility of death or disease is entirely different than caring for someone who is dealing with it. This part of the program gives us essential real life clinical experience, and it‘s pretty tough. Incidentally, they also make us intern in an office as a lesson in how not to ruin a business. 

From what I have understood from therapists here, they touch on ortho. The class might visit a Parkinson clinic here, and they might learn the techniques from a book just as we did, but they don't have the time to work in those environments.  In essence, the program here is a tasting platter and the Canadian is a full 6 course dinner. There is nothing wrong with the program here, it is just different. It is designed to give a great relaxation massage and show the therapists IF they wanted to learn more that there is more out there. Many, of course, have learned more, and are working in hospitals, teaching throughout NY and generally doing great work. Many therapists never move beyond working in a spa however. But why the difference? Why educate all therapists to work in a way only a handful do in NYC?

Massage Therapy in Canada is covered by the NHS, and since the insurance  is paying, they are invested in the product. The massage therapy program in Ontario fills the gap between physical therapy and your doctor. We handle the manual therapy components that often pt's are uninterested in, pain management, and the physical components of stress-related problems,  while keeping the doctors’ offices clear of minor bumps, sprains and strains. My days were filled with never ending streams of very normal problems ranging from headaches, surgery recovery, car accidents, over training, back pain and fibromyalgia. The end result is less people in the doctor’s office, less prescriptions for pain relief, and more problems caught before they become serious. 

You might pose the question of litigation. Here in NY we worry about litigation a lot. Therapists here are trained to explain that their care is not a substitute for medical care, which is really confusing as we are listed as medical professionals. You might think that, because we more frequently work with injured in Canada that the risk would be higher, however it is the opposite. Canadian therapists are far more likely to stay out of trouble by being able to accurately identify problems before they start. We have the extra training to understand when a problem is too big for us, and our training prepares us to work in emotionally difficult scenarios. 

So what is Orthopedic Massage? For me it’s being a trained professional, knowing what I can provide, and understanding my limits so I can make available the best care possible to the people seeking me out. Good care comes from understanding and pulling in the right resources, not from being the only stop in health care. Orthopedic treatment means I can pull from lots of sources and work in conjunction with trainers, and other health care providers to get the best.

For more information on Orthopedic massage in NYC please visit our website a