What are the Twelve Steps of Orthopedic Massage?
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The Twelve-Step Approach Assessment, Treatment, and Rehabilitation
It is vital that the following twelve steps are not used as a "cookbook" approach to therapy. Each step is dependent on the client's individual response to the preceding step. You do not progress to the next step until each area of tension is appropriately released. It is critical to apply specific work to release specific structures and also critical to differentiate between soft tissue problems due to myofascial restrictions, versus trigger point tension, or strained muscle fibers since the specific release techniques for each will vary greatly. The goal is to maintain structure, posture, movement and balance. As you put this twelve-step program into use, you will realize that soft tissue balancing is the missing link to long term pain free musculoskeletal alignment. *Precaution note- do not work on a client with a recent injury (acute condition).
Twelve Steps:
  1. Client History
  2. Assess Active Range of Motion
  3. Assess Passive Range of Motion
  4. Assess Resisted Range of Motion
  5. Area Preparation
  6. Myofascial Release
  7. Trigger Point Therapy
  8. Cross Fiber or Multidirectional Friction
  9. Pain Free Movement
  10. Eccentric Scar Tissue Alignment
  11. Stretching
  12. Strengthening
1. Client History:
Take a client history including information on when, where, and how the problem began. Ask the client to generally describe the area of pain and what makes it better or worse. If the discomfort occurs with movement, then the problem is most likely with the muscles and soft tissues.
The therapist needs to be confident and use positive words to help re-pattern the client's pain response to their brain. The client's mind can change its ability to believe what can work. Tell the client to visualize letting go, releasing, or melting during the therapy. Give the client permission to heal. Remember, therapists are only facilitators of the client's body's ability to heal.
Make sure you re-evaluate your clients each time you see them. Do not rely on previous history since the point of therapy is to alter it. Also, do not rely on the client's diagnosis from other practitioners, as many clients have been misdiagnosed. Listen to the client's diagnosis, but set it aside and re-evaluate using the following steps.
2. Assess Active Range of Motion:
These movements are performed solely by the client. Know the normal range of motion of the muscles at each joint. Explain to the client that the movements must be performed with zero discomfort. Test the uninjured, unrestricted, or normal side first. Demonstrate to the client the movement to be performed. Note any abnormal or restricted areas. Note the site and movement performed at the onset of pain. Note any abnormalities in the client's posture as this can also give you an indication of where the problem is. What you want to discover is what is restricting the muscles from performing the normal range of motion pain free. Become a healing detective.
3. Assess Passive Range of Motion:
These are performed on the client by the therapist to differentiate between inert tissues and contractile tissues. Start by bringing the muscles into a lengthening position and then gently stretch that tissue. Stretching the client's muscles can aggravate their condition. If they experience muscle-tendon discomfort or neuromuscular tension during the stretch, have them isolate the specific spot and point to it with their finger. Remember to be sensitive to your client's breathing and patterns of guarding. Your voice tonality and over all confidence can help the client to relax.
Passive movements allow the therapist to determine the "end feel" of the physiological barrier at the end of each joint's range of motion. Knowing what is abnormal can help you determine the presence of joint dysfunction or soft tissue pathology. The most common "end feel" is described as soft and leathery and is the stretch of soft tissues around the joint. Bone on bone "end feel" is when two bones contacting each other stop the range of motion (elbow extension). Tissue on tissue "end feel" can be found where the range of motion is stopped by muscle contacting muscle (elbow flexion). Follow the same rules as above for the active range of motion and then compare your notes
4.   Assess Resisted Range of Motion:
This is muscle resistance testing. It will help you assess the difference between myofascial pain, neuromuscular pain, and muscle-tendon strain pain. Problems usually occur at the periosteal junction where the tendon attaches to the bone or at the muscle-tendon junction where the muscle fibers become tendons. Both of these are weak, transition areas. Through assessment skills you can isolate the client's condition and determine what pathology is present so you can treat it effectively and appropriately.
Tendinitis is inflammation of tendons and of tendon-muscle attachments Tendinosis is tearing of tendon fibers in the absence of an inflammatory process. Tenosynovitis is the inflammation of a tendon sheath.
*Note- if there is a torn tendon; it will be treated last, after you have addressed the problems in the muscle belly. Think of the tendon as a tight cable, which must be released before it can be treated. Tendinous adhesions are secondary to repetitive motions or prolonged muscle imbalances due to poor posture.
Get into a comfortable position to test the muscle. Test the normal side first. Give kinesthetic cues or show the client what movement you want them to perform. Have the client contract the muscle you are testing while you apply reverse resistance. You, not the client, control the amount of pressure or force being applied on the muscle. For precaution, start the test with minimal resistance and then slowly increase the resistance to fully recruit the muscle fibers. This is to insure that you do not go too fast, too much, or too soon with the movements. If the client experiences muscle discomfort, have them isolate the specific area by pointing to it. Listen to the client and let them direct the treatment by telling you where the pain or discomfort is located .
5.  Area Preparation:
The therapist utilizes general massage strokes such as myofascial spreading, palmar friction, and compression to bring about soft tissue release. You will treat the cause of pain, not the source of pain.
Warm the areas of chronic, non-acute pain using oil applied with palmar friction, moist heat, or apply heating ointments, using minimal lubrication. You will release tissue from superficial to deep, moving from the origin to the insertion of each muscle. This is where it is very important to observe and evaluate results of the technique, the depth of pressure, and the amount of movement used to get into the tissue.
If the client is experiencing discomfort, pain, or muscle spasms you can use a gentle, non-invasive manual therapy called strain-counterstrain which eliminates inappropriate proprioceptive activity. The therapist shortens the painful muscle fibers by positioning the muscles in a relaxed position. An example would be when you work the iliopsoas (client supine). Bringing the client's knee into flexion results in a shortened position of the iliopsoas and therefore relaxes it. This allows you to work more effectively into the relaxed, non-guarded muscle. When muscle fibers are relaxed they "re-set" the proprioceptors, which allow you to gently stretch and realign them slowly, without pain .
*Note- do not use ice unless there is inflammation (heat, redness, or swelling). Ice causes the fascia to become less mobile and restricts movement. This is counter­productive to the realigning and healing process, which the therapy work is promoting.
6.   Myofascial Release:
This is one of the most important of the twelve steps. Fascia surrounds every muscle, muscle fiber, and every component within the body's compartments. Injury, accident, muscle imbalance and/or immobility can cause tight fascia .
Myofascia responds to heat, pressure, and movement. You want to create a melting sensation to help melt the "glue" around the connective tissue. You can use this therapy on pain that is described by the client as general, broad, or diffuse. The goal is to basically move the connective tissue back to where it belongs (functional, anatomical position) and to maximize space. You will release connective tissue at a 45° angle up and out from superficial through progressively deeper layers, slowly and with very little lubrication .
Expanding the connective tissue will maximize blood flow to the ischemic tissues and facilitate faster healing. As a result, you will find less neuromuscular treatment or trigger point therapy is needed .
You will perform myofascial techniques specifically on the contracted, tight muscles first. An example is that most clients' shoulders are forward due to short, tight pectoralis and subscapularis muscles resulting in over stretched, weak rhomboids, infraspinatus and teres minor muscles. The average massage therapist would typically treat the pain in the back rather than focus on the structural problem in the front. Myofascial work creates space around muscle tissue and is a preparatory step to further access structures within and surrounding the muscles.
7.   Trigger Point Therapy:
Trigger point therapy is also known as neuromuscular therapy. Trigger points are described as small tender nodules that when pressed on refer or radiate pain away from the site of pressure. They are a neuromuscular response caused by the fight for balance created between the antagonist muscles.
As you glide across congested tissue and find a tender area ask the client for feedback. When you press on the tender spot is the pain directly under your finger or does it radiate? If it radiates or refers, apply direct moderate pressure for 10-12 seconds until a proprioceptive change occurs and the tissue releases. Have the client take a deep breath and perform compressions over the area to further soften it and to pump blood to the ischemic tissue. Then finish by gently stretching the tissue.
It is important to work pain free. If the client is "guarding" or apprehensive, back off a little bit. Remember to evaluate which muscles are contracted and which are over stretched. Concentrate on performing trigger point therapy only on the contracted muscles. Working trigger points (or tender points) with direct pressure on the over stretched and often painful muscles first, is a waste of time.
8.   Cross Fiber or Multidirectional Friction:
As you glide through fibers and find tender areas you need to differentiate; does the pain refer and you treat it as a trigger point, or is the pain tight muscle fibers you tease apart with basic cross fiber friction techniques. Performing cross fiber gliding strokes spreads tight bands apart to further open up and affect the fibers.
When you come to an area of deep pain, described by the client, as directly under your finger (muscle strain or ligament sprain), you need to perform multidirectional friction. Typically, injuries occur either at the muscle-tendon junction or at the periosteal junction. A sprain is an injury to the ligamentous tissue. A strain involves injury to the muscle or muscle-tendon unit. After an injury, collagen fibers are laid down in a fiberglass like matrix in multiple directions and multiple layers. Only multidirectional friction can best affect it to free up the collagen (scar tissue) that is causing pain, thickening, and limiting range of motion. Using a supported finger, go in at different directions to mobilize the collagen fibers for 30-45 seconds only. Make sure you do not overwork the area and use only enough pressure to soften the fiber matrix.
9.   Pain Free Movement:
Movement following multidirectional friction provides the force necessary to create functional scar tissue (see "Theory of Scar Tissue Mobilization" in the next section). The goal is to create pain free movement and a balance of the muscles in all of the joints of the body (structural integration). Some muscles are over stretched because others are contracted and tight. Reassess the client's active range of motion. Have the client actively perform the specific single plane movement several times for neuromuscular re-education. If the movement is pain free proceed to the next step. If the movement is not pain free then return to the previous steps and continue to mobilize the tissue until the client achieves pain free movement before you progress to the next step.
10. Eccentric Scar Tissue Alignment:
*Precaution Note- after surgery, do not disrupt the proper healing of scar tissue by beginning this protocol too soon. Consult the client's physician.
After multidirectional friction you will then apply eccentric contraction, which is a resistive force that overpowers a muscle contraction. Have the client actively lengthen the specific involved muscle to its full (pain free) range of motion. This activates and restructures the myofibrils. Then, ask the client to contract the specific involved muscle. The therapist then provides a resistance that is greater than the force of the client's contraction, asking the client to "barely resist, but let me win". The therapist's resistance overcomes the client's contraction and allows the muscle to lengthen. Start with a resistance of only two fingers (the "two finger rule") and then have the client only increase their pressure if they have zero discomfort. This pain free force of movement is performed to help realign scar tissue.
Perform a resisted test on the involved muscle. If the client is still experiencing pain at the specific spot, repeat the multidirectional friction working pain free, progressively deeper followed by pain free movement and then with eccentric alignment. Continue to reassess and repeat until the pain is gone.
*Note- the old myth was that you could perform 6 minutes of cross fiber friction, apply ice, and somehow the fibers would magically realign themselves. This type of therapy can actually cause additional inflammation. What does provide results is mobilization and softening of tissue, cross fiber and multidirectional friction, movement, stretching, and then alignment of the collagen fibers to a healthy and functional format, all performed pain free.
11.   Stretching (Pain Free):
*Precaution note- in certain states massage therapists are not allowed to "prescribe" stretches.
But, you can "suggest" stretching to a client by telling them "if I were you this is what I would do". If you are not competent or if you feel that suggesting stretches is outside of your scope of practice, do not follow this step. Be safe, refer out. Wait until you become competent by adding stretching certification classes such as an Aaron Mattes seminar to your toolbox or become certified as a personal trainer or athletic trainer .
Once the client has achieved pain free movement you will apply specific, isolated flexibility techniques to the muscle-tendon problem. This is performed only on the tight, contracted muscles and not on the over stretched, weak muscles. PNF (proprioceptive neuromuscular facilitation) stretching uses the nervous system to turn the muscles on and off. This allows the subconscious brain to remember pain free movement so it doesn't sabotage your work. Most people not only try to stretch tissue before it has the ability to release, but also for too long. You will only stretch for 2 seconds to bring blood and oxygen to the area and to promote optimum results . Prolonged stretching can cause ischemia, muscle tears, and lead to chronic pain and injury .
The technique you will use is called contract-relax, contract-antagonist (PNF) with active assisted stretching. Ask the client to lengthen or stretch their agonist muscle (prime mover) only to where it is comfortable. They will then contract the agonist isometrically at 20% force for 10 seconds against the therapist's resistance. This fatigues the muscle. They then relax for 2-3 seconds and take a deep breath to allow the proprioception to adjust to the fatigue and create post-isometric relaxation. Then, on their exhale, they actively contract their antagonist muscle to facilitate reciprocal inhibition, which shuts down the nerve impulses in the agonist and allows a greater range of motion to occur. You assist the stretch. At the new stretched position repeat the sequence several times. It is important that the client exhales during the contract-antagonist phase so that they do not hold their breath (which could increase their blood pressure). Remember to traction the joint before and during stretching, as this increases space, which improves vascular circulation. Finally, it is imperative that the clients learn these techniques and perform them at home to re-educate their brain to remember the "new" pain free range of motion. Teach the clients active stretching first. Once they understand the stretches and can correctly perform them for you, teach them the more advanced PNF stretches. The best time to stretch is after a hot shower when the fascia and muscles are warm. Make sure the client understands that they do not stretch into pain. They need to learn to differentiate between uncomfortable stretching due to tight muscles and painful stretching that can tear muscle fibers and lead to injury. The client will start the stretches with the tightest side until they attain balance, and then continue to stretch both sides for symmetry. Without this final step, therapy results will usually last less than 72 hours, as the client returns to their same poor postural patterns and repetitive day to day motions.
12. Strengthening (Pain Free):
The over stretched muscles are ischemic; they lack blood flow and oxygen. And because they are weak they need to be strengthened to allow complete structural integration around the joint.
You will demonstrate these exercises to the clients and then require them to practice them at home. All they will need is surgical tubing and a towel. The tubing is inexpensive and you could provide it for them. It will take them only 5-10 minutes per day to perform both the stretches and the strengthening exercises and is imperative for their continued improvement and recovery. Without this final step, the results of therapy will be minimized. Empower the client to take responsibility to re­educate their muscles, keep their body in alignment, and be a part of their own wellness.
These twelve steps where reprinted with kind permission from the author James Waslaski, LMT http://www.orthomassage.net/home
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