The purpose of this section of the Journal of Massage Science to inform the practitioners about valuable articles that frequently go unnoticed, as well as to point to those authors and publications who exhibit low educational standards. We do not play politics and we are not associated with any publishing company or professional association. We are a completely independent voice and we promise you direct unbiased reviews based strictly on the science.

If the author of the reviewed article does not agree with our opinion, we will be more than happy to publish his or her response and have a productive discussion over the article’s subject.

At the end of the year we will recognize and reward the author of the most important publication(s) and point to the authors of the most unscientific publication(s). We hope this will help to raise the bar of published materials in massage journals for the benefit of the entire profession.




Massage Today


    
Treating Depression with Massage. Massage Today, Volume 9, Number 2:1;3;17, 2009, by Don McCann

This article raises a very important subject. From our point of view, each person with any type of depression ought to routinely receive massage treatment. Initially, such treatment should be conducted over 7 to 10 sessions (with 2-to-3-day breaks between each session); later, 1 to 2 sessions per month is a great help for these clients. Many scientific publications have pointed out the clinical significance of massage therapy as part of an integrative approach to the rehabilitation of patients with depression.

Of course, the restrictions on the article’s size did not permit the author to discuss this important issue in great detail, but he nevertheless managed to deliver basic necessary information on the major types of depression, and provided the framework for a massage therapy session aimed at addressing the postural changes in a client with depression. The author’s recommendations are correct, and we think that the practitioner who suspects their client to be suffering from depression should turn to these recommendations as basic guidelines.



    
Patella Pain. Massage Today, Volume 9, Number 2: 11-12, 2009, by E. Dalton

This is a very good article, and the author shows that he knows his subject well. The biomechanical relationships between the major players involved in anterior knee function are very well explained. The only minor disappointment lies in the fact that there is not enough practical information for the practitioner. We feel that Mr. Dalton could stand to split this article into two parts and present more practical recommendations in the second part of the article.

We would like to add only one piece of information. Knee pain in general and patellar pain in particular can be result of chronic low-grade irritation of the L2 to L4 spinal nerves by the quadratus lumborum (QL) muscle. In such a case, the client will never complain about pain in the lower back, but about pain in the areas where the affected nerve ends — in this particular scenario of patellar pain, the femoral nerve.

Every practitioner who sees a client with knee pain should examine the upper and lower trigger points in the QL muscle (see video). If there are signs of femoral nerve irritation (active trigger points in the QL muscle), local treatment of the knee alone will never produce stable clinical results.

In the video: the dashed line indicates the last rib; the solid line indicates the iliac crest; the waved line indicates the medial edge of the lumbar erectors; the two solid dots indicate the upper and lower trigger points in the QL muscle. The video shows the direction of the pressure (the white arrows) for each point when the patient is positioned on the stomach.



    
Back Pain: Often a Pain in the Gluteus Medius. Massage Today, 9(3):7, 2009, by David Kent

The article is good as the original source upon which it draws (Travell and Simons, 1992) is excellent. The author is right in every line, and this article may serve those who are not aware of the clinical importance of the gluteus medius muscle.

We would like to add only one point. The author correctly points out that the gluteus medius constitutes the middle layer of the gluteus group, i.e., it is covered by the gluteus maximus muscle. The author correctly locates three common trigger points in the gluteus medius muscle. From a clinical perspective he could have mentioned that trigger point #1 in the gluteus medius muscle (shown in the article) and trigger point #1 in the gluteus maximus muscle have a similar location but on the different levels of depth.

Thus, if the practitioner is able to generate the jump symptom in this area using minimal to moderate pressure, he or she is dealing with the trigger point in the gluteus maximus muscle, while slow submergence into the tissue using deeper pressure will test the trigger point in the gluteus medius muscle.



     
Technique Isn’t Enough. Massage Today, 9(3):14, 2009, by Whitney Lowe

This is an excellent article! We are afraid that the readers won’t noticed it. The article raises a critically important topic for the massage practitioner. In any journal or during every convention, the practitioners are bombarded with countless offers of “new” techniques or method to quickly fix anything which is possible to fix. You can encounter a class to teach you how to fix knee or shoulder pain of any origin within 30 seconds (we are not kidding).

The author underscores the importance of another issue: techniques mean little if the practitioner who uses it does not apply clinical reasoning. Unfortunately, there is no school or college where practitioners can obtain such critical skills in clinical reasoning; they can rely only on self-education and personal clinical experience.

As correctly pointed out by the author: “Use of effective clinical reasoning is an art and skill that is developed with constant practice and study,” and “Treatment techniques will help you fill your bag, but if all you do is amass a series of techniques you only have a bag of tools and no knowledge about how to effectively use them.”

It maybe sound trivial, but it is a sad reality because many educators have, in the interest of their own personal benefit, contributed to an unfortunate fragmentation of the profession. As we have always insisted, it is often the case that stable clinical results from massage treatments can be achieved only using a combination of techniques and approaches.

Generally, each new client with a health problem requires a unique protocol of medical massage therapy only with such integrative approach to somatic rehabilitation can the practitioner be successful and build a thriving practice. Finally someone else besides us raises this point! Thank you!



Massage


     
Expert Advice: How Can I Tone Weak Muscles During a Massage Session?Massage 154, March:48-51, 2009, by Erik Dalton

Excellent article! The author shows a great understanding of the topic and we agree with every word he offers. The only point we should like to add is regarding how to tone muscles during a stress-reduction massage session.

The author is entirely correct in his recommendations, but these form more a part of treatment protocols for pathological conditions. If the practitioner applies them during a stress-reduction massage session, they will interfere with the ultimate goal of relaxation of body and mind.

To tone muscles as part of a stress-reduction massage session, without interfering with the client’s relaxation curve, there is a simpler approach: the application of kneading techniques in the stimulating regime. In such a case, the practitioner applies two types of kneading (one with a stretching component, the other with a lifting component) in a special sequence designed to alternatively stimulate muscle spindle receptors and Golgi tendon organ receptors.

As these kneading techniques are part of any stress-reduction massage, the session will flow naturally and will serve its final goal of relaxation. (We will discuss the stimulating and inhibitory regimes of kneading techniques in one of the upcoming issues of our Journal.)



     
How can I incorporate CranioSacral Therapy into my practice? MassageFeb:50-53, 2009, by L. Upledger, DC

Dr. Upledger answered this question in the Expert Advice column of Massage Magazine. There are a lot of statements in this article with which we are not in agreement, and which we consider at the very least controversial. First of all we would like to state that we have nothing against Craniosacral Therapy and consider it a great and helpful type of bodywork. We completely agree with the following statements the author makes in regard to the effects of Craniosacral Therapy: “CTS reduces stress on the central nervous system”; “rebalance autonomic nervous system”; “by increasing fluid flow within dural tube… the practitioner can …reduce headache and sinus problems as well as hyperactivity.”

However, we have a lot to say about other statements within the article. First of all, there is no silver bullet in medicine and in bodywork especially. Each technique and approach has its own niche of application. It is a massage practitioner’s responsibility to learn a sufficient number of methods and techniques such as to be able to combine them together for the client’s health benefits.

However, many authors and educators, in the hopes of promoting their own methods, try to present them as universally applicable. A wrong and misleading approach for practitioners such as this is seen in this article as well. The key to the practitioner’s greatest effectiveness and professional success lies in an integrative approach to somatic rehabilitation, whereby CST is used where it is clearly helpful, and other methods where they are deemed more beneficial.

In illustrating our point of view, the reader may decide for themselves. Dr. Upledger correctly points out the importance of the fascia in the body, and after that she writes that: “CTS can release fascial restrictions with a touch lighter than the weight of a nickel,” and, “…therapists help free up layered patterns of restriction in the transverse-oriented tissues we call diaphragms. This removes restrictions and tightness within the connective tissue and relieves fascial tension.”

We have significant problems with these statements because they send the practitioners along the completely wrong pass, in our view wasting their time and their clients’ money. There are basic principles of tissue arrangement and function with which these statements do not conform. Pressure “lighter than the weight of a nickel” will not do anything to superficial fascia if the client has a thick layer of subcutaneous fat, and it may (theoretically) only mildly affect tension in the superficial fascia of very skinny person.

Light pressure may also be used, for example, on the head to reduce tension in the cranial aponeurosis (though scalpotherapy is still much more effective). There is no possible way even to conceive that such recommended light pressure could affect the deep fascia which separates superficial and deep skeletal muscles. And without releasing the tension in the deep fascia, the entire treatment is useless.

In countless prestigious publications, the world’s most respected scientists (Dickle, 1979, Ebner, 1985, etc.) who actually studied the features of fascia and developed massage techniques and methods (tested in clinical trials) to reduce tension and scarification therein, have stated that the following modalities allow to effectively reduce tension in the superficial and deep fascia:

1. Passive stretching alone, or as part of muscle energy techniques or myofascial release: targets the superficial and deep fascia simultaneously, however should be combined with two other modalities because the passive stretching alone is unable to reduce the tension completely;

2. Connective tissue massage: especially effective in reducing tension in the superficial fascia. The practitioner forms and pushes the fold of skin along and across fibers of the superficial fascia, stretching them by alternating the direction of application;

3. Different variants of the kneading technique: target the deep fascia by moving the superficial muscle group along and across the deep fascia; and,

4. Lymph-drainage massage: helps to reduce interstitial edema in the fascia, however it is but supportive treatment in the addressing of fascial tension.

Existing clinical methods like segment-reflex massage, neuromuscular therapy and myofascial release, despite their different names, all nevertheless use these basic modalities in different combinations.

Why would the light pressure recommended in the article not be able to reduce tension in the fascia? Because fascia is very strong and resistant tissue. If the author has ever had occasion to conduct or observe a surgery, she would have seen how surprisingly strong and firm fascia is. Members of our Editorial Board can assure readers from their own clinical experience that in some parts of the body fascia can initially resist even the scalpel!

However, that is not all. Tension in the fascia develops as a result of yet another factor: restricted elasticity of the fibrotic bridges which attach the superficial fascia to the subcutaneous tissue and the deep fascia to the superficial skeletal muscles. These bridges are key components to fascial tension. This is why the applied pressure should be strong enough such as to gently grasp the soft tissue (the skin in the case of superficial fascia, or the superficial muscles in the case of deep fascia) while trying to displace the tissue along and across the fascia, i.e. apply pressure in the horizontal plane. Only in this way can the practitioner stretch the fibrotic bridges, and as a result reduce tension in the underlying fascia.

Let us look at another statement from the article which we find highly problematic: “Let’s say a therapist has a client who is suffering from chronic or acute pain so severe that standard massage techniques, such as myofascial release and neuromuscular massage are painful to the client. In a traditional session, this might limit effectively treat the client and provide relief from pain – but the application of the CST allows a therapist to pass energy through contracted parts of the body and achieve releases in problem areas without great deal of manual therapy. Because CST works with body’s own innate forces…”

From this statement we can conclude only one thing: that author does not have any idea about myofascial release or neuromuscular therapy, and that she never uses it on a patient. Getting right to the core of the problem: there is no way that CST can substitute any of these methods, say, for instance, for acute spasm of the piriformis muscle with a subsequent clinical picture of sciatica. We would like to point out that if a client is in acute pain, myofascial release, neuromuscular massage, as well as other methods of manual therapy (e.g., rolfing, segment-reflex massage, etc.) offer techniques and approaches which are especially designed for such cases; however, only after the pain-analyzing system is under control can the practitioner move forward with his or her treatment protocol without harming the client.

Should the practitioner who is trained in Craniosacral therapy use this modality in cases of acute pain caused, for example, by sciatica? Yes of course, but the practitioner should see the bigger picture whereby craniosacral therapy is of value to reduce stress and anxiety developed as a body reaction to acute or chronic pain. However, to target the initial problem, sciatica in our example, the practitioner should use modalities (e.g. segment-reflex massage or neuromuscular therapy) which are specifically designed to free the client of acute pain as soon as possible. This would represent an integrative approach to somatic rehabilitation.

Finally, we would like to ask the author for one more clarification: What innate forces of the body does CST work with that other modalities can’t access as well? Is there some special body department that can be accessed only by using CST? Maybe it is just us, but we feel that this statement about CST’s supposed unique capacity to work with the body’s innate forces insults our intelligence.



    
Relieve Pain and Tension With Bilateral Palpation, Phasing and Active Isolated Release. Massage Feb:65-68, 2009, by R. A. Johnson, L. Stockton, DC

This is a promotional article which offers very limited practical information, and the authors could have stood to provide more illustrations so as to give the readers an idea of what they need to do exactly.

There are also several issues which demand clarification. First of all, any palpatory evaluation of the soft tissue needs to be conducted bilaterally. We don’t understand why the authors made such a big deal over this simple and trivial matter when everyone involved in manual therapy routinely uses bilateral palpation.

The authors stated that they developed a new diagnostic technique called Phasing, and that “With Phasing, the therapist moves the head gently and with caution in different directions; this is done on each side for comparison. Once a problem, such as limited range of motion, tightness or inconsistent movement, is identified it can be addressed with various stretching and soft tissue techniques…”

Hmmm… It is as if the complex diagnostic evaluation of the soft tissue in such an anatomically complex area as a the posterior and anterior neck is a most simple procedure with Phasing. Could the authors be specific and explain how the gentle passive movement of the client’s head will provide the therapist with enough diagnostic clues about the exact pathology he or she is dealing with?

The practitioner cannot rely on such a narrow way to obtain comprehensive clinical information in order to formulate the correct treatment protocol. Only the complete evaluation of active and passive range of motion, in combination with a layer-by-layer examination of the soft tissue in the affected area, can give the practitioner enough diagnostic information. The authors did not share with readers valuable information on what criteria they used to differentiate which muscles are affected when they moved the client’s head from side to side. Instead, they refer readers to their website. It is to be hoped that the curious reader will find the answers to these questions there without spending too much money.

The authors wrote, in regard to evaluation and treatment of neck extension: “Working from superficial to deep, a therapist will encounter splenius capitis, splenius cervicus, longissimus capitis and longissimus cervicus.” Wait a minute! Did we miss something? Where has the trapezius muscle gone? Did the authors consider that the trapezius is not a superficial muscle of the posterior neck, or perhaps is not involved in neck extension? Let’s turn to Travell and Simmons (Myofascial Pain and Dysfunction, 1983) for their opinion: “The paired trapezius muscles are synergistic for extension of the head, neck or thoracic spine, and during symmetrical upper extremity activities (Volume I, p. 182).”

In contrast to the discussion regarding diagnostic evaluation of the tissue, the treatment part of the article looks much more promising. Our only suggestion to the authors is to not begin therapy of spastic muscles with stretching, and instead to switch part A of the treatment protocol with part B. Without wishing to enter into a lengthy explanation of the physiology of muscle innervation and contraction, we should say that the protocol as presented, beginning with stretching, to some degree works against the final goal of quick elimination of tension.



Massage & Bodywork


 
Functional Anatomy: Pectoralis Minor. Massage & Bodywork March/April:99-100, 2009, by Christy Cael

This is a helpful article which discusses the anatomy of the pectoralis minor muscle, as well as its palpation and stretching.

There are two points we would like to add. We consider them equally important. First is regarding the anatomical correlation between the pectoralis minor muscle and the brachial plexus. There is no mention, in the article, of this critically important point.

The pectoralis minor muscle is the final guard protecting the brachial plexus, on the anterior shoulder, from direct impact. It is the final point at which all peripheral nerves which innervate the upper extremity stay together to form the brachial plexus. Inferiorly to the pectoralis minor muscle, each nerve takes on its own specific route. Thus, even residual tension in the pectoralis minor can irritate different parts of the brachial plexus and can trigger a variety of abnormalities in the upper extremity, from Deltoid Muscle Syndrome to a clinical picture similar to that of Carpal Tunnel Syndrome.

The second issue regards palpation, or actual work, on the pectoralis minor muscle. The picture in the article illustrates the author’s way of approaching the pectoralis minor muscle. However, palpation from this angle is much less informative, and effective work on the pectoralis minor muscle from this position simply impossible.

The position of the upper extremity recommended in the article (see video 1) for palpation of the pectoralis minor muscle requires the rotation of the client’s shoulder backward, which then tightens the pectoralis minor muscle like a string. At first glance, this may seem a good idea as this position stabilizes the pectoralis minor muscle for palpation. However, in this position, the pectoralis minor muscle is pulled upward and medially, and the practitioner is able to reach only the lateral edge of the muscle. Additionally this position places the pectoralis major muscle under tension, blocking access to the pectoralis minor muscle located underneath it. In such a case, the practitioner has very limited access for palpation

Another issue is the positioning of the practitioner’s hand. Yes, the tips of the practitioner’s fingers are in contact with the lateral edge of the pectoralis minor muscle, as recommended in the article (see video 1). However, the fingertips are much less discriminative, and are consequently less informative parts of the fingers, if we compare these areas with the palmar surfaces of the distal phalanges. The actual tip of the finger has less sensory receptors as compared with the palmar surface of the entire distal phalanx (see video 2).

Let us now review a much more efficient approach to the palpation of and work on the pectoralis minor muscle (see video 2). Grasp the client’s upper extremity and lift the entire shoulder along with the scapula upward (skyward). Slide the thumb of your other hand under the free edge of the pectoralis major muscle, as shown in video. In this position, the practitioner is able to use the entire palmar surface of the thumb’s distal phalanx for palpation.

Now, apply pressure laterally and you will feel the spindle of the pectoralis minor’s belly just underneath the pectoralis major muscle. The great advantage of this position lies in the fact that the practitioner can examine not only the lateral edge of the pectoralis minor muscle but also its anterior surface, if he or she adducts the client’s arm in the shoulder joint. In such a case, the relaxed pectoralis major muscle can be easily pushed medially, which will expose almost the entire anterior surface of the pectoralis minor muscle.



     
Essential Skills: Golfer’s Elbow. Massage & Bodywork March/April:106-109, 2009, by Ben Bengamin

Great article! The author covered all the major issues associated with Golfer’s Elbow, from anatomy to self-treatment. The article stands out because the author addresses the bigger picture, not just the massage treatment. He correctly points out the importance of a rehabilitative program of the entire elbow, where several components are combined together to actually heal the injury completely, rather than simply sending it into a state of temporary remission.

Considering that Golfer’s Elbow is a very common pathology, we would like to add some important information for the readers.


1. Evaluation test

The test provided in the article is useful and is applied correctly. However, this particular test stands a lesser chance of detecting a Golfer’s Elbow in remission, or one in its very early stages during which the flexor carpi ulnaris muscle is under tension with as yet no injury to the tenoperiosteal junction.

In such cases, it is more useful to apply a resistance test which combines flexion (which the author mentions in the article) with simultaneous ulnar deviation of the hand at the wrist joint (see video). The combination of these two movements against the practitioner’s resistance allows the detection of even the initial stages of this pathology.



2. We would like to add another important point regarding Golfer’s Elbow. A clinical picture resembling that of Golfer’s Elbow can be the result of mild to moderate irritation of the ulnar nerve by the posterior cervical muscles, anterior scalene muscle or pectoralis minor muscle. 

Entrapment of the fibers of the ulnar nerve in any of these three areas will cause a similar clinical picture such as this, in the absence of any actual injury to the tenoperiosteal junction. In such cases, local treatment solely in the area of the medial epicondyle is useless. The practitioner should always remember this during initial evaluation, and should apply compression tests to rule out ulnar nerve irritation at the levels of the neck or/and shoulder.

3. Our only minor disagreement with the author is in regards to the combination of active exercise and treatment. Based on our collective clinical experience, we strongly believe that the local acute inflammation and pain must be controlled first, with active exercises to strengthen the affected muscles being properly the second part of a rehabilitation program. 

While the client is going through the initial therapy, which is correctly summarized by the author, the client should use only gentle passive self-stretching of the affected muscles. This passive stretching should be done only within the client’s comfort level, i.e., without any activation of the pain-analyzing system. Only after local inflammation has subsided and the pain-analyzing system is under control should the practitioner recommend active exercises to the client. This is a much quicker way to heal the injury.



     
Myofascial Techniques: Working with the Cervical Core. Massage & Bodywork March/April:122-127, 2009, by Til Luchau

This is a very good article, and is the second part of the similarly-titled article from the previous issue of the Massage & Bodywork. The author remains faithful to the concept of the layered arrangement of the soft tissue, and provides a lot of helpful tips which can be used effectively by the practitioners.

We would like only to add the notion that the complete release of tension in the superficial and deep muscles of the posterior neck requires the practitioner to work on the cervical paravertebral muscles in such a way that the superficial layer is pushed laterally from the line of the spinous processes of the cervical vertebrae. An approach such as this greatly helps to reduce the tension in the deep fascia which separates both muscle layers.


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